Evaluation in Ayres Sensory Integration: An OT assessment guide
As therapists, it’s important to stay up to date on the latest research and clinical guidelines for the most common mental health disorders that people seek help for.
Given the fact that depression is common in outpatient mental health clinics and nearly 50,000 people have died by suicide in the U.S. in 2024, it’s particularly important that we have common language and an up-to-date understanding of what depression is and isn’t.
What is major depressive disorder in the DSM-5?
Major depressive disorder in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is characterized by at least five of the following symptoms (at least one of which must be numbers 1 or 2) that are present for at least two weeks and show a significant difference in how the person was doing beforehand:
Depressed mood much of the day
Anhedonia (significant lack of interest or pleasure in various aspects of life)
Weight or appetite changes
Too much or too little sleep
Changes in energy
Slowness in speed of functioning (psychomotor retardation) or restlessness
Feelings of guilt or worthlessness
Difficulty concentrating or making decisions
Thoughts of suicide or death
Major depressive disorder in the DSM-5 can be found in the “depressive disorders” chapter (pages 160 to 168). Other common depressive-type disorders in this chapter include persistent depressive disorder, disruptive mood dysregulation disorder, and premenstrual dysphoric disorder.
Important considerations of major depressive disorder in the DSM-5
To meet criteria for major depressive disorder in the DSM-5, the symptoms cause clinically significant distress and may not be attributed to other medical, psychological, or substance use concerns.
DSM-5-TR uses ICD-10-CM codes for major depressive disorder: F32 for a single episode and F33 for a recurrent one, with the characters after the decimal indicating severity, psychotic features, or remission. For example, F32.0 is a single mild episode, F32.1 is a single moderate episode, and F33.1 is a recurrent moderate episode. Many clinicians wonder how to tell a single episode vs. recurrent MDD. To count as recurrent, there must be an interval of at least two consecutive months between separate episodes in which the client does not meet criteria for a major depressive episode.
To assess how severe a major depressive disorder is in the DSM-5, clinicians can take three separate data points into consideration:
The number of symptoms.
How distressing the symptoms are.
How impairing the symptoms are on the person's life.
For example, a client can meet the minimum number of symptoms to be diagnosed (e.g., five symptoms out of nine), but still be diagnosed as moderate or severe if those symptoms are quite distressing and debilitating.
Severity also changes the final digits of the major depressive disorder ICD-10 code F32 (single episode) or F33 (recurrent). For example, F32.2 is a single severe episode without psychotic features, and F32.3 is a single severe episode with psychotic features.
Although psychometrically validated instruments like the PHQ-9 or the BDI don’t map onto the DSM-5 diagnostic criteria perfectly, they can help provide diagnostic clarity and an understanding of the disorder's severity.
Changes to major depressive disorder in the DSM-5
DSM-5 made several changes to major depressive disorder from DSM-IV. The most debated was removing the bereavement exclusion. In DSM-IV, clinicians were advised not to diagnose major depression in the first two months after a loss unless symptoms lasted longer or included marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
DSM-5 replaced that exclusion with a note and footnote that help clinicians distinguish normal grief from a major depressive episode, and DSM-5-TR added prolonged grief disorder for grief that persists beyond 12 months in adults. DSM-5 also added the “with anxious distress” and “with mixed features” specifiers, and it consolidated chronic major depressive disorder and dysthymic disorder into persistent depressive disorder.
Persistent depressive disorder vs. MDD
The DSM-5 for major depressive disorder highlights several important differential diagnoses to be aware of when assessing whether or not major depressive disorder is present. There are many key differences and similarities to consider when deciphering between persistent depressive disorder vs. MDD.
Persistent depressive disorder (e.g., chronic, low-grade depression) can look quite similar to major depressive disorder at first glance, but takes quite a different trajectory. The simplest way to tell the difference between persistent depressive disorder vs. MDD is to assess for how long the client has been depressed.
To meet criteria for persistent depressive disorder, the individual must have been depressed for at least two consecutive years, or one year for adolescents and children. Also, to diagnose persistent depressive disorder, there can be no longer than a two-month period (within the two-year time span) where the individual is not feeling depressed.
It’s also important to note that clients may be diagnosed with both MDD and persistent depressive disorder, either at the same time or at different periods in their life. Persistent depressive disorder is coded F34.1 rather than under the major depressive disorder ICD-10 code F32 or F33.
MDD specifiers in DSM-5
The diagnosis of major depressive disorder in DSM-5 has several important clinical specifiers you should know about. These specifiers can improve diagnostic clarity and report writing, and they can also inform your conceptualization and treatment plan. The MDD specifiers in DSM-5 include:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With a seasonal pattern
Bringing it all together
As the field of psychology grows, so has our common language and knowledge of various mental health disorders. While it’s far from perfect, the DSM-5 has given us a comprehensive resource for understanding various forms of human suffering and supporting our assessment, conceptualization, and therapeutic interventions.
While it’s expensive and time-consuming to go through, it’s important to stay up to date with the latest updates and changes in the DSM. Whether you land on the major depressive disorder ICD-10 code F32 or F33, the code should match the episode history and severity that your note documents.
Sources
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
American Psychiatric Association. (2013). Major depressive disorder and the "bereavement exclusion".
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
American Psychiatric Association. (2022). Facts about DSM-5-TR. Psychiatric News.
Centers for Disease Control and Prevention. (2026). Suicide data and statistics.
Chand, S. P., & Arif, H. (2023). Depression. StatPearls.
Gotlib, I. H., & LeMoult, J. (2014). The "ins" and "outs" of the depressive disorders section of DSM-5. Clinical Psychology: Science and Practice.
National Center for Health Statistics. (2026). ICD-10-CM files. Centers for Disease Control and Prevention.
Pies, R. W. (2014). The bereavement exclusion and DSM-5: An update and commentary. Innovations in Clinical Neuroscience.
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