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ICD-10 Criteria for Major Depressive Disorder

Contents

• F33 Recurrent Depressive Disorder
• F32 Depressive Episode
• F32.0 Mild Depressive Episode
• F32.1 Moderate Depressive Episode
• F32.2 Severe Depressive Episode Without Psychotic Symptoms
• F32.3 Severe Depressive Episode With Psychotic Symptoms

F33 Recurrent Depressive Disorder

The disorder is characterized by repeated episodes of depression as specified in depressive episode (mild, moderate, or severe), without any history of independent episodes of mood elevation and overactivity that fulfill the criteria of mania. However, the category should still be used if there is evidence of brief episodes of mild mood elevation and overactivity which fulfill the criteria of hypomania immediately after a depressive episode (sometimes apparently precipitated by treatment of a depression). The age of onset and the severity, duration, and frequency of the episodes of depression are all highly variable. In general, the first episode occurs later than in bipolar disorder, with a mean age of onset in the fifth decade. Individual episodes also last between 3 and 12 months (median duration about 6 months) but recur less frequently. Recovery is usually complete between episodes, but a minority of patients may develop a persistent depression, mainly in old age (for which this category should still be used). Individual episodes of any severity are often precipitated by stressful life events; in many cultures, both individual episodes and persistent depression are twice as common in women as in men.

The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes he or she has experienced. If a manic episode does occur, the diagnosis should change to bipolar affective disorder.

Recurrent depressive episode may be subdivided, as below, by specifying first the type of the current episode and then (if sufficient information is available) the type that predominates in all the episodes.

Includes:
* recurrent episodes of depressive reaction, psychogenic depression, reactive depression, seasonal affective disorder
* recurrent episodes of endogenous depression, major depression, manic depressive psychosis (depressed type), psychogenic or reactive depressive psychosis, psychotic depression, vital depression

Excludes:
* recurrent brief depressive episodes

F32 Depressive Episode

In typical depressive episodes of all three varieties described below (mild, moderate, and severe), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:

(a) reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.

The lowered mood varies little from day to day, and is often unresponsive to circumstances, yet may show a characteristic diurnal variation as the day goes on. As with manic episodes, the clinical presentation shows marked individual variations, and atypical presentations are particularly common in adolescence. In some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression, and the mood change may also be masked by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations. For depressive episodes of all three grades of severity, a duration of at least 2 weeks is usually required for diagnosis, but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset.

Some of the above symptoms may be marked and develop characteristic features that are widely regarded as having special clinical significance. The most typical examples of these "somatic" symptoms are: loss of interest or pleasure in activities that are normally enjoyable; lack of emotional reactivity to normally pleasurable surroundings and events; waking in the morning 2 hours or more before the usual time; depression worse in the morning; objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people); marked loss of appetite; weight loss (often defined as 5% or more of body weight in the past month); marked loss of libido. Usually, this somatic syndrome is not regarded as present unless about four of these symptoms are definitely present.

The categories of mild, moderate and severe depressive episodes described in more detail below should be used only for a single (first) depressive episode. Further depressive episodes should be classified under one of the subdivisions of recurrent depressive disorder.

These grades of severity are specified to cover a wide range of clinical states that are encountered in different types of psychiatric practice. Individuals with mild depressive episodes are common in primary care and general medical settings, whereas psychiatric inpatient units deal largely with patients suffering from the severe grades.

Acts of self-harm associated with mood (affective) disorders, most commonly self-poisoning by prescribed medication, should be recorded by means of an additional code from Chapter XX of ICD-10 (X60-X84). These codes do not involve differentiation between attempted suicide and "parasuicide", since both are included in the general category of self-harm.

Differentiation between mild, moderate, and severe depressive episodes rests upon a complicated clinical judgement that involves the number, type, and severity of symptoms present. The extent of ordinary social and work activities is often a useful general guide to the likely degree of severity of the episode, but individual, social, and cultural influences that disrupt a smooth relationship between severity of symptoms and social performance are sufficiently common and powerful to make it unwise to include social performance amongst the essential criteria of severity.

The presence of dementia or mental retardation does not rule out the diagnosis of a treatable depressive episode, but communication difficulties are likely to make it necessary to rely more than usual for the diagnosis upon objectively observed somatic symptoms, such as psychomotor retardation, loss of appetite and weight, and sleep disturbance.

Includes:
* single episodes of depression (without psychotic symptoms), psychogenic depression or reactive depression)

F32.0 Mild Depressive Episode

Diagnostic Guidelines

Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks.

An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

A fifth character may be used to specify the presence of the somatic syndrome:

F32.00 Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there are few or none of the somatic symptoms present.

F32.01 With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four or more of the somatic symptoms are also present. (If only two or three somatic symptoms are present but they are unusually severe, use of this category may be justified.)

F32.1 Moderate Depressive Episode

Diagnostic Guidelines

At least two of the three most typical symptoms noted for mild depressive episode should be present, plus at least three (and preferably four) of the other symptoms. Several symptoms are likely to be present to a marked degree, but this is not essential if a particularly wide variety of symptoms is present overall. Minimum duration of the whole episode is about 2 weeks.

An individual with a moderately severe depressive episode will usually have considerable difficulty in continuing with social, work or domestic activities.

A fifth character may be used to specify the occurrence of somatic symptoms:

F32.10 Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and few if any of the somatic symptoms are present.

F32.11 With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and four or more or the somatic symptoms are present. (If only two or three somatic symptoms are present but they are unusually severe, use of this category may be justified.)

F32.2 Severe Depressive Episode Without Psychotic Symptoms

In a severe depressive episode, the sufferer usually shows considerable distress or agitation, unless retardation is a marked feature. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases. It is presumed here that the somatic syndrome will almost always be present in a severe depressive episode.

Diagnostic Guidelines

All three of the typical symptoms noted for mild and moderate depressive episodes should be present, plus at least four other symptoms, some of which should be of severe intensity. However, if important symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. An overall grading of severe episode may still be justified in such instances. The depressive episode should usually last at least 2 weeks, but if the symptoms are particularly severe and of very rapid onset, it may be justified to make this diagnosis after less than 2 weeks.

During a severe depressive episode it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent.

This category should be used only for single episodes of severe depression without psychotic symptoms; for further episodes, a subcategory of recurrent depressive disorder should be used.

Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms

F32.3 Severe Depressive Episode With Psychotic Symptoms

Diagnostic Guidelines

A severe depressive episode which meets the criteria given for severe depressive episode without psychotic symptoms and in which delusions, hallucinations, or depressive stupor are present. The delusions usually involve ideas of sin, poverty, or imminent disasters, responsibility for which may be assumed by the patient. Auditory or olfactory hallucinations are usually of defamatory or accusatory voices or of rotting filth or decomposing flesh. Severe psychomotor retardation may progress to stupor. If required, delusions or hallucinations may be specified as mood-congruent or mood-incongruent.

Differential Diagnosis
Depressive stupor must be differentiated from catatonic schizophrenia, from dissociative stupor, and from organic forms of stupor. This category should be used only for single episodes of severe depression with psychotic symptoms; for further episodes a subcategory of recurrent depressive disorder should be used.

Includes:
* single episodes of major depression with psychotic symptoms, psychotic depression, psychogenic depressive psychosis, reactive depressive psychosis

DSM-IV Criteria for Major Depressive Disorder

Contents

• Diagnostic Criteria
• Essential Features
• Associated Features and Comorbidity
• Mortality
• Premorbid History
• Laboratory Findings
• Gender
• Prevalence
• Onset And Course
• Recurrence
• Recovery
• Poor Outcome
• Familial Pattern And Genetics
• Differential Diagnosis

Diagnostic Criteria

1. At least one of the following three abnormal moods which significantly interfered with the person's life:
   1. Abnormal depressed mood most of the day, nearly every day, for at least 2 weeks.
   2. Abnormal loss of all interest and pleasure most of the day, nearly every day, for at least 2 weeks.
   3. If 18 or younger, abnormal irritable mood most of the day, nearly every day, for at least 2 weeks.
2. At least five of the following symptoms have been present during the same 2 week depressed period.
   1. Abnormal depressed mood (or irritable mood if a child or adolescent) [as defined in criterion A].
   2. Abnormal loss of all interest and pleasure [as defined in criterion A2].
   3. Appetite or weight disturbance, either:
      • Abnormal weight loss (when not dieting) or decrease in appetite.
      • Abnormal weight gain or increase in appetite.
   4. Sleep disturbance, either abnormal insomnia or abnormal hypersomnia.
   5. Activity disturbance, either abnormal agitation or abnormal slowing (observable by others).
   6. Abnormal fatigue or loss of energy.
   7. Abnormal self-reproach or inappropriate guilt.
   8. Abnormal poor concentration or indecisiveness.
   9. Abnormal morbid thoughts of death (not just fear of dying) or suicide.
3. The symptoms are not due to a mood-incongruent psychosis.
4. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.
5. The symptoms are not due to physical illness, alcohol, medication, or street drugs.
6. The symptoms are not due to normal bereavement.

Essential Features

By definition, Major Depressive Disorder cannot be due to:

• Physical illness, alcohol, medication, or street drug use.
• Normal bereavement.
• Bipolar Disorder
• Mood-incongruent psychosis (e.g., Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified).

Major Depressive Disorder causes the following mood symptoms:

• Abnormal depressed mood:
  • Sadness is usually a normal reaction to loss. However, in Major Depressive Disorder, sadness is abnormal because it:
    • Persists continuously for at least 2 weeks.
    • Causes marked functional impairment.
    • Causes disabling physical symptoms (e.g., disturbances in sleep, appetite, weight, energy, and psychomotor activity).
    • Causes disabling psychological symptoms (e.g., apathy, morbid preoccupation with worthlessness, suicidal ideation, or psychotic symptoms).
  • The sadness in this disorder is often described as a depressed, hopeless, discouraged, "down in the dumps," "blah," or empty. This sadness may be denied at first. Many complain of bodily aches and pains, rather than admitting to their true feelings of sadness.
• Abnormal loss of interest and pleasure mood:
  • The loss of interest and pleasure in this disorder is a reduced capacity to experience pleasure which in its most extreme form is called anhedonia.
  • The resulting lack of motivation can be quite crippling.
• Abnormal irritable mood:
  • This disorder may present primarily with irritable, rather than depressed or apathetic mood. This is not officially recognized yet for adults, but it is recognized for children and adolescents.
  • Unfortunately, irritable depressed individuals often alienate their loved ones with their cranky mood and constant criticisms.

Major Depressive Disorder causes the following physical symptoms:

• Abnormal appetite:
  • Most depressed patients experience loss of appetite and weight loss. The opposite, excessive eating and weight gain, occurs in a minority of depressed patients. Changes in weight can be significant.
• Abnormal sleep:
  • Most depressed patients experience difficulty falling asleep, frequent awakenings during the night or very early morning awakening. The opposite, excessive sleeping, occurs in a minority of depressed patients.
• Fatigue or loss of energy:
  • Profound fatigue and lack of energy usually is very prominent and disabling.
• Agitation or slowing:
  • Psychomotor retardation (an actual physical slowing of speech, movement and thinking) or psychomotor agitation (observable pacing and physical restlessness) often are present in severe Major Depressive Disorder.

Major Depressive Disorder causes the following cognitive symptoms:

• Abnormal self-reproach or inappropriate guilt:
  • This disorder usually causes a marked lowering of self-esteem and self-confidence with increased thoughts of pessimism, hopelessness, and helplessness. In the extreme, the person may feel excessively and unreasonably guilty.
  • The "negative thinking" caused by depression can become extremely dangerous as it can eventually lead to extremely self-defeating or suicidal behavior.
• Abnormal poor concentration or indecisiveness:
  • Poor concentration is often an early symptom of this disorder. The depressed person quickly becomes mentally fatigued when asked to read, study, or solve complicated problems.
  • Marked forgetfulness often accompanies this disorder. As it worsens, this memory loss can be easily mistaken for early senility (dementia).
• Abnormal morbid thoughts of death (not just fear of dying) or suicide:
  • The symptom most highly correlated with suicidal behavior in depression is hopelessness.

Associated Features and Comorbidity

• Anxiety:
  • 80 to 90% of individuals with Major Depressive Disorder also have anxiety symptoms (e.g., anxiety, obsessive preoccupations, panic attacks, phobias, and excessive health concerns).
  • Separation anxiety may be prominent in children.
  • About one third of individuals with Major Depressive Disorder also have a full-blown anxiety disorder (usually either Panic Disorder, Obsessive-Compulsive Disorder, or Social Phobia).
  • Anxiety in a person with major depression leads to a poorer response to treatment, poorer social and work function, greater likelihood of chronicity and an increased risk of suicidal behavior.
• Eating Disorders:
  • Individuals with Anorexia Nervosa and Bulimia Nervosa often develop Major Depressive Disorder.
• Psychosis:
  • Mood congruent delusions or hallucinations may accompany severe Major Depressive Disorder.
• Substance Abuse:
  • The combination of Major Depressive Disorder and substance abuse is common (especially Alcohol and Cocaine).
  • Alcohol or street drugs are often mistakenly used as a remedy for depression. However, this abuse of alcohol or street drugs actually worsens Major Depressive Disorder.
  • Depression may also be a consequence of drug or alcohol withdrawal and is commonly seen after cocaine and amphetamine use.
• Medical Illness:
  • 25% of individuals with severe, chronic medical illness (e.g., diabetes, myocardial infarction, carcinomas, stroke) develop depression.
  • About 5% of individuals initially diagnosed as having Major Depressive Disorder subsequently are found to have another medical illness which was the cause of their depression.
  • Medical conditions often causing depression are:
    • Endocrine disorders: hypothyroidism, hyperparathyroidism, Cushing's disease, and diabetes mellitus.
    • Neurological disorders: multiple sclerosis, Parkinson's disease, migraine, various forms of epilepsy, encephalitis, brain tumors.
    • Medications: many medications can cause depression, especially antihypertensive agents such as calcium channel blockers, beta blockers, analgesics and some anti-migraine medications.

Mortality

Up to 15% of patients with severe Major Depressive Disorder die by suicide. Over age 55, there is a fourfold increase in death rate.

Premorbid History

10-25% of patients with Major Depressive Disorder have preexisting Dysthymic Disorder. These "double depressions" (i.e., Dysthymia + Major Depressive Disorder) have a poorer prognosis.

Laboratory Findings

There are no laboratory findings that are diagnostic for this disorder.

Gender

Males and females are equally affected by Major Depressive Disorder prior to puberty. After puberty, this disorder is twice as common in females as in males. The highest rates for this disorder are in the 25- to 44-year-old age group.

Prevalence

The lifetime risk for Major Depressive Disorder is 10% to 25% for women and from 5% to 12% for men. At any point in time, 5% to 9% of women and 2% to 3% of men suffer from this disorder. Prevalence is unrelated to ethnicity, education, income, or marital status.

Onset And Course

• Onset:
  • Average age at onset is 25, but this disorder may begin at any age.
• Psychological stress:
  • Stress appears to play a prominent role in triggering the first 1-2 episodes of this disorder, but not in subsequent episodes.
• Duration:
  • An average episode lasts about 9 months.
• Course:
  • Course is variable. Some people have isolated episodes that are separated by many years, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older.
  • About 20% of individuals with this disorder have a chronic course.

Recurrence

• The risk of recurrence is about 70% at 5 year follow up and at least 80% at 8 year follow-up.
• After the first episode of Major Depressive Disorder, there is a 50%-60% chance of having a second episode, and a 5-10% chance of having a Manic Episode (i.e., developing Bipolar I Disorder). After the second episode, there is a 70% chance of having a third. After the third episode, there a 90% chance of having a fourth.
• The greater number of previous episodes is an important risk factor for recurrence.

Recovery

For patients with severe Major Depressive Disorder, 76% on antidepressant therapy recover, whereas only 18% on placebo recover. For these severely depressed patients, significantly more recover on antidepressant therapy than on interpersonal psychotherapy. For these same patients, cognitive therapy has been shown to be no more effective than placebo.

Poor Outcome

Poor outcome or chronicity in Major Depressive Disorder is associated with the following:

• Inadequate treatment
• Severe initial symptoms
• Early age of onset
• Greater number of previous episodes
• Only partial recovery after one year
• Having another severe mental disorder (e.g. Alcohol Dependency, Cocaine Dependency)
• Severe chronic medical illness
• Family dysfunction

Familial Pattern And Genetics

There is strong evidence that major depression is, in part, a genetic disorder:

• Individuals who have parents or siblings with Major Depressive Disorder have a 1.5-3 times higher risk of developing this disorder.
• The concordance for major depression in monozygotic twins is substantially higher than it is in dizygotic twins. However, the concordance in monozygotic twins is in the order of about 50%, suggesting that factors other than genetic factors are also involved.
• Children adopted away at birth from biological parents who have a depressive illness carry the same high risk as a child not adopted away, even if they are raised in a family where no depressive illness exists.
• Interestingly, families having Major Depressive Disorder have an increased risk of developing Alcoholism and Attention-Deficit Hyperactivity Disorder.

Differential Diagnosis

1. Exclude depressions due to physical illness, medications, or street drug use:
   • If due to physical illness, diagnose: Mood Disorder Due to a General Medical Condition.
   • If due to alcohol, diagnose: Alcohol-Induced Mood Disorder.
   • If due to other substance use, diagnose: Other Substance-Induced Mood Disorder.

   Organic Causes Of Severe Depression

   Illnesses:
   Organic Mood Syndromes caused by: Acquired Immune Deficiency Syndrome (AIDS), Adrenal (Cushing's or Addison's Diseases), Cancer (especially pancreatic and other GI), Cardiopulmonary disease, Dementias (including Alzheimer's Disease); Epilepsy, Fahr's Syndrome, Huntington's Disease, Hydrocephalus, Hyperaldosteronism, Infections (including HIV and neurosyphilis), Migraines, Mononucleosis, Multiple Sclerosis, Narcolepsy, Neoplasms, Parathyroid Disorders (hyper- and hypo-), Parkinson's Disease, Pneumonia (viral and bacterial), Porphyria, Postpartum, Premenstrual Syndrome, Progressive Supranuclear Palsy, Rheumatoid Arthritis, Sjogren's Arteritis, Sleep Apnea, Stroke, Systemic Lupus Erythematosus, Temporal Arteritis, Trauma, Thyroid Disorders (hypothyroid and "apathetic" hyperthyroidism), Tuberculosis, Uremia (and other renal diseases), Vitamin Deficiencies (B12, C, folate, niacin, thiamine), Wilson's Disease.

   Drugs:
   Acetazolamine, Alphamethyldopa, Amantadine, Amphetamines, Ampicillin, Azathioprine (AZT), 6-Azauridine, Baclofen, Beta Blockers, Bethanidine, Bleomycin, Bromocriptine, C-Asparaginase, Carbamazepine, Choline, Cimetidine, Clonidine, Clycloserin, Cocaine, Corticosteroids (including ACTH), Cyproheptadine, Danazol, Digitalis, Diphenoxylate, Disulfiram, Ethionamide, Fenfluramine, Griseofulvin, Guanethidine, Hydralazine, Ibuprofen, Indomethacin, Lidocaine, Levodopa, Methoserpidine, Methysergide, Metronidazole, Nalidixic Acid, Neuroleptics (butyrophenones, phenothiazines, oxyindoles), Nitrofurantoin, Opiates, Oral Contraceptives, Phenacetin, Phenytoin, Prazosin, Prednisone, Procainamide, Procyclidine, Quanabenzacetate, Rescinnamine, Reserpine, Sedative/Hypnotics (barbiturates, benzodiazepines, chloral hydrate), Streptomycin, Sulfamethoxazole, Sulfonamides, Tetrabenazine, Tetracycline, Triamcinolone, Trimethoprim, Veratrum, Vincristine.

2. Exclude depressions having a previous history of elevated, expansive, or euphoric mood:
   • If previous history of a Manic Episode, diagnose: Bipolar I Disorder.
   • If previous history of recurrent Major Depressive Episodes and at least one Hypomanic Episode, diagnose: Bipolar II Disorder.
   • If previous history of recurrent Hypomanic Episodes and brief, mild depressive episodes (milder than Major Depressive Episodes), diagnose: Cyclothymic Disorder.
3. Exclude depressions that merely represent normal bereavement, instead diagnose: Uncomplicated Bereavement.
4. Exclude depressions associated with mood-incongruent psychosis:
   • If previous history of at least 2 weeks of delusions or hallucinations occurring in the absence of prominent mood symptoms, diagnose either: Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
5. Exclude mild depressions:
   • If only mild depression present for most of past 2 years (or 1 year in children), diagnose: Dysthymic Disorder.
   • If only brief mild depression clearly triggered by stress, diagnose: Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood.
   • If mild depression is clinically significant, but does not meet the criteria for any of the previously described disorders, diagnose: Depressive Disorder Not Otherwise Specified.
6. In the elderly, it is often difficult to distinguish between early dementia or Major Depressive Disorder:
   • If there is a premorbid history of declining cognitive function in the absence of severe depression, diagnose: Dementia.
   • If there was a relatively normal premorbid state and somewhat abrupt cognitive decline associated with severe depression, diagnose: Major Depressive Disorder.