Mood Disorders

Major Depressive Episode

In the same 2 weeks, the patient has had 5 or more of the following symptoms, which are a definite change from usual functioning. Either depressed mood or decreased interest or pleasure must be one of the five.
-Mood. For most of nearly every day, the patient reports depressed mood or appears depressed to others.
-Interests. For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (noted by the patient or by others).
-Eating and weight. Although not dieting, there is a marked loss or gain of weight (such as five percent in one month) or appetite is markedly decreased or increased nearly every day.
-Sleep. Nearly every day the patient sleeps excessively or not enough.
-Motor activity. Nearly every day others can see that the patient's activity is agitated or retarded.
-Fatigue. Nearly every day there is fatigue or loss of energy.
-Self-worth. Nearly every day the patient feels worthless or inappropriately guilty. These feelings are not just about being sick; they may be delusional.
-Concentration. Noted by the patient or by others, nearly every day the patient is indecisive or has trouble thinking or concentrating.
-Death. The patient has had repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt.

These symptoms cause clinically important distress or impair work, social or personal functioning.

They don't fulfill criteria for Mixed Episode (page 168).

This disorder is not directly caused by a general medical condition or the use of substances, including prescription medications.

Unless the symptoms are severe (defined as severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations or psychomotor retardation), the episode has not begun within two months of the loss of a loved one.

Use the following codes (including Chronic) for the current or most recent Major Depressive Episode in Major Depressive, Bipolar I or Bipolar II Disorders.

Fifth Digit Severity Code for Major Depressive Episode.

.x1 Mild. Symptoms barely meet criteria for major depression and result in little distress or interference with the patient's ability to work, study or socialize.

.x2 Moderate. Intermediate between Mild and Severe.

.x3 Severe without Psychotic Features. The number of symptoms well exceeds the minimum for diagnosis, and they markedly interfere with patient's work, social or personal functioning.

.x4 With Psychotic Features. The patient has delusions or hallucinations, which may be mood-congruent or mood-incongruent. Specify, if possible:

Severe With Mood-congruent Psychotic Features. The content of the patient's delusions or hallucinations is completely consistent with the typical themes of depression: death, disease, guilt, nihilism, personal inadequacy or punishment that is deserved.

Severe With Mood-incongruent Psychotic Features. The content of the patient's delusions or hallucinations is not consistent with the typical themes of depression. Mood incongruent themes include delusions of control, persecution, thought broadcasting and thought insertion.

.x5 In Partial Remission. Use this code for patients who formerly met full criteria for Major Depressive Episode and now either (1) have fewer than five symptoms or (2) have had no symptoms for less than two months.

.x6 In Full Remission. The patient has had no material evidence of Major Depressive Episode during the past 2 months.

.x0 Unspecified.

Chronicity Specifier: Chronic. All the criteria for a Major Depressive Episode have been met without interruption for the previous 2 years or longer.

Coding Notes

When applied to children or adolescents, the abnormal mood can be irritable instead of depressed and there can be failure to gain weight, rather than actual weight loss.

Don't count a symptom that is obviously explained by a general medical condition or by a mood-congruent delusion or hallucination.

No diagnosis of Major Depressive Episode can be given if it was superimposed onto a Dysthymic Disorder and the full criteria are no longer present. Then, only diagnose Dysthymic Disorder.

The Chronicity specifier can be used with any of the above severity specifiers except Partial or Full Remission. It carries no code number.

Manic Episode

For at least one week (or less, if hospitalized) the patient's mood is abnormally and persistently high, irritable or expansive.

To a material degree during this time, the patient has persistently had 3 or more of these symptoms (4 if the only abnormality of mood is irritability):
-Grandiosity or exaggerated self-esteem
-Reduced need for sleep
-Increased talkativeness
-Flight of ideas or racing thoughts
-Easy distractibility
-Psychomotor agitation or increased goal-directed activity (social, sexual, work or school)
-Poor judgment (as shown by spending sprees, sexual adventures, foolish investments)

Symptom severity results in at least 1 of:
-causes material distress
-causes psychotic features
-requires hospitalization to protect the patient or others
-impairs work, social or personal functioning.

The symptoms don't fulfill criteria for Mixed Episode.

They are not directly caused by a general medical condition or the use of substances, including prescription medications.

Fifth Digit Severity Code for Manic Episode. Use this code for the current or most recent episode.

.x1 Mild. Symptoms barely meet criteria for an episode of mania.

.x2 Moderate. There is an extreme increase in either activity level or impaired judgment.

.x3 Severe Without Psychotic Features. The patient requires nearly continuous supervision to prevent physical harm to self or to others.

.x4 Severe With Psychotic Features. The patient has delusions or hallucinations, which may be mood-congruent or mood-incongruent (specify, if possible).

Severe With Mood-Congruent Psychotic Features. The content of the patient's delusions or hallucinations is completely consistent with typical themes of mania: exaggerated ideas of identity, knowledge, power, self-worth or relationship to someone famous.

Severe With Mood-Incongruent Psychotic Features. The content of the patient's delusions or hallucinations is not consistent with typical themes of mania. Mood incongruent delusions include control, persecution, thought broadcasting and thought insertion.

.X5 In Partial Remission. Use this code for patients who formerly met criteria for Manic Episode and now either (1) have fewer than the required number of symptoms or (2) have had no symptoms for less than two months.

.x6 In Full Remission. These patients formerly met criteria for mania but have had no material evidence of mania for at least 2 months.

.x0 Unspecified.

Coding Note

If a patient's manic episode has been precipitated by somatic therapy (such as ECT, antidepressants or bright light), it cannot be used as evidence of Bipolar I Disorder.

Mixed Episode

The patient has fulfilled symptom criteria for both Major Depressive and Manic Episodes nearly every day for a week or more.

The symptoms are severe enough that they (one or more of):
-Include psychotic features
-Require hospitalization to protect the patient or others
-Impair work, social or personal functioning

They are not directly caused by a general medical condition or the use of substances, including prescription medications.

Fifth Digit Severity Code for Mixed Episode. Use this code for the current or most recent episode.

.x1 Mild. Symptoms barely meet criteria for both Manic and Major Depressive Episodes.

.x2 Moderate. Intermediate between Mild and Severe.

.x3 Severe without Psychotic Features. The patient requires nearly continual supervision to avert physical harm to self or to others.

.x4 Severe With Psychotic Features. The patient has delusions or hallucinations, which may be mood-congruent or mood-incongruent. Specify, if possible:

Severe With Mood-Congruent Psychotic Features. The content of the patient's delusions or hallucinations is completely consistent with the typical themes of depression or mania.

Severe With Mood-Incongruent Psychotic Features. The content of the patient's delusions or hallucinations is not consistent with the typical themes of depression or mania.

.x5 In Partial Remission. Use this code for patients who formerly met full criteria for Mixed Episode and now either (1) have too few symptoms to fulfill criteria or (2) have had no symptoms for less than 2 months.

.x6 In Full Remission. The patient has had no material evidence of Mixed Episode for at least 2 months.

.x0 Unspecified.

Coding Note

If a patient's Mixed Episode has been precipitated by somatic therapy (such as ECT, antidepressants or bright light), it cannot be used as evidence of Bipolar I Disorder.

Hypomanic Episode

For at least 4 days the patient has a distinct, sustained mood that is elevated, expansive or irritable. This is different from the patient's usual nondepressed mood.

During this time, the patient has persistently had 3 or more of the following symptoms (4 if the only abnormality of mood is irritability). They have been present to an important degree.
-Grandiosity or exaggerated self-esteem
-Reduced need for sleep
-Increased talkativeness
-Flight of ideas or racing thoughts
-Easy distractibility
-Psychomotor agitation or increased goal-directed activity (social, sexual, work or school)
-Poor judgment (as shown by spending sprees, sexual adventures, foolish investments)

The patient has no features of psychosis (delusions, hallucinations, bizarre behavior or speech).

These symptoms represent a distinct change from the patient's usual functioning.

Other people can notice the change in mood and functioning.

The episode does not require hospitalization or markedly impair work, social or personal functioning.

The symptoms are not directly caused by a general medical condition or the use of substances, including prescription medications.

Coding Note

If a patient's hypomanic episode has been precipitated by somatic therapy (such as ECT, antidepressants or bright light), it cannot be used as evidence of Bipolar II Disorder.

There are no severity codes for Hypomanic Episode.

Major Depressive Disorder

Major Depressive Disorder, Single Episode

The patient has one Major Depressive Episode

Schizoaffective disorder doesn't explain the episode better, and it isn't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

If the patient has ever had Manic, Mixed or Hypomanic Episodes, all were directly precipitated by substance use or by antidepressant therapy, such as with ECT, medication or bright light.

Include any specifiers that apply to this Major Depressive Episode.

Major Depressive Disorder, Recurrent

The patient has had at least two Major Depressive Episodes.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

If the patient has ever had Manic, Mixed or Hypomanic Episodes, all were precipitated by substance use or by antidepressant therapy, such as with ECT, medication or bright light.

Include any specifiers that apply to this Major Depressive Episode.

Coding Note

To count as more than one, episodes must be separated by at least a two-month period during which criteria for Major Depressive Episode are not fulfilled.

Bipolar I Disorder

Bipolar I Disorder, Single Manic Episode

The patient has had just one Manic Episode (page 166) and no Major Depressive Episodes (page 160).

Schizoaffective disorder doesn't explain the Manic Episode better, and it isn't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

Specify Mixed: If a single episode meets the criteria for Mixed Episode (page 168), it would be recorded, for example:

Axis I 296.02 Bipolar I Disorder, Single Manic Episode, Mixed, Moderate

Include any specifiers that apply to this Manic Episode.

Bipolar I Disorder, Most Recent Episode Manic

The patient's most recent episode is of mania.

The patient has had at least one Major Depressive (page 162), Manic (page 167) or Mixed Episode (page 168).

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

Include any specifiers that apply to this Manic Episode or to the overall course of the disorder.

Bipolar I Disorder, Most Recent Episode Hypomanic

The patient's most recent episode is hypomanic.

The patient has previously had one or more Manic or Mixed Episodes.

The symptoms cause clinically important distress or impair work, social or personal functioning.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

Include any specifiers that apply to the overall course of the disorder.

Bipolar I Disorder, Most Recent Episode Mixed

The patient's most recent episode is of mixed mania and depression.

The patient has had at least one Major Depressive, Manic or Mixed Episode.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

Include any specifiers that apply to this Mixed Episode or to the overall course of the disorder.

Bipolar I Disorder, Most Recent Episode Depressed

The patient's most recent episode is Major Depressive.

The patient has had at least one previous Manic or Mixed Episode.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

Include any specifiers that apply to this Major Depressive Episode or to the overall course of the disorder.

Bipolar I Disorder, Most Recent Episode Unspecified

Other than duration, the patient currently or recently meets criteria for Major Depressive, Manic, Mixed, or Hypomanic episode.

The patient has had at least one previous Manic or Mixed episode.

These symptoms cause clinically important distress or impair work, social or personal functioning.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

The symptoms are not directly caused by a general medical condition or the use of substances, including prescription medications.

Include any specifiers that apply to the overall course of the disorder.

Bipolar II Disorder

The patient has had at least one Major Depressive Episode.

The patient has had at least one Hypomanic Episode.

There have been no Manic or Mixed episodes.

Schizoaffective disorder doesn't explain the above episodes better, and they aren't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

These symptoms cause clinically important distress or impair work, social or personal functioning.

Specify Current or Most Recent Episode:

Hypomanic

Depressed

Include any specifiers that apply to the most recent episode, if it is depressive, or to the overall course of the disorder.

Dysthymic Disorder

On the majority of days for 2 years or more, the patient reports depressed mood or appears depressed to others for most of the day.

When depressed, the patient has 2 or more of:
-Appetite decreased or increased
-Sleep decreased or increased
-Fatigue or low energy
-Poor self-image
-Reduced concentration or indecisiveness
-Feels hopeless

During this 2 year period, the above symptoms are never absent longer than 2 consecutive months.

During the first 2 years of this syndrome, the patient has not had a Major Depressive Episode.

The patient has had no Manic, Hypomanic or Mixed Episodes.

The patient has never fulfilled criteria for Cyclothymic Disorder.

The disorder does not exist solely in the context of a chronic psychosis (such as Schizophrenia or Delusional Disorder) .

The symptoms are not directly caused by a general medical condition or the use of substances, including prescription medications.

The symptoms cause clinically important distress or impair work, social or personal functioning.

Specify whether:

Early onset, if it begins by age 20

Late onset, if it begins at age 21 or later

The only specifier that can apply is With Atypical Features.

Coding Notes

In children, the abnormal mood may be one of irritability and the time required is only one year.

A Major Depressive Episode may precede Dysthymia if it has remitted for a full two months before Dysthymia begins. Also, Dysthymia may begin first, if it lasts at least two years before the major depression begins. In this case, the two diagnoses may be made together.

After the first two years, Major Depressive Episodes may also be diagnosed with Dysthymic Disorder, if the symptoms are met for both.

Cyclothymic Disorder

For at least 2 years,* the patient has had many periods of hypomanic symptoms and many periods of low mood that don't fulfill criteria for Major Depressive Disorder.

The longest the patient has been free of mood swings during this period is 2 months.

During the first 2 years of this disorder, the patient has not fulfilled criteria for Manic, Mixed, or Major Depressive Episode.

Schizoaffective disorder doesn't explain the disorder better, and it isn't superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder Not Otherwise Specified.

The symptoms are not directly caused by a general medical condition or the use of substances, including prescription medications.

These symptoms cause clinically important distress or impair work, social or personal functioning.

Coding Notes

*In children and adolescents, the time required is only one year.

After the required 2 years (1 for children), a Manic, Mixed or Major Depressive Episode may be superimposed on the Cyclothymia. Then, a Bipolar I or II diagnosis may be made concomitant with Cyclothymic Disorder.

Mood Disorder Due to a General Medical Condition

The patient's clinical presentation is dominated by a mood disorder that persists and is characterized by either or both of:
-Depressed mood or markedly decreased interest or pleasure in nearly all activities, or
-Mood that is elevated, expansive or irritable.

History, physical exam or laboratory findings suggest a general medical condition that seems likely to have directly caused these symptoms.

No other mental disorder (such as Adjustment Disorder secondary to having a medical disorder) better accounts for these symptoms.

The symptoms don't occur solely during a delirium.

These symptoms cause clinically important distress or impair work, social or personal functioning.

Specify whether:

With Manic Features. Mood is mainly elevated or irritable.

With Depressive Features. Mood is mainly depressed, but criteria for Major Depressive Episode are not fulfilled.

With Major Depressive-Like Episode. All criteria (other than the general medical condition exclusion) are fulfilled.

With Mixed Features. Manic and depressive symptoms are present in about equal parts

Coding Notes

Depression associated with the general medical condition of Alzheimer's or vascular dementia is designated as part of the Axis I code for the dementia (see pages 27 and 32). Depression that occurs with other dementias must be coded separately on Axis I.

On Axis III, also code the specific general medical condition that has caused the mood disorder. The name of the specific general medical condition also goes into the Axis I diagnosis.

Substance-Induced Mood Disorder

The patient's clinical presentation is dominated by a mood disorder that persists and is characterized by either or both
-Depressed mood or markedly decreased interest or pleasure in nearly all activities, or
-Mood that is elevated, expansive or irritable.

History, physical exam or laboratory data substantiate that either
-These symptoms have developed within a month of Substance Intoxication or Withdrawal, or
-Medication use has caused the symptoms

The symptoms cause clinically important distress or impair work, social or personal functioning.

This disorder does not occur solely during a delirium.

A nonsubstance-induced mood disorder does not better explain the symptoms.*

Code according to the specific substance involved:

291.8 Alcohol

292.84 Amphetamine [or Amphetamine-Like Substance]; Cocaine; Hallucinogen; Inhalant; Opioid; Phencyclidine [or Phencyclidine-Like Substance]; Sedative, Hypnotic or Anxiolytic; Other [or Unknown] Substance

Specify the type:

With Depressive Features. Mood is mainly depressed

With Manic Features. Mood is mainly elevated or irritable

With Mixed Features. Manic and depressive symptoms are present in about equal parts

When criteria are met for substance-specific intoxication or withdrawal, specify whether:

With Onset During Intoxication

With Onset During Withdrawal

Coding Notes

Use this diagnosis instead of Substance Intoxication or Substance Withdrawal only (1) when the symptoms exceed those you would expect from a syndrome of intoxication or withdrawal and (2) when they are serious enough by themselves to require clinical care.

*Although the diagnosis of Substance-Induced Mood Disorder has no time or symptom requirements, there must be no non-substance mood disorder that better explains the symptoms. Look for these indications of a non-substance mood disorder:

a. Previous episodes of Bipolar or Recurrent Depressive Disorder

b. Previous manias

c. Symptoms that are much worse than you would expect for the amount and duration of the substance abuse

d. Mood disorder symptoms precede onset of substance abuse

e. Mood disorder symptoms continue long (at least a month) after substance abuse or withdrawal stops

f. Strong family history of mood disorder

Mood Disorders caused by most medications taken in therapeutic doses would be coded as, for example:

Axis I 292.11 Reserpine-Induced Mood Disorder, With Depressive Features, With Onset During Intoxication

Axis III E942.6 Reserpine

311 Depressive Disorder Not Otherwise Specified

296.80 Bipolar Disorder Not Otherwise Specified

296.90 Mood Disorder Not Otherwise Specified

Specifiers that Describe the Most Recent Episode

With Atypical Features

For the most recent 2 weeks or more of a Major Depressive Episode or predominating during the most recent 2 years of Dysthymic Disorder:

The patient experiences mood reactivity, with improved mood when something good happens or seems about to happen (e.g., presence of friends).

At least 2 of the following:
-Material increase in appetite or weight
-Excessive sleeping
-Arms or legs feel heavy, leaden
Work or interpersonal relations are impaired by sensitivity to rejection that is long-standing and not limited to periods of depression.

During the same episode, the patient does not qualify for With Melancholic Features or With Catatonic Features.

With Catatonic Features

Two or more of the following dominate the clinical picture:
-Immobility (catalepsy or waxy flexibility) or stupor
-Apparently purposeless hyperactivity not influenced by external stimuli
-Mutism or extreme negativism
-Prominent posturing, stereotypies, mannerisms, or grimacing
-Echolalia (repeating words or phrases someone else has just said) or echopraxia (mimicking another's gestures)

With Melancholic Features

When symptoms of a Major Depressive Episode are most severe, the patient has either or both of:
-Loses pleasure in nearly all activities
-Feels no better when something good happens (when in the company of friends; when given a raise)

The patient has 3 or more of the following:
-Perceives the depressed mood as different from what would be experienced at the death of a relative
-Diurnal variation of mood in which the depression is consistently worse in the mornings
-Terminal insomnia, awakening at least 2 hours early
-Marked agitation or psychomotor retardation
-Marked loss of appetite or weight
-Guilt feelings that have been inappropriate or excessive

With Postpartum Onset

An episode of the disorder begins within four weeks after childbirth.

Specifiers for Longitudinal Course of Recurrent Episodes

With and Without Full Interepisode Recovery

Specify if:

With Full Interepisode Recovery. There is a full remission between the two most recent episodes.

Without Full Interepisode Recovery. There isn't.

With Rapid Cycling

In the past year there have been four or more episodes that meet criteria for Major Depressive Episode, Manic Episode, Mixed Episode, or Hypomanic Episode. The boundaries of these episodes are indicated by a switch between high and low or by a period of remission.

Coding Note

To count as a separate episode, it must be marked by a partial or full remission for at least 2 months or by a change in polarity (such as mania to depression).

With Seasonal Pattern

Major Depressive Episodes regularly begins at a particular season of the year.

Complete recovery or change of polarity also occurs regularly during a particular season.

These seasonal changes have occurred in each of the previous two years, during which no other nonseasonal Major Depressive Episodes have occurred.

Over the patient's lifetime, seasonal Major Depressive Episodes materially outnumber nonseasonal episodes.

Coding Note

Disregard examples where there has been a clear seasonal cause, such as being unemployed every summer.

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