DSM-5-TR - Depressive Disorders

Major Depressive Disorder

Codes: F32.x (single), F33.x (recurrent)

≥5 symptoms in 2 weeks; must include depressed mood or loss of interest

Symptoms: depressed/irritable mood, anhedonia, weight/appetite change, sleep change, psychomotor change, fatigue, worthlessness/guilt, poor concentration, suicidal thoughts/plan/attempt

Causes distress/impairment; not due to substances/medical condition; no mania/hypomania

Specifiers

Anxious distress, mixed features, melancholic, atypical, psychotic features, catatonia, peripartum onset, seasonal pattern

Clinical Features

Low mood, loss of pleasure, appetite/sleep changes, fatigue, poor concentration, guilt, suicidal ideation

Children/adolescents: irritability may replace sadness

Common presenting complaints: fatigue, insomnia

Prevalence & Course

12-month prevalence ~7% (U.S.)

Onset any age; peak in 20s

Females ~2x higher risk than males

40% recover in 3 months, 80% in 1 year

High recurrence risk; early onset = worse prognosis

Risk Factors

Temperament: neuroticism

Environment: childhood adversity, poverty, discrimination

Genetics: 2-4x risk in first-degree relatives; ~40% heritability

Medical illness increases risk/chronicity

Suicide

Strongly associated; 17x higher risk than general population

Risks: past attempts, hopelessness, anhedonia, isolation, comorbid BPD, substance use

Functional Consequences

Impairment ranges mild → complete incapacity

Poor work/school performance, relationship disruption

Higher medical illness burden

Differential Dx

Bipolar disorders

Substance/medical-induced depression

Persistent depressive disorder

PMDD

DMDD (children)

Psychotic disorders

ADHD, adjustment disorder, bereavement

Comorbidity

Anxiety, PTSD, OCD

Substance use

Eating disorders

Borderline personality disorder

Persistent Depressive Disorder

Code: F34.1

Depressed mood ≥2 yrs (≥1 yr kids/adolescents, irritable possible)

Never symptom-free >2 months

Criteria: depressed mood + ≥2 → poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness

No mania/hypomania, not due to substances/medical/psychotic disorder

Causes distress/impairment

Major depressive episodes may overlap → diagnose both

Specifiers

Early (<21), Late (≥21)

Pure dysthymic, Persistent MDE, Intermittent MDE (with/without current)

Severity: mild, moderate, severe

Prevalence & Course

~0.5% dysthymia, ~1.5% chronic MDD (U.S.)

Women 1.5-2x more

Early, insidious onset; chronic course; low remission

Risk/Prognosis

Temperamental: neuroticism, anxiety, conduct disorder

Environmental: childhood adversity, parental loss

Genetic: more common in relatives with depression

Consequences

Work, school, relationships impaired

High suicide risk

Differential Dx

MDD, bipolar disorders, cyclothymia, psychotic disorders, substance/medical-induced depression, personality disorders

Comorbidity

Anxiety, substance use, personality disorders (esp. Cluster B/C)

Substance/Medication-Induced Depressive Disorder

Criteria:

Prominent depressed mood or loss of interest

Onset during/soon after intoxication, withdrawal, or medication use

Substance/medication capable of causing symptoms

Not better explained by independent depressive disorder (e.g., persists >1 month after cessation, prior history)

Not exclusive to delirium

Causes distress/impairment

Coding:

Based on substance class + comorbid use disorder (mild, moderate/severe, none)

Specify: with onset during intoxication, withdrawal, or after medication use

Common Substances:

Depressants: alcohol, benzodiazepines, sedatives

Stimulants: cocaine, amphetamines (esp. withdrawal)

Medications: steroids, interferon, antihypertensives, L-dopa, contraceptives, isotretinoin, varenicline, chemotherapy agents

Course:

Symptoms begin with intoxication/withdrawal/medication use

Usually remit within days-weeks after cessation

If >4 weeks post-cessation → consider independent depression

Prevalence:

Substance-induced episodes common in alcohol/stimulant users (>40%)

General population prevalence ~0.3%

Risk Factors:

Antisocial personality, schizophrenia, bipolar disorder

Recent stressors

Family history of substance use disorders

Prior substance-induced depression

Suicide:

Elevated risk, especially with alcohol-related episodes

Differential Dx:

Substance intoxication/withdrawal (if mood symptoms predominate → diagnose depressive disorder)

Independent depressive disorder (occurs outside substance use/withdrawal window)

Depressive disorder due to another medical condition

Comorbidity:

High with substance use disorders, tobacco use, gambling disorder, antisocial personality disorder

Less likely to have persistent depressive disorder