Depression: What the DSM-5 Doesn't Tell You That You Need to Know

Patient Expert

I accidentally posted this under Bipolar by mistake. Here it is, in depression, where it belongs ...

Yesterday, I  posted  on two easy-to-overlook but significant changes the DSM-5 made to the depression diagnosis. In a nutshell, the DSM now recognizes that anxiety and manic symptoms can occur inside our depressions. These extras may profoundly change the character of the illness, with important treatment and recovery implications.

Unfortunately, the DSM-5 left the rest of its depression criteria exactly as they found it, virtually unchanged since the 1980 publication of the DSM-III. There would be nothing wrong with this had the DSM (psychiatry's diagnostic bible) got it right the first time. Let's just say that what the original leaves considerable room for improvement. Let's get started:

The Symptom Checklist

Most of us know the drill: Nine symptoms, five which must be checked off, including one of the first two. The catch is it is possible to check off all nine and still not know what is going on inside our heads. We know it is depression, but what is depression, and - more to the point - what does OUR depression look like?

The sensible course would have been to subdivide depression the way other disciplines subdivide cancer or cardiac events. Different types, different checklists. It's easy to understand why the DSM-5 passed on this thankless task, but - with our lives at stake - it is impossible to excuse.

Vegetative vs Agitated

The DSM-5 sticks to past categories of "melancholic" vs "atypical" depressions, but these are classified as "specifiers." This means first ticking off the checklist, then seeing if the depression subdivides (or not) into two highly confusing distinctions. Far more useful would have been two separate checklists. Can't get out of bed? Or are you all keyed up? Call the first vegetative, the second agitated. Both suggest entirely different treatments.

Recurrent vs Chronic

Some depressions come and go. Others hang around forever. The ones that come and go have a certain bipolar pattern to them, even if they lack the ups of mania or hypomania. "Up" in this context could mean simply feeling better or less depressed. The DSM makes provision for recurrent depression as a specifier, but their definition of recurrent looks far too much like chronic.

Why this is important is that experts such as Frederick Goodwin, former head of the NIMH, feel that recurrent depression more closely resembles bipolar than it does chronic depression. Again, different depressions, different treatments.

Gender Considerations

Twice as many women are diagnosed with depression, and it's easy to see why. "Appears tearful" is used to illustrate the all-important "depressed mood" of symptom number one. How many men appear tearful? Other symptoms play into the types of maladaptive behavior we identify with women (eating issues, feelings of worthlessness and guilt).

How about looking at depression from a male perspective, for a change? How do men express their feelings of hopelessness and being unable to cope? Rage? Frustration? Drinking too much?


The DSM treats depression as something that mysteriously turned up inside our brains. But what was going on in our lives at the time? We often use the term "situational" to distinguish common reactive depressions (say to getting downsized) from "clinical" depression. The assumption is that the depression will clear up once we adapt or once the issue is resolved. But is that a valid assumption?

So-called situational depressions may tell us that our brains have a more difficult time adjusting to the stresses and strains of daily life, including dealing with other people. Turn up the heat and even "normal" people will crack. But how do we determine what is normal, much less what is a normal reaction? Don't expect to find it in the DSM.


Let's think of depression as a condition where you do not feel like yourself. But suppose your true self is depressed. Personality and temperament are inherited conditions that are not subject to considerable change over a lifetime. Staying home and contemplating dark thoughts may be natural for you. Your gregarious sister may think she is doing you a favor by dragging you to a party. No, you�re fine. On the other hand, if your gregarious sister were to suddenly stay home and contemplate dark thoughts, well - maybe we can call that depression.

Compare: In hypomania (mania lite), the DSM advises that the episode is "uncharacteristic of the individual." In other words, the symptom list is not the final word. But we don't see this qualifying criterion in depression. We should.

Moral of the Story

You know you are depressed. No question about it. But what does YOUR depression look like? A clinician you can work with can guide you in your understanding. But you also need to do your own digging. The DSM promotes a simplistic mindset that militates against your own personal understanding. The DSM-5 continues this tradition. You need to start your own.