The criterion symptoms for major depressive disorder must be present nearly every day to
be considered present, with the exception of weight change and suicidal ideation. Depressed
mood must be present for most of the day, in addition to being present nearly every
day. Often insomnia or fatigue is the presenting complaint, and failure to probe for
accompanying depressive symptoms will result in underdiagnosis. Sadness may be denied
at first but may be elicited through interview or inferred from facial expression and
demeanor. With individuals who focus on a somatic complaint, clinicians should determine
whether the distress from that complaint is associated with specific depressive
symptoms. Fatigue and sleep disturbance are present in a high proportion of cases; psychomotor
disturbances are much less common but are indicative of greater overall severity,
as is the presence of delusional or near-delusional guilt.
The essential feature of a major depressive episode is a period of at least 2 weeks during
which there is either depressed mood or the loss of interest or pleasure in nearly all activities
(Criterion A). In children and adolescents, the mood may be irritable rather than sad.
The individual must also experience at least four additional symptoms drawn from a list
that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy;
feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions;
or recurrent thoughts of death or suicidal ideation or suicide plans or attempts. To
count toward a major depressive episode, a symptom must either be newly present or must
have clearly worsened compared with the person’s pre-episode status. The symptoms
must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The episode
must be accompanied by clinically significant distress or impairment in social, occupational,
or other important areas of functioning. For some individuals with milder
episodes, functioning may appear to be normal but requires markedly increased effort.
The mood in a major depressive episode is often described by the person as depressed,
sad, hopeless, discouraged, or “down in the dumps” (Criterion A1). In some cases, sadness
may be denied at first but may subsequently be elicited by interview (e.g., by pointing out
that the individual looks as if he or she is about to cry). In some individuals who complain
of feeling “blah,” having no feelings, or feeling anxious, the presence of a depressed mood
can be inferred from the person’s facial expression and demeanor. Some individuals emphasize
somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of
sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a
tendency to respond to events with angry outbursts or blaming others, an exaggerated
sense of frustration over minor matters). In children and adolescents, an irritable or cranky
mood may develop rather than a sad or dejected mood. This presentation should be differentiated
from a pattern of irritability when frustrated.
Loss of interest or pleasure is nearly always present, at least to some degree. Individuals
may report feeling less interested in hobbies, “not caring anymore,” or not feeling any
enjoyment in activities that were previously considered pleasurable (Criterion A2). Family
members often notice social withdrawal or neglect of pleasurable avocations (e.g., a formerly
avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to
practice). In some individuals, there is a significant reduction from previous levels of sexual
interest or desire.
Appetite change may involve either a reduction or increase. Some depressed individuals
report that they have to force themselves to eat. Others may eat more and may crave
specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in
either direction), there may be a significant loss or gain in weight, or, in children, a failure
to make expected weight gains may be noted (Criterion A3).
Sleep disturbance may take the form of either difficulty sleeping or sleeping excessively
(Criterion A4). When insomnia is present, it typically takes the form of middle insomnia
(i.e., waking up during the night and then having difficulty returning to sleep) or
terminal insomnia (i.e., waking too early and being unable to return to sleep). Initial insomnia
(i.e., difficulty falling asleep) may also occur. Individuals who present with oversleeping
(hypersomnia) may experience prolonged sleep episodes at night or increased
daytime sleep. Sometimes the reason that the individual seeks treatment is for the disturbed
Psychomotor changes include agitation (e.g., the inability to sit still, pacing, handwringing;
or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g.,
slowed speech, thinking, and body movements; increased pauses before answering;
speech that is decreased in volume, inflection, amount, or variety of content, or muteness)
(Criterion A5). The psychomotor agitation or retardation must be severe enough to be observable
by others and not represent merely subjective feelings.
Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may report
sustained fatigue without physical exertion. Even the smallest tasks seem to requiresubstantial effort. The efficiency with which tasks are accomplished may be reduced. For
example, an individual may complain that washing and dressing in the morning are exhausting
and take twice as long as usual.
The sense of worthlessness or guilt associated with a major depressive episode may include
unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations
over minor past failings (Criterion A7). Such individuals often misinterpret neutral
or trivial day-to-day events as evidence of personal defects and have an exaggerated sense
of responsibility for untoward events. The sense of worthlessness or guilt may be of delusional
proportions (e.g., an individual who is convinced that he or she is personally responsible
for world poverty). Blaming oneself for being sick and for failing to meet
occupational or interpersonal responsibilities as a result of the depression is very common
and, unless delusional, is not considered sufficient to meet this criterion.
Many individuals report impaired ability to think, concentrate, or make even minor
decisions (Criterion A8). They may appear easily distracted or complain of memory difficulties.
Those engaged in cognitively demanding pursuits are often unable to function. In
children, a precipitous drop in grades may reflect poor concentration. In elderly individuals,
memory difficulties may be the chief complaint and may be mistaken for early signs
of a dementia (“pseudodementia”). When the major depressive episode is successfully
treated, the memory problems often fully abate. However, in some individuals, particularly
elderly persons, a major depressive episode may sometimes be the initial presentation
of an irreversible dementia.
Thoughts of death, suicidal ideation, or suicide attempts (Criterion A9) are common.
They may range from a passive wish not to awaken in the morning or a belief that others
would be better off if the individual were dead, to transient but recurrent thoughts of committing
suicide, to a specific suicide plan. More severely suicidal individuals may have put
their affairs in order (e.g., updated wills, settled debts), acquired needed materials (e.g., a
rope or a gun), and chosen a location and time to accomplish the suicide. Motivations for
suicide may include a desire to give up in the face of perceived insurmountable obstacles,
an intense wish to end what is perceived as an unending and excruciatingly painful emotional
state, an inability to foresee any enjoyment in life, or the wish to not be a burden to
others. The resolution of such thinking may be a more meaningful measure of diminished
suicide risk than denial of further plans for suicide.
The evaluation of the symptoms of a major depressive episode is especially difficult
when they occur in an individual who also has a general medical condition (e.g., cancer,
stroke, myocardial infarction, diabetes, pregnancy). Some of the criterion signs and symptoms
of a major depressive episode are identical to those of general medical conditions
(e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in pregnancy;
insomnia later in pregnancy or the postpartum). Such symptoms count toward a
major depressive diagnosis except when they are clearly and fully attributable to a general
medical condition. Nonvegetative symptoms of dysphoria, anhedonia, guilt or worthlessness,
impaired concentration or indecision, and suicidal thoughts should be assessed with
particular care in such cases. Definitions of major depressive episodes that have been modified
to include only these nonvegetative symptoms appear to identify nearly the same individuals
as do the full criteria.