What are the forms of Major Depressive Disorder?

Major Depressive Disorder is a crippling condition.

In the severest form, as well as a greater intensity of the symptoms mentioned in the classification system called the DSM  (see Is The Rate of Depression Actually Increasing or Not?), there can also be what are called psychotic symptoms in the form of delusions and hallucinations.

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A delusion is a firmly held fixed belief that is out of keeping with the person’s social and cultural background. It is held with strong conviction despite evidence to the contrary. Types of delusions that are present can relate to feelings of worthlessness, guilt or persecution. So called delusions of reference are that insignificant remarks, events, or objects in one’s environment have personal meaning or significance.

A hallucination is a perception in the absence of an external stimulus that at the same time has the quality of a real perception. Hallucinations can manifest in many forms. Examples include voices when no one is present or seeing things that are not actually there.

It is important to mention that psychotic symptoms are not always a feature of mental illness and can be present at the time of waking up or going to sleep, as well as when very tired.

It can be helpful to distinguish between 4 forms of MDD:

1. The symptoms are always present and never go away.

Under the stresses of life the constant low-level depression becomes worse. This may be for a few weeks or a few months. You can compare it to a being like a constant dull headache that suddenly becomes sharp now and again. A sudden setback or disappointment; a difficult meeting or confrontation with someone. Such things happen to all of us, but most of us don’t develop clinical depression as a result. The old name for this was “neurotic depression”.

Usually there are symptoms of anxiety that go along with the general pessimistic and fearful attitude to life. On reflection I think this is the form I am most prone to (see video Just As I Am).

When my children were younger, I was reminded of this when we had a fun exercise of giving each other nicknames. It was a salutatory wake up call when my children decided that my nick name should be ‘Puddleglum’! In case you don’t know Puddleglum is a  fictional character from C.S. Lewis’ children’s novel, “The Silver Chair”.  He is caricature of pessimissim and a bastion of gloomy fortitude.  In the past the word ‘neurotic’ was used to describe such people and more recent terms include ‘dysthymia’ and ‘generalised anxiety disorder’.

2. The symptoms of depression come and go with periods when they are completely or nearly completely healthy.

When they are unwell they can be deeply sick, seriously low in mood, non-functional and even suicidal. So called episodes of depression can happen alone (s0 called unipolar depression) or with periods of high mood called mania (so called bipolar depressive disorder).

3. With some people they are generally healthy with no symptoms of depression. They have a severe depressive episode and then then they never have another one.

It is estimated that this accounts for about 1/3 of people who develop MDD.

4. A medical condition causes the MDD.

Such people are generally very healthy. But then they develop a physical illness such as hypothyroidism,  a stoke, or a heart attack or cancer. If the medical illness is cured then the depression goes away never to return.

For an example of the devastating personal impact of MDD see Rick Warren and the Anguish of Major Depressive Disorder.

These 4 forms of MDD also reveal a spectrum of symptoms that range from neurotic low-level symptoms of anxiety and depression that can persist over many years to  a single episode (with or without a medical cause) to recurrent depressive episodes.

It is MDD that is the illness part of what gets called depression. However, it is important to reflect that most of what gets called depression is not actually in the strict sense actual illness (see Why has there been a 400% increase in the prescribing of antidepressants?)

What questions do you have about MDD as an illness?


“Life is either a daring adventure or nothing. Security does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than exposure.”
~ Helen Keller
US blind & deaf educator (1880 – 1968)

Rick Warren and the secret anguish of Major Depressive Disorder

Rick Warren is the founding pastor of one of the largest churches in the United States with an attendance of approximately 20,000 every week. He is also the author of The Purpose Driven Life book which has sold over 30 million copies. In 2005 Time magazine named him as one of the 100 most influential people in the world. In 2006 Newsweek called him “One of the 15 People who make America Great.” For someone with such outer success he has attracted both great appreciation and great antagonism.

However, Rick and his wife Kay have for many years carried a heavy burden. They have been through an experience no parent should every go through. On 5 April 2013 their younger son Matthew committed suicide after a long battle with Major Depressive Disorder.

The short 4 minute video below illustrates something of the deep pain and anguish they have had to carry for several years as well as the extreme emotion of coming to terms with Matthew’s death.

This is the letter that Rick and Kay Warren wrote to their congregation at Saddleback Church immediately after Matthew’s death:

Our Dearest Saddleback Family,

Over the past 33 years we’ve been together through every kind of crisis. Kay and I’ve been privileged to hold your hands as you faced a crisis or loss, stand with you at gravesides, and prayed for you when ill.  Today, we need your prayer for us.

            No words can express the anguished grief we feel right now. Our youngest son, Matthew, age 27, and a lifelong member of Saddleback, died today.

            You who watched Matthew grow up knew he was an incredibly kind, gentle, and compassionate man. He had a brilliant intellect and a gift for sensing who was most in pain or most uncomfortable  in a room. He’d then make a bee-line to that person to engage and encourage them. 

            But only those closest knew that he struggled from birth with mental illness, dark holes of depression, and even suicidal thoughts. In spite of America’s best doctors, meds, counselors, and prayers for healing, the torture of mental illness never subsided. Today, after a fun evening together with Kay and me, in a momentary wave of despair at his home, he took his life.

            Kay and I often marveled at his courage to keep moving in spite of relentless pain. I’ll never forget how, many years ago, after another approach had failed to give relief, Matthew said “ Dad, I know I’m going to heaven. Why can’t I just die and end this pain?” but he kept going for another decade.

            Thank you for your love and prayers.  We love you back.

Also a few days later they were able to ask their church to mobilize themselves in the fight against mental illness. This is the open letter they wrote to their church congregation. I include it here as it provides such a positive response to a heart-rending tragedy.

Dear Friends,

Kay and I have been overwhelmed by your outpouring of love since Matthew’s tragic death. You are true friends, especially with the vitriol from haters we’ve received. Friends show up when others walk away.

If you missed what happened, click here to read my letter.

You’ve asked, “Is there anything we can do to help you?”

The answer is yes! We could use your help right now in THREE PRACTICAL WAYS:

1. Sign a petition that urges educators, lawmakers, healthcare, and congregations to raise the awareness and lower the stigma of mental illness, and also to support families that are dealing with mental illness on a daily basis. Thanks for adding your voice!

2. Offer your help and prayers to those around you who are caring for mentally ill family and friends. They need your encouragement more than you realize.

3. Fight mental illness with an online gift to The Matthew Warren Fund for Mental Health. Your gift is tax-deductible.

We are reading every note. We’d love to hear from you here on Facebook, or you can email us at PastorRick@saddleback.com. Your prayers and words continue to strengthen us.

Pastor Rick

My purpose in this blog post is to show the human cost of such a tragedy, and also the importance of highlighting the nature of serious mental illness.

We have also previously highlighted the role of what was likely to have been MDD in the lives of Lincoln and Churchill. The author Matthew Johnstone eloquently expresses his inner battle with the video I Had A Black Dog.

Deep suffering reveals what is inside of us. I have also written about Why Does a Loving God allow Pain and Suffering?

I close with some final reflections by Rick Warren in an interview with Justin Brierley about a year after Matthew’s death:

“When Matthew died I received 5,000 letters of condolence from around the world. Everyone wrote from rock stars and prime ministers to presidents. But the ones that meant the most to me weren’t from the VIPs; they were letters from people that Matthew had led to faith in Christ. They said, ‘I’m going to be in heaven because your son brought me to Jesus.’ I wrote in my journal:
‘In God’s garden of grace, even broken trees bear fruit.’ And we are all broken. … God only uses broken people.”

Please feel free to add your thoughts, comments and reflections below.



Hurry is the great enemy of spiritual life in our day. You must ruthlessly eliminate hurry from your life.

(Dallas Willard)

Why has there been a 400% increase in the prescribing of antidepressants?

We have been looking at making sense of how the word ‘Depression’ is used. This is particularly important as rates of depression appear to be rising dramatically around the world (see previous post).

depression - boy

We have looked at how psychiatrists diagnose depression using the DSM and ICD classification systems. One of the unintended consequences of this has been that there has been the confusion of distinguishing general sadness from actual depressive illness.

Depression is used as a synonym for sadness. However, there is also a clinical condition of Major Depressive Disorder (MDD) that can be a lethal debilitating illness.

Those with depression as illness (MDD that is sometimes called melancholia) have a severe lowering of their mood along with prominent physical effects on the body and can at times become psychotic. This is the group that is most at risk of suicide and responds best to medication.

However, studies that look at just the rate of MDD indicate that the prevalence is actually remarkably stable.

Is the rate of depression actually increasing or not?

The word ‘depression’ is such a confusing term. It is used frequently in day-to-day conversation and it is also used in what is intended to be a more precise clinical way by doctors and psychiatrists.

depression - boy

According to the psychologist Martin Seligman, people born since 1945 are 10 times more likely to suffer from depression than those born before.

Depression has been described as the number 1 psychological disorder in the western world. It is said to be growing in all age groups, in virtually every community, and the growth is seen most in the young, especially teens. At this rate of increase, it will be the 2nd most disabling condition in the world by 2020, behind heart disease.

But because the word depression is used so  freely and interchangeably in many different ways we need to be careful to explain what we actually mean by the D word.

I had a black dog

The following 4 minute video was produced by the World Health Organisation in collaboration with the writer and illustrator Matthew Johnstone. It simply and powerfully depicts the struggles of depression along with the importance of getting outside help:

It was Churchill who first referred to his depression as his ‘black dog’. It is a useful metaphor as it helps the individual to separate themselves from the negative feelings they are going through.

The author C.S. Lewis’ description from his children’s book The Lion, The Witch and the Wardrobe describes Narnia under the white witch when it is ‘always winter, but never Christmas.’ That explains a dark bleak time with no apparent end in sight. It also captures something of the emotion and sentiment of the darkness of depressive thinking.

Other descriptions of depression I have heard include
- like being pushed into a pit you can’t climb out of.
- like being lost in a fog
- like drowning in quicksand

Some important points to consider:

What can J. K. Rowling teach us about imagination?

Her books have captured the imagination of millions of children and adults around the world. She is widely regarded as one of the greatest living story tellers in the world.

The 21 minute video below that was given by J K Rowling to the graduations class of Harvard University in 2008 is based around 2 themes - the benefits of failure and the importance of imagination. (For a discussion of the benefits of failure see here).

On her website, Rowling described the how the idea of Harry Potter came to her in 1990:

I was travelling back to London on my own on a crowded train, and the idea for Harry Potter simply fell into my head. I had been writing almost continuously since the age of six but I had never been so excited about an idea before. To my immense frustration, I didn’t have a pen that worked, and I was too shy to ask anybody if I could borrow one… I did not have a functioning pen with me, but I do think that this was probably a good thing. I simply sat and thought, for four (delayed train) hours, while all the details bubbled up in my brain, and this scrawny, black-haired, bespectacled boy who didn’t know he was a wizard became more and more real to me. Perhaps, if I had slowed down the ideas to capture them on paper, I might have stifled some of them (although sometimes I do wonder, idly, how much of what I imagined on that journey I had forgotten by the time I actually got my hands on a pen). I began to write ‘Philosopher’s Stone’ that very evening, although those first few pages bear no resemblance to anything in the finished book.

What can J. K. Rowling teach us about failure?

By anybody’s standards she is a remarkable woman. Her Harry Potter series is the best selling book compilation  in history. It has sold more than 450 million copies and has been translated into  70 languages. In October 2010 the Guardian newspaper declared her the most influential woman in Britain. She is now one of the world’s richest women.

This short 21 minute speech that J. K. Rowling gave to the graduating class of Harvard University in 2008 gives a fascinating glimpse into her life and the experiences that have moulded her.

Her speech covers two main areas. In this post we will cover the first – the benefits of failure. So what can such an apparently successful woman teach you and me about failure?

The Impossible Football Club

With all the excitement about the World Cup, I love this true story about the Ko Panyee Football Club in Thailand. It is only 5 minutes long. Whatever challenges you may be facing I hope it will encourage you in your day:

Here is a short synopsis of the video and some reflections:

It starts in 1986 with the children who live on a floating village in the middle of the sea. They love watching football on TV and want to start a football team. The only problem is that there is no where to play or even practice.