the symptoms must cause considerable distress or impair functioning at work, in social settings, or in other important areas to qualify as an episode. workup no labs are diagnostic of a depressive episode. but some labs can help rule out general medical conditions that may mimic the symptoms of a depressive episode. healthcare providers may order some routine blood work, including routine blood chemistry, cbc with differential, thyroid function studies, and vitamin b12 levels, before making a diagnosis. differential diagnosis there are other mental health disorders or medical conditions to consider before diagnosing a major depressive episode: a doctor or psychiatrist should consider these options before making a definitive diagnosis, in order to avoid misdiagnosing a patient. adjustment disorder anxiety disorder (generalized anxiety, ptsd, obsessive-compulsive disorder) bipolar disorder cyclothymic disorder depression due to a general medical condition disruptive mood dysregulation disorder gender dysphoria persistent depressive disorder personality disorder with depressive symptoms premenstrual dysphoric disorder substance abuse or substance use disorder screening healthcare providers may screen patients in the general population for depression using a screening tool, such as the patient healthcare questionnaire-2 (phq-2). if the phq-2 screening is positive for depression, a provider may then administer the phq-9. the geriatric depression scale is a screening tool that can be used in the elderly population. treatment depression is a treatable illness. treatments for a major depressive episode may be provided by mental health specialists (i.e. psychologists, psychiatrists, social workers, counselors, etc.), mental health centers or organizations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programs. the treatment plan could include psychotherapy alone, antidepressant medications alone, or a combination of medication and psychotherapy. for major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy, and antidepressant medications are more effective than psychotherapy alone. meta-analyses suggest that the combination of psychotherapy and antidepressant medications is more effective in treating mild and moderate forms of depression as well, compared to either type of treatment alone. patients with severe symptoms may require outpatient treatment or hospitalization. the treatment of a major depressive episode can be split into 3 phases: acute phase: the goal of this phase is to resolve the current major depressive episode continuation: this phase continues the same treatment from the acute phase for 4–8 months after the depressive episode has resolved and the goal is to prevent relapse maintenance: this phase is not necessary for every patient but is often used for patients who have experienced 2–3 or more major depressive episodes. treatment may be maintained indefinitely to prevent the occurrence and severity of future episodes. therapy psychotherapy, also known as talk therapy, counseling, or psychosocial therapy, is characterized by a patient talking about their condition and mental health issues with a trained therapist. therapy alone has been proven to benefit people who are struggling with various mental illnesses. different types of psychotherapy are used as a treatment for depression. these include cognitive behavioral therapy, interpersonal therapy, dialectical behavior therapy, acceptance and commitment therapy, and mindfulness techniques. evidence shows that cognitive behavioral therapy can be as effective as medication in the treatment of a major depressive episode. psychotherapy may be the first treatment used for mild to moderate depression, especially when psychosocial stressors are playing a large role. psychotherapy alone may not be as effective for more severe forms of depression, such as depression where there's a chemical imbalance in the brain. some of the main forms of psychotherapies used for the treatment of a major depressive episode, along with what makes them unique are included below: cognitive psychotherapy: focus on patterns of thinking interpersonal psychotherapy: focus on relationships, losses, and conflict resolution problem-solving psychotherapy: focus on situations and strategies for problem-solving psychodynamic psychotherapy: focus on defense mechanisms and coping strategies medication prozac is one example of an ssri, the class of antidepressant medications that are used as the first line in the treatment of depression. medications used to treat depression include selective serotonin reuptake inhibitors (ssris), serotonin-norepinephrine reuptake inhibitors (snris), norepinephrine-dopamine reuptake inhibitors (ndris), tricyclic antidepressants, monoamine oxidase inhibitors (maois), and atypical antidepressants such as mirtazapine, which do not fit neatly into any of the other categories. different antidepressants work better for different individuals, it simply comes down to the person and what they prefer. it is often necessary to try several before finding one that works best for a specific patient. some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant. if a person's close relative has responded well to a certain medication, that treatment will likely work well for him or her. for example, if the depression is familial and the person's mother is prescribed an ssri, then the same ssri will most likely benefit the person as well. antidepressant medications are effective in the acute, continuation, and maintenance phases of treatment, as described above. the treatment benefits of antidepressant medications are often not seen until 1–2 weeks into treatment, with maximum benefits being reached around 4–6 weeks. it is likely that the person will actually experience more negative side effects during the first week or two, and want to stop taking their medication. however, it is crucial that they push through until the 4–6-week mark to know for sure how they feel about it. most healthcare providers will monitor patients more closely during the acute phase of treatment and continue to monitor them at longer intervals in the continuation and maintenance phases. sometimes, people stop taking antidepressant medications due to side effects, although side effects often become less severe over time. suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms. some studies have shown that antidepressants may increase short-term suicidal thoughts or actions, especially in children, adolescents, and young adults. however, antidepressants are more likely to reduce a person's risk of suicide in the long run. below are listed the main classes of antidepressant medications, some of the most common drugs in each category, and their major side effects: monoamine oxidase inhibitors (isocarboxazid, phenelzine, selegiline): major side effects include high blood pressure (emergency) if eaten with foods rich in tyramine (e.g. cheeses, some meats, and home-brewed beer), sedation, tremor, and orthostatic hypotension selective serotonin reuptake inhibitors (citalopram, escitalopram, paroxetine, fluoxetine, sertraline): major side effects include nausea, diarrhea, and sexual dysfunction such as erectile dysfunction or anorgasmia serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine): major side effects include nausea, diarrhea, increased heart rate, increased blood pressure, and tremors tricyclic antidepressants (amitryptiline, desipramine, doxepin, imipramine, nortriptyline): major side effects include sedation, low blood pressure when moving from sitting to standing (orthostatic hypotension), tremor, and heart issues like conduction delays or arrhythmias alternative treatments there are several treatment options that exist for people who have experienced several episodes of major depression or have not responded to several treatments. electroconvulsive therapy is a treatment in which a generalized seizure is induced by means of electrical current. the mechanism of action of the treatment is not clearly understood but has been shown to be most effective in the most severely depressed patients. for this reason, electroconvulsive therapy is preferred for the most severe forms of depression or depression that has not responded to other treatments, known as refractory depression. vagus nerve stimulation is another alternative treatment that has been proven to be effective in the treatment of depression, especially people that have been resistant to four or more treatments. some of the unique benefits of vagus nerve stimulation include improved neurocognitive function and a sustained clinical response. transcranial magnetic stimulation is also an alternative treatment for a major depressive episode. it is a non-invasive treatment that is easily tolerated and shows an antidepressant effect, especially in more typical depression and younger adults. prognosis if left untreated, a typical major depressive episode may last for several months. about 20% of these episodes can last two years or more. about half of depressive episodes end spontaneously. however, even after the major depressive episode is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability. fifty percent of people will have another major depressive episode after the first. however, the risk of relapse is decreased by taking antidepressant medications for more than 6 months. symptoms completely improve in six to eight weeks in sixty to seventy percent of patients. the combination of therapy and antidepressant medications has been shown to improve resolution of symptoms and outcomes of treatment. suicide is the 8th leading cause of death in the united states. the risk of suicide is increased during a major depressive episode. however, the risk is even more elevated during the first two phases of treatment. there are several factors associated with an increased risk of suicide, listed below: alcohol or drug use or comorbid psychiatric disorder detailed plan family history of suicide or mental illness greater than 45 years of age history of suicide attempt or self-injurious behaviors inability to accept help lack of social support male poor health psychotic features (auditory or visual hallucinations, disorganization of speech, behavior, or thought) recent severe loss severe depression epidemiology estimation of the number of people with major depressive episodes and major depressive disorder (mdd) vary significantly. overall, 13–20% of people will experience significant depressive symptoms at some point in their life. the overall prevalence of mdd is slightly lower ranging from 3.7 to 6.7% of people. in their lifetime, 20% to 25% of women, and 7% to 12% of men will have a major depressive episode. the peak period of development is between the ages of 25 and 44 years. onset of major depressive episodes or mdd often occurs to people in their mid-20s, and less often to those over 65. the prevalence of depressive symptoms in the elderly is around 1–2%. elderly persons in nursing homes may have increased rates, up to 15–25%. african-americans have higher rates of depressive symptoms compared to other races. prepubescent girls are affected at a slightly higher rate than prepubescent boys. in a national institute of mental health study, researchers found that more than 40% of people with post-traumatic stress disorder had depression four months after the traumatic event they experienced. women who have recently given birth may be at increased risk for having a major depressive episode. this is referred to as postpartum depression and is a different health condition than the baby blues, a low mood that resolves within 10 days after delivery.