Depressive Disorders

Threshold and duration: At least five symptoms are present during the same two-week period and represent a change from prior functioning. At least one must be depressed mood or diminished interest or pleasure.

Symptoms: Depressed mood; diminished interest or pleasure; meaningful appetite or weight change; insomnia or hypersomnia; observable psychomotor agitation or slowing; fatigue; worthlessness or excessive or inappropriate guilt; reduced concentration or indecisiveness; and recurrent thoughts of death, suicidal ideation, suicide planning, or an attempt.

Required context and exclusions: The episode causes clinically significant distress or impairment, is not attributable to a substance or medical condition, and is not better explained by a schizophrenia-spectrum or other psychotic disorder. There must be no lifetime manic or hypomanic episode unless it was substance-induced or due to another medical condition.

Threshold and duration: Depressed mood for most of the day, on more days than not, for at least two years; irritable mood may substitute in children and adolescents, whose duration threshold is one year.

Associated symptoms: At least two of poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, impaired concentration or difficulty making decisions, and hopelessness.

Required course and exclusions: During the qualifying period, symptoms are not absent for longer than two months at a time. The presentation causes clinically significant distress or impairment, is not due to a substance or medical condition, is not better explained by a psychotic disorder, and has no qualifying history of mania, hypomania, or cyclothymic disorder.

Timing: In most cycles, symptoms emerge during the final week before menses, begin improving within a few days after onset, and become minimal or absent during the following week. Confirm the pattern with prospective daily ratings during at least two symptomatic cycles.

Threshold: At least five symptoms are present, including at least one core affective symptom: marked mood lability, irritability or anger, depressed mood or hopelessness, or anxiety or tension. Other qualifying symptoms include reduced interest, concentration difficulty, low energy, appetite change, sleep change, feeling overwhelmed or out of control, and physical symptoms.

Required context and exclusions: Symptoms cause clinically significant distress or interference and are not merely an exacerbation of another disorder, a substance effect, or another medical condition. See Perinatal & Reproductive Psychiatry.

Core pattern: Severe verbal or behavioral temper outbursts are markedly inconsistent with developmental level, occur three or more times per week on average, and are accompanied by persistently irritable or angry mood between outbursts that is observable by others.

Duration and settings: The pattern persists for at least twelve months without a symptom-free interval of three or more consecutive months. It occurs in at least two settings and is severe in at least one.

Age and exclusions: Onset is before age ten, and diagnosis is made only from ages six through eighteen. There has never been a distinct manic or hypomanic episode lasting longer than one day. Exclude episodic irritability occurring only during major depression, other better explanations, substances, and medical or neurologic conditions. See Child & Adolescent Psychiatry.

A prominent and persistent depressed mood or loss of interest develops during or soon after intoxication, withdrawal, or exposure to a medication capable of producing the syndrome. The timing and pharmacology support causation, the presentation is not better explained by an independent depressive disorder, and it does not occur exclusively during delirium. It must cause clinically significant distress or impairment.

A prominent and persistent period of depressed mood or markedly diminished interest or pleasure is judged to be the direct pathophysiologic consequence of another medical condition. The presentation is not better explained by another mental disorder, does not occur exclusively during delirium, and causes clinically significant distress or impairment.

Use other specified depressive disorder when clinically significant depressive symptoms cause distress or impairment but do not meet full criteria and the clinician documents why—for example, short-duration episodes or insufficient symptoms. Use unspecified depressive disorder when the reason is not stated or available information is insufficient, including some urgent settings.

Bereavement does not exclude a major depressive episode; determine whether the full depressive syndrome and impairment criteria are met. Prolonged grief disorder is a separate trauma- and stressor-related diagnosis characterized by persistent separation distress and associated symptoms beyond the expected time threshold, with clinically significant impairment and attention to cultural context.

PHQ-9

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Nine-item self-report tool for depressive symptom screening and severity monitoring. Review every response, including the self-harm item, and use Safety & Risk Assessment to assess safety directly when indicated.

PHQ-2

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Brief initial screen using depressed mood and loss of interest. A positive screen should lead to a fuller diagnostic and safety assessment.

Beck Depression Inventory-II

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Self-report measure of depressive symptom severity. Use according to licensing, administration, and interpretation requirements.

HAM-D

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Clinician-rated measure used mainly in specialty and research settings. Reliable scoring requires training and consistent administration.

MADRS

Clinician-rated measure of depressive symptom severity, common in specialty settings and treatment trials. Reliable use requires training and consistent administration.

EPDS

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Ten-item self-report screen used during pregnancy and the postpartum period. It supports screening rather than diagnosis; review the self-harm item directly and see Perinatal & Reproductive Psychiatry.

SSRIs

Common first-line options include sertraline, escitalopram, fluoxetine, and others. Consider adverse effects, interactions, discontinuation symptoms, age, pregnancy, and prior response.

SNRIs

Venlafaxine, desvenlafaxine, and duloxetine may be useful when clinically appropriate. Monitor blood pressure, tolerability, interactions, and discontinuation risk.

Other antidepressants

Bupropion, mirtazapine, vortioxetine, vilazodone, and older agents offer different benefit and adverse-effect profiles. Match the choice to symptoms, comorbidity, safety, and patient priorities.

Augmentation and advanced treatment

Lithium, selected second-generation antipsychotics, ketamine/esketamine, ECT, TMS, and other strategies may be considered after careful reassessment of diagnosis, adequate trials, adherence, and contributing conditions.

Cognitive Behavioral Therapy

Targets patterns among thoughts, emotions, and behavior while developing practical strategies for symptom and relapse management.

Interpersonal Psychotherapy

Focuses on interpersonal transitions, disputes, grief, and role changes associated with depressive episodes.

Behavioral Activation

Uses structured re-engagement with meaningful and reinforcing activity to address avoidance, withdrawal, and reduced function.

Additional approaches

Mindfulness-based cognitive therapy, psychodynamic therapy, and family or couples work may be appropriate depending on the clinical need, recurrence pattern, relationships, and patient preference.

Movement, sleep, and daily rhythm

Graded exercise, regular sleep-wake timing, meaningful activity, and social connection can support recovery and function when adapted to health status and current capacity.

Bright-light therapy

May be considered for seasonal-pattern depression and selected other presentations. Screen for bipolar-spectrum illness and review timing, eye health, medications, and activation risk.

Nutrient and supplement review

Omega-3 products, SAMe, folate or L-methylfolate, vitamin B12, and other products require attention to evidence, deficiency, dose, quality, interactions, cost, and the reason for use.

St. John’s wort

Has substantial interaction potential, variable product quality, serotonergic risk, and important reproductive considerations. Complete a medication and supplement reconciliation before use and consult Perinatal & Reproductive Psychiatry when reproductive context is relevant.