Depressive Disorder Due to Another Medical Condition 181
Specify if: (F06.31) With depressive features: Full criteria are not met for a major depressive episode. ‘ (F06.32) With major depressive—llke episode: FuII criteria are met (except Criterion
C) for a major depressive episode.
(F06.34) With mixed features: Symptoms of mania or hypomania are also present but do not predominate in the clinical picture.
Coding note: Include the name of the other medical condition in the name of the mental dis- order (e.g., 293.83 [F0631] depressive disorder due to hypothyroidism, with depressive fea- tures). The other medical condition should also be coded and listed separately immediately before the depressive disorder due to the medical condition (e.g., 244.9 [E039] hypothyroid- ism; 293.83 [F0631] depressive disorder due to hypothyroidism, with depressive features).
The essential feature of depressive disorder due to another medical condition is a promi- nent and persistent period of depressed mood or markedly diminished interest or plea- sure in all, or almost all, activities that predominates in the clinical picture (Criterion A) and that is thought to be related to the direct physiological effects of another medical con- dition (Criterion B). In determining whether the mood disturbance is due to a general medical condition, the clinician must first establish the presence of a general medical con— dition. Further, the clinician must establish that the mood disturbance is etiologically re- lated to the general medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Al- though there are no infallible guidelines for determining whether the relationship between the mood disturbance and the general medical condition is etiological, several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and that of the mood disturbance. A second consideration is the presence of fea— tures that are atypical of primary Mood Disorders (e.g., atypical age at onset or course or absence of family history). Evidence from the literature that suggests that there can be a di- rect association between the general medical condition in question and the development of mood symptoms can provide a useful context in the assessment of a particular situation.
Etiology (i.e., a causal relationship to another medical condition based on best clinical ev- idence) is the key variable in depressive disorder due to another medical condition. The listing of the medical conditions that are said to be able to induce major depression is never complete, and the clinician’s best judgment is the essence of this diagnosis.
There are clear associations, as well as some neuroanatomical correlates, of depression with stroke, Huntington’s disease, Parkinson’s disease, and traumatic brain injury. Among the neuroendocrine conditions most closely associated with depression are Cushing’s dis- ease and hypothyroidism. There are numerous other conditions thought to be associated with depression, such as multiple sclerosis. However, the literature’s support for a causal association is greater with some conditions, such as Parkinson’s disease and Huntington’s disease, than with others, for which the differential diagnosis may be adjustment disorder, with depressed mood.
Following stroke, the onset of depression appears to be very acute, occurring within 1 day or a few days of the cerebrovascular accident (CVA) in the largest case series. However, in some cases, onset of the depression is weeks to months following the CVA. In the largest series, the duration of the major depressive episode following stroke was 9—11 months on average. Similarly, in Huntington’s disease the depressive state comes quite early in the course of the illness. With Parkinson’s disease and Huntington’s disease, it often precedes the major motor impairments and cognitive impairments associated with each condition.