How To Manage Moderately Severe Depression

Depression is a mental health condition that causes sadness, low mood, and impairments in people’s functioning and enjoyment of day-to-day life. One in six people in the United States will experience depression at some point, making it a relatively common condition.¹

Depression can vary in severity, with symptoms ranging from mild to moderate to severe.

In all cases, it’s vital to seek help for depression, whether this involves making lifestyle changes or taking part in formal treatment. For people with moderate depression, the recommended treatment is usually to involve a bit of both.

What is moderate depression?

Moderate depression is a classification of major depressive disorder (MDD). It’s determined by the severity and frequency of depression symptoms that a person experiences.

In 2019, about 4% of all adults in the United States experienced moderately severe depression symptoms.²

What are the different types/classifications of depression?

The three classifications of depression are mild, moderate, and severe.

People can also suffer from different types of depression, including:

• Major depressive disorder, which is what we discuss in this article. MDD is when a person has persistently low or depressed mood, loss of interest in pleasurable experiences or activities, as well as a range of other physical and psychological symptoms.

• Persistent depressive disorder (dysthymia), which is a less severe but longer-lasting form of depression.

• Disruptive mood dysregulation disorder, which occurs in children. It causes irritability, anger, and temper outbursts. Often, children with disruptive mood dysregulation disorder develop MDD during adolescence.

• Premenstrual dysphoric disorder, which is a condition that causes extreme mood shifts and physical symptoms before a woman’s monthly menstrual cycle.

• Substance/medication-induced depressive disorder, which can arise from substance or medication abuse.

• Depressive disorder due to another medical condition, which can arise from a wide variety of physical medical conditions.

• Unspecified depressive disorder, which is when the depression does not fit into any of the above categories.

Mild, moderate, or severe depression? How to tell the difference

Everyone with depression experiences the symptoms differently.

Whether depression is mild, moderate, or severe, it will interfere with daily life to some extent. How significant and debilitating this depends on the severity of the depression.

What does mild depression feel like?

The symptoms of mild depression can be distressing but are usually manageable.

The impact on day-to-day life that mild depression causes is less intense than in moderate depression. This means that in some cases, mild depression is challenging to recognize and diagnose.

Often, mild depression doesn’t require treatment with antidepressant medication. Many people with mild depression find that lifestyle changes and psychotherapy are enough to help them feel better.

What does moderate depression feel like?

In general, the symptoms of moderate depression are the same as the symptoms experienced in mild depression.

The key difference is that the symptoms of moderate depression tend to be more intense and may be experienced more frequently. This causes greater dysfunction in daily life, including at home and at work.

What does severe (major) depression feel like?

Severe depression causes seriously distressing symptoms that can be very hard to manage.

The symptoms cause significantly greater impairments in day-to-day functioning. In some people, severe depression leads to suicidal thoughts, hallucinations, or delusions.

Distinguishing between moderate and severe depression

The key differences between moderate and severe depression that help to distinguish them are that:

• Severe depression often causes greater difficulty with daily functioning and basic activities.

• Moderate depression is less likely to involve suicidal thoughts and anhedonia (an inability to feel any pleasure) compared to severe depression.

• People with moderate depression are more likely to experience somatic (physical) symptoms than cognitive symptoms.³ For example, these may include sleep difficulties or appetite and weight changes. On the other hand, people with severe depression are more likely to experience cognitive symptoms.

It should be noted that these aren’t clear-cut rules. There’s no clear line between moderate and severe depression, and some people are in between the categories.

Causes of moderate depression

Depression is believed to be caused by an imbalance of chemical messengers in the brain (known as neurotransmitters), including serotonin, norepinephrine, and dopamine. These chemical messengers are responsible for regulating mood in the brain and must be present at optimal levels in order to carry out this important function.

Genetic, biological, environmental, and psychological factors can contribute to depression. One sole cause of depression in a person often can’t be pinned down. In some people, the causes of depression may relate to challenges experienced in childhood.

What are the main risks and predisposing factors?

Although anyone can develop depression, certain risk factors make some people more likely to develop it.

These include:

• A history of mental health issues: Having had depression in the past, or other mental health conditions such as anxiety, psychotic symptoms, substance abuse, or borderline personality disorder (BPD), can make someone more likely to develop depression. People with a history of mental health struggles are more likely to experience depression symptoms for longer, and their symptoms tend to be more severe.

• A family history of depression: People who have close relatives with depression are more likely to develop depression themselves. While genetics likely plays a significant role in this, it’s uncertain exactly how depression is inherited. Environmental factors, including social patterns such as how relationships are managed, are also likely to play a role.

• Physical illnesses: Some medical conditions are risk factors for depression. Common examples of this include diabetes, cancer, heart disease, and Parkinson’s disease, although there are many other examples. People with these physical illnesses are also more likely to experience more severe depression symptoms, particularly if they’re older adults.

• Some medications: Certain medications are associated with an increased risk of developing depression. These include certain anti-seizure drugs, medications that alter hormone levels, corticosteroids (which are used to address excessive inflammation), and others.

• Sex: Women are two times more likely to develop MDD than men.⁴ Researchers still aren’t sure exactly why this is, but it might be due to hormonal differences, the effects of childbirth, and/or psychological stresses that are specific to women.

• Lack of personal relationships: Being divorced, widowed, or separated from a partner has been found to increase the risk of developing depression.⁴ The risk is also higher for people who lack close interpersonal relationships.

• Trauma and stress: A personal history of trauma, stress, or other significant life changes makes someone more likely to develop depression. 

• Rural living: People living in rural areas may be more likely to develop depression than people living in urban areas.⁵

All said it’s difficult to predict whether someone is more likely to develop mild, moderate, or severe depression.

Symptoms of moderate depression

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the main source that’s used by mental health professionals to diagnose mental illnesses. According to the DSM-5, the core symptoms of depression that may be experienced in moderate depression are:

• A depressed mood most of the day, nearly every day

• Significantly diminished interest or pleasure in activities that one used to enjoy, occurring most of the day, nearly every day

The DSM-5 also lists additional depression symptoms, which include:

• Significant weight loss or weight gain

• Difficulty or excessive sleeping

• Agitation or restlessness

• Fatigue or lack of energy nearly every day

• Feeling worthless or guilty

• Inability to concentrate or being indecisive

• Thinking about death or suicide

Someone with moderate depression might not experience all of these symptoms. 

How is moderate depression diagnosed?

Depression can be diagnosed by a doctor using the DSM-5. In general, to diagnose depression, a person must have the following:

• Experienced at least one of the two core symptoms

• Experienced a total of at least five symptoms of depression

• Experienced these symptoms for at least two weeks 

Although the DSM-5 can help a doctor diagnose depression, it doesn’t give much insight into how to classify depression as mild, moderate, or severe. This means the doctor or other mental health professional must use different tools to help them come to a conclusion.

Differential diagnosis

The differential diagnosis for depression, of any severity, involves ruling out other medical and mental health conditions that may be causing the depressive symptoms.

These conditions may include the following:

• Neurological causes, such as epilepsy, Parkinson’s disease, Alzheimer’s disease, and multiple sclerosis

• Hormone-related conditions, such as diabetes and thyroid disorders

• Substance abuse problems or withdrawal, including withdrawal from steroids, antibiotics, sedatives, stimulants, and alcohol

• Malignancies (e.g., cancer)

• Nutrient deficiencies, such as vitamin D, B6, B9 (folate), B12, and iron

• Chronic infectious diseases such as HIV

• Manic episodes, or a history of manic episodes, which could suggest a person has bipolar disorder instead of depression

• Other mental health conditions, such as adjustment disorders, anxiety disorders, and eating disorders

• Bereavement

To rule out these other conditions, a doctor may carry out a physical and mental status exam, do blood tests, and ask questions about the symptoms the person is experiencing to see whether they correlate to the DSM-5.

Having an understanding of one’s personal medical history, family history, social history, and use of substances is essential for an individual to be able to answer these questions.

A doctor can then differentiate between mild, moderate, and severe depression based on the patient’s symptoms and the criteria listed below.

How do you assess the severity of depression?

The severity of depression is based on assessing how many symptoms an individual has, how long they’ve experienced them, and how much the symptoms interfere with daily life.

Once any other causes of depression have been ruled out and the diagnosis of major depression has been confirmed, the next step is to assess the severity. The DSM-5 doesn’t offer a simple way to do this. A mental health professional can evaluate the severity of depression using one or more of the following methods.

The Patient Health Questionnaire-9

The Patient Health Questionnaire-9 (PHQ-9) is a standardized depression screening tool that can help monitor and determine how severe a person’s depression is based on their degree of psychosocial impairment, meaning how much the symptoms interfere with their life.⁶

The PHQ-9 is typically used in primary care settings, such as by the patient’s family doctor.

The patient is asked how often they’ve been bothered by the following indications in the past two weeks. The patient replies with either “not at all,” “several days,” “more than half the days,” or “nearly every day.” Based on this answer, a score from 0 to 3 is given for each item. The scores are then added up to give the total score.

The indications correlate to the diagnostic symptoms in the DSM-5, and they include the following:

• Little interest or pleasure in doing things

• Feeling down, depressed, or hopeless

• Trouble falling or staying asleep or sleeping too much

• Feeling tired or having little energy

• Poor appetite or overeating

• Feeling bad about yourself, or that you are a failure or have let yourself or your family down

• Having trouble concentrating on things, such as reading the newspaper or watching television

• Moving or speaking so slowly that other people have noticed, or being so fidgety or restless that others have noticed

• Thoughts that you would be better off dead, or thoughts of hurting yourself in some way 

The higher the total score on the PHQ-9, the more severe the patient’s depression is.

Depression rating scales/questionnaires

In addition to the PHQ-9, some other depression rating scales include:

• Beck Depression Inventory (BDI). This questionnaire asks 21 questions about the extent to which the patient feels sad, discouraged about the future, feels like a failure, feels dissatisfied with life, cries more than usual, and more.

• Hamilton Depression Rating Scale (HAM-D). The HAM-D asks 21 questions relating to the extent to which the person has a depressed mood, feelings of guilt, thoughts of suicide, insomnia, their situation with work and interests, slowness of thought, agitation, mental and physical anxiety symptoms, and weight loss. The HAM-D is often used in hospital settings. 

• Quick Inventory of Depressive Symptomatology (QIDS-CR16). This 16-question questionnaire assesses various factors related to sleep, sadness, appetite, weight gain or loss, concentration, self-esteem, thoughts of death or suicide, interest in activities, energy levels, and restlessness. 

While many of these questionnaires are available for free online and can be self-administered, it’s always best to consult a doctor or other mental health professional to discuss your symptoms and be properly diagnosed rather than attempting to diagnose yourself.

What is the score for moderately severe depression?

The answers that a patient chooses in the depression rating questionnaires are added up and checked against the cut-off points provided by the questionnaire. Depression can then be classified as mild, moderate, or severe.

The score range that indicates moderate depression depends on what questionnaire or scale was used. For example:

• PHQ-9: a score of 10–14

• BDI: a score of 20–28

• HAM-D: a score of 18–24

• QIDS-CR16: a score of 11–15

How to manage moderately severe depression

Depression is a serious mental health condition. No matter how severe it’s classified as, depression should be treated appropriately and as soon as possible. 

Moderate depression, in particular, may increase the risk of heart disease, showing how necessary treatment is. Leaving depression untreated also contributes to a lower quality of life and increases the risk of suicide. It leads to worse physical outcomes and may even worsen pre-existing medical conditions.

Fortunately, the earlier that treatment and management of symptoms begin, the better the outcome is. 

What are the different types of interventions?

No single best treatment for depression exists. The most effective plan for treating depression varies from person to person.

The main types of interventions for depression are lifestyle modification, medications, psychotherapy, and inpatient care.

The first step towards managing and treating depression is to see a healthcare professional who can diagnose and classify depression and suggest treatments. Healthcare professionals that may be involved in depression care include family doctors, psychologists, counselors, and psychiatrists, among others. 

Moderate depression can often be managed as an outpatient. 

However, sometimes the patient may not respond well to treatment and may lack adequate social support, which is needed to recover safely at home. In that case, a doctor can refer their patient to psychiatric services where they can receive inpatient residential care. Most commonly, this option is used for people who have severe depression, not moderate depression.

If you, or someone you know, has thoughts of suicide or self-harm, you should contact your local crisis hotline or seek emergency care immediately.

Lifestyle changes and self-care

Lifestyle changes and self-care may not cure moderately severe depression on their own. However, they can help a person manage their symptoms while they undergo other types of treatments. 

Some lifestyle changes that may help to manage moderate depression symptoms include:

Staying physically active

Staying active and finding healthy ways to exercise is a recommended way to help with the management of moderate depression. 

Around 30 minutes a day is believed to help with symptoms. This doesn’t have to be intense workouts — any form of aerobic exercise can improve mood by increasing endorphins.  Walking, hiking, swimming, jogging, or riding a bike are good options. In some cases, physicians even write prescriptions for exercise because it’s so beneficial for depression and many other health conditions.

Good sleep hygiene

Getting enough high-quality sleep is crucial for maintaining mental health. Unfortunately, many people with depression experience sleep problems as a symptom of their condition, making it difficult to get the sleep that they need. However, ways to improve sleep hygiene and, in turn, improve sleep are available. 

Some useful sleep hygiene tips include sleeping in a dark and quiet bedroom that is at a comfortable temperature; turning off and putting away electronic devices; and avoiding large meals, caffeine, and alcohol within a few hours before going to bed. 

Eating a healthy diet

Eating regular and healthy meals is recommended for people with depression. The brain needs enough energy and nutrients in order to function well.

Some key nutrients that might help to improve mood are:

• Folate: Folate (vitamin B9) is found in dark leafy greens, fresh fruits, seafood, and some fortified bread and cereals. Folate might help people experience the full benefit of their antidepressant medication.

• Omega-3 fatty acids: Omega-3s are found in oily fish (such as salmon, sardines, anchovies, and mackerel), fish oils, walnuts, and flaxseeds. Omega-3s are thought to help with the transmission of chemical messengers in the brain and help to produce chemicals that regulate cognition and emotion.

• Some amino acids: Tryptophan and tyrosine are two amino acids that are found in milk, cheese, meat, chicken, fish, eggs, beans, nuts, and grains. These two amino acids are important in producing serotonin and dopamine, both of which are important chemical messengers that impact mood regulation in the brain.

Some studies have also found that a higher intake of vitamins K and E, and the minerals zinc and magnesium, might help reduce depression symptoms.⁷

Staying connected with loved ones

Depression can cause a person to isolate themselves from loved ones. However, staying connected with trusted friends and family and opening up and talking about feelings is essential in managing and treating the condition. 

Engaging in community support is another helpful way to stay connected with people. Support groups can help people with depression share their experiences and effective coping methods with each other.  

Limit alcohol and substance use

Some people with depression believe that alcohol and drugs improve their symptoms in the short term. However, long term, they can worsen the condition and make it more difficult to treat.

Because of this, it’s strongly recommended to stop smoking, drinking alcohol, and using substances. If it feels overwhelming to consider quitting, talk with your doctor or a mental health professional about resources that can assist you. Many treatments can help people to quit, and you don’t have to try and do it alone.

Manage daily stressors

Major stress is a risk factor for depression. So, finding healthy ways to manage these stressors can help simplify life and make it easier to manage depressive symptoms. 

This could involve:

• Prioritizing things that are most important and putting off less important things

• Avoiding making important decisions when feeling depressed or stressed 

Use relaxation techniques

Some people with mild to moderate depression find that relaxation techniques help them manage or improve their symptoms. The following techniques could be of use: 

• Yoga, which uses physical movements to help a person feel grounded in the present moment

• Tai chi, which is a similar practice to yoga and can also help to improve mood

• Meditation, where the person uses mindfulness to bring their attention and awareness to the present moment

• Guided imagery, where the person learns to use their senses to imagine a positive image or message

• Progressive muscle relaxation, which helps to reduce stress by slowly tensing and then relaxing muscles throughout the body

Taking up hobbies

People with depression often find it hard to participate in hobbies they once enjoyed. This is known as anhedonia, or the loss of the ability to feel pleasure and enjoy things.

However, it’s highly recommended to try to re-discover the joy in these activities. Having things to do that you enjoy and look forward to is crucial for mental health. Creative activities like music or art can even be therapeutic for people with depression. 

It may be a good idea to start with something small every day and, as it gets easier, increase the time spent on the activity. Try activities that you used to enjoy or anything that sounds even a little bit fun or interesting to you.

Treatment options for moderate depression

In addition to the lifestyle management strategies described above, moderate depression should involve treatment by a doctor or a mental health professional. While lifestyle changes are often very helpful, they’re often not enough by themselves to address the patient’s depression.

The treatment recommended depends on an individual’s personal circumstances. 

Medications

Antidepressants can be used as an initial treatment for moderate depression. 

Antidepressants help balance the brain's chemical messengers that affect mood and emotion. Depending on the specific antidepressant used, these medications usually work within four to eight weeks. They’re generally taken for four to nine months in total, which is usually enough time to prevent depression from relapsing or recurring. 

Antidepressants are only available by prescription. You will need to talk to a doctor in order to discuss the possibility of trying antidepressants. If your doctor believes that they might help you, then they’ll write the prescription and will continue to follow up with you to ensure that the medication works well and to manage any side effects.

It can take some time to find the correct medication. The medication a doctor chooses for a particular individual depends on his/her previous responses to treatment, any side effects they have experienced, whether they have any pre-existing health conditions, the cost and availability of the medication, and the patient’s personal choice. 

Side effects also need to be considered — but for most people with moderate depression, the medication is safe and the side effects go away after a few days. 

However, some groups of people may not be able to take antidepressants, so they will be advised to try other medications or treatment strategies. For example, for pregnant women, it’s generally recommended that they try psychotherapy first before trying antidepressant medications. Some antidepressant medications are dangerous to take during pregnancy.

Always follow the instructions carefully and take the medication as prescribed, even if all of your symptoms are gone. Suddenly stopping these medications can cause the depressive symptoms to come back. Some people also experience side effects from stopping antidepressants. It’s a good idea to speak with a doctor if you want to stop taking your medication so that a safe plan can be discussed. 

The specific FDA-approved antidepressants that have been proven to treat moderate depression include: 

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are often the first choice of medication for treating moderate depression. This is because they’re considered to be a safer class of medication and typically have fewer side effects than comparable options. They’ve also been shown to be effective for people with moderate to severe depression, although it’s not clear that they’re helpful for those with mild depression.

SSRIs include sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and citalopram (Celexa), among others.

Serotonin/norepinephrine reuptake inhibitors

If SSRIs are not effective, there are other medication options available, including serotonin/norepinephrine reuptake inhibitors (SNRIs). SNRIs that are used to treat moderate depression include venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq), among others. 

Atypical antidepressants

Atypical antidepressants, such as bupropion (Wellbutrin) and mirtazapine (Remeron), may help treat moderate depression.

Tricyclic antidepressants

Tricyclic antidepressants are an older class of antidepressant medications. They tend to have more side effects than other options, and because of this, they aren’t used often anymore. However, for some people, they may be the best option. Some tricyclic antidepressants include imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin).

Alternative medications

Some alternative medications may help treat moderate depression. Always check with your doctor before starting any natural or other alternative medication, especially if you’re already taking other prescription medications. This is to ensure that it will be safe for you and won’t interact with any other medications you may be taking. 

Some alternative medications that may help with moderate depression include:

St. John’s wort

St. John’s wort is an herbal supplement that may help to treat depression. One study of 440 patients with mild to moderate depression showed that people taking St. John’s wort experienced a reduction in their depression scores.⁸

Keep in mind that St John’s wort has not been FDA-approved to treat depression, and it should never be taken alongside antidepressants such as SSRIs. St John’s Wort and SSRIs have a very similar chemical composition, which means they can interact with each other. This can lead to developing dangerously high serotonin levels.

Dietary supplements

Making dietary changes directly through food is one way to manage depression. Some people also choose to take dietary supplements. 

Although the relationship between dietary supplements and depression is still being studied, supplementation with vitamin A, vitamin C, vitamin D, and omega-3 fatty acids might reduce symptoms of depression.⁹ Since vitamin and mineral supplements often have high doses, it’s best to check with a doctor before starting them.

Psychotherapy

Psychotherapy, also known as “talk therapy,” is a highly effective intervention for moderate depression. In some cases, it may be as effective as antidepressants. Psychotherapy can help people develop healthy coping skills for dealing with their depression.

Psychotherapy should be carried out by a trained mental health professional, such as a psychiatrist or a clinical psychologist. Sessions can be delivered online or in person.

Two highly recommended types of psychotherapy for treating moderate depression include: 

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) helps people understand how their beliefs and thought patterns impact their behavior. CBT aims to help the patient learn to identify potentially harmful thought patterns, replace them with more positive ways of thinking, and subsequently modify their behavior or response to their emotions.

Interpersonal therapy

Interpersonal therapy (IPT) helps people find better ways to manage their personal relationships and other circumstances that may be contributing to their depressive symptoms. This can involve learning how to discuss and better communicate their emotions in a relationship. IPT can help a person to build more supportive relationships, which is a key component of mental health.

In addition to CBT and IPT, there are also other types of psychotherapy that can be used to help people with moderate depression. The specific type of therapy that’s most effective for an individual patient depends on many personal factors. It’s also important that the patient and the therapist feel like a good match and the patient feels safe with their therapist. This may involve trying out a few different therapists until a good match is found. 

In some cases, moderately severe depression can be treated with either medication or psychotherapy. Other times, a combination of both treatments is the best option. 

Brain stimulation therapy

Brain stimulation therapy is another treatment that can help to treat moderate depression. There are two main types of brain stimulation therapy: electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a type of brain stimulation therapy. It involves giving the brain brief electrical stimulations that can change its chemistry. 

While ECT is mainly used in people with severe depression, people who have moderately severe depression symptoms may also have ECT recommended if they haven’t responded well to medication.

Transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS) uses a strong magnet to generate electrical impulses within the brain. A device containing a magnetic coil is placed against the skull in particular locations. When activated, it creates a brief but strong magnetic field, which then alters electrical activity in the brain.

TMS is not painful, although it can sometimes produce side effects. Multiple studies have shown that TMS is effective in treating depression.¹⁰ However, it must be performed several times a week for a few weeks, which can be inconvenient for many patients.

The lowdown

Moderate depression is a serious mental health condition that can make it difficult to function in daily life. The severity of depression is classified based on how intense and frequent the symptoms are. 

If you think you may have depression, consider reaching out to a loved one and visiting your doctor. Whether your depression is mild, moderate, or severe, you deserve to get help. To prevent moderate depression from worsening to severe depression, starting treatment as soon as possible is important. 

If you or someone you know has thoughts of self-harm, please contact your local crisis line or emergency services, or go to a hospital emergency department if it’s safe for you to do so. 

Frequently asked questions

What is the meaning of moderately severe depression?

Moderately severe depression is a classification of depression. It involves having a low mood, irritability most days of the week, and a loss of interest in everyday activities that had been previously enjoyed, among other cognitive and physical symptoms. Moderately severe depression impacts daily life and can make it difficult for a person to manage their life independently. 

What are the five levels of depression?

Depression can be classified according to three levels of severity: mild, moderate, and severe. It can also be classified as either melancholic (also known as endogenous) or reactive, based on whether or not there’s a clear triggering event (such as a death or a serious illness). 

What score is moderate depression?

Different questionnaires and screening tools have different scores that indicate moderate depression. For example, scores of 10–14 on the PHQ-9, 20–28 on the BDI, 18–24 on the HAM-D, and 11–15 on the QIDS-16 all indicate moderate depression.

What is the difference between moderate and severe MDD?

Moderate and severe MDD may have the same symptoms, but these are more intense in severe depression. 

People with severe depression may experience hallucinations and delusions, which aren’t as common in moderate depression. Also, people with severe MDD may need a higher level of care, such as in a hospital setting. However, people with moderate depression are usually able to manage the condition as an outpatient.