DSM Criteria for Major Depressive Disorder
Diagnostic Criteria
A major depressive episode requires at least 5 of the following 9 symptoms present nearly every day for at least 2 weeks, with at least one symptom being either depressed mood or loss of interest/pleasure 1:
- Depressed mood most of the day 1, 2
- Loss of interest or pleasure in usual activities (anhedonia) 1, 2
- Significant weight change (loss or gain) and/or appetite disturbance 1, 2
- Sleep disturbance: insomnia or hypersomnia 1, 2
- Psychomotor changes: agitation or retardation observable by others 1, 2
- Fatigue or loss of energy 1, 2
- Feelings of worthlessness or excessive/inappropriate guilt 1, 2
- Diminished ability to think or concentrate, or indecisiveness 1, 2
- Recurrent thoughts of death, suicidal ideation, suicide plan, or suicide attempt 1, 2
Functional Impact
- The symptoms must cause prominent and relatively persistent depressed or dysphoric mood that interferes with daily functioning 1
- The episode represents a change from previous functioning and causes clinically significant distress or impairment 1
Initial Treatment Selection
Start with second-generation antidepressants selected based on adverse effect profiles, cost, and patient preferences, as no second-generation antidepressant demonstrates superior efficacy over another 3:
- SSRIs, SNRIs, and other second-generation agents have equivalent effectiveness 3
- Cognitive behavioral therapy has similar efficacy to antidepressants and may be used as first-line monotherapy 3
- Bupropion has lower rates of sexual dysfunction compared to SSRIs 3
- Paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline 3
Monitoring Timeline
Begin assessment within 1-2 weeks of treatment initiation and continue regularly throughout treatment 3, 4:
- Monitor specifically for increased suicidal thoughts and behaviors, as risk is greatest during the first 1-2 months 3
- Assess for emergence of agitation, irritability, or unusual behavioral changes indicating worsening depression 3
- Evaluate therapeutic response and adverse effects at each visit 3
Response Assessment and Treatment Modification
Modify treatment if inadequate response occurs within 6-8 weeks of optimized therapy at adequate doses 3, 4:
- Response rates to initial antidepressant therapy may be as low as 50% 3
- For second-step therapy, either switch to another antidepressant, switch to cognitive therapy, or augment with medication (such as aripiprazole 2-20 mg/day) or cognitive therapy 3, 4
- The choice of second-step strategy matters less than simply trying a different evidence-based approach 3
Duration of Treatment
Continue treatment for 4-9 months after achieving satisfactory response in first-episode depression 3, 4:
- For patients with 2 or more depressive episodes, longer maintenance therapy is beneficial 3, 4
- Patients achieving remission with acute-phase treatment require continuation therapy to prevent relapse 3
Emerging Treatment Options
- The VA/DoD 2022 guidelines recommend ketamine and esketamine for patients who have not responded to other treatments 3
- Electroconvulsive therapy is recommended for patients with multiple prior treatment failures or need for rapid improvement 3
- Bright light therapy has expanded indications beyond seasonal affective disorder 3