What are the symptoms and management of depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)?

Depression in DSM-5: Symptoms and Management

According to the DSM-5, Major Depressive Disorder (MDD) is defined as having five or more specific symptoms present during the same 2-week period, with at least one symptom being either depressed mood or loss of interest/pleasure in activities, accompanied by significant distress or impairment in functioning. 1

Diagnostic Criteria for Major Depressive Disorder

Core Symptoms (at least one required)

• Depressed mood most of the day, nearly every day 1
• Markedly diminished interest or pleasure in all or almost all activities (anhedonia) 1, 2

Additional Symptoms (need total of 5 including core symptoms)

• Significant weight loss/gain or decrease/increase in appetite 1, 3
• Insomnia or hypersomnia nearly every day 1, 2
• Psychomotor agitation or retardation nearly every day 1, 2
• Fatigue or loss of energy nearly every day 1, 4
• Feelings of worthlessness or excessive/inappropriate guilt 1
• Diminished ability to think or concentrate, or indecisiveness 1, 3
• Recurrent thoughts of death, suicidal ideation, or suicide attempt 1, 3

Assessment Tools for Depression

Several validated assessment tools can help quantify depression severity:

• Patient Health Questionnaire (PHQ-9): 9-item self-report scale assessing symptoms of major depressive disorder as defined by the DSM-IV 5
• Beck Depression Inventory (BDI): 21-item self-report scale with scores ≥20 suggesting clinical depression; assesses behavioral, cognitive, and somatic components including suicidal ideation 5
• Hamilton Rating Scale for Depression (HAM-D): 17-item clinician-administered scale with scores 7-17 suggesting mild depression, 18-24 moderate depression, and ≥25 severe depression 5
• Center for Epidemiological Studies-Depression Scale (CES-D): 20-item self-report scale with scores ≥16 suggesting moderate to severe depressive symptomatology 5

Depression Severity Classification

Depression severity can be categorized based on symptom presentation:

• Mild Depression: Typically presents with fewer symptoms and minimal functional impairment 5, 2
• Moderate Depression: Often presents with somatic symptoms cluster (sleep disturbance, appetite changes, fatigue, psychomotor changes) 2
• Severe Depression: Characterized by anhedonia and non-somatic symptoms (feelings of worthlessness, guilt, suicidal thoughts) 2

Management Approach

Pharmacological Treatment

• First-line treatment: Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly used as first-line pharmacological treatment 1, 4
• Treatment duration: Medication should be continued for at least 16-24 weeks after symptom remission to prevent recurrence 1
• The American College of Physicians recommends either cognitive behavioral therapy or second-generation antidepressants (SSRIs, SNRIs, or selective serotonin norepinephrine reuptake inhibitors) after discussing treatment effects, adverse effects, cost, accessibility, and patient preferences 5

Non-Pharmacological Interventions

• Psychotherapy: Particularly cognitive-behavioral therapy (CBT) has strong evidence for effectiveness 5
• Exercise: Regular physical activity can help reduce depressive symptoms 5
• Psychoeducational therapy: Provides information about depression and coping strategies 5

Treatment Phases

Treatment of depression occurs in three phases:

• Acute phase (6-12 weeks): Focus on symptom reduction 5
• Continuation phase (4-9 months): Prevent relapse 5
• Maintenance phase (≥1 year): Prevent recurrence, particularly important for those with multiple episodes 5, 4

Special Considerations

• Suicide risk: Any patient identified as at risk of harm to self or others should be referred for emergency evaluation 5
• Medical causes: Rule out medical causes of depressive symptoms (e.g., unrelieved pain, fatigue) and delirium (e.g., infection, electrolyte imbalance) 5
• Referral indications: Consider referral to psychiatry when diagnosis is unclear, symptoms don't improve with standard treatment, or suicide risk is present 1, 4

Treatment Algorithm

1. Screen and diagnose using DSM-5 criteria and validated assessment tools 1, 2
2. Assess severity based on symptom presentation and functional impairment 2
3. Evaluate suicide risk and refer for emergency evaluation if present 5
4. For mild to moderate depression: Consider starting with either CBT or an SSRI 5
5. For severe depression: Consider combination therapy with both medication and psychotherapy 5, 1
6. Monitor response and adjust treatment if inadequate improvement after 4-6 weeks 1
7. Continue treatment for at least 16-24 weeks after symptom remission 1
8. Consider maintenance therapy for patients with recurrent episodes 5, 4