Depression

Sadness is a normal response to loss, disappointment, or stress; it tracks the situation and lifts when the situation changes. A depressive disorder is a sustained change in mood, energy, sleep, appetite, concentration, and capacity for pleasure that lasts most of the day for two weeks or longer, that is out of proportion to what is happening, and that interferes with daily function. Persistent thoughts of death, worthlessness, or suicide are clinical warning signs that warrant care regardless of the surrounding circumstances.

Grief is the natural response to loss. It comes in waves, is usually tied to memories or reminders of the person or situation lost, and tends to evolve over months. Depression is more continuous, less situation-linked, and more often involves global feelings of worthlessness or hopelessness. Grief can complicate into depression (called complicated grief or persistent complex bereavement), and depression can follow loss. The presence of grief does not rule out a treatable depressive episode; clinicians evaluate both.

For moderate to severe major depressive disorder, the strongest first-line treatments are an SSRI or SNRI medication, evidence-based psychotherapy (cognitive behavioral therapy or interpersonal therapy), or the combination of medication and therapy. Choice depends on severity, history, preference, and what has worked before. Lifestyle interventions (exercise, sleep regulation, light exposure, social connection) add measurable benefit alongside, not instead of, the first-line treatments.

SSRIs and SNRIs typically begin to produce noticeable benefit by two to four weeks and reach full effect by six to eight weeks. Side effects often peak in the first one to two weeks and ease as the body adjusts. Initial improvements often show up first in sleep, appetite, and energy before mood lifts. If there is no meaningful change by six to eight weeks at an adequate dose, that is a signal to revisit the diagnosis, adjust the dose, switch medications, or add a second treatment.

About one in three people with major depression do not respond adequately to the first medication. There are well-established next steps: switching to a different SSRI/SNRI, switching class (mirtazapine, bupropion, vortioxetine, trazodone), adding a second agent (an atypical antipsychotic, lithium, or a thyroid hormone), or moving to a procedure-based treatment. Transcranial magnetic stimulation (TMS) is FDA-approved for treatment-resistant depression and is widely available in the Seattle area. Esketamine and ECT are additional evidence-based options for more severe cases. Which step comes next is individualized: it depends on the diagnosis, prior medication trials, symptom severity, and personal preference, among other factors, and is worked out together rather than following a fixed ladder.