Decoding DSM-5 Depression

Patient Expert

Last year, around this time, the American Psychiatric Association issued the fifth edition of its diagnostic bible, the DSM-5. This replaces the DSM-IV, which had been in service for nearly twenty years. Both copies run over 900 pages and are best left unopened, preferably undisturbed in their original shrink wrap.

But someone actually has to read these things and explain its contents to people, and that person is yours truly. Please hold me in your thoughts and prayers ...

Getting Started

The DSM-5 Table of Contents directs us to "Depressive Disorders" on page 155. Page 155 comprises 43 lines of densely packed gobbledygook. The ink on the page weighs more than my heaviest kitchen skillet.

Turn the page and we come to "Disruptive Mood Dysregulation Disorder (DMDD)." In case you're wondering, DMDD is a newly minted label-of-convenience for doctors who don't want to be accused of diagnosing their underage patients with bipolar disorder. I'm serious about this. But I digress.

You have to flip through five pages of DMDD before you stumble upon "Major Depressive Disorder." This occurs at the bottom of page 160. Believe me, the DSM doesn't make this easy.

The Checklist

Immediately, we come to the trademark DSM symptom checklist, which constitutes "Criterion A" of the depression diagnosis. The checklist is an exact replica of the list that appeared in the DSM-IV.

The DSM-IV had the checklist on one page. But since DSM-5 depression starts at the bottom of the page, our eyes have to flit back and forth, up and down, across two pages, like a driver negotiating four lanes on the infamous 405 in LA.

As many of you already know, the checklist contains nine symptoms, that need to last at least two weeks. For a diagnosis to occur, at least five of these symptoms need to be checked off. And at least one of these checkmarks must land on one of the first two symptoms.

The first symptom is "depressed mood most of the day," which involves feeling "sad, empty, hopeless."

The second is "diminished interest or pleasure in all, or almost all, activities."

So: 1) Feeling sad or hopeless. 2) No pleasure. There must be a checkmark on one or the other or both. No checkmark here, no diagnosis.

The next six symptoms involve sleep dysregulation, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, difficulty concentrating, and suicidal thinking.

So: If you checked off the first two symptoms, you need three more from the next seven. If only one checkmark, you need four to bring your total to the magic five. Clear as day, right?

Criterion B states the symptoms must cause "clinically significant distress or impairment."

Criteria C-E rule out depression due to other causes or illnesses. A major change from the DSM-IV is that the clinician now has discretion to treat an individual who has experienced significant loss (such as bereavement) as depressed.


Jumping slightly ahead to page 162, the "Diagnostic Features" section provides a commentary to the checklist. Thus we learn:

"A symptom may be newly present or must have completely worsened compared with the person's pre-episode status." If the episode is relatively mild, "functioning may appear normal but requires markedly increased effort."

"Sadness may be denied at first, but ... may be inferred through facial expression and demeanor." Also, "the mood may be be irritable rather than sad."

"Psychomotor changes may include "inability to sit still" at one extreme and "slowed speech" at the other.

Suicidal thoughts "may range from a passive wish not to awaken in the morning ... to a specific suicide plan."


We flip back to page 162, just above "Diagnostic Features" to a bolded list of specifiers. Thus, depression with ... : Anxious distress, Mixed features, Melancholic features, Atypical features, Mood-congruent psychotic features, Mood-incongruent psychotic features, Catatonia, Peripartum onset, Seasonal pattern.

Each specifier refers us to a distant page for further explanation. Thus for "anxious distress," we jump 22 pages to page 184. Seriously, if I drop the DSM-5 on my foot in the process, the American Psychiatric Association will have a major lawsuit on its hands.

Anxious distress and mixed features are new to the list. Basically, the DSM now recognizes that anxious or manic features can accompany depression. The DSM makes no attempt, though, to distinguish a mixed episode occurring in depression from a mixed episode occurring in bipolar.

"Melancholic" and "atypical" depressions date back from the pre-SSRI era when researchers wondered why some patients responded better to energizing MAO-I antidepressants and others did better on tricyclics. The main distinction appears to be that those with atypical depression appear to react to their surroundings, either by perking up or shutting down.

But, trust me, the experts are in major disagreement, so please take melancholic/atypical with a grain of salt.

"Peripartum" is the new "postpartum." This is in recognition of the fact that mood disturbances may occur prior to delivery.

"Seasonal pattern" is what we commonly refer to as "seasonal affective disorder (SAD)" or winter depression. Technically, SAD is a specifier rather than a separate disorder.

"Severity" is another specifier - mild, moderate, severe.

What happened to dysthymia?

Dysthymia (what was then less severe chronic depression) is now "Persistent Depressive Disorder," though "dysthymia" is retained in parenthesis.

The major differentiator between dysthymia and major depression used to be severity. The DSM-5 now emphasizes the chronic aspect of the condition. These are depressions that persist over at least two years, and may be mild, moderate, or severe.

Now that you're totally confused

The DSM-5 also includes "Unspecified Depressive Disorder." This is an update of "Depressive Disorder Not Otherwise Specified (NOS)." In other words, if you don't meet the DSM criteria for depression, a clinician may diagnose you with depression, anyway. The same applies to all the other entries in the DSM.

So - excuse me, ahem - what, then, was the point of filling up 900-plus pages?