Major Depressive Disorder: From Accurate Diagnosis to Effective Treatment

Abstract

This article critically examines the diagnostic criteria for Major Depressive Disorder as presented in the DSM-5-TR, with a particular focus on the symptoms of ‘depressed mood’ and ‘psychomotor agitation or retardation’. While existing literature in both humanistic psychology and phenomenological psychopathology has highlighted the limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptom-based and externalist model, this article contributes to the discussion by grounding its critique in first-person accounts and by analysing how the aforementioned symptoms, as conceptualised in the DSM, flatten and obscure the lived experience of depression. It argues that the symptom of ‘depressed mood’ is conceptually circular and diagnostically imprecise, while ‘psychomotor agitation or retardation’, insofar as it is diagnosed based on being ‘observable by others’, fails to capture the phenomenological nuances of the experience, such as the loss of volition. Such limitations point to the need for an approach that takes seriously the lived, first-person dimensions of depression, rather than reducing the experience to externally verifiable signs. In this regard, by advancing a symptom-specific critique grounded in phenomenology, this article calls for a more person-centred approach to psychiatric diagnosis, one that considers the role of first-person experience. Finally, this article reflects on the implications of a person-centred approach for the evaluation of psychotropic medication, especially with regard to experiential phenomena such as depersonalisation and derealisation.

Keywords

phenomenology psychopathology major depressive disorder DSM subjective experience

Introduction

Major Depressive Disorder (MDD) is a complex and multifaceted condition that affects about 300 million people worldwide (Global Burden of Disease Collaborative Network, 2020). This article critically examines the diagnostic framework for MDD in the Text Revision of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association [APA], 2022), the most widely used classificatory system in contemporary psychiatry. Despite its widespread impact, the diagnostic framework of the DSM-5-TR has faced significant criticism for its oversimplification of mental disorders (Maj, 2011), including MDD (Herrman et al., 2022). Such critiques are grounded in both humanistic psychology and phenomenological psychopathology, which have long argued that mental illness must be understood not merely through behavioural indicators or through a checklist of symptoms but through the structures of experience that give the depressive experience its distinctive character (Fuchs, 2010; May, 1961; Ratcliffe, 2015; Rogers, 1970). An overarching worry with diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) is that ‘the assessment of subjective experience is nearly excluded on the theoretical level and undervalued on the pragmatic level, with detrimental consequences for the validity of psychiatric diagnosis, empirical research and therapeutic purposes’ (Fuchs, 2010, p. 268). In this regard, there is a profound lack of engagement with the lived realities of individuals who are experiencing mental distress as the DSM is ‘primarily a tool developed for professionals to communicate about patients instead of with patients’ (Veldmeijer et al., 2024, p. 1). These concerns include the superficiality of certain symptoms described in the DSM-5-TR, such as depressed mood, and the exclusion of fundamental experiential dimensions of depression from the diagnostic criteria, such as distorted experiences of one’s own body and time, or feelings of detachment from oneself, other people, and the world, often conceptualised in terms of depersonalisation and derealisation.

Critiques of the DSM’s neglect of subjective experience have been extensively developed within phenomenological and humanistic traditions (Ghaemi, 2009; Nordgaard et al., 2012; Parnas & Zahavi, 2002; Schwartz & Wiggins, 2010; Stanghellini & Fuchs, 2013). Previous phenomenological work has addressed disturbances within existential structures of depressive experience, such as disruptions in temporality (Fuchs, 2001; Moskalewicz, 2020), embodiment (Fuchs, 2005; Ratcliffe, 2015), and intersubjectivity (Fuchs, 2013; Stanghellini, 2016) and has criticised the flattening or omission of these experiential dimensions within the DSM. This article further enhances the critical approach by specifically examining two diagnostic criteria of MDD in more depth: depressed mood and psychomotor agitation or retardation. The analysis presented here is therefore symptom-specific and grounded in first-person accounts and phenomenological theory, with the aim of demonstrating how even widely accepted criteria risk obscuring key experiential realities of depression. In this context, this article aims to deepen the critique of diagnostic reductionism and open a pathway for integrating subjective experience into psychiatric diagnosis and psychopharmacological treatment.

It is a longstanding concern within humanistic psychology that the primarily psychiatric understanding favoured by the DSM neglects subjective experience in favour of observable, externally codified symptom clusters. Carl Rogers (1959, 1970), one of the founding figures of humanistic psychology, consistently emphasised the primacy of first-person experience both in understanding and treating psychological distress. The individual, Rogers highlights, is the best authority on their own mental distress, and mental distress itself often arises when there is a breakdown in the congruence between the person’s lived experience and their self-concept, which typically happens due to external conditions imposed by others. The DSM, however, frames psychological disorders such as depression in terms of outwardly measurable symptoms, thereby ignoring the personal meaning and context through which depression is lived. For instance, as will be further discussed, the DSM-5-TR’s (APA, 2022) criterion of ‘psychomotor agitation or retardation’ is problematic in that it is considered present only when it is ‘observable by others’ (p. 183), rather than when reported by the individual themselves. Such a diagnostic approach alienates the person from their own lived experience by imposing fixed categories that may fail to capture the way depression is actually lived and endured in everyday life. Rather than treating diagnosis as the classification of fixed traits, humanistic psychology promotes an approach that is relational and participatory – instead of objective and content-based – in this way co-exploring meaning and experience with the patient. This perspective is strikingly absent from the DSM-5-TR framework. Taking into consideration the subjective experience of the individual can offer a richer and more comprehensive understanding of MDD in a way that informs diagnostic accuracy and treatment efficacy. By acknowledging the complexity and variability in how depression manifests experientially in different people, a more holistic diagnostic framework can be developed.

In this regard, the guiding research question of this article is: In what ways do the DSM-5 criteria of ‘depressed mood’ and ‘psychomotor agitation or retardation’ fail to reflect the lived experience of depression, and how might phenomenological insights offer a more adequate understanding of these symptoms?

This article is organised as follows: First, an overview of the DSM-5-TR’s diagnostic framework for MDD is provided and the conceptualisation of depression through observable symptoms is discussed. Three core problems with this psychiatric model are then examined: (a) the pathologisation of ordinary sadness and behaviour, (b) the conceptual circularity and superficiality of the criterion ‘depressed mood’, and (c) the reductive framing of ‘psychomotor agitation or retardation’, which fails to encompass the full somatic and existential disruptions described in first-person accounts of depression.

Next, the article argues that the DSM’s neglect of subjective experience limits both diagnostic precision and therapeutic efficacy. As Herrman et al. (2022) have suggested, in a Lancet–World Psychiatric Association Commission article calling for a ‘united action on depression’, ‘the nature of the subjective experience of depression may not be fully conveyed by current diagnostic systems’ (p. 965). Drawing on phenomenological accounts (Kendler, 2016; Parnas & Zahavi, 2002), this article demonstrates how incorporating first-person experiential data into diagnosis can lead to a more nuanced understanding of the depressive experience. On this basis, the paper explores how a phenomenological approach to subjective experience can inform psychopharmacological treatment, particularly by clarifying how antidepressant medication influences one’s sense of self. As Kramer (1993) observed, such effects may either support or disrupt the individual’s experiential integrity, thereby alleviating or intensifying features of depression such as depersonalisation and derealisation. Finally, this article concludes by reflecting on the broader clinical implications of a phenomenologically informed, person-centred model of psychopharmaceutical care.

Before proceeding, it is essential to highlight what guided the selection of texts and sources in this article. Given the breadth and complexity of the phenomenological tradition, and since this article is not a systematic literature review, it is beyond the scope of this article to provide a systematic organisation of depressive experience into all existential structures such as temporality, spatiality, intersubjectivity, and embodiment. Instead, a more modest and targeted approach is adopted, and the selection of first-person accounts is guided by a focused conceptual aim: to examine how specific DSM-5-TR symptoms (particularly ‘depressed mood’ and ‘psychomotor agitation or retardation’) fail to capture core aspects of lived experience in MDD. In this regard, first-person accounts of depression and phenomenological analyses that engage directly with these two diagnostic criteria are deliberately prioritised. The inclusion of the first-person accounts, as well as of the phenomenological literature, was based on three criteria: (a) direct engagement with subjective or experiential features of depression, (b) relevance to diagnostic discourse or psychiatric framing, and (c) contribution to the phenomenological understanding of the depressive experience. As such, this article offers a targeted contribution by examining how even widely accepted diagnostic criteria flatten or omit core experiential structures of depression, and by suggesting that these shortcomings can be addressed by prioritising the individual’s subjective experience, thereby contributing to more effective treatment. The focused scope of this article is intentional and aims to bridge phenomenological insight with the practical realities of psychiatric diagnosis and treatment.

The Psychiatric Understanding of Depression

The DSM holds significant sway as the leading classification manual in the world today. As Horwitz and Wakefield (2007) have noted, the DSM definitions ‘have become the authoritative arbiter of what is and is not considered mental disorder throughout our society’ (p. 7) and have been used widely ‘in epidemiological studies of disorder in the community, in research studies of treatment outcomes, in marketing of antidepressant medication, in preventive efforts in schools, in screening in general medical practice [and] in court proceedings’ (p. 7). Currently, the 5th version of the DSM is in use – first published in 2013 – and particularly the 2022 Text Revision (DSM-5-TR). The DSM-5-TR (2002) defines a mental disorder as follows:

A mental disorder is a syndrome characterised by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behaviour (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual. (p. 14)

Regarding MDD, the DSM-5-TR classifies MDD under the category of depressive disorders, which also includes ‘mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder’ (p. 178). What defines the category of depressive disorders, according to the DSM-5-TR, is ‘the presence of sad, empty, or irritable mood, accompanied by related changes that significantly affect the individual’s capacity to function (e.g. somatic and cognitive changes in MDD and persistent depressive disorder)’ (p. 178). The DSM-5-TR specifically provides a list of nine symptoms for the diagnosis of MDD.¹ In order to be diagnosed with MDD, the individual must experience five or more symptoms, out of these nine, during the same 2-week period. At least one of the symptoms must be ‘depressed mood’ (p. 184) or ‘markedly diminished interest or pleasure in all, or almost all, activities’ (p. 184), which must be present ‘for most of the day nearly every day’ (p. 184).

In examining the criteria for the diagnosis of MDD in the DSM-5-TR, certain issues with particular symptoms can be identified that are rooted in the neglect of the individual’s subjective experience. In what follows, I discuss (a) how the DSM-5-TR criteria pathologise ordinary behaviour, (b) the problem of circularity with the core criterion of ‘depressed mood’ which defines depression through a term that is itself part of the phenomenon under description, and (c) the omission of the phenomenological dimensions of the symptom of ‘psychomotor agitation or retardation’. In exploring these issues, I consider how the diagnostic criteria for MDD could be revised to incorporate the subjective experience of depression, including the individual’s experience of taking psychotropic medication and its perceived clinical utility. In this regard, revising the psychiatric understanding of MDD to include the lived experience of the individual can encourage a person-centred approach to mental health care and drug prescription.

The Pathologisation of Ordinary Behaviour

In examining the DSM-5 diagnostic criteria of depression, there emerges the question of what exactly the DSM-5 diagnostic criteria represent and whether they are successful in picking out the unique experiential aspects of depression. As Horwitz and Wakefield (2007) have argued, the DSM-5 depression criteria make it possible for clinicians to incorrectly diagnose patients with MDD, leading to an ‘overdiagnosis’ (p. 163) of depression cases. This is because when following the current criteria and guidelines for diagnosing MDD, clinicians are unable to distinguish between sadness ‘with cause’ (p. 71) – that is, normal sadness – and ‘sadness without cause’ (p. 71) – that is, abnormal sadness. According to Wakefield (2013), therefore, the essential question that clinicians must address when making a diagnosis for an individual is the following:

Is there a sufficient cause in the individual’s circumstances to explain the individual’s depressive symptoms as likely a normal reaction to loss or stress, or are the symptoms so severe or enduring or independent of context to be better explained as a pathological failure of normal mood regulation? (p. 30)

Wakefield argues for the contextualisation of symptoms within the individual’s background when making an assessment. In this regard, he criticises the DSM criteria for failing to distinguish between ordinary and pathologised behaviour, a shortcoming that can ultimately result in treating normal emotional responses with psychotropic medication. Complementing this critique, Veldmeijer et al. (2024) highlight that ‘there are no laboratory tests or biological markers to set the boundary between ‘normal’ and ‘pathological’, thus, it cannot confirm or reject the presumed pathologies underlying the DSM classifications’ (p. 2). This further highlights the potential problems with the (yet unfulfilled) validity of DSM results (Hyman, 2010; Scull, 2021), since without external markers or clear conceptual criteria, the reliability of diagnosis does not guarantee its accuracy.

In this context, according to Allen Frances (2013), Chair of the DSM-IV Task Force, the failure to distinguish between normal behaviour and pathologised behaviour has caused the ‘medicalisation of ordinary life’ (p. 1). One example that demonstrates this, according to Frances, concerns the removal of the ‘bereavement exclusion’ in the transition from the DSM-IV (APA, 1994) to the DSM-5 (APA, 2013). Under the DSM-IV diagnostic criteria, individuals who exhibited symptoms of MDD in the first few weeks following the death of a loved one could not be diagnosed with MDD. Under the DSM-5 criteria, however, such individuals are no longer excluded from being diagnosed with MDD. Frances (2013) contends that the removal of the ‘bereavement exclusion’ has led to the pathologisation of one’s ordinary response to loss and sadness. More broadly, the expansion of diagnostic boundaries by reframing grief and other life stresses as medical disorders ‘represents medical intrusion on personal emotions [which] adds unnecessary medication and costs, and distracts attention and resources from those who really need them’ (Dowrick & Martin, 2015, p. 20). In this regard, antidepressant medication might be prescribed where it is not essential, raising significant risks for its effects, particularly ‘in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions’ (Brisnik et al., 2024, p. 1). Hence, examining the context in which a particular symptom arises, as well as how it is experienced by the individual, is critical in order to inform clinical practice and thereby ensure that medication is prescribed only when necessary. This also extends to the consideration of possible adverse effects that appear in the individual’s experience, resulting from psychotropic drugs. In what follows, I will discuss specific issues with the psychiatric understanding of MDD as outlined in the DSM, with reference to the symptoms of ‘depressed mood’ and ‘psychomotor agitation or retardation’, and the implications that the omission of the subjective experience of the individual can have for diagnosis and treatment.

The Problem With ‘Depressed Mood’

In examining whether the DSM-5 accurately depicts the complexity of the experience of MDD, particular issues arise in regard to the representativeness of the diagnostic criteria – such as ‘depressed mood’, which will be examined in this section – and how well these capture specific experiential features of depression. As one of the two core depression symptoms in the DSM-5, ‘depressed mood’ is present in the majority of depression diagnoses – more precisely, in 93.7% (Zimmerman et al., 2015) to 98.2% (Park et al., 2017) of cases. ‘Depressed mood’ is a highly superficial and brief term for an experience which is extremely diverse and complex, and which varies, sometimes to a great extent, amongst different individuals.

The Circularity of the Term ‘Depressed Mood’

Within the context of a diagnostic manual, it is unclear what aspect of the experience of depression the term ‘depressed mood’ aims to capture, and in what way ‘depressed mood’ is to be distinguished from depression as the disorder that it is designed to diagnose. As Ratcliffe (2015) highlights, ‘the suggestion that we identify something called ‘depression’ by identifying something else called ‘depressed mood’ is uninformative, as it is unclear what a depressed mood is’ (p. 5). On these grounds, incorporating ‘depressed mood’ as a core symptom of depression risks circularity, insofar as depression is defined in terms of a feature that is itself part of the phenomenon being described.

It is thus not immediately clear what the DSM-5 diagnostic criteria aim to capture when designating ‘depressed mood’ as a core symptom of the depressive experience, nor does the DSM-5 provide sufficient guidance on what qualifies as ‘depressed mood’. As Fernandez (2016) notes, DSM-5 offers ‘very little instruction on how to go about deciding which other affective phenomena or changes in mood actually count as “depressed mood”’ (p. 95), which results in ambiguity as to whether the presence of ‘depressed mood’ should be regarded as pathological.

In this regard, a closer examination of how individuals describe depressed mood can clarify the experiential richness of depression. Such inquiry moves beyond a simplistic yes-or-no response and instead uncovers the specific textures of the individual’s condition. As Nordgaard et al. (2013) explain,

When a patient says ‘I feel depressed, sad, or down’, such statement may, if further explored, be found to indicate a bewildering variety of experiences with varying affinities to the concept of depression: not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychic anxiety, varieties of depersonalisation, and even voices with negative content, and so forth. . .It therefore requires a careful interviewing effort to specify the salient profile of the presented distress. Taking a confirmatory or disconfirmatory answer at face value endangers the validity of the response. (p. 360)

It is therefore essential to contextualise MDD symptoms as they are experienced by the individual. In this regard, ‘depressed mood’ is not conceptualised as arising from an introspective act (i.e. through a self-report such as ‘I am in a depressed mood’ or ‘I am not in a depressed mood’), but as arising from a broader experiential context. In other words, depression is experienced as depressed mood, thereby making it virtually impossible to establish a distinction between a mood (i.e. depressed mood) and a condition (i.e. MDD) in the context of the DSM-5. As Nordgaard et al. (2013) further note,

[M]ood is not an isolated mental object, easily dissociated from its experiential context and identified in an act of introspection (i.e. converted to a reportable symptom). It is, so to say, a pregiven and pre-reflective manner of our experiencing, something that, to the one who lives, is almost too immediate and encompassing to be recognised as such. (p. 360)

Building on this, Rogers (1970) underscores the limitations of a symptom-based diagnostic model, such as the DSM, when it relies too heavily on the explicit self-reporting of internal states like ‘depressed mood’. Individuals may not experience or articulate their distress in such direct or readily recognisable terms, and this can lead the DSM to overlook certain presentations of depression, particularly in cases where a person does not explicitly identify or label their experience as depression.

This is especially pertinent given the large number of first-person accounts of depression which highlight that the experience of depression is incommunicable to others due to its fundamentally distinct nature when compared to ordinary experience (e.g., Kristeva, 1980; Manning, 1994; Shaw, 2001; Styron, 2004; Wallace, 1998; Wolpert, 1999).

In this regard, strictly adhering to diagnostic checklists may lead to false negatives, overlooking the depth and reality of emotional suffering that falls outside their predefined categories. As Rogers (1970) puts it, from within the psychiatric perspective, ‘[i]nternal problems can be perceived and communicated about as entirely external. [The patient] is not saying ‘I am depressed’ or even ‘I was depressed’. Her feeling is handled as a remote, unowned object, entirely external to self’ (p. 134). Thus, even in the absence of a report of ‘depressed mood’ – which is, as already mentioned, one of the DSM’s core symptoms for diagnosis – the individual may still be undergoing a form of intense emotional suffering, but in a way that resists standardised categorisation.

Hence, it is problematic when a core symptom of depression is labelled as depressed mood, for it is not explained what ‘depressed mood’ is or whether the underlying features of the experience of ‘depressed mood’ necessarily call for the pathologisation of that particular experience within a particular context. Accordingly, it is also problematic that the role of the social environment and context is neglected, causing a lack of clinical understanding of depression (Gómez-Carrillo et al., 2023). Recent research has increasingly recognised that the social environment and its determinants play a vital role in the development, progression, and resolution of mental distress (Alon et al., 2024; Huggard et al., 2023; Kirkbride et al., 2024). As Pearce (2014) has put it, ‘the uncritical use of diagnostic checklists puts clinicians and researchers at risk of an overconfident and decontextualised approach to diagnosis’ (p. 515). In this regard, there is merely a surface-level confirmation of criteria that is being mistaken for a meaningful understanding of depression, as it bypasses the context-sensitive work that is required to understand how an individual experiences depression.

Further Insights From Humanistic Psychology and Phenomenology

The aforementioned concerns regarding the lack of contextual sensitivity and the reliance on superficial symptom checklists echo fundamental critiques raised by pioneers of the humanistic approach to psychotherapy, such as Rollo May (1961, 1983), who advocated for a therapeutic process grounded in the unfolding of meaning through the therapist-patient relationship. A genuine understanding of a person’s condition, May notes, cannot emerge from checklist-based assessments, but from a dialogical process that allows the unique experience of the patient to reveal itself over time, particularly through the therapist-patient relationship. In this regard, diagnosis must not begin with the abstraction of symptoms, but with the formation of a relational and empathic space within which therapeutic insight can arise. This is not to happen from the identification of discrete clinical signs (i.e. through a checklist of symptoms), but from the co-construction of understanding and meaning through dialogue. As May puts it,

[I]f a person comes to me and he says, ‘Well, I’m very depressed’ first of all, I don’t ask him to focus on this or that. What I do is to build a relationship with him. That does tremendous things about the depression. [. . .] Once there’s a good relationship between you and a patient or a client then you can begin to get at the sources of depression. I think empathy is tremendously important in psychotherapy. It’s one of the most important, if not the most important, aspect of psychotherapy. (Schneider et al., 2009, p. 429)

What May wishes to highlight by emphasising the importance of the therapist-patient relationship is that reducing depression to isolated symptoms such as ‘depressed mood’ entails the risk of bypassing the depth and uniqueness of the patient’s condition and the very way in which they experience depression. As mentioned in the previous sub-section, we can understand this as being a consequence of the fact that diagnostic manuals, such as the DSM, rely on symptom abstraction rather than lived meaning, hence becoming prone to superficial categorisations that may misrepresent or flatten the condition being described. As Parnas and Gallagher (2015) highlight,

[the] ontological oversimplification [of the ‘psychiatric object’] has resulted in an epistemological naïveté with reliance on methodologies (e.g. the structured interview, checklists) that are unsuited and therefore unable to capture valid phenomenal (‘phenotypic’) distinctions concerning the patient’s experience, expression, and existence (p. 66; also see Nordgaard et al., 2012).

This brings us back to the diagnostic prominence of depressed mood in the DSM-5 and the kinds of reductive claims it encourages within clinical and research contexts. As Nordgaard et al. (2013) argue, construing depression primarily in terms of ‘depressed mood’ risks compromising the validity of clinical assessments by encouraging superficial or overly simplistic interpretations of complex experiences, leading to claims such as ‘depressed mood is the most reliable DSM-5 symptom to discriminate moderate depression from non-depression’ (Tolentino & Schmidt, 2018, p. 5). However, it is unclear what genuine epistemic or clinical value such a statement offers, since it merely reiterates a definitional point: that the presence of depressed mood is essentially what differentiates the presence of depression from its absence. In this regard, the claim is tautological rather than informative, as it would be incoherent to suggest the presence of depression in the absence of depressed mood, especially given that the latter is one of the core criteria for the diagnosis itself. In this context, as Freeman (2015) highlights in describing Heidegger’s (1962) phenomenological thesis, ‘human beings are always attuned through mood and never exist in moodless states’ (p. 446), further adding that ‘[b]eing attuned through mood cannot be severed or isolated from the context – the world, environment, and our particular situation in it – in which it manifests itself’ (p. 446). In this light, the concept of ‘depressed mood’ must be understood not as an isolated mental state that can be separated and treated abstractly from the depressed individual’s experience, but as a way of being-in-the-world that is shaped – and disclosed through – the situational context and one’s background. What is problematic with the DSM’s approach is that it treats the concept of ‘depressed mood’ as though it were detached from any existential grounding and as a discrete and measurable object, rather than as a constitutive characteristic of lived experience.

In this light, the DSM’s reductionist approach does not adequately capture the complexity of depression as it reduces the condition to a single mood descriptor, thereby failing to capture the depth of the depressed individual’s experience. This emphasises the need for a more nuanced and comprehensive understanding of depression that goes beyond superficial symptom categorisations, and takes takes into consideration the subjective experience of the individual. A diagnostic model that would better reflect the lived experience of depression, and which would make it possible to distinguish between normal behaviour and pathologised behaviour, would encourage a more patient-centred approach to mental health care.

The Problem With ‘Psychomotor Agitation or Retardation’

In going beyond superficial descriptions of depression symptoms and in examining the underlying experiential aspects of different depression criteria, we can illuminate the phenomenological dimensions of depression that these criteria aim at capturing. What calls for such an approach is that certain depression symptoms in the DSM-5 are not only superficially described (such as ‘depressed mood’, as discussed in the previous section) but are also incomplete and inaccurately depicted, such as in the case of ‘psychomotor agitation or retardation’.

On the Impossibility of Taking Action

To begin, the DSM-5-TR (APA, 2022) identifies ‘psychomotor agitation or retardation’ (p. 183) as one of nine possible symptoms of depression, of which at least five must be present ‘nearly every day’ (p. 183) for a diagnosis to be made. This can include reports by the individual that ‘even the smallest tasks seem to require substantial effort’ (p. 186). DSM-5-TR authors accurately highlight that psychomotor disruptions in depression entail the feeling that ordinary daily tasks can become effortful or unmanageable, such as getting out of bed, having a shower, or making a cup of tea. As the following first-person depression accounts highlight,

[E]verything seems like it takes so much more effort and sometimes even getting out of bed seems like such a monumental task that it can take hours to do. [Depression Questionnaire (DQ), #277]²

I feel tired, all the time. It doesn’t matter how much sleep I’ve had, I have no energy. I’m exhausted. It’s an effort to do anything. I feel so heavy, like gravity has increased or there’s an enormous weight on my shoulders, pushing me down. (Dowrick & Martin, 2015, p. 7)

It is, in fact, common in depression accounts to experience the disorder in terms of somatic disruptions, where individuals report their body as being ‘heavy’ or ‘lethargic’, characterised by a lack of vitality, hence communicating that ordinary activities require immense effort. However, these accounts only capture one dimension of the experience of depression and are not representative of the full range of somatic and psychomotor challenges that depressed individuals experience. As Ratcliffe (2015) points out, such cases ‘[do] not accommodate those cases where action seems not merely difficult but impossible, in a way that is not attributable solely to the amount of actual or perceived effort required’ (p. 5). In fact, a wide range of somatic disruptions in depression also incorporates cases in which everyday tasks are not merely challenging or effortful but impossible to carry out. As David Karp (1996) notes in his book Speaking of Sadness, where he provides an extensive analysis of interviews he conducted with depressed individuals: ‘depression, during its bleakest moments, utterly robs [depressed people] of concentration, motivation, and energy [and even] the simplest acts can become impossible’ (p. 30). First-person depression accounts do, in fact, portray this impossibility:

[W]hen you’re really depressed, you know, if you’re in your bedroom and someone said there’s a million dollars on the other side of the room and all you have to do is swing your feet over the edge of the bed, and walk over and get the million, you couldn’t get the million. I mean you literally couldn’t. (Karp, 1996, p. 30)

I wake up tired, amazed that I can even get out of bed. And often I can’t. . .I am trapped in my body as I have never been before. (Wurtzel, 1994, p. 2)

Sometimes [depression] comes with a despair that sucks all power of movement from my limbs and renders me incapable of the smallest decisions, so that all I can do is lie down with the curtains closed, facing the wall. (Merritt, 2009, p. 5)

As such, in certain cases, carrying out particular activities extends beyond the individual’s will to summon sufficient effort and instead enters the realm of the impossible. In this regard, a critical aspect of the depressive experience is omitted from diagnosis when the DSM-5-TR symptom of ‘psychomotor agitation or retardation’ (APA, 2022, p. 183) is conceptualised only in terms of situations where ‘even the smallest tasks seem to require substantial effort’ (p. 186), without acknowledging those in which action itself becomes virtually impossible.

A further concern with the DSM-5-TR’s conceptualisation of ‘psychomotor agitation or retardation’ lies in its requirement that the symptom must be ‘observable by others’ (APA, 2022, p. 183) in order to count as diagnostically valid. This emphasis on external, behavioural verification reflects a broader objectivist orientation in the DSM’s framework, in which symptoms are validated through what can be observed by the therapist rather than what is experienced subjectively by the individual. However, this is deeply problematic as the individual has primacy in conceptualising and validating their own mental distress (Rogers, 1959, 1970). For Rogers, the individual is the most reliable authority on their inner world, since only they can access the immediacy and depth of their own feelings and perceptions. What Rogers wishes to highlight is that therapeutic progress depends upon taking the client’s lived experience seriously, rather than subordinating it to external categories or professional interpretations.

In this regard, a deeper exploration of the nuances of the subjective experience of ‘psychomotor agitation or retardation’ can disclose the unique way in which this specific symptom is experienced, and can reveal its connection to other experiential dimensions of depression, even ones that are not caught by the DSM-5 symptoms, such as the temporal dimension. As Rollo May (1970) observes in Love and Will, depression involves a fundamental incapacity to actualise one’s will through the lived sense of an ‘I can’. This does not mean simply lacking the wish to act, but rather experiencing oneself as unable to act at all; for example, not merely wanting to get out of bed but finding oneself unable to do so. In these terms, May describes depression as ‘the inability to see or construct a future’ (p. 227), suggesting that what is disrupted is not merely physical movement, but the very structure of intentionality – that is, the person’s capacity to project themselves into meaningful possibilities. May further notes that will is always entwined with the future, not simply as a temporal category, but as a dimension of resolve – that is, of putting oneself ‘on the line’ in the form of commitments and projects. In other words, to will something is never just to wish or desire in the present; it is to orient oneself toward a future possibility and to stake one’s existence on bringing it about. For May, this makes will inseparable from the capacity to envision and pursue meaningful possibilities. This is precisely the capacity that becomes disrupted in depression (Ratcliffe, 2015). Empirical studies reinforce this point: Desai et al. (2019) found that individuals often described their condition in terms of profound ruptures to what they were living for – the collapse of life goals, relationships, and projects – which were no longer experienced as possible in the future.

The Problem With External Verification

Building on May’s insight, the DSM-5-TR’s characterisation of psychomotor agitation or retardation as something that must be ‘observable by others’ exemplifies a broader externalist bias that fails to grasp the existential significance of the depressive experience. What appears as slowness or agitation to the observer may, from within the person’s lived experience, be the embodied manifestation of a more fundamental breakdown – namely, a collapse in the sense of possibility or agency. In this regard, the symptom demonstrates the individual’s inability to inhabit a future-oriented mode of being, showing that it is not simply behavioural but existential, as the concept of meaningful future possibilities is significantly modified or even absent. Ratcliffe (2014, 2015) echoes May’s concerns, arguing that depression is marked by a pervasive sense of the impossibility of possibility itself, which is characterised by a loss of the sense that anything meaningful could emerge in the future. As Ratcliffe (2014) puts it,

Although things do still happen, the world offers no possibility of one’s future situation being significantly different from one’s current situation; there is no possibility of meaningful change and the world of depression thus seems eternal. (p. 273)

In this context, psychomotor retardation is not just a physiological symptom but the bodily sedimentation of a collapsed horizon of possibility, a profound transformation in how the future is experienced.

It is, therefore, problematic when diagnosis neglects subjective feeling in favour of observable criteria, as it risks alienating individuals from their own condition and disqualifying experiences that are present but may not be externally visible. In the context of somatic symptoms, this means that a person’s sense of bodily distress risks being excluded from diagnostic consideration simply because it does not manifest itself outwardly.

In this regard, with reference to the symptom of ‘psychomotor agitation or retardation’, the DSM-5, as a diagnostic manual, does not adequately account for the full range of experiential manifestations of the symptom. Thereby, by exploring first-person depression accounts, we can investigate the various dimensions in which depression is subjectively experienced, hence enriching the psychiatric understanding of depression and developing more efficient and effective therapeutic practices. As Parnas and Zahavi (2002) point out, the DSM’s approach has led to an insufficient consideration of subjective experience and an excessive focus on behavioural signs and symptoms due to its ‘lack of a suitable theoretical psychopathological framework to address human experience’ (p. 140). In this regard, they suggest, phenomenology can provide a comprehensive framework that enables the creation of precise portrayals of the subjective experiences associated with mental disorders, all while avoiding unwarranted metaphysical commitments or assumptions.

Revising the DSM-5 Diagnostic Criteria for Depression

Given the problems identified with the DSM approach, it is noteworthy that a study by Gayle and Raskin (2017) found counsellors acknowledged significant issues with the DSM (including overdiagnosis, underdiagnosis, and bias in labelling), yet almost 98% of them intended to use it. One reason for this, as Veldmeijer et al. (2024) note, is that the DSM is so deeply embedded in mental health care, society, healthcare funding, and research that it cannot simply be discarded. In fact, abandoning the DSM ‘may jeopardise access to care and impact insurance coverage for treatment and services that people with mental distress need’ (p. 10). Thus, given the aforementioned issues, the question arises as to how the DSM-5 diagnostic criteria might be revised to better capture the experiential nature of depression and develop improved treatment and therapy approaches.

In a review titled The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria, psychiatrist Kenneth Kendler (2016) explored how accurately the DSM-5 criteria for depression capture the phenomenology of depression experiences. By examining 19 textbooks of psychiatry and psychological medicine published from 1899 to 1956 and evaluating the extent to which the symptomatic criteria for MDD in the DSM-5 align with the clinical descriptions of depression within the post-Kraepelinian Western psychiatric tradition, Kendler concludes that ‘important features of major depression are not captured by DSM criteria’ (p. 771). More specifically, identified 18 signs and symptoms of depression mentioned in these textbooks. Kendler reported that ten of those signs and symptoms are ‘well described’ (p. 773) in the DSM-5 criteria for depression, and one (‘circadian effects’) satisfies the criterion for melancholia. In addition, Kendler notes, two of the signs and symptoms (‘mood changes’ and ‘changes in cognitive content’) are ‘partly covered’ (p. 773) by the DSM-5 criteria, and five signs and symptoms (‘changes in volition/motivation’, ‘slowing of speech’, ‘anxiety’, ‘other physical symptoms’, and ‘depersonalisation/derealisation’) are not included in the DSM-5 criteria at all.

As Kendler notes, certain experiential aspects of depression – such as depersonalisation and derealisation – are not included in the DSM-5, yet such descriptions often arise in first-person accounts of depression. For instance, in certain reports, individuals describe their experience of the world as fake, artificial, two-dimensional, or lacking depth (Church, 2003; Gaebler et al., 2013; Medford et al., 2005). Further exploring the intricacies and nuances of these descriptors can provide a deeper and more thorough understanding of the specificities of depression experiences. For example, it is important to examine whether experiencing the world as unreal also entails experiencing other people as unreal in a way in which ‘the line between ‘my world’ and a ‘shared world’. . .becomes blurred’ (Ratcliffe, 2015, p. 261) or whether experiencing the world as flat bears resemblance to claims that in depression the individual experiences the loss of ‘participation in the shared space of affective attunement’ (Fuchs, 2013, p. 228). In this regard, attaining a comprehensive understanding of depression necessitates not only grasping individual symptoms in isolation but also recognising their interconnectedness within the individual’s lived experience.

Solely relying on the DSM-5 criteria as if they fully capture the experiential nature of depression neglects the individual’s lived experience and promotes an incomplete and inaccurate understanding of the disorder, a tendency that has encouraged ‘the rise of diagnostic literalism’ (Kendler, 2016, p. 771). Diagnostic literalism refers to taking the DSM-5 criteria at face value while dismissing broader perspectives or additional dimensions of depressive experience. Kendler’s concern resonates with Nordgaard et al.’s (2013) aforementioned observation regarding the symptom of ‘depressed mood’, namely that ‘[t]aking a confirmatory or disconfirmatory answer at face value endangers the validity of the response’ (p. 360). By focusing exclusively on the DSM-5 criteria, the psychiatrist risks producing a narrow and impoverished understanding of depression, as central aspects of the experience are overlooked. As Kendler (2016) further notes,

The DSM symptomatic criteria for major depression do a reasonable but incomplete job of assessing the prominent clinical symptoms and signs of depressive illness. . .In their use as diagnostic criteria, this is unproblematic because, across all of medicine, diagnostic criteria are designed to index rather than exhaustively describe a clinical syndrome. That is, criteria need only to identify true cases with sufficient sensitivity and specificity, and not to reflect complete catalogues of important symptoms and signs. But it is problematic when we focus our teaching, our clinical work, and our research solely around DSM criteria. (p. 779)

In these terms, the DSM-5-TR depression criteria fail to capture the multitude of ways in which depression can be experienced, while the experience extends beyond the nine symptoms listed. As noted by Haroz et al. (2017) in their global systematic review of qualitative research on depression, ‘we do find it striking that some features, though nearly ubiquitous across populations, are not part of current DSM diagnostic criteria: loneliness, anger, crying, and somatic complaints’ (p. 160), supporting the claim that the current DSM-5 criteria do not fully encompass the lived experience of depression across different cultures and individuals. Phenomenological investigations of first-person depression accounts have demonstrated that other core aspects of the experience of depression concern intersubjective disruptions (Fuchs, 2013; Ratcliffe, 2018; Sofocleous, 2023), temporal disruptions (Fuchs, 2021; Lenzo & Gallagher, 2021; Moskalewicz, 2020), disruptions in embodiment (Fuchs, 2013; Wyllie, 2005), and feelings of depersonalisation/derealisation (Fortuna & Golonka, 2024; Ratcliffe, 2015). Taking this into account, revising the DSM-5 criteria should begin with a shift from a solely symptom-focused framework to one that also recognises the phenomenological depth of depression – that is, how it is felt, lived, and expressed by those who experience it.

In this regard, neglecting or dismissing experiential dimensions of depression that extend beyond the scope of the DSM-5 can hinder not only our understanding of depression but also research, teaching, and clinical work on depression. As Nancy Coover Andreasen (2007) – a DSM-III and DSM-IV Task Force member – has put it,

Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual person’s problems and social context and that is enriched by a good general knowledge of psychopathology. Students are taught to memorise DSM rather than to learn complexities from the great psychopathologists of the past. (p. 108)

Therefore, a narrow focus on the DSM diagnostic criteria leads to a diminished emphasis on a nuanced clinical assessment, which would take into consideration the individual contexts under which a symptom arises and the unique way in which it manifests within the individual’s experience. As Andreasen further adds,

First, the criteria include only some characteristic symptoms of a given disorder. They were never intended to provide a comprehensive description. Rather, they were conceived of as ‘gatekeepers’ – the minimum symptoms needed to make a diagnosis. Because DSM is often used as a primary textbook or the major diagnostic resource in many clinical and research settings, students typically do not know about other potentially important or interesting signs and symptoms that are not included in DSM. Second, DSM has had a dehumanising impact on the practice of psychiatry. History taking – the central evaluation tool in psychiatry – has frequently been reduced to the use of DSM checklists. DSM discourages clinicians from getting to know the patient as an individual person. (p. 111)

In this regard, omitting the subjective dimensions of the experience of depression ‘discourages clinicians from getting to know the patient as an individual person’ (p. 111) and can contribute to an incomplete and even inaccurate perspective of what the depressive experience entails. Given the DSM’s inability to interpret and understand experiences of depression by taking into consideration the context in which they arise, it becomes imperative to accentuate the diverse spectrum of subjective encounters that can characterise these experiences, not only in diagnosis but in psychopharmaceutical treatment as well.

Phenomenology and Psychopharmacology

The subjective experience of the depressed individual is crucial when a psychiatrist evaluates an individual’s condition, particularly in the context of psychopharmacological treatment. Sole reliance on the DSM-5 criteria during both the initial assessment and subsequent reassessments provides an incomplete, and at times misleading, picture of how depression manifests in lived experience. Such reliance risks reducing a complex existential condition to a checklist of observable signs, thereby neglecting the very dimensions of selfhood, temporality, and embodiment that are most profoundly affected in depression. In this respect, a genuinely person-centred approach to mental health care requires systematic attention to the individual’s first-person perspective throughout therapy, from diagnosis to long-term management (Dixon et al., 2016). Incorporating lived experience into psychiatric understanding (e.g., through a more phenomenologically sensitive reading of symptoms such as ‘depressed mood’ and ‘psychomotor agitation or retardation’) not only enriches diagnostic accuracy but also provides psychiatrists with a deeper grasp of the patient’s ongoing condition. This becomes especially significant in later stages of treatment, where the effects of antidepressant medication can alter not just observable behaviour but also the individual’s felt relation to their own self, other people, and the world.

For instance, psychiatrist Peter D. Kramer (1993), in his influential book Listening to Prozac, draws attention to how his patients, when taking the antidepressant Prozac, reported strikingly different effects on their sense of self – ranging from experiences of ‘self-enhancement’, to a feeling of ‘becoming oneself’, to the troubling sense of ‘losing oneself’. Such variations raise questions that cannot be adequately addressed within a purely biological or symptom-based psychiatric framework. As Kramer observes, it is far from clear how the medical professional could make sense of expressions such as ‘enhancing the self’, ‘becoming oneself’, or ‘losing oneself’ without reference to the subjective and existential dimensions of the patient’s experience. These phrases gesture towards fundamental shifts in identity, authenticity, and selfhood, which elude reduction to neurochemical explanations alone. In this regard, phenomenology provides a framework which enables us to interpret what it means, for example, to ‘lose oneself’, not merely as a metaphor, but as a lived disruption of one’s relation to self, world, and other people (Svenaeus, 2007). Such an interpretation allows us to move beyond descriptive psychiatry and towards an understanding of how medication transforms the very structures of selfhood and intersubjectivity in a shared world. In this regard, depression is not simply a matter of symptoms – understood as biological markers – but of ruptures in the fabric of life itself: individuals confront a declining sense of purpose and incapacity to reach valued goals, where what professionals call ‘depression’ is experienced instead as the collapse of what one lives for, such as their interpersonal relationships and a sense of a meaningful future (Desai et al., 2019). From this perspective, to ‘lose oneself’ is also to lose the teleological structure of one’s life, the horizon of possibilities that ordinarily sustains one’s being-in-the-world. The implications of these findings for clinical practice are significant. As Desai et al. (2017) also emphasise, responding to depression in light of lived experience requires a reordering of clinical priorities: rather than patients being expected to adhere to nonpersonalised or decontextualised treatment requirements, medical professionals must instead respond directly to patients’ own goals and commitments.

In conceptualising expressions such as ‘losing oneself’, it is necessary to examine the depersonalising dimension of depression, which can be intensified or complicated by antidepressant medication. These experiences are not marginal but central to the phenomenology of depression, as they point to a disruption in the most basic sense of selfhood and world-relation. In this regard, Michal et al. (2024), in a large-sample study on the impact of depersonalisation on the course of depression, observed that ‘the co-occurrence of [depersonalisation] symptoms more than doubled the risk for recurrence or persistence of depression’ (p. 1). Depersonalisation has further been associated with ‘a bigger number of manifest symptoms which have a tendency to continuous duration’ (Žikić et al., 2009, p. 320), often manifesting in ‘predominantly severe episodes [including] feelings of sadness, insomnia, and decrease of energetic potentials’ (p. 320). What these findings highlight is how the presence of depersonalisation does not merely add another symptom to the clinical profile but, as a matter of fact, transforms the character and course of the illness. Therefore, by taking into account the lived experience of the individual, medical professionals can move beyond checklist-based assessments towards a more comprehensive understanding of how psychotropic medication is experienced, not only in terms of observable outcomes, but also in how it reshapes the individual’s felt relation to the self, body, and the world.

For instance, in exploring the different ways depersonalisation is experienced in depression – including in the context of antidepressant medication – it is essential to examine particular features such as disruptions of embodiment, alienation, and detachment from the world (Fusar-Poli et al., 2023). These are not to be conceptualised as abstract notions but as concrete realities expressed in patients’ testimonies: individuals describe feeling ‘cut off from the rest of humanity, the rest of the world, the rest of existence’ (Kadir & Bifulco, 2010, p. 455), or that ‘[d]epression feels like the most isolated place on earth’ (Brampton, 2008, p. 1). Such reports must be taken seriously and understood as pathways to understanding the altered relation of the depressed individual to the self and the world. In this regard, Breeksema et al. (2023), in their study of phenomenological experiences among patients with treatment-resistant depression undergoing esketamine administration, note that patients’ accounts ‘provide insights into potentially relevant psychological processes, which may help optimise treatment approaches’ (p. 1548). Attending to these first-person reports not only helps to assess the therapeutic potential of antidepressant medication but also reveals its possible limitations and risks. Some participants in Breeksema et al.’s study, for instance, reported profound feelings of detachment from their sense of self, their body, and the surrounding world, alongside feelings of worthlessness, emotional numbness, and hopelessness. What these dimensions highlight are empirical phenomena that, when carefully investigated, hold the potential to refine therapeutic strategies and improve outcomes for people with treatment-resistant depression.

Conclusion

This article has argued that the DSM-5-TR diagnostic criteria for MDD, particularly ‘depressed mood’ and ‘psychomotor agitation or retardation’, fail to capture the lived experience of depression. These criteria, though central to diagnosis, are often superficially defined and externally focused, neglecting the experiential and existential dimensions through which depression is lived. The term ‘depressed mood’ is not only diagnostically vague but conceptually circular, while ‘psychomotor agitation or retardation’, when framed as observable by others, disregards the inner collapse of will and future-directedness that many individuals report.

By drawing on insights from phenomenology and humanistic psychology, this article has argued that these symptoms must be recontextualised within the structures of embodiment, temporality, and agency. Depression is not simply a cluster of discrete symptoms but a transformation in the individual’s being-in-the-world. A person-centred, phenomenologically informed approach can help distinguish genuine clinical distress from ordinary emotional suffering and avoid the over-pathologisation of contextually meaningful experiences.

This is not a call to discard diagnostic tools, but to complement them with a more nuanced, empathic understanding of what it means to be depressed. Integrating first-person experience into psychiatric understanding is essential if diagnosis is to support, rather than obscure, the depressed individual’s path to recovery.

Footnotes

Acknowledgements

The author would like to thank Prof Keith Allen (University of York) for his insightful comments and feedback on earlier versions of this manuscript.

ORCID iD

Angelos Sofocleous

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Notes

Author Biography

Angelos Sofocleous, PhD, is a postdoctoral researcher in philosophy at the Department of Philosophy, National and Kapodistrian University of Athens, working on the phenomenology of grief. He holds a PhD in Philosophy from the University of York, an MA in Philosophy, and a BA in Philosophy and Psychology from the University of Durham. He specialises in phenomenological psychopathology and the philosophy of psychiatry. He has previously taught at the University of York, the University of Leeds, and the University of Nicosia.

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