Refining DSM-III criteria in Major Depression. An assessment of the descriptive validity of criterion symptoms

Efficacy and tolerability of antidepressant drugs in treatment of depression in children and adolescents: a network meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of antidepressants in treatment of depression disorder in children and adolescents by network meta-analysis.

METHODS

Databases of PubMed, Cochrane Library, EMBASE, Web of Science, PsycINFO, CBM, CNKI and Wanfang Data were searched for randomized controlled trials (RCT) related to antidepressants in treatment of children and adolescents with depression from inception to December 2021. Quality assessment and data extraction from the included RCTs were performed. Statistical analyses of efficacy and tolerability were conducted with Stata 15.1 software. Surface under the cumulative ranking (SUCAR) was used to rank the value of the antidepressants.

RESULTS

A total of 33 RCTs were included in 32 articles, involving 6949 patients. There are 13 antidepressants used in total, including amitriptyline, vilazodone, fluoxetine, selegiline, paroxetine, imipramine, desipramine, sertraline, nortriptyline, escitalopram, citalopram, venlafaxine and duloxetine. The results of network meta-analysis showed that the efficacy of duloxetine ( OR=1.95, 95% CI: 1.41-2.69), fluoxetine ( OR=1.73, 95% CI: 1.40-2.14), venlafaxine ( OR=1.37, 95% CI: 1.04-1.80) and escitalopram ( OR=1.48, 95% CI: 1.12-1.95) were significantly higher than that of placebos (all P<0.05); the probability cumulative ranks were duloxetine (87.0%), amitriptyline (83.3%), fluoxetine (79.0%), escitalopram (62.7%), etc. The results showed that the intolerability of patients receiving imipramine ( OR=0.15, 95% CI: 0.08-0.27), sertraline ( OR=0.33, 95% CI: 0.16-0.71), venlafaxine ( OR=0.35, 95% CI: 0.17-0.72), duloxetine ( OR=0.35, 95% CI: 0.17-0.73) and paroxetine ( OR=0.52, 95% CI: 0.30-0.88) were significantly higher than that of placebos (all P<0.05), and the probability cumulative ranks were imipramine (95.7%), sertraline (69.6%), venlafaxine (68.6%), duloxetine (68.2%), etc. Conclusion: Among 13 antidepressants, duloxetine, fluoxetine, escitalopram and venlafaxine are significantly better than placebo in terms of efficacy, but duloxetine and venlafaxine are less well tolerated.

The Psychopathology of Worthlessness in Depression

BACKGROUND

Despite common dissatisfaction with the syndromic heterogeneity of major depression, investigations into its symptom structure are scarce. Self-worthlessness/inadequacy is a distinctive and consistent symptom of major depression across cultures.

AIMS

We investigated whether self-worthlessness is associated with self-blaming attribution-related symptoms or is instead an expression of reduced positive feelings overall, as would be implied by reduced positive affect accounts of depression.

METHODS

44,161 undergraduate students in Study 1, and 215 patients with current Major Depressive Disorder (MDD) and 237 age-matched healthy control participants in Study 2 completed the well-validated Symptom Check List-90. Depression-relevant items were used to construct regularized partial correlation networks with bootstrap estimates of network parameter variability.

RESULTS

Worthlessness co-occurred more strongly with other symptoms linked to self-blaming attributions (hopelessness, and self-blame), displaying a combined edge weight with these symptoms which was significantly stronger than the edge weight representing its connection with reduced positive emotion symptoms (such as reduced pleasure/interest/motivation, difference in edge weight sum in Study 1 = 2.95, in Study 2 = 1.64; 95% confidence intervals: Study 1: 2.6-3.4; Study 2: 0.02-3.5; Bonferroni-corrected p < 0.05).

CONCLUSIONS

This confirms the prediction of the revised learned helplessness model that worthlessness is most strongly linked to hopelessness and self-blame. In contrast, we did not find a strong and direct link between anhedonia items and a reduction in self-worth in either study. This supports worthlessness as a primary symptom rather than resulting from reduced positive affect.

Impact, Diagnosis, Phenomenology, and Biology

This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.

Comparing depressive symptoms in teenage boys and girls

Introduction

Symptoms of depression vary between the males and females. Depressed men show behaviors such as irritability, restlessness, difficulty in concentrating, and instead of the usual behaviors. Sleep disturbance is a common symptom in depressed men. Men are less likely to go to doctors and unconsciously show other behaviors such as anger instead of the sadness. It seems that considering depression as "feminine" is a great injustice toward male patients whom their illness will not be diagnosed nor treated.

Materials and Methods

The sample consisted of 191 depressed adolescents, 108 males and 83 females aged 13-19 years old. Data collected for 10 years from 2005 to 2015 and their depressive symptoms were evaluated by the Beck Depression Inventory-Second Edition.

Results

Depressed girls felt sadness, guilt, punishment, worthlessness, low energy and fatigue, or more asthenia, whereas depressed boys have symptoms such as irritability, depression, suicidal thoughts, or desires to reduce their pleasure. The results of t-test showed that the difference between the total scores of boys and girls with depressive disorder (16.93) is significant at 0.001. F values for feeling sad (58.13), hatred of self (12.38), suicidal thoughts or desires (12.97), restlessness (17.35), and irritability (46. 41) were significant in the 0.001.

Conclusion

Experiencing depression in boys and girls according to the role of gender was different. Gender can have an effective role in showing depression symptoms in adolescents.

The role of self-blame and worthlessness in the psychopathology of major depressive disorder

BACKGROUND

Cognitive models predict that vulnerability to major depressive disorder (MDD) is due to a bias to blame oneself for failure in a global way resulting in excessive self-blaming emotions, decreased self-worth, hopelessness and depressed mood. Clinical studies comparing the consistency and coherence of these symptoms in order to probe the predictions of the model are lacking.

METHODS

132 patients with remitted MDD and no relevant lifetime co-morbid axis-I disorders were assessed using a phenomenological psychopathology-based interview (AMDP) including novel items to assess moral emotions (n=94 patients) and the structured clinical interview-I for DSM-IV-TR. Cluster analysis was employed to identify symptom coherence for the most severe episode.

RESULTS

Feelings of inadequacy, depressed mood, and hopelessness emerged as the most closely co-occurring and consistent symptoms (≥90% of patients). Self-blaming emotions occurred in most patients (>80%) with self-disgust/contempt being more frequent than guilt, followed by shame. Anger or disgust towards others was experienced by only 26% of patients. 85% of patients reported feelings of inadequacy and self-blaming emotions as the most bothering symptoms compared with 10% being more distressed by negative emotions towards others.

LIMITATIONS

Symptom assessment was retrospective, but this is unlikely to have biased patients towards particular emotions relative to others.

CONCLUSIONS

As predicted, feelings of inadequacy and hopelessness were part of the core depressive syndrome, closely co-occurring with depressed mood. Self-blaming emotions were highly frequent and bothering but not restricted to guilt. This calls for a refined assessment of self-blaming emotions to improve the diagnosis and stratification of MDD.

A simpler definition of major depressive disorder

BACKGROUND

The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples.

METHOD

We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients.

RESULTS

In all three samples high levels of agreement were found between the DSM-IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87.

CONCLUSIONS

After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.

Accuracy of specific symptoms in the diagnosis of major depressive disorder in psychiatric out-patients: data from the MIDAS project

BACKGROUND

There is uncertainty about the diagnostic significance of specific symptoms of major depressive disorder (MDD). There is also interest in using one or two specific symptoms in the development of brief scales. Our aim was to elucidate the best possible specific symptoms that would assist in ruling in or ruling out a major depressive episode in a psychiatric out-patient setting.

METHOD

A total of 1523 psychiatric out-patients were evaluated in the Methods to Improve Diagnostic Assessment and Services (MIDAS) project. The accuracy and added value of specific symptoms from a comprehensive item bank were compared against the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

The prevalence of depression in our sample was 54.4%. In this high prevalence setting the optimum specific symptoms for ruling in MDD were psychomotor retardation, diminished interest/pleasure and indecisiveness. The optimum specific symptoms for ruling out MDD were the absence of depressed mood, the absence of diminished drive and the absence of loss of energy. However, some discriminatory items were relatively uncommon. Correcting for frequency, the most clinically valuable rule-in items were depressed mood, diminished interest/pleasure and diminished drive. The most clinically valuable rule-out items were depressed mood, diminished interest/pleasure and poor concentration.

CONCLUSIONS

The study supports the use of the questions endorsed by the two-item Patient Health Questionnaire (PHQ-2) with the additional consideration of the item diminished drive as a rule-in test and poor concentration as a rule-out test. The accuracy of these questions may be different in primary care studies where prevalence differs and when they are combined into multi-question tests or algorithmic models.

Diagnosing major depressive disorder VI: performance of an objective test as a diagnostic criterion

Considerable research has evaluated biological and psychological tests for various psychiatric disorders; however, few objective tests are included in DSM-IV as diagnostic criteria. It was recently suggested that existing tests are insufficiently accurate to be included as diagnostic criteria. While it is true that there are limitations in the sensitivity and/or specificity of such tests, this should not rule them out as effective diagnostic criteria. Studies examining the diagnostic efficiency of the DSM criteria sets demonstrate that the individual criteria vary in their sensitivity and specificity. In the present article, we suggest that the same standard should be applied to the evaluation of objective tests. That is, we suggest changing the perspective used to evaluate the performance of biological and psychological measures from the traditional one examining them as diagnostic tests to one in which these measures are evaluated as diagnostic criteria. To our knowledge, no previous investigators have compared the psychometric performance of an objective test to the psychometric performance of the DSM-IV symptom criteria. The recent report from the committee to develop a research agenda for the initial planning phase for DSM-V discussed the use of self-report symptom scales as possible diagnostic criteria in nonpsychiatric settings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the performance of a self-report depression questionnaire as a diagnostic criterion for major depressive disorder (MDD). We compared the performance of the Diagnostic Inventory for Depression to the performance of the DSM-IV MDD symptom criteria in 1138 psychiatric outpatients. The results indicated that the diagnostic efficiency of the Diagnostic Inventory for Depression was similar to the loss of interest or pleasure criterion, and superior to all of the remaining DSM-IV MDD symptom criteria except low mood. We discuss issues related to the possible use of a self-administered depression symptom scale as a diagnostic criterion.

Diagnosing major depressive disorder III: can some symptoms be eliminated from the diagnostic criteria?

All criteria used to diagnose a psychiatric disorder should contribute to distinguishing cases from noncases. The principal of parsimony argues for defining a disorder with as few criteria as possible. Thus, criteria that do not contribute to the case-noncase distinction should be eliminated from the list of defining features because they unnecessarily increase the complexity of the definition of the disorder. In polythetically defined disorders such as major depressive disorder (MDD), diagnosis is based on the presence of a minimum number of features from a list. For a criterion to be retained on such a list, it should contribute to distinguishing between individuals with and without MDD. Simply demonstrating that a criterion is significantly more common in individuals with MDD than individuals without MDD is not a sufficient demonstration of its necessity. Rather, to demonstrate an impact on diagnosis, it should be shown that eliminating the criterion from the list results in individuals being reclassified from a case to a noncase. A criterion does not contribute to determining caseness if its elimination does not result in diagnostic reclassification. The goal of this report from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services project was to determine if any of the criteria of MDD are candidates for elimination because of their lack of impact on diagnosis. The results indicated that the symptoms of increased weight, decreased weight, and indecisiveness rarely influenced diagnostic classification and thus are candidates for elimination.

Diagnosing major depressive disorder: II: is there justification for compound symptom criteria?

The DSM-IV symptom inclusion criteria for the diagnosis of major depressive disorder (MDD) are constructed in three ways: single symptom criteria, compound criteria encompassing opposite variants of the same disturbance, and compound criteria encompassing related problems. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the following three hypotheses: (1) the components of compound-opposite criteria rarely occur simultaneously, (2) the components of the compound-related criteria frequently occur simultaneously, and (3) the components of the compound-related criteria more frequently co-occur than other pairs of the MDD criteria. We also examined how many patients would be rediagnosed if the compound criteria were split into separate items. One thousand eight hundred psychiatric outpatients were evaluated with a semistructured diagnostic interview. We inquired about all of the DSM-IV diagnostic criteria for MDD for all patients. As hypothesized, the symptoms of the compound-opposite criteria usually did not co-occur, whereas the symptoms of the compound-related criteria frequently were present simultaneously. However, the results also indicated that other pairs of symptoms were as likely to co-occur, and were as strongly associated with each other, as the symptoms of the compound-related criteria. Thus, the findings provide mixed support for the assumptions hypothesized to underlie the composition of the DSM-IV criteria for MDD. When the compound criteria were subdivided and the diagnostic threshold for MDD was kept constant, only a small percentage of patients was reclassified from a noncase to a case. The implications of these results for constructing diagnostic criteria, and for developing measures to assess the severity of depression, are discussed.

Diagnosing major depressive disorder I: A psychometric evaluation of the DSM-IV symptom criteria

The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria. We also conducted a regression analysis to determine whether all criteria are independently associated with the diagnosis of major depressive disorder. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. All of the DSM-IV symptom criteria for major depressive disorder were significantly associated with the diagnosis. Contrary to our prediction, symptoms such as insomnia, fatigue, and impaired concentration, which are also criteria of other disorders, generally performed as well as the criteria that are unique to depression such as suicidality, worthlessness, and guilt. The results of the regression analysis, which controlled for symptom covariation, indicated that five symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis of depression. The implications of these results for revising the diagnostic criteria for major depression are discussed.

Gender differences in adolescent depression: do symptoms differ for boys and girls?

BACKGROUND

Limited prior research suggests that depressed women are more likely to experience certain symptoms of depression than are depressed men. The purpose of this study was to examine whether such gender differences in depressive symptoms are present during adolescence.

METHODS

The Childhood Version of the Schedule for Affective Disorders and Schizophrenia and the Beck Depression Inventory were administered to adolescents presenting for evaluation at an outpatient clinic (n=383; ages 11.9 to 20.0).

RESULTS

Depressed girls and boys had similar symptom prevalence and severity ratings for most depressive symptoms. However, depressed girls had more guilt, body image dissatisfaction, self-blame, self-disappointment, feelings of failure, concentration problems, difficulty working, sadness/depressed mood, sleep problems, fatigue, and health worries than depressed boys on some comparisons. In contrast, depressed boys had higher clinician ratings of anhedonia, depressed morning mood, and morning fatigue.

LIMITATIONS

Longitudinal research is needed to test whether such relatively gender-specific symptoms play different roles in the onset, maintenance, or remittance of depression for boys and girls.

CONCLUSIONS

These findings indicate that, in general, the experience of depression is highly similar for adolescent girls and boys. However, some gender differences previously found among depressed adults appear to be present by adolescence, possibly suggesting somewhat distinct etiologies for depression among males and females.

An exploration of nutrition and eating disabilities in relation to quality of life at 6 months post-stroke

Quality of life (QoL) is increasingly recognised as an important healthcare outcome, especially for those living with enduring disability. Stroke is a major source of long-term disablement and many aspects of life after stroke have been explored. Little attention has been paid to nutritional issues despite the cultural and hedonistic importance of food and eating, and the deleterious effects of malnutrition. The present study employed an epidemiological survey to investigate the contribution of dietary and nutritional factors in relation to QoL after stroke. The participants were 206 survivors of a cohort of acute stroke patients consecutively admitted to a National Health Service trust hospital in South London, UK, between March 1998 and April 1999. They were interviewed in their homes at 6 months post-stroke. Cognitively or communication-impaired patients were precluded from interview except where a live-in carer participated as a proxy (n = 10). The participation rate for those who were eligible and could be contacted was 206 out of 218 (94%). Participants were assessed using standardised, validated tools for functional abilities in activities of daily living and eating, cognition and mood state, social support and economic indices, nutritional status, dietary intake, and QoL. Overall group scores demonstrated relatively minor degrees of physical disablement; exclusion of those with limited cognition and communication precluded assessment of a small subgroup with greater disablement at hospital discharge. Nonetheless, the overall assessment results were not dissimilar to other reported groups. Indices of poor nutritional status and substantial dietary inadequacy were revealed, linked with reduced appetite and depression. Multiple regression analyses revealed the dominant impact of mood state in relation to QoL scores; additional significant effects were identified for social support, eating-related disabilities and age. The effects of mood and social support are well-recognised, whilst nutrition-related effects have previously received little attention. Intervention in these areas might achieve improvements in survivors' perceived QoL.

Defining guilt in depression: a comparison of subjects with major depression, chronic medical illness and healthy controls

BACKGROUND

Although guilt is a widely accepted feature of depression, there is limited and inconsistent data defining the nature of this symptom. The purpose of the current study was to examine the specificity and nature of guilt in subjects with major depression as compared to patients with another chronic medical illness and healthy controls.

METHODS

Outpatients with current major depressive episode (MDE; n=34), past-MDE (n=22), chronic cardiac illness (n=20) and healthy controls (n=59) were administered the following measures: The Guilt Inventory (GI), State Shame and Guilt Scale (SSGS), 17-item Hamilton Rating Scale for Depression (Ham-D) and the Structured Clinical Interview for DSM-IV.

RESULTS

Overall multivariate analysis of covariance comparing mean scores for the six guilt subscales [state-guilt, trait-guilt, moral standards (from the GI); state-guilt, -pride, and -shame (from the SSGS)] across the four groups was significant (F=9.1, df=6:121, p<0.0001). Post-hoc analysis revealed the following differences (each at least p<0.01): for state-guilt (GI), current-MDE>past-MDE>cardiac=healthy controls; for trait-guilt (GI), current-MDE=past-MDE>cardiac=healthy controls; for state-shame, -guilt and -pride (SSGS), current-MDE>past-MDE, past-MDE=cardiac, past-MDE>healthy, cardiac=healthy controls. Among depressed patients, there was significant correlation between Ham-D score and all guilt sub-scales (p<0.01), except moral standards.

LIMITATIONS

The cardiac group may have less illness burden than currently depressed.

CONCLUSIONS

State expression of guilt, shame and low pride distinguish acutely depressed from all other groups, and are highly influenced by severity of depression. Trait-guilt does not differentiate acute from past depressed. Data suggests guilt may represent both an enduring and fluctuating feature of depressive illness over its longitudinal course.

Psychosocial factors as predictors of maternal well-being and pregnancy-related complaints

The aim of the current study was to investigate the effects of psychosocial variables on well-being and on pregnancy-related complaints throughout pregnancy. Three hundred and ninety-six nulliparous women completed questionnaires on number of daily stressors, social support, gestational factors and mental and physical work load in each trimester of pregnancy. In addition, the following dependent measures were assessed: depression, anxiety, somatic complaints, and the pregnancy-related complaints fatigue, nausea and back pain. The independent variables predicted depression best (r2 = 42-44%), followed by anxiety (R2 = 13-20) and somatic complaints (R2 = 16-21%). Number of daily stressors explained most of the variance. Satisfaction with social support and maternal age were negatively correlated with depression. In contrast, pregnancy-related complaints could be less accurately predicted by psychosocial factors. The amount of explained variance for fatigue ranged between 6 and 10%, for nausea between 2 and 6%, and for back pain between 5 and 7% for the three trimesters. It is concluded that depressive symptoms during pregnancy are associated with negative psychosocial factors, particularly the number of daily stressors and low satisfaction with received social support. To a lesser degree, this is also the case with anxiety and somatic complaints. Pregnancy-related complaints, on the other hand, appear to be relatively independent of psychosocial conditions.

The Cronholm-Ottosson Depression Scale: the first depression scale designed to rate changes during treatment

In 1960 Ottosson published the first specific depression rating scale (the Cronholm-Ottosson Depression Scale) designed to be sensitive in measuring change during antidepressive therapy. Ottosson and his group have never used factor analysis to validate the scale, as the items of the scale were used factor analysis to validate the scale, as the items of the scale were selected on a preconceived idea for homogeneity, i.e. having a monotonic correspondence to the underlying dimension of severity of depression. The most appropriate method of testing the construct validity of the Cronholm-Ottosson Depression Scale is latent structure analysis. Using the original Ottosson data, a latent structure analysis has been made showing that the 8 items of the scale are homogeneously related, i.e. can be ordered on one dimension of severity of depression. The descriptive statistic of a 50% reduction of pretreatment score (or more) equaled the global clinical score of moderate to excellent improvement. Both scales showed that, already after 4 electroconvulsive treatments, about 80% of depressed patients who received adequate fits had moderate to excellent improvement, whereas only around 40% of depressed patients who received inadequate fits improved moderately or excellently.

Secondary depression in panic disorder: an indicator of severity with a weak effect on outcome in alprazolam and imipramine treatment

Depressive symptoms are frequent in panic disorder. Among 123 Scandinavian patients participating in a placebo-controlled multicenter study of the efficacy of alprazolam and imipramine treatment in panic disorder, 21% and 23% fulfilled the DSM-III criteria of current and past major depressive episode, respectively, and 17% had dysthymia, even when melancholia and depressive episode with onset prior to the panic symptoms were excluded. According to a subscale of the Hamilton Rating Scale for Depression (HRSD) with higher validity than the full scale, 18% were classified as major depression and 57% as minor depression. A major finding was that patients with affective symptoms had higher scores on many psychopathological measures, including several Symptom Checklist-90 factors. Accordingly, secondary depression was suggested as an indicator of the severity of panic disorder. Depressed and nondepressed patients significantly improved on major outcome measures, but patients with current minor or major depression improved less. Although the sample was too small for detailed analysis of differences in drug efficacy, there was no indication that imipramine was more effective than alprazolam, considering scores on an HRSD subscale.