Major depressive disorder

Depression sits underneath a large share of NCMHCE cases, and the scoring turns on two skills: confirming the episode actually meets threshold and screening for suicide risk before anything else.

Criteria at exam depth. A major depressive episode requires five or more of nine symptoms present during the same two-week period, representing a change from prior functioning, and at least one must be depressed mood or loss of interest or pleasure (anhedonia). The other symptoms are significant weight or appetite change, insomnia or hypersomnia, observable psychomotor agitation or retardation, fatigue, worthlessness or excessive guilt, poor concentration or indecisiveness, and recurrent thoughts of death or suicidal ideation, plan or attempt. Symptoms must cause clinically significant distress or impairment and not be due to a substance or medical condition. In children and adolescents, mood can be irritable rather than sad. Major depressive disorder also requires that there has never been a manic or hypomanic episode (unless substance- or medically induced). Code the course as single episode or recurrent; episodes count as separate when at least two consecutive months without meeting episode criteria fall between them. Specify severity (mild, moderate, severe), psychotic features, remission status, and course specifiers such as anxious distress or peripartum onset. Grief does not automatically exclude the diagnosis; the counselor judges whether a full episode is present alongside the loss.

Hinge differentials.

• Bipolar I/II: any history of mania or hypomania changes the diagnosis; always ask.
• Persistent depressive disorder: chronic course of two years without more than two symptom-free months, versus a discrete episode.
• Adjustment disorder: a stressor-linked reaction that does not reach five symptoms for two weeks.
• Normal grief: waves of pain tied to reminders of the deceased, with self-esteem preserved; MDD brings pervasive anhedonia and worthlessness.
• Substance/medication-induced or medical (e.g., hypothyroidism): onset tied to the substance or illness.
• Demoralization in medical illness: hopelessness with preserved capacity for pleasure.

On the NCMHCE. The first move is a suicide risk assessment (ideation, plan, intent, means, history, protective factors) and a safety plan when indicated. Recommend a medical evaluation to rule out thyroid, anemia and medication effects, and screen alcohol and drug use. Use a standardized measure such as the PHQ-9 or BDI-II for a baseline and progress monitoring. First-line counseling approaches include CBT, behavioral activation and interpersonal therapy; refer for an antidepressant evaluation when severity is moderate to severe or symptoms are not improving. Psychoeducation links the client's own symptoms to depression. In older adults, watch for cognitive complaints and somatic presentations; across cultures, depression may present through bodily symptoms and should be explored in the client's own terms.

Clinical Pearl: Count the symptoms: five of nine, two weeks, with mood or anhedonia as a gatekeeper. Then ask two questions every time: "Any history of mania or hypomania?" and "Are you having thoughts of suicide?"