Depressive Disorders

The depressive disorders criteria sets are derived from the DSM-5-TR.

This EEG provides the DSM-5-TR diagnostic criteria; however, the International Classification of Diseases 11^th Revision (ICD-11) is also considered an acceptable diagnostic standard.

Criteria set for major depressive disorder

Criterion A

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

Note: Does 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., appearing 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., a 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 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 physiologic effects of a substance or another medical condition.

Note:

• Criteria A-C represent indicate a major depressive episode.
• 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

At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on 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 physiological effects of another medical condition.

Criteria set for 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 by either subjective account or observation by others, for at least two 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 two-year period of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than two 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.

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.

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Entitlement considerations

In this section

Section A: Causes and/or aggravation

Section B: Medical conditions which are to be included in entitlement/assessment

Section C: Common medical conditions which may result, in whole or in part, from depressive disorders and/or their treatment

Section 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 make an individual more susceptible to developing the claimed condition. They are experiences or exposures which affect the individual's ability to cope with stress. For example, severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life. These factors do not cause a claimed condition. Partial entitlement should not be considered for predisposing factors.

Physical/constitutional symptoms are common in people living with psychiatric diagnoses and are often associated with psychological distress. Physical and mental health symptoms frequently co-occur. Physical symptoms associated with psychiatric conditions are included in entitlement/assessment. However, once a symptom has developed into a separate and distinct diagnosis, the new diagnosis becomes a separate entitlement consideration.

For Veterans Affairs Canada (VAC) entitlement purposes, the following factors are accepted to cause or aggravate the conditions included in the Definition section of this EEG, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended. 

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors

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:

   • exposure to military combat
   • threatened or actual physical assault
   • threatened or actual sexual trauma
   • being kidnapped
   • being taken hostage
   • being in a terrorist attack
   • being tortured
   • being in a natural or human-made disaster
   • being in a severe motor vehicle accident
   • killing or injuring a person
   • experiencing a sudden, catastrophic medical incident.

   Note:

   • Moral injury related to service may occur in response to a traumatic event. Moral injury refers to the psychological, emotional, and spiritual distress that arises from actions, or the witnessing of actions, that challenge one’s moral and ethical values or beliefs. The resulting distress may contribute to the development of a depressive disorder. Morally injurious events are often associated with situations where individuals feel a profound sense of guilt, shame, or betrayal due their own actions or the actions of others. These certainly may occur in the context of war, combat, or other high-stakes, morally-challenging experiences.
   • Repeated exposure to prejudicial or unjust treatment may be considered  a traumatic event.
3. In-person witnessing of 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:

   • threatened or serious injury to another person
   • an unnatural death
   • physical or sexual abuse of another person
   • 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:

   • physical assault
   • sexual trauma
   • serious accident
   • serious injury.

   Note: The relationship between individuals in a leadership role and subordinates should be considered akin to close family or friend when reviewing a traumatic event.

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:

   • viewing and/or collecting human remains
   • viewing and/or participating in the clearance of critically injured casualties
   • repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   • dispatch operators exposed to violent or accidental traumatic event(s).

   Note: If the exposure under factor five is to electronic media, television, movies and pictures, the exposure must be 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 a depressive disorder.

   Situations or settings which have a pervasive threat to life or body including but not limited to:

   • being under threat of artillery, missile, rocket, mine or bomb attack
   • being under threat of nuclear, biologic or chemical agent attack
   • 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.

   Note: The relationship between individuals in a leadership role with subordinates should be considered akin to close family or friend.

8. Experiencing a stressful life event within one year before the clinical onset or aggravation of a depressive disorder.

   Stressful life events include, but are not limited to:

   • being socially isolated and unable to maintain friendships or family relationships due to physical location, language barriers, disability, or medical or psychiatric illness
   • experiencing a break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce
   • ongoing conflict with fellow work or school colleagues, perceived lack of social support, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   • experiencing serious legal issues including, but not limited to, being detained, or held in custody, ongoing involvement with law enforcement concerning violations of the law, or court appearances associated with personal legal problems
   • having severe financial hardship including, but not limited to, loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   • having a close family member or close friend experience a major deterioration in health
   • 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 as defined by the DSM-5-TR is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion, regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
10. Having a serious 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 (as defined in DSM-5-TR) for six months before the clinical onset or aggravation of a depressive disorder.
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. Inability to obtain appropriate clinical management of a depressive disorder.

Section B: Medical conditions which are to be included in entitlement/assessment

Section B provides a list of diagnosed medical conditions/categories which are considered, for VAC purposes, to be included in the entitlement and assessment of depressive disorders.

• All other depressive disorders
• All other trauma-and stressor-related disorders
• Anxiety disorders
• Adjustment disorder
• Bipolar and related disorders
• Dissociative disorders
• Feeding and eating disorders
• Neurodevelopmental disorders
  • Attention-deficit/hyperactivity disorder
• Obsessive-compulsive and related disorders
• Pain disorder (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Text Revision [DSM-4-TR] Axis I Diagnosis)
• Posttraumatic Stress Disorder
• Somatic symptom disorder with predominant pain (previously pain disorder in the DSM-4-TR)
• Personality disorders
• Schizophrenia spectrum and other psychotic disorders
• Sleep-wake disorders
  • Insomnia disorder
  • Hypersomnolence disorder
• Substance use disorders

Note :

• If specific conditions are listed for a category, only those conditions are included in the entitlement and assessment of a depressive disorder. Otherwise, all conditions within the category are included in the entitlement and assessment of a depressive disorder.
• Separate entitlement is required for a DSM-5-TR condition not included in Section B of this EEG.
• Somatic symptom and related disorders, such as functional neurological symptom disorder (conversion disorder), somatic symptom disorder, illness anxiety disorder, and bodily distress disorder (ICD-11 diagnosis), are entitled separately and assessed on individual merits.

Section C: Common medical conditions which may result in whole or in part, from depressive disorders and/or their treatment

Section C is a list of conditions which can be caused or aggravated by depressive disorders and/or their treatment. Conditions listed in Section C are not included in the entitlement and assessment of depressive disorders. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship. Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

• Bruxism
• Irritable bowel syndrome
• Ischemic heart disease
• Obstructive sleep apnea
• Periodic limb movement disorder
• Restless leg syndrome
• Salivary gland hypofunction disorder (xerostomia)
• Sexual dysfunction

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:

• The medication was prescribed to treat a depressive disorder.
• The individual was receiving the medication at the time of the clinical onset or aggravation of the condition being claimed to the medication.
• The current medical literature supports the medication can result in the clinical onset or aggravation of the condition being claimed to the medication.
• The medication use is long-term, ongoing, and cannot reasonably be replaced with another medication or the medication is known to have enduring effects after discontinuation.

Note: Individual medications may belong to a class of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered.

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Links

Related VAC guidance and policy:

• Adjustment Disorder – Entitlement Eligibility Guidelines
• Anxiety Disorders – Entitlement Eligibility Guidelines
• Bipolar and Related Disorders – Entitlement Eligibility Guidelines
• Bruxism – Entitlement Eligibility Guidelines
• Feeding and Eating Disorders – Entitlement Eligibility Guidelines
• Ischemic Heart Disease - Entitlement Eligibility Guidelines
• Posttraumatic Stress Disorder – Entitlement Eligibility Guidelines
• Salivary Gland Hypofunction Disorder (Xerostomia) – Entitlement Eligibility Guidelines
• Schizophrenia – Entitlement Eligibility Guidelines
• Sexual Dysfunction – Entitlement Eligibility Guidelines
• Sleep-Related Breathing Disorders – Entitlement Eligibility Guidelines
• Substance Use Disorders – Entitlement Eligibility Guidelines
• Pain and Suffering Compensation – Policies
• Royal Canadian Mounted Police Disability Pension Claims – Policies
• Dual Entitlement – Disability Benefits – Policies
• Establishing the Existence of a Disability – Policies
• Disability Benefits in Respect of Peacetime Military Service – The Compensation Principle – Policies
• Disability Benefits in Respect of Wartime and Special Duty Service – The Insurance Principle – Policies
• Disability Resulting from a Non-Service RelatedInjury or Disease – Policies
• Consequential Disability – Policies
• Benefit of Doubt – Policies

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