What are the possible DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) codes for a 63-year-old male patient with severe major depressive disorder (MDD), anxiety, insomnia, diabetes, and hypertension?

DSM-5 Diagnostic Codes for a 63-Year-Old Male with Severe MDD, Anxiety, Insomnia, Diabetes, and Hypertension

The primary diagnosis is Major Depressive Disorder, Severe (F32.2 or F33.2 depending on episode history), with the anxious distress specifier, given the patient's severe depression with comorbid anxiety and insomnia. 1, 2

Primary Psychiatric Diagnosis

Major Depressive Disorder - Severity and Episode Specification:

• F33.2 - Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features (if multiple prior episodes) 1, 2
• F32.2 - Major Depressive Disorder, Single Episode, Severe without Psychotic Features (if first episode) 1, 2

The severe classification is warranted when all or most of the 9 DSM-5 depressive symptoms are present with severe functional impairment and marked interference with daily functioning. 2 Severity is determined by three dimensions: symptom count, symptom intensity, and degree of functional impairment. 2

Required Specifiers for This Patient

With Anxious Distress (DSM-5 Specifier):

• This specifier should be added given the patient's comorbid anxiety symptoms. 3, 4
• The anxious distress specifier is clinically critical as it predicts higher depression severity, lower remission rates (OR = 0.44), and greater frequency of antidepressant side effects (OR = 2.74). 3
• Approximately 50-75% of patients with MDD meet DSM-5 criteria for anxious depression, and these patients have significantly worse psychosocial functioning and take longer to achieve remission. 4

Additional Psychiatric Diagnoses to Consider

Insomnia Disorder:

• F51.01 - Insomnia Disorder (if insomnia persists independent of the depressive episode or causes significant distress beyond the depression) 5
• Severe insomnia is present in approximately 45% of patients with MDD and is independently correlated with low educational qualification, subjective depression and anxiety severity, and poor physical health. 5
• However, if insomnia is better explained as a symptom of the depressive episode itself, it should not be coded separately but rather documented as part of the MDD presentation. 1

Generalized Anxiety Disorder:

• F41.1 - Generalized Anxiety Disorder (if anxiety symptoms meet full criteria independent of the depressive episode) 6
• This should only be coded if the anxiety represents excessive, uncontrollable worries regarding numerous everyday situations beyond the anxious distress seen with MDD. 6
• Approximately 60-70% of patients with comorbid anxiety and depression experience anxiety first, though depression often leads them to seek treatment. 4

Medical Conditions Requiring Documentation

Relevant Medical Comorbidities:

• E11.9 - Type 2 Diabetes Mellitus without complications (or appropriate E11.x code with complications if present)
• I10 - Essential (Primary) Hypertension

These medical conditions must be documented as they influence treatment selection, particularly regarding antidepressant choice and monitoring requirements. 1 The American College of Physicians recommends selecting second-generation antidepressants based on adverse effect profiles, which is particularly relevant given this patient's diabetes and hypertension. 1

Critical Diagnostic Considerations

Rule Out Substance/Medication-Induced Disorders:

• Before finalizing psychiatric diagnoses, verify that depressive and anxiety symptoms are not better explained by substance use or medications for diabetes/hypertension. 6
• DSM-5 requires that substance/medication-induced disorders "resemble" the full criteria for the relevant disorder and that the substance must be pharmacologically capable of producing the psychiatric symptoms. 6

Assessment for Bipolar Disorder:

• Document absence of manic or hypomanic episodes to rule out Bipolar Disorder with mixed features, as first-degree family history of bipolar disorder is a high-risk feature that would alter diagnosis and treatment. 2, 7

Documentation Requirements

Severity Justification:

• Document all three severity dimensions: symptom count (should be ≥7 of 9 DSM-5 symptoms), symptom intensity (severe), and functional impairment (marked interference with daily activities). 2
• Use PHQ-9 scores ≥15 to support severe classification, though clinical judgment incorporating all three dimensions takes precedence. 2

High-Risk Features to Document:

• Assess and document presence or absence of: suicidal ideation with plan/intent, psychotic symptoms, and severe functional impairment, as these automatically classify depression as severe regardless of symptom count. 2