Major depressive disorder is a treatable medical condition: at least two weeks of low mood or loss of interest plus changes in sleep, energy, appetite and concentration. First-line treatment is an SSRI or SNRI antidepressant, psychotherapy, or both. Most people improve within 6 to 12 weeks, and non-responders have options including Deep TMS and Spravato.
Not sure? Take the two-minute depression self-check.
At Stedfast Psychiatry we treat depression the way a chronic medical condition should be treated: with a careful diagnosis, a clear plan, measurable goals and regular follow-up. Our psychiatrists, psychiatric nurse practitioners and physician assistants combine medication management with psychotherapy, and for people who have not responded to standard antidepressants, we offer Deep TMS at Palm Beach Gardens and Spravato at Boynton Beach, Palm Beach Gardens and Royal Palm Beach.
Symptoms of depression
- Depressed mood most of the day, nearly every day
- Loss of interest or pleasure in activities you used to enjoy
- Sleeping much more or much less than usual
- Fatigue or low energy that rest does not fix
- Appetite or weight changes without trying
- Difficulty concentrating, deciding or remembering
- Feelings of worthlessness or excessive guilt
- Moving or speaking more slowly, or feeling restless
- Thoughts of death or suicide
Causes and risk factors
Depression does not have a single cause. Genetics account for roughly 35 to 40 percent of risk, and the rest comes from an interaction between biology and life. Chronic stress, trauma, grief, medical illness (thyroid disease, anemia, heart disease, chronic pain), certain medications (some steroids, interferon, isotretinoin), alcohol and substance use, and disrupted sleep all raise the risk. Hormonal transitions such as the postpartum period and perimenopause are common triggers in women. Neurobiologically, depression involves changes in serotonin, norepinephrine, dopamine and glutamate signaling, stress hormone regulation, inflammation and the connectivity of brain networks that govern mood and motivation. That is why effective treatments work through several different pathways rather than one.
An estimated 21 million US adults (8.3 percent) had at least one major depressive episode in 2021.
Source: NIMH, based on the National Survey on Drug Use and Health
In the STAR*D trial, about one third of patients reached remission on their first antidepressant, and roughly two thirds eventually remitted after up to four treatment steps.
Source: STAR*D, National Institute of Mental Health
Depression is a leading cause of disability worldwide, affecting an estimated 5 percent of adults.
Source: World Health Organization
Combining psychotherapy with antidepressant medication is more effective than either treatment alone for moderate to severe depression.
Source: American Psychiatric Association Practice Guideline
How we diagnose it at Stedfast Psychiatry
A depression evaluation at Stedfast Psychiatry starts with a structured clinical interview lasting about 45 to 60 minutes. We review the timeline of your symptoms, prior episodes, family history, sleep, substance use, medical conditions and current medications. We screen for bipolar disorder before prescribing any antidepressant, because an antidepressant given alone to someone with undiagnosed bipolar disorder can trigger mania. We use validated scales, usually the PHQ-9 for depression severity and the GAD-7 for anxiety, and repeat them at follow-ups so progress is measured rather than guessed. When the picture suggests a medical contributor, we order labs: thyroid function (TSH), complete blood count, vitamin B12 and vitamin D, and a metabolic panel. We also assess suicide risk directly at every visit, because asking does not increase risk and not asking can miss it.
Treatment options
Medication management
First-line antidepressants are SSRIs such as sertraline, escitalopram and fluoxetine, and SNRIs such as venlafaxine and duloxetine. Bupropion is a good option when fatigue, low motivation or sexual side effects are concerns, and mirtazapine helps when insomnia and poor appetite dominate. We start at a low dose, increase over two to four weeks, and expect early improvement in sleep and energy by week two to three with full mood response by week six to eight. If a medication has not helped at an adequate dose for six to eight weeks, we switch or augment rather than wait. Augmentation options include adding bupropion, a low-dose atypical antipsychotic such as aripiprazole, or lithium. We monitor side effects, blood pressure for SNRIs, and ask about activation or suicidal thoughts in the first weeks, especially in patients under 25.
Psychotherapy
Cognitive behavioral therapy (CBT) and behavioral activation have the strongest evidence for depression and work about as well as medication for mild to moderate episodes. For moderate to severe depression, the combination of medication and therapy outperforms either alone. Interpersonal therapy helps when depression is tied to a role change, conflict or loss. Our therapists coordinate directly with the prescriber so your care is one plan rather than two.
Interventional options
If two or more antidepressant trials have not produced remission, you may be a candidate for Deep TMS or Spravato. Deep TMS (BrainsWay) is FDA-cleared for major depressive disorder (2013) and for anxious depression (2021). It uses magnetic pulses to stimulate the prefrontal cortex, requires no anesthesia, and a typical course is 36 sessions over six to nine weeks at our Palm Beach Gardens office. Spravato (esketamine) nasal spray is FDA-approved for treatment-resistant depression (2019) and for depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior (2020), for adults 18 and older. It is taken in our office under the REMS program with two hours of monitoring, twice weekly for four weeks during induction and then weekly or every other week. Both are covered by most commercial insurance and Medicare when criteria are met.
If medications have not worked or caused strong side effects, ask about pharmacogenomic (genetic) testing.
What to expect
Your first visit is a full psychiatric evaluation, in person or by video. You leave with a diagnosis, a written plan and, when appropriate, a prescription sent to your pharmacy. Follow-ups are scheduled at two to four weeks while we adjust medication, then every one to three months once you are stable. Most follow-ups can be done by telehealth from anywhere in Florida or South Carolina, which makes it easier to stay consistent. We track your PHQ-9 at each visit and treat to remission, not just improvement.
When to seek help
See a psychiatric provider if low mood or loss of interest has lasted more than two weeks, if you are struggling to work or care for yourself, or if a prior episode seems to be returning. If you are having thoughts of suicide or self-harm, call or text 988 (the Suicide and Crisis Lifeline) or go to the nearest emergency room. If someone is in immediate danger, call 911. Depression is treatable, and the people who recover fastest are usually the ones who were evaluated earliest.
Types of depression we treat
Major depressive disorder is the most common diagnosis, but several related conditions need slightly different plans. Persistent depressive disorder (dysthymia) is a lower-grade depression that lasts two years or more and is easy to mistake for personality. Seasonal pattern depression recurs in the darker months and often responds to bright light therapy in addition to standard treatment. Depression with anxious distress, with melancholic features (early waking, loss of appetite, worse in the morning) or with psychotic features each change how we choose medication. Bipolar depression looks like unipolar depression on the surface but requires mood stabilizers rather than antidepressants alone, which is why screening for past hypomania is part of every evaluation.
Ruling out other causes
Several conditions mimic depression. Hypothyroidism, anemia, vitamin B12 deficiency, obstructive sleep apnea and the side effects of medications such as beta blockers or corticosteroids can all produce fatigue, low mood and poor concentration. Alcohol is a depressant and regular heavy use can cause or maintain a depressive episode. Grief shares many features with depression but tends to come in waves tied to reminders of the loss, with self-esteem usually intact. ADHD in adults is frequently misread as depression because chronic underperformance leads to low mood; treating the ADHD often resolves it. Part of our job is to sort these out before committing to a treatment.
Lifestyle factors that support recovery
Medication and therapy do the heavy lifting, but daily habits change the slope of recovery. Regular aerobic exercise, even 20 to 30 minutes of walking most days, has a measurable antidepressant effect in clinical trials. A consistent sleep and wake time stabilizes mood more than most people expect. Reducing alcohol, keeping some social contact even when you do not feel like it, and scheduling small activities that used to bring pleasure (the core of behavioral activation) all help. We do not ask you to fix your habits before treatment starts; we help you rebuild them as energy returns.
Prognosis
Most people with depression get better with treatment. With a systematic approach that adjusts medication when the first choice does not work and adds therapy, two thirds of patients reach remission. The main risk is recurrence: about half of people who have one episode will have another, and the odds rise after each additional episode. That is why we continue treatment for months after you feel well, teach relapse-prevention skills, and keep the door open for quick follow-up if early warning signs return. For the minority who do not respond to medication, Deep TMS and Spravato have moved what used to be a dead end into a next step.
Frequently asked questions
How do I know if I have depression or am just going through a hard time?
Sadness after a loss or setback is normal and usually lifts as the situation changes. Depression is different in duration and reach: symptoms last at least two weeks, show up nearly every day, and spread into sleep, energy, appetite, concentration and self-worth. If you cannot point to a reason for how bad you feel, or the reason has resolved and the feeling has not, it is worth an evaluation. A short screening with the PHQ-9 takes two minutes and gives a clear starting point.
Medication or therapy: which is better for depression?
For mild to moderate depression they work about equally well, and the right choice depends on your preference, history and access. For moderate to severe depression, the combination is better than either alone. Medication tends to work faster on sleep, energy and appetite; therapy builds skills that lower relapse risk after treatment ends. Many patients start both and taper one later.
How long does it take for antidepressants to work?
Most people notice better sleep and energy within one to three weeks, and improvement in mood by four to six weeks. A full trial is six to eight weeks at an adequate dose. If there is no meaningful change by then, we adjust the dose, switch to a different medication, or add a second one. About one third of people respond fully to the first antidepressant, which is why follow-up and a willingness to adjust matter.
How long will I need to stay on medication?
After a first episode, we usually recommend continuing medication for at least six to twelve months after you feel well, then tapering gradually under supervision. After two or more episodes, longer maintenance treatment is often advised because the risk of recurrence rises with each episode. Stopping abruptly can cause discontinuation symptoms and relapse, so changes are always planned.
Can I be treated for depression through telehealth?
Yes. Stedfast Psychiatry provides video visits for patients anywhere in Florida and South Carolina. Evaluation, antidepressant prescribing, follow-ups and therapy all work well by telehealth, and studies show outcomes comparable to in-person care. Deep TMS and Spravato require in-person visits at the offices that offer them, but the medication management around them can be done remotely, which lets patients outside Palm Beach County combine both.
What does depression treatment cost and is it covered by insurance?
We accept most major insurance plans and Medicare, and visits are typically billed as a specialist office visit with your usual copay. For patients without insurance, a new-patient evaluation is $185. Generic SSRIs and SNRIs cost a few dollars a month at most pharmacies. Deep TMS and Spravato are covered by most plans after documented antidepressant trials; our staff handles the prior authorization.
What if antidepressants have not worked for me?
You are not out of options. Treatment-resistant depression, usually defined as no remission after two adequate antidepressant trials, responds to augmentation strategies, Deep TMS and Spravato. In clinical trials, roughly half of patients who had failed prior medications responded to TMS, and Spravato produced faster improvement than placebo when added to an oral antidepressant. Ask about our treatment-resistant depression program.
Do you treat depression in teenagers?
Yes. Several of our providers specialize in child and adolescent psychiatry. Depression in teens often looks like irritability, withdrawal, falling grades or sleep changes rather than obvious sadness. Fluoxetine and escitalopram are FDA-approved for adolescent depression, and CBT is a core part of treatment. We involve parents in the plan while respecting the teen's privacy.
Where to get treatment for major depressive disorder
Evaluation and treatment for major depressive disorder is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.