Updates to the DSM-5 and How We Diagnose Depression

How is the DSM-5 different from the DSM-IV?

The DSM-5 made some changes to the diagnosis of depression.

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In This Article

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook that provides guidelines for clinicians who diagnose psychiatric illnesses. Each condition is categorized and given a clear set of criteria that must be met for a diagnosis to be made. 

The latest edition, commonly known as the DSM-5, was released by the American Psychiatric Association on May 18, 2013. It replaced the DSM-IV, which had been in use since 1994.

As is the case with each new edition of the DSM, there have been some changes made to the diagnostic criteria for certain disorders, including depression. Some disorders have been removed while others have been modified or added. 

Here’s an overview of the changes to diagnosing depression with the DSM-5, as well as what it means for healthcare providers and patients.

New specifiers for depression added to the DSM-5
 Verywell / JR Bee 

Tests and Scales

While the DSM-5 didn’t introduce any new diagnostic tests for depression, it does promote a new “integrated” approach for clinicians to diagnose mental health disorders. 

Instead of thinking about depression as being either present or absent (normal or abnormal) the new approach considers that the symptoms of mental health disorders exist on a continuum. The severity of an individual’s depression will depend on where their symptoms fall along the spectrum.

Using an integrated approach to diagnosing depression allows clinicians to recognize and attend to the different ways in which each person they treat will experience depression. 

Prior editions of the DSM outlined narrower approaches. The view could be problematic for doctors working with patients who did not necessarily fit into a specific diagnostic category or “box," and therefore may not respond well to standard treatments.

The new approach could also be useful to researchers trying to account for these variations when designing studies. The new model is intended to provide a more effective framework for the researchers to use when testing out their hypothesis. If researchers have more reliable data, they may be able to develop more effective treatments.

Clinicians who are used to using the older methods for diagnosing depression won’t have to completely change how they approach the process, as the new integrated approach is compatible with previous assessment tools

Common Depression Tests and Scales

New Tools for Assessing Suicide Risk

The DSM-5 does include new scales for assessing suicide risk: one for adults and one for adolescents. These scales are intended to help clinicians identify suicide risk in patients as they are developing treatment plans. 

The tools are included in the new Section III of the DSM-5 and are intended to better support clinicians in identifying risk factors for suicide as well as scales for assessing suicidal behaviors (which includes differentiating self-harm from suicide attempts). 

Diagnosing Depression

New Mood Disorders Added

One major area of change in the DSM-5 is the addition of two new depressive disorders: disruptive mood dysregulation disorder and premenstrual dysphoric disorder. 

The diagnosis of disruptive mood dysregulation disorder is reserved for children between the ages of 6 and 18 who demonstrate persistent irritability and frequent episodes of out-of-control behavior. The diagnosis was added to address concerns that bipolar disorder in children was being overdiagnosed. 

PMDD is a more severe form of premenstrual syndrome (PMS). The conditions are characterized by intense depression, anxiety, moodiness, and irritability related to the hormonal fluctuations throughout the menstrual cycle.

PMDD previously appeared in Appendix B of the DSM-IV under "Criteria Sets and Axes Provided for Further Study." In the DSM-5, PMDD appears in the depressive disorders section.

Dysthymia Removed

Another change addresses the way chronic depression is conceptualized and distinguished from episodic depression. Dysthymia (or dysthymic disorder) is now included under the umbrella of persistent depressive disorder (PDD). 

Persistent depressive disorder also includes chronic major depression, which was added because researchers did not find a significant difference between dysthymia and chronic major depression. 

Major Depressive Disorder: No Major Changes

No significant changes were made to the diagnostic criteria for major depressive disorder. The core symptoms, as well as the requirement for the symptoms to have lasted for at least two weeks, remain the same. 

The DSM-5 reminds clinicians to assess patients with depression for symptoms of mania and hypomania. The presence of these symptoms may indicate the new specifier for depression, “with mixed features,” (see below) should be added.

New Specifiers for Depression

The DSM-5 has added some new specifiers to further clarify diagnoses:

  • With Mixed Features - This new specifier allows for the presence of manic symptoms within a diagnosis of depression for patients who do not meet the full criteria for a hypomanic/manic episode (as in bipolar disorder).
  • With Anxious Distress - This specifier was added to account for the presence of anxiety with the potential to impact prognosis and treatment choices.

Bereavement Exclusion Removed

The DSM-5 removed what was known as the bereavement exclusion for major depressive episodes. In the past, depression symptoms lasting less than two months following the death of a loved one would have been classified as a major depressive episode. 

The new edition of the DSM acknowledges that there is no scientifically valid reason for treating the grieving process any differently from other stressors that can trigger a depressive episode.

Additionally, it acknowledges that symptoms of bereavement may last much longer than two months. In fact, losing a loved one can lead to depressive symptoms that last for years. 

The new edition includes a detailed footnote to help clinicians distinguish between normal grief and a major depressive episode which can help them decide whether an individual would benefit from a specific treatment.

A major depressive episode triggered by bereavement may respond to the same treatment used for other forms of depression, including medication, therapy, or a combination of the two interventions. 

How It All Fits Together

The updated DSM-5 introduced several subtle, but important, changes to the way doctors, mental health providers, and researchers approach depression.

The updates were intended to help healthcare professionals make more timely and accurate diagnoses of depression, as well as inform their decisions about treatment. 

The shift toward patient-centered approaches in healthcare, but especially mental healthcare, will also influence how the diagnostic process feels for patients. Ideally, the updates to the DSM-5 that support doctors and mental health professionals with diagnosis and treatment will have a positive impact on patient experience.

Overall, these changes reflect the desire to improve outcomes for people with mental health disorders. To manage depression effectively, a person needs to receive a timely and accurate diagnosis, have support from others, and be able to access resources and treatment. 

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Article Sources

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