Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may re- port sustained fatigue without physical exertion. Even the smallest tasks seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are ex- hausting and take twice as long as usual.
The sense of worthlessness or guilt associated with a major depressive episode may in- clude unrealistic negative evaluations of one’s worth or guilty preoccupations or rumina- tions over minor past failings (Criterion A7). Such individuals often misinterpret neutral or trivial day-to—day events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events. The sense of worthlessness or guilt may be of delu- sional proportions (e.g., an individual who is convinced that he or she is personally re- sponsible for world poverty). Blaming oneself for being sick and for failing to meet occupational or interpersonal responsibilities as a result of the depression is very common and, unless delusional, is not considered sufficient to meet this criterion.
Many individuals report impaired ability to think, concentrate, or make even minor decisions (Criterion A8). They may appear easily distracted or complain of memory diffi— culties. Those engaged in cognitively demanding pursuits are often unable to function. In children, a precipitous drop in grades may reﬂect poor concentration. In elderly individ- uals, memory difficulties may be the chief complaint and may be mistaken for early signs of a dementia (”pseudodementia”). When the major depressive episode is successfully treated, the memory problems often fully abate. However, in some individuals, particu- larly elderly persons, a major depressive episode may sometimes be the initial presenta- tion of an irreversible dementia.
Thoughts of death, suicidal ideation, or suicide attempts (Criterion A9) are common.
They may range from a passive wish not to awaken in the morning or a belief that others would be better off if the individual were dead, to transient but recurrent thoughts of com- mitting suicide, to a specific suicide plan. More severely suicidal individuals may have put their affairs in order (e.g., updated wills, settled debts), acquired needed materials (e.g., a rope or a gun), and chosen a location and time to accomplish the suicide. Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles, an intense wish to end what is perceived as an unending and excruciatingly painful emo- tional state, an inability to foresee any enjoyment in life, or the wish to not be a burden to others. The resolution of such thinking may be a more meaningful measure of diminished suicide risk than denial of further plans for suicide.
The evaluation of the symptoms of a major depressive episode is especially difficult when they occur in an individual who also has a general medical condition (e.g., cancer, stroke, myocardial infarction, diabetes, pregnancy). Some of the criterion signs and symp- toms of a major depressive episode are identical to those of general medical conditions (e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in preg- nancy; insomnia later in pregnancy or the postpartum). Such symptoms count toward a major depressive diagnosis except when they are clearly and fully attributable to a general medical condition. Nonvegetative symptoms of dysphoria, anhedonia, guilt or worthless- ness, impaired concentration or indecision, and suicidal thoughts should be assessed with particular care in such cases. Definitions of major depressive episodes that have been mod- ified to include only these nonvegetative symptoms appear to identify nearly the same in- dividuals as do the full criteria.