When it comes to mental health conditions, no resource is more important than the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM. This handbook establishes the guidelines by which mental disorders, including depression, are identified, evaluated and diagnosed. The common language and guidelines established by the manual also create a consistent basis by which to research mental health conditions in the future.
The DSM was originally published in 1952, and it has been revised multiple times since then. Each revision of the DSM is named with an updated number, and the most recent revision, the DSM-5, was released in 2013.
DSM-5 and depression
If you have a friend or loved one with depression or you have it yourself, then you know it can be a challenging diagnosis. The many different ways that depression can manifest itself is one thing that makes a diagnosis so tricky.
According to the National Institute of Mental Health (NIMH), depressive disorders include major depression, which interferes with a person’s daily ability to work, sleep and function in other ways; persistent depressive disorder, in which major depression alternates with less severe symptoms over several years; seasonal affective disorder; postpartum depression and many others.
One way that the DSM-5 helps therapists and other mental health professionals is by distinguishing the differences between major depressive disorder and other forms of depression. According to the DSM-5, several criteria must be present for someone to be diagnosed as having a major depressive order.
The first way to identify major depressive disorder is by its symptoms. From the following list, the DSM-5 notes that at least five symptoms must have been present during the previous two weeks, and one of the symptoms has to be loss of interest or pleasure or a depressed mood. The symptoms must also be a change from how the individual was functioning previously.
Symptoms the DSM-5 uses in its depression criteria are:
- Reduced interest or pleasure in almost all activities each day
- Noticeable feelings of hopelessness, emptiness and sadness almost every day
- Either trouble sleeping or oversleeping
- Feeling either agitated and moving quickly or being noticeably slower in movements and behavior
- Fatigue or lack of energy
- Unusual weight loss or weight gain
- Inappropriate guilt or feelings of worthlessness
- Trouble concentrating or thinking clearly
- Suicidal thoughts or actions
In addition to having at least five criteria from the previous list, the DSM-5 also outlines four additional criteria that must be met for a diagnosis of major depression to be made. These criteria are:
- The symptoms lead to substantial concerns in a person’s job, social settings or other areas of life
- The symptoms are not due to a separate medical condition or substance use
- The person has not had a manic or hypomanic episode
- The symptoms are not due to schizophrenia, psychosis, delusions or other related disorders
Changes to depression criteria in the DSM-5
In the DSM-5, the American Psychiatric Association (APA) made one major change to the criteria for identifying major depressive disorder, and the change was the subject of some controversy. In the previous version (DSM-4), mental health professionals were directed toward not diagnosing major depression in people who had recently lost a loved one. This was known as the “bereavement exclusion,” and its intent was to prevent individuals from being misdiagnosed with major depression when they were grieving normally.
However, the APA was concerned that this exclusion may prevent therapists from identifying and helping people who had major depression due to their grieving. As a result, the bereavement exclusion was removed from the DSM-5. Instead, there is a series of notes that help mental health professionals properly identify the distinctions between normal grieving and major depression.
Like depression itself, grieving can look different in different people. But some simple ways to distinguish it from major depression include the following:
- A grieving person maintains their sense of self esteem; a person with major depression often feels worthless and hopeless.
- Grief brings both positive and negative feelings intermingled, while depression is almost entirely negative.
- Some aspects of depression are common during the grieving process, but they tend to improve with time and should be treated differently from major depression.
Distinguishing between grief and major depression can be challenging for therapists, and some have criticized the change in criteria removing this distinction. However, others note that the new approach in the DSM-5 errs on the side of caution to prevent individuals with severe grief from falling through the cracks. Another concern is that people with major depression are especially vulnerable to the impact of grief and may have even greater needs during this time.
With extra education on the distinction between grief and depression, the main objective of the DSM-5 is to assist therapists in making the correct diagnosis. The key factors that they suggest focusing on to identify major depression are feelings of worthlessness, loss of function and suicidal thoughts. All of these criteria suggest that the person has moved beyond normal grief and is coping with major depression.
The bottom line on the DSM-5 and depression
The DSM-5 made some significant changes to the criteria used to assess and diagnose depression, particularly in regard to how it looks at grief after the death of a loved one. But just as before, the manual is intended to give the full picture of what depression might look like, and how it should be treated. The change to how bereavement is viewed in the DSM-5 was intended to help therapists and other mental health professionals not overlook grieving individuals who have advanced to major depression and may be in need of treatment.
- DSM-5: Frequently Asked Questions, American Psychiatric Association, 2019. https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions
- Major Depressive Disorder and the “Bereavement Exclusion,” American Psychiatric Association, 2013. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Depression-Bereavement-Exclusion.pdf
- Depression: What You Need to Know, National Institute of Mental Health, 2019. https://www.nimh.nih.gov/health/publications/depression-what-you-need-to-know/index.shtml
- DSM-5 Criteria: Major Depressive Disorder, MedicaidMentalHealth.org, 2018. http://www.medicaidmentalhealth.org/_assets/file/Guidelines/2017-2018%20Treatment%20of%20Adult%20Major%20Depressive%20Disorder.pdf