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Section XII: Addressing Diagnostic Complexities – Depressive Disorders

Statistic: Unipolar depression - or major depressive disorder - is the second largest source of disease burden (Murray & Lopez, 1996).

Once the existence of a Bipolar and Related Disorder has been ruled out for a client presenting with depression, the diagnostic process can focus in on what was formerly called unipolar depression, or simply Depressive Disorders. This section will examine the complexities of diagnosing depressive disorders.


Key Knowledge Point to Follow:

The main classes of depressive disorders are:

- Major depressive disorder

- Persistent Depressive Disorder/Dysthymia

- Substance/Medication Induced Depressive Disorder

- Mood disorders NOS (not otherwise specified).

Additionally, the DSM-5 has two new diagnoses that were not present in the DSM-IV-TR. Both of these diagnoses have generated some controversy as to their validity and usefulness. These two are:

- Disruptive Mood Dysregulation Disorder

- Premenstrual Dysphoric Disorder 

The NOS diagnosis is given if the person’s reasons for seeking counseling do not fully meet criteria for any one diagnosis. (APA, 2000). Because it can be tricky to find the differentiating features between these different categories of mood disorders, we will take some time here to unravel some of the complexities.

Moods are seen to range on a spectrum, with one extreme being depressed and the other extreme being manic. People in the general population fall somewhere in the middle of the two mood extremes and may tend toward slightly elevated or slightly depressed mood without causing significant problems in their lives.


Key Knowledge Point to Follow: 

It is important to remember that if the depressed mood does not cause significant impairment in a person’s life in functional, occupational, educational, relationship, or legal arenas, then there is no need for a diagnosis and no diagnosis is made. Once we have identified the presence of depression without the concurrent presence of mania, our next step is to begin to assess the severity of the symptoms. We'll start by examining the differences between Major Depressive Disorder, and Persistent Depressive Disorder/Dysthymia.


Major Depressive Disorder:

A major depressive is an episode of sadness or loss of pleasure that lasts at least two weeks. Five or more of the following symptoms will be present:

- Depressed mood most of the day

- Markedly diminished interest in pleasure in all, or mostly all, activities

- Significant weight loss or gain (5% or more) or increase or decrease in appetite

- Increased or decreased need for sleep

- Psychomotor agitation or retardation

- Fatigue or loss of energy

- Feelings of worthlessness or guilt

- Diminished ability to concentrate or think

- Recurrent thoughts of death or suicidal thoughts.


Major depressive disorder is coded based upon a number of components. First, is the episode of depression a single episode, or a recurrent episode. Next, the clinician needs to make a determination of whether the episode is mild, moderate, or severe; with or without psychotic features; in partial remission, in full remission or unspecified.



There are also a number of specifiers that should be recorded to present a more accurate picture of the client’s overall state of being. They are as follows:

- With anxious distress

- With mixed features (meaning both anxious and melancholic symptoms)

- With melancholic features

- With atypical features

- With mood-incongruent psychotic features

- With catatonia

- With peripartum onset (after birth)

- With seasonal pattern


Coding for Major Depressive Disorders

Major depressive disorders will be coded differently based upon these different factors. It is important to know each of them, so that the code selected can accurately describe the severity and course of the illness, as well as any specifiers accompanying the disorder. A single episode will be coded as F32.x  in ICD-10, while any further episodes of major depression beyond the initial episode will be coded as F33.x, indicating that the depression is recurrent. 

Key Knowledge Point to Follow:

Under ICD-10, the first digit to the right of the decimal point will indicate the factors related to severity: 0=mild, 1=moderate, 2=severe, 3=with psychotic features, 9=unspecified.

ICD-10 coding for full and partial remission will be composed differently from ICD-9. For a single episode, partial remission will be coded with a single digit: F32.4, as will full remission: F32.5.  For a recurrent episode, partial and full remission will be coded with an added digit: F32.41 for partial remission and F32.42 for full remission.

A fully articulated diagnosis would therefore look something like this:

Major depression, recurrent, in partial remission, with seasonal pattern (ICD-10: F32.4)

Because there has been a change in how grief has been conceptualized in the DSM-5, a section under major depression suggests a useful clarification to distinguish major depression from grief, some of which will be noted here:

“In distinguishing grief from a major depressive episode, it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE (major depressive episode, it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so called pangs of grief. . . .The depressed mood of an MDE is more persistent and not tied to specific thoughts or pre-occupations. . .”

Persistent Depressive Disorder/Dysthymia:

Persistent Depressive Disorder/Dysthymia (PDD/D) is a long-term - but less intense – condition than major depressive disorder or a major depressive episode, in which for the past two years (adults) or for the past one year (adolescents or children), the person has felt depressed and has two or more of the depressive symptoms noted below. PDD/Dysthymia is therefore a less severe form of a depressive mood disorder in terms of both course and intensity. Two or more of the following symptoms will be present:

- Increased or decreased appetite

- Increased or decreased sleep

- Low energy or fatigue

- Low self esteem

- Feelings of hopelessness

- Poor concentration or difficulty making decisions

(APA, 2013)


Key Knowledge Point to Follow:

We noted earlier that the DSM-5 has removed the diagnosis of dysthymia from the DSM and reformulated it into the diagnosis of PDD/D. As has been noted, this new diagnosis represents “a consolidation of DSM-IV-TR chronic depressive disorder and dysthymic disorder.” (DSM, 2013) This re-conceptualization may make sense from a medical sense, but it poses some problems in terms of differential diagnosis. It can be difficult to distinguish PDD/D from a mild major depressive disorder where episodes of depression recur and persist. The most contrasting feature is the depth of depression that occurs. In contrast to PDD/D, the depression in a major depressive episode is typically deeper than the lower grade depression of PDD/D, causing greater disruption to the person’s major life areas.

Nevertheless, the depressive symptoms in PDD/D can exist at a low grade level for a very long time, sometimes over many years of a person’s life, dating back to adolescence or even childhood. Clients who were raised in very dysfunctional families and subjected to various kinds of abuse and/or neglect are susceptible for the long-term kinds of less severe depression that lead to this diagnosis.