Major Depressive Disorder

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
  • AIDS
  • Parkinson’s disease
  • Multiple sclerosis

Document treatment plan:

  • Psychotherapy
  • 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

More information

  • 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.
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