DSM-5-TR Diagnostic Criteria for Major Depressive Disorder
To diagnose Major Depressive Disorder (MDD) according to DSM-5-TR, at least 5 out of 9 specific symptoms must be present during the same 2-week period, with at least one symptom being either depressed mood or loss of interest/pleasure (anhedonia), and these symptoms must cause clinically significant distress or functional impairment. 1
Core Symptom Requirements
The diagnosis requires at least 5 symptoms from the following 9-symptom list, representing a change from previous functioning: 1, 2
- Depressed mood most of the day, nearly every day 3
- Markedly diminished interest or pleasure in activities (anhedonia) 3
- Significant weight loss or gain (>5% body weight in a month), or decreased/increased appetite 3, 2
- Insomnia or hypersomnia nearly every day 3, 2
- Psychomotor agitation or retardation observable by others 3, 2
- Fatigue or loss of energy nearly every day 3, 2
- Feelings of worthlessness or excessive/inappropriate guilt 3, 2
- Diminished ability to think or concentrate, or indecisiveness 3, 2
- Recurrent thoughts of death, suicidal ideation, suicide plan, or suicide attempt 3, 2
At least one of the 5 symptoms must be either depressed mood or anhedonia—these are the mandatory "main criteria" that anchor the diagnosis. 1, 4
Essential Diagnostic Requirements
Functional impairment must be present: symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 1 Simply meeting the symptom count without functional impairment does not warrant diagnosis—this is a critical pitfall to avoid. 1
The episode must not be attributable to substances (medications, drugs of abuse) or another medical condition. 1
Bipolar disorder must be ruled out: the presence of even one lifetime manic or hypomanic episode excludes the diagnosis of MDD and indicates bipolar disorder instead. 1
Severity Classification
Depression severity is classified based on symptom count, intensity, and functional impairment: 3
- Mild: 5-6 symptoms with minimal functional impairment 1, 3
- Moderate: symptom count, intensity, and impairment fall between mild and severe categories 1
- Severe: all or most of the 9 symptoms present with severe functional impairment 1, 3
Special Diagnostic Considerations
Bereavement and Grief
Depression during bereavement should be diagnosed with caution. The diagnosis requires persistence of symptoms for at least one month AND the presence of features atypical for normal grief: 1
- Extreme beliefs of worthlessness or guilt unrelated to the deceased 1
- Psychotic symptoms 1
- Suicidal ideation 1
- Psychomotor retardation 1
Normal grief is distinguished from MDD by the absence of pervasive anhedonia, feelings of worthlessness, suicidal ideation, psychomotor retardation, and severe functional impairment. 3 This represents an important area where clinical judgment is required, as DSM-5 removed the bereavement exclusion that was present in DSM-IV. 5
DSM-5 Changes from DSM-IV
A small but significant wording change expanded the core mood criterion to include hopelessness as part of the depressed mood presentation, potentially broadening the diagnosis. 5 The hopelessness symptom has been found to outperform more than half of DSM symptoms in differentiating depressed from non-depressed individuals. 6
Dimensional Specifiers
DSM-5 introduced multiple specifiers to characterize additional symptom features: 5
- With anxious distress 5
- With mixed features (presence of manic symptoms) 5
- With melancholic features 7
- With seasonal pattern 7
- With peripartum onset (expanded from "postpartum" to include onset during pregnancy) 5
- With psychotic features (for moderate to severe episodes) 7
Critical Diagnostic Pitfalls to Avoid
Do not diagnose based solely on symptom count without assessing functional impairment. 1
Do not omit assessment of suicidal ideation (PHQ-9 item 9 or equivalent direct questioning). 1
Do not fail to rule out bipolar disorder before diagnosing MDD—ask specifically about lifetime history of manic or hypomanic episodes. 1
Do not confuse normal grief with MDD without carefully assessing for the atypical features listed above. 1, 3
Assessment Tools
Validated instruments for diagnosis include the Structured Clinical Interview for DSM-5 (SCID) and Mini International Neuropsychiatric Interview (MINI). 7 For severity quantification and monitoring, use the Patient Health Questionnaire-9 (PHQ-9), Hamilton Depression Rating Scale (HAM-D), Montgomery-Åsberg Depression Rating Scale (MADRS), or Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR). 7, 3, 2