Classification of depressive illness in the ICD

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Depression in the ICD is just graded as mild, moderate, or severe, depending upon the number and severity of the symptoms.

F32.0 Mild depressive episode. Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1 Moderate depressive episode. Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2 Severe depressive episode without psychotic symptoms. An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of 'somatic' symptoms are usually present.

There are obvious problems with the practical use of ICD in daily clinical psychiatry, however. For example, there is no minimum time period. If one takes the description literally, a person who has a brief episode of, say, 'decrease in activity . . . and . . . marked tiredness after even minimum effort', and who is able to 'to continue with most activities' would nevertheless be diagnosable with a mild depressive episode.

The DSM-IV is slightly more rigorous, in that it does at least require, for a diagnosis of 'major depression', all of the following:

• a 2-week minimum period

• five symptoms out of nine (see list below)

• at least one of the symptoms being either depressed mood or loss of interest or pleasure.

However, this continues to set the bar very low in order to contain a very wide potential diversity among different patients with the same diagnosis. DSM symptoms are as follows:

1. depressed mood, most of the day, nearly every day

2. diminished interest or pleasure in all or almost all activities most of the day, nearly every day

3. significant weight loss when not dieting, or weight gain

4. insomnia or hypersomnia nearly every day

5. agitation or retardation

6. fatigue or loss of energy

7. worthlessness or inappropriate guilt

8. reduced ability to think or concentrate

9. thoughts of death, or suicidal ideation or plan.

There is much more common ground between the subtype of major depression termed 'melancholia' in DSM-IV, and the 'severe depressive episode' of ICD-10. Patients with these diagnoses have a condition which has always been recognized by psychiatrists. It is the much larger numbers of milder cases where the potential for disagreement is greater.

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