The full rendition of the American criterion from the DSM IV is quite
long. I provide a quick check guide to depression on this site. You
can find it here. Below is the full DSM IV Diagnostic Criterion.
At least one of the following three abnormal moods which significantly
interfered with the person's life:
- Abnormal depressed mood most of the day, nearly every day, for
at least 2 weeks.
- Abnormal loss of all interest and pleasure most of the day, nearly
every day, for at least 2 weeks.
- If 18 or younger, abnormal irritable mood most of the day, nearly
every day, for at least 2 weeks.
At least five of the following symptoms have been present during
the same 2 week depressed period.
- Abnormal depressed mood (or irritable mood if a child or adolescent)
[as defined in criterion A].
- Abnormal loss of all interest and pleasure [as defined in criterion
- Appetite or weight disturbance, either:
- Abnormal weight loss (when not dieting) or decrease in appetite.
- Abnormal weight gain or increase in appetite.
- Sleep disturbance, either abnormal insomnia or abnormal hypersomnia.
- Activity disturbance, either abnormal agitation or abnormal slowing
(observable by others).
- Abnormal fatigue or loss of energy.
- Abnormal self-reproach or inappropriate guilt.
- Abnormal poor concentration or indecisiveness.
- Abnormal morbid thoughts of death (not just fear of dying) or
- The symptoms are not due to a mood-incongruent psychosis.
- There has never been a Manic Episode, a Mixed Episode, or
a Hypomanic Episode.
- The symptoms are not due to physical illness, alcohol, medication,
or street drugs.
- The symptoms are not due to normal bereavement.
By definition, Major Depressive Disorder cannot be due to:
- Physical illness, alcohol, medication, or street drug use.
- Normal bereavement.
- Bipolar Disorder
- Mood-incongruent psychosis (e.g., Schizoaffective Disorder, Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified).
Major Depressive Disorder causes the following mood symptoms:
Abnormal depressed mood:
- Sadness is usually a normal reaction to loss. However, in Major
Depressive Disorder, sadness is abnormal because it:
- Persists continuously for at least 2 weeks.
- Causes marked functional impairment.
- Causes disabling physical symptoms (e.g., disturbances in
sleep, appetite, weight, energy, and psychomotor activity).
- Causes disabling psychological symptoms (e.g., apathy, morbid
preoccupation with worthlessness, suicidal ideation, or psychotic
- The sadness in this disorder is often described as a depressed,
hopeless, discouraged, "down in the dumps," "blah," or empty. This
sadness may be denied at first. Many complain of bodily aches and
pains, rather than admitting to their true feelings of sadness.
Abnormal loss of interest and pleasure mood:
- The loss of interest and pleasure in this disorder is a reduced
capacity to experience pleasure which in its most extreme form is
- The resulting lack of motivation can be quite crippling.
Abnormal irritable mood:
- This disorder may present primarily with irritable, rather than
depressed or apathetic mood. This is not officially recognized yet
for adults, but it is recognized for children and adolescents.
- Unfortunately, irritable depressed individuals often alienate
their loved ones with their cranky mood and constant criticisms.
Major Depressive Disorder causes the following physical symptoms:
- Most depressed patients experience loss of appetite and weight
loss. The opposite, excessive eating and weight gain, occurs in
a minority of depressed patients. Changes in weight can be significant.
- Most depressed patients experience difficulty falling asleep,
frequent awakenings during the night or very early morning awakening.
The opposite, excessive sleeping, occurs in a minority of depressed
Fatigue or loss of energy:
- Profound fatigue and lack of energy usually is very prominent
Agitation or slowing:
- Psychomotor retardation (an actual physical slowing of speech,
movement and thinking) or psychomotor agitation (observable pacing
and physical restlessness) often are present in severe Major Depressive
Major Depressive Disorder causes the following cognitive symptoms:
Abnormal self-reproach or inappropriate guilt:
- This disorder usually causes a marked lowering of self-esteem
and self-confidence with increased thoughts of pessimism, hopelessness,
and helplessness. In the extreme, the person may feel excessively
and unreasonably guilty.
- The "negative thinking" caused by depression can become extremely
dangerous as it can eventually lead to extremely self-defeating
or suicidal behavior.
Abnormal poor concentration or indecisiveness:
- Poor concentration is often an early symptom of this disorder.
The depressed person quickly becomes mentally fatigued when asked
to read, study, or solve complicated problems.
- Marked forgetfulness often accompanies this disorder. As it worsens,
this memory loss can be easily mistaken for early senility (dementia).
Abnormal morbid thoughts of death (not just fear of dying) or
- The symptom most highly correlated with suicidal behavior in depression
- 80 to 90% of individuals with Major Depressive Disorder also have
anxiety symptoms (e.g., anxiety, obsessive preoccupations, panic
attacks, phobias, and excessive health concerns).
- Separation anxiety may be prominent in children.
- About one third of individuals with Major Depressive Disorder
also have a full-blown anxiety disorder (usually either Panic Disorder,
Obsessive-Compulsive Disorder, or Social Phobia).
- Anxiety in a person with major depression leads to a poorer response
to treatment, poorer social and work function, greater likelihood
of chronicity and an increased risk of suicidal behavior.
- Individuals with Anorexia Nervosa and Bulimia Nervosa often develop
Major Depressive Disorder.
- Mood congruent delusions or hallucinations may accompany severe
Major Depressive Disorder.
- The combination of Major Depressive Disorder and substance abuse
is common (especially Alcohol and Cocaine).
- Alcohol or street drugs are often mistakenly used as a remedy
for depression. However, this abuse of alcohol or street drugs actually
worsens Major Depressive Disorder.
- Depression may also be a consequence of drug or alcohol withdrawal
and is commonly seen after cocaine and amphetamine use.
- 25% of individuals with severe, chronic medical illness (e.g.,
diabetes, myocardial infarction, carcinomas, stroke) develop depression.
- About 5% of individuals initially diagnosed as having Major Depressive
Disorder subsequently are found to have another medical illness
which was the cause of their depression.
- Medical conditions often causing depression are:
- Endocrine disorders: hypothyroidism, hyperparathyroidism,
Cushing's disease, and diabetes mellitus.
- Neurological disorders: multiple sclerosis, Parkinson's disease,
migraine, various forms of epilepsy, encephalitis, brain tumors.
- Medications: many medications can cause depression, especially
antihypertensive agents such as calcium channel blockers, beta
blockers, analgesics and some anti-migraine medications.
Up to 15% of patients with severe Major Depressive Disorder die by suicide.
Over age 55, there is a fourfold increase in death rate.
10-25% of patients with Major Depressive Disorder have preexisting Dysthymic
Disorder. These "double depressions" (i.e., Dysthymia + Major Depressive
Disorder) have a poorer prognosis.
There are no laboratory findings that are diagnostic for this disorder.
Males and females are equally affected by Major Depressive Disorder
prior to puberty. After puberty, this disorder is twice as common in females
as in males. The highest rates for this disorder are in the 25- to 44-year-old
The lifetime risk for Major Depressive Disorder is 10% to 25% for women
and from 5% to 12% for men. At any point in time, 5% to 9% of women and
2% to 3% of men suffer from this disorder. Prevalence is unrelated to
ethnicity, education, income, or marital status.
- Average age at onset is 25, but this disorder may begin at any
- Stress appears to play a prominent role in triggering the first
1-2 episodes of this disorder, but not in subsequent episodes.
- An average episode lasts about 9 months.
- Course is variable. Some people have isolated episodes that are
separated by many years, whereas others have clusters of episodes,
and still others have increasingly frequent episodes as they grow
- About 20% of individuals with this disorder have a chronic course.
- The risk of recurrence is about 70% at 5 year follow up and at least
80% at 8 year follow-up.
- After the first episode of Major Depressive Disorder, there is a 50%-60%
chance of having a second episode, and a 5-10% chance of having a Manic
Episode (i.e., developing Bipolar I Disorder). After the second episode,
there is a 70% chance of having a third. After the third episode, there
a 90% chance of having a fourth.
- The greater number of previous episodes is an important risk factor
For patients with severe Major Depressive Disorder, 76% on antidepressant
therapy recover, whereas only 18% on placebo recover. For these severely
depressed patients, significantly more recover on antidepressant therapy
than on interpersonal psychotherapy. For these same patients, cognitive
therapy has been shown to be no more effective than placebo.
Poor outcome or chronicity in Major Depressive Disorder is associated
with the following:
- Inadequate treatment
- Severe initial symptoms
- Early age of onset
- Greater number of previous episodes
- Only partial recovery after one year
- Having another severe mental disorder (e.g. Alcohol Dependency, Cocaine
- Severe chronic medical illness
- Family dysfunction
There is strong evidence that major depression is, in part, a genetic
- Individuals who have parents or siblings with Major Depressive Disorder
have a 1.5-3 times higher risk of developing this disorder.
- The concordance for major depression in monozygotic twins is substantially
higher than it is in dizygotic twins. However, the concordance in monozygotic
twins is in the order of about 50%, suggesting that factors other than
genetic factors are also involved.
- Children adopted away at birth from biological parents who have a
depressive illness carry the same high risk as a child not adopted away,
even if they are raised in a family where no depressive illness exists.
- Interestingly, families having Major Depressive Disorder have an increased
risk of developing Alcoholism and Attention-Deficit Hyperactivity Disorder.
Exclude depressions due to physical illness, medications, or street
- If due to physical illness, diagnose: Mood Disorder Due to
a General Medical Condition.
- If due to alcohol, diagnose: Alcohol-Induced Mood Disorder.
- If due to other substance use, diagnose: Other Substance-Induced
Organic Causes Of Severe Depression
Organic Mood Syndromes caused by: Acquired Immune Deficiency Syndrome
(AIDS), Adrenal (Cushing's or Addison's Diseases), Cancer (especially
pancreatic and other GI), Cardiopulmonary disease, Dementias (including
Alzheimer's Disease); Epilepsy, Fahr's Syndrome, Huntington's Disease,
Hydrocephalus, Hyperaldosteronism, Infections (including HIV and neurosyphilis),
Migraines, Mononucleosis, Multiple Sclerosis, Narcolepsy, Neoplasms,
Parathyroid Disorders (hyper- and hypo-), Parkinson's Disease, Pneumonia
(viral and bacterial), Porphyria, Postpartum, Premenstrual Syndrome,
Progressive Supranuclear Palsy, Rheumatoid Arthritis, Sjogren's Arteritis,
Sleep Apnea, Stroke, Systemic Lupus Erythematosus, Temporal Arteritis,
Trauma, Thyroid Disorders (hypothyroid and "apathetic" hyperthyroidism),
Tuberculosis, Uremia (and other renal diseases), Vitamin Deficiencies
(B12, C, folate, niacin, thiamine), Wilson's Disease.
Acetazolamine, Alphamethyldopa, Amantadine, Amphetamines, Ampicillin,
Azathioprine (AZT), 6-Azauridine, Baclofen, Beta Blockers, Bethanidine,
Bleomycin, Bromocriptine, C-Asparaginase, Carbamazepine, Choline,
Cimetidine, Clonidine, Clycloserin, Cocaine, Corticosteroids (including
ACTH), Cyproheptadine, Danazol, Digitalis, Diphenoxylate, Disulfiram,
Ethionamide, Fenfluramine, Griseofulvin, Guanethidine, Hydralazine,
Ibuprofen, Indomethacin, Lidocaine, Levodopa, Methoserpidine, Methysergide,
Metronidazole, Nalidixic Acid, Neuroleptics (butyrophenones, phenothiazines,
oxyindoles), Nitrofurantoin, Opiates, Oral Contraceptives, Phenacetin,
Phenytoin, Prazosin, Prednisone, Procainamide, Procyclidine, Quanabenzacetate,
Rescinnamine, Reserpine, Sedative/Hypnotics (barbiturates, benzodiazepines,
chloral hydrate), Streptomycin, Sulfamethoxazole, Sulfonamides, Tetrabenazine,
Tetracycline, Triamcinolone, Trimethoprim, Veratrum, Vincristine.
- Exclude depressions having a previous history of elevated, expansive,
or euphoric mood:
- If previous history of a Manic Episode, diagnose: Bipolar I
- If previous history of recurrent Major Depressive Episodes and
at least one Hypomanic Episode, diagnose: Bipolar II Disorder.
- If previous history of recurrent Hypomanic Episodes and brief,
mild depressive episodes (milder than Major Depressive Episodes),
diagnose: Cyclothymic Disorder.
- Exclude depressions that merely represent normal bereavement, instead
diagnose: Uncomplicated Bereavement.
- Exclude depressions associated with mood-incongruent psychosis:
- If previous history of at least 2 weeks of delusions or hallucinations
occurring in the absence of prominent mood symptoms, diagnose either:
Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise
- Exclude mild depressions:
- If only mild depression present for most of past 2 years (or 1
year in children), diagnose: Dysthymic Disorder.
- If only brief mild depression clearly triggered by stress, diagnose:
Adjustment Disorder with Depressed Mood, or Adjustment
Disorder with Mixed Anxiety and Depressed Mood.
- If mild depression is clinically significant, but does not meet
the criteria for any of the previously described disorders, diagnose:
Depressive Disorder Not Otherwise Specified.
- In the elderly, it is often difficult to distinguish between early
dementia or Major Depressive Disorder:
- If there is a premorbid history of declining cognitive function
in the absence of severe depression, diagnose: Dementia.
- If there was a relatively normal premorbid state and somewhat
abrupt cognitive decline associated with severe depression, diagnose:
Major Depressive Disorder.