Clinical depression differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Major depressive disorder must be differentiated from other causes of depressive symptoms.

Differential Diagnosis

• Major depressive disorder is characterized by one or more episodes of depressed mood or diminished interest or pleasure (anhedonia) that last at least 2 weeks and are accompanied by 4 or more of the characteristic associated symptoms (including changes in sleep, appetite, or activity level); energy loss and fatigue; difficulty concentrating; excessive guilt or feelings of worthlessness; suicidal ideation or behavior).
• Major depressive disorder must be differentiated from other causes of depressive symptoms:

Differential diagnosis for Major Depressive Disorder
Depressive disorder	Distinguishing feature from Major depressive Disorder
Bipolar I or Bipolar II disorder	One or more manic or hypomanic episodes are required for diagnosis. If manic or hypomanic episodes have ever been present, the patient cannot be diagnosed with major depressive disorder. If patients with major depressive symptoms have some manic or hypomanic symptoms that are not enough for diagnosis of mania and hypomania episode (i.e. fewer symptoms or shorter duration), they are specified as "major depressive disorder with mixed features".
Depressive disorder due to another medical condition	Diagnosis of Depressive disorder due to another medical condition requires the presence of a medical condition as the etiology of depressive symptoms. In Fact, Major depressive Disorder is not diagnosed if depressive symptoms are due to the direct physiologic effects of a medical condition.
Substance/medication-induced depressive disorder	Substance/medication-induced depressive disorder is diagnosed when depressive symptoms are due to direct physiologic effects of a substance or medication. In Fact, a diagnosis of Major Depressive Disorder cannot be made when depressive symptoms are due to the direct physiologic effects of a substance or medication.
Persistent depressive disorder (Dysthymia)	Persistent depressive disorder is characterized by a depressed mood, on most days, for at least 2 years. Of note, a patient can be diagnosed with both Major Depressive Disorder and Persistent Depressive Disorder if the diagnostic criteria are met for both disorders.
Premenestrual dysphoric disorder	Premenstrual dysphoric disorder is characterized by the presence of dysphoric mood in the few days before the onset of menses that improves within a few days after the onset of menses. In contrast, no temporal connection is present between the depressive symptoms in Major Depressive Disorder and the menstrual cycles.
Disruptive mood dysregulation disorder	Disruptive mood dysregulation disorder is characterized by severe, recurrent temper outbursts (verbally and/or behaviorally). In between the outbursts, persistently irritable or angry mood, most of the day, almost every day, is present. In contrast, in major depressive disorder, irritability is present only during depressive episodes.
Schizoaffective disorder	Schizoaffective disorderis characterized by major depressive episodes with concurrent active-phase symptoms of schizophrenia, AND presence of hallucinations or delusions for two or more weeks in the absence of a major mood episode, AND major depressive episodes are present for the majority of the total duration of illness. If psychotic symptoms are present exclusively during major depressive episodes, the diagnosis of "Major depressive disorder with psychotic features" is made.
Adjustment disorder with depressed mood	It is characterized by depressive symptoms occurring within 3 months of an identifiable psychological stressor that last <6 months after the stressor has ended. Symptoms should not meet the criteria for a major depressive episode.
Bereavement	Bereavement occurs in response to the loss of a loved one. The symptoms are generally milder than a major depressive episode. Feelings of emptiness and loss are the predominant affects in bereavement, in contrast to depressed mood and inability to experience pleasure (anhedonia) in major depressive episodes. The dysphoric mood in grief usually decreases in intensity over days to weeks, occurs in wanes, and tend to be associated with thoughts and reminders of the deceased, whereas the depressed mood in major depressive episode that is more persistent and not related to particular thoughts or preoccupations.
Sadness	Nonpathological periods of sadness are characterized by the short duration of few depressive symptoms that are not associated with significant functional impairment or distress.