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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The Diagnostic and Statistical Manual of Mental Disorders is a handbook that provides guidelines for clinicians in diagnosing psychiatric illnesses. Each mental illness is categorized and given clear criteria that must be met for the diagnosis to be made. 

The latest edition, commonly known as the DSM-5, was released by the American Psychiatric Association on May 18, 2013, at its annual meeting in San Francisco. 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 diagnoses. Some disorders have also been removed altogether, while some new disorders have been added. 

Which New Mood Disorders Have Been 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

Disruptive mood dysregulation disorder is a diagnosis reserved for children between 6 and 18 years of age who show persistent irritability and frequent episodes of out-of-control behavior. This new diagnosis was added to address concerns that bipolar disorder in children was being overdiagnosed. 

Premenstrual dysphoric disorder (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. PMDD is a more severe form of premenstrual syndrome (PMS), which is characterized by strong emotional symptoms such as depression, anxiety, moodiness, and irritability.

Dysthymia Was Removed

Another area of change is in how chronic forms of depression are conceptualized and distinguished from episodic depression. What was once referred to as dysthymia—or dysthymic disorder—is now included under the umbrella of persistent depressive disorder (PDD). 

Persistent depressive disorder also includes chronic major depression. This was added because researchers couldn't find a significant enough difference between dysthymia and chronic major depression.  

Major Depressive Disorder Remains Relatively the Same

No major changes were made to the diagnostic criteria for the 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 Bereavement Exclusion Was Removed

The DSM-5 removed what was known as the bereavement exclusion for major depressive episodes. In the past, any major depressive episode following the death of a loved one that lasted less than two months was not classified as a major depressive episode. 

By leaving out this exclusion, the new edition of the DSM acknowledges that there is no scientifically valid reason for treating the grieving process differently from any other stressor that might trigger a depressive episode.

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

In lieu of the bereavement exclusion, the new edition includes a detailed footnote to help clinicians distinguish between normal grief and a major depressive episode so they can make a better decision about whether a particular individual may benefit from treatment.

When a major depressive episode is triggered by bereavement, it may respond to the same treatment as other episodes of depression. Therapy and/or medication may be successful in reducing symptoms. 

New Specifiers for Depression Were Added

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

  • With Mixed Features - This new specifier can be present in bipolar and depressive disorders. It allows for the presence of manic symptoms as part of the depression diagnosis in patients who do not meet the full criteria for a manic episode.
  • With Anxious Distress - This specifier was added due to the fact that the presence of anxiety can impact prognosis, treatment choices, and the patient's response to them.

In addition, guidance was provided to clinicians for the assessment of suicidal thinking, plans, and risk factors so that they can better determine just how prominent a role suicide prevention should play in an individual patient's treatment.

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