When major depression is diagnosed in an individual, additional characteristics of the depression are specified. These characteristics are called “specifiers.” These specifiers apply to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode. If criteria are currently met for the Major Depressive Episode, it can be classified as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria are no longer met, the specifier indicates whether the episode is in partial or full remission. For Major Depressive Disorder and most of the Bipolar I Disorders, the specifier is reflected in the fifth-digit coding for the disorder.
1–Mild, 2–Moderate, 3–Severe Without Psychotic Features. Severity is judged to be mild, moderate, or severe based on the number of criteria symptoms, the severity of the symptoms, and the degree of functional disability and distress. Mild episodes are characterized by the presence of only five or six depressive symptoms and either mild disability or the capacity to function normally but with substantial and unusual effort. Episodes that are Severe Without Psychotic Features are characterized by the presence of most of the criteria symptoms and clear-cut, observable disability (e.g., inability to work or care for children). Moderate episodes have a severity that is intermediate between mild and severe.
4–Severe With Psychotic Features. This specifier indicates the presence of either delusions or hallucinations (typically auditory). Most commonly, the content of the delusions or hallucinations is consistent with the depressive themes. Such mood congruent psychotic features include delusions of guilt (e.g., of being responsible for illness in a loved one), delusions of deserved punishment (e.g., of being punished because of a moral transgression or some personal inadequacy), nihilistic delusions (e.g., of world or personal destruction), somatic delusions (e.g., of cancer or one’s body “rotting away”), or delusions of poverty (e.g., of being bankrupt). Hallucinations, when present, are usually transient and not elaborate and may involve voices that berate the person for shortcomings or sins.
Less commonly, the content of the hallucinations or delusions has no apparent relationship to depressive themes. Such mood-incongruent psychotic features include persecutory delusions (without depressive themes that the individual deserves to be persecuted), delusions of thought insertion (i.e., one’s thoughts are not one’s own), delusions of thought broadcasting (i.e., others can hear one’s thoughts) and delusions of control (i.e., one’s actions are under outside control). These features are associated with a poorer prognosis. The clinician can indicate the nature of the psychotic features by specifying With Mood-Congruent Features or With Mood-Incongruent Features.
5–In Partial Remission, 6–In Full Remission. Full Remission requires a period of at least 2 months in which there are no significant symptoms of depression. There are two ways for the episode to be In Partial Remission: 1) some symptoms of a Major Depressive Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a Major Depressive Episode, but the period of remission has been less than 2 months. If the Major Depressive Episode has been superimposed on Dysthymic Disorder, the diagnosis of Major Depressive Disorder, In Partial Remission, is not given once the full criteria for a Major Depressive Episode are no longer met; instead, the diagnosis is Dysthymic Disorder and Major Depressive Disorder, Prior History.
Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episode
Note: These criteria are coded for in fifth digit of the DSM-IV diagnostic code. Can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.
.x1–Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.
.x2–Moderate: Symptoms or functional impairment between “mild” and “severe.”
.x3–Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.
.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control.
.x5–In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)
.x6–In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.