What Is Double Depression?
Updated May 21, 2020
Reviewer Kelly L. Burns, MA, LPC, ATR-P
Double depression is when a person with a Persistent Depressive Disorder (PDD), sometimes known as dysthymia, also experiences an episode of Major Depressive Disorder (MDD). The name "double depression" comes from the layering of two separate kinds of depressive disorders.
It can be difficult to recognize double depression, and difficult to treat it. One of the best ways to understand double depression is to understand how the two parts of it relate - dysthymia vs. major depression disorder.
Persistent Depressive Disorder (dysthymia)
Persistent Depressive Disorder affects about 1.5% of adults in the United States or approximately 3.3 million people in the US alone. The official diagnosis of PDD is a combination of several older diagnoses. It usually, but not always, refers to the milder form of chronic depression usually associated with the term "dysthymia."
One of the most basic symptoms of PDD is simply a low mood, like a dark feeling or subtle sadness, for most of the day, on most days, over a period of several years. Over these years, the symptoms can fluctuate, but they don't go away completely for more than two months at a time.
More specifically, the symptoms for PDD include:
- Loss of interest in daily activities
- Sadness, emptiness, or feeling down
- Tiredness and lack of energy
- Low self-esteem, self-criticism, or feeling incapable
- Trouble concentrating and trouble making decisions
- Irritability or excessive anger
- Decreased activity, effectiveness, and productivity
- Avoidance of social activities
- Feelings of guilt and worries over the past
- Poor appetite or overeating
- Sleep problems
PDD often shows up early in life, in childhood or young adult years, but adults without a history of depression are also susceptible.
As is the case with most mental health disorders, PDD doesn't seem to have one cause. Instead, there are several potential causes. In any one person, PDD can be caused by one or a mix of biological, neurochemical, genetic/inherited, and situational factors.
It is possible that PDD either stems from or causes changes in brain shape and size. More information about this part of PDD could help with developing effective treatments.
Our brains run on chemicals. Neurotransmitters influence the messages that our brains send, and how our brains regulate our moods and emotions. A lack of some of these chemicals, an imbalance in their levels, or a change in their function seems to be a part of depression.
Genetic Or Inherited
If you have relatives with depressive disorders, you are more likely to have a depressive disorder, including PDD, yourself. There is some disagreement about whether things like PDD are inherited through genes or things like shared social environments. Although the reasons for heritability aren't clear, the facts are not in dispute: depressive disorders, including PDD, run in families.
In addition to the above, PDD can have a situational element. The stress of major life events can trigger PDD, even when the events themselves are positive. It seems obvious that grief or negative stress from the death of a loved one or the loss of a job could bring on depressive episodes. Surprisingly, PDD can be also be triggered by positive but stressful events - having a baby, getting a new job, or moving to a new house.
In addition to current events, early traumatic life events or negative family situations can leave people with a higher risk of PDD. Specifically, abusive or neglectful family situations seem to make it more likely that people will develop PDD later in life. Also, these early traumas seem to make it more likely that people will develop double depression, or be more impacted by their PDD.
Effects Of PDD
Part of the diagnosis of PDD is its effect on people's relationships, social lives, and work lives. This is usually referred to as "function" - the ability to lead a normal life. People with PDD may find it much more difficult to function normally. The effects of PDD on function depend heavily on how severe other symptoms are. Mild PDD does not generally cause a loss of function. Some people with PPD, however, may find it difficult to sustain family or social relationships. In some cases, the PDD can impact their ability to do their jobs.
People who have PDD are much more likely than most people to suffer a major depressive episode or double depression. This might, in part, be because people who have PDD are less likely to look for help right away when they experience major depressive symptoms.
Although PDD or dysthymia are often referred to as chronic depression, most people with PDD recover after some time. Unfortunately, there is a very high relapse rate. Around 70% of people who have had PDD are likely to have it again.
Treating PDD can be tricky, as it is often less responsive to antidepressants than other types of depression. It is, however, important to treat PDD. Although antidepressants are effective in fewer people with PDD, they can still be very helpful for some people. Talk therapy is also helpful for managing depressive symptoms. For many people, combining therapy and medication is the most effective treatment.
In addition to these treatments, good self-care is helpful in manage the symptoms of PDD. Controlling stress is important. Building and maintaining relationships, even though this is difficult, can help to counteract the isolating effects of PDD. Also, being sure to seek treatment at the first sign of depressive symptoms, considering maintenance treatments to prevent a relapse, is critical.
Major Depressive Disorder
Major Depressive Disorder (MDD) is what most people think of when they hear the word "depression." About 6.7% of adults (approximately 16.1 million people) in the United States alone are diagnosed with MDD in any given year. MDD differs from PDD in severity, timescale, and some important symptoms.
Unlike PDD, which is characterized by a low mood or pervasive sadness, the basic symptoms of MDD are an overwhelming sadness or a loss of interest in everyday life. Also, MDD includes symptoms such as:
- Appetite changes
- Sleep issues
- Hyperactivity or lethargy
- Guilt or feelings of worthlessness disconnected from reality
- "Recurrent thoughts of death" and suicidal ideation
- Cognitive difficulties (including difficulty with decision making)
In MDD, these symptoms have a strong impact on the ability of people to function normally in their work, relationships, and social lives.
Differences Between Groups
There are important differences in the ways that MDD presents in different groups. In general, men tend to display more irritability, fatigue, and anger. They are more likely to self-medicate with alcohol, illicit substances, or risky activity. As a group, women are more likely to have symptoms related to sadness. They may feel worthless or struggle with unreasonable guilt.
Children with MDD often worry about separation from their parents. They might not want to go to school. Sometimes they have dreams or fears about their parents dying. Teens with symptoms of MDD often have other mental health issues as well. They may struggle with substance abuse or eating disorders in addition to MDD.
Dysthymia Vs. Depression
When it comes to symptoms, one of the most basic differences between PDD (dysthymia) and MDD (depression) is time. The differences are big. To be diagnosed with PDD, a person has to suffer from their depressive symptoms for years (1-2 years, depending on age). PDD also generally last longer than MDD. MDD, on the other hand, can be diagnosed after only two weeks.
Another difference between PDD and MDD is the severity of the symptoms. Generally speaking, most people with PDD do not experience symptoms as severe as those of MDD.
Similar To PDD
Since MDD and PDD are two kinds of depressive disorders, their causes are similar. As with PDD, MDD does not have a single cause, but rather seems to be triggered by a variety of things including physical changes in the brain. There also seem to be inherited causes for MDD, as people with relatives with MDD are much more likely to develop it themselves.
Not all of the causes of PDD and MDD are the same. MDD is more likely to be caused by hormonal issues in the body. Thyroid issues and hormonal changes related to pregnancy, childbirth, and menopause can all be a factor in MDD. In these cases, treating the hormonal imbalances is often an effective treatment.
As with PDD, MDD is usually treated with medication, therapy, or both. There are at least five categories of medications that can be used to treat depression. People respond differently to different types of medication, and when medication doesn't work, another might. Doctors often try multiple medications within one category before moving to another category.
Therapy of various kinds can be helpful in treating depression. These include face-to-face therapies, but also online therapies.
As if PDD and MDD were not bad enough, double depression happens when a Major Depressive Episode (MDE) occurs at least two years after the onset of PDD. The symptoms of MDD layer on top of PDD, rather than replacing it.
How Is Double Depression Different?
We've gone over some of the symptoms, causes, effects, and treatments for both Persistent Depressive Disorder (PDD) and Major Depressive Disorder (MDD). Since double depression is a layering of these two types of depression, it shares many of the same characteristics. There, are, however, some things that are unique about double depression.
All of the symptoms listed above for PDD and MDD are possible symptoms of double depression. Double depression, however, seems to be particularly characterized by hopelessness. People who suffer from PDD already have a greater tendency to feel like they are not in control of their lives, and double depression seems to make that worse. Unlike most people who suffer from MDD, people with double depression often doubt that they will be able to get better.
Loss Of Function
PDD and MDD both bring with them some loss of function - a decrease in a person's ability to lead healthy work, social, and family lives. Double depression, however, has a greater impact on people's ability to live a normal life than do either PDD or MDD by themselves.
People with double depression - those who have been diagnosed with PDD, then suffer an episode of MDD on top of that - are much more likely to suffer a relapse than those without double depression. People who suffer from MDD are somewhat likely to experience more than one episode during their lifetime. However, those who have double depression are much more likely to experience more episodes of MDD than people who only have one diagnosis (PDD or MDD).
Anxiety disorders are somewhat common alongside any diagnosis of depression. People who have double depression, however, are more likely to have an anxiety disorder alongside their depression.
Treatment For Double Depression
Medication And Therapy
The same treatments that are used for PDD and MDD are used for double depression. Depending on the individual case, it may be more effective to focus on treatments for one or the other of the two depressive disorders present. Although a combination of medication and therapy is the most helpful treatment for both PDD and MDD, double depression is more likely than either disorder on its own to require both kinds of treatment.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is a type of therapy that teaches people to recognize false or unhelpful thought patterns and change them. The hopelessness that often accompanies double depression is a negative thought pattern that can be changed. People with double depression - like people with PDD - are more likely to think that they do not have any control over their lives, and cannot change things for the better. CBT can target that sense of hopelessness, and help people with double depression to replace those thought patterns with more positive ones.
Is This You?
Depressive disorders such as PDD, MDD, and double depression are relatively common. If you recognize yourself in the symptom lists, or if you have been diagnosed with one of these or another depressive disorder, here are some steps that you can take.
It can seem overwhelming even to figure out where to get help. Since one of the symptoms and effects of depression is difficulty with decision making, this can make it even more difficult to find treatment. But it doesn't have to be complicated. Two good places to start are your primary care physician and BetterHelp.com.
Your primary care physician can do several things for you. First, they can put you in touch with any other resources that you might need. You don't necessarily need to find all of your help. Second, they can perform tests that can help rule out physical causes of depression - such as hormone imbalances - that can be corrected with non-psychiatric meds or procedures. Third, they can prescribe some anti-depressants if they think that these will be useful for you.
Trained professionals, like those at BetterHelp, can help you figure out what's going on, and what you can do about it. After diagnosis, they might recommend that you get medication from your doctor. On their end, therapists can help you sort through negative thought patterns created by depression. They can help you manage and process negative emotions that you might have about your diagnosis. If depression is impacting your relationships or other parts of your life, a therapist can help you develop plans to strengthen those relationships and deal effectively with the challenging areas of life.
It may seem unfair that something like double depression, which can be so debilitating in everyday life, is so difficult to treat. It would be nice if there were a silver bullet that could cure you in an instant. Instead, treating depression - especially double depression - can be a slow process. You might need to try multiple medications or forms of therapy. This can be discouraging. Don't give up.
Establishing a relationship with a trained professional, like those at BetterHelp, can be an important part of hanging on. A therapist or counselor can be a supportive relationship to help you cope with the time that it takes for effective treatment.
When You Feel Like Giving Up
If you are considering suicide, don't wait. Reach out now. You can call 1-800-273-8255 to talk to someone at a local crisis center. This person can listen to you, and help you form a plan for what to do next. You can also visit https://suicidepreventionlifeline.org/ for more resources and information.
Things Are Never Hopeless
Although depression, and double depression, in particular, can lead to feelings of hopelessness or despair, things are never truly hopeless. Double depression is a very difficult thing to handle, but there is always hope. Use the information here to empower yourself to take the next step - reach out, seek help, hang on.