Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5): classification of depressive disorders[1]

Categorises depressive disorders in children into the following categories: major depressive disorder (MDD), persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder (DMDD), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. This topic focuses on MDD and persistent depressive disorder (dysthymia).

DSM-5: criteria for major depressive episode[1]

To diagnose major depressive disorder, a child needs to have at least 5 of the following 9 symptoms, which indicate a significant change from his or her baseline presentation, during a same 2-week period, with at least one symptom being either depressed or irritable mood or anhedonia:

  • Depressed or irritable mood

  • Decreased interest or lack of enjoyment

  • Decreased concentration or indecision

  • Insomnia or hypersomnia

  • Change of appetite or change of weight

  • Excessive fatigue

  • Feelings of worthlessness or excessive guilt

  • Recurrent thoughts of death or suicidal ideation

  • Psychomotor agitation or retardation.

In addition, these symptoms must cause significant functional impairments in school, social settings, and/or family. They are not better accounted for by a grief reaction, and are not due to a substance or to a medical illness. There should not be a history of manic or hypomanic episode.

MDD can be classified according to how many episodes have occurred.

  • MDD, single episode: the presence of 1 major depressive episode, not part of schizoaffective disorder or superimposed on a psychotic disorder; no history of a manic episode or a hypomanic episode.

  • MDD, recurrent: criteria are the same as MDD, single episode, but with at least 2 major depressive episodes.

MDD is also classified according to 3 levels of severity:

  • Mild

  • Moderate

  • Severe, with or without psychotic features.

Exact features for each of these severity levels are not clearly defined. Individual physicians make a judgement of the severity of the depressive disorder based on global functional impairment ratings, and the severity and number of symptoms present. For the severe form with psychotic features, the psychotic features could be either mood-congruent or mood-incongruent, depending on whether the content of the delusions or hallucinations is consistent or inconsistent with depressive themes.

There are 9 specifiers:

  • With anxious distress

  • With mixed features

  • With catatonia

  • With melancholic features

  • With atypical features

  • With mood-congruent psychotic features

  • With mood-incongruent psychotic features

  • With peripartum onset

  • With seasonal pattern.

DSM-5: criteria for persistent depressive disorder (dysthymia)[1]

A child needs to have at least 3 of the following symptoms, which occur most of the day, more days than not, and for at least 1 year, and sad or irritable mood must be one of the symptoms:

  • Sad or irritable mood

  • Increased or decreased appetite

  • Insomnia or hypersomnia

  • Fatigue

  • Decreased self-esteem

  • Poor concentration or indecision

  • Feelings of hopelessness.

In addition, the following criteria need to be met to make a persistent depressive disorder diagnosis:

  • During the year, the child has never been without sad or irritable mood and 2 other symptoms for >2 months at a time

  • These symptoms cause significant distress or impairment in multiple areas of functioning

  • There has never been a manic or hypomanic episode, or symptoms meeting the criteria for cyclothymic disorder

  • The symptoms are not caused by a substance or medical condition

  • The symptoms are not better explained by schizoaffective disorder or other psychotic disorder.

DSM-5: criteria for DMDD[1]

  • A new category of depressive disorders for children 6 to 18 years of age, with age of onset before 10 years of age.

  • Characterised by severe and persistent irritability or angry mood nearly every day, and severe and recurrent temper outbursts at least 3 times a week.

  • Symptoms are inconsistent with developmental level, present in at least 2 out of 3 settings (i.e., home, school, and with peers) and are severe in at least one setting.

  • Symptoms have occurred for at least 12 months and during this time the child must not have gone 3 or more consecutive months without symptoms.

  • There have never been symptoms lasting for more than 1 day that meet the criteria for a manic or hypomanic episode except for duration.

  • Symptoms do not occur during an MDD episode and are not better accounted for by another mental disorder, and are not due to a substance/medication or other medical condition.

DSM-5: criteria for premenstrual dysphoric disorder[1]

  • An independent category of depressive disorders in DSM-5.

  • Characterised by at least 5 mood symptoms that have been present a week before the onset of the majority of menstrual cycles in the preceding year. Symptoms become minimal or absent within a few days after the onset of menses.

  • At least one symptom is one of the following symptoms: marked affective lability (mood swing), marked irritability or anger or interpersonal conflict, marked depression, and marked anxiety or tension.

  • At least one symptom is one of the following symptoms: anhedonia, poor concentration, fatigue, change in appetite, insomnia or hypersomnia, sense of feeling out of control/overwhelmed, and physical symptoms (e.g., aches and pains, sensation of bloating).

  • Symptoms cause significant distress or interference with functioning and are not part of, or an exacerbation of, another disorder.

  • Symptoms are not due to a substance/medication or another medical condition.

DSM-5: criteria for substance/medication-induced depressive disorder[1]

  • Marked, persistent, and function-impairing depressed mood or anhedonia caused by a substance or medication.

  • Symptoms developed during or soon after exposure to a substance or medication known to cause the types of depressive symptoms.

  • Symptoms are not better accounted for by an independent, non-substance/medication-induced depressive disorder, and do not occur exclusively during the course of a delirium.

DSM-5: criteria for depressive disorder due to another medical condition[1]

  • Marked, persistent, and function-impairing depressed mood or anhedonia caused by another medical condition.

  • Symptoms are not better accounted for by another mental disorder, and do not occur exclusively during the course of a delirium.

DSM-5: criteria for other specified depressive disorder and unspecified depressive disorder[1]

  • Formerly known (in DSM-IV) as depressive disorder not otherwise specified.

  • Symptoms do not meet criteria for any of the other depressive disorder categories.

  • Characterised by fewer depressive symptoms, or shorter duration, than the other types of depressive disorders.

  • Examples of the other specified depressive disorder include recurrent brief depressive disorder and short-duration depressive episode.

  • The unspecified depressive disorder does not specify the reason for not meeting criteria for other depressive disorder categories.

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