What Is Depression Not Otherwise Specified (NOS)?

What Is Depression?

Depression is an illness that has physical, emotional, and cognitive symptoms that negatively impact one’s ability to function in one or more areas of one’s life.¹ The person feels sad, discouraged, or hopeless, and expresses a lack of interest or enjoyment in activities previously enjoyed. To meet the diagnostic criteria for depression, symptoms must occur almost daily for at least two weeks.

Symptoms of depression can range from mild to severe, and in the most severe cases might involve a near total shutdown of the person (i.e., depressed and unable to get out of bed.)  Depression might occur as a single episode with no recurrence, episodes with periods of remission, or chronic illness with no remission.

What Is Depression Not Otherwise Specified (NOS)?

Depression (NOS) has been used as a diagnostic category for depressive illness that caused significant distress and functioning impairment, but did not meet the full criteria for any other depressive disorder diagnosis.² It has been replaced by two new categories:  other specified depressive disorder; and unspecified depressive disorder.¹

A characteristic of other specified depressive disorder, is that the clinician diagnosing the illness will include the reason(s) why the illness does not meet the full diagnostic criteria for other depressive disorders.  In contrast, in unspecified depressive disorder diagnosis, the clinician does not specify the reasons why the criteria for a specific depressive diagnosis have not been met – possibly due to insufficient information.

Differentiating Depression NOS From Other Depressive Disorders

While depression NOS still causes clinically significant distress and impacts one’s ability to function in one or more areas of  life – it does not last as long, nor does it have the number of symptoms required to meet the full diagnostic criteria for other depressive disorders.  Thus, depression NOS is sometimes referred to as “subclinical depression”.³

Depression NOS Vs Major Depressive Disorder (MDD)

Major depressive disorder and depression NOS are both characterized by depressed mood and significant distress or impairment.  The differences between these diagnoses however, lies in the number of depressive symptoms the individual is experiencing (i.e., at least 5 for MDD and 1-4 for depression NOS), and the length of time that the depressive episode lasts (i.e., at least 2 weeks for MDD, and 2-14 days for depression NOS).

Depression NOS Vs Persistent Depressive Disorder (Dysthymia)

While depression NOS involves a depressive episode that lasts up to 14 days, persistent depressive disorder (dysthymia) is characterized by a depressive episode that lasts for at least 2 years.  To meet the criteria for a dysthymia diagnosis, the individual will experience a depressed mood for the majority of the day, almost daily, as well as 2 or more of the following symptoms:¹

• Significant loss or increase in appetite
• Insomnia or oversleeping
• Fatigue or low energy
• Low self-esteem
• Concentration or decision making difficulties
• Hopelessness

Diagnostic Criteria for Depression NOS

You may have received a diagnosis of depression NOS, instead of a diagnosis for one of the other types of depressive disorders, if your symptoms did not meet the full criteria of these other depressive disorders due to an insufficient number and/or duration of symptoms.

The depression NOS diagnosis has been formally redefined into two new separate diagnoses:¹

1. Otherwise specified depressive disorder (OSSD).  In this category the reason as to why the criteria do not meet other depressive disorders is specified by the clinician.

Some examples include:

• Recurrent brief depression – depressed mood with at least 4 of the 8 symptoms of a major depressive episode, that last for periods of 2-13 days at least once a month, for 12 consecutive months.
• Short-duration depressive episode – depressed mood with at least 4 of the 8 symptoms of a major depressive episode that cause significant distress or functioning impairment that lasts for 4-14 days.
• Depressive episode with insufficient symptoms – depressed mood and at least 1 of the 8 symptoms of major depressive episode that causes severe impairment or distress that lasts for at least 2 weeks.

2. Unspecified depressive disorder.  This category applies to situations as indicated above, but for which the clinician does not specify the reason why the criteria for other depressive disorders have not been met.

Examples of People Who May Have a Depression NOS Diagnosis

Depression not otherwise specified (NOS) was a category used to describe depressive symptoms that didn’t fully align with the criteria for other specific depressive disorders. This diagnosis may have applied to a range of individuals with varied experiences.

Examples of people who may have received a depression NOS diagnosis include:

• A person with depressive symptoms that are not frequent enough to meet the full criteria for major depressive disorder. For example, someone might experience persistent sadness and fatigue, but without other symptoms such as feelings of worthlessness or significant weight change.
• A person who experiences significant mood disturbances following a medical illness or medication, but the symptoms do not align precisely with typical depression diagnoses. This could include depression due to hormonal imbalances, post-surgery recovery, or chronic illness.
• Children or adolescents who exhibit depressive symptoms that do not fit into adult criteria, such as irritability or behavior changes, rather than typical adult manifestations of depression.
• Someone who experiences depressive episodes that don’t last long enough to be considered major depressive episodes, yet are more intense or frequent than what is typically expected.
• Elderly individuals whose depressive symptoms might be intertwined with cognitive decline or physical health issues, making it challenging to fit into a standard depression category.
• Individuals with depressive symptoms that follow a seasonal pattern but do not meet the full criteria for seasonal affective disorder (SAD), either due to severity of symptoms or having a different timing of episodes.

In each of these examples, while the individual’s symptoms impact their quality of life, they do not match the full set of criteria for a more specific depressive disorder, and therefore may have received a depression NOS diagnosis.

Symptoms of Depression NOS

A person who is experiencing depression NOS will have a depressed mood plus 1-4 additional symptoms below, which will be associated with significant distress and will impair their ability to function in one or more areas of their life.  Symptoms of depression NOS vary depending on the individual.

Depression NOS symptoms experienced might include:¹

• Depressed mood most of the day and almost every day (for up to 2 weeks at a time)
• Loss of interest or pleasure in most activities
• Significant increase or decrease in appetite/weight
• Significant change in sleep patterns – sleeping too much or too little
• Physical agitation or sluggishness
• Fatigue, exhaustion, and/or little energy
• Feelings of worthlessness/intense guilt
• Difficulty with thinking clearly, concentration, problem-solving and/or decision-making
• Recurrent thoughts of death or suicide

Causes & Contributing Factors of Depression NOS

Generally speaking, depressive disorders are thought to be caused by factors related to temperament, environment (adverse or stressful life events), genetics, and physiology.¹

While the research on the contributing factors to depression NOS specifically, is sparse, one study with adolescents was able to identify the following factors that were significantly higher among individuals with depression NOS as compared to a control group:⁴

• Ruminative response style: repetitively focusing on negative thoughts and feelings associated with depression
• Dysfunctional attitudes: consistent negative evaluations of oneself, the world, and the future
• Negative inferential style: the tendency to draw negative conclusions about the cause and importance of negative events
• Negative life events: the number of negative (stressful) events that the individual experienced in the preceding 3 months

Additionally, perceived social support was significantly lower among individuals with a depression NOS diagnosis.

Coping Strategies for Living With Depression NOS

Feeling powerless in the face of your symptoms adds an additional burden to the stress you are already carrying.  There are many coping skills for depression that can help to give you a sense of control, as well as the ability to better manage and reduce symptoms – thereby increasing your capacity to function in different areas of your life.

Educate Yourself About Depression NOS

Understanding more about your illness and how it affects you personally – as well as accepting that it is a physical illness and not your “fault” or a sign of “weakness” – can help to significantly reduce the emotional burden you are carrying.  Additionally, learning what coping strategies work best for you can increase your confidence in managing your symptoms.

Obtain a Medical Assessment

If you have never spoken to your family doctor about your symptoms, this is often an important step.  Your doctor might wish to run tests to ensure that your symptoms are not the consequence of some other type of illness (e.g., hypothyroidism)  This helps to verify your diagnosis and ensure that all potential treatment options are considered.

Work With a Therapist

Working with a licensed therapist who specializes in treating depression can provide you with a safe environment to explore the impact of your symptoms on your life, while identifying and implementing interventions and strategies to help to decrease distress and increase your capacity to function.

Eliminate/Reduce Any Unnecessary Stressors in Your Life

Stressors, by their nature, use up valuable energy.  If you are already dealing with depression NOS, you won’t have a lot of energy to spare.

During a flare-up of symptoms, it might be helpful to:

• Ask for assistance with essential responsibilities
• Take a break from, or let go of, non-essential responsibilities
• Accept help with practical tasks when others offer

By reducing or eliminating non-essential stressors in your life, you free up energy to cope with your illness.

Prioritize Self-Care & Wellness

Self-care refers to taking active steps to address your needs and provide comfort.   These strategies can focus on physical, emotional, cognitive, and/or spiritual needs and supports.

Some self-care practices for depression include:

• Eating nutritious food, and ensuring you are eating regularly throughout the day.  You might want to consider foods that can help depression.
• Getting enough sleep and taking time to rest before you feel overwhelmed
• Exercise can help depression. Engaging in regular moderate to physical activity can have a significant impact on depression, similar to that observed with antidepressants.⁵
• Scheduling time for people and activities that give you joy or comfort
• Not over-extending yourself.  Saying “no” when you need to.
• Ensuring your self-talk is supportive and kind

Create a Support Network

It can be helpful to have people in your life, with whom you can honestly share your challenges, without fear of judgment or criticism.  These might be friends, coworkers, family members, or professionals.  They might also be others who also have the same diagnosis, that you might meet in a therapy or peer support group.

Practicing Mindfulness

Mindfulness strategies help you to redirect your attention, from negative thought spirals,  to the present moment in ways that promote a calmer state.

Some examples of mindfulness include:

• If you are feeling overwhelmed, try asking yourself “What is being asked of me at this moment?” – where a moment is only 15-20 minutes, and focusing on that.
• Yoga or meditation

Self-Soothing Strategies

Self-soothing strategies focus on consciously taking action to calm yourself by targeting your senses.

Some examples of self-soothing strategies, for each sense, include:

• Sight: use a candle to soften light in a room, look at a picture of a loved one or favorite place
• Sound: listen to comforting music or the sounds of nature
• Taste: enjoy a favorite food or non-alcoholic drink
• Touch:  wear comfortable clothes, take a hot bath or shower
• Smell:  breathe in the scents of nature, use a scented lotion

Depression NOS Treatment

Treatment strategies for depression NOS are the same as those for other depressive disorders and should be tailored to the individual – taking into account their specific medical, social, and cultural contexts.  Treatment plans might include a medical assessment, medication, and/or psychotherapeutic interventions.

Medication Management

You and your doctor might decide that medication is appropriate for your situation.  If so, your doctor will determine which antidepressant to try.  Not all medications work for every person, so sometimes it will take some time to find the right medication and dosage for you.  Generally it can take 2-4 weeks for any side effects to stop, and for improvements to be felt.

Psychotherapy & Support

Therapy for depression can be very effective in reducing the intensity of symptoms and increasing your capacity to cope and function during depressive episodes.  Some common therapies used to treat depression include:

• Cognitive behavioral therapy (CBT):   CBT for depression is a short-term therapeutic intervention which works on identifying and shifting maladaptive thoughts and behaviors in order to reduce distress and enhance your ability to cope in healthy and supportive ways.
• Dialectical behavioral therapy (DBT):  DBT for depression focuses on building healthy and effective skills with respect to  relationships, managing emotions, mindfulness, and distress tolerance.
• Cognitive therapy:  Cognitive therapy focuses on identifying and changing unhelpful, inaccurate, and distressing ways of perceiving and thinking to reduce distress and improve coping.
• Interpersonal psychotherapy: Interpersonal psychotherapy works on the premise that relationship conflicts can negatively impact your ability to cope,and increase symptoms of depression.  The focus is thus on better understanding yourself and resolving relationship issues to reduce distress.
• Mindfulness-based cognitive therapy (MBCT): MBCT is typically delivered in a group setting and focuses on both mindfulness and cognitive strategies to help you learn how not to become tangled in distressing emotions and thoughts, to let them go, and to focus on the present moment.
• Psychodynamic therapy:  Psychodynamic therapy uses several different techniques to help to reveal unconscious fears, trauma, unresolved conflicts, and provide a safe space to understand and work through them thereby reducing distress and depression symptoms.
• Supportive therapy:  Supportive therapy provides a safe, compassionate and non-judgmental therapeutic relationship in which you can express and explore distressing thoughts, emotions, situations.  This therapy focuses on hearing and understanding your experiences.

The Importance of Personalized Care in Treating Depression NOS

Each person who is diagnosed with depression NOS will have their own experience of the illness.  Your symptoms, and how they impact your life, will be unique to you.  Thus, it is important that your treatment plan is personalized to take into account not only your symptoms, but also your strengths, priorities, values, supports, and resources. But, even though your experience is unique to you, it’s important to keep in mind that you are not alone and that depression NOS is a well recognized and treatable condition.

Where to Find Professional Help for Depression NOS

When trying to find the right therapist for you, you might want to ask your family doctor or friends for a referral.  An online therapist directory can also be a helpful resource – in that it provides profiles of different therapists to give you a sense of who they are, as well as information on the issues and therapies they have expertise in.  Some people find that mental health apps can also be a valuable support.