Major Depressive Disorder DSM-5 296.20-296.36 (ICD-10-CM Multiple Codes)


DSM-5 category: Depressive Disorders


Major Depressive Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.) diagnosis assigned to individuals who feel down and/or have lost interest in activities they previously enjoyed. This depressed feeling must occur daily for at least 2 weeks for a diagnosis to be given. Children and adolescence may be more irritable than sad. In addition to a low or irritable mood a person may experience low energy, lack motivation, weight changes, sleep changes, negative thoughts, lack of focus and avoid activities.

Symptoms of Major Depressive Disorder

  • Feelings of sadness and hopelessness.
  • Loss of interest or pleasure in activities.
  • Loss or weight or weight gain.
  • Difficulties sleeping or excessive sleepiness.
  • Noticeable restlessness or slowness.
  • Lack of energy.
  • Troubles concentrating and indecisiveness.
  • Feeling of worthless and excessive guilt.
  • Continued thoughts of wanting to die.

Diagnostic Criteria For Major Depressive Disorder 

1. Five (or more) of the following symptoms have to be 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 attributable to another medical condition. 
  • Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg., feels sad, empty, hopeless) or observation made by others (eg., appears tearful). (NOTE: in children and adolescence, can be irritable mood).
  • Markedly diminished interest or pleasure in all , or almost all, activities most of the day (as indicated by either subjective account or observation).
  • Significant weight loss when not dieting or weight gain (eg. 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).
  • Insomnia or hypersonic nearly every day.
  • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  • Fatigue or loss of energy nearly every day.
  • Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  • 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.
  1. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  2. The episode is not attributable to the physiological effects of a substance or to another medical condition.
  3. 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.
  4. There has never been a manic episode or a hypo manic episode. Note: this exclusion does not apply if all of the manic-like or hypo manic-like episodes are substance –induced or are attributable to the physiological effects of another medical condition.

Major Depressive Disorder ranges from mild, moderate to severe depending on the intensity of symptoms and the extent of impaired functioning. Psychotic features may be present. If repeated episodes occur, it is considered recurring and can be in partial or full remission.
Peripartum onset is specified if the onset to symptoms occurs during pregnancy or 4 weeks following delivery. Postpartum mood (major depressive or manic) occurs in 1 in 500 to 1 in 1000 deliveries. The risk of postpartum with psychotic features is increased for women with a history of depression, bipolar disorder or a family history of bipolar (DSM-5). Additional specifies include anxious distress, mixed features, melancholic, atypical features, mood-incongruent psychotic features, mood-congruent psychotic features, catatonia, and seasonal pattern.

The incidence of Major Depressive disorder in 18 to 20 year olds is three times that of 60 year olds. Onset is more common in adolescence, but can appear at any age. Females are diagnosed with depression 1.5 to 3 times more than males (DSM-5). People with depression are at risk of suicide, especially if they have made attempts or threats in the past. According to DSM-5. high levels of negativity, a difficult childhood, and life stressors like divorce or loosing a job can be precursors to depression. There is also a genetic component and people with an immediate family member who has experienced depression are two to four times more likely to have depressive symptoms than the general population (DSM-5).

Treatment For Major Depressive Disorder

Antidepressants and psychotherapy are the most common treatments for Major Depressive Disorder. Jonghe, Kool, Aalst, Dekker and Penn (2001) found that Depressed people who received combined treatment of psychotherapy and antidepressants were more likely to recover than those who received psychotherapy or pharmacotherapy separately. Studies have shown that the different types of psychotherapies have similar success rates. A study comparing the outcome rates of 7 different psychotherapies found that there was no difference in the success rate of the different psychotherapies (Cuijuper, Van Straten, Anderson, & Van Oppen, 2008; Bart et al., 2013), although the drop out rate for cognitive-behaviour therapy was significantly higher than with the other therapies. It seems reasonable to surmise that given the diversity of those experiencing depression that different psychotherapies do not work equally for all people. Ideally people should choose the type of therapy that makes sense to them and they feel comfortable with. It is essential that there is a good connection between client and therapist for optimal positive changes to occur. Attachment based psychotherapy supports the importance and recognition of the relationship between client and therapist. Siegel (2012) argues that the relationship between therapist and client in conjunction with psychotherapeutic techniques can establish new pathways in the clients brain that increases brain integration and healthier functioning.

Exercise can be an important aspect of treating depression. Studies have shown that aerobic exercise is effective in treating depression (Blumenthal et al., 1999). Blumenthal et al. (1999) found exercise to be as effective as antidepressant medication in treating mild to moderate depression. Bluementhal et al. (1999) found the positive effects of medicine occur more quickly than exercise, but the positive effects of exercise are longer lasting. Dunn, Madhukar, Trivedl and Chamliss (20005) found that fast walking 36 minutes 5 times a week had a significant effect on mild to moderate depression. Carek, Laibstain, and Carek (2011) in their review of the research conclude that exercise has been shown to reduce symptoms of depression and could lessen the need for psychopharmacology.

Positive psychotherapy (PPI) has shown to be effective in enhancing well being and decreasing depression (Sin & Lyubomirsky, 2009). Positive psychotherapy interventions include identifying and using one’s strengths, engaging in enjoyable activities, replaying positive experiences, and socialising. Sin and Lyubomirsky (2009) based on their meta-analysis of positive psychotherapy suggest that incorporating positive psychotherapy interventions into psychotherapy with depressed clients increases the effectiveness of therapy. Self-compassion which means having empathy for oneself has also been found to be associated with less negative affect, higher levels of happiness, and optimism (Neff & Kirkpatrick, & Rude, 2007).

Living With Major Depressive Disorder

We all feel sad and unhappy at times. Sadness is a normal response to a loss or other upsetting events. Depression, however, is sadness that is long lasting and when severe can be debilitating. It leaves people feeling sapped of energy and unable to enjoy once-pleasurable activities. When it is severe people lose all hope, are in so much pain they have thoughts of ending their life and at times take their own life. People isolate themselves, further depriving them of the positive support that comes from being with others. Sometimes they feel overwhelmed, in a cloud, and may want to stay in bed all day. People may stare at the wall for long periods of time, struggle to make decisions, and may neglect personal hygiene. They may avoid friends, have difficulties sleeping and miss work. It can be very frustrating for family members who do not understand the illness, feel helpless, and scared about the depressed person self harming.
In contrast to people with Severe Depression, people with mild depression can function relatively normally. They may continue to go to work, but struggle with focusing at work. They may feel insecure, assume others don't like them, and avoid conversing with others. People may notice that they are more quiet than usual, smile less, and are more irritable. Relationships are strained when people are easily annoyed, are less talkative and intimacy avoided. Sometimes people with depression complain about physical pain, have a low frustration tolerance and have angry outbursts (DSM-5). Sleep disturbance is a common concern which exacerbates the low energy and fatigue.
Fortunately treatment is available as discussed in the previous section. Effective treatment can begin to lift the sense of lethargy so people can start to become active and engaged with people and life again.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Barth, J., Munder, T., Gerger, , H., Nuesch, E.,Trelle, S., Znoj, H., Juni., P., Cuijpers (2013). Comparative efficacy of seven, psychotherapeutic interventions for patients with Depression: A Network meta-analysis. PLoS Med 10(5): e1001454. Doi:10.1371/journal.pmed.1001454

Blumenthal, J. Baby all, M.,Moore, K., Craighead, W., Herman, S., Khatri, P., Napolitano, M., Forman, L., & Appelbaum, M., Doraiswamy, P., Krishna , K. (1999). Effects of exercise training on older patients with major depression. Archives of Intern Medicine, 159(19), 2349-56. Doi:10.1001/arch-inte.159.19.2349

Carek P., Laibstain, S., Carek S (2011). Exercise for the treatmento of depression and anxiety. International Journal of Psychiatric Medicine, 41(1), 15-28. https: // end/21495519

Cuijupers, p., Van Straten, Andersson, G., & van Oppen, P. (2008)). Psychotherapy for Depression in Adults: A Meta-Analysis Comparative Outcome Studies. Journal of Clinical Psychology. 76. (6), 909-22. Published online (2010).doi:10.1037/a0013075

Dunn, A., Madhukar, H., Trivedl, M., & Chambliss, H.(2005). Exercise Treatment for depression. American Journal of Preventative Medicine. 28(1), 1-8.

Jonghe, F., Kool, S., van Aalast, G.., Dekker, J. Penn, J. (2001). Combining psychotherapy and antidepressants in the treatment of depression. Journal of Affective Disorders , 64 , 217-229.

Neff, K., Kirkpatrick, K., & Rude, S. (2007). Self-compassion and its link to adaptive psychological functioning. Journal of are search in Personality, 41, 139-154.

Siegel, D. The Developing Mind: How relationships and the brain interact to shape who we are. New York. The Guilford Press.

Sin, N., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology in Session, 65(5), 467-487. Doi:10.1002/Jclp.20593

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