DEPRESSIVE DISORDER
Depressive disorder, often referred to as depression, is
a common and serious mental health condition characterized by
persistent feelings of sadness, hopelessness, and a lack of
interest or pleasure in most activities. It can significantly affect
a person's thoughts, emotions, behavior, and physical wellbeing. Depression is not just a passing mood or a normal
response to life's challenges; it is a medical condition that
requires attention and treatment.
DISRUPTIVE MOOD DYSREGULATION DISORDER
Disruptive Mood Dysregulation Disorder is a mental
health condition characterized by severe and chronic irritability
that was recently added to the Diagnostic and Statistical Manual
of Mental Disorders, fifth edition (DSM-5) for childhood and
adolescent disorders (APA, 2013). It was specified by acute and
recurrent temper outbursts that are disproportionate to the
situation and inconsistent with the developmental level of a
child.
DIAGNOSTIC FEATURE AND CRITERIA
Criteria A: Severe recurrent temper outburst out of proportion
in intensity or duration to
stressor.
Criteria B: Temper outburst is inconsistent with
developmental level
Criteria C: Temper outburst occur three or more times per
week
Criteria D: Mood persistently irritable most of the day, nearly
everyday, and observable by others.
Criteria E: Doesn’t have a period lasting 3 or more consecutive
months without all the symptoms of Criteria A-D.
Criteria F: Criteria A-D are present in at least 2 or 3 settings,
and are severe in at least one of these
Criteria G: Diagnosis should not be made for the first time
before age 6 years or after age 18 years.
Criteria H: The age at onset of Criteria A-E is before 10 years.
Criteria I: Never had a manic episode
Criteria J: Not exclusively during depressed episodes
Criteria K: Symptoms are not attributable to the physiological
effects of a substance or to another medical condition.
Disruptive mood dysregulation disorder is
characterized by chronic, severe persistent irritability, which
includes frequent temper outbursts in response to frustration
(averaging three or more times per week over at least a year in
at least two settings) and a persistently irritable or angry mood
present most of the day, nearly every day, and noticeable by
others in the child's environment. Disruptive mood
dysregulation disorder was introduced in DSM-5 to distinguish
it from classic bipolar disorder, which requires distinct episodes
of mania or hypomania, aiming to address concerns about the
classification and treatment of children with chronic, severe
irritability compared to episodic bipolar disorder.
DEVELOPMENT AND COURSE
Disruptive Mood Dysregulation Disorder typically
starts before the age of 10, and should not be diagnosed in
children with a developmental age of less than 6 years old.
These symptoms may change as children grow, so the diagnosis
should be limited to age groups where its validity has been
established (7-18 years). About half of children with severe and
chronic irritability will continue to meet the criteria of this
symptom for one year. The likelihood of children with chronic
irritability developing bipolar disorder is very low. However,
they are at risk for developing unipolar depressive or anxiety
disorders in adulthood. Bipolar disorder is rare before
adolescence but increases into early adulthood. In contrast,
Disruptive Mood Dysregulation Disorder is more common than
bipolar disorder in children, and its symptoms generally
become less common as children transition into adulthood.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Differentiating disruptive mood dysregulation
disorder from bipolar disorders involves recognizing the
persistent irritability in the former as opposed to episodic mood
perturbations in the latter, while distinguishing it from
oppositional defiant disorder hinges on severe recurrent
outbursts and mood disruption, and comorbid diagnoses of
ADHD, major depressive disorder, or anxiety disorders are
possible as long as irritability is not solely linked to a major
depressive episode or anxiety exacerbation.
Rates of comorbidity in disruptive mood dysregulation
disorder are extremely high, with individuals rarely meeting
criteria for this disorder alone, often having diverse comorbid
illnesses including oppositional defiant disorder, but it should
not be diagnosed if symptoms align with bipolar disorder or if
they occur only in specific contexts like anxiety-provoking
situations or during routines disrupted by other disorders.
TREATMENT APPROACH
Disruptive Mood Dysregulation Disorder (DMDD) is often
treated with a combination of therapeutic and pharmacological
approaches. List below are some of the approaches in treating
DMDD:
Therapeutic Approach:
Cognitive-Behavioral Therapy (CBT): Identifies and alters
the negative thought patterns and behaviors that contribute to
emotional distress and mental health issues.
Parent Training: Focuses on training parents to learn how to
manage and respond to their child's disruptive behavior
effectively.
Dialectical behavior therapy for children (DBT-C): Focuses
on helping children learn to regulate their emotions and avoid
extreme or prolonged outbursts.
Pharmacological Approach:
Antidepressants: Selective Serotonin Reuptake Inhibitors
(SSRIs) like citalopram, when combined with the stimulant
methylphenidate, decreases irritability and help manage mood
symptoms in patients with DMDD.
Atypical Antipsychotic Medication: Medications like
aripiprazole or risperidone are used to treat children with
irritability, severe outbursts, or aggression.
MAJOR DEPRESSIVE DISORDER
Major Depressive Disorder is a medical condition that
includes abnormalities of affect and mood, neurovegetative
functions (such as appetite and sleep disturbances), cognition
(such as inappropriate guilt and feelings of worthlessness), and
psychomotor activity (such as agitation or retardation). It is the
most prevalent form of depressive disorder that significantly
affects an individual’s everyday life, including their thoughts,
behavior, and well-being.
DIAGNOSTIC FEATURE AND CRITERIA
Criteria A: Five (or more) of the following symptoms must be
present during the same two-week period and represent a
change from previous functioning. At least one of the symptoms
must be either (1) depressed mood or (2) loss of interest or
pleasure.
1. Depressed or Low Mood
2. Anhedonia (loss of interest and pleasure)
3. Weight Gain or Loss
4. Loss or increase of appetite
5. Insomnia or Hypersomnia
6. Psychomotor agitation or retardation
7. Unexplained Fatigue
8. Difficulty in concentrating
9. Recurrent thoughts of death
Criteria B: The symptoms cause clinically significant distress
or impairment in social, occupational, or other important areas
of functioning.
Criteria C: The episode is not attributable to the physiological
effects of a substance or another medical condition.
Criteria D: The occurrence of the major depressive episode is
not better explained by other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
Criteria E: There has never been a manic or hypomanic
episode.
Major depressive disorder is diagnosed when an
individual experiences nearly daily symptoms, including
persistent depressed mood, loss of interest in most activities,
appetite and sleep disturbances, psychomotor changes, fatigue,
feelings of worthlessness or guilt, difficulty concentrating,
thoughts of death or suicide, and functional impairment, lasting
for at least 2 weeks, with careful consideration for potential cooccurring medical conditions.
DEVELOPMENT AND COURSE
Major Depressive Disorder (MDD) can manifest at
any age but becomes more likely with puberty. It has variable
courses; some experience chronic symptoms, while others have
periods of remission. Chronicity of depressive symptoms is
associated with underlying personality, anxiety, and substance
use disorders and lower chances of full recovery. Recovery
often starts within 3 months for 2 in 5 individuals and within 1
year for 4 in 5. The recent onset correlates with better near-term
recovery, while factors like psychosis, anxiety, and severity
hinder recovery. Recurrence risk decreases with remission
duration but rises with severe prior episodes and multiple
episodes. Even mild symptoms during remission predict
recurrence risk. Some initially diagnosed with major depressive
disorder may later have bipolar disorder, especially with onset
in adolescence, psychotic features, or a family history of bipolar
illness. Also, Major depressive disorder can sometimes
transition into schizophrenia, more commonly than the reverse.
Suicide attempts become less likely in middle and late life, but
the risk of completed suicide remains. Early-onset depression is
more likely to involve personality disturbances. The course of
major depressive disorder typically remains consistent with age,
and recovery times remain stable over time.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Distinguishing between major depressive episodes and
manic episodes with irritable mood or mixed episodes requires
careful evaluation of manic symptoms, while diagnoses like
mood disorder due to another medical condition,
substance/medication-induced depressive or bipolar disorder,
attention-deficit/hyperactivity disorder, adjustment disorder
with depressed mood, and normal sadness have distinct criteria,
such as medical causation, substance involvement, symptom
characteristics, stressors, and severity/duration considerations.
Major depressive disorder often co-occurs with other
conditions, including substance-related disorders, panic
disorder, obsessive-compulsive disorder, anorexia nervosa,
bulimia nervosa, and borderline personality disorder.
TREATMENT APPROACHES
Several studies have shown that Medications and
Psychological interventions are the most effective way to treat
an individual with a Major Depressive Disorder (MDD),
especially when combining both of these treatments. There are
many types of antidepressants that's used for treating
depression. List below are the commonly known medications:
Selective serotonin reuptake inhibitors (SSRIs). These drugs
are considered safer and generally cause fewer bothersome side
effects than other types of antidepressants. It includes
citalopram (Celexa), escitalopram (Lexapro), fluoxetine
(Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft) and
vilazodone (Viibryd) which helps increase the level of serotonin
in the brain.
Serotonin-norepinephrine reuptake inhibitors (SNRIs).
This medication includes duloxetine (Cymbalta), venlafaxine
(Effexor XR), desvenlafaxine (Pristiq, Khedezla) and
levomilnacipran (Fetzima) which helps regulate the mood and
relieve depression.
Monoamine oxidase inhibitors (MAOIs). This drug includes
tranylcypromine (Parnate), phenelzine (Nardil) and
isocarboxazid (Marplan) which helps increase the levels of
certain neurotransmitters in the brain to boost the mood and
improve other depressive symptoms.
Cognitive-Behavioral Therapy, on the other hand, is one of
the commonly used psychological interventions in treating
depression. It focuses on identifying how negative thoughts,
false beliefs and attitudes affect the feelings and actions of an
individual.
PERSISTENT DEPRESSIVE DISORDER
(Dysthymia)
Persistent depressive disorder (PDD), is a chronic
depression that persists for most days over a period of 2 years
(or longer). It also originally known as dysthymia, came from
the Greek roots dys, meaning "ill" or "bad," and thymia,
meaning "mind" or "emotions." The terms dysthymia and
dysthymic disorder referred to a mild, chronic state of
depression.
part of the psychiatric evaluation to provide context to
symptoms.
DIAGNOSTIC CRITERIA AND FEATURE
The general symptoms are milder than major
depressive disorder but additional symptoms involved in MDD
may develop during dysthymia and lead to a diagnosis of MDD.
They may have episodes of MDD at least once at some point
and the comorbidity of both these disorders is known as a
double depression, the co-existence of major depressive
disorder and persistent depressive disorder. It is frequently
comorbid with other psychiatric and medical conditions. As
always, the above symptoms and criteria must cause significant
distress and impairment in critical areas of functioning to meet
the threshold for diagnosis.
To meet the diagnostic criteria of PDD, two or more
of the following must be present or cannot be absent for more
than 2 consecutive months:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration
• Feelings of hopelessness
DEVELOPMENT AND COURSE
Criteria A
During the 2 year period of the disturbance, the person has
never been without symptoms from the above two criteria for
more than 2 months at a time.
Criteria B
Criteria for MDD may be continuously present for 2 years, in
which case patients should be given comorbid diagnoses of
persistent depressive disorder and MDD.
Criteria C
There has never been a manic episode, a mixed episode, or a
hypomanic episode and the criteria for cyclothymia have never
been met.
Criteria D
The symptoms are not better explained by a psychotic disorder.
Criteria E
The disturbance is not due to the direct physiological effects of
a substance (e.g., a drug of abuse or a medication) or a general
medical condition.
Criteria F
The symptoms cause clinically significant distress or
impairment in important areas of functioning.
For adults, symptoms of depression must be
experienced more often than not for at least two years prior. On
the other hand, for children or adolescents, the mood can be
irritable instead of depressed, and the time requirement was
lowered to 1 year.
Affected patients may be habitually gloomy,
pessimistic, humorless, passive, lethargic, introverted,
hypercritical of self and others, and complaining. Patients with
PDD are also more likely to have underlying anxiety disorders,
substance use disorders, or personality (ie, borderline
personality) disorders.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Differential diagnosis for persistent depressive
disorder includes ruling out medical/organic causes as well as
screening for other DSM diagnoses, including major
depression, bipolar, psychotic disorders, substance-induced
states, and personality disorders. Also, a thorough assessment
of patients presenting with mental health symptoms involves
ruling out medical and biological causes with their current and
past medical history, as well as current medications, should be
Symptoms of PDD typically begin insidiously during
adolescence and may persist for 2 years or more in decades. It
can have early onset (before age 21 years) or late onset (at age
21 years or older) and the number of symptoms often fluctuates
above and below the threshold for major depressive episodes.
There are no known biological causes that apply
consistently to all cases of persistent depressive disorder, which
suggests diverse origins for the disorder, but there are a number
of factors that are believed to play a role, including:
• Brain chemistry: The balance of neurotransmitters in the
brain can play a role in the onset of depression. Some
environmental factors, such as prolonged stress, can actually
alter these brain chemicals.
• Environmental factors: Situational variables such as stress,
loss, grief, major life changes, and trauma can also cause
depression.
• Genetics: Having close family members with a history of
depression or doubles a person's risk of also developing
depression.
When it comes to gender, the prevalence of persistent
depressive disorder is two times higher in females than in males,
and this is fairly consistent worldwide. While frequency in age
groups for persistent depressive disorder, depression rates tend
to decrease with increasing age, especially age greater than 65.
Admittedly, estimates of depression may be low in the elderly
due to increasing confounding physical disorders with age.
TREATMENT APPROACHES
A combination of antidepressant medication and
psychotherapy has consistently been shown to be the most
effective line of treatment for people diagnosed with persistent
depressive disorder.
In psychotherapy it may involve a range of different
techniques, but two that are often used are cognitive behavioral
therapy (CBT) and interpersonal therapy (IPT).
●
Cognitive Behavioral Therapy (CBT): Focuses on
learning to identify and change the underlying
●
negative thought patterns that often contribute to
feelings of depression.
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●
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Interpersonal Therapy (IPT): Similar to CBT but
focuses on identifying problems in relationships and
communication and then finding ways to make
improvements in how you relate to and interact with
others.
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For antidepressants there are different types that may be
prescribed to treat PDD, including:
• Selective serotonin reuptake inhibitors (SSRIs): These
medications include sertraline Zoloft (sertraline) and Prozac
(fluoxetine) that works by increasing serotonin levels in the
brain, which can help improve and regulate mood.
• Serotonin and norepinephrine reuptake inhibitors
(SNRIs): These medications include Cymbalta (duloxetine)
and Pristiq (desvenlafaxine) that also works by increasing the
amount of serotonin and norepinephrine in the brain.
PREMENSTRUAL DYSPHORIC DISORDER
Premenstrual dysphoric disorder (PMDD) is
conceptualized as a more serious form of premenstrual
syndrome (PMS). It causes physical and emotional symptoms
every menstrual cycle in the week or two before your period. It
is characterized by dysphoria, mood lability, irritability,
anxiety, and cognitive changes that occur repeatedly during the
premenstrual phase of the cycle and resolve around the time of
(or after) menses.
DIAGNOSTIC FEATURES AND CRITERIA
Currently, PMDD is listed in the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as
a separate entity under Depressive disorders, with the criteria
for diagnosis as follows:
Criterion A - At least 5 of the following 11 symptoms
(including at least 1 of the first 4 listed) should be present:
● Markedly depressed mood, feelings of hopelessness,
or self-deprecating thoughts
● Marked anxiety, tension, feelings of being “keyed up”
or “on edge”
● Marked affective lability
● Persistent and marked anger or irritability or increased
interpersonal conflicts
● Decreased interest in usual activities (eg, work, school,
friends, and hobbies)
● Subjective sense of difficulty in concentrating
● Lethargy, easy fatigability, or marked lack of energy
● Marked change in appetite, overeating, or specific
food cravings
● Hypersomnia or insomnia
● A subjective sense of being overwhelmed or out of
control
Other physical and behavioral symptoms:
● breast tenderness or swelling
● pain in your muscles and joints
headaches
feeling bloated
changes in your appetite, such as overeating or having
specific food cravings
sleep problems
increased anger or conflict with people around you
becoming very upset if you feel that others are
rejecting you.
Criterion B - symptoms severe enough to interfere
significantly with social, occupational, sexual, or scholastic
functioning.
Criterion C - symptoms discretely related to the menstrual
cycle and must not merely represent an exacerbation of the
symptoms of another disorder, such as major depressive
disorder, panic disorder, dysthymic disorder, or a personality
disorder (although the symptoms may be superimposed on
those of these disorders).
Criterion D - criteria A, B, and C are confirmed by prospective
daily ratings during at least 2 consecutive symptomatic
menstrual cycles. The diagnosis may be made provisionally
before this confirmation.
For some people, symptoms of PMDD last until
menopause. And so, women with moderate-to-severe PMS or
PMDD experience more quality-of-life detriments and workproductivity losses and incur greater healthcare costs than
women with no or only mild symptoms, as some symptoms are
severe enough to interfere with functioning at home, school, or
work. It occurs in an estimated 5% of women, and if left
untreated, may become more severe and extend in duration over
time.
DEVELOPMENT AND COURSE
The onset of PMDD, symptoms typically emerge
during the mid- to late twenties and follow a chronic course if
left untreated. In women with PMDD, symptoms tend to worsen
over time but discontinue during interruptions of the ovulatory
cycle (i.e., menopause, pregnancy, and ovariectomy).
The main cause of PMDD is still not known. However,
decreasing levels of estrogen and progesterone hormones
after ovulation and before menstruation may trigger symptoms.
Also, serotonin, a brain chemical that regulates mood, hunger
and sleep, may also play a role as it changes throughout your
menstrual cycle.There are also risk factors associated with the
development of PMS/PMDD which are the following:
● Past traumatic events: Traumatic events or even
interpersonal trauma associated with stress and
preexisting anxiety disorders are risk factors for the
development of PMDD.
● Cigarette smoking: There is a strong association of
moderate-to-severe forms of PMS with current
smoking status compared to non-smokers because of
hormonal sensitivity. The risk is elevated even for
former smokers, and the of incident PMS tends to
increase with the quantity of cigarette smoking (20
pack-years). Further, the risk of PMDD is significantly
higher for women who began smoking during
adolescence.
●
Genetics: Some research suggests that increased
sensitivity to changes in hormone levels may be
caused by genetic variations or from inherited
disorders that might have caused PMDD.
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DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Lifetime comorbidity rates are high (30–70%), PMDD
may put women at risk for later depression, including
perimenopausal, postpartum depression and some have
previous history of a major depressive episode which is the
most common comorbidity with PMDD. Conversely, mood or
anxiety disorders may put women at risk for later development.
As symptoms of PMDD can overlap with other
psychiatric disorders, most importantly major depression, it is
imperative to rule out another existing disorder before making
the diagnosis of PMS/PMDD. The key factor in making the
diagnosis is the temporal association of symptoms with the
menstrual cycle. Some common differentials include:
● Major depressive disorder: Depression symptoms
include low mood, low energy, appetite change, sleep
disturbance, difficulty concentrating, and thoughts of
suicide. Roughly half the cases of PMS/PMDD can
have a coexisting diagnosis of depression. A diagnosis
of PMS or PMDD may predate a diagnosis of
depression or depression and PMDD may coexist.
Criteria for the diagnosis of these disorders are
different but not exclusive.
● Thyroid disease (hyperthyroid or hypothyroid):
Hypothyroid symptoms and signs include weight gain,
constipation, cold intolerance, depression, dry skin,
and delayed deep tendon reflexes. Hyperthyroid signs
and symptoms include weight loss, poor sleep, heat
intolerance, heart rhythm disturbance such as atrial
fibrillation, and hyperreflexia.
● Generalized anxiety disorder: Symptoms of anxiety
include palpitations and feelings of fear. Triggers may
be identified for anxiety attacks, and the patient shows
avoidance of these triggers. Chronic or situational
anxiety does not vary with the menstrual cycle.
Generalized anxiety disorder and PMDD may coexist.
Criteria are different but not exclusive.
● Mastalgia: Symptoms of mastalgia may be limited to
just breast tenderness and swelling, and mastalgia may
be present at times other than during the luteal phase
but worsen during the luteal phase.
There are also Assessment Scales used to acquire a
certain and exact diagnosis of the PMDD, and these are the
following:
● Premenstrual Symptom Screening Tool (PSST): A
questionnaire used to diagnose PMDD with 19 items
that allow the patient to rate the severity of their
symptoms.
● Calendar
of
Premenstrual
Experiences
(COPE): Includes 22 symptoms grouped into 4
categories: mood reactivity, autonomic/ cognitive,
appetitive, and related to fluid retention.
Visual Analogue Scale (VAS): This scale is used in
1999 to rate each of the 4 core symptoms of PMDD:
mood swings, irritability, tension, and depression. The
scale consisted of a 100 vertical line labeled 0 or “no
symptom” at the left end and 100 or “severe” at the
right.
Daily Record of Severity of Problems (DRSP): This
scale consists of 24 items, out of which 21 items are
grouped into 11 distinct symptoms and 3 functional
impairment items. The items are rated from 1 (not at
all) to 6 (extreme).
TREATMENT APPROACHES
Treatment modalities for PMDD can be divided into 2
categories:
1. Non-Pharmacological Methods
● Exercise: Get regular aerobic exercise throughout the
month to reduce the severity of PMS symptoms. As it
improves symptoms through elevation of betaendorphin levels.
● Dietary modifications: Increased intake of complex
carbohydrates or proteins ("slow-burning fuels");
healthy diet is believed to increase tryptophan
availability, leading to increased serotonin levels.
● Stress management: Relaxation, meditation, yoga,
and breathing techniques.
2.
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Pharmacological Methods
Serotonin Reuptake Inhibitors (SRIs): SRIs have
been proven to be effective in the treatment of severe
mood and somatic symptoms of PMDD
Cognitive behavioral therapy (CBT): Has been
shown to be an effective treatment for mood and
anxiety disorders and has been shown to help people
cope better with physical symptoms, such as pain.
However, effectiveness to PMDD still requires further
study.
Benzodiazepines (BZDs): BZDs have been found to
be effective only in women with severe anxiety and
premenstrual insomnia. However, since there is a risk
of dependence, careful monitoring is required,
especially in cases with reported prior substance
abuse.
Drospirenone (a gestagen): Particularly found to be
effective in treating PMDD symptoms because of its
anti-aldosterone and anti-androgenic effects.
Oral contraceptive pills (OCPs): Although widely
used in clinical practice, their efficacy in treating
PMDD has not been strongly supported by evidence.
Women on OCP experience more hormone-related
symptoms on hormone-free days, and hence OCP
treatment with fewer hormone-free days might be
beneficial to these women.
Other medicines (such as Depo-Lupron) suppress the
ovaries and ovulation, although the side effects that
occur are similar to those occurring in women in
menopause
Pain relievers such as aspirin or ibuprofen that may be
prescribed for headache, backache, menstrual cramps,
and breast tenderness.
SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE
DISORDER
Substance/Medication-Induced Depressive Disorder is
a specific type of depressive disorder that is triggered by the use
of a substance, such as drugs or medications. The diagnosis of
this disorder is typically made based on specific criteria
outlined in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), which is a widely accepted
reference for mental health professionals.
DIAGNOSTIC CRITERIA
A. A prominent and persistent disturbance in mood that
predominates in the clinical picture and is
characterized by depressed mood or markedly
diminished interest or pleasure in all, or almost all,
activities.
B. There is evidence from the history, physical
examination, or laboratory findings of both (1)and(2):
1. The symptoms in Criterion A developed
during or soon after substance intoxication or
withdrawal or after exposure to a medication.
2. The involved substance/medication is
capable of producing the symptoms in
Criterion A.
C. The disturbance is not better explained by a depressive
disorder that is not substance/medication-induced.
Such evidence of an independent depressive disorder
could include the following:
The symptoms preceded the onset of the
substance/medication use; the symptoms persist for a
substantial period of time (e.g., about 1 month) after
the cessation of acute withdrawal or severe
intoxication; or there is other evidence suggesting the
existence
of
an
independent
nonsubstance/medication-induced depressive disorder
(e.g., a history of recurrent non-substance/medicationrelated episodes).
D. The disturbance does not occur exclusively during the
course of a delirium.
E. The disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
Note: This diagnosis should be made instead of a
diagnosis of substance intoxication or substance
withdrawal only when the symptoms in Criterion A
predominate in the clinical picture and when they are
sufficiently severe to warrant clinical attention.
DIAGNOSIS FEATURES
The diagnostic features of substance/medicationinduced depressive disorder include the symptoms of a
depressive disorder, such as major depressive disorder;
however, the depressive symptoms are associated with the
ingestion, injection, or inhalation of a substance (e.g., drug of
abuse, toxin, psychotropic medication, other medication), and
the depressive symptoms persist beyond the expected length of
physiological effects, intoxication, or withdrawal period. As
evidenced by clinical history, physical examination, or
laboratory findings, the relevant depressive disorder should
have developed during or within 1 month after use of a
substance that is capable of producing the depressive disorder
(Criterion Bl). In addition, the diagnosis is not better explained
by an independent depressive disorder. Evidence of an
independent depressive disorder includes the depressive
disorder preceded the onset of ingestion or withdrawal from the
substance; the depressive disorder persists beyond a substantial
period of time after the cessation of substance use; or other
evidence suggests the existence of an independent nonsubstance/medication-induced depressive disorder (Criterion
C). This diagnosis should not be made when symptoms occur
exclusively during the course of a delirium (Criterion D). The
depressive disorder associated with the substance use,
intoxication, or withdrawal must cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning to qualify for this diagnosis
(Criterion E). Some medications (e.g., stimulants, steroids, Ldopa, antibiotics, central nervous system drugs, dermatological
agents, chemotherapeutic drugs, immunological agents) can
induce depressive mood disturbances. Clinical judgment is
essential to determine whether the medication is truly
associated with inducing the depressive disorder or whether a
primary depressive disorder happened to have its onset while
the person was receiving the treatment. For example, a
depressive episode that developed within the first several weeks
of beginning alpha-methyldopa (an antihypertensive agent) in
an individual with no history of major depressive disorder
would qualify for the diagnosis of medication-induced
depressive disorder. In some cases, a previously established
condition (e.g., major depressive disorder, recurrent) can recur
while the individual is coincidentally taking a medication that
has the capacity to cause depressive symptoms (e.g., L-dopa,
oral contraceptives). In such cases, the clinician must make a
judgment as to whether the medication is causative in this
particular
situation.
A
substance/medication-induced
depressive disorder is distinguished from a primary depressive
disorder by considering the onset, course, and other factors
associated with the substance use. There must be evidence from
the history, physical examination, or laboratory findings of
substance use, abuse, intoxication, or withdrawal prior to the
onset of the depressive disorder. The withdrawal state for some
substances can be relatively protracted, and thus intense
depressive symptoms can last for a long period after the
cessation of substance use.
DEVELOPMENT AND COURSE
The
development
and
course
of
Substance/Medication-Induced Depressive Disorder are closely
tied to the use of substances or medications and can vary
depending on several factors, including the type of substance or
medication involved, individual susceptibility, and treatment
interventions. Here's an overview of the development and
course of this disorder, along with relevant references:
DEVELOPMENT
1. Exposure to Substances/Medications: The disorder
develops when an individual is exposed to a substance
(e.g., drugs, alcohol) or medication that can trigger
depressive symptoms. These substances may include
2.
alcohol, stimulants, opioids, sedatives, medications
with depressant effects, or others.
Temporal Relationship: Depressive symptoms
typically emerge during or shortly after the use of the
substance, withdrawal from the substance, or exposure
to a medication. It's crucial to establish a temporal
relationship between the substance use/exposure and
the onset of depressive symptoms.
COURSE
1. Acute Phase: During the acute phase, individuals
experience significant depressive symptoms that are
related to substance use or medication exposure. These
symptoms can include a persistently low mood, loss of
interest or pleasure in activities, changes in appetite or
weight,
sleep
disturbances,
and
impaired
concentration.
2. Duration: The duration of Substance/MedicationInduced Depressive Disorder can vary. It may be
relatively short-lived, especially if related to acute
intoxication or withdrawal. In some cases, depressive
symptoms may persist for a more extended period after
substance use has ceased.
3. Severity: The severity of symptoms can range from
mild to severe, depending on the specific substance,
the individual's vulnerability, and the duration of
exposure. In some instances, individuals may
experience severe depressive symptoms requiring
immediate attention.
4. Remission: In cases where the disorder is related to
substance use, depressive symptoms often improve or
remit once the substance is no longer in use, or
withdrawal symptoms have resolved. However, in
some cases, individuals may require additional
treatment for underlying depressive symptoms that
may persist independently of substance use.
5. Relapse Risk: There is a risk of relapse if the
individual resumes substance use after a period of
abstinence, which can lead to a recurrence of
depressive symptoms.
6. Treatment: The course can be influenced by
treatment
interventions.
Individuals
with
Substance/Medication-Induced Depressive Disorder
may benefit from substance abuse treatment,
psychotherapy, and sometimes pharmacotherapy to
manage
depressive
symptoms.
Treatment
effectiveness can vary depending on individual factors
and the specific substance or medication involved.
It's
important
to
emphasize
that
Substance/Medication-Induced Depressive Disorder is
distinct from primary depressive disorders, such as
Major Depressive Disorder or Persistent Depressive
Disorder. Proper assessment by a mental health
professional is essential to differentiate between these
conditions.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITIES
Differential
diagnosis
and
comorbidity of
Substance/Medication-Induced Depressive Disorder involve
distinguishing this condition from other mental disorders and
recognizing its frequent co-occurrence with substance use
disorders.
DIFFERENTIAL DIAGNOSIS
1. Primary Depressive Disorders: One of the key
differential
diagnoses
is
differentiating
Substance/Medication-Induced Depressive Disorder
from primary depressive disorders, such as Major
Depressive Disorder (MDD) or Persistent Depressive
Disorder (PDD). Clinicians must assess whether the
depressive symptoms are primarily due to substance
use or medication exposure or whether they represent
a separate, independent depressive disorder.
2. Other Substance-Induced Disorders: It's essential to
distinguish
Substance/Medication-Induced
Depressive Disorder from other substance-induced
disorders, such as Substance-Induced Mood Disorder
with Depressive Features. In this case, the depressive
symptoms are not severe enough to meet the criteria
for a major depressive episode.
3. Medical Conditions: Some medical conditions, such
as hypothyroidism, can present with symptoms of
depression. A comprehensive medical evaluation
should rule out medical causes of depressive
symptoms.
4. Other Psychiatric Disorders: Clinicians should
consider other psychiatric disorders that may mimic
depressive symptoms, such as bipolar disorders,
schizoaffective disorder, and adjustment disorders.
COMORBIDITY
1. Substance Use Disorders: Substance/MedicationInduced Depressive Disorder often co-occurs with
substance use disorders, as the depressive symptoms
are induced or exacerbated by substance use. This
comorbidity can complicate treatment and recovery.
2. Anxiety
Disorders:
Individuals
with
Substance/Medication-Induced Depressive Disorder
may also have comorbid anxiety disorders, such as
generalized anxiety disorder or panic disorder.
3. Personality Disorders: There is an increased
likelihood of comorbid personality disorders,
particularly borderline and antisocial personality
disorders, among individuals with substance use
disorders and associated depressive symptoms.
4. Other Mental Health Conditions: Depending on the
individual's history and circumstances, comorbid
mental health conditions, such as post-traumatic stress
disorder (PTSD), may be present.
TREATMENT APPROACHES
The treatment approaches for Substance/MedicationInduced Depressive Disorder primarily focus on addressing
both the substance use or medication-related issues and the
depressive symptoms. Here are common treatment modalities
with references:
1. Substance Use or Medication Intervention:
 Detoxification: In cases where substance use
is the primary cause of depressive symptoms,
detoxification and withdrawal management
may be necessary to address acute
2.
3.
4.
5.
6.
intoxication or withdrawal. This is typically
done under medical supervision to ensure
safety and minimize discomfort.
 Substance Abuse Treatment: Following
detoxification, individuals may benefit from
substance abuse treatment, which can include
inpatient or outpatient rehabilitation
programs, counseling, and support groups.
Behavioral
therapies
like
cognitivebehavioral therapy (CBT) and motivational
interviewing have shown effectiveness in
substance use disorder treatment.
 Medication-Assisted Treatment (MAT):
For specific substances, such as opioids or
alcohol, medications like methadone,
buprenorphine, or naltrexone may be
prescribed in combination with counseling as
part of MAT programs.
Psychiatric Treatment for Depressive Symptoms:
 Psychotherapy:
Psychotherapeutic
interventions, including cognitive-behavioral
therapy (CBT), interpersonal therapy (IPT),
and dialectical-behavior therapy (DBT), can
be beneficial in addressing depressive
symptoms. Therapy helps individuals
understand the connection between substance
use and mood and develop coping strategies.
 Medication: In some cases, antidepressant
medications may be prescribed to alleviate
depressive symptoms. The choice of
medication depends on the specific
symptoms and the individual's response to
treatment. SSRIs (selective serotonin
reuptake inhibitors) and other antidepressants
are commonly used.
Integrated Treatment:
 Integrated Dual Diagnosis Treatment
(IDDT): This approach combines mental
health and substance use treatment in a
coordinated manner. IDDT recognizes the
interplay between substance use and mental
health disorders and provides comprehensive
care.
Supportive Interventions:
 Support Groups: Participation in support
groups, such as Alcoholics Anonymous (AA)
or Narcotics Anonymous (NA), can provide
individuals with peer support and a sense of
community during their recovery.
Relapse Prevention:
 Relapse Prevention Skills: Individuals are
taught coping strategies and relapse
prevention skills to help them manage
triggers and stressors that might lead to
substance use and, subsequently, depressive
symptoms.
Education and Family Involvement:
 Psychoeducation: Educating individuals and
their families about the relationship between
substance use and depressive symptoms, as
well as the importance of treatment
compliance, can enhance the overall
treatment outcome.
It's crucial to tailor treatment to the individual's
specific needs and circumstances. The effectiveness of
treatment can vary based on factors such as the
severity of substance use, the duration of depressive
symptoms, and the presence of comorbid conditions.
DEPRESSIVE DISORDER DUE TO ANOTHER
MEDICAL CONDITION
Depressive Disorder Due to Another Medical
Condition, also known as depressive disorder associated with a
medical condition, is a specific type of depressive disorder
outlined in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5). It occurs when an individual
experiences symptoms of depression that can be directly
attributed to an underlying medical condition.
This depressive disorder occurs when the symptoms of
depression are caused by or linked to a medical illness or
condition. The medical condition can be either a general
medical condition (e.g., cancer, heart disease, diabetes) or a
neurological disorder (e.g., multiple sclerosis, Parkinson's
disease).
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.
1. Depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g., feeling sad,
empty, hopeless) or observation made by others (e.g.,
appears tearful).
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
(as indicated by either subjective account or
observation).
3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or a decrease or increase in appetite nearly
every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings
of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing
suicide.
B. The individual's depressive symptoms are directly related to
the physiological effects of a medical condition. Evidence from
the history, physical examination, or laboratory findings
demonstrates that the disturbance is a consequence of the
medical condition.
C. The depressive symptoms are not better explained by a
primary mental disorder, such as Major Depressive Disorder,
and do not occur exclusively during the course of a delirium.
D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
E. The symptoms are not attributable to the psychological
effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hypothyroidism).
F. The symptoms do not occur exclusively during the course of
a schizophrenia spectrum and other psychotic disorder.
It's important to note that the diagnosis of Depressive Disorder
Due to Another Medical Condition requires careful evaluation
by a qualified healthcare provider, including a thorough
assessment of the medical condition causing the depressive
symptoms.
Reference: American Psychiatric Association. (2013).
Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5). American Psychiatric Publishing.

2.
DIAGNOSTIC FEATURE
The essential feature of depressive disorder due to
another medical condition is a prominent and persistent period
of depressed mood or markedly diminished interest or pleasure
in all, or almost all, activities that predominates in the clinical
picture (Criterion A) and that is thought to be related to the
direct physiological effects of another medical condition
(Criterion B). In determining whether the mood disturbance is
due to a general medical condition, the clinician must first
establish the presence of a general medical condition. Further,
the clinician must establish that the mood disturbance is
etiologically related to the general medical condition through a
physiological mechanism. A careful and comprehensive
assessment of multiple factors is necessary to make this
judgment. Although there are no infallible guidelines for
determining whether the relationship between the mood
disturbance and the general medical condition is etiological,
several considerations provide some guidance in this area. One
consideration is the presence of a temporal association between
the onset, exacerbation, or remission of the general medical
condition and that of the mood disturbance. A second
consideration is the presence of features that are atypical of
primary Mood Disorders (e.g., atypical age at onset or course
or absence of family history). Evidence from the literature that
suggests that there can be a direct association between the
general medical condition in question and the development of
mood symptoms can provide a useful context in the assessment
of a particular situation.
DEVELOPMENT AND COURSE
Depressive disorder due to another medical condition,
often referred to as "depression secondary to a medical
condition," is a type of depression that occurs as a result of a
coexisting medical condition or illness. This condition can
significantly impact a person's emotional well-being and overall
quality of life. Here is an overview of the development and
course of depressive disorder due to another medical condition:
1. Onset and Development:
3.
Precipitating Medical Condition: This type
of depression typically arises as a response to
a pre-existing medical condition. Common
medical conditions that can lead to
depression include chronic illnesses (e.g.,
cancer, diabetes, heart disease), neurological
disorders
(e.g.,
multiple
sclerosis,
Parkinson's disease), and autoimmune
disorders (e.g., lupus).
 Biological Mechanisms:
The
exact
mechanisms underlying the development of
depression in these cases are not fully
understood, but it is believed that biological
factors, such as changes in neurotransmitter
levels,
inflammation,
and
hormonal
imbalances, play a role.
Symptoms:
 Individuals with depressive disorder due to
another medical condition may experience
symptoms similar to major depressive
disorder, including persistent sadness, loss of
interest or pleasure in activities, changes in
appetite or weight, sleep disturbances,
fatigue, feelings of guilt or worthlessness,
difficulty concentrating, and thoughts of
death or suicide.
 The severity of symptoms can vary
depending on the individual, the underlying
medical condition, and its progression.
Course and Prognosis:
 The course of depression in the context of a
medical condition can be chronic or episodic.
Some individuals may experience periods of
remission and exacerbation.
 The prognosis can vary widely, depending on
several factors:
 Severity of the underlying medical
condition.
 Adequacy of treatment for both the
medical
condition
and
the
depression.
 Individual resilience and coping
skills.
 Social support system.
 In some cases, successful management and
treatment of the medical condition can lead to
improvements in the associated depressive
symptoms.
DIFFERENTIAL DIAGNOSIS AND COMMORBIDITY
Differential diagnosis and comorbidity play crucial
roles in understanding depressive disorder due to another
medical condition. When a person presents with symptoms of
depression, it's important for healthcare providers to
differentiate between depression that arises as a result of an
underlying medical condition and depression that occurs
independently. Here's an overview of the differential diagnosis
and comorbidity associated with depressive disorder due to
another medical condition:
DIFFERENTIAL DIAGNOSIS:
Distinguishing between depressive disorder due to another
medical condition and primary depressive disorders (such as
major depressive disorder) is essential because the treatment
approach may differ. Here are some key considerations in the
differential diagnosis:
Medical Condition Assessment: Healthcare providers must
thoroughly evaluate the patient's medical history, perform a
physical examination, and conduct appropriate diagnostic tests
to identify and assess the severity of any underlying medical
conditions. The presence of a medical condition and its impact
on the patient's mental health is a critical factor.
Symptom Profile: Clinicians carefully assess the symptoms to
determine whether they are primarily related to the medical
condition, the depression, or a combination of both. For
example, somatic symptoms (physical complaints) may be
more pronounced in depressive disorder due to another medical
condition.
Temporal Relationship: Understanding the timing of
symptom onset is important. Depressive symptoms that
coincide with the onset or exacerbation of a medical condition
may suggest a causal relationship.
Response to Treatment: Response to treatment can also
provide diagnostic information. If depressive symptoms
significantly improve when the underlying medical condition is
effectively managed or treated, it suggests a secondary
depression.
Substance Use Disorders: Some individuals may turn to
alcohol or drugs as a way to cope with their depression, leading
to substance use disorders.
Cognitive Impairment: Cognitive impairment, including
problems with memory and concentration, can be a feature of
both depression and certain medical conditions.
Suicidal Ideation: Individuals with depressive disorder due to
another medical condition may be at an increased risk of
suicidal thoughts and behaviors, especially when coping with
both physical illness and depression.
Impaired Functioning: Depression can lead to impaired
social, occupational, and functional abilities, which can further
worsen the impact of the underlying medical condition.
Comorbidity underscores the importance of a comprehensive
assessment and treatment plan. Healthcare providers need to
address not only the depressive symptoms but also any
coexisting medical or psychological conditions to provide
holistic care for the patient's well-being.
TREAMENT APPROACHES
The treatment of depressive disorder due to another medical
condition involves a comprehensive and multidisciplinary
approach. The primary goal is to alleviate depressive symptoms
while also addressing and managing the underlying medical
condition. Here are the key treatment approaches:
1.
Exclusion of Primary Depressive Disorder: Clinicians must
exclude the possibility of primary depressive disorders, which
can occur independently of medical conditions. These include
major depressive disorder, persistent depressive disorder
(dysthymia), and bipolar disorder.
COMORBIDITY:
Comorbidity refers to the co-occurrence of multiple medical or
psychological conditions in the same individual. In the case of
depressive disorder due to another medical condition,
comorbidity is common and can significantly impact a person's
overall health and well-being. Here are some common
comorbidities associated with this type of depression:
2.
Anxiety Disorders: Individuals with depressive disorder due to
another medical condition may also experience anxiety
disorders such as generalized anxiety disorder, panic disorder,
or social anxiety disorder.
Pain Syndromes: Many medical conditions associated with
depression can also cause chronic pain syndromes. These
include conditions like fibromyalgia, arthritis, or chronic
headaches.
Sleep Disorders: Sleep disturbances are common in depression
and can further exacerbate depressive symptoms. Conditions
like insomnia or sleep apnea may co-occur.
3.
Medical Management of the Underlying Condition:
 Effectively managing the medical condition
that is contributing to the depressive
symptoms is of paramount importance. This
may involve surgery, medications, physical
therapy, lifestyle modifications, or other
appropriate treatments.
 Stabilizing the underlying condition can
sometimes lead to an improvement in
depressive symptoms.
Psychotherapy (Talk Therapy):
 Psychotherapy is a crucial component of
treatment for depressive disorder due to
another medical condition. Cognitivebehavioral therapy (CBT), supportive
therapy, and problem-solving therapy are
often used.
 Psychotherapy helps individuals address the
emotional and psychological impact of both
the medical condition and the depression,
teaches coping strategies, and promotes
resilience.
Medication:
 Antidepressant
medications
may
be
prescribed to alleviate depressive symptoms.
The choice of medication depends on factors
such as the type and severity of depression,
the individual's medical condition, and
potential drug interactions.
 Careful monitoring is essential, as some
medications may have side effects or
interactions with medications used to treat the
underlying medical condition.
4. Integrated Care Teams:
 A coordinated healthcare team, including
primary care physicians, specialists,
psychiatrists, psychologists, and social
workers, is often necessary to ensure
comprehensive care.
 Regular communication and collaboration
among team members help in tailoring
treatment plans to individual needs.
5. Social Support:
 Building a strong support network is vital.
Friends and family members can provide
emotional support, assistance with daily
activities, and encouragement during the
treatment process.
 Support groups for individuals facing similar
medical conditions or mental health
challenges can also be beneficial.
6. Lifestyle Modifications:
 Encouraging a healthy lifestyle can have a
positive impact on both the medical condition
and depression. This includes regular
exercise, a balanced diet, adequate sleep, and
stress reduction techniques.
 Avoiding alcohol and substance abuse is
essential, as these can worsen both the
medical condition and depressive symptoms.
7. Stress Management:
 Learning stress management techniques,
such as relaxation exercises, mindfulness,
and meditation, can help individuals better
cope with the challenges of managing a
medical condition and depression.
8. Education and Self-Management:
 Providing patients and their families with
information about the medical condition and
depressive disorder can empower them to
actively participate in their care and make
informed decisions.
9. Regular Monitoring and Follow-Up:
 Continuous monitoring of both the medical
condition and depressive symptoms is
crucial. Treatment plans may need to be
adjusted over time based on the individual's
progress and changing needs.
10. Suicide Risk Assessment and Prevention:
 Assessing and addressing suicidal thoughts
or behaviors is a critical aspect of care,
especially in cases of severe depression.
11. Crisis Intervention:
 In emergency situations or when there is a
risk of harm to oneself or others, immediate
crisis intervention and hospitalization may be
necessary.
It's important to note that the specific treatment plan will vary
depending on the individual's unique circumstances, the
severity of the medical condition, and the nature of the
depressive symptoms. Treatment should be tailored to address
both the physical and mental health aspects of the individual's
well-being. Close collaboration between healthcare providers,
specialists, and mental health professionals is essential for the
best outcomes.
OTHER SPECIFIED DEPRESSIVE DISORDER
This category applies to presentations in which
symptoms characteristic of a depressive disorder that cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the
disorders in the depressive disorders diagnostic class. The other
specified depressive disorder category is used in situations in
which the clinician chooses to communicate the specific reason
that the presentation does not meet the criteria for any specific
depressive disorder. This is done by recording “other specified
depressive disorder” followed by the specific reason (e.g.,
“short-duration
depressive
episode”).
Examples
of
presentations that can be specified using the “other specified”
designation include the following: 1. Recurrent brief
depression: Concurrent presence of depressed mood and at least
four other symptoms of depression for 2-13 days at least once
per month (not associated with the menstrual cycle) for at least
12 consecutive months in an individual whose presentation has
never met criteria for any other depressive or bipolar disorder
and does not currently meet active or residual criteria for any
psychotic disorder. 2. Short-duration depressive episode (4-13
days): Depressed affect and at least four of the other eight
symptoms of a major depressive episode associated with
clinically significant distress or impairment that persists for
more than 4 days, but less than 14 days, in an individual whose
presentation has never met criteria for any other depressive or
bipolar disorder, does not currently meet active or residual
criteria for any psychotic disorder, and does not meet criteria
for recurrent brief depression. 3. Depressive episode with
insufficient symptoms: Depressed affect and at least one of the
other eight symptoms of a major depressive episode associated
with clinically significant distress or impairment tliat persist for
at least 2 weeks in an individual whose presentation has never
met criteria for any other depressive or bipolar disorder, does
not currently meet active or residual criteria for any psychotic
disorder, and does not meet criteria for mixed anxiety and
depressive disorder symptoms.
UNSPECIFIED DEPRESSIVE DISORDER
This category applies to presentations in which
symptoms characteristic of a depressive disorder that cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the
disorders in the depressive disorders diagnostic class. The
unspecified depressive disorder category is used in situations in
which the clinician chooses not to specify the reason that the
criteria are not met for a specific depressive disorder, and
includes presentations for which there is insufficient
information to make a more specific diagnosis (e.g., in
emergency room settings).
SPECIFIERS FOR DEPRESSIVE DISORDER
In the diagnosis of depressive disorders, clinicians often use
specifiers to provide additional information about the nature
and course of the depressive episode. Specifiers help in
describing the specific features and characteristics of the
depression, which can be important for treatment planning and
understanding the patient's condition. Here are some common
specifiers used for depressive disorders:
1. Severity Specifiers:
 Severity specifiers are used to classify the
severity of a depressive episode based on the
number and intensity of symptoms. The two
main severity specifiers are:
 Mild: Few, if any, symptoms
beyond the minimum required for
diagnosis, and the symptoms result
in only minor impairment in daily
functioning.
 Moderate: Symptoms are more
numerous or intense than in mild
depression, and they result in
moderate impairment in daily
functioning.
 Severe: Symptoms are highly
distressing and significantly impact
daily functioning. In severe
depression, there may be psychotic
features (e.g., hallucinations or
delusions) or a risk of self-harm or
suicide.
2. Psychotic Features:
 Some individuals with depressive disorder
may experience psychotic symptoms, such as
hallucinations (false sensory perceptions) or
delusions (strongly held false beliefs). This
specifier is used when these features are
present.
3. Anxious Distress:
 This specifier is used when the individual
with depression also experiences prominent
anxiety symptoms, such as excessive worry,
restlessness, or a feeling of inner tension.
4. Atypical Features:
 Atypical features include mood reactivity
(the ability to experience improved mood in
response to positive events), increased
appetite or weight gain, hypersomnia
(excessive sleepiness), leaden paralysis (a
heavy, leaden feeling in the limbs), and longstanding interpersonal rejection sensitivity.
5. Melancholic Features:
 This specifier is used when the individual
experiences a more severe and classic form of
depression. Features may include profound
loss of pleasure in almost all activities
(anhedonia), excessive guilt, early morning
awakening, and marked psychomotor
retardation or agitation.
6. Catatonia:
 Catatonia is a severe psychomotor
disturbance that can occur in the context of
depression. It involves a range of symptoms,
such
as
stupor
(motionless
and
unresponsive), mutism (inability or refusal to
speak), negativism (oppositional behavior),
rigidity, and other unusual motor behaviors.
7. Peripartum Onset (Postpartum Depression):
 This specifier is used when the onset of a
depressive episode occurs during pregnancy
or within four weeks after giving birth.
Postpartum depression is a specific subtype
of depressive disorder that affects some new
mothers.
8. Seasonal Pattern (Seasonal Affective Disorder):
 Seasonal pattern specifier is used when an
individual's depressive episodes consistently
occur at specific times of the year, typically
in the fall or winter, and remit in the spring or
summer.
9. Chronic:
 This specifier indicates that the depressive
episode has lasted for two years or more
without a significant period of remission.
This condition is known as Persistent
Depressive Disorder (formerly called
Dysthymia).
10. In Partial Remission or Full Remission:
 These specifiers are used to describe the
course of the depressive episode. Partial
remission indicates that some symptoms
persist but are less severe, while full
remission means that no significant
symptoms are present.
These specifiers help clinicians better characterize and
understand the specific features of a person's depressive
episode. They can also guide treatment decisions, as certain
specifiers may indicate the need for specific interventions or
approaches. It's important for mental health professionals to
carefully assess and document these specifiers to provide the
most appropriate care for individuals with depressive disorders.