Major Depressive Disorder 163
The essential feature of a major depressive episode is a period of at least 2 weeks during
which there is either depressed mood or the loss of interest or pleasure in nearly all activi-
ties (Criterion A). In children and adolescents,  the mood may be irritable rather than sad.
The individual must also expe rience at least four additional symptoms drawn from a list
that includes changes in appetite or weigh t, sleep, and psychomotor activity; decreased en-
ergy; feelings of worthlessness or guilt; difficulty thinking, co ncentrating, or making deci-
sions; or recurrent thoughts of death or suicid al ideation or suicide plans or attempts. To
count toward a major depressive episode, a sy mptom must either be newly present or must
have clearly worsened compared with the person’s pre- episode status. The symptoms
must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The ep-
isode must be accompanied by clinically signif icant distress or impairment in social, occu-
pational, or other important areas of func tioning. For some in dividuals with milder
episodes, functioning may appear  to be normal but requires markedly increased effort.
The mood in a major depressive episode is of ten described by the person as depressed,
sad, hopeless, discouraged, or “down in the du mps” (Criterion A1). In some cases, sadness
may be denied at first but may subsequently be  elicited by interview (e.g., by pointing out
that the individual looks as if he or she is ab out to cry). In some individuals who complain
of feeling “blah,” having no feelings, or feeling anxious, the presence of a depressed mood
can be inferred from the pers on’s facial expression and de meanor. Some individuals em-