Diagnosing Depressive Disorders

Depression is subject to misdiagnosis because its symptoms can often be confused with symptoms of other conditions (e.g., hypothymia) and it frequently co-occurs with other disorders (e.g., substance disorders or substance-induced mood disorders, cardiac problems, personality disorders).

An accurate diagnosis requires careful evaluation by a trained mental health professional.

Major Depressive Disorder or Major Depression is a Mood Disorder characterized by a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and enjoy once-pleasurable activities. The median age of onset is 32.

Major depressive disorder is made up of one or more depressive episodes.

A Major Depressive Episode is characterized by at least two weeks of depressed mood and/or loss of interest in normal activities, accompanied by at least four other symptoms of depression. A Major Depressive Episode is not a codable psychological disorder in itself; rather, it is one of the building blocks of a Mood Disorder (e.g., Major Depressive Disorder or Bipolar Disorder).

Major Depression may occur only once in a person’s lifetime or in recurrent episodes, with periods of remission.

Major Depression does have a high recurrence rate…

• At least 60% of people who experience a single Major Depressive Episode can be expected to experience a second episode
• People who have had two episodes have a 70% chance of experiencing a third episode
• People who have had three episodes have a 90% chance of experiencing a fourth episode

While symptoms of a Major Depressive Episode develop over days to weeks, sometimes, an episode is preceded by mild symptoms of depression and/or anxiety.

Symptoms of a Major Depressive Episode usually develop over days to weeks. A Major Depressive Episode may be preceded by what’s known as a prodromal or pre-episode period that includes anxiety and mild depression symptoms. This prodromal period can last for weeks or even months before the onset of a full-blown Major Depressive Episode.

Untreated depression may resolve in time, but for some, symptoms persist.

An untreated Major Depressive Episode typically lasts for 4 months or longer, regardless of age or onset. In 70 to 80 percent of these cases, functioning returns to normal with a complete remission of symptoms. In 20 to 30 percent of cases, some depressive symptoms remain but don’t meet the criteria for a Major Depressive Episode. These symptoms may persist for months or years.

Criteria for Major Depressive Episode

To warrant a diagnosis of Major Depressive Episode, the episode must be severe enough to cause significant distress or impairment in a person’s work performance or social life. The impact on a person’s occupational functioning may be the hardest to detect because earning a livelihood is so important that most people will go to great lengths to hide symptoms that could threaten their employment.

Beyond transient feelings of sadness, a Major Depressive Episode is an impairment to a person’s daily functioning.

A. In the same two-week period, the person has had five or more of the following symptoms, which represent a definite change from usual functioning. *Either depressed mood or decreased interest or pleasure must be one of the five.

• Mood. For most of nearly every day, the person reports depressed mood (e.g., feels sad or empty) or appears depressed to others. (e.g., tearful). Note: In children and adolescents, depression can present as irritable mood.
• Interests. For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (as noted by the person or by others), including activities that the person normally enjoys doing. The person may lose interest in work, hobbies, and sexual activity.
• Eating & Weight. Although the person is not dieting, there is a marked loss or gain of weight (e.g., 5% in one month) or appetite is markedly decreased or increased nearly every day.
• Sleep. (Nearly every day, the person sleeps excessively or not enough. (Insomnia or hypersomnia) Even if sleeping excessively, the person often still feels tired.
• Observable Psychomotor Activity. Nearly every day, others can see that the person’s activity is sped up or slowed down.
• Fatigue. Nearly every day, there is tiredness or loss of energy.
• Self-worth. Nearly every day, the person feels worthless or inappropriately guilty. These feelings are not just about being sick; they may be unwarranted or even delusional.
• Concentration. As noted by the person or by others, nearly every day, the person is indecisive, or has trouble thinking or concentrating.
• Thoughts about dying. The person has had repeated thoughts about death (other than the fear of dying), or about suicide (with or without a plan), or has made a suicide attempt.

B. Substance Exclusion. Regardless of the severity or duration of the symptoms, Major Depressive Episode should not be diagnosed if the disorder is directly caused by a general medical condition, or by the use of substances, including prescription medications.

C. Bereavement Exclusion. Major Depressive Episode should not be diagnosed if the episode began within two months of the loss of a loved one. There is, however, an exclusion for the bereavement exclusion: If the symptoms are unusually severe, a Major Depressive Episode may be diagnosed, regardless of the time elapsed since the death of a friend or relative. Examples of severity might include: severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations, or slowed psychomotor activity.

People who experience a Major Depressive Episode(s) may experience full or partial remission. Partial remission means that the person has either fewer than five symptoms or no symptoms for less than two months. Full Remission means that the person has exhibited no symptoms of Major Depression during the past two months.

Women at greater risk for Postpartum Depression include those who have:

• Experienced prior Mood Disorder, such as Major Depressive Episodes or Mania
• Experienced anxiety and depression symptoms during pregnancy, or the baby blues following birth
• A family history of Mood Disorder, such as depression or mania

Postpartum Depression is diagnosed when a new mother has a Major Depressive Episode within one month to one year following the birth of the baby, and can develop gradually or suddenly. Postpartum Depression symptoms may include:

• Total loss of enjoyment in life (anhedonia)
• Feelings of helplessness and despair
• Abnormal maternal attitudes, which can vary widely from disinterest and fear of being alone with the baby, to obsessiveness with the baby’s well-being and even over-intrusiveness that doesn’t allow the baby to properly rest.

Psychotic Postpartum Depression (PPPD).

Extreme postpartum episodes (depressive, manic or mixed episodes) can include psychotic or delusional behavior. Somewhere between 1 in 500 to 1 in 1000 postpartum women experience psychotic symptoms. Once a woman has experienced one postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30 and 50 percent.

The risk of psychotic postpartum depression increases for women with:

• Prior postpartum episodes
• Prior history of Mood Disorder, especially Bipolar I Disorder
• Family history of Bipolar Disorders, even if the mother has no personal history of Mood Disorders

In its usual pattern, Seasonal Affective Disorder (SAD) is characterized by the onset of depression during the winter months, when there is less natural sunlight. For most people, the depression generally lifts during spring and summer, but “seasonality” varies from individual to individual.

The diagnostic criteria for SAD include:

• Major Depressive Episodes regularly begin during a particular season of the year
• Complete recovery also occurs regularly during a particular season
• These seasonal changes have occurred in each of the previous two years, with no other nonseasonal depressive episodes

Dysthymic Disorder or Dysthymia is chronic, long-term depression, characterized by at least two years of depressed mood for more days than not. Dysthymics may exhibit many of the symptoms characteristic of Major Depressive Episodes, but the symptoms are less severe and not disabling, though they can prevent normal functioning. Dysthymia, unlike Major Depression, does not include thoughts of death or suicidal ideation.

Dysthymic Disorder occurs in approximately 6% of adults with a median onset age of 31.

Criteria for Dysthymic Disorder:

A. On the majority of days for two years or more, the person reports depressed mood or appear depressed to others for most of the day.

B. When depressed, the patient has two or more of these symptoms:

• Appetite decreased or increased
• Sleep decreased or increased
• Fatigue or low energy
• Poor self-image
• Reduced concentration or indecisiveness
• Feelings of hopelessness

C. During this two year period, the above symptoms are never absent longer than two consecutive months.

D. During the first two years of this syndrome, the patient has not had a Major Depressive Episode, Manic, Hypomanic or Mixed Episode, Cyclothymic Disorder. The disorder also cannot exist solely in the context of a chronic psychosis such as Schizophrenia or Delusional Disorder.

E. The symptoms are not directly caused by a general medical condition or the use of substances, including prescription medications.

F.  The symptoms must cause clinically important distress or impair work, social or personal functioning.