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Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

Major Depressive Episode

  1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

    Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions and hallucinations.

    1. depressed mood

    1. markedly diminished interest or pleasure

    1. significant weight loss when not dieting or weight gain, or decrease or increase in appetite

    1. insomnia or hypersomnia

    1. psychomotor agitation or retardation

    1. fatigue or loss of energy

    1. feelings of worthlessness or excessive or inappropriate guilt

    1. diminished ability to think or concentrate, or indecisiveness

    1. recurrent thoughts of death or suicide

  2. The symptoms do not meet criteria for a Mixed Episode.

  3. The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.

  4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

  5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months and are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

(Adapted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Washington DC: American Psychiatric Association, 2000.)

General Considerations


The separation into bipolar and non-bipolar disorder has proved clinically and diagnostically useful. It is supported by family studies, twin studies, and biological studies. It is supported further by differential clinical responses to treatment and differential disease onsets and outcomes. To these factors, we can add the epidemiologic risk factors detailed in Table 18–1.

Table 18–1. Risk Factors for Major Depressive Disorder

Symptoms and disorders of the depression spectrum are rather common. Lifetime prevalence rates for significant depressive symptoms are 13–20% and for major depressive disorder 3.7–6.7%. Major depressive disorder is about two to three times as common in adolescent and adult females as in adolescent and adult males. In prepubertal children, boys and girls are affected equally. Rates in women and men are highest in the 25–44-year-old age group.


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