Diagnosis of Depression

Dear Sam: Depression is classified as a mood disorder. All mood disorders are diagnosed by examining mood episodes the patient is experiencing.  A thorough history and physical exam has to be undertaken to ensure you symptoms are not better explained by other medical conditions.

In order to diagnose depression, health professionals rely on the Diagnostic and statistical manual of mental disorders published by the American Psychiatric Association.

It helps to look at depression as a medical condition that affects your mood.  There are other psychiatric disorders that primarily affect your mood and include: dysthymia, bipolar I, bipolar II, cyclothymia.

In order to diagnose a mood disorder, your health care practitioner will determine what type of mood state or mood episode you are currently experiencing or have experienced in the past.  Mood states include: major depressive, manic, mixed and hypomanic.

In simple terms, to be diagnosed with depression (Major Depressive Disorder), you have to have had a depressive mood state (Major Depressive Episode).

DSM IV CRITERIA FOR MAJOR DEPRESSIVE EPISODE

A.  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 note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

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

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

D. 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).

E. 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 or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

As you can see, depression can be difficult to diagnose in one visit. I usually have to see my patients over a few visits to verify the symptoms they are experiencing are not due to another medical condition, another psychiatric condition, substance abuse or normal expected reactions to life events such as a loss of a loved one.  Once diagnosed properly, there are a variety of treatment options.