MAJOR DEPRESSIVE DISORDER INFORMATION PAGE

Mayo Clinic information https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

THE DESCRIPTIONS HERE ARE TAKEN FROM THE DSM-V STATISTICAL MANUEL OF MENTAL DISORDERS

Major Depressive Disorder

Diagnostic Criteria

A. Five (or more) of the following symptoms have been present during the same 2-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). (Note: In children and adolescents, can be irritable mood.)

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).

Major Depressive Disorder 161

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.

(Note: In children, consider failure to make expected weight gain.)

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 cause clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

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 the 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

and the cultural norms for the expression of distress in the context of loss.1

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.

1 In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in

grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent

depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is

likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of

grief. These waves tend to be associated with thoughts or reminders of the deceased. The

depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations.

The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic

of the pervasive unhappiness and misery characteristic of MDE. The thought content associated

with grief generally features a preoccupation with thoughts and memories of the deceased,

rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally

preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If selfderogatory

ideation is present in grief, it typically involves perceived failings vis-à-vis the

deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was

loved). If a bereaved individual thinks about death and dying, such thoughts are generally

focused on the deceased and possibly about “joining” the deceased, whereas in MDE such

thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life,

or unable to cope with the pain of depression.

162 Depressive Disorders

Coding and Recording Procedures

The diagnostic code for major depressive disorder is based on whether this is a single or

recurrent episode, current severity, presence of psychotic features, and remission status.

Current severity and psychotic features are only indicated if full criteria are currently met

for a major depressive episode. Remission specifiers are only indicated if the full criteria

are not currently met for a major depressive episode. Codes are as follows:

In recording the name of a diagnosis, terms should be listed in the following order: major

depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers,

followed by as many of the following specifiers without codes that apply to the current

episode.

Specify:

With anxious distress (p. 184)

With mixed features (pp. 184–185)

With melancholic features (p. 185)

With atypical features (pp. 185–186)

With mood-congruent psychotic features (p. 186)

With mood-incongruent psychotic features (p. 186)

With catatonia (p. 186). Coding note: Use additional code 293.89 (F06.1).

With peripartum onset (pp. 186–187)

With seasonal pattern (recurrent episode only) (pp. 187–188)

Diagnostic Features

The criterion symptoms for major depressive disorder must be present nearly every day to

be considered present, with the exception of weight change and suicidal ideation. Depressed

mood must be present for most of the day, in addition to being present nearly every

day. Often insomnia or fatigue is the presenting complaint, and failure to probe for

accompanying depressive symptoms will result in underdiagnosis. Sadness may be denied

at first but may be elicited through interview or inferred from facial expression and

demeanor. With individuals who focus on a somatic complaint, clinicians should determine

whether the distress from that complaint is associated with specific depressive

symptoms. Fatigue and sleep disturbance are present in a high proportion of cases; psychomotor

disturbances are much less common but are indicative of greater overall severity,

as is the presence of delusional or near-delusional guilt.

Severity/course specifier Single episode Recurrent episode*

Mild (p. 188) 296.21 (F32.0) 296.31 (F33.0)

Moderate (p. 188) 296.22 (F32.1) 296.32 (F33.1)

Severe (p. 188) 296.23 (F32.2) 296.33 (F33.2)

With psychotic features** (p. 186) 296.24 (F32.3) 296.34 (F33.3)

In partial remission (p. 188) 296.25 (F32.4) 296.35 (F33.41)

In full remission (p. 188) 296.26 (F32.5) 296.36 (F33.42)

Unspecified 296.20 (F32.9) 296.30 (F33.9)

*For an episode to be considered recurrent, there must be an interval of at least 2 consecutive months

between separate episodes in which criteria are not met for a major depressive episode. The definitions

of specifiers are found on the indicated pages.

**If psychotic features are present, code the “with psychotic features” specifier irrespective of episode

severity.

Major Depressive Disorder 163

The essential feature of a major depressive episode is a period of at least 2 weeks during

which there is either depressed mood or the loss of interest or pleasure in nearly all activities

(Criterion A). In children and adolescents, the mood may be irritable rather than sad.

The individual must also experience at least four additional symptoms drawn from a list

that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy;

feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions;

or recurrent thoughts of death or suicidal ideation or suicide plans or attempts. To

count toward a major depressive episode, a symptom must either be newly present or must

have clearly worsened compared with the person’s pre-episode status. The symptoms

must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The episode

must be accompanied by clinically significant distress or impairment in social, occupational,

or other important areas of functioning. For some individuals with milder

episodes, functioning may appear to be normal but requires markedly increased effort.

The mood in a major depressive episode is often described by the person as depressed,

sad, hopeless, discouraged, or “down in the dumps” (Criterion A1). In some cases, sadness

may be denied at first but may subsequently be elicited by interview (e.g., by pointing out

that the individual looks as if he or she is about to cry). In some individuals who complain

of feeling “blah,” having no feelings, or feeling anxious, the presence of a depressed mood

can be inferred from the person’s facial expression and demeanor. Some individuals emphasize

somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of

sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a

tendency to respond to events with angry outbursts or blaming others, an exaggerated

sense of frustration over minor matters). In children and adolescents, an irritable or cranky

mood may develop rather than a sad or dejected mood. This presentation should be differentiated

from a pattern of irritability when frustrated.

Loss of interest or pleasure is nearly always present, at least to some degree. Individuals

may report feeling less interested in hobbies, “not caring anymore,” or not feeling any

enjoyment in activities that were previously considered pleasurable (Criterion A2). Family

members often notice social withdrawal or neglect of pleasurable avocations (e.g., a formerly

avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to

practice). In some individuals, there is a significant reduction from previous levels of sexual

interest or desire.

Appetite change may involve either a reduction or increase. Some depressed individuals

report that they have to force themselves to eat. Others may eat more and may crave

specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in

either direction), there may be a significant loss or gain in weight, or, in children, a failure

to make expected weight gains may be noted (Criterion A3).

Sleep disturbance may take the form of either difficulty sleeping or sleeping excessively

(Criterion A4). When insomnia is present, it typically takes the form of middle insomnia

(i.e., waking up during the night and then having difficulty returning to sleep) or

terminal insomnia (i.e., waking too early and being unable to return to sleep). Initial insomnia

(i.e., difficulty falling asleep) may also occur. Individuals who present with oversleeping

(hypersomnia) may experience prolonged sleep episodes at night or increased

daytime sleep. Sometimes the reason that the individual seeks treatment is for the disturbed

sleep.

Psychomotor changes include agitation (e.g., the inability to sit still, pacing, handwringing;

or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g.,

slowed speech, thinking, and body movements; increased pauses before answering;

speech that is decreased in volume, inflection, amount, or variety of content, or muteness)

(Criterion A5). The psychomotor agitation or retardation must be severe enough to be observable

by others and not represent merely subjective feelings.

Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may report

sustained fatigue without physical exertion. Even the smallest tasks seem to require

164 Depressive Disorders

substantial effort. The efficiency with which tasks are accomplished may be reduced. For

example, an individual may complain that washing and dressing in the morning are exhausting

and take twice as long as usual.

The sense of worthlessness or guilt associated with a major depressive episode may include

unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations

over minor past failings (Criterion A7). Such individuals often misinterpret neutral

or trivial day-to-day events as evidence of personal defects and have an exaggerated sense

of responsibility for untoward events. The sense of worthlessness or guilt may be of delusional

proportions (e.g., an individual who is convinced that he or she is personally responsible

for world poverty). Blaming oneself for being sick and for failing to meet

occupational or interpersonal responsibilities as a result of the depression is very common

and, unless delusional, is not considered sufficient to meet this criterion.

Many individuals report impaired ability to think, concentrate, or make even minor

decisions (Criterion A8). They may appear easily distracted or complain of memory difficulties.

Those engaged in cognitively demanding pursuits are often unable to function. In

children, a precipitous drop in grades may reflect poor concentration. In elderly individuals,

memory difficulties may be the chief complaint and may be mistaken for early signs

of a dementia (“pseudodementia”). When the major depressive episode is successfully

treated, the memory problems often fully abate. However, in some individuals, particularly

elderly persons, a major depressive episode may sometimes be the initial presentation

of an irreversible dementia.

Thoughts of death, suicidal ideation, or suicide attempts (Criterion A9) are common.

They may range from a passive wish not to awaken in the morning or a belief that others

would be better off if the individual were dead, to transient but recurrent thoughts of committing

suicide, to a specific suicide plan. More severely suicidal individuals may have put

their affairs in order (e.g., updated wills, settled debts), acquired needed materials (e.g., a

rope or a gun), and chosen a location and time to accomplish the suicide. Motivations for

suicide may include a desire to give up in the face of perceived insurmountable obstacles,

an intense wish to end what is perceived as an unending and excruciatingly painful emotional

state, an inability to foresee any enjoyment in life, or the wish to not be a burden to

others. The resolution of such thinking may be a more meaningful measure of diminished

suicide risk than denial of further plans for suicide.

The evaluation of the symptoms of a major depressive episode is especially difficult

when they occur in an individual who also has a general medical condition (e.g., cancer,

stroke, myocardial infarction, diabetes, pregnancy). Some of the criterion signs and symptoms

of a major depressive episode are identical to those of general medical conditions

(e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in pregnancy;

insomnia later in pregnancy or the postpartum). Such symptoms count toward a

major depressive diagnosis except when they are clearly and fully attributable to a general

medical condition. Nonvegetative symptoms of dysphoria, anhedonia, guilt or worthlessness,

impaired concentration or indecision, and suicidal thoughts should be assessed with

particular care in such cases. Definitions of major depressive episodes that have been modified

to include only these nonvegetative symptoms appear to identify nearly the same individuals

as do the full criteria.

Associated Features Supporting Diagnosis

Major depressive disorder is associated with high mortality, much of which is accounted

for by suicide; however, it is not the only cause. For example, depressed individuals admitted

to nursing homes have a markedly increased likelihood of death in the first year. Individuals

frequently present with tearfulness, irritability, brooding, obsessive rumination,

anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g., headaches;

joint, abdominal, or other pains). In children, separation anxiety may occur.

Major Depressive Disorder 165

Although an extensive literature exists describing neuroanatomical, neuroendocrinological,

and neurophysiological correlates of major depressive disorder, no laboratory test

has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for

this disorder. Until recently, hypothalamic-pituitary-adrenal axis hyperactivity had been

the most extensively investigated abnormality associated with major depressive episodes,

and it appears to be associated with melancholia, psychotic features, and risks for eventual

suicide. Molecular studies have also implicated peripheral factors, including genetic variants

in neurotrophic factors and pro-inflammatory cytokines. Additionally, functional

magnetic resonance imaging studies provide evidence for functional abnormalities in specific

neural systems supporting emotion processing, reward seeking, and emotion regulation

in adults with major depression.

Prevalence

Twelve-month prevalence of major depressive disorder in the United States is approximately

7%, with marked differences by age group such that the prevalence in 18- to 29-year-old individuals

is threefold higher than the prevalence in individuals age 60 years or older. Females experience

1.5- to 3-fold higher rates than males beginning in early adolescence.

Development and Course

Major depressive disorder may first appear at any age, but the likelihood of onset increases

markedly with puberty. In the United States, incidence appears to peak in the 20s;

however, first onset in late life is not uncommon.

The course of major depressive disorder is quite variable, such that some individuals

rarely, if ever, experience remission (a period of 2 or more months with no symptoms, or

only one or two symptoms to no more than a mild degree), while others experience many

years with few or no symptoms between discrete episodes. It is important to distinguish

individuals who present for treatment during an exacerbation of a chronic depressive illness

from those whose symptoms developed recently. Chronicity of depressive symptoms

substantially increases the likelihood of underlying personality, anxiety, and substance

use disorders and decreases the likelihood that treatment will be followed by full symptom

resolution. It is therefore useful to ask individuals presenting with depressive symptoms

to identify the last period of at least 2 months during which they were entirely free of

depressive symptoms.

Recovery typically begins within 3 months of onset for two in five individuals with major

depression and within 1 year for four in five individuals. Recency of onset is a strong

determinant of the likelihood of near-term recovery, and many individuals who have been

depressed only for several months can be expected to recover spontaneously. Features associated

with lower recovery rates, other than current episode duration, include psychotic

features, prominent anxiety, personality disorders, and symptom severity.

The risk of recurrence becomes progessively lower over time as the duration of remission

increases. The risk is higher in individuals whose preceding episode was severe,

in younger individuals, and in individuals who have already experienced multiple episodes.

The persistence of even mild depressive symptoms during remission is a powerful

predictor of recurrence.

Many bipolar illnesses begin with one or more depressive episodes, and a substantial

proportion of individuals who initially appear to have major depressive disorder will

prove, in time, to instead have a bipolar disorder. This is more likely in individuals with

onset of the illness in adolescence, those with psychotic features, and those with a family

history of bipolar illness. The presence of a “with mixed features” specifier also increases

the risk for future manic or hypomanic diagnosis. Major depressive disorder, particularly

with psychotic features, may also transition into schizophrenia, a change that is much

more frequent than the reverse.

166 Depressive Disorders

Despite consistent differences between genders in prevalence rates for depressive disorders,

there appear to be no clear differences by gender in phenomenology, course, or treatment

response. Similarly, there are no clear effects of current age on the course or treatment

response of major depressive disorder. Some symptom differences exist, though, such that

hypersomnia and hyperphagia are more likely in younger individuals, and melancholic

symptoms, particularly psychomotor disturbances, are more common in older individuals.

The likelihood of suicide attempts lessens in middle and late life, although the risk of completed

suicide does not. Depressions with earlier ages at onset are more familial and more

likely to involve personality disturbances. The course of major depressive disorder within

individuals does not generally change with aging. Mean times to recovery appear to be stable

over long periods, and the likelihood of being in an episode does not generally increase

or decrease with time.

Risk and Prognostic Factors

Temperamental. Neuroticism (negative affectivity) is a well-established risk factor for the

onset of major depressive disorder, and high levels appear to render individuals more likely

to develop depressive episodes in response to stressful life events.

Environmental. Adverse childhood experiences, particularly when there are multiple

experiences of diverse types, constitute a set of potent risk factors for major depressive disorder.

Stressful life events are well recognized as precipitants of major depressive episodes,

but the presence or absence of adverse life events near the onset of episodes does

not appear to provide a useful guide to prognosis or treatment selection.

Genetic and physiological. First-degree family members of individuals with major depressive

disorder have a risk for major depressive disorder two- to fourfold higher than

that of the general population. Relative risks appear to be higher for early-onset and recurrent

forms. Heritability is approximately 40%, and the personality trait neuroticism accounts

for a substantial portion of this genetic liability.

Course modifiers. Essentially all major nonmood disorders increase the risk of an individual

developing depression. Major depressive episodes that develop against the background

of another disorder often follow a more refractory course. Substance use, anxiety,

and borderline personality disorders are among the most common of these, and the presenting

depressive symptoms may obscure and delay their recognition. However, sustained

clinical improvement in depressive symptoms may depend on the appropriate

treatment of underlying illnesses. Chronic or disabling medical conditions also increase

risks for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity,

and cardiovascular disease are often complicated by depressive episodes, and these episodes

are more likely to become chronic than are depressive episodes in medically healthy

individuals.

Culture-Related Diagnostic Issues

Surveys of major depressive disorder across diverse cultures have shown sevenfold differences

in 12-month prevalence rates but much more consistency in female-to-male ratio,

mean ages at onset, and the degree to which presence of the disorder raises the likelihood

of comorbid substance abuse. While these findings suggest substantial cultural differences

in the expression of major depressive disorder, they do not permit simple linkages between

particular cultures and the likelihood of specific symptoms. Rather, clinicians

should be aware that in most countries the majority of cases of depression go unrecognized

in primary care settings and that in many cultures, somatic symptoms are very likely

to constitute the presenting complaint. Among the Criterion A symptoms, insomnia and

loss of energy are the most uniformly reported.

Major Depressive Disorder 167

Gender-Related Diagnostic Issues

Although the most reproducible finding in the epidemiology of major depressive disorder

has been a higher prevalence in females, there are no clear differences between genders in

symptoms, course, treatment response, or functional consequences. In women, the risk for

suicide attempts is higher, and the risk for suicide completion is lower. The disparity in

suicide rate by gender is not as great among those with depressive disorders as it is in the

population as a whole.

Suicide Risk

The possibility of suicidal behavior exists at all times during major depressive episodes.

The most consistently described risk factor is a past history of suicide attempts or threats,

but it should be remembered that most completed suicides are not preceded by unsuccessful

attempts. Other features associated with an increased risk for completed suicide

include male sex, being single or living alone, and having prominent feelings of hopelessness.

The presence of borderline personality disorder markedly increases risk for future

suicide attempts.

Functional Consequences of

Major Depressive Disorder

Many of the functional consequences of major depressive disorder derive from individual

symptoms. Impairment can be very mild, such that many of those who interact with the affected

individual are unaware of depressive symptoms. Impairment may, however, range

to complete incapacity such that the depressed individual is unable to attend to basic selfcare

needs or is mute or catatonic. Among individuals seen in general medical settings,

those with major depressive disorder have more pain and physical illness and greater decreases

in physical, social, and role functioning.

Differential Diagnosis

Manic episodes with irritable mood or mixed episodes. Major depressive episodes

with prominent irritable mood may be difficult to distinguish from manic episodes with

irritable mood or from mixed episodes. This distinction requires a careful clinical evaluation

of the presence of manic symptoms.

Mood disorder due to another medical condition. A major depressive episode is the

appropriate diagnosis if the mood disturbance is not judged, based on individual history,

physical examination, and laboratory findings, to be the direct pathophysiological consequence

of a specific medical condition (e.g., multiple sclerosis, stroke, hypothyroidism).

Substance/medication-induced depressive or bipolar disorder. This disorder is distinguished

from major depressive disorder by the fact that a substance (e.g., a drug of abuse,

a medication, a toxin) appears to be etiologically related to the mood disturbance. For example,

depressed mood that occurs only in the context of withdrawal from cocaine would

be diagnosed as cocaine-induced depressive disorder.

Attention-deficit/hyperactivity disorder. Distractibility and low frustration tolerance

can occur in both attention-deficit/ hyperactivity disorder and a major depressive episode;

if the criteria are met for both, attention-deficit/hyperactivity disorder may be diagnosed

in addition to the mood disorder. However, the clinician must be cautious not to

overdiagnose a major depressive episode in children with attention-deficit/hyperactivity

disorder whose disturbance in mood is characterized by irritability rather than by sadness

or loss of interest.

168 Depressive Disorders

Adjustment disorder with depressed mood. A major depressive episode that occurs in

response to a psychosocial stressor is distinguished from adjustment disorder with depressed

mood by the fact that the full criteria for a major depressive episode are not met in

adjustment disorder.

Sadness. Finally, periods of sadness are inherent aspects of the human experience.

These periods should not be diagnosed as a major depressive episode unless criteria are

met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly every

day for at least 2 weeks), and clinically significant distress or impairment. The diagnosis

other specified depressive disorder may be appropriate for presentations of depressed

mood with clinically significant impairment that do not meet criteria for duration or severity.

Comorbidity

Other disorders with which major depressive disorder frequently co-occurs are substancerelated

disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia

nervosa, and borderline personality disorder.