DSM 5 Depression

People come to this page for one of two reasons. Either a clinician has used a phrase like major depressive disorder, or they are trying to work out whether what they are living with counts.

We are Richard and Helena Boyd and we have practised in Perth since 2005. To be clear about what follows, we are psychotherapists and we do not diagnose. Only a registered practitioner, usually a GP, psychiatrist or psychologist, can do that. What we can do is explain the criteria accurately and tell you what they leave out.

If you are having thoughts of suicide, please call Lifeline on 13 11 14 or Beyond Blue on 1300 22 4636. In an emergency, call 000.

What The DSM-5 Actually Is

The Diagnostic and Statistical Manual of Mental Disorders is the reference used to define and classify psychiatric disorders.

Published by the American Psychiatric Association, it gives clinicians and researchers a shared language. Without it, one practitioner’s severe depression could be another’s mild case.

It is worth knowing what it is not. It is a classification system, not an explanation. It describes what a set of depressive symptoms looks like from outside, and says almost nothing about why it happened to you.

DSM-5 Or DSM-5-TR?

Most people search for DSM 5, and the current edition is technically DSM-5-TR.

DSM-5 was published in 2013 and a text revision, DSM-5-TR, followed in March 2022. For depression the diagnostic criteria are effectively unchanged, so anything you read about DSM-5 depression still applies. The revision added prolonged grief disorder as a new diagnosis.

The manual of mental disorders is revised periodically because the evidence moves. A roadmap for a future edition exists, but no publication date has been announced.

The Depressive Disorders In DSM-5

Depression is not one diagnosis. The depressive disorders chapter contains several.

They are major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, disruptive mood dysregulation disorder, substance induced depressive disorder, depressive disorder due to another medical condition, and two catch-all categories.

These sit within the broader group of mood disorders, alongside bipolar disorder. Which one applies changes the treatment, so the distinctions are not academic.

Major Depression: The Core Rule

Major depressive disorder is defined by the presence of a major depressive episode, and the rule is precise.

Five or more of nine symptoms must be present during the same two week period, and must represent a change from how you were functioning before. At least one of the five has to be either depressed mood or loss of interest and pleasure.

This is the most commonly misreported part of the depression criteria DSM 5 sets out. It is five, not four, and one must be a cardinal symptom.

The Nine Symptoms

Here are the following symptoms the manual lists, in plain terms.

• Depressed mood most of the day, nearly every day, which in children and adolescents may present as irritability
• Markedly diminished interest or pleasure in all or almost all activities
• Significant weight loss without dieting, or weight gain, with more than five per cent of body weight in a month as the example, or appetite change nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or psychomotor retardation, observable by others
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive guilt
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation, a suicide attempt, or a specific plan

Such symptoms have to be more than a bad fortnight. The phrase nearly every day does a lot of work.

The Qualifiers Most Summaries Leave Out

Three qualifiers change how that list is read, and they are routinely dropped.

The psychomotor item must be observable by other people. The guilt item specifies not merely self reproach or guilt about being sick, a qualifier there to exclude symptoms that are really the ordinary frustration of being unwell.

The death item is broader than suicidal thinking. It covers recurrent thoughts of death, and the manual is explicit that this means more than a passing fear of dying, not just fear itself.

What Has To Be Excluded

Meeting the symptom count is not enough.

The symptoms must cause clinically significant distress or impairment in social, work or other important areas. Emotional pain that has not touched your functioning does not meet the bar, which is a limitation of the system rather than a comment on your experience.

The episode must also not be attributable to a substance or another medical condition, not be better explained by schizophrenia, delusional disorder or other specified and unspecified schizophrenia spectrum and other psychotic disorders, and there must never have been a manic or hypomanic episode.

Why The Bipolar Question Matters

That last exclusion carries more weight than any other line in the criteria.

A single lifetime manic or hypomanic episode moves the diagnosis from major depression to bipolar disorder, and because depression is usually the pole that brings people in, this gets missed. Antidepressants given alone in undiagnosed bipolar disorder carry an increased risk of switching someone into mania.

How Symptom Severity Is Rated

There is a myth that symptom severity is a simple symptom count. It is not.

DSM-5 rates an episode as mild, moderate or severe using three things together: how many symptoms are present beyond the five required, how intense they are, and how much they interfere with functioning. Severe depression means the number is substantially in excess, the intensity is unmanageable, and functioning is markedly affected.

More severe symptoms and greater disability both count. Someone with six severe symptoms can rate above someone with eight mild ones.

Specifiers And What They Add

Specifiers are tags added to a diagnosis to describe the shape of an episode, and each carries treatment implications.

The main ones are with anxious distress, with mixed features, with melancholic features, with atypical features, with psychotic features, with catatonia, with peripartum onset and with seasonal pattern.

The peripartum specifier is what most people mean by postpartum depression, though the DSM window is narrower than everyday usage. It covers onset during pregnancy or within four weeks of delivery, narrower than perinatal services use it, and about half of these episodes begin before the birth.

The Anxious Distress Specifier

This one deserves its own note because it is common and it changes prognosis.

It applies when two or more of these are present on most days: feeling keyed up or tense, unusually restless, difficulty concentrating because of worry, fear that something awful may happen, or a sense of losing control. Two rates as mild, three as moderate, four or five as moderate to severe.

It exists because anxiety symptoms alongside depression predict longer episodes, poorer treatment response and higher suicide risk. That is not the same as having depression plus one of the anxiety disorders, though that is common too.

Persistent Depressive Disorder

Persistent depressive disorder is the diagnosis for depression that is lower grade and much longer running.

It requires depressed mood for most of the day, more days than not, for at least two years in adults and one year in children, plus two or more of poor appetite or overeating, sleep disturbance, low energy, low self esteem, poor concentration and hopelessness. You must never have been symptom free for more than two months at a time.

DSM-5 consolidated the old dysthymic disorder and chronic major depression under this label. Both survive inside it as course specifiers, so the distinction was retained.

Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder moved from an appendix into the main manual in DSM-5, recognised as a depressive disorder rather than one of the normal variations of the cycle.

It requires five or more symptoms in most menstrual cycles across the preceding year, appearing in the final week before menses, improving within days of onset, and minimal the week after. At least one must be marked mood swings, marked irritability or increased interpersonal conflicts, markedly depressed mood, or marked anxiety.

The rest include decreased interest, decreased concentration, fatigue, appetite changes or specific food cravings, hypersomnia or insomnia, feeling overwhelmed, and physical symptoms such as breast tenderness, joint or muscle pain or weight gain. Diagnosis needs prospective daily ratings across two menstrual cycles.

Disruptive Mood Dysregulation Disorder

The other addition in 2013 was for children, and it exists to solve a specific problem.

Disruptive mood dysregulation disorder describes severe recurrent temper outbursts, three or more times a week on average, with persistently irritable or angry mood in between, for twelve months or more, across at least two settings. It should not be diagnosed before age six or after eighteen, with onset before ten.

It was added because chronic irritability in children was increasingly being read as paediatric bipolar disorder. Follow-up research showed these children were at higher risk of depressive and anxiety disorders as adults, not bipolar.

When Something Else Is Causing It

Two diagnoses exist for depression that is downstream of something else.

Substance induced depressive disorder applies when mood symptoms develop during or soon after intoxication, withdrawal or exposure to a medication capable of producing them. Depressive disorder due to another medical condition applies when the disturbance is a direct consequence of a physical health problem.

Thyroid disease is the most cited example. Others include anaemia, vitamin B12 and vitamin D deficiency, sleep apnoea and Parkinson’s disease. A baseline workup including a complete blood count and thyroid function tests is standard for this reason.

Grief, Adjustment And The Bereavement Exclusion

DSM-IV said major depression could not be diagnosed within two months of a death. DSM-5 deleted that rule, and it was controversial.

The case for removing the bereavement exclusion criterion was that normal grief commonly lasts one to two years rather than two months, that bereavement genuinely can trigger a depressive episode, and that no other severe loss carried a similar exemption. The case against was that it risks pathologising the first fortnight of grief.

What replaced it is guidance rather than a rule. In normal grief the pain comes in waves tied to reminders of the person, and self esteem stays intact. In a depressive episode the mood is more constant and self loathing is common.

Prolonged Grief And Adjustment Disorders

Two diagnoses sit close to this territory and are regularly confused with depression.

Prolonged grief disorder, added in 2022, applies when intense yearning or preoccupation with the deceased persists at least twelve months after a death in adults, or six months in children. It sits in the trauma and stressor related chapter.

Adjustment disorders cover symptoms following a stressor within three months that fall short of full criteria for another diagnosis. If the depression criteria are met, the diagnosis is depression, whatever the trigger was.

What The Criteria Do Not Tell You

This is the part we care most about, and it is not a criticism of the manual.

The diagnostic criteria describe a pattern. They do not tell you what the depression is about, what preceded it, what your body is doing, or what will shift it. Two people with identical symptom profiles can have entirely different pictures underneath.

A diagnosis is a starting point and a way of accessing care. It is not an account of you.

How Depression Is Treated In Australia

Treatment is generally matched to symptom severity.

For mild to moderate presentations, psychological therapy is usually first line. For moderate to severe presentations, medication combined with therapy is standard. Selective serotonin reuptake inhibitors are the usual first choice.

Where two adequate medication trials have not helped, this is often called treatment resistant depression. Options then include repetitive transcranial magnetic stimulation, on the Medicare Benefits Schedule since November 2021 under specific eligibility rules, and electroconvulsive therapy, still the most effective acute treatment for severe depression.

Who Can Diagnose Depression In Australia

This matters practically, because it determines where to start.

A GP is the usual entry point and can diagnose depression, prescribe, and write a Mental Health Treatment Plan giving you Medicare rebated psychology sessions. Psychiatrists and psychologists also diagnose within their scope. Counsellors and psychotherapists are not AHPRA registered and do not diagnose.

We say this plainly because the distinction gets blurred online. If you want a diagnosis, see your GP.

Where We Fit

Our approach is Integrative Body Mind Psychotherapy, and we work alongside medical care rather than instead of it.

Depression is not only a set of thoughts. It shows up in posture, breathing, energy and the way a person occupies a room, and talking about it while the body stays collapsed changes very little. That physical layer is where we work.

Many of the people we see are already on medication or under a GP, which is the arrangement we prefer.

What This Looks Like In Practice

These are composite examples drawn from our clinical work, with identifying details changed.

A man in his fifties had been told he had treatment resistant depression after two medications failed. Nobody had asked about a fortnight in his thirties where he had not slept and had made decisions his family still talked about. That question changed his treatment.

A woman in her thirties had been unwell for eleven years and had never met criteria for a major depressive episode, because she had never been acutely bad enough for two weeks. She fitted persistent depressive disorder, and had spent a decade assuming the flatness was her personality.

A man in his forties was referred with low mood, fatigue and poor concentration. His GP checked his bloods first. The problem was an underactive thyroid, and the depressive symptoms lifted once it was treated.

Frequently Asked Questions

The questions people ask us most often about this, and our honest answers.

How Many Symptoms Do You Need For A Depression Diagnosis?

Five or more of the nine, present during the same two week period, at least one being depressed mood or loss of interest. They also have to cause clinically significant distress or impairment, and not be explained by a substance or medical condition.

What Is The Difference Between Clinical Depression And Feeling Depressed?

Clinical depression is a threshold judgement about duration, symptom count and functional impact. Feeling low for a few days after something difficult is a normal response. The line is duration and interference rather than intensity of feeling.

Can You Have Depression And Other Psychiatric Disorders At Once?

Frequently. Anxiety disorders are the most common companion, and depression also co-occurs with substance use and chronic physical health conditions. Comorbidity is the norm rather than the exception.

Where To Go From Here

The DSM-5 criteria are a useful thing to understand and a poor thing to self-apply. They are a clinical shorthand for practitioners comparing notes, and reading them cold usually produces either false reassurance or unnecessary alarm. A diagnosis describes a period rather than a permanent state.

If this sounds like your last few months, the next step is a GP appointment rather than more reading. Bring the specifics: how long, how many days a week, and what has stopped happening since it started. That is what a diagnosis is built from.

If you want to work on what sits underneath a diagnosis, we see people individually and as couples at our Inglewood rooms.

Book a session with us, or read more about our depression counselling.