The content in this entire annotation comes from the American Psychiatric Association, 2013: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.
This section begins with the lists of specific criteria required for diagnosing major depression, persistent depressive disorder, other specified depressive disorder and unspecified depressive disorder. Next, it offers guidance on considering alternative diagnoses. Finally, this section provides guidance on obtaining an appropriate patient history, including history of present illness, medical history and medication history, including any substance abuse/dependence.
Sadness is a part of human existence that the majority of the time does not necessitate treatment. These periods should not be diagnosed as a depressive episode if they do not met criteria for severity and duration, and include clinically significant distress or impairment (American Psychiatric Association, 2013).
Depressed mood or anhedonia (diminished interest or pleasure in activities) is necessary to diagnose major depression.
The use of a mnemonic may be helpful for remembering the symptoms of major depression and persistent depressive disorder. SIGECAPS or SIG + Energy + CAPS is easily remembered and can be used in the clinical interview. Developed by Dr. Carey Gross of Massachusetts General Hospital, it stands for:
Sleep disorder (increased or decreased)
Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Appetite disorder (increased or decreased)
Psychomotor retardation or agitation
Criteria Required for Diagnosis
DSM-5 Criteria: Major Depressive Episode
To qualify for a diagnosis of major depressive episode, the patient must meet criteria A through E:
A. Five or more of the following symptoms have been present and documented during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)
3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed episode.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history of and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
Severity is based on the number of criterion, the severity of those symptoms and the degree of functional disability.
- Mild, single episode ICD-10 F32.0, recurrent episode ICD-10 F33.0: Few, if any symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
- Moderate, single episode ICD-10 F32.1, recurrent episode ICD-10 F33.1: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for "mild" and "severe."
- Severe, single episode ICD-10 F32.2, recurrent episode ICD-10 F33.2: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
Further specifications include:
- In partial remission, single episode ICD-10 F32.4, recurrent episode ICD-10 F33.41: Symptoms of the immediately previously major depressive episode are present, but full criteria are not met, or there is a period lasting less than two months without any significant symptoms of a major depressive episode following the end of such an episode.
- In full remission, single episode, recurrent episode ICD-10 F33.42: During the past two months, no significant signs or symptoms of the disturbance were present.
DSM-5 Criteria: Persistent Depressive Disorder
This disorder represents a consolidation of the DSM-IV-defined chronic major depressive disorder and dysthymic disorder, ICD-10 F34.1. To qualify for a diagnosis of persistent depressive disorder, the patient must meet criteria A through H:
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account of observation by others, for at least two years.
B. Presence while depressed of two or more of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
C. During the two-year period of the disturbance, the individual has never been without the symptoms in criteria A and B for more than two months at a time.
D. Criteria for major depressive disorder may be continuously present for two years.
E. There has never been a manic episode or hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum or other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder, a very limited number of individuals will have depressive symptoms that have persisted longer than two years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder is warranted.
Severity is based on the number of criterion, the severity of those symptoms and the degree of functional disability.
- Mild: Few, if any symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
- Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for "mild" and "severe."
- Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
(American Psychiatric Association, 2013)
Other specified depressive disorder ICD-10 F32.8
This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The other specified depressive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. This is done by recording "other specified depressive disorder" followed by the specific reason (e.g., "short-duration depressive episode").
Examples of presentations that can be specified using the "other specified" designation include the following:
- Recurrent brief depression – Depressed mood and at least four other symptoms of depression for 2-13 days at least once/month (not associated with menstrual cycle for at least 12 months)
- Short-duration depressive episode – Depressed mood plus greater than or equal to four other symptoms of depression for 4-13 days
- Depressive episode with insufficient symptoms – Depression with greater than or equal to one other symptom with clinically significant distress/impairment for more than two weeks
Unspecified Depressive Disorder ICD-10 F32.9
This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The unspecified depressive disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). It should also be noted that premenstrual dysphoric disorder is now a separate diagnosis.
Consider Alternate Diagnoses
Anxiety or somatic symptom and related disorders
- Presentations particularly suggestive of an anxiety or somatoform disorder include medically unexplained symptoms such as:
- Cardiac (chest pain, atypical chest pain, palpitations, shortness of breath, hyperventilation)
- Gastrointestinal (epigastric distress chronic nausea, bloating vomiting)
- Neurologic (headache, dizziness, paresthesias) pseudoseizures, paralysis, aphonia, blindness
- Sexual or reproductive symptoms (other than pain)
- Panic attacks
The text of the fifth edition of DSM-5 includes seven specific somatic symptom and related disorders: somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. Refer to the DSM-5 for a full description of each somatic symptom and related disorder. Treatment of these disorders falls out of the scope of this guideline.
Adjustment disorder is the development of emotional or behavioral symptoms in response to an identifiable stressor. The symptoms occur within three months of the onset of the stressor and last less than six months after the termination of the stressor. These symptoms or behaviors are in excess of what would be expected from exposure to the stressor, and they cause significant impairment in social and occupational functioning. In adjustment disorder with depressed mood, predominant symptoms such as low mood, feelings of hopelessness and tearfulness are exhibited. Treatment of adjustment disorder falls out of the scope of this guideline.
Many patients with bipolar disorder experience hypomania or mania before their first major depressive episode. Ask patients about personal history of mania or hypomania. If any, ask about family history and, if any consider using MDQ, if any, to assess further. The diagnostic criteria for an episode of major depression in bipolar disorder are the same as the criteria for unipolar major depressive disorder. Use DSM-5 criteria when considering a diagnosis of unipolar major depressive disorder:
A) A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B) During the period of mood disturbances and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only three hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions or foolish business investments)
C) The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D) The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode, and therefore, a bipolar I diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.
In addition to screening for hypomania and mania, consider the following historical elements that are more likely to occur in bipolar depression than unipolar depression: a family history of bipolar disorder, onset of depressive symptoms before 25 years of age, and more frequent depressive episodes of shorter duration (Goodwin, 2007). Hypersomnia and hyperphagia may also be more common features of bipolar depression than early morning awakening and reduced appetite, which are more typical of unipolar depression (Frye, 2011; Goodwin, 2007). For more guidance on diagnosing and treating bipolar depression, consider psychiatric consultation.
One screening tool for further assessment is the Mood Disorder Questionnaire (MDQ) (Hirschfeld, 2000) for bipolar disorder. Treatment for bipolar disorder falls out of the scope of this guideline.
The M-3 (My Mood Monitor) Checklist, has been created to assess for the presence of depression, anxiety, bipolar disorder and post-traumatic stress disorder (Gaynes, 2010). It has similar specificity and sensitivity to the single-disorder screens currently in use, with the advantage of being a single page that the patient can complete. More than 80% of clinicians were able to review it in 30 seconds or less. It needs further validation but is a promising tool for primary care in screening for mental health disorders.
Post-traumatic stress disorder (PTSD)
PTSD may include symptoms shared by a depressive episode and may also be comorbid with a depressive episode. PTSD is associated with exposure to actual or threatened death, serious injury, and/or sexual violence. It includes intrusive flashbacks, nightmares, psychological and/or physical reactivity to cues of the event, avoidance of cues of the event (both internal and external), negative alterations in mood, and hyperarousal and reactivity (American Psychiatric Association, 2013).
Obtain Patient History
An appropriate patient history includes information about the present illness, the medical history and medication history, including any substance abuse or dependence.
History of present illness
Determine history of present illness:
- Onset may be gradual over months or years or may be abrupt.
- Severity of symptoms and degree of functional impairment:
People diagnosed with major depression have a heterogeneous course from self-limiting to life-threatening. Predictors of poor outcome include higher severity at initial assessment, lack of reduction of social difficulties at follow-up and low educational level.
Categorize severity of symptoms and degree of functional impairment as follows:
Mild: Few, if any, symptoms in excess of those required to make the diagnosis and only minor impairment in occupational and/or social functioning
Moderate: Symptoms or functional impairment between mild and severe
Severe: Several symptoms in excess of those necessary to make the diagnosis and marked interference with occupational and/or social functioning
- Determine prior history: Number and severity of previous episodes, treatment responses and suicide attempts.
- Ask about concurrent psychiatric conditions. Obtaining a past psychiatric history is important in terms of understanding prognosis and risk factors. For example, knowing past episodes of major depression, past co-occuring mental/behavioral health conditions, and past self-harm attempts helps establish risk and need to involve other mental health professionals.
- Assess psychosocial stressors (significant loss, conflict, financial difficulties, life change, abuse). Consider duration and severity of stressor(s) and likelihood for spontaneous improvement.
For short-term subclinical and mild cases, close follow-up and monitoring are still needed (Fournier, 2010). Ongoing utility of behavioral activation, skill building and self-management practices is recommended (Mazzucchelli, 2009; Vittengl, 2009; Cuijpers, 2007).
It is important to consider medical conditions that may mimic or directly cause symptoms of depression. A past medical history and brief review of systems is generally sufficient to rule out medical disorders causing major depression.
Examples of such disorders include:
- Parkinson's disease
- Connective tissue diseases
A review of the patient's medication and substance use may also provide an explanation for depressive symptoms. Sedatives, withdrawal from stimulants and other specific medications (e.g., interferon alpha, varenicline) may be contributing.
Review of the patient's medical history may find conditions that can impact pharmacological treatments: for example, prostatism, cardiac conduction abnormalities and impaired hepatic function.
Perform a focused physical examination and diagnostic testing as indicated by the review of systems. The benefit of screening laboratory tests, including thyroid tests, to evaluate major depression has not been established.
Consideration of laboratory tests should be greater if:
- the medical review of systems detects symptoms that are rarely encountered in mood or anxiety disorders,
- the patient is older,
- the first major depressive episode occurs after the age of 40, or
- the depression does not respond fully to routine treatment.
Medication history and substance abuse/dependence
Determine medication history and substance abuse/dependence:
- Medications such as steroids, interferon, alpha-methyldopa, isotretinoin, varenicline and hormonal therapy may be associated with major depression.
- Use of alcohol and hypnotics might mimic and/or induce depression, and comorbidity is common (Davis, 2006).
- Withdrawal from cocaine, anxiolytics and amphetamines may mimic depression.
- Idiosyncratic reactions to other medications can occur. If possible, a medication should be stopped or changed if depression develops after beginning its use. If symptoms persist after stopping or changing medication, reevaluate for a primary mood or anxiety disorder.