Diagnostic Criteria for Major Depressive Disorder

DSM-5 Diagnostic Criteria for Major Depressive Disorder (MDD)

Major Depressive Disorder is characterized by one or more major depressive episodes. It’s one of the most common and serious mental health conditions.

Criterion A: Five (or More) Symptoms

Required: At least 5 of the following 9 symptoms present during same 2-week period, representing change from previous functioning

CRITICAL: At least one symptom must be EITHER:

1. Depressed mood, OR
2. Loss of interest or pleasure (anhedonia)

If neither of these two core symptoms present, cannot diagnose MDD even if have 5 other symptoms

The Nine Symptoms (DSM-5)

1. Depressed Mood Most of the Day, Nearly Every Day

Description:

• Persistent sad, empty, or hopeless feeling
• Mood is predominantly negative
• Present most of the day, almost every day

Subjective Experience (Patient Reports):

• “I feel sad all the time”
• “I feel empty inside”
• “I feel hopeless”
• “I feel down and can’t shake it”
• Profound sadness that won’t lift
• May feel tearful, cry frequently (or feel like crying but can’t)

Some Experience:

• Emotional numbness or emptiness (feel nothing)
• Irritability (especially in men, adolescents)

Observation by Others:

• May appear sad, tearful
• Downcast facial expression
• Lack of emotional expression
• Withdrawn

Children and Adolescents:

• May present as irritable mood rather than sad
• More anger, frustration, agitation than sadness

Most of the Day, Nearly Every Day:

• Not just occasional sadness
• Pervasive, persistent
• May have brief moments of relief but mood returns to depressed state

Not Normal Sadness:

• Everyone feels sad sometimes
• MDD: Sadness is intense, persistent, unrelenting
• Doesn’t correspond to situation (or grossly disproportionate)
• Interferes with functioning

2. Markedly Diminished Interest or Pleasure in All, or Almost All, Activities (Anhedonia)

Anhedonia: Loss of ability to experience pleasure or interest

Description:

• Loss of interest in activities that were previously enjoyable
• No longer find pleasure in anything
• “Nothing seems fun anymore”
• Pervasive across activities

Subjective Experience:

• “I don’t enjoy anything anymore”
• “Nothing interests me”
• “I used to love [hobby/activity] but now I don’t care”
• “Everything feels pointless”
• Can’t motivate self to do activities
• Hobbies, socializing, sex, entertainment all feel meaningless

Most of the Day, Nearly Every Day:

• Not occasional lack of interest
• Persistent, pervasive loss of pleasure

Examples:

• Previously loved reading → Now hasn’t picked up book in weeks
• Enjoyed socializing with friends → Now avoids social contact or feels nothing during it
• Passionate about sports → Now doesn’t watch games or play
• Enjoyed cooking → Now food tastes bland, no interest in preparing meals
• Active sex life → Complete loss of libido and interest

All or Almost All Activities:

• Pervasive across life domains
• Not just one activity but everything

Observation:

• Patient appears disengaged
• Stops participating in hobbies, social activities
• May still go through motions but without enjoyment

Distinguishing from Normal:

• Everyone has times of less interest
• MDD: Complete, pervasive loss of pleasure and interest across almost everything

3. Significant Weight Loss or Weight Gain, or Decrease or Increase in Appetite

Weight Changes:

• Significant: More than 5% of body weight in a month
• Can be loss OR gain

Example:

• Person weighing 150 lbs loses more than 7.5 lbs in a month (150 × 0.05 = 7.5)
• Or gains more than 7.5 lbs

Weight Loss (More Common):

• Significant unintentional weight loss
• Not dieting

Associated with:

• Loss of appetite (don’t feel like eating)
• “Food doesn’t appeal to me”
• Food tastes bland (taste changes)
• Have to force self to eat
• May skip meals, forget to eat

Weight Gain (Less Common but Occurs):

• Significant weight gain

Associated with:

• Increased appetite (eating more than usual)
• Comfort eating, emotional eating
• Craving carbohydrates

Both Can Occur in MDD:

• Different people have different patterns
• Some lose appetite; others eat more

Appetite Changes Without Weight Change:

• If significant appetite change (eating much less or much more) but weight hasn’t changed yet, still counts
• May be early in episode or metabolism compensates

Not Due to Other Causes:

• Weight changes should be primarily due to depression, not intentional dieting or medical condition

4. Insomnia or Hypersomnia Nearly Every Day

Sleep Disturbances: Very common in MDD; can be either too little or too much sleep

Insomnia (Difficulty Sleeping - More Common):

Three Types:

a) Initial Insomnia (Difficulty Falling Asleep):

• Lie awake for long time trying to fall asleep
• Mind racing, ruminating
• Takes hours to fall asleep

b) Middle Insomnia (Difficulty Staying Asleep):

• Wake up multiple times during night
• Difficulty returning to sleep
• Fragmented sleep

c) Terminal Insomnia (Early Morning Awakening):

• Most characteristic of MDD
• Wake up 2-3 hours earlier than usual (e.g., 4 or 5 AM)
• Cannot fall back asleep
• Lie awake with negative thoughts

Experience:

• “I can’t sleep”
• “I wake up too early and lie there worrying”
• “My mind won’t turn off”
• Sleep is non-restorative (don’t feel rested)

Hypersomnia (Excessive Sleep - Less Common):

Description:

• Sleeping much more than usual
• Sleep excessively long at night (10-12+ hours)
• Napping during day
• Difficulty getting out of bed
• Want to sleep all the time

Experience:

• “I sleep all the time but still feel exhausted”
• “I can’t get out of bed”
• “All I want to do is sleep”

Function:

• Escape from reality
• Avoidance of negative feelings
• Profound fatigue makes staying awake difficult

Nearly Every Day:

• Not occasional poor sleep
• Persistent sleep disturbance

Note: Specify if insomnia or hypersomnia in diagnosis

5. Psychomotor Agitation or Retardation Nearly Every Day

Psychomotor = Motor Behavior (how person moves and acts)

Must be observable by others (not just subjective feeling of restlessness or slowness)

Psychomotor Agitation (Increased Movement, Restlessness):

Observable Signs:

• Cannot sit still
• Pacing, fidgeting
• Hand-wringing
• Pulling or rubbing skin, clothes, hair
• Restless movements
• Appearing keyed up, on edge physically

Patient Experience:

• Feel restless, agitated
• Can’t relax
• Need to move
• Inner tension

Psychomotor Retardation (Slowed Movement, Sluggishness):

Observable Signs:

• Slowed speech: Speaking very slowly, long pauses before answering
• Slowed movements: Moving very slowly, as if in slow motion
• Reduced gestures: Little body language, limited facial expression
• Difficulty initiating movement
• May sit motionless for long periods

Patient Experience:

• “I feel like I’m moving through mud”
• “Everything takes so much effort”
• “I feel heavy, sluggish”
• “My brain is slow”

Cognitive Slowing:

• Slowed thinking
• Difficulty concentrating, making decisions (covered in criterion 8)

Observable by Others:

• Key point: Must be observable to others
• Not just subjective feeling (that would be criterion 8)
• Clinician or family members can see the agitation or retardation

Nearly Every Day:

• Persistent motor disturbance

Note: Agitation OR retardation (not both typically, though can vary)

6. Fatigue or Loss of Energy Nearly Every Day

Description:

• Profound tiredness, exhaustion
• Complete lack of energy
• “Running on empty”

Subjective Experience:

• “I’m exhausted all the time”
• “I have no energy”
• “Everything feels like it takes enormous effort”
• “I feel drained”
• “I can barely get out of bed”

Physical Sensation:

• Body feels heavy, leaden
• Simple tasks feel overwhelming
• Need to rest after minimal activity

Examples:

• Taking shower feels like major undertaking
• Preparing meal exhausting
• Getting dressed tiring
• Walking up stairs feels like mountain climbing

Different from Normal Tiredness:

• Not just tired from poor sleep (though that contributes)
• Pervasive, unrelenting fatigue
• Rest doesn’t restore energy
• Present even if sleeping adequately (in hypersomnia cases)

Nearly Every Day:

• Constant, persistent
• Not just occasional tiredness

Impact:

• Reduces motivation to do anything
• Contributes to inactivity, withdrawal
• Makes all symptoms worse (can’t engage in activities that might help mood)

7. Feelings of Worthlessness or Excessive or Inappropriate Guilt Nearly Every Day

Two Related but Distinct Symptoms:

Feelings of Worthlessness:

Description:

• Belief that one is worthless, of no value
• Negative self-evaluation

Common Thoughts:

• “I’m worthless”
• “I’m a failure”
• “I’m no good”
• “I have nothing to offer”
• “I’m a burden”
• “The world would be better without me”

Pervasive Negative View of Self:

• See self as fundamentally flawed, defective
• Overgeneralized (“I always fail at everything”)
• Can’t see own positive qualities

Excessive or Inappropriate Guilt:

Description:

• Feeling guilty about things beyond one’s control
• Out of proportion guilt
• Ruminating on past minor mistakes as if major moral failings

Common Thoughts:

• “Everything is my fault”
• “I let everyone down”
• Blaming self for things not responsible for
• Disproportionate guilt over minor errors

Examples:

• Feel guilty about being depressed (“I should be able to snap out of this”)
• Feel guilty for burdening others with depression
• Ruminate on minor mistake from years ago
• Blame self for things clearly beyond control (e.g., someone else’s illness)

Excessive = Disproportionate:

• Not appropriate guilt (e.g., guilt after truly hurting someone)
• Guilt that is irrational, exaggerated, unwarranted

Nearly Every Day:

• Persistent negative self-thoughts
• Rumination on worthlessness and guilt

Note: This is not psychotic (delusional) level unless specified (see severe episode with psychotic features)

Normal vs. MDD:

• Normal: Occasional self-doubt, appropriate guilt
• MDD: Pervasive, constant, irrational negative self-evaluation

8. Diminished Ability to Think or Concentrate, or Indecisiveness, Nearly Every Day

Cognitive Impairment in depression:

Three Manifestations:

A) Diminished Ability to Think:

• Thinking is slow, effortful
• Mind feels foggy, cloudy
• “My brain doesn’t work right”
• Difficulty thinking clearly
• Mental sluggishness

B) Diminished Ability to Concentrate:

• Cannot focus on tasks
• Mind wanders constantly
• Cannot read (lose track of what reading)
• Cannot follow conversations or TV shows
• Easily distracted

Examples:

• Read same paragraph multiple times without comprehending
• Sit in meeting but can’t focus on what’s being said
• Start task but mind drifts
• Cannot complete work that requires concentration

C) Indecisiveness:

• Difficulty making decisions, even minor ones
• Paralyzed by choices
• Ruminate endlessly over decisions

Examples:

• Cannot decide what to wear, what to eat
• Struggle with work decisions
• Overthink simple choices
• Fear of making wrong decision

Subjective Experience:

• “I can’t think straight”
• “I can’t make decisions”
• “I can’t focus on anything”
• “My mind is a fog”

Observable by Others or Subjective Report:

• Can be reported by person
• Or observed by others (e.g., “You seem unable to make any decisions lately”)

Impact on Functioning:

• Major impact on work, school
• Cannot perform cognitive tasks
• Productivity drops dramatically
• Academic performance suffers

Nearly Every Day:

• Persistent cognitive impairment

Not Due to Substance or Medical Condition:

• Should be manifestation of depression, not other cause

9. Recurrent Thoughts of Death, Recurrent Suicidal Ideation, Suicide Attempt, or Specific Plan for Committing Suicide

Most Serious Symptom: Indicates severe depression and requires immediate attention

Four Levels (from least to most severe):

A) Recurrent Thoughts of Death (Passive):

• Thinking about death frequently
• Not necessarily suicide but preoccupation with death
• “I wish I were dead”
• “I wish I could just not wake up”
• “I wish I could disappear”
• Passive death wish
• No active plan or intent

B) Suicidal Ideation Without Specific Plan:

• Thinking about suicide
• “I want to kill myself”
• “I think about ending my life”
• But no specific plan
• May think about methods vaguely but hasn’t formulated plan

C) Specific Plan:

• Detailed plan for how would commit suicide
• Thought about method, timing, location
• “I’m going to [specific method] on [specific date]”
• Very serious: Indicates high risk

D) Suicide Attempt:

• Actual attempt to end own life
• Most serious
• Immediate crisis

Even Without Action, the Thoughts Count:

• Don’t need to have attempt to meet this criterion
• Recurrent thoughts of death or suicidal ideation sufficient

Recurrent = Multiple Times:

• Not just one fleeting thought
• Repeated, persistent thoughts

Frequency:

• No “nearly every day” requirement for this symptom (unlike others)
• If thoughts recurrent during the depressive episode, criterion met

Critical for Assessment:

• Always assess for suicidality in depression
• If present, assess:
  • Intent: Does person intend to act on thoughts?
  • Plan: Is there specific plan?
  • Access to means: Does person have access to method (guns, pills, etc.)?
  • Protective factors: Reasons for living, social support
• High risk requires immediate intervention (hospitalization may be necessary)

Normal vs. MDD:

• Fleeting thought “I wish I were dead” in moment of stress: Not necessarily MDD
• MDD: Recurrent, persistent thoughts during depressive episode

Criterion B: Symptoms Cause Clinically Significant Distress or Impairment

Not Enough to Have Symptoms: Symptoms must cause problems

Clinically Significant Distress:

• Symptoms cause considerable emotional suffering
• Person is distressed by the symptoms
• Seeks help due to distress

Impairment in Functioning:

• Must cause problems in one or more important areas of life

Social Functioning:

• Withdrawal from relationships
• Conflicts with family, friends
• Isolation
• Loss of friendships

Occupational/Academic Functioning:

• Cannot perform at work or school
• Missing work/school frequently
• Productivity severely reduced
• Risk of job loss or academic failure
• Cannot maintain employment

Other Important Areas:

• Self-care (hygiene, eating, basic activities)
• Parenting (if have children)
• Household management
• Financial management

Examples:

• Cannot go to work due to depression
• Grades drop from A’s to failing
• Withdraw from all social contact
• Cannot take care of children
• Neglect personal hygiene

Why This Criterion:

• Distinguishes clinical depression from temporary sadness
• Everyone experiences some depressive symptoms occasionally
• MDD: Symptoms interfere with life

Criterion C: Not Attributable to Physiological Effects of Substance or Medical Condition

Rule Out Other Causes: Must ensure symptoms not better explained by substance use or medical illness

Substance-Induced:

• Depression caused by:
  • Drugs: Alcohol, marijuana, cocaine, etc.
  • Medications: Some medications cause depression (e.g., certain blood pressure medications, corticosteroids)
  • Withdrawal: From stimulants, alcohol

Medical Conditions That Can Cause Depression:

• Hypothyroidism: Low thyroid hormone
• Other hormonal disorders: Cushing’s disease
• Neurological conditions: Parkinson’s disease, stroke, brain tumor, multiple sclerosis
• Nutritional deficiencies: Vitamin B12 deficiency
• Chronic illnesses: Cancer, heart disease, diabetes
• Chronic pain

How to Determine:

• Thorough medical evaluation
• Timeline: Did depression begin after starting medication or substance use?
• If stop substance/treat medical condition, does depression resolve?

If Due to Medical Condition or Substance:

• Diagnose as: Depressive disorder due to another medical condition, OR Substance-induced depressive disorder
• Not MDD

Can Have Both:

• Medical condition AND MDD (two separate issues)
• Need clinical judgment

Criterion D: Not Better Explained by Schizophrenia Spectrum or Other Psychotic Disorder

Rule Out Psychotic Disorders:

• If depressive symptoms occur exclusively during psychotic disorder (schizophrenia, schizoaffective disorder), don’t diagnose separate MDD
• Depression symptoms may be part of psychotic disorder

Exception:

• If have clear major depressive episodes in addition to psychotic disorder, may diagnose both

Schizoaffective Disorder:

• If have both mood episodes and psychotic symptoms with specific pattern, diagnose schizoaffective disorder instead

Criterion E: Never Been Manic or Hypomanic Episode

Critical Distinction:

If Ever Had Manic or Hypomanic Episode:

• Cannot diagnose MDD
• Must diagnose Bipolar Disorder (Bipolar I if manic, Bipolar II if hypomanic)

Why:

• Presence of even one manic/hypomanic episode changes diagnosis fundamentally
• Indicates bipolar disorder, not unipolar depression
• Treatment differs (bipolar requires mood stabilizers)

Assessment:

• Must ask about history of manic or hypomanic symptoms
• Sometimes people forget or don’t recognize hypomania
• Family history helpful (bipolar runs in families)

Exception:

• If manic/hypomanic episode was clearly substance-induced or due to medical condition, may still diagnose MDD

Additional Diagnostic Features

Duration: At Least 2 Weeks

Minimum Duration:

• Symptoms must be present for at least 2 consecutive weeks

Representing Change:

• Must represent change from previous functioning
• Not person’s baseline

Most of the Time:

• Symptoms present most of the day, nearly every day (for applicable symptoms)

Why 2 Weeks:

• Distinguishes clinical depression from transient sadness
• Temporary bad mood for few days: Not MDD
• Persistent symptoms ≥ 2 weeks: May be MDD

Can Last Much Longer:

• 2 weeks is minimum
• Episodes often last months if untreated
• Average untreated episode: 6-9 months

First Episode vs. Recurrent

Specify:

• Single episode: First major depressive episode
• Recurrent: Two or more major depressive episodes
  • Separated by at least 2 months of no/minimal symptoms

Recurrent Depression Common:

• About 50% of people who have one episode will have another
• 80% of those with two episodes will have third
• MDD often chronic, recurring disorder

Severity Specifiers

Mild:

• Few symptoms beyond the minimum (5)
• Symptoms result in minor impairment in functioning
• Can still work, maintain relationships (though with difficulty)

Moderate:

• Symptoms/impairment between mild and severe
• Significant functional impairment
• Major difficulties in work, relationships, daily activities

Severe:

• Many symptoms beyond the minimum
• Symptoms severely interfere with functioning
• May be unable to work, care for self
• With psychotic features: Severe depression with delusions or hallucinations (mood-congruent themes like worthlessness, guilt, death)
• Without psychotic features: Severe without psychosis

Other Specifiers

With Anxious Distress:

• Prominent anxiety symptoms during depressive episode
• Feeling tense, restless, worried
• Very common (more than 50% of MDD patients)

With Mixed Features:

• Some manic/hypomanic symptoms during depressive episode
• But not enough to diagnose bipolar
• May indicate bipolar risk

With Melancholic Features:

• Severe anhedonia (no pleasure in anything)
• Lack of mood reactivity (nothing, even good news, improves mood)
• Early morning awakening
• Psychomotor agitation or retardation
• Significant weight loss or appetite loss
• Excessive guilt
• Classic “biological” depression

With Atypical Features:

• Mood reactivity: Mood brightens in response to positive events (opposite of melancholic)
• Increased appetite or weight gain
• Hypersomnia (sleeping too much)
• Leaden paralysis (heavy, leaden feeling in limbs)
• Rejection sensitivity

With Peripartum Onset:

• Onset during pregnancy or within 4 weeks after delivery
• “Postpartum depression”

With Seasonal Pattern:

• Regular pattern: Episodes in fall/winter, remission in spring/summer
• “Seasonal affective disorder” (SAD)
• Related to reduced daylight

With Catatonia:

• Rare
• Catatonic features (immobility, mutism, rigidity)

How Diagnosis Is Made

Step-by-Step:

1. Identify Depressive Symptoms:

• Does person have at least 5 of the 9 symptoms?
• Including either depressed mood OR anhedonia?

2. Duration:

• Present for at least 2 weeks?

3. Distress/Impairment:

• Causing significant problems in functioning?

4. Rule Out Other Causes:

• Not due to substance or medical condition?
• Not better explained by psychotic disorder?

5. Rule Out Bipolar:

• No history of mania or hypomania?

If All Criteria Met: Diagnose Major Depressive Disorder

Common Presentations and Variations

Typical MDD:

• Depressed mood
• Anhedonia
• Insomnia, especially early morning awakening
• Fatigue
• Worthlessness/guilt
• Concentration problems
• Psychomotor retardation
• Appetite/weight loss
• Suicidal thoughts

Atypical Depression:

• Mood improves with positive events
• Increased appetite, weight gain
• Hypersomnia
• Rejection sensitivity
• Still MDD but different symptom profile

Agitated Depression:

• Depressed mood
• But prominent psychomotor agitation (not retardation)
• Restlessness, anxiety
• More common in older adults

Masked Depression:

• Prominent physical symptoms (pain, fatigue)
• Mood symptoms less obvious
• Person may not recognize depression

Depression in Elderly:

• More physical complaints
• More cognitive symptoms (may appear like dementia)
• Less likely to report sadness (may deny)

Depression in Children/Adolescents:

• May present as irritability more than sadness
• Behavioral problems
• School refusal
• Social withdrawal

Why Accurate Diagnosis Matters

Treatment Planning:

• MDD treated differently than bipolar depression
• Different medications, therapies

Prognosis:

• Understanding course and likely outcomes
• Recurrence rates

Identifying Risk:

• Suicide risk assessment critical
• Severity determines intensity of treatment

Research and Communication:

• Standardized diagnosis allows comparison across studies
• Clear communication among professionals

Key Points for Exams

Core Criteria:

• 5 of 9 symptoms for at least 2 weeks
• Must include either depressed mood OR anhedonia
• Symptoms cause significant distress/impairment
• Not due to substance/medical condition
• No history of mania/hypomania (if yes, it’s bipolar)

9 Symptoms (Remember with Acronym SIG E CAPS):

• Sleep disturbance (insomnia or hypersomnia)
• Interest loss (anhedonia)
• Guilt or worthlessness
• Energy loss (fatigue)
• Concentration problems
• Appetite/weight changes
• Psychomotor agitation or retardation
• Suicidal thoughts
• Plus: Depressed mood (included in I or can be separate)

Duration: At least 2 consecutive weeks

Must Cause Impairment: In social, occupational, or other important functioning

Severity: Mild, moderate, severe (with/without psychotic features)

Recurrence Common: 50% have second episode; highly recurrent disorder

Always Assess Suicide Risk: Criterion 9 requires careful evaluation; high risk requires immediate intervention