Research

JAMA Psychiatry | Original Investigation

Epidemiology of Adult DSM-5 Major Depressive Disorder

and Its Specifiers in the United States
Deborah S. Hasin, PhD; Aaron L. Sarvet, MPH; Jacquelyn L. Meyers, PhD; Tulshi D. Saha, PhD; W. June Ruan, MA;
Malka Stohl, MS; Bridget F. Grant, PhD, PhD

Supplemental content
IMPORTANCE No US national data are available on the prevalence and correlates of
DSM-5–defined major depressive disorder (MDD) or on MDD specifiers as defined in DSM-5.

OBJECTIVE To present current nationally representative findings on the prevalence,

correlates, psychiatric comorbidity, functioning, and treatment of DSM-5 MDD and initial
information on the prevalence, severity, and treatment of DSM-5 MDD severity,
anxious/distressed specifier, and mixed-features specifier, as well as cases that would have
been characterized as bereavement in DSM-IV.

DESIGN, SETTING, AND PARTICIPANTS In-person interviews with a representative sample of US

noninstitutionalized civilian adults (ⱖ18 years) (n = 36 309) who participated in the
2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III).
Data were collected from April 2012 to June 2013 and were analyzed in 2016-2017.

MAIN OUTCOMES AND MEASURES Prevalence of DSM-5 MDD and the DSM-5 specifiers. Odds
ratios (ORs), adjusted ORs (aORs), and 95% CIs indicated associations with demographic
characteristics and other psychiatric disorders.

RESULTS Of the 36 309 adult participants in NESARC-III, 12-month and lifetime prevalences
of MDD were 10.4% and 20.6%, respectively. Odds of 12-month MDD were significantly lower
in men (OR, 0.5; 95% CI, 0.46-0.55) and in African American (OR, 0.6; 95% CI, 0.54-0.68),
Asian/Pacific Islander (OR, 0.6; 95% CI, 0.45-0.67), and Hispanic (OR, 0.7; 95% CI,
0.62-0.78) adults than in white adults and were higher in younger adults (age range, 18-29
years; OR, 3.0; 95% CI, 2.48-3.55) and those with low incomes ($19 999 or less; OR, 1.7; 95%
CI, 1.49-2.04). Associations of MDD with psychiatric disorders ranged from an aOR of 2.1
(95% CI, 1.84-2.35) for specific phobia to an aOR of 5.7 (95% CI, 4.98-6.50) for generalized
anxiety disorder. Associations of MDD with substance use disorders ranged from an aOR of
1.8 (95% CI, 1.63-2.01) for alcohol to an aOR of 3.0 (95% CI, 2.57-3.55) for any drug. Most
lifetime MDD cases were moderate (39.7%) or severe (49.5%). Almost 70% with lifetime
MDD had some type of treatment. Functioning among those with severe MDD was Author Affiliations: Department of
approximately 1 SD below the national mean. Among 12.9% of those with lifetime MDD, all Psychiatry, Columbia University
Medical Center, New York, New York
episodes occurred just after the death of someone close and lasted less than 2 months. The (Hasin, Sarvet); Department of
anxious/distressed specifier characterized 74.6% of MDD cases, and the mixed-features Epidemiology, Mailman School of
specifier characterized 15.5%. Controlling for severity, both specifiers were associated with Public Health, Columbia University,
New York, New York (Hasin);
early onset, poor course and functioning, and suicidality.
New York State Psychiatric Institute,
New York (Hasin, Sarvet, Stohl);
CONCLUSIONS AND RELEVANCE Among US adults, DSM-5 MDD is highly prevalent, comorbid, Department of Psychiatry, State
and disabling. While most cases received some treatment, a substantial minority did not. University of New York Downstate
Medical Center, Brooklyn (Meyers);
Much remains to be learned about the DSM-5 MDD specifiers in the general population. Epidemiology and Biometry Branch,
National Institute on Alcohol Abuse
and Alcoholism, National Institutes of
Health, Rockville, Maryland (Saha,
Ruan); Fedpoint Systems, LLC,
Arlington, Virginia (Grant).
Corresponding Author: Deborah S.
Hasin, PhD, Department of
Psychiatry, Columbia University
Medical Center, 1051 Riverside Dr,
JAMA Psychiatry. 2018;75(4):336-346. doi:10.1001/jamapsychiatry.2017.4602 Ste 123, New York, NY 10032
Published online February 14, 2018. (dsh2@cumc.columbia.edu).

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 Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers Original Investigation Research

O
ver the past 25 years, the US prevalence of adoles-
cent and adult depression indicators has increased.1,2 Key Points
However, national epidemiologic information on ma-
Question What is the national prevalence of DSM-5 major
jor depressive disorder (MDD) is limited to pre–DSM-5 stud- depressive disorder, the DSM-5 anxious/distressed and
ies conducted more than 15 years ago. The DSM-IV diagnosis mixed-features specifiers, and their clinical correlates?
of MDD was associated with impairment,3,4 psychiatric and
Findings In this national survey of 36 309 US adults, the
substance use disorders (SUDs),5-9 poor health,10,11 mortality,12
12-month and lifetime prevalences of major depressive disorder
disease and economic burden,12 and disability-years.13-16 were 10.4% and 20.6%, respectively, with most being moderate
Updated knowledge is needed on the prevalence of MDD and (6-7 symptoms) or severe (8-9 symptoms) and associated with
its association with sociodemographic and clinical character- comorbidity and impairment. The anxious/distressed specifier
istics, including other psychiatric disorders, suicidality, characterized 74.6% of major depressive disorder cases, and the
impairment, and treatment use. mixed-features specifier characterized 15.5%; almost 70% with
lifetime major depressive disorder received some type of
In 2013, DSM-IV17 was replaced with the fifth edition of the
treatment.
DSM-5.18 Among changes in MDD,19 DSM-5 added specifiers.
One specifier indicates MDD episodes associated with anx- Meaning Major depressive disorder remains a serious US health
ious distress. A second indicates “mixed” MDD episodes (ie, problem, with much to be learned about its specifiers.
accompanied by manic or hypomanic features not meeting cri-
teria for a bipolar disorder). These specifiers have been stud- Data were adjusted for oversampling and nonresponse and
ied in patients20-23 but not national data; the proportion of MDD weighted to represent the US civilian population based on the
cases diagnosed as positive after bereavement has also not 2012 American Community Survey.25 Weighting adjustments
been studied. The DSM-IV and DSM-5 include a severity compensated for nonresponse.24 Comparing participants with
specifier (mild, moderate, or severe) not previously exam- the total eligible sample (including nonrespondents), no sig-
ined in national data. Furthermore, DSM-5 removed the DSM-IV nificant differences were found in percentages of African
MDD exclusion criterion for bereavement. While DSM-5 does American, Asian, or Hispanic individuals or in population den-
not include bereavement as a new MDD specifier, exploring sity, vacancy rate, or proportion in group quarters or renters.
the potential influence of this change on national rates of DSM-5 Compared with the eligible sample, respondents included
MDD by identifying the proportion of MDD cases that would slightly different percentages of men (46.2% vs 48.1%) and
have been excluded as bereavement under DSM-IV rules is of those aged 30 to 39 years (17.4% vs 16.7%), 40 to 49 years (18.3%
considerable interest. vs 18.1%), and 60 to 69 years (12.6% vs 13.7%), respectively.24
The National Epidemiologic Survey on Alcohol and The sample sociodemographic characteristics are reported
Related Conditions III (NESARC-III) is a nationally represen- elsewhere.24
tative 2012-2013 survey of DSM-5 psychiatric and SUDs in Interviewer field methods and quality control included struc-
adults 18 years or older, including MDD and the specifiers tured training, supervision, and random respondent verification
described above. Herein, we report NESARC-III findings on callbacks, as previously reported.24 Oral informed consent was
the adult prevalence, sociodemographic and clinical corre- recorded, and respondents received $90. The National Institutes
lates, disability, course, and treatment for 12-month and of Health and Westat, Inc (NESARC-III contractor) institutional
lifetime DSM-5 MDD, as well as on the specifiers and review boards approved the protocols.
bereavement.
DSM-5 Diagnostic Interview
The National Institute on Alcohol Abuse and Alcoholism
DSM-5 version of the Alcohol Use Disorder and Associated
Methods
Disabilities Interview Schedule 5 (AUDADIS-5)26,27 was used.
Sample and Procedures This fully structured interview for lay interviewers was
The NESARC-III target population was the US noninstitu- used to measure DSM-5 mood, anxiety, substance use, and
tionalized civilian population aged at least 18 years, includ- personality disorders.
ing household and selected group quarter residents (eg,
group homes and dormitories). Probability sampling was DSM-5 MDD
used to select respondents.24 Primary sampling units were Major depressive episode was diagnosed when at least 2 weeks
counties or groups of counties, secondary sampling units of persistent depressed mood, anhedonia, or hopelessness oc-
(SSUs) were groups of US Census–defined blocks, and ter- curred (reported by self or observed by others), plus addi-
tiary sampling units were households within SSUs; within tional symptoms from criterion A, for a total of 5 of the 9 DSM-5
households, eligible adults were randomly selected. African major depression criteria26 and the clinical significance crite-
American, Asian, and Hispanic adults were oversampled; in rion. Lifetime DSM-5 MDD was defined as at least one life-
households with at least 4 eligible racial/ethnic minority time major depressive episode without full DSM-5 manic,
individuals, 2 were selected (n = 1661). The sample size was mixed, or hypomanic episodes,26,28 excluding substance-
36 309. The total response rate was 60.1%. Data were col- induced and medical-induced disorders. Those with at least
lected from April 2012 to June 2013 and were analyzed in one episode in the prior 12 months were classified as having
2016-2017. 12-month MDD.

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 Research Original Investigation Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers

In a test-retest study26 of NESARC-III participants, inter- Other Psychiatric Disorders

viewers blinded to the initial interview results conducted The AUDADIS-5 DSM-5 anxiety disorder diagnoses (panic,
separate retest AUDADIS-5 interviews with 1006 NESARC- agoraphobia, social phobia, specific phobia, and generalized
III participants (test-retest interval, 1-10 weeks; mean, 2.86 anxiety disorder) excluded substance-induced and medical-
weeks). Test-retest reliability of AUDADIS-5 DSM-5 MDD induced disorders, consistent with DSM-5. The DSM-5 posttrau-
was fair 29 (κ = 0.40) 26 ; reliability of the corresponding matic stress disorder (PTSD) generally followed the DSM-5
dimensional MDD measure was higher (intraclass correla- definition, but criteria C and D more strictly required at least 3
tion [ICC], 0.59).26 Clinical validity was assessed through positive criteria rather than at least 2 positive criteria. Test-retest
concordance with blinded clinician reappraisals using the reliability of these diagnoses was fair to good (κ = 0.35-0.54),26
Psychiatric Research Interview for Substance and Mental with higher reliability for associated DSM-5 dimensional scales
Disorders, DSM-5 version (PRISM-5)30,31 (the eAppendix in (ICC, 0.50-0.79).26 Clinical validity (concordance with PRISM-5)
the Supplement provides details on PRISM-5 and the clini- was fair to good (κ = 0.20-0.59) and was greater for correspond-
cal validity study). Concordance for binary MDD diagnoses ing dimensional scales (ICC, >0.53 for all).30 The DSM-5 schizo-
was fair29 (κ = 0.35-0.46)30 and higher with corresponding typal, borderline, and antisocial personality disorders were
DSM-5 MDD dimensional scales (ICC, 0.60-0.64).30 assessed as defined in DSM-IV, as described previously.33-35 Test-
retest reliability of these personality disorders was very good
DSM-5 MDD Specifiers (κ = 0.67-0.71), was higher for corresponding dimensional mea-
Severity Specifier sures (κ = 0.71-0.79),36,37 and was validated by associations
The DSM-5 does not state the number of MDD symptoms with psychiatric comorbidity and disability.33-35
required for each severity level, so these levels were defined
as follows: mild is 5 symptoms (minimum for a diagnosis), Substance Use Disorders
moderate is 6 to 7 symptoms, and severe is 8 to 9 symp- AUDADIS-5 operationalizes DSM-5 criteria for alcohol and drug–
toms. The DSM-5 also states that distress and impairment specific disorders for 10 drug classes,26 aggregated herein. In
should increase across levels but without clear definitions. DSM-5, the 12-month or lifetime diagnoses of alcohol or drug
Therefore, we used the symptom count only, which is clear. disorders require at least 2 of 11 criteria within a 12-month
The symptom count was based on the lifetime MDD episode period.38 These diagnoses had fair to good test-retest reliabil-
when mood or anhedonia was the worst. ity (κ = 0.40-0.62); reliability of dimensional criteria scales was
fair to excellent (ICC, 0.45-0.85).26 Clinical validity (concor-
Anxious/Distressed Specifier dance with PRISM-5) was fair to good for alcohol and drug use
The DSM-5 defines this specifier as at least 2 of the follow- disorders (κ = 0.40-0.66) and higher for their dimensional
ing 5 anxiety or distress symptoms during an episode: feel- counterparts (ICC, 0.68).30
ing keyed up or tense, being unusually restless, having
trouble concentrating due to worry, fearing something Impairment
awful would happen, and thinking one might lose control of Impaired functioning was assessed with version 2 of the 12-Item
oneself. These symptoms were required for at least 2 weeks Short Form Health Survey (SF-12v2), a reliable, valid, widely used
during the episode when mood or anhedonia was the worst measure of impairment in the prior 30 days.39 The SF-12v2 scales
(a lesser threshold than the actual DSM-5 definition, which include mental health, social functioning, role-emotional func-
requires symptoms on more days than not). tioning, and mental component summary, with norm-based
scores (mean [SD], 50 [10]; range, 0-100). Lower scores indicate
Mixed-Features Specifier poorer functioning.
The DSM-5 defines this specifier as at least 3 of the following
symptoms during episodes not meeting criteria for mania or hy- Statistical Analysis
pomania: elevated or expansive mood, inflated self-esteem or Weighted means and percentages were computed for continu-
grandiosity, unusual talkativeness or pressure to keep talking, ous and categorical correlates of 12-month and lifetime DSM-5
flight of ideas or racing thoughts, increased energy or goal- MDD and the DSM-5 specifiers. Adjusted odds ratios (aORs)
directed activity, involvement in activities (eg, financial or sexual) from multivariable logistic regressions were used to test as-
with potential for painful consequences, and decreased need for sociations of MDD with sociodemographic characteristics, con-
sleep (rested despite sleeping less). These symptoms were re- trolling for all others, as was done previously in NESARC
quired for most days during at least one lifetime episode. studies.5,24,28,40-43 Similar logistic regression models were
used to test psychiatric comorbidity with MDD, adjusted first
Bereavement for sociodemographic characteristics and then also for other
Bereavement is not a DSM-5 specifier, and cases of bereave- substance use and psychiatric disorders, as was done
ment were not excluded in estimates of MDD reported previously.24,28,41-44 Eating disorders and persistent depres-
herein. However, participants meeting criteria for DSM-5 sion were too rare to report separately but were included as
MDD were coded positive on a variable representing covariates in adjusted comorbidity analyses. Logistic regres-
bereavement if all MDD episodes began just after someone sions indicating the association between SF-12v2 scores and
close died and lasted less than 2 months, consistent with MDD were adjusted for sociodemographic characteristics and
DSM-IV and previous reports.32 other psychiatric disorders. Odds ratios (ORs), computed with

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 Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers Original Investigation Research

Table 1. Prevalence and OR of 12-Month and Lifetime DSM-5 MDD by Sociodemographic Characteristicsa

12-mo MDD (n = 3963) Lifetime MDD (n = 7432)

Sociodemographic Prevalence, Prevalence,
Characteristic % (SE) OR (95% CI) % (SE) OR (95% CI)
Total 10.4 (0.25) NA 20.6 (0.37) NA
Sex
Male 7.2 (0.26) 0.5 (0.46-0.55) 14.7 (0.40) 0.5 (0.46-0.53)
Female 13.4 (0.37) 1 [Reference] 26.1 (0.50) 1 [Reference]
Race/ethnicity
White 10.8 (0.35) 1 [Reference] 23.1 (0.47) 1 [Reference]
African American 9.3 (0.42) 0.6 (0.54-0.68) 15.2 (0.49) 0.5 (0.46-0.55)
Native American 15.9 (1.86) 1.2 (0.87-1.63) 28.2 (2.12) 1.1 (0.89-1.35)
Asian/Pacific Islander 6.8 (0.53) 0.6 (0.45-0.67) 12.2 (0.83) 0.4 (0.36-0.50)
Hispanic 10.0 (0.40) 0.7 (0.62-0.78) 16.2 (0.55) 0.6 (0.52-0.64)
Age, y
18-29 12.9 (0.47) 3.0 (2.48-3.55) 20.2 (0.55) 1.9 (1.65-2.10)
30-44 11.2 (0.40) 3.0 (2.54-3.54) 22.0 (0.61) 2.2 (1.92-2.44)
45-64 10.7 (0.39) 2.7 (2.30-3.10) 22.9 (0.54) 2.1 (1.91-2.33)
≥65 5.4 (0.33) 1 [Reference] 14.4 (0.56) 1 [Reference]
Marital status
Married or cohabiting 8.2 (0.30) 1 [Reference] 18.7 (0.40) 1 [Reference]
Widowed, separated, or divorced 13.8 (0.49) 1.7 (1.49-1.84) 25.9 (0.65) 1.5 (1.38-1.59)
Never married 13.2 (0.47) 1.4 (1.21-1.60) 20.7 (0.57) 1.2 (1.07-1.30)
Educational level
<High school 11.4 (0.54) 1.2 (1.01-1.32) 17.8 (0.65) 0.9 (0.79-0.97)
High school 11.0 (0.47) 1.1 (0.98-1.20) 19.3 (0.60) 0.9 (0.82-0.96)
≥Some college 9.9 (0.28) 1 [Reference] 21.8 (0.44) 1 [Reference]
Family income, $
0-19 999 14.1 (0.49) 1.7 (1.49-2.04) 22.5 (0.61) 1.3 (1.13-1.39)
20 000-34 999 11.4 (0.39) 1.5 (1.30-1.72) 20.8 (0.61) 1.2 (1.06-1.28)
35 000-69 999 9.9 (0.38) 1.3 (1.16-1.50) 20.1 (0.55) 1.1 (0.98-1.18)
≥70 000 7.5 (0.41) 1 [Reference] 19.6 (0.58) 1 [Reference]
Urbanicity
Urban 10.5 (0.29) 1.1 (0.95-1.28) 20.5 (0.42) 1.1 (0.93-1.21)
Rural 9.9 (0.54) 1 [Reference] 21.1 (0.98) 1 [Reference]
Region
Northeast 10.7 (0.67) 1.0 (0.85-1.17) 21.8 (0.81) 1.0 (0.89-1.16) Abbreviations: MDD, major
Midwest 9.9 (0.51) 0.9 (0.75-0.99) 20.6 (0.90) 0.9 (0.78-1.01) depressive disorder; NA, not
applicable; OR, odds ratio.
South 10.4 (0.47) 0.9 (0.82-1.06) 20.1 (0.62) 0.9 (0.84-1.04)
a
Controlling for all other
West 10.6 (0.35) 1 [Reference] 20.5 (0.65) 1 [Reference]
sociodemographic characteristics.

statistical software (SUDAAN, version 11.0; RTI International)45 lower among African American, Asian, and Hispanic adults.
to take the sample design into account, were considered sta- Compared with respondents 65 years or older, odds of 12-
tistically significant when 95% CIs excluded 1.00. month MDD were greater for younger age groups. Compared
with the highest income category ($70 000 or higher), odds
of 12-month MDD were greater in each successively lower
household income category (higher categories differed little
Results from $70 000 or higher) (eTable in the Supplement). The as-
DSM-5 MDD Prevalence and Sociodemographic Correlates sociations between lifetime MDD and sociodemographic char-
Of the 36 309 adult participants in NESARC-III, the 12-month acteristics were similar (Table 1).
and lifetime prevalences of DSM-5 MDD were 10.4% and 20.6%,
respectively (Table 1). The respective 12-month and lifetime Associations With Other Psychiatric Disorders
prevalences were 13.4% and 26.1% among women and 7.2% and All disorders were significantly associated with 12-month and
14.7% among men. As summarized in Table 1, men had sig- lifetime MDD (Table 2). The aORs were larger for drug use dis-
nificantly lower odds of 12-month MDD (OR, 0.5) than women. order than for alcohol or nicotine use disorders and were larger
Compared with white adults, odds of 12-month MDD were for borderline than other personality disorders. Additional

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 Research Original Investigation Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers

Table 2. Twelve-Month and Lifetime Prevalence of Other Psychiatric Disorders Among Those With DSM-5 MDDa

12 mo Lifetime
Comorbid Prevalence Adjusted aOR Prevalence Adjusted aOR
Psychiatric Disorder (SD)b aOR (95% CI)c (95% CI)d (SD)b aOR (95% CI)c (95% CI)d
Any substance use disorder 45.3 (0.86) 2.0 (1.84-2.16) 1.4 (1.24-1.52) 57.9 (0.75) 2.2 (2.02-2.31) 1.5 (1.35-1.57)
Alcohol use disorder 22.2 (0.86) 1.8 (1.63-2.01) 1.2 (1.06-1.33) 40.8 (0.86) 2.0 (1.88-2.20) 1.3 (1.16-1.40)
Any drug use disorder 10.1 (0.57) 3.0 (2.57-3.55) 1.5 (1.20-1.79) 17.6 (0.65) 2.5 (2.21-2.78) 1.3 (1.14-1.49)
Nicotine use disorder 32.8 (0.94) 1.9 (1.69-2.07) 1.3 (1.12-1.41) 38.9 (0.83) 1.9 (1.75-2.02) 1.2 (1.12-1.34)
Any anxiety disorder 36.4 (0.96) 4.2 (3.81-4.57) 2.2 (1.94-2.44) 37.3 (0.70) 3.9 (3.57-4.17) 2.2 (2.05-2.43)
Panic 11.4 (0.59) 4.4 (3.73-5.25) 1.8 (1.45-2.21) 12.8 (0.53) 3.4 (3.05-3.89) 1.6 (1.40-1.86)
Agoraphobia 05.6 (0.44) 4.2 (3.28-5.27) 1.3 (1.05-1.70) 05.0 (0.33) 3.7 (3.04-4.54) 1.3 (1.07-1.64)
Social phobia 09.4 (0.64) 3.9 (3.32-4.66) 1.5 (1.19-1.76) 08.7 (0.46) 3.4 (2.95-3.86) 1.4 (1.22-1.61)
Specific phobia 11.6 (0.59) 2.1 (1.84-2.35) 1.0 (0.86-1.15) 12.2 (0.40) 2.3 (2.10-2.57) 1.3 (1.10-1.41)
Generalized anxiety disorder 19.9 (0.76) 5.7 (4.98-6.50) 2.4 (2.10-2.83) 20.5 (0.57) 4.9 (4.39-5.47) 2.5 (2.18-2.78)
Posttraumatic stress disorder 16.3 (0.85) 4.4 (3.92-5.03) 1.8 (1.54-2.12) 15.6 (0.64) 4.1 (3.70-4.63) 1.9 (1.67-2.23)
Any personality disordere 40.9 (1.13) 4.6 (4.12-5.03) 2.4 (2.10-2.70) 31.9 (0.86) 3.9 (3.58-4.29) 2.0 (1.83-2.25)
Schizotypal 18.4 (0.94) 3.8 (3.33-4.30) 1.2 (1.04-1.46) 13.6 (0.68) 3.4 (2.90-3.88) 1.2 (1.03-1.47)
Borderline 35.7 (1.06) 5.2 (4.70-5.74) 2.6 (2.28-2.94) 26.6 (0.73) 4.4 (4.02-4.81) 2.2 (1.94-2.43)
Antisocial 08.4 (0.56) 2.3 (1.92-2.72) 0.9 (0.76-1.15) 07.4 (0.39) 2.5 (2.15-2.84) 1.2 (0.97-1.35)
Abbreviations: aOR, adjusted odds ratio; MDD, major depressive disorder. among individuals who do not have MDD. The aORs were adjusted for sex,
a
The aORs indicate associations of MDD with other psychiatric disorders. race/ethnicity, age, marital status, educational level, family income, urbanicity,
b
and region.
Prevalence of the given disorder among those with MDD in the corresponding
d
time frame (eg, prevalence of 12-month disorders among those with 12-month The aORs were adjusted for sex, race/ethnicity, age, marital status, educational
MDD). level, family income, urbanicity, region, and psychiatric disorders other than
c
bipolar I disorder.
All aORs represent the odds of having a specific comorbid disorder among
e
individuals with MDD relative to the odds of having specific comorbid disorder Personality disorders assessed on a lifetime basis.

adjustment for other psychiatric disorders decreased all aORs past-year suicide attempts were reported by 13.6% and
(some substantially), but most remained significant. 4.8%, respectively.

MDD Characteristics Functioning

As summarized in Table 3, the mean (SE) age at onset of MDD Table 4 lists SF-12v2 scores overall and by severity level of MDD
was 29.05 (0.21) years. Overall, a mean (SE) of 3.86 (0.10) life- among those whose only episodes of MDD occurred in the prior
time episodes were reported. The median duration of life- 12 months. Mental health, social functioning, role-emotional
time longest or only episode was 25.9 weeks. functioning, and mental component summary scores ranged
from 42.1 to 43.9 (approximately 0.8 SD below the mean), in-
Treatment dicating significantly poorer functioning (P < .001) than in par-
Treatment for MDD was reported by 69.4% of participants with ticipants without MDD (range, 49.3-53.1). Moderate and se-
a lifetime MDD diagnosis (Table 3); 53.1% reported using medi- vere cases had worse functioning, with scores for severe cases
cation, 62.5% reported talking with a professional, 14.9% re- (range, 38.6-40.4) approximately 1 SD below the national mean.
ported receiving nonprofessional support (ie, self-help or sup- In participants whose only MDD episode extended into the
port group, hotline, or internet chat room), 10.2% reported prior 30 days (Table 4), scores were poorer overall (range, 38.5-
going to an emergency department, and 11.8% reported being 40.2), especially among severe cases (range, 35.3-36.6).
hospitalized overnight or longer. The mean age at first treat-
ment for MDD was 32.0 years, resulting in a mean delay from DSM-5 Specifiers and Bereavement
onset to first treatment of 47.5 months. While the prevalence When mood or anhedonia was at its worst during lifetime MDD
of different types of treatment was lower among those whose (Table 3), 10.8% of the episodes were at the mild severity level
only MDD was within the past 12 months, more than 50% of (5 MDD symptoms), 39.7% were moderate (6-7 symptoms), and
these received some type of treatment for MDD. 49.5% were severe (8-9 symptoms). Among those whose only
MDD episode was in the prior 12 months, 14.4%, 38.8%, and
Suicidality 46.8% were mild, moderate, and severe, respectively. The anx-
During the lifetime MDD episode when mood or anhedonia was ious/distressed specifier characterized 74.6% of those with life-
at its worst, 34.8% thought about their own death, 46.7% time MDD and 70.0% of those with only 12-month MDD, while
wanted to die, and 39.3% contemplated suicide; among those the mixed-features specifier characterized 15.5% of those with
with MDD only within the past year, 28.8%, 32.1%, and 22.8% lifetime MDD and 20.6% of those with only 12-month MDD.
had these thoughts, respectively (Table 3). Lifetime and Of participants who ever had MDD, 12.9% had all their

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 Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers Original Investigation Research

episodes characterized as bereavement (ie, started just after

Table 3. MDD Characteristics, Clinical Correlates, Specifiers,
someone close died and lasted <2 months); among partici- and Treatment
pants with only 12-month MDD, 15.5% had all their MDD epi-
Lifetime MDD Began
sodes characterized as bereavement. MDD in Past 12 mo
Table 5 lists clinical correlates of the anxious/distressed Characteristic (n = 7432) (n = 448)
specifier and the mixed-features specifier. Both specifiers were Age at onset of first episode, 29.05 (0.21) 39.14 (1.01)
mean (SE), y
significantly associated with earlier onset, number of epi- No. of lifetime episodes, mean (SE) 3.86 (0.10) 1.48 (0.05)
sodes, longest duration, severity, MDD treatment overall and
Duration of longest or only lifetime 25.90 (1.47) 8.81 (0.69)
by type, suicidality, and poorer SF-12v2 scores. Most of these episode, median (SE), wk
correlates remained significant when controlling for socio- 2-3 8.59 (0.38) 18.34 (1.96)
demographic characteristics and MDD severity. 4-8 12.26 (0.47) 20.01 (2.48)
9-12 9.24 (0.42) 14.72 (2.20)
13-25 11.66 (0.44) 20.97 (2.64)
26-51 (Half-year or more but <1 y) 14.17 (0.50) 25.96 (2.70)
Discussion
52-103 (Year or more but <2 y) 14.40 (0.42) NA
In 2012-2013, over 10% of US adults experienced DSM-5 MDD ≥104 (≥2 y) 29.68 (0.81) NA
in the prior 12 months, and over 20% experienced lifetime DSM-5 DSM-5 Specifiers and Bereavement, % (SE)
MDD. Major depressive disorder was associated with other psy- Severitya
chiatric disorders, especially generalized anxiety disorder and Mild (5 symptoms) 10.80 (0.41) 14.38 (1.98)
borderline personality disorder, associations found in previous
Moderate (6-7 symptoms) 39.67 (0.78) 38.81 (3.11)
studies.5,46-49 On average, episodes lasted more than 6 months.
Severe (8-9 symptoms) 49.53 (0.72) 46.81 (2.97)
Few were mild; most were moderate or severe. Of those with
Anxious/distressed specifiera 74.63 (0.61) 70.04 (2.22)
MDD, approximately 75% had the anxious/distressed specifier
Mixed-features specifierb 15.53 (0.63) 20.63 (2.36)
during their worst episode, while 15.5% had the mixed-features
Bereavement (DSM-IV)c 12.91 (0.46) 15.50 (1.80)
specifier during any episode. Only among 12.9% did all MDD epi-
Lifetime Treatment
sodes begin just after someone close died and last less than 2
Any treatment for MDD, % (SE) 69.42 (0.71) 51.93 (3.15)
months. Almost 70% with lifetime MDD reported lifetime treat-
Medication 53.11 (0.80) 36.93 (2.98)
ment for MDD; more than 13% attempted suicide during their
worst episode. Major depressive disorder was associated with Talk therapy with a professional 62.49 (0.79) 44.01 (2.95)

impaired functioning, especially in severe cases. Therefore, MDD Nonprofessional organized support 14.93 (0.53) 5.77 (1.13)

remains a widespread, serious US health problem. Emergency department 10.15 (0.47) 3.82 (1.04)
Demographic correlates were consistent with previous Hospitalized overnight or longer 11.84 (0.46) 2.60 (0.88)
surveys.2,5 Major depressive disorder was more prevalent among Age at first MDD treatment, 31.98 (0.29) 40.19 (1.54)
mean (SE), y
women, possibly related to gender discrimination,50 differen-
Duration from onset to first treatment, 47.54 (1.63) 01.18 (0.32)
tial exposure to childhood or adult adversities51 such as sexual mean (SE), mo
abuse,52 differential exposure to a complex host of different de- Suicidality, % (SE)a
velopmentally organized risk factors,53 or biologically differ- Thought a lot about one’s own death 34.78 (0.72) 28.79 (2.69)
ent stress responses.54 Greater prevalence was found among Wanted to die 46.74 (0.91) 32.05 (2.45)
younger adults and among white adults and Native American Thought a lot about suicide 39.31 (0.80) 22.75 (2.19)
adults than among African American, Asian American, and His- Attempted suicide 13.62 (0.58) 4.77 (1.09)
panic adults. Reasons for racial/ethnic differences in MDD re-
Abbreviations: MDD, major depressive disorder; NA, not applicable.
main unclear55 but do not reduce the importance of treatment a
When mood or anhedonia was at its worst.
for minorities, among whom treatment disparities remain.56 b
Mixed features do not meet full criteria for either mania or hypomania and
This study found association between low income and could characterize any MDD episode.
12-month MDD, consistent with other studies conducted within c
All or only episodes began just after someone close died and were less than 2
the last 3 years.1,57,58 While this association could be due to months in duration.
depression-impaired functioning leading to lower income, the
increases in depression and suicide that have accompanied
growing income inequality suggest that the relationship of low ciations by a factor of approximately 50%, although ORs re-
income to MDD is due to stress from inadequate financial re- mained statistically significant. These findings reflect the
sources for life necessities or pessimism about improved future underlying association of anxiety disorders with each other and
prospects.1 If so, while treatment can benefit those with MDD, MDD within the internalizing component of the transdiagnos-
prevention may require change in larger societal processes.59,60 tic spectrum.61
Major depressive disorder was associated with anxiety dis- M a j o r d e p re s s ive d i s o rd e r w a s a s s o c i ate d w it h
orders, particularly panic disorder and generalized anxiety dis- SUDs, particularly drug disorders, as found previously for
order, as well as with PTSD. Associations were strongest with cannabis,40,62 nonmedical prescription opioids,5,57,63 and
models adjusting only for sociodemographic characteristics. drug use disorders.41 With increasingly positive attitudes
Further adjusting for psychiatric comorbidity reduced asso- toward substance use64-66 and increasing rates of adult SUDs

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 Research Original Investigation Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers

Table 4. MDD and SF-12v2 Norm-Based Disability Scoresa

Mental Health Social Functioning Role-Emotional Functioning Mental Component Summary

Mean (SE) Mean (SE) Mean (SE) Mean (SE)
Variable Score P Value Score P Value Score P Value Score P Value
MDD in Past 12 mob
No lifetime MDD 53.12 (0.09) NA 51.65 (0.09) NA 49.31 (0.13) NA 52.16 (0.09) NA
(n = 28 877)
Any MDD (n = 448) 42.29 (0.71) <.001 43.85 (0.80) <.001 42.94 (0.70) <.001 42.10 (0.76) <.001
Severity of worst episode
in past 12 moc
Mild (5 symptoms) 47.25 (1.74) .004 46.62 (1.53) .003 47.82 (1.46) .62 47.19 (1.72) .02
(n = 65)
Moderate (6-7 44.46 (1.06) <.001 46.96 (1.05) .002 44.81 (0.96) .003 44.41 (1.00) <.001
symptoms) (n = 188)
Severe (8-9 symptoms) 38.95 (1.01) <.001 40.42 (1.19) <.001 39.90 (1.08) <.001 38.61 (1.14) <.001
(n = 218)
MDD in Past 30 dd
No lifetime MDD 53.12 (0.09) NA 51.65 (0.09) NA 49.31 (0.13) NA 52.16 (0.09) NA
(n = 28 877)
Single episode of MDD 39.59 (0.89) <.001 40.15 (0.93) <.001 38.52 (0.89) <.001 38.80 (0.83) <.001
extending into past month
(n = 411)
Mild (5 symptoms) 45.52 (2.78) .01 43.86 (3.27) .03 44.63 (2.73) .29 44.75 (2.89) .03
(n = 35)
Moderate (6-7 43.32 (1.21) <.001 45.30 (1.39) <.001 42.62 (1.15) <.001 43.15 (1.13) <.001
symptoms) (n = 143)
Severe (8-9 symptoms) 36.58 (1.12) <.001 36.59 (1.20) <.001 35.26 (1.09) <.001 35.42 (1.08) <.001
(n = 233)
Abbreviations: MDD, major depressive disorder; NA, not applicable; SF-12v2, antisocial personality disorder).
version 2 of the 12-Item Short Form Health Survey, b
Includes participants whose only episodes of MDD occurred in the past 12
a
Tests for differences with participants who had no lifetime MDD using linear months. Participants with episodes before the past 12 months were excluded
regression models, adjusted for sociodemographic characteristics (sex, from the analysis.
race/ethnicity, age, marital status, educational level, family income, urbanicity, c
Worst lifetime episode, defined as when mood was lowest or anhedonia was
and region) and other DSM-5 psychiatric disorders (alcohol use disorder, any at its worst.
drug use disorder, nicotine use disorder, panic disorder, agoraphobia, social d
Participants with multiple episodes of MDD and those whose single episode
phobia, specific phobia, generalized anxiety disorder, posttraumatic stress
ended before the past 30 days were excluded from the analysis.
disorder, schizotypal personality disorder, borderline personality disorder, and

and associated problems, 24,41,42,67-69 MDD comorbidity treatment.12,84 Studies should examine the demographic and
with SUDs remains a substantial public health 24,70 and clinical correlates of treatment and whether these factors are
economic16 burden. Evidence suggests that efforts to self- changing over time.
manage depression with cannabis are increasing71-75 (also This study contributes novel information about the epi-
Aaron L. Sarvet, MPH, written communication, January 2, demiology of 2 new DSM-5 major depression specifiers. That
2018) despite lack of evidence that cannabinoids are almost three-quarters of those with MDD had the anxious/
effective for this purpose 76,7 7 ; prospectively, cannabis distressed specifier confirms clinical observation and
worsens the course of depressive disorders.78 The likelihood research.46 We also provide the first nationally representa-
of treatment for depression is reduced in those with SUDs.79 tive information on demographic and clinical correlates of
However, dual-focused treatment is more effective when these specifiers. In patient samples, the anxious/distressed
2 disorders are present. 70 Therefore, clinician education specifier predicts a poor course of MDD.20,21 Clearly, more
and training in dual-disorder screening and treatment information on both specifiers is needed.
should be prioritized.
Of participants with lifetime DSM-5 MDD, 69.4% re- Limitations
ceived any treatment for their disorder, slightly higher than in This study has limitations. The study was cross-sectional;
the 2001-2002 NESARC (60.6%).5 This result is higher than the associations do not necessarily indicate causal relationships.
treatment rate in one recent study80 that used less specific mea- Lifetime associations of MDD with other psychiatric disor-
sures to identify depression but is consistent with rates from ders may be influenced by recall bias, although this possibil-
other studies published in the last 4 years.81,82 The NESARC- ity is less likely for 12-month findings, which were similar. Some
III treatment rates are plausible given the extent of direct-to- groups were not included (eg, homeless and prisoners), so
consumer advertising of antidepressants83 and widespread dis- NESARC-III may underestimate MDD prevalence. Also, as
tribution through primary care. 79 However, with 30% of noted,85 DSM-5 left differentiating MDD from normal bereave-
patients still untreated, improved treatment delivery for MDD ment to clinical judgment. The NESARC-III interviews were
remains needed; much distress or social or economic burden conducted by lay interviewers, precluding clinical judg-
is avoidable through behavioral and pharmacologic MDD ments. Therefore, all cases of MDD beginning shortly after the

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 Table 5. Associations Between MDD Specifiers, Clinical Correlates, Treatment, and Impaired Functioning in 7432 Participants With Lifetime MDDa

Anxious/Distressed Specifierb Mixed-Features Specifierc

P Value P Value
No Yes No Yes
Characteristic (n = 1901) (n = 5531) Model 1d Model 2e Model 3f (n = 6235) (n = 1197) Model 1d Model 2e Model 3f

jamapsychiatry.com
Age at onset of first episode, mean (SE), y 31.16 (0.35) 28.34 (0.23) <.001 <.001 <.001 29.60 (0.22) 26.11 (0.47) <.001 .009 .17
No. of lifetime episodes, mean (SE) 2.70 (0.12) 4.26 (0.13) <.001 <.001 <.001 3.69 (0.12) 4.81 (0.36) .006 .009 .09
Duration of longest or only lifetime episode, 22.60 (1.19) 33.43 (2.99) .001 .002 .08 25.70 (0.12) 51.41 (0.39) .002 <.001 <.001
median (SE), wk
DSM-5 Specifiers, % (SE)
Severitya
Mild (5 symptoms) 23.53 (1.17) 6.48 (0.41) 12.06 (0.47) 3.93 (0.55)
Moderate (6-7 symptoms) 53.53 (1.25) 34.96 (0.87) <.001 <.001 NA 42.12 (0.80) 26.32 (1.55) <.001 <.001 NA

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Severe (8-9 symptoms) 22.95 (1.16) 58.57 (0.90) 45.82 (0.74) 69.75 (1.61)
Anxious/distressed specifiera NA NA NA NA NA 71.29 (0.72) 92.83 (0.84) <.001 <.001 <.001
Mixed-features specifierb 4.39 (0.47) 19.32 (0.85) <.001 <.001 <.001 NA NA NA NA NA
Lifetime Treatment
Any treatment for MDD, % (SE) 61.06 (1.40) 72.27 (0.84) <.001 <.001 <.001 68.82 (0.79) 72.72 (1.83) .05 <.001 .02
Medication 42.26 (1.40) 56.80 (0.88) <.001 <.001 <.001 52.52 (0.85) 56.33 (1.92) .06 <.001 .05
Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers

Talk therapy with a professional 54.79 (1.49) 65.11 (0.92) <.001 <.001 <.001 61.99 (0.89) 65.22 (1.73) .10 <.001 .02
Nonprofessional organized support 9.87 (0.83) 16.65 (0.65) <.001 <.001 <.001 13.48 (0.55) 22.83 (1.52) <.001 <.001 <.001
Emergency department 5.06 (0.61) 11.88 (0.62) <.001 <.001 <.001 9.07 (0.46) 16.02 (1.38) <.001 <.001 .001
Hospitalized overnight or longer 6.23 (0.63) 13.75 (0.58) <.001 <.001 <.001 10.60 (0.49) 18.60 (1.41) <.001 <.001 <.001
Age at first MDD treatment, mean (SE), y 33.74 (0.48) 31.46 (0.34) <.001 <.001 .008 32.56 (0.29) 29.02 (0.62) <.001 .04 .17
Duration from onset to first treatment, 41.36 (3.83) 49.37 (1.73) .06 .09 .31 46.27 (1.83) 54.02 (4.28) .11 .04 .07
mean (SE), mo
Suicidality, % (SE)a
Thought a lot about one’s own death 19.97 (1.14) 39.82 (0.87) <.001 <.001 <.001 31.55 (0.80) 52.36 (1.58) <.001 <.001 <.001
Wanted to die 31.39 (1.45) 51.95 (1.08) <.001 <.001 .07 43.82 (0.91) 62.59 (1.76) <.001 <.001 <.001
Thought a lot about suicide 25.90 (1.23) 43.87 (0.96) <.001 <.001 .02 36.85 (0.83) 52.68 (1.77) <.001 <.001 .002
Attempted suicide 6.27 (0.74) 16.12 (0.70) <.001 <.001 <.001 11.97 (0.64) 22.59 (1.52) <.001 <.001 <.001

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SF-12v2 Score, Mean (SE)
Mental health 49.14 (0.31) 45.58 (0.19) <.001 <.001 <.001 46.93 (0.17) 44.05 (0.45) <.001 <.001 .006
Social functioning 49.55 (0.31) 45.82 (0.20) <.001 <.001 <.001 47.39 (0.19) 43.41 (0.42) <.001 <.001 <.001
Role-emotional functioning 47.72 (0.25) 44.20 (0.18) <.001 <.001 <.001 45.71 (0.18) 41.73 (0.42) <.001 <.001 <.001
Mental component summary 48.70 (0.29) 44.86 (0.17) <.001 <.001 <.001 46.40 (0.16) 42.75 (0.44) <.001 <.001 <.001
d
Abbreviations: MDD, major depressive disorder; NA, not applicable; SF-12v2, version 2 of the 12-Item Short Form Crude association.
Health Survey. e
Controls for sociodemographic variables (sex, race/ethnicity, age, marital status, educational level, family
a
Dichotomous row variables were modeled with logistic regression. Continuous row variables were modeled with income, urbanicity, and region).
linear or log-linear regression. f
Controls for sociodemographic variables (sex, race/ethnicity, age, marital status, educational level, family
b
During the lifetime episode when mood or anhedonia was at its worst. income, urbanicity, and region) and severity (mild, moderate, or severe).
c
Mixed features do not meet full criteria for either mania or hypomania and could characterize any MDD episode.

(Reprinted) JAMA Psychiatry April 2018 Volume 75, Number 4

Original Investigation Research

343
 Research Original Investigation Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers

death of someone close and remitting in less than 2 months reasons, 90 including methodological (eg, DSM changes
were characterized as bereavements, as was done in previous and unspecified survey effects) or substantive (eg, true
research.32 Other studies with relevant data could explore other increases, perhaps due to growing economic insecurities1 or
bereavement definitions. Our definition of the anxious/ other societal changes). Removing the bereavement exclu-
distressed specifier used a lower threshold than DSM-5, which sion in DSM-5 could have accounted for a small amount of
may have somewhat inflated the rates, an issue meriting fu- the prevalence increase in NESARC-III, but not for all of it by
ture study using different data. AUDADIS-5 used a slightly dif- any means. Studies examining methodological issues would
ferent algorithm for PTSD than the final DSM-5 definition, be valuable but are beyond the present scope. The likeli-
caused by a last-minute DSM-5 change that occurred too late hood that NESARC-III indicates valid increases in preva-
to implement in NESARC-III. Furthermore, we defined the lence is supported by the coherence of its results with 6
DSM-5 severity specifier by MDD symptom counts, which are other reports showing national increases in depression
straightforward, transparent, and replicable. This approach indicators1,2 (also Katherine M. Keyes, PhD, written commu-
enabled us to examine the association between these sever- nication, January 2, 2018) and suicidality.1,86,91,92 Based on
ity levels and SF-12v2 impairment scores. The DSM-5 also sug- this consistent picture of increasing depression indicators
gests incorporation of distress and impairment levels into the from multiple sources, we suggest that a prudent public
severity classifications but defines these vaguely. Future stud- health response would be to take these increases seriously
ies should develop brief, psychometrically sound measures of in formulating service delivery and policy rather than dis-
these domains for epidemiologic studies. Also, a response rate missing all of the findings, including the NESARC to
greater than 60.1% would be preferable. However, NESARC-III NESARC-III increases, on methodological grounds. Of some
response rates compare favorably with other recent national interest is whether participants diagnosed as having MDD in
health surveys.86-88 Finally, methodological studies address- NESARC and NESARC-III differ on severity indicators,
ing the addition of hopelessness and symptoms observed by including suicide attempts and hospitalization rates, a
others but not subjectively experienced would contribute use- useful topic to address in a future study.
ful information, as would future surveys using DSM-5 foot-
notes to MDD on bereavement to develop a new bereavement
instrument or incorporating complicated grief measures (eg,
those by Shear and colleagues).89 These limitations are offset
Conclusions
by the large sample, reliable and valid measures of psychiat- This study on MDD prevalence, demographic and psychiatric
ric and substance disorders, and rigorous study methods. correlates, disability, treatment use, and specifiers can in-
NESARC-III is also unique in providing current, comprehen- form policymakers, clinicians, and the public, as well as stimu-
sive national information on DSM-5 MDD and its specifiers that late investigation in several areas. While many with MDD re-
is unavailable from any other source. ceive treatment, others remain untreated. The high prevalence
The NESARC-III 12-month and lifetime MDD preva- of MDD among US adults is a substantial concern given the per-
lences (10.4% and 20.6%, respectively) are higher than sonal, public health, and economic burdens that the disorder
those of the 2001-2002 NESARC (5.3% and 13.2%, respec- imposes. Therefore, the need to reduce the prevalence of this
tively). Increases between surveys can occur for many disorder remains.

ARTICLE INFORMATION with supplemental support by the National Institute 3. Spijker J, Graaf R, Bijl RV, Beekman AT, Ormel J,
Accepted for Publication: December 14, 2017. on Drug Abuse, and by the Intramural Research Nolen WA. Functional disability and depression in
Program of the NIAAA. Support is also the general population: results from the
Published Online: February 14, 2018. acknowledged from the New York State Psychiatric Netherlands Mental Health Survey and Incidence
doi:10.1001/jamapsychiatry.2017.4602 Institute (Dr Hasin), from the State University of Study (NEMESIS). Acta Psychiatr Scand. 2004;
Author Contributions: Drs Hasin and Grant had full New York (Dr Meyers), and from grant 110(3):208-214.
access to all of the data in the study and take K01DA037914 from the National Institutes of 4. Kessler RC, Bromet EJ. The epidemiology of
responsibility for the integrity of the data and the Health (Dr Meyers). depression across cultures. Annu Rev Public Health.
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collection, management, analysis, and Epidemiology of major depressive disorder: results
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