# Depressive disorders The curriculum's second named type of mental illness, and a leading cause of disability worldwide. **If you or someone you love is thinking about death or suicide:** call [1166](tel:1166) or [1660 012 1600](tel:16600121600) now, or [112](tel:112) / [100](tel:100) in an emergency. Asking about it directly is safe, and it helps. ## Major Depressive Disorder (MDD) At least two weeks of depressed mood or loss of pleasure, plus enough companion symptoms to reach five. **In plain words:** Two weeks or more of feeling low or empty, or losing interest in everything, with sleep, appetite, energy and hope all worse. DSM-5 Criteria 1. **5 or more of the 9** symptoms below, during the same **2-week** period, a change from before, and at least one is **(1) depressed mood** or **(2) anhedonia**. 2. Clinically significant distress or impairment. 3. Not attributable to a substance or medical condition. 4. Not better explained by a schizophrenia-spectrum disorder. 5. There has **never been a manic or hypomanic episode** (if there has, the diagnosis is bipolar disorder). 1 · coreDepressed mood most of the day, nearly every day (in children: irritability) 2 · coreMarkedly diminished interest or pleasure in almost all activities (anhedonia) 3Significant weight/appetite change (loss or gain) 4Insomnia or hypersomnia nearly every day 5Psychomotor agitation or retardation, observable by others 6Fatigue or loss of energy 7Feelings of worthlessness or excessive, inappropriate guilt 8Diminished ability to think or concentrate; indecisiveness 9Recurrent thoughts of death, suicidal ideation, plan, or attempt Key specifiers: with anxious distress · with melancholic features · with psychotic features · **with peripartum onset** (pregnancy or within 4 weeks of delivery: "postpartum depression") · with seasonal pattern. Severity: mild / moderate / severe. International WHO ranks depression among the leading causes of disability worldwide: over 330 million people affected. Women are affected about 1.5 times as often as men. The "with peripartum onset" specifier matters everywhere: postpartum depression affects more than 1 in 10 mothers globally and is routinely missed. Nepal The Nepali client says "man dukhcha", "man bhari bhayo", "jiu galyo": the heart-mind hurts, the body has wilted, not "I am depressed". Suicide is the sharpest edge: studies since the 2008/09 maternal mortality review have repeatedly flagged suicide as a leading cause of death among Nepali women of reproductive age. The National Mental Health Survey 2020 found major depressive disorder in 2.9% of adults at some point (95% CI 2.3 to 3.7) and in 1.0% currently; most are never counted. See [Nepal in numbers](https://manoatlas.com/data.md) for the full figures. Every depression assessment includes a direct, calm suicide question: asking does not plant the idea. Watch new mothers especially: family attention goes to the baby, and the mother's withdrawal is read as tiredness. ## Persistent Depressive Disorder · and the bipolar boundary **Persistent depressive disorder (dysthymia):** depressed mood most of the day, more days than not, for **2 years or more** (1 year in children or adolescents, where mood can be irritable), with 2+ of the following. Symptoms include: poor appetite or overeating, insomnia or hypersomnia, low energy, low self-esteem, poor concentration or indecisiveness, and hopelessness. Never symptom-free for more than 2 months. The client who says "I have been like this my whole life." A **manic episode** (at least one week, or any duration if hospitalised) makes it **Bipolar I**; a milder **hypomanic** episode (at least four days, no marked impairment) plus major depression makes it **Bipolar II**. Antidepressants alone can flip an unrecognised bipolar client into mania: this question is a safety question, and a referral trigger. The depression spiral. Each link feels reasonable from inside ("I will go out when I feel better"), yet each turn tightens the next. Behavioural activation attacks the easiest link to move: the activity, not the mood; the steps a counselor uses are on [Techniques step by step](https://manoatlas.com/techniques.md). A skill to try · two minutes **One tiny scheduled action.** Pick something five minutes small: wash one cup, step onto the balcony, message one person. Give it a time ("after tea") and do it whether or not the mood agrees; the spiral diagram above shows why action comes first. Tonight, name one thing that went okay. A coping skill, not a treatment: it supports care, it does not replace it. **A worked example:** A 32-year-old named Sita, a mother of two, has lost interest in playing with her children and feels most drained in the afternoons. Her counselor confirms that low mood, poor sleep, and loss of pleasure have lasted over three weeks, meets the five-symptom threshold, and rules out bipolar disorder before beginning treatment. Key points 1. Depression is at least two weeks of low mood or lost pleasure plus enough other symptoms to reach five, with daily life affected. 2. Always ask about thoughts of death; asking never plants the idea, and it opens the door to help. 3. Behavioural activation (small planned activity) and talking treatments work; in Nepal it often shows as aches, tiredness and 'man dukhcha'. Learn more Pick one, not all: these are chosen to be light, not exhaustive. Video · 4 min[What is depression? (TED-Ed, Helen Farrell)](https://www.youtube.com/watch?v=z-IR48Mb3W0): The clearest four minutes on MDD anywhere. Article[WHO fact sheet: Depression](https://www.who.int/news-room/fact-sheets/detail/depression); Global burden and treatment gap in two pages. Book chapter**Feeling Good (David Burns): ch. 1–3**: CBT for depression, written for the client; easy read. Documentary[Stephen Fry: The Secret Life of the Manic Depressive](https://www.imdb.com/title/tt0808482/); The bipolar boundary, lived; pairs with the callout above. --- *Source: https://manoatlas.com/depression · Licence: CC BY-NC-SA 4.0. Mano Atlas is an educational resource, not a diagnostic tool.*