Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

Table 4 Changes to the diagnostic guidelines for bipolar depression in the International Classification of Diseases, 11^th version

	ICD-11-CDDR	DSM-5	ICD-10
Core symptoms	One of the following: Depressed mood or diminished interest or pleasure	One of the following: Depressed mood or loss of interest or pleasure	Two of the following: Depressedmood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability, diminished activity, and marked tiredness
	Reported or observed changes	Reported or observed changes
	Change from usual functioning	Change from usual functioning
Accessory symptoms	Eight symptoms including the new symptoms of hopelessness, fatigue, and agitation/retardation	Seven symptoms: Hopelessness is not included, but fatigue and psychomotor changes are included	Seven symptoms: Bleak and pessimistic views of future instead of hopelessness, no psychomotor changes or fatigue that are part of the core symptoms
	Other symptoms (unchanged) are inattentiveness, changes in sleep and appetite, low self-worth or guilt, and suicidal ideation	Other symptoms are the same as in the ICD-11	Other symptoms are the same as in the ICD-11
Persistence and duration	Symptoms occur most of the day, nearly every day during a minimum period of two weeks	Symptoms occur most of the day, nearly every day during a minimum period of two weeks	Minimum duration of two weeks usually required but shorter periods suffice if symptoms are unusually severe and of rapid onset
Diagnostic threshold	Five out of ten symptoms	Five out of nine symptoms	Four out of ten symptoms
Functional impairment	Part of the diagnostic criteria	Part of the diagnostic criteria	Used to rate severity
Exclusions	Depression secondary to medical conditions or substance use and mixed episodes; mixed episodes excluded	Depression secondary to medical conditions or substance use; diagnosis of depressive episodes with mixed features possible	No clear exclusions
Bereavement exclusion	Operationalized definition present	Only an explanatory note that advises the use of clinical judgement in such instances	Not mentioned as a part of the diagnostic guidelines
Severity ratings	Mild, moderate and severe depressive episodes based on symptom-severity and functional impairment; no requirement for a minimum number of symptoms	Grading similar to the ICD-11; no requirement for a minimum number of symptoms	Grading similar to the ICD-11, but a minimum number of symptoms required for grading different levels of severity; clinical judgement also advised
Psychotic symptoms	Moderate depression with psychotic symptoms is a new category	Mood congruent and incongruent symptoms distinguished	Mood congruent and incongruent symptoms distinguished
Description of melancholia	Descriptions similar to the ICD-10, but no requirement for a minimum number of symptoms	Description more elaborate; a minimum of four symptoms required	Descriptions similar to the ICD-11; a minimum of four symptoms required
Additional specifiers	With prominent anxiety, panic attacks, chronicity, seasonal pattern, puerperal onset	Similar to the ICD-11; additionally mixed features, atypical features, and catatonia	No other specifiers

DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5^th edition[6]; ICD-10: International Classification of Diseases, 10^th version[14]; ICD-11-CDDR: International Classification of Diseases, 11^th version, Clinical Descriptions and Diagnostic Requirements[8].