Depressive Disorders

Definition

Depressive Disorders is a category of conditions in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).

The Depressive Disorders included in this Entitlement Eligibility Guideline (EEG) are:

• Major Depressive Disorder
• Persistent Depressive Disorder (Dysthymia).

The common feature of Depressive Disorders is the presence of sad, empty or irritable mood with somatic and cognitive changes which significantly affect an individual's ability to function.

NOTE: Substance/Medication-Induced Depressive Disorder and Depressive Disorder due to Another Medical Condition are also mental disorders included in this category.

If a substance(s), medication(s) or another medical condition(s) is claimed to be related to the clinical onset or aggravation of a Depressive Disorder, consultation with Medical Advisory is strongly recommended.

Criteria Sets for Depressive Disorders

The Depressive Disorder criteria sets are derived from the DSM-5.

Major Depressive Disorder :

Criterion A

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g. change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Criterion B

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion C

The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: Criteria A-C represent a Major Depressive Episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a Major Depressive Episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.

Criterion D

The occurrence of the Major Depressive Episode is not better explained by Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Other Specified and Unspecified Schizophrenia Spectrum and other Psychotic Disorders.

Criterion E

There has never been a Manic Episode or a Hypomanic Episode.

Note: This exclusion does not apply if all the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiologic effects of another medical condition.

Persistent Depressive Disorder (Dysthymia):

This disorder represents a consolidation of DSM-IV-defined Chronic Major Depressive Disorder and Dysthymic Disorder.

Criterion A

Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.

Criterion B

Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

Criterion C

During the 2-year period of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

Criterion D

Criteria for a Major Depressive Disorder may be continuously present for two years.

Criterion E

There has never been a Manic Episode or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.

Criterion F

The disturbance is not better explained by a persistent Schizoaffective Disorder, Schizophrenia, Delusional Disorder, or Other Specified or Unspecified Schizophrenia Spectrum and Other Psychotic Disorder.

Criterion G

The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

Criterion H

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes And/Or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Depressive Disorders. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate a Depressive Disorder. Other factors may be considered based upon the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Being a prisoner of war before the clinical onset or aggravation of a Depressive Disorder


2. Directly experiencing a traumatic event(s) within the five years before the clinical onset or aggravation of a Depressive Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. being in a natural or human-made disaster
   9. being in a severe motor vehicle accident
   10. killing or injuring a person in a non-criminal act
   11. experiencing a sudden, catastrophic medical incident
3. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the five years before the clinical onset or aggravation of a Depressive Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend
4. Learning a close family member or close friend experienced a violent or accidental traumatic event(s) within the two years before the clinical onset or aggravation of a Depressive Disorder
   
   Traumatic events include, but are not limited to:
   1. physical assault
   2. sexual assault
   3. serious accident
   4. serious injury
5. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) within the five years before the clinical onset or aggravation of a Depressive Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)
   Note: Factor 5 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.
6. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Depressive Disorder
   
   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:
   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
7. Experiencing the death of a close family member or close friend within the two years before the clinical onset or aggravation of a Depressive Disorder
8. Experiencing a stressful life event within one year before the clinical onset or aggravation of a Depressive Disorder
   
   Events which qualify as stressful life events include, but are not limited to:
   1. being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   2. experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce
   3. having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   4. experiencing serious legal issues including: being detained or held in custody, on-going involvement with law enforcement concerning violations of the law, or court appearances associated with personal legal problems
   5. having severe financial hardship including, but not limited to: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   6. having a close family member or close friend experience a major deterioration in their health
   7. being a full-time caregiver to a family member or close friend with a severe physical, mental or developmental disability
9. Having a clinically significant psychiatric condition within the two years before the clinical onset or aggravation of a Depressive Disorder
   
   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.
10. Having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within the five years before the clinical onset or aggravation of a Depressive Disorder
11. Having chronic pain of at least three months duration at the time of the clinical onset or aggravation of a Depressive Disorder
12. Having a clinically significant Sleep-Wake Disorder for the six months before the clinical onset or aggravation of a Depressive Disorder
    
    A clinically significant Sleep-Wake Disorder as defined in the DSM-5.
13. Being in the second or third trimester of pregnancy, or the one year period following childbirth, at the time of the clinical onset or aggravation of a Depressive Disorder
14. Having a miscarriage, fetal death in-utero or stillbirth, within the six months before the clinical onset or aggravation of a Depressive Disorder
15. Having experienced severe childhood abuse before the clinical onset of a Depressive Disorder
    
    Severe childhood abuse is:
    1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
    2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing of a child under the age of 16 years;
    where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.
16. Inability to obtain appropriate clinical management of a Depressive Disorder

NOTE: Substance/Medication-Induced Depressive Disorder and Depressive Disorder due to Another Medical Condition are also mental disorders included in this category.

If a substance(s), medication(s) or another medical condition(s) is claimed to be related to the clinical onset or aggravation of a Depressive Disorder, consultation with Medical Advisory is strongly recommended.

B. Medical Conditions Which Are To Be Included In Entitlement/Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of a Depressive Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of a Depressive Disorder.

• Other Depressive Disorders
• Trauma- and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Substance-Related and Addictive Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Depressive Disorders Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result In Whole Or In Part From Depressive Disorder And/Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of a Depressive Disorder, from the treatment of a Depressive Disorder or the combined effects of a Depressive Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat a Depressive Disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of a Depressive Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to a Depressive Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Sexual Dysfunction (e.g. Erectile Dysfunction)
• Irritable Bowel Syndrome
• Bruxism
• Xerostomia
• Periodic Limb Movement Disorder
• Restless Leg Syndrome
• Obstructive Sleep Apnea

References For Depressive Disorders

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. (DSM-5) Washington: American Psychiatric Association, 2013.
3. Australia. (2008) Statement of principles concerning depressive disorder. No. 27 of 2008.
4. Australia. (2010). Amendment statement of principles concerning depressive disorder. No. 40 of 2010.
5. Australia. (2008). Statement of principles concerning depressive disorder. No. 28 of 2008.
6. Australia. (2010). Amendment statement of principles concerning depressive disorder. No. 41 of 2010.