Healthcare professionals rely on the DSM-5 to determine mental health diagnoses. The manual has updated its classifications of depressive disorders with critical new guidelines.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is a reference guide used by healthcare and mental health professionals to more accurately identify and diagnose mental health conditions.

The American Psychiatric Association (APA) created the tool to be the go-to guide for mental health conditions in the United States.

Important updates and changes have been made to depressive disorders, including major depression — aka depression, major depression, or clinical depression.

These changes allow healthcare and mental health professionals to determine the most accurate diagnosis and treatment plan for these conditions.

In 1952, the APA published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify mental health conditions and outline their associated diagnosing criteria.

Healthcare and mental health professionals often use the DSM as a reference guide for diagnosing mental health conditions.

With its latest revision released in 2013, the DSM is now in its 5th edition (DMS-5).

Many experts in the mental health field used evidence-based research, literature reviews, and other credible diverse sources of information to revise the DSM.

You can find symptoms, criteria, contributing factors, and much more for more than 20 mental health classifications, and even some new conditions were identified and added.

Specifiers for each condition listed are added extensions that provide medical professionals with clarifying information to ensure a more accurate diagnosis.

When making a diagnosis, all the answers may not be found in this manual, but it’s a great place to start.

The DSM-4 was published in 1994. Due to advancements in neuroscience since that time, clinical and public health experts found problems with the previous DSM-4 classification system and its criteria, according to a 2013 article.

While the overall impact on the manual was small, the depressive disorders classifications saw significant changes.

Mental health and science constantly evolve as new modalities, treatments, and technologies are updated, discovered, or refuted by research and scientific breakthroughs.

The DSM changes with each new edition as the medical community learns more about mental health, and it will continue to do so.

The updated DSM-5 added two new disorders to depressive disorders:

It also updated previous conditions with new criteria, exclusions, and specifiers.

What’s new for depressive disorders in the DSM-5?

DSM-4DSM-5
Bereavement excluded as criteria for major depressive disorderBereavement no longer excluded and is discussed as possibly contributing to major depressive disorder
Major depressive disorderNo changes (see added specifiers)
Substance and medication induced depressive disorderNo changes
Depressive disorder due to another medical conditionNo changes
Other specified depressive disorderNo changes
Chronic major depressive disorder and dysthymic disorderMerged and renamed to persistent depressive disorder
Added premenstrual dysphoric disorder
Added disruptive mood dysregulation disorder (DMDD)
Added “mixed features” specifier for bipolar and depressive disorders
Added “anxious distress” specifier

Let’s dive into these changes further to better understand their impact.

Disruptive mood dysregulation disorder (DMDD)

Disruptive mood dysregulation disorder (DMDD) is a new condition introduced in the DSM-5 to address symptoms once diagnosed and treated as childhood bipolar disorder. It can be diagnosed in children ages 6 to 18 years of age who exhibit persistent irritability and frequent episodes of extreme out-of-control behavior.

Children living with DMDD show symptoms usually before the age of 10, according to the National Institutes of Mental Health (NIMH).

Some of these symptoms can include the following:

  • aggressive behavior
  • severe tantrums several times a week for at least one year
  • chronic irritability
  • difficulty functioning due to their heightened irritability
  • reacting out of proportion to the situation

DMDD may be a newly classified disorder, but treatment is available.

Treatment often centers around what has worked for similar disorders such as attention deficit hyperactivity disorder (ADHD) and anxiety.

A combination of medication and psychotherapy treatments, such as parent training, is often recommended.

Premenstrual dysphoric disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) is now an official diagnosis in the DSM-5. It differs from other depressive disorders because of its connection to menstruation.

In most menstrual cycles during a year:

  • at least 5 (or more) of the following symptoms must be present in the week before menstruation
  • symptoms must start to improve within a few days after the onset of menstruation
  • symptoms must resolve or become minimal in the week following menstruation

To be diagnosed with premenstrual dysphoric disorder, at least one more of these symptoms must also be present:

  • affective lability: shifts in mood, sudden sadness or crying, increased sensitivity to rejection
  • irritability: anger or increased interpersonal conflicts
  • depression: depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • anxiety: feelings of anxiousness, tension, or being “keyed up” or “on edge”

In addition, at least five of the symptoms below must be present:

  • lack of or decreased interest in usual activities
  • difficulty concentrating
  • fatigue or lack of energy
  • change in appetite, overeating, or specific food cravings
  • hypersomnia or insomnia
  • sense of being overwhelmed or out of control
  • other physical symptoms such as:
    • breast tenderness or swelling
    • joint or muscle pain
    • bloating
    • weight gain

For a diagnosis of PMDD, these symptoms must cause significant distress or interfere with your ability to function in daily life.

Persistent depressive disorder (dysthymia)

The DSM-5 also updated persistent depressive disorder, also known as dysthymia. The condition is classified as having a lower level of depression that’s less severe than major depressive disorder but with chronic (long-term) symptoms.

This new condition is a combination of chronic major depressive disorder and dysthymic disorder.

For this diagnosis, a person must experience the symptoms for at least 2 years.

Overall, the diagnosis of this condition is rare. Of the estimated 17% of U.S. adults diagnosed with a major depressive disorder, only 3% have been diagnosed with persistent depressive disorder.

The symptoms of this disorder are similar to other forms of depression. A thorough assessment is required to rule out other diagnoses such as bipolar disorder and major depressive disorder.

Major depressive disorder (MDD)

Clinical depression, formerly known as major depressive disorder in the DSM, is commonly diagnosed. Changes to its diagnostic criteria were limited.

The core criteria of symptoms for MDD weren’t changed, nor was the requisite 2-week time period needed before it can be diagnosed.

Some of the criteria for this diagnosis include:

  • persistent feelings of sadness, emptiness, or hopelessness most of the day, nearly every day
  • decreased pleasure and interest in most of your regular activities
  • a sense of worthlessness or excessive or inappropriate feelings of guilt
  • energy loss and fatigue
  • noticeable physical restlessness or slowed movements
  • difficulty concentrating or making decisions
  • changes in appetite and weight
  • sleeping more or less than usual
  • regular thoughts of death or suicide, with or without a plan for suicide

In addition to either the first or second criteria being present for at least 2 weeks, at least 4 more symptoms must also be present for a diagnosis of MDD. Most symptoms should be present nearly every day.

Bereavement exclusion

There’s been much discussion about removing the “bereavement exclusion” from the diagnosis of major depression, but not much will change for most clinicians.

This exclusion is applied only if a person presents with major depressive symptoms within the first 2 months after the death of a loved one.

This exclusion was omitted in the DSM-5 for several reasons, including:

  • removing the idea that bereavement lasts only 2 months
  • acknowledging that bereavement can lead to a major depressive episode and generally begin soon after a loss
  • bereavement-related major depression may more likely occur in people with a history of major depressive episodes
  • the depressive symptoms associated with bereavement can be treated with the same therapy and medication options as depression that’s not related to bereavement

When MDD occurs in the context of bereavement, in addition to depressive symptoms, a person might also experience:

  • feelings of worthlessness
  • poor physical (somatic) health
  • inability to function in daily life, including at home, work, or with friends
  • increased chance for persistent complex bereavement disorder
  • suicidal ideation

A detailed footnote is included in the criteria for MDD to help mental health professionals determine whether a person is experiencing bereavement-related major depressive disorder.

Specifiers for depressive disorders

There are a few new specifiers added:

  • mixed symptoms: this new specifier has been added across the bipolar and depressive disorders to allow for the possibility of manic features in people with unipolar depression
  • anxious distress: this specifier allows for the ability to rate the severity of anxious distress in people with bipolar or depressive disorders

Major depressive disorder impacts the lives of many people in the United States. The National Institutes of Health (NIH) estimates that nearly 21 million adults in the United States had at least 1 major depressive episode in 2020.

Mental health professionals rely on the DSM-5 to provide an accurate and consistent diagnosis.

With the implementation of the DSM-5, depressive disorders saw some new classifications added with current conditions updated to reflect new research and scientific breakthroughs in mental health.