Conceptualization Of Severe Depression

The severity of a major depressive disorder is generally defined according to the number of symptoms present, the severity of the symptoms, and the associated functional impairment or distress (American Psychiatric Association, 1994). According to criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), mild depression is indicated by the presence of five or six symptoms, mild functional impairment, or the ability to function normally with significant effort. Severe depression is indicated by the presence of most of the symptoms of a major depressive episode and clear functional impairment. Up to 15% of severely depressed individuals also die by suicide (American Psychiatric Association, 1994); readers are strongly encouraged to consult specific guidelines regarding the assessment and management of suicidality (e.g., Ghahramanlou-Holloway, Brown, & Beck, Chapter 7, this volume). Moreover, severe depression may also be accompanied by psychotic symptoms; however, such presentations are not the focus of this chapter. Moderate depression is indicated by symptom severity and impairment that falls between the levels of mild and severe. Severity of depression is also commonly defined according to scores obtained on self-report or interview-based measures; the most common severity assessment tools are reviewed below.

In general, the conceptualization of severe depression follows the same general framework for case conceptualization of standard CT. To the extent that severe depression may be associated with increased comorbidity and psychosocial impairment, it may be important to highlight the importance of these factors in the patient's experience of depression. The case illustration below provides an extended example of discussion of the cognitive model of depression with a more severely depressed patient.

Defeat Depression

Defeat Depression

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