Major Depressive Disorder DSM-5

Diagnostic Symptoms

1) depressed mood, almost all day almost every day (objective or subjective)

2) loss of interest/pleasure in all/almost all activities, almost all day almost every day (objective or subjective)

3) significant change in appetite, almost every day / significant weight loss or weight gain (more than 5% of body weight)

4) insomnia or hypersomnia, almost every day

5) physical agitation or retardation, almost every day (objective)

6) fatigue / energy loss, almost every day

7) feeling worthless / excessive guilt, almost every day

8) reduced ability to think, concentrate, make decisions, etc., almost every day (objective or subjective)

9) recurring thoughts of death (NOT fear of dying) or suicidal ideation or any suicide plan / suicide attempt

Diagnostic Criteria

• must show at least 5 out of 9 symptoms for at least two weeks, and one of those symptoms MUST be either depressed mood or loss of interest/pleasure

• symptoms must be newly present or significantly worse than pre-episode status

• symptoms must cause clinically significant distress or impairment in important areas of functioning

• episode can’t be attributed to substance use or another medical condition

• at least one major depressive episode can’t be better explained by a psychotic disorder

• must not have any history of manic/hypomanic episodes

Diagnostic Features

• Major Depressive Disorder requires presence of at least one major depressive episode (determined by severity, duration, and impairment of symptoms) in absence of history of manic/hypomanic episodes

• often patients will present with insomnia or fatigue, rather than complaints of mood

• psychomotor issues are less common, but indicate higher level of severity

• guilt over being sick / failing to fulfill responsibilities is very common, but not enough to meet the criterion for excessive guilt — guilt must be delusional in nature (if over present conditions) or rooted in past failings

• getting accurate symptom report may be difficult because of symptoms regarding concentration and memory, or because of patient tendency to deny or rationalise

Prevalence

• 7% over 12-month period in US

• 2x more common in women (prevalence peaks in adolescence and then stabilises)

• 3x more common in young adults (18-29) than elderly (60+)

Development

• can appear at any age, but likelihood increases significantly in puberty

• peak incidence in 20s

• many who initially present with MDD will later be diagnosed with bipolar disorder, especially if onset is during adolesence or there is family history of bipolar or presence of psychotic features

• MDD with psychotic features may also later transition into schizophrenia

• recovery is variable — some never experience remission, some have many years of no symptoms between episodes. chronicity of symptoms indicates lesser chance of full symptom resolution + higher chance of comorbid disorder. experiences of marginalisation may also contribute.

• recovery from a major depressive episode begins in 3 months for 40% of people and within 1 year for 80% of people

Temperamental / Psychological Etiology

• neurotic personality organisation or negative affect is a risk factor

• high levels of neuroticism suggest individual is more likely to develop major depressive episode during stressful periods

Environmental Etiology

• adverse childhood experiences (esp. multiple experiences of diverse types) are potential risk factors

• social determinants of mental health (low-income, lack of education, racism, other forms of marginalisation) indicate higher risk

• stressful life events may precipitate major depressive episodes

Genetic / Biological Etiology

• first-degree family members of people with MDD are 2 - 4x more at risk of developing MDD than genpop

• 40% chance of heritability

• women are at higher risk during some reproductive life stages (premenstrual, post-partum, perimenopause)

Course Modifiers

• all major non-mood disorders increase the risk of MDD (most common: substance use, anxiety, BPD)

• chronic and/or disabling medical conditions also increase risks for major depressive episodes, and these episodes are more likely to become chronic than those of medically healthy individuals

Functional Consequences

• impairment may range from mild (symptoms are not observable by others) to severe (complete incapacity/mutism/catatonia)

• more pain and and physical illness than those without MDD in clinical settings

Differential Diagnosis: Manic Episodes w/ Irritable Mood or Mixed Features

not MDD if there are enough manic symptoms to meet threshold criteria for diagnosis (either 3 or 4 depending on presence of manic mood)

Differential Diagnosis: Bipolar Disorders

not MDD if there is any history of hypomanic episodes without manic episodes (bipolar 2) or if there’s any history of manic episodes (bipolar 1). if patient has experienced a period of hypomania that didn’t meet the criteria for a hypomanic episode, diagnosis can be either MDD or other-specified bipolar disorder, depending on clinical judgment.

Differential Diagnosis: Depressive Disorder Due to Other Medical Condition

not MDD if major depressive-like episodes can be attributed to pathophysiological consequences of a medical condition (eg: MS, stroke, hypothyroidism)

Differential Diagnosis: Substance or Medication-Induced Depressive Disorder

not MDD if the mood disturbances only happen in relation to a substance (either when on the substance or when withdrawing from it)

Differential Diagnosis: Persistent Depressive Disorder

PDD is diagnosed if the depressed mood occurs more days than not for at least 2 years. if criteria for both PDD and MDD are met, both can be diagnosed.

Differential Diagnosis: Premenstrual Dysphoric Disorder

not MDD if the depressive episodes occur in relation to menstrual cycle (in PMDD, dysphoric mood begins 1 wk before period and becomes minimal or absent in the week after it is over).

Differential Diagnosis: Disruptive Mood Regulation Disorder

not MDD if mood is labile almost all day every day and accompanied by outbursts; irritability should be limited to depressive episodes

Differential Diagnosis: Major Depressive Episodes Superimposed on Schizophrenic Spectrum or Psychotic Disorders

depressive synptoms are often considered associated features of schizophrenia, delusional disorder, schizophreniform disorder, or other schizophrenia spectrum and psychotic disorders, and usually don’t merit a second diagnosis. when depressive symptoms fully meet criteria for a major depressive episode, an additional diagnosis of “other specified depressive disorder” may be made

Differential Diagnosis: Schizoaffective Disorder

differentiated from MDD with psychotic features — in schizoaffective disorder, delusions or hallucinations must be present for at least 2 weeks in absence of a major depressive episode

Differential Diagnosis: ADHD

can be comorbid with MDD, but shouldn’t overdiagnose MDD in children with ADHD whose primary mood disturbance is irritability

Differential Diagnosis: Adjustment Disorder w/ Depressed Mood

distinguished from MDD where major depressive episode is triggered by a psychosocial stressor bc the full criteria for a major depressive episode won’t be met

Differential Diagnosis: Bereavement

while there are many overlapping symptoms (depressed mood, sleep disturbances, concentration problems), bereavement is distinguished by the primary feelings of emptiness and loss (not lack of pleasure and depressed mood), as well as the intensity of the grief fading over time and only spiking when reminded of the loss (rather than persistent presence without specific triggers. however, bereavement may trigger a major depressive episode or worsen a pre-existing major depressive episode in vulnerable people (eg, people with previous histories of MDD)

Differential Diagnosis: Prolonged Grief Disorder

prolonged grief disorder requires some form of preoccupation with the deceased, and can be differentiated by the presence of other symptoms like emotional pain, reduction in emotion, and difficulty reengaging socially being the result of loss, rather than a more general depressed mood not associated with loss. can be comorbid with MDD if criteria for both disorders are met.

Differential Diagnosis: Sadness

sometimes people are just sad lol. if that sadness does not meet the MDD criteria for severity and duration, but IS significantly impairing client’s life, Other Specified Depressive Disorder can be diagnosed.

Differential Diagnoses List

• ADHD

• Sadness

• Persistent Depressive Disorder

• Prolonged Grief Disorder

• Bereavement

• Schizoaffective Disorder

• Depressive Episodes Superimposed on Schizophrenic Spectrum and Other Psychotic Disorders

• Premenstrual Dysphoric Disorder

• Bipolar Disorders

• Adjustment Disorder w/ Depressed Mood

• Manic Episodes w/ Irritable Mood or Mixed Features

• Depressive Disorder due to Another Medical Condition

• Substance / Medication-Induced Depressive Disorder

• Disruptive Mood Regulation Disorder

Frequent Comorbidities

• substance-related disorder

• generalised anxiety disorder

• panic disorder

• PTSD

• OCD

• anorexia

• bulimia

• BPD