New York State Medical Treatment Guidelines for Diagnosis of Major Depressive Disorder in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for diagnosing Major Depressive Disorder (MDD). These directives are designed to assist mental health professionals in identifying appropriate diagnostic criteria within the context of a comprehensive assessment.

Mental health professionals with expertise in diagnosing Major Depressive Disorder (MDD) can rely on the guidance outlined by the Workers Compensation Board to make well-informed diagnostic decisions for their clients.

It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The final diagnosis of Major Depressive Disorder (MDD) should be made based on a thorough evaluation and collaboration between the mental health professional and the client.

DSM 5 Diagnostic Criteria for Major Depressive Disorder (MDD)

Criterion A: Symptoms

  • Overview: To meet Criterion A for a major depressive episode, at least five of the following symptoms must be present during the same 2-week period, with at least one being depressed mood or loss of interest or pleasure.
  1. Depressed Mood: Persistent sadness, emptiness, or hopelessness, or observed tearfulness in others. In children and adolescents, irritability may be present.
  2. Loss of Interest or Pleasure: Markedly reduced interest or pleasure in activities that were once enjoyable.
  3. Changes in Appetite or Weight: Significant weight loss or gain, or changes in appetite. In children, failure to gain expected weight may be observed.
  4. Sleep Disturbances: Insomnia or hypersomnia nearly every day.
  5. Psychomotor Changes: Observable psychomotor agitation or retardation.
  6. Fatigue: Persistent fatigue or loss of energy.
  7. Feelings of Worthlessness or Guilt: Excessive feelings of worthlessness, guilt, or inappropriate guilt.
  8. Cognitive Impairment: Difficulty concentrating, making decisions, or thinking clearly.
  9. Suicidal Thoughts: Recurrent thoughts of death or suicide, suicide attempts, or specific plans for suicide.

Criterion B: Distress or Impairment

  • Symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion C: Exclusion of Substance/Medical Condition

  • The episode cannot be attributed solely to the effects of substance use or another medical condition.

Criterion D: Exclusion of Psychotic Disorders

  • The episode is not better explained by psychotic disorders like schizophrenia or delusional disorder.

Criterion E: Exclusion of Manic or Hypomanic Episodes

  • There should be no history of manic or hypomanic episodes. If such episodes occur, they cannot be attributed solely to substance use or another medical condition.

Note: Criteria A to C define a major depressive episode, indicating a significant period of depressive symptoms causing distress or impairment, unrelated to substance use or medical conditions.


DSM 5 Diagnostic Criteria for Depressive Disorder Due to Another Medical Condition

Criteria A: Depressive Symptoms

  • A significant and persistent period characterized by depressed mood or markedly reduced interest or pleasure in almost all activities is evident.

Criteria B: Medical Condition Correlation

  • Evidence from medical history, physical examination, or lab findings indicates that the disturbance directly results from another medical condition.

Criteria C: Exclusion of Other Mental Disorders

  • The disturbance cannot be better explained by another mental disorder, such as adjustment disorder, unless the stressor is a serious medical condition.

Criteria D: Exclusion of Delirium

  • The disturbance does not occur solely during a delirium episode.

Criteria E: Impairment

  • The disturbance leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Subtypes of Depressive Disorders:

  • With Depressive Features: Criteria for a major depressive episode are not fully met.
  • With Major Depressive-Like Episode: Full criteria for a major depressive episode are met, except for criterion C.
  • With Mixed Features: Symptoms of mania or hypomania coexist but do not dominate the clinical presentation.

Differential Diagnosis

  • Depressive Disorders Not Due to Another Medical Condition: Diagnosis depends on the absence of prior depressive episodes, the likelihood of the medical condition causing depression, and the course of depressive symptoms relative to the medical condition’s onset or improvement.
  • Medication-Induced Depressive Disorder: Some medications, like steroids or alpha-interferon, can induce depressive or manic symptoms. Clinical judgment is crucial in distinguishing between medication-induced symptoms and those caused by the medical condition.
  • Adjustment Disorders: It’s essential to differentiate between depressive episodes and adjustment disorders, especially when the onset of a medical condition acts as a stressor. The pervasiveness and quality of depressive symptoms play a key role in differentiation.


DSM 5 Diagnostic Criteria for Adjustment Disorders

Criteria A: Onset in Response to Stressor

  • Emotional or behavioral symptoms develop in response to identifiable stressors within a 3-month period from the onset of the stressor(s).

Criteria B: Clinical Significance

  1. The symptoms cause marked distress, disproportionate to the severity of the stressor, considering external context and cultural factors.
  2. There’s significant impairment in social, occupational, or other important areas of functioning.

Criteria C: Exclusion of Other Mental Disorders

  • The stress-related disturbance doesn’t meet criteria for another mental disorder and isn’t just an exacerbation of a preexisting one.

Criteria D: Not Normal Bereavement

  • Symptoms don’t represent typical bereavement.

Criteria E: Duration

  • Symptoms don’t persist for more than 6 additional months after the stressor or its consequences end.

Subtypes Specification:

  • With Depressed Mood: Predominance of low mood, tearfulness, or feelings of hopelessness.
  • With Anxiety: Predominance of nervousness, worry, jitteriness, or separation anxiety.
  • With Mixed Anxiety and Depressed Mood: Predominance of both depression and anxiety.
  • With Disturbance of Conduct: Predominance of conduct disturbance.
  • With Mixed Disturbance of Emotions and Conduct: Predominance of both emotional symptoms (e.g., depression, anxiety) and conduct disturbance.
  • Unspecified: For maladaptive reactions not classifiable under specific subtypes of adjustment disorder.


Differential Diagnosis

Major Depressive Disorder (MDD) vs. Adjustment Disorder

  • If symptoms align with major depressive disorder (MDD) criteria due to a stressor, adjustment disorder isn’t applicable. The symptom profile of MDD distinguishes it from adjustment disorders.

Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder

  • In adjustment disorders, the stressor’s severity isn’t limited, unlike the criteria for PTSD and acute stress disorder (ASD). Adjustment disorders can occur immediately after a traumatic event and persist for up to 6 months. In contrast, ASD can only be diagnosed within 3 days to 1 month post-event, while PTSD requires at least 1 month post-event. The symptom profile required for PTSD and ASD sets them apart from adjustment disorders.

Relationship with Personality Disorders

  • Some personality traits may resemble adjustment disorders’ situational distress vulnerability. Considering lifetime personality functioning can help differentiate long-standing personality disorders from adjustment disorders. Stressors can exacerbate personality disorder symptoms. If symptom criteria for adjustment disorder are met alongside a personality disorder, and the stress-related disturbance exceeds that attributable to the personality disorder (Criterion C), adjustment disorder should be diagnosed.

Psychological Factors Affecting Other Medical Conditions

  • Here, specific psychological elements exacerbate medical conditions, precipitating or worsening them. Adjustment disorder, however, is a reaction to the stressor, not to the medical condition itself.

Normative Stress Reactions

  • Feeling upset when bad things happen is normal. Adjustment disorder is diagnosed only when distress surpasses what’s typically expected or leads to functional impairment. The magnitude of distress varies across cultures.


DSM 5 Diagnostic Criteria for Substance/Medication Induced Depression

Criteria for Substance/Medication-Induced Depressive Disorder

  • Criterion A: Persistent mood disturbance characterized by depressed mood or significantly reduced interest or pleasure in most activities, dominating the clinical picture.
  • Criterion B: Evidence from history, physical examination, or lab findings indicating:
    1. Symptoms developed during or after substance intoxication, withdrawal, or exposure to medication.
    2. The substance or medication can cause these symptoms.
  • Criterion C: The disturbance isn’t better explained by a non-substance-induced depressive disorder. Evidence might include symptoms preceding substance use, persisting after withdrawal, or history of non-substance-induced depressive episodes.
  • Criterion D: The disturbance doesn’t occur solely during delirium.
  • Criterion E: The disturbance causes significant distress or impairs social, occupational, or other important functions.

Additional Notes

  • Diagnosis is made when Criterion A symptoms predominate and warrant clinical attention, instead of solely diagnosing substance intoxication or withdrawal.
  • If a mild substance use disorder coexists, it’s noted before the substance-induced depressive disorder (e.g., “mild [substance] use disorder with substance-induced depressive disorder”). For moderate/severe use disorder, severity is specified.
  • Specify if:
    • With onset during intoxication: Symptoms develop during substance intoxication.
    • With onset during withdrawal: Symptoms arise during or shortly after substance withdrawal.

Differential Diagnosis

Substance Intoxication and Withdrawal:

  • Depressive symptoms are common during substance intoxication and withdrawal, and diagnosing substance-specific intoxication or withdrawal typically suffices.
  • However, if mood symptoms are severe enough to merit independent clinical attention, a diagnosis of substance-induced depressive disorder is warranted instead of substance intoxication or withdrawal. For instance, dysphoric mood during cocaine withdrawal.

Primary Depressive Disorder:

  • Substance/medication-induced depressive disorder is distinct from primary depressive disorder because a substance is deemed causally linked to the symptoms.

Depressive Disorder Due to Another Medical Condition:

  • Considering individuals with medical conditions often take medications, it’s essential to discern if mood symptoms arise from the physiological effects of the medical condition rather than medication. In such cases, depressive disorder due to another medical condition is diagnosed, often relying on history for judgment. Sometimes, altering the treatment for the medical condition may help determine if medication is the causative factor.
  • If it’s determined that the disturbance stems from both another medical condition and substance use or withdrawal, both diagnoses may be assigned.
  • When evidence is insufficient to discern whether depressive symptoms relate to substance ingestion or withdrawal, another medical condition, or are primary, a diagnosis of other specified depressive disorder or unspecified depressive disorder is appropriate.

DSM-IV vs. DSM-5: Implications for Clinical Practice Guidelines

  • If a diagnosis of DDD (Depressive Disorders Due to Another Medical Condition) was established using DSM-IV criteria before the DSM-V criteria were released, these treatment guidelines apply to the worker’s care.
  • However, any diagnosis of DDD made after the publication of DSM-V criteria must align with the DSM-V criteria.


  • Workers previously diagnosed with DDD under DSM-IV retain that diagnosis, and their care should adhere to these guidelines.



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