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F33.2·CIM-10-CM

Major Depressive Disorder, Recurrent, Severe Without Psychotic Features

Recurrent depressive disorder with a current episode of severe intensity meeting DSM-5-TR criteria, without delusions or hallucinations.

Outil de dépistage recommandé

Outil de dépistage validé
Patient Health Questionnaire-9 (PHQ-9)
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DSM-5-TR diagnostic criteria summary

F33.2 requires recurrent MDD with the current episode meeting MDE criteria at severe intensity:

  • At least one prior major depressive episode separated from the current by ≥2 consecutive months without meeting full criteria.
  • Current major depressive episode at severe intensity, most/all 9 symptoms endorsed at high frequency, with marked functional impairment, marked psychomotor changes, severe self-loathing, or persistent suicidal ideation.
  • No psychotic features (if present, code F33.3).
  • No history of mania or hypomania (if present, code F31.x bipolar).
  • Clinically significant distress or impairment, typically marked or severe at this severity level.

Severity codes within F33: F33.0 mild, F33.1 moderate, F33.2 severe without psychotic features, F33.3 severe with psychotic features, F33.40/F33.41/F33.42 in remission states.

Source: American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), p. 183–192.

Differential diagnosis

  • F33.3 MDD with Psychotic Features, when delusions or hallucinations are present.
  • F32.2 MDD Single Episode, Severe, same severity, but first lifetime depressive episode.
  • F31.4 Bipolar I, Severe Depressed without Psychotic Features, when prior mania/hypomania is identified.
  • F25.0 Schizoaffective Disorder, Bipolar Type; F25.1 Schizoaffective Disorder, Depressive Type, when psychotic symptoms occur outside of mood episodes.
  • Substance/Medication-Induced Depressive Disorder with severe presentation, typically resolves after sustained abstinence.

Common comorbidities

Severe MDD has very high comorbidity with anxiety, substance use, and physical conditions that may be exacerbating depression. Common comorbidities: Generalized Anxiety Disorder (F41.1), PTSD (F43.10), Substance Use Disorders (F10–F19), and chronic medical conditions (cardiovascular disease, diabetes, chronic pain). Routinely co-administer GAD-7, AUDIT, and (when trauma history present) PCL-5 alongside PHQ-9 and C-SSRS.

Sources

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), F33.2, p. 183–192.
  • Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
  • Centers for Disease Control and Prevention. ICD-10-CM Official Coding Guidelines.

Foire aux questions

What is ICD-11 code F33.2?

F33.2 is the ICD-11-CM code for Major Depressive Disorder, Recurrent, Severe Without Psychotic Features. It denotes a recurrent depressive disorder where the current episode meets DSM-5-TR criteria for major depressive episode at severe intensity, without delusions or hallucinations.

What are the diagnostic criteria for F33.2?

DSM-5-TR criteria require five or more depression symptoms during a 2-week period (including depressed mood or anhedonia), causing clinically significant impairment, with a history of at least one prior major depressive episode and no history of mania or hypomania. F33.2 specifies severe intensity, typically PHQ-9 scores 20–27 or symptoms producing marked functional impairment.

What scale is used to screen for F33.2?

The Patient Health Questionnaire-9 (PHQ-9) is the standard scale. PHQ-9 scores of 20–27 typically align with severe major depression (F33.2 or F32.2). Item 9 (suicidal ideation) requires immediate clinical follow-up if endorsed at any level. Severe presentations frequently require co-administration of the C-SSRS for full suicide risk assessment.

What is the difference between F33.2 and F33.3?

F33.2 is severe MDD, recurrent, without psychotic features. F33.3 is severe MDD, recurrent, with psychotic features (delusions, hallucinations). Psychotic features can be mood-congruent (themes of personal inadequacy, guilt, deserved punishment, death) or mood-incongruent (no clear connection to depressive themes). F33.3 has different treatment implications including potential indication for combined antidepressant/antipsychotic or ECT.

Does severe depression always require hospitalization?

No. Hospitalization is determined by safety risk and functional capacity, not severity classification alone. Severe MDD (F33.2) without imminent suicide risk, psychotic features, or inability to maintain basic self-care can often be managed in intensive outpatient or partial hospitalization settings. Item 9 endorsement on the PHQ-9 plus a positive C-SSRS warrants urgent re-evaluation of level of care.

Is F33.2 a billable ICD-11-CM code?

Yes, F33.2 is a billable ICD-11-CM code as of the 2025 official tabular list. It is the standard reimbursed code for a recurrent severe major depressive episode without psychotic features. When psychotic features are present, F33.3 should be used instead. Both codes are billable at maximum specificity.

What are the symptoms of severe depression?

Severe major depression produces the full symptom cluster of major depression at high frequency and intensity. Most or all nine DSM-5-TR symptoms are present: persistent low mood, complete loss of interest, marked sleep and appetite disturbance, profound fatigue, severe self-loathing or guilt, marked concentration impairment, psychomotor slowing or agitation, and persistent suicidal ideation. Functional impairment is marked, often preventing work, basic self-care, or social contact.

How is severe depression diagnosed?

Severe recurrent major depressive disorder is diagnosed by a clinician using DSM-5-TR criteria, with severity graded by symptom count, functional impact, and PHQ-9 score (typically 20 or higher). Diagnosis requires a current major depressive episode plus at least one prior episode, ruling out psychotic features, mania or hypomania, substance-induced causes, and another medical condition. The C-SSRS is co-administered to assess suicide risk.

What causes severe depression?

Severe depression arises from the same genetic, neurobiological, and psychosocial factors as milder presentations, often with greater symptom load. Heritability is estimated at 30% to 40%; severe and recurrent presentations show stronger family-history loading. Risk factors include early-life trauma, chronic medical illness, untreated prior episodes, comorbid anxiety or substance use, and inadequate social support. HPA axis dysregulation and inflammatory markers are more pronounced in severe presentations.

Can severe depression be cured?

Severe major depressive disorder is treatable, though full and lasting recovery typically requires combined and intensive treatment. First-line approaches include antidepressant medication (often combined with augmentation strategies), evidence-based psychotherapy (CBT, IPT, behavioral activation), and (in treatment-resistant cases) ketamine or ECT. Roughly 30% to 40% of patients with severe depression achieve full remission with first-line care; staged treatment reaches 60% to 70% remission across multiple steps.

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