Substance intoxication and withdrawal. Depressive symptoms occur commonly in sub- stance intoxication and substance withdrawal, and the diagnosis of the substance-specific intoxication or withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of substance-induced depressive disorder should be made instead of a diag- nosis of substance intoxication or substance withdrawal when the mood symptoms are sufficiently severe to warrant independent clinical attention. For example, dysphoric mood is a characteristic feature of cocaine withdrawal. Substance/ medication-induced depressive disorder should be diagnosed instead of cocaine withdrawal only if the mood disturbance is substantially more intense or longer lasting than what is usually encountered with cocaine withdrawal and is sufficiently severe to be a separate focus of attention and treatment.
Primary depressive disorder. A substance/medication-induced depressive disorder is distinguished from a primary depressive disorder by the fact that a substance is judged to be etiologically related to the symptoms, as described earlier (see section "Development and Course” for this disorder).
Depressive disorder due to another medical condition. Because individuals with other medical conditions often take medications for those conditions, the clinician must consider the possibility that the mood symptoms are caused by the physiological consequences of the med- ical condition rather than the medication, in which case depressive disorder due to another medical condition is diagnosed. The history often provides the primary basis for such a judg- ment. At times, a change in the treatment for the other medical condition (e.g., medication sub- stitution or discontinuation) may be needed to determine empirically whether the medication is the causative agent. If the clinician has ascertained that the disturbance is a function of both another medical condition and substance use or withdrawal, both diagnoses (i.e., depressive disorder due to another medical condition and substance/ medication-induced depressive disorder) may be given. When there is insufficient evidence to determine Whether the depres- sive symptoms are associated with substance (including a medication) ingestion or with- drawal or with another medical condition or are primary (i.e., not a function of either a substance or another medical condition), a diagnosis of other specified depressive disorder or unspecified depressive disorder would be indicated.
Compared with individuals with major depressive disorder and no comorbid substance use disorder, those with substance/medication-induced depressive disorder have higher rates of comorbidity with any DSM-IV mental disorder; are more likely to have specific
DSM-IV disorders of pathological gambling and paranoid, histrionic, and antisocial per- sonality disorders; and are less likely to have persistent depressive disorder (dysthymia).
Compared with individuals with major depressive disorder and a comorbid substance use disorder, individuals with substance/medication-induced depressive disorder are more likely to have alcohol use disorder, any other substance use disorder, and histrionic per- sonality disorder; however, they are less likely to have persistent depressive disorder.
Due to Another Medical Condition
A. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture.
8. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condi- tion.
C. The disturbance is not better explained by another mental disorder (e.g., adjustment disorder, with depressed mood, in which the stressor is a serious medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning.
Coding note: The |CD-9-CM code for depressive disorder due to another medical condi- tion is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code de- pends on the specifier (see below).