The Diagnostic and Statistical Manual of Mental Disorders (fifth edition) defines major depression as an individual experiencing five or more symptoms during the same two-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure. Major depression symptoms include:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day
- A slowing down of thought and a reduction of physician movement (observable by others, not merely subjective feelings of restlessness or being slowed down)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for coming suicide
Documentation and coding tips:
Documents major depressive disorder to the highest level of specificity, including recurrence, severity and current status:
- Episode: Single episode or recurrent
- Severity: Mild, moderate, severe, with or without psychotic symptoms
- Status: In partial remission or in full remission
Document any underlying causes of depression, if known, such as:
- Thyroid or adrenal gland disorders
- Benign or malignant brain tumors
- Parkinson’s disease
- Multiple sclerosis
Document treatment plan:
- Antidepressant medications such as tricyclic antidepressants; monoamine oxidase inhibitors, or MAOIs; selective serotonin reuptake inhibitors, or SSRIs, or serotonin-norepinephrine reuptake inhibitors, or SNRIs.
- Electroconvulsive therapy, or ECT
- A single episode of depression is commonly triggered by a life event or an underlying cause, and after a period of treatment, patients are successfully weaned off.
- Recurrent depression is typically lifelong and, although the severity may fluctuate, patients require ongoing treatment to alleviate their depression symptoms.
- With appropriate treatment, the patient’s depression symptoms may be controlled, in which case he or she is considered in remission. The patient still, however, carries the diagnosis of major depression.