Last reviewed: 30 Oct 2021
Last updated: 11 Aug 2020



History and exam

Key diagnostic factors

  • chronic mood disorder lasting greater than 2 years
  • depressive symptoms present for most of the day, most days
  • no periods of euthymia in the past 2 years (1 year for children or adolescents)
  • symptoms of major depression may be continuously present for 2 or more years

Other diagnostic factors

  • no symptoms of mania/hypomania or schizophrenia
  • absence of underlying medical conditions, medication use, or substance abuse that could cause the mood disorder
  • fatigue or low energy
  • low self-esteem
  • poor concentration
  • feelings of hopelessness
  • weight changes
  • sleep disturbance

Risk factors

  • positive family history
  • female sex

Diagnostic investigations

1st investigations to order

  • Patient Health Questionnaire (PHQ-9)
  • Beck Depression Inventory (BDI)
  • Quick Inventory of Depressive Symptoms (QIDS)

Treatment algorithm



David J. Hellerstein, MD
David J. Hellerstein

Professor of Clinical Psychiatry

Columbia University Medical Center

Director, Depression Evaluation Service

New York State Psychiatric Institute

New York



DJH has received grant support from Eli Lilly, Pfizer, Forest Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb, GeneSight, Marinus, Takeda, Intracellular Therapies, and Compass Pathways. He is an author of a number of references cited in this topic.


Dr David J. Hellerstein would like to gratefully acknowledge Dr David L. Dunner, a previous contributor to this topic. DLD has received grant support from Cyberonics. DLD has received fees for consulting from: Eli Lilly, Pfizer, GlaxoSmithKline, Wyeth, Bristol-Myers Squibb, Forest, Cyberonics, Roche Diagnostics, Cypress, Corcept, Janssen, Novartis, Shire, Somerset, Otsuka, Healthcare Technology Sys, Jazz Pharma, Sanofi-Aventis, and MedAvante. DLD is on the Speaker's Bureau for: Eli Lilly, Pfizer, GlaxoSmithKline, Wyeth, Bristol-Myers Squibb, Organon, Jazz Pharma, Neuronetics, and Astra-Zeneca. DLD is an author of several references cited in this topic.

Peer reviewers

Ricardo Gusmao, MD, PhD

Professor of Psychiatry and Mental Health

National Coordinator of the OSPI-Europe and EAAD projects

Mental Health Department of the Faculty of Medical Sciences

New University of Lisbon (UNL)




RG has been paid by Bristol-Myers Squibb for being on the advisory board.

Stuart Seidman, MD

Assistant Professor

Columbia University College of Physicians & Surgeons

New York



SS declares that he has no competing interests.

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