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DSM-II

In DSM-II, this disorder is called Manic-depressive illness, depressed type (Manic-depressive psychosis, depressed type)

This disorder consists exclusively of depressive episodes. These episodes are characterized by severely depressed mood and by mental and motor retardation progressing occasionally to stupor. Uneasiness, apprehension, perplexity and agitation may also be present. When illusions, hallucinations, and delusions (usually of guilt or of hypochondriacal or paranoid ideas) occur, they are attributable to the dominant mood disorder. Because it is a primary mood disorder, this psychosis differs from the Psychotic depressive reaction, which is more easily attributable to precipitating stress. Cases incompletely labelled as "psychotic depression" should be classified here rather than under Psychotic depressive reaction.

DSM-III

In DSM-III, this disorder is called Major Depression

Diagnostic Criteria

A. One or more major depressive episodes.

B. Has never had a manic episode.

Specify:

  • Major Depression, Single Episode
  • Major Depression, Recurrent

DSM-IV

Diagnostic Criteria

Major Depressive Disorder, Single Episode

A. Presence of a single Major Depressive Episode.

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Specify (for current or most recent episode):

  • Severity/Psychotic/Remission Specifiers
  • Chronic
  • With Catatonic Features
  • With Melancholic Features
  • With Atypical Features
  • With Postpartum Onset

Major Depressive Disorder, Recurrent

A. Presence of two or more Major Depressive Episodes.

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Specify (for current or most recent episode):

  • Severity/Psychotic/Remission Specifiers
  • Chronic
  • With Catatonic Features
  • With Melancholic Features
  • With Atypical Features
  • With Postpartum Onset

Specify:

  • Longitudinal Course Specifiers (With and Without Interepisode Recovery)
  • With Seasonal Pattern

Specifiers

The following specifiers may be used to describe the current Major Depressive Episode (or, if criteria are not currently met for a Major Depressive Episode, the most recent Major Depressive Episode):

  • Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Partial Remission, In Full Remission
  • Chronic
  • With Catatonic Features
  • With Melancholic Features
  • With Atypical Features
  • With Postpartum Onset

The following specifiers may be sued to indicate the pattern of the episodes and the presence of interepisode symptomatology for Major Depressive Disorder, Recurrent:

  • Longitudinal Course Specifiers (With or Without Full Interepisode Recovery)
  • With Seasonal Pattern

Catatonic Features Specifier

The specifier With Catatonic Features can be applied to the current (or most recent) Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder. The specifier With Catatonic Features is appropriate when the clinical picture is characterized by marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Motoric immobility may be manifested by catalepsy (waxy flexibility) or stupor. The excessive motor activity is apparently purposeless and is not influenced by external stimuli. There may be extreme negativism that is manifested by the maintenance of a rigid posture against attempts to be moved or resistance to all instructions. Peculiarities of voluntary movement are manifested by the assumption of innapropriate or bizarre postures or by prominent grimacing. Echolalia (the pathological, parrotlike, and apparently senseless repetition of a word or phrase just spoken by another person) and echopraxia (the repetitive imitation of the movements of another person) are often present. Additional features may include stereotypies, mannerisms, and automatic obedience or mimicry. During severe catatonic stupor or excitement, the person may need careful supervision to avoid self-harm or harm to others. Potential consequences include malnutrition, exhaustion, hyperpyrexia, or self-inflicted injury. The differential diagnosis of a Mood Episode With Catatonic Features includes Catatonic Disorder Due to a General Medical Condition, Schizophrenia, Catatonic Type, or a side effect of a medication (e.g., a Medication-Induced Movement Disorder).

Criteria

Specify if:

  • With Catatonic Features (can be applied to the current or most recent Major Depressive Episode, Manic Episode, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder)

The clinical picture is dominated by at least two of the following:

  1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
  2. excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
  3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
  4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing
  5. echolalia or echopraxia

Melancholic Features Specifier

The specifier With Melancholic Features can be applied to the current (or most recent) Major Depressive Episode that occurs in the course of Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode. The essential feature of a Major Depressive Episode, With Melancholic Features is loss of interest or pleasure in all, or almost all, activities or a lack of reactivity to usually pleasurable stimuli. The individual's depressed mood does not improve, even temporarily, when something good happens (Criterion A). In addition, at least three of the following symptoms are present: a distinct quality of the depressed mood, depression that is regularly worse in the morning, early morning awakening, psychomotor retardation or agitation, significant anorexia or weight loss, or excessive or inappropriate guilt (Criterion B).

The specifier With Melancholic Features is applied if these features are present at the nadir of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that, even for very desired events, the depressed mood does not brighten at all or brightens only partially (e.g., up to 20%-40% of normal for only minutes at a time). The distinct quality of mood that is characteristic of the With Melancholic Features specifier is experienced by individuals as qualitatively different from the sadness experienced during bereavement or a nonmelancholic depressive episode. This may be elicited by asking the person to compare the quality of the current depressed mood with the mood experienced after the death of a loved one. A depressed mood that is described as merely more severe, longer-lasting, or present without a reason is not considered distinct in quality. Psychomotor changes are nearly always present and are observable by others. Individuals with melancholic features are less likely to have a premorbid Personality Disorder, to have a clear precipitant to the episode, and to respond to a trial of placebo medication. They are more likely to have responded to antidepressant medications or electroconvulsive therapy in the past and are also more likely to respond in the current episode. Melancholic features are encountered equally in both genders, but are more likely in older individuals. These features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients, and are less likely to occur in milder than in more severe Major Depressive Episodes and are more likely to occur in those with psychotic features. Melancholic features are more frequently associated with laboratory findings of dexamethasone nonsuppression, hyperadrenocorticism, reduced rapid eye movement (REM) latency, abnormal tyramine challenge test, and an abnormal asymmetry on dichotic listening tasks.

Criteria

Specify if:

  • With Melancholic Features (can be applied ot the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it is the most recent type of mood episode)

A. Either of the following, occurring during the most severe period of the current episode:

  1. loss of pleasure in all, or almost all, activities
  2. lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporally, when something good happens)

B. Three (or more) of the following:

  1. distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)
  2. depression regularly worse in the morning
  3. early morning awakening (at least 2 hours before usual time of awakening)
  4. marked psychomotor retardation or agitation
  5. significant anorexia or weight loss
  6. excessive or inappropriate guilt

Atypical Features Specifier

The specifier With Atypical Features can be applied to the current (or most recent) Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it is the most recent type of mood episode, or to Dysthymic Disorder. The essential features are mood reactivity (Criterion A) and the presence of at least two of the following features (Criterion B): increased appetite or weight gain, hypersomnia, leaden paralysis, and a long-standing pattern of extreme sensitivity to perceived interpersonal rejection. These features predominate during the most recent 2-week period (or the most recent 2-year period for Dysthymic Disorder). The specifier With Atypical Features is not given if the criteria for With Melancholic Features or With Catatonic Features have been met during the same Major Depressive Episode.

Mood reactivity is the capacity to be cheered up when presented with positive events (e.g., a visit from children, compliments from others). Mood may become euthymic (not sad) even for extended periods of time if the external circumstances remain favorable. Increased appetite may be manifested by an obvious increase in food intake or by weight gain. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or weighted down, usually in the arms or legs; this is generally present for at least an hour a day but often lasts for many hours at a time. Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has en early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods. The problems that result from rejection sensitivity must be significant enough to result in functional impairment. There may be stormy relationships with frequent disruptions and an inability to sustain a longer-lasting relationship. The individual's reaction to rebuff or criticism may be manifested by leaving work early, using substances excessively, or displaying other clinically significant maladaptive behavioral responses. There may also be avoidance of relationships due to the fear of interpersonal rejection. Being occasionally touchy or overemotional does not qualify as a manifestation of interpersonal rejection sensitivity. Personality Disorders (e.g., Avoidant Personality Disorder) and Anxiety Disorders (e.g., Separation Anxiety Disorder, Specific Phobia, or Social Phobia) may be more common in those with atypical features. The laboratory findings associated with a Major Depressive Episode With Melancholic Features are generally not present in association with an episode with atypical features.

Atypical features are two to three times more common in women. Individuals with atypical features report an earlier age at onset of their depressive episodes (e.g., while in high school) and frequently have a more chronic, less episodic course, with only partial interepisode recovery. Younger individuals may be more likely to have episodes with atypical features, whereas older individuals may more often have episodes with melancholic features. Episodes with atypical features are more common in Bipolar I Disorder, Bipolar II Disorder, and in Major Depressive Disorder, Recurrent, occurring in a seasonal pattern.

Criteria

Specify if:

  • With Atypical Features (can be applied when these features predominante during the most recent 2 weeks of a Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when the Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder)

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:

  1. significant weight gain or increase in appetite
  2. hypersomnia
  3. leaden paralysis (i.e., heavy leaden feelings in arms or legs)
  4. long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment)

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Postpartum Onset Specifier

The specifier With Postpartum Onset can be applied to the current (or most recent) Major Depressive, Manic, or Mixed Episode of Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder or to Brief Psychotic Disorder if onset is within 4 weeks after delivery of a child. In general, the symptomatology of the postpartum Major Depressive, Manic, or Mixed Episode does not differ from the symptomatology in nonpostpartum mood episodes and may include psychotic features. A fluctuating course and mood lability may be more common in postpartum episodes. When delusions are present, they often concern the newborn infant (e.g., the newborn is possessed by the devil, has special powers, or is destined for a terrible fate). In both the psychotic and nonpsychotic presentations, there may be suicidal ideation, obsessional thoughts regarding violence to the child, lack of concentration, and psychomotor agitation. Women with postpartum Major Depressive Episodes often have severe anxiety, Panic Attacks, spontaneous crying long after the usual duration of "baby blues" (i.e., 3-7 days postpartum), disinterest in their new infant, and insomnia (more likely to manifest as difficulty falling asleep than as early morning awakening).

Many women feel especially guilty about having depressive feelings at a time when they believe they should be happy. They may be reluctant to discuss their symptoms or their negative feelings toward the child. Less-than-optimal development of the mother-infant relationship may result from the clinical condition itself or from separations from the infant. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but it can also occur in severe postpartum mood episodes without such specific delusions or hallucinations. Postpartum mood (Major Depressive, Manic, or Mixed) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a Mood Disorder (especially Bipolar I Disorder). once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. There is also some evidence of increased risk of postpartum psychotic mood episodes among women without a history of Mood Disorders with a family history of Bipolar Disorders. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a decreased level of awareness or attention.

Criteria

Onset of episode within 4 weeks postpartum.

Longitudinal Course Specifiers

The specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery are provided to help characterize the course of illness in individuals with Recurrent Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder. These specifiers should be applied to the period of time between the two most recent episodes. The characterization of course is further enhanced by noting the presence of antecedent Dysthymic Disorder.

In general, individuals with a history of Without Full Interepisode Recovery between episodes have a persistence of that pattern between subsequent episodes. They also appear more likely to have more Major Depressive Episodes than those with full interepisode recovery. Dysthymic Disorder prior to the first episode of major Depressive Disorder is most likely to be associated with lack of full interepisode recovery subsequently. These specifiers may also be applied to the period of time between the most recent mood episodes in Bipolar I Disorder or Bipolar II Disorder to indicate presence or absence of mood symptomatology.

Criteria
  • With Full Interepisode Recovery: if full remission is attained between the two most recent Mood Episodes
  • Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood Episodes

Seasonal Pattern Specifier

The specifier With Seasonal Pattern can be applied to the pattern of Major Depressive Episodes in Bipolar I Disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent. The essential features is the onset and remission of Major Depressive Episodes at characteristic times of the year. In most cases, the episodes begin in fall or winter and remit in spring. Less commonly, there may be recurrent summer depressive episodes. This pattern of onset and remission of episodes must have occurred during the last 2 years, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressive episodes must substantially outnumber any nonseasonal depressive episodes over the individual's lifetime. This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule). Major Depressive Episodes that occur in a seasonal pattern are often characterized by prominent anergy, hypersomnia, over-eating, weight gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in Major Depressive Disorder, Recurrent, or in Bipolar Disorders. However, within the Bipolar Disorders group, a seasonal pattern appears to be more likely in Bipolar II Disorder than in Bipolar I Disorder. In some individuals, the onset of Manic or Hypomanic Episodes may also be linked to a particular season. Bright visible-spectrum light used in treatment may be associated with switches into Manic or Hypomanic episodes.

The prevalence of winter-type seasonal pattern appears to vary with latitude, age, and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of seasonality, with younger persons at higher risk for winter depressive episodes. Women compromise 60%-90% of persons with seasonal pattern, but it is unclear whether female gender is a specific risk factor over and above the risk associated with recurrent Major Depressive Disorder. Although this specifier applies to seasonal occurrence of full Major Depressive Episodes, some research suggests that a seasonal pattern may also describe the presentation in some individuals with recurrent winter depressive episodes that do not meet criteria for a Major Depressive Episode.

Criteria

A. There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter). (Note: Do not include cases in which there is an obvious effect of seasonal-related psychosocial stressors (e.g., regularly being unemployed every winter).)

B. Full remissions (or a change from depression to mania or hypomania also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C. In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period.

D. Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive Episodes that may have occurred over the individual's lifetime.

Recording Procedures

In recording the name of a diagnosis, terms should be listed in the following order: Major Depressive Disorder, episodic specifiers (e.g., Recurrent), severity specifiers (e.g., Mild, Severe With Psychotic Features, In Partial Remission), as many specifiers as apply to the most recent episode (e.g., With Melancholic Features, With Postpartum Onset, and as many specifiers as apply to the course of episodes (e.g., With Full Interepisode Recovery); for example, Major Depressive Disorder, Recurrent, Moderate, With Atypical Features, With Seasonal Pattern, With Full Interepisode Recovery.

Differential Diagnosis

See the Differential Diagnosis section for Major Depressive Episode.

Bipolar I and Bipolar II Disorder

A history of a Manic, Mixed, or Hypomanic Episode precludes the diagnosis of Major Depressive Disorder. The presence of Hypomanic Episodes (without any history of Manic Episodes) indicated a diagnosis of Bipolar II Disorder. The presence of Manic or Mixed Episodes (with or without Hypomanic Episodes) indicated a diagnosis of Bipolar I Disorder.

Mood Disorder Due to a General Medical Condition

Major Depressive Episodes in Major Depressive Disorder must be distinguished from a Mood Disorder Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidism). This determination is based on the history, laboratory findings, or physical consequences of the general medical condition, then the primary Mood Disorder is recorded (e.g., Major Depressive Disorder) and the general medical condition is recorded separately (e.g., myocardial infarction). This would be the case, for example, if the Major Depressive Episode is considered to be the psychological consequence of having the general medical condition or if there is no etiological relationship between the Major Depressive Episode and the general medical condition.

Substance-Induced Mood Disorder

A Substance-Induced Mood Disorder is distinguished from Major Depressive Episodes in Major Depressive Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged 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 Mood Disorder, With Depressive Features, With Onset During Withdrawal.

Dysthymic Disorder

Dysthymic Disorder and Major Depressive Disorder are differentiated based on severity, chronicity, and persistence. In Major Depressive Disorder, the depressed mood must be present for most of the day, nearly every day, for a period of at least 2 weeks, whereas Dysthymic Disorder must be present for more days than not over a period of at least 2 years. The differential diagnosis between Dysthymic Disorder and Major Depressive Disorder is made particularly difficult by the fact that the two disorders share similar symptoms and that the differences between them in onset, duration, persistence, and severity are not easy to evaluate retrospectively. Usually Major Depressive Disorder consists of one or more discrete Major Depressive Episodes that can be distinguished from the person's usual functioning, whereas Dysthymic Disorder is characterized by chronic, less severe depressive symptoms that have been present for many years. If the initial onset of chronic depressive symptoms is of sufficient severity and number to meet criteria for a Major Depressive Episode, the diagnosis would be Major Depressive Disorder, Chronic (if the criteria are still met), or Major Depressive Disorder, In Partial Remission (if the criteria are no longer met). The diagnosis of Dysthymic Disorder is made following Major Depressive Disorder only if the Dysthymic Disorder was established prior to the first Major Depressive Episode (i.e., no Major Depressive Episodes during the first 2 years of dysthymic symptoms), or if there has been a full remission of the Major Depressive Episode (i.e., lasting at least 2 months) before the onset of the Dysthymic Disorder.

Psychotic Disorders

Schizoaffective Disorder differs from Major Depressive Disorder, With Psychotic Features, by the requirement that in Schizoaffective Disorder there must be at least 2 weeks of delusions or hallucinations occurring in the absence of prominent mood symptoms. Depressive symptoms may be present during Schizophrenia, Delusional Disorder, and Psychotic Disorder Not Otherwise Specified. Most commonly, such depressive symptoms can be considered associated features of these disorders and do not merit a separate diagnosis. However, when the depressive symptoms meet full criteria for a Major Depressive Episode (or are of particular clinical significant), a diagnosis of Depressive Disorder Not Otherwise Specified may be made in addition to the diagnosis of Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Schizophrenia, Catatonic Type, may be difficult to distinguish from Major Depressive Disorder, With Catatonic Features. Prior history or family history may be helpful in making this distinction.

Dementia

In elderly individuals, it is often difficult to determine whether cognitive symptoms (e.g., disorientation, apathy, difficulty concentrating, memory loss) are better accounted for by a dementia or by a Major Depressive Episode in Major Depressive Disorder. This differential diagnosis may be informed by a thorough general medical evaluation and consideration of the onset of the disturbance, temporal sequencing of depressive and cognitive symptoms, course of illness, and treatment response. The premorbid state of the individual may help to differentiate a Major Depressive Disorder from dementia. In dementia, there is usually a premorbid history of declining cognitive function, whereas the individual with Major Depressive Disorder is much more likely to have a relatively normal premorbid state and abrupt cognitive decline associated with the depression.

DSM-5

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, or 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).
  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 another medical condition.

Note: Criteria A-C constitute 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 judgement based on the individual's history 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.)

Specify if:

  • Single episode
  • Recurrent episode

Specify:

  • With anxious distress
  • With mixed features
  • With melancholic features
  • With atypical features
  • With mood-congruent psychotic features: Delusions or hallucinations are present at any time in the episode. The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
  • With mood-incongruent psychotic features: Delusions or hallucinations are present at any time in the episode. The content of delusions and hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.
  • With catatonia
  • With peripartum onset: This specifier can be applied to the current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.
  • With seasonal pattern (recurrent episode only)

Specify course if full criteria for a mood episode are not currently met:

  • In partial remission: Symptoms of the immediately previous major depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a major depressive episode following the end of such an episode.
  • In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.

Specify severity if full criteria for a mood episode are currently met:

  • Mild: Few, if any, symptoms in excess of those required to meet the diagnostic criteria 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 those required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.

Recording Procedures

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.

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 specifiers that apply to the current episode.

Specifiers

Anxious Distress Specifier

The presence of at least two of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression:

  1. Feeling keyed up or tense.
  2. Feeling unusually restless.
  3. Difficulty concentrating because of worry.
  4. Fear that something awful may happen.
  5. Feeling that the individual might lose control of himself or herself.

Specify current severity:

  • Mild: Two symptoms.
  • Moderate: Three symptoms.
  • Moderate-severe: Four or five symptoms.
  • Severe: Four or five symptoms with motor agitation.

Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.

Mixed Features Specifier

A. At least three of the following manic/hypomanic symptoms are present during the majority of days of a major depressive episode:

  1. Elevated, expansive mood.
  2. Inflated self-esteem or grandiosity.
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
  6. Increased or 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).
  7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).

B. Mixed symptoms are observable by others and represent a change from the person's usual behavior.

C. For individuals whose symptoms meet the full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features.

D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).

Note: Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.

Melancholic Features Specifier

A. One of the following is present during the most severe period of the current episode:

  1. Loss of pleasure in all, or almost all, activities.
  2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).

B. Three (or more) of the following:

  1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
  2. Depression that is regularly worse in the morning.
  3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
  4. Marked psychomotor agitation or retardation.
  5. Significant anorexia or weight loss.
  6. Excessive or inappropriate guilt.

Note: The specifier "with melancholic features" is applied if these features are present at the most severe stage of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked brightening of mood. Either mood does not brighten at all, or it brightens only partially (e.g., up to 20%-40% of normal for only minutes at a time). The "distinct quality" of mood that is characteristic of the "with melancholic features" specifier is experienced as qualitatively different from that during a nonmelancholic depressive episode. A depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality. Psychomotor changes are nearly always present and observable by others.

Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.

Atypical Features Specifier

This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode or persistent depressive disorder.

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).

B. Two (or more) of the following features:

  1. Significant weight gain or increase in appetite.
  2. Hypersomnia.
  3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
  4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.

C. Criteria are not met for "with melancholic features" or "with catatonia" during the same episode.

Note: "Atypical depression" has historical significance (i.e., atypical in contradistinction to the more classical agitated, "endogenous" presentations of depression that were the norm when depression was rarely diagnosed in outpatients and almost never in adolescents or younger adults) and today does not connote an uncommon or unusual clinical presentation as the term might imply.

Mood reactivity is the capacity to be cheered up when presented with positive events (e.g., a visit from children, compliments from others). Mood may become euthymic (not sad) even for extended periods of time if the external circumstances remain favorable. Increased appetite may be manifested by an obvious increase in food intake or by weight gain. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or weighted down, usually in the arms or legs. This sensation is generally present for at least an hour a day but often lasts for many hours at a time. Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive episodes.

Catatonia Specifier

The catatonia specifier can apply to an episode of depression if catatonic features are present during most of the episode.

A. The clinical picture is dominated by three (or more) of the following symptoms:

  1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
  2. Catalepsy (i.e., passive induction of a posture held against gravity).
  3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
  4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
  5. Negativism (i.e., opposition or no response to instructions or external stimuli).
  6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
  7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
  8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
  9. Agitation, not influenced by external stimuli.
  10. Grimacing.
  11. Echolalia (i.e., mimicking another's speech).
  12. Echopraxia (i.e., mimicking another's movements).

Peripartum Onset Specifier

Extra information

Mood episodes can have their onset either during pregnancy or postpartum. Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery. Fifty percent of "postpartum" major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively asperipartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the "baby blues," increase the risk for a postpartum major depressive episode.

Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations.

Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. The postpartum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment planning, and the long-term implications of a history of postpartum mood disorder on subsequent family planning.

Seasonal Pattern Specifier

This specifier applies to recurrent major depressive disorder

A. There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter). (Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter).

B. Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C. In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships as defined above and no nonseasonal major depressive episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above) substantially outnumber any nonseasonal major depressive episodes that may have occurred over the individual's lifetime.

Note: The specifier "with seasonal pattern" can be applied to the pattern of major depressive episodes in major depressive disorder, recurrent. The essential feature is the onset and remission of major depressive episodes at characteristic times of the year. In most cases, the episodes begin in fall or winter and remit in spring. Less commonly, there may be recurrent summer depressive episodes. This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressive episodes must substantially outnumber any nonseasonal depressive episodes over the individual's lifetime.

This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule). Major depressive episodes that occur in a seasonal pattern are often characterized by prominent energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in recurrent major depressive disorder or in bipolar disorders. However, within the bipolar disorders group, a seasonal pattern appears to be more likely in bipolar II disorder than in bipolar I disorder. In some individuals, the onset of manic or hypomanic episodes may also be linked to a particular season.

The prevalence of winter-type seasonal pattern appears to vary with latitude, age, and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of seasonality, with younger persons at higher risk for winter depressive episodes.

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-induce 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.

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), durations (i.e., most of the day, nearly every day for at least 2 weekS), and clinically significant distress or impairment. The diagnosed 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.

Related Criteria

Manic Episode

These criteria must have never been met:

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 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance 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:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  7. 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.)

Hypomanic Episode

These criteria must have never been met:

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 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance 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, and have been present to a significant degree:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
  7. 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 episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). (Note: A full hypomanic 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 hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms [particularly increased irritability, edginess, or agitation following antidepressant use] are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis).