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

Elemental psychopathology: distilling constituent symptoms and patterns of repetition in the diagnostic criteria of the DSM-5

BACKGROUND

The DSM-5 features hundreds of diagnoses comprising a multitude of symptoms, and there is considerable repetition in the symptoms among diagnoses. This repetition undermines what we can learn from studying individual diagnostic constructs because it can obscure both disorder- and symptom-specific signals. However, these lost opportunities are currently veiled because symptom repetition in the DSM-5 has not been quantified.

METHOD

This descriptive study mapped the repetition among the 1419 symptoms described in 202 diagnoses of adult psychopathology in section II of the DSM-5. Over a million possible symptom comparisons needed to be conducted, for which we used both qualitative content coding and natural language processing.

RESULTS

In total, we identified 628 distinct symptoms: 397 symptoms (63.2%) were unique to a single diagnosis, whereas 231 symptoms (36.8%) repeated across multiple diagnoses a total of 1022 times (median 3 times per symptom; range 2-22). Some chapters had more repetition than others: For example, every symptom of every diagnosis in the bipolar and related disorders chapter was repeated in other chapters, but there was no repetition for any symptoms of any diagnoses in the elimination disorders, gender dysphoria or paraphilic disorders. The most frequently repeated symptoms included insomnia, difficulty concentrating, and irritability - listed in 22, 17 and 16 diagnoses, respectively. Notably, the top 15 most frequently repeating diagnostic criteria were dominated by symptoms of major depressive disorder.

CONCLUSION

Overall, our findings lay the foundation for a better understanding of the extent and potential consequences of symptom overlap.

Standardized Extract of Valeriana officinalis Improves Overall Sleep Quality in Human Subjects with Sleep Complaints: A Randomized, Double-Blind, Placebo-Controlled, Clinical Study

INTRODUCTION

Sleep deficit or poor sleep leads to ill-health, whereas sleep deprivation for longer periods of time increases the risk of developing adverse conditions associated with poor quality of life, and high socioeconomic impact. The treatments for sleep disturbances include melatonin and over-the-counter medicines like diphenhydramine and doxylamine, all of which have negative side effects. Valerian (Valeriana officinalis L.) is a traditional herb and the most preferred alternate sleep solution to manage sleep complaints.

METHODS

Eighty adult subjects with sleep complaints were randomized in 1:1 ratio to receive either V. officinalis extract (VE) or placebo for 8 weeks in a double-blind, placebo-controlled, parallel, clinical study. Primary efficacy endpoints included the Pittsburgh Sleep Quality Index (PSQI) and sleep latency using wrist actigraphy (WA), as well as a number of secondary endpoints, including sleep parameters such as actual sleep time and sleep efficiency using WA, the Epworth Sleepiness Scale (ESS), the Beck Anxiety Inventory (BAI), the Visual Analogue Scale (VAS) for the feeling of waking up refreshed, and a tertiary endpoint of sleep parameters using polysomnography (PSG) in a subset of 20 subjects per group. Safety parameters included physical examination, vital sign measurements, hematology, and clinical chemistry tests. Adverse events and serious adverse events were monitored throughout the study period.

RESULTS

Seventy-two subjects (35 and 37 subjects in the placebo and VE groups, respectively) completed the study and were included in the efficacy assessments. On Days 14, 28, and 56, the PSQI Total Score in the VE group decreased significantly (p < 0.05) compared to the placebo group. Further, the VE group showed significant improvements (p < 0.05) in sleep latency and actual sleep time on Days 3, 14, 28, and 56, and sleep efficiency on Days 14, 28, and 56, as evaluated by WA. There was a decrease (p < 0.05) in anxiety (BAI) on Days 14, 28, and 56, daytime drowsiness (ESS) on Days 28 and 56, and an increased feeling of waking up refreshed (VAS) on Days 28 and 56 compared to placebo. PSG results carried out in subset of subjects revealed significant improvements (p < 0.05) in total sleep time, sleep latency, and sleep efficiency on Day 56 in the VE group compared to the placebo group. No safety concerns were observed throughout the study.

CONCLUSION

VE supplementation significantly improved various subjective and objective parameters of sleep in young subjects with mild insomnia symptoms, such as overall sleep quality, sleep latency, sleep efficiency, and total sleep time. We also observed decreased anxiety and daytime sleepiness, and improved feeling of being refreshed after waking up with VE supplementation. VE was found to be safe and well tolerated throughout the study.

TRIAL REGISTRATION

Clinical Trials Registry of India: CTRI/2022/05/042818.

Positive valence system function and anhedonia in middle-aged and older adults at high suicide risk

Positive valence systems are disrupted in late-life depression and in individuals at risk for suicide. The reward positivity (RewP) is an event-related potential measure of positive valence system function that relates to depression and anhedonia in children and young adults. However, it is unclear whether a reliable RewP signal can be elicited in middle-aged and older adults at high risk for suicide and, if so, whether this signal is similarly associated with clinical symptoms. In the current study, a RewP was elicited with a standard gambling task in middle-aged and older adults (N = 31) at discharge from a hospitalization for suicidal thought or behaviors. The resulting electrocortical response differed significantly for monetary wins compared to losses. Internal reliability of the RewP and the feedback negativity (FN) to monetary loss was good to excellent. Internal reliability of difference measures was lower but still largely acceptable, with residualized differences scores demonstrating stronger reliability than subtraction-based scores. A smaller residualized RewP, after accounting for the influence of the FN, was associated with greater severity of lassitude, an index of appetitive anhedonia. These findings set the groundwork for future studies of positive valence system function and depression in middle-aged and older adults at high risk for suicide.

Major depressive disorder

Major depressive disorder (MDD) is characterized by persistent depressed mood, loss of interest or pleasure in previously enjoyable activities, recurrent thoughts of death, and physical and cognitive symptoms. People with MDD can have reduced quality of life owing to the disorder itself as well as related medical comorbidities, social factors, and impaired functional outcomes. MDD is a complex disorder that cannot be fully explained by any one single established biological or environmental pathway. Instead, MDD seems to be caused by a combination of genetic, environmental, psychological and biological factors. Treatment for MDD commonly involves pharmacological therapy with antidepressant medications, psychotherapy or a combination of both. In people with severe and/or treatment-resistant MDD, other biological therapies, such as electroconvulsive therapy, may also be offered.

Effect of sleep disorders on the risks of cancers and site-specific cancers

PURPOSE

Whether preexisting sleep disorder is an independent risk factor for cancer remains unclear. Therefore, we performed this propensity score-matched population-based cohort study to compare the incidence rate ratios (IRRs) of specific cancers between patients with and without sleep disorders.

PATIENTS AND METHODS

Patients were categorized into two groups on the basis of the presence or absence of sleep disorders and matched at a 1:1 ratio.

RESULTS

Propensity score matching yielded a final cohort of 289,162 patients (i.e., 144,581 and 144,581 in the sleep disorder and nonsleep disorder groups, respectively) who were eligible for further analysis. In multivariate Cox regression analysis, the adjusted hazard ratio (aHR; 95% confidence interval [CI]) of cancer risk in the sleep disorder group compared with the nonsleep disorder group was 1.07 (1.04-1.12; P = 0.0001). Furthermore, the adjusted IRRs (95% CIs) for all cancers, breast cancer, and ovarian cancer in the patients with sleep disorders were 1.08 (1.02-1.18), 1.20 (1.08-1.32), and 1.30 (1.10-1.52), respectively.

CONCLUSION

The results suggested that sleep disorders are a significant risk factor for all cancers, breast cancer, and ovarian cancer.

Aerobic Exercise Alleviates the Impairment of Cognitive Control Ability Induced by Sleep Deprivation in College Students: Research Based on Go/NoGo Task

The purpose of this study was to observe whether aerobic exercise is able to alleviate the impairment of cognitive control ability in college students by sleep deprivation through cognitive control (Go-NoGo task) and blood-based markers. Taking 30 healthy college students (15 males and 15 females) as participants, using a random cross-over design within groups, respectively perform one night of sleep deprivation and one night of normal sleep (8 h). The exercise intervention modality was to complete a 30-min session of moderate-intensity aerobic exercise on a power bicycle. Change in cognitive control was assessed using the Go/NoGo task paradigm; 5-ht and blood glucose contentwere determined by enzyme-linked immuno sorbent assay and glucose oxidase electrode Measurement, respectively. The results showed that sleep deprivation could significantly reduce the response inhibition ability and response execution ability, and significantly reduce the blood 5-ht content (p< 0.01). Thirty minutes of moderate intensity aerobic exercise intervention significantly increased response inhibition ability and response execution ability, significantly increased blood 5-ht content (p<0.01), and did not change serum glucose levels. Conclusion: An acute aerobic exercise can alleviate the cognitive control impairment caused by sleep deprivation, and 5-ht may be one of the possible mechanisms by which aerobic exercise alleviates the cognitive control impairment caused by sleep deprivation.

Childhood Obesity Is Associated with Poor Academic Skills and Coping Mechanisms

OBJECTIVE

To assess the relationship between obesity and select childhood flourishing markers including academic skills and coping strategies.

STUDY DESIGN

Cross-sectional study utilizing parental reported data for children aged 10-17 years (n = 22 914) from the 2016 National Survey of Children's Health. Multiple binary regressions assessed the association between body mass index-for-age and 5 school-related and behavioral childhood flourishing markers independently and combined, including completing homework, showing interest in learning, finishing tasks, staying calm when challenged, and caring about academics. Analyses were adjusted for age, sex, depression, sleep, digital media exposure, poverty, and parental education level.

RESULTS

Only 28.9% of children with obesity were reported to have all 5 markers, compared with 38% with overweight, and 40.5% with normal body mass index. In an adjusted model, children with obesity had significantly decreased odds of demonstrating 4 of 5 markers: showing interest in learning (aOR, 0.78; 95% CI, 0.62-0.97), finishing tasks (aOR, 0.77; 95% CI, 0.63-0.94), staying calm when challenged (aOR, 0.73; 95% CI, 0.59-0.90), and caring about academics (aOR, 0.69; 95% CI, 0.55-0.86). Completing homework was not associated with obesity. Youth with obesity also had 23% decreased odds (aOR, 0.77; 95% CI, 0.61-0.98) of meeting the combined measure for flourishing markers.

CONCLUSIONS

Childhood obesity is associated with poor academic skills and coping strategies which may lead to worse individual and public health outcomes. Further studies are needed to create validated flourishing measures and identify interventions that promote healthy youth behavior and academic success.

The clinical characterization of the adult patient with depression aimed at personalization of management

Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.

Screen viewing behavior and sleep duration among children aged 2 and below

Background

Few studies have investigated the association between screen viewing (SV) and sleep duration among young children. This study aims to examine the association between total and device-specific SV and sleep duration among children aged 2 and below.

Methods

We conducted a cross-sectional study of 714 Singaporean children aged 2 years and below. Parents were recruited during routine well-child clinic visits from two national polyclinics. In Singapore, all parents visit well-child clinics with their children at regular intervals for routine check-ups and vaccinations. Socio-demographic characteristics, duration of total and device-specific SV, and sleep duration were reported by parents via interviewer-administered questionnaires. Multiple linear regression analysis was used to assess associations between various types of SV and sleep duration, adjusted for socio-demographic variables. Due to significant interaction between SV and age, stratified analyses for children aged less than 6 months and those aged 7–24 months were performed.

Results

The prevalence of daily SV among children was 53.1%; 28.3% in children up to 6 months and 73.8% in children aged 7 to 24 months. TV viewing was reported for 44.3% of all children and mobile device SV for 30.1%. Children’s average sleep duration was 13.9 (SD = 3.5) hours daily and younger children had longer sleep duration than older ones (up to 6 months: mean = 15.6 h, SD = 3.9; 7–24 months: mean = 12.4 h, SD = 2.2; P < 0.01). In the regression analysis among all children, each 1 h per day increment in total SV was significantly associated with 0.26 h shorter sleep duration with similar significant associations for TV (β = − 0.28 h, 95%CI: -0.50, − 0.06) and mobile devices (β = − 0.35 h, 95%CI: -0.61, − 0.09). Stratified analysis revealed significantly greater reductions in sleep with higher SV among children aged 6 months and below (β = − 0.73 h, 95%CI: -1.12, − 0.34), while associations were weaker in older children (β = − 0.13 h, 95% CI: -0.24, − 0.01).

Conclusions

This study provides evidence for a substantial association between longer SV and shorter sleep duration among very young children. These associations appeared stronger among children aged 6 months and below as compared with those aged 7 to 24 months. Further studies are warranted to confirm our findings.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6385-6) contains supplementary material, which is available to authorized users.

Adaptation and testing of an assessment for mental health and alcohol use problems among conflict-affected adults in Ukraine

Background

In Ukraine, a large number of internally displaced persons (IDPs) and veterans experience social and psychological problems as a result of the ongoing conflict between Ukraine and Russia. Our purpose was to develop reliable and valid instruments to screen for common mental health and alcohol use problems in these populations.

Methods

We used a three-step process of instrument adaptation and testing. The instrument-the Mental Health Assessment Inventory (MHAI)-combines adapted standard screeners with items derived locally in Ukraine. A validity study was conducted using a sample of 153 adults (54% male) ages 18 years and older. All participants in the sample were IDPs or veterans living in or near the major urban areas of Kyiv and Zaporizhia. Reliability testing (internal consistency, test-retest) and validity testing (construct, criterion) of the MHAI were conducted using classical test theory. After initial testing, we used Item Response Theory (IRT) to shorten and further refine the instrument.

Results

The MHAI showed good internal consistency and test-retest reliability for the main outcomes: depression (α = 0.94; r = .84), post-traumatic stress (PTS; α = 0.97; r = 0.87), anxiety (α = 0.90; r = 0.80), and alcohol use (α = 0.86; r = 0.91). There was good evidence of convergent construct validity among the scales for depression, PTS, and anxiety, but not for alcohol use. Item Response Theory (IRT) analysis supported use of shortened versions of the scales for depression, PTS, and anxiety, as they retained comparable psychometric properties to the full scales of the MHAI.

Conclusion

The findings support the reliability and validity of the assessment-the MHAI-for screening of common mental health problems among Ukrainian IDPs and veterans. Use of IRT shortened the instrument to improve practicality and potential sustainability.

Longitudinal Associations Between Anhedonia and Body Mass Index Trajectory Groups Among Adolescents

PURPOSE

Although evidence suggests that anhedonia-a reduced ability to experience pleasure in response to rewarding stimuli-may predict weight gain during adolescence, it remains unclear whether changes in anhedonia during adolescence are associated with changes in body mass index (BMI). This study examines longitudinal associations between changes in anhedonia and developmental trajectories of BMI during adolescence.

METHODS

Self-report measures of anhedonia and BMI were collected at five semiannual assessments among students from 10 high schools in Los Angeles, CA, area (N = 3,396) followed up from the 9th grade to the 11th grade. Four BMI trajectories were identified using growth mixture modeling: (1) stable normative weight; (2) overweight to normative weight (i.e., decreasing BMI); (3) overweight to chronically obese (increasing BMI); and (4) normative weight to overweight (increasing BMI). Latent growth curve modeling estimated baseline level and changes in anhedonia. A multinomial logistic regression model tested associations of baseline level and slope of anhedonia with the four BMI trajectory groups.

RESULTS

Compared with the stable normative BMI trajectory group, each 1-unit standard deviation increase in anhedonia slope increased the odds of membership in the overweight to chronically obese group (odds ratio [OR] [95% confidence interval {CI}] = 1.29 [1.09-1.49], p < .001) and in the normative weight to overweight group (OR [95% CI] = 1.28 [1.04-1.53], p = .006), and decreased the odds of membership in the overweight to normative weight group (OR [95% CI] = .78 [.57-.95], p = .01).

CONCLUSIONS

Across a 2-year period of high school, the rate of change in anhedonia is associated with certain BMI trajectories linked with poorer metabolic health. Increasing anhedonia may be an important risk factor to consider in adolescent obesity prevention.

Targeting and transforming major depression

OBJECTIVE

To detail limitations to the construct of 'major depression', argue for repositioning it as a proxy for 'clinical depression' and then operationalize it and its principal constituent depressive subtypes, while preserving the DSM criteria-based format.

METHOD

We summarize limitations to major depression being viewed as a diagnostic entity. Data from 391 clinically depressed patients were analysed to identify high-prevalence non-specific depressive symptoms to define 'clinical depression' as well as the features showing specificity to a melancholic depressive subtype.

RESULTS

We identified a set of high-prevalence and generalized symptoms for defining clinical depression and with many being current criteria for major depression. We also developed a refined set of melancholic features and with their underlying distributions generating two classes that correlated strongly with clinical diagnoses of a melancholic or non-melancholic depression, thus validating its capacity to so differentiate. We append criteria sets for diagnosing clinical depression and its principal diagnostic subtypes (psychotic, melancholic and non-melancholic).

CONCLUSION

This heuristic study reframes and modifies major depression's criteria set to define a domain of clinical depression with additional criteria and then allowing the delineation of three diagnostic subtypes. If this paradigm shift is accepted and further refined, greater precision in diagnosis, treatment and research would be anticipated.

Has the symptom severity inclusion requirement narrowed the definition of major depressive disorder in antidepressant efficacy trials?

BACKGROUND

The inclusion criteria of all placebo-controlled studies of antidepressants have required a minimum level of severity on standardized measures of symptoms of depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between scores on the Hamilton Depression Rating Scale (HAMD) and the number of criteria met for MDD, as well as the impact of different HAMD cutoff scores on the distribution of the number of DSM-IV criteria met. We speculated that the use of a minimum symptom severity score (MSSS) for inclusion in an antidepressant efficacy trial (AETs) disproportionately excludes patients who are at or just above the diagnostic threshold for MDD, whereas patients who are well above the diagnostic threshold are not excluded.

METHODS

Seven hundred forty outpatients with current MDD were evaluated with a semi-structured diagnostic interview. We compared the distribution of DSM-IV MDD criteria scores in patients who scored at or above or below the 3 cutoff scores on the HAMD most commonly used for inclusion in an AET.

RESULTS

The distribution of the number of DSM-IV MDD symptom criteria met was significantly associated with HAMD scores. Compared to patients scoring below 18 on the HAMD the patients scoring 18 and above were less likely to report 5 MDD criteria (13.9% vs. 43.7%, χ²=82.2, p<0.001; RR 0.32 [95% C.I. 0.24-0.41]) and more likely to report 9 criteria (9.3% vs. 0.3%, χ²=27.6, p<0.001; RR 28.7 [95% C.I. 4.0-207.5]). The pattern was similar when comparing patients scoring above and below the cutoffs of 20 and 22. At a cutoff of 22 on the HAMD more than 85% of the patients meeting 5 or 6 MDD criteria would be excluded from a trial. In contrast, less than 10% of the patients meeting 8 or 9 criteria would be excluded based on a HAMD cutoff of 18.

LIMITATIONS

The present study was conducted in a single outpatient practice in which the majority of patients were white, female, and had health insurance. Although the study was limited to a single site, a strength of the recruitment procedure was that the sample was not selected for participation in a treatment study, and exclusion and inclusion criteria did not reduce the representativeness of the patient groups.

CONCLUSIONS

While there is not a perfect relationship between the HAMD score and the number of DSM MDD criteria present, the results of the current study suggest that HAMD scores can be thought of as a proxy for the number of DSM diagnostic criteria. Thus, the recruitment strategy for AETs has increasingly redefined the MDD diagnostic category by requiring a greater number of criteria than that required in the DSM.

Preferences of psychiatric practitioners for core symptoms of major depressive disorder: a hidden conjoint analysis

According to ICD-10 and DSM-V, symptoms of depressive disorder are considered to be equally important for severity judgment. It was the goal to investigate the weight of selected symptom complexes for severity judgment. In workaday life severity judgment results from an overall impression rather than from calculating severity in different symptom complexes, separately. In fact, the drivers for overall judgment may not be known explicitly to the psychiatrist himself. A method of choice to resolve this is conjoint analysis. Based on the Montgomery-Asberg Depression Scale (MADRS) and the Sheehan Disability Scale (SDS) case vignettes were constructed. Different symptom severity in the domains mood, vegetative symptoms, cognition/inhibition, suicidality, and everyday functioning were worked into the vignettes. Different symptom complexes influence the severity judgment by clinical psychiatrists to a rather different extent. Mood has a greater impact on severity judgment than suicidality, cognition/inhibition, vegetative symptoms, and everyday functioning. We conclude that core complexes of major depressive disorder are valued with different clinical relevance by psychiatrists. Thus, diagnosis and appraisal of therapeutic efficacy are subject to individual preferences of clinical psychiatrists and prevalence and therapeutic efficacy may be over- or under-estimated unless these differences in preferences are taken into account.

Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches

BACKGROUND

The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously.

OBJECTIVES

The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity.

RESULTS

Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.

CONCLUSION

Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

Smoking-related correlates of psychomotor restlessness and agitation in a community sample of daily cigarette smokers

BACKGROUND AND OBJECTIVES

Psychomotor restlessness and agitation (PMA) is a putatively important, yet understudied, psychopathologic correlate of smoking. The scant smoking research on PMA previously conducted has been narrow in scope and conducted among psychiatric patients. To examine the generalizability and relevance of PMA to smoking, this cross-sectional study investigated associations between PMA and a variety of smoking processes in a community sample.

METHODS

Participants in this study were non-treatment-seeking smokers (N = 254, ≥10 cig/day, M age = 44 years) from the community without an active mood disorder. At baseline, they completed a PMA symptom checklist, a composite depressive symptom index, and a battery of smoking questionnaires.

RESULTS

Linear regression models adjusting for depressive symptoms and demographics indicated that PMA level was positively associated with severity of nicotine withdrawal symptoms during prior quit attempts (β = .18, p < .05), anticipated likelihood of withdrawal in a future quit attempt (β = .19, p < .05), motivation to smoke for negative reinforcement (β = .14, p < .05), and smoking expectancies for negative reinforcement (β = .17, p < .05), negative consequences (β = .22, p < .01), and positive reinforcement (β = .14, p < .05). PMA was not significantly associated with smoking chronicity, frequency, or dependence severity.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Smokers with elevated PMA appear to experience greater smoking-induced affect modulation and nicotine withdrawal than the average smoker, regardless of other depressive symptoms. Given that PMA differentiates a qualitatively unique profile of smoking characteristics, PMA warrants consideration in tobacco addiction research and practice.

Clinical Significance of the Number of Depressive Symptoms in Major Depressive Disorder: Results from the CRESCEND Study

Our study aimed to establish the relationship between the number of depressive symptoms and the clinical characteristics of major depressive disorder (MDD). This would enable us to predict the clinical significance of the number of depressive symptoms in MDD patients. Using data from the Clinical Research Center for Depression (CRESCEND) study in Korea, 853 patients with DSM-IV MDD were recruited. The baseline and clinical characteristics of groups with different numbers of depressive symptoms were compared using the χ(2) test for discrete variables and covariance (ANCOVA) for continuous variables. In addition, the scores of these groups on the measurement tools were compared by ANCOVA after adjusting the potential effects of confounding variables. After adjusting the effects of monthly income and history of depression, a larger number of depressive symptoms indicated higher overall severity of depression (F [4, 756] = 21.458, P < 0.001) and higher levels of depressive symptoms (F [4, 767] = 19.145, P < 0.001), anxiety symptoms (F [4, 765] = 12.890, P < 0.001) and suicidal ideation (F [4, 653] = 6.970, P < 0.001). It also indicated lower levels of social function (F [4, 760] = 13.343, P < 0.001), and quality of life (F [4, 656] = 11.975, P < 0.001). However, there were no significant differences in alcohol consumption (F [4, 656] = 11.975, P < 0.001). The number of depressive symptoms can be used as an index of greater illness burden in clinical psychiatry.

Association between depression and survival in Chinese amyotrophic lateral sclerosis patients

To determine the prevalence of depression, to identify correlated factors for depression, and to explore the impact on the progression or survival of amyotrophic lateral sclerosis (ALS) by depression in a Chinese population. A total of 166 ALS patients were recruited. Diagnosis of depression disorders and the severity of depression were established by using the fourth diagnostic and statistical manual of mental disorders, Hamilton Depression Rating Scale-24 items (HDRS-24) and Beck Depression Inventory (BDI). Major depression was found in 15 patients (9.6 %). The multiple regression analysis showed that a lower ALS Functional Rating Scale-Revised (ALSFRS-R) score was correlated with increasing HDRS scores and BDI scores (P = 0.018 and P = 0.012). No significant difference in the median survival time between ALS patients with and without depression was revealed by Kaplan-Meier analysis (log-rank P = 0.282). Cox hazard model showed that the presence of depression in ALS was unrelated to the survival, while the severity of depression in ALS was correlated with the survival. The presence and severity of depression in ALS did not correlate with the progression of ALS. Major depression in ALS is uncommon. Depression evaluation should be given to ALS patients, especially those with lower ALSFRS-R score. The severity of depression may be associated with the survival; however, depression does not worse the progression of ALS.

What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis

BACKGROUND

The symptoms for Major Depression (MD) defined in the DSM-5 differ markedly from symptoms assessed in common rating scales, and the empirical question about core depression symptoms is unresolved. Here we conceptualize depression as a complex dynamic system of interacting symptoms to examine what symptoms are most central to driving depressive processes.

METHODS

We constructed a network of 28 depression symptoms assessed via the Inventory of Depressive Symptomatology (IDS-30) in 3,463 depressed outpatients from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. We estimated the centrality of all IDS-30 symptoms, and compared the centrality of DSM and non-DSM symptoms; centrality reflects the connectedness of each symptom with all other symptoms.

RESULTS

A network with 28 intertwined symptoms emerged, and symptoms differed substantially in their centrality values. Both DSM symptoms (e.g., sad mood) and non-DSM symptoms (e.g., anxiety) were among the most central symptoms, and DSM criteria were not more central than non-DSM symptoms.

LIMITATIONS

Many subjects enrolled in STAR*D reported comorbid medical and psychiatric conditions which may have affected symptom presentation.

CONCLUSION

The network perspective neither supports the standard psychometric notion that depression symptoms are equivalent indicators of MD, nor the common assumption that DSM symptoms of depression are of higher clinical relevance than non-DSM depression symptoms. The findings suggest the value of research focusing on especially central symptoms to increase the accuracy of predicting outcomes such as the course of illness, probability of relapse, and treatment response.

Anhedonia and the relative reward value of drug and nondrug reinforcers in cigarette smokers

Anhedonia-a psychopathologic trait indicative of diminished interest, pleasure, and enjoyment-has been linked to use of and addiction to several substances, including tobacco. We hypothesized that anhedonic drug users develop an imbalance in the relative reward value of drug versus nondrug reinforcers, which could maintain drug use behavior. To test this hypothesis, we examined whether anhedonia predicted the tendency to choose an immediate drug reward (i.e., smoking) over a less immediate nondrug reward (i.e., money) in a laboratory study of non-treatment-seeking adult cigarette smokers. Participants (N = 275, ≥10 cigarettes/day) attended a baseline visit that involved anhedonia assessment followed by 2 counterbalanced experimental visits: (a) after 16-hr smoking abstinence and (b) nonabstinent. At both experimental visits, participants completed self-report measures of mood state followed by a behavioral smoking task, which measured 2 aspects of the relative reward value of smoking versus money: (1) latency to initiate smoking when delaying smoking was monetarily rewarded and (2) willingness to purchase individual cigarettes. Results indicated that higher anhedonia predicted quicker smoking initiation and more cigarettes purchased. These relations were partially mediated by low positive and high negative mood states assessed immediately prior to the smoking task. Abstinence amplified the extent to which anhedonia predicted cigarette consumption among those who responded to the abstinence manipulation, but not the entire sample. Anhedonia may bias motivation toward smoking over alternative reinforcers, perhaps by giving rise to poor acute mood states. An imbalance in the reward value assigned to drug versus nondrug reinforcers may link anhedonia-related psychopathology to drug use.

Suicidal ideation and sex differences in relation to 18 major psychiatric disorders in college and university students: anonymous web-based assessment

College/university students are at high risk for psychiatric disorder and suicide secondary to age, campus stressors, and social pressures. We therefore report frequencies of 18 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision disorders and suicidal ideation (SI) acquired anonymously from a Web site receiving 113,181 visits from more than 1,500 predominantly US colleges/universities. Depression was foremost, followed by social phobia and eating disorders. Substance-related disorders were less frequent than expected. SI occurred in 47.1% of students, with women evidencing somewhat stronger findings than men. SI was more associated with substance, bipolar, and panic disorders than depression. Self-reported emotional volatility exceeded thoughts of self-harm for all disorders. The results support two subtypes of suicide risk: dysphoric premeditators and those primarily angry and/or impulsive. Clinicians and researchers should therefore consider suicide as an independent psychopathological phenomenon that includes emotional volatility as a risk factor and thoroughly evaluate psychiatric disorders potentially conferring greater suicidal propensity than depression.

In Search of a Safe Natural Sleep Aid

Sleep deprivation is associated with an elevated risk of various diseases and leads to a poor quality of life and negative socioeconomic consequences. Sleep inducers such as drugs and herbal medicines may often lead to dependence and other side effects. L-Theanine (γ-glutamylethylamide), an amino acid naturally found abundant in tea leaves, has anxiolytic effects via the induction of α brain waves without additive and other side effects associated with conventional sleep inducers. Anxiolysis is required for the initiation of high-quality sleep. In this study, we review the mechanism(s), safety, and efficacy of L-theanine. Collectively, sleep studies based on an actigraph, the obstructive sleep apnea (OSA) sleep inventory questionnaire, wakeup after sleep onset (WASO) and automatic nervous system (ANS) assessment, sympathetic and parasympathetic nerve activities, and a pediatric sleep questionnaire (PSQ) suggest that the administration of 200 mg of L-theanine before bed may support improved sleep quality not by sedation but through anxiolysis. Because L-theanine does not induce daytime drowsiness, it may be useful at any time of the day. The no observable adverse effect level (NOAEL) for the oral administration of L-theanine was determined to be above 2000 mg/kg bw/day. KEY TEACHING POINTS: Sleep deprivation-associated morbidity is an increasing public health concern posing a substantial socioeconomic burden. Chronic sleep disorders may seriously affect quality of life and may be etiological factors in a number of chronic diseases such as depression, obesity, diabetes, and cardiovascular diseases. Most sleep inducers are sedatives and are often associated with addiction and other side effects. L-Theanine promotes relaxation without drowsiness. Unlike conventional sleep inducers, L-theanine is not a sedative but promotes good quality of sleep through anxiolysis. This review suggests that L-theanine is a safe natural sleep aid.

Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study

BACKGROUND

The DSM-5 encompasses a wide range of symptoms for Major Depressive Disorder (MDD). Symptoms are commonly added up to sum-scores, and thresholds differentiate between healthy and depressed individuals. The underlying assumption is that all patients diagnosed with MDD have a similar condition, and that sum-scores accurately reflect the severity of this condition. To test this assumption, we examined the number of DSM-5 depression symptom patterns in the "Sequenced Treatment Alternatives to Relieve Depression" (STAR*D) study.

METHODS

We investigated the number of unique symptom profiles reported by 3703 depressed outpatients at the beginning of the first treatment stage of STAR*D.

RESULTS

Overall, we identified 1030 unique symptom profiles. Of these profiles, 864 profiles (83.9%) were endorsed by five or fewer subjects, and 501 profiles (48.6%) were endorsed by only one individual. The most common symptom profile exhibited a frequency of only 1.8%. Controlling for overall depression severity did not reduce the amount of observed heterogeneity.

LIMITATIONS

Symptoms were dichotomized to construct symptom profiles. Many subjects enrolled in STAR*D reported medical conditions for which prescribed medications may have affected symptom presentation.

CONCLUSIONS

The substantial symptom variation among individuals who all qualify for one diagnosis calls into question the status of MDD as a specific consistent syndrome and offers a potential explanation for the difficulty in documenting treatment efficacy. We suggest that the analysis of individual symptoms, their patterns, and their causal associations will provide insights that could not be discovered in studies relying on only sum-scores.

Clinical preference for factors in treatment of geriatric depression

Little is known about symptom preferences of clinical psychiatrists in the treatment of geriatric depression and preferences for avoiding adverse drug effects. Participants (board-certified psychiatrists) were recruited prior to a lecture on geriatric depression during a continuing education program. An analytic hierarchy process was performed and participants were asked for pairwise comparison of criteria guiding them in appraising therapeutic efficacy, and in avoiding toxicity and adverse events. Of the 61 participants from the continuing education program, 42 (69%) returned their data sheet. Avoidance of cardiotoxicity was regarded as more important than avoidance of hepatotoxicity or hematotoxicity. Concerning adverse events, highest preference was given to avoidance of falls and drug interactions, followed by avoidance of sedation, weight change, and impairment of sexual function. The most important preferences for appraisal of therapeutic efficacy were suicidality over ability to concentrate and sleep. Clinical psychiatrists have a hierarchy of preferences for treatment goals and avoidance of adverse events and toxicity. This raises the question for future research whether these preferences cause differences in prescription patterns in clinical practice even though a multitude of antidepressants are similarly effective when judged with instruments used in clinical trials.

Anxiety, depression, and cigarette smoking: a transdiagnostic vulnerability framework to understanding emotion-smoking comorbidity

Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes, with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking: (a) anhedonia (Anh; diminished pleasure/interest in response to rewards), (b) anxiety sensitivity (AS; fear of anxiety-related sensations), and (c) distress tolerance (DT; ability to withstand distressing states). We conclude that Anh, AS, and DT collectively (a) underpin multiple emotional psychopathologies, (b) amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking, (c) promote progression across the smoking trajectory (i.e., initiation, escalation/progression, maintenance, cessation/relapse), and (d) are promising targets for smoking intervention. After existing gaps are identified, an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects, AS amplifies smoking's anxiolytic effects, and poor DT amplifies smoking's distress terminating effects. Collectively, these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation, progression, maintenance, cessation avoidance, and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

How many different ways do patients meet the diagnostic criteria for major depressive disorder?

There are 227 possible ways to meet the symptom criteria for major depressive disorder (MDD). However, symptom occurrence is not random, and some symptoms co-occur significantly beyond chance. This raises the questions of whether all of the theoretically possible different ways of meeting the MDD criteria actually occur in patients, and whether some combinations of criteria are much more common than others. More than 1500 patients who met DSM-IV criteria for MDD at the time of the evaluation were interviewed with semi-structured interviews. The patients met the MDD symptom criteria in 170 different ways. Put another way, one-quarter (57/227) of the criteria combinations did not occur. The most frequent combination was the presence of all 9 criteria (10.1%, n=157). Nine combinations (all 9 criteria, 3 of the 8-criterion combinations, 4 of the 7-criterion combinations, and one 6-criterion combination) were present in more than 2% of the patients, together accounting for more than 40% of the diagnoses. The polythetic definition of MDD, which requires a minimum number of criteria from a list, results in significant diagnostic heterogeneity because there are many different ways to meet criteria. While there is significant heterogeneity amongst patients meeting the MDD diagnostic criteria, a relatively small number of combinations could be considered as diagnostic prototypes as they account for more than 40% of the patients diagnosed with MDD.

Effects of Dimensional and Categorical Classification on the Clinical Manifestation of Major Depressive Disorder

INTRODUCTION

The aim of this study was to combine the dimensional concept with the categorical system in major depressive disorder (MDD) to reduce the complexity of the diagnosis. Furthermore, it was aimed to match categorical and dimensional approaches in a clear and simple manner.

METHOD

The study included a patient group of 131 consecutive outpatients diagnosed with MDD according to the DSM-IV diagnosis criteria, and a control group of 99 people that is matched with the patient group by gender, age and education level. All subjects completed the Beck Depression Inventory, the Beck Anxiety Inventory and the Toronto Alexithymia Scale (TAS).

RESULTS

Cronbach's alpha values for the analysis of the internal consistency of the scale for the patients group, control group and the total participants were determined as .94-.97, .87-.92 and .93-.96, respectively. Nine factors were obtained from the results of exploratory factor analysis. According to the Scree-plot, it was decided that the two-factor structure represents best. Although depression and anxiety are two distinct dimensions, the relationship between them was found to be significantly significant. This was valid for both patient and control groups. When the relationship between the DSM-IV diagnosis criteria and all variables (depression and its sub-dimensions, anxiety and its sub-dimensions and the number of symptoms) was evaluated, the number of symptoms was found to be significantly related with all of the criteria.

CONCLUSION

The number of symptoms and the severity of illness are found to be important in the clinical manifestation of MDD. The relationship of the severity of the illness with sleep and appetite seems weaker. While loss of interest was mainly predicting the disorder, weight changes, psychomotor changes, difficulty in concentration, fatigue, and worthlessness were determined not to be predictors of the manifestations. According to dimensional approach, somatic anxiety and deterioration in performance predict the presence of the disorder. According to categorical and dimensional approaches, some of the DSM-IV criteria (#2, #1, #9, #4, number of symptoms, severity of symptoms, somatic anxiety, performance deterioration) are seen to contribute to the matchability between the approaches.

Depression is more than the sum score of its parts: individual DSM symptoms have different risk factors

BACKGROUND

For diagnostic purposes, the nine symptoms that compose the DSM-5 criteria for major depressive disorder (MDD) are assumed to be interchangeable indicators of one underlying disorder, implying that they should all have similar risk factors. The present study investigates this hypothesis, using a population cohort that shifts from low to elevated depression levels.

METHOD

We assessed the nine DSM-5 MDD criterion symptoms (using the Patient Health Questionnaire; PHQ-9) and seven depression risk factors (personal and family MDD history, sex, childhood stress, neuroticism, work hours, and stressful life events) in a longitudinal study of medical interns prior to and throughout internship (n = 1289). We tested whether risk factors varied across symptoms, and whether a latent disease model could account for heterogeneity between symptoms.

RESULTS

All MDD symptoms increased significantly during residency training. Four risk factors predicted increases in unique subsets of PHQ-9 symptoms over time (depression history, childhood stress, sex, and stressful life events), whereas neuroticism and work hours predicted increases in all symptoms, albeit to varying magnitudes. MDD family history did not predict increases in any symptom. The strong heterogeneity of associations persisted after controlling for a latent depression factor.

CONCLUSIONS

The influence of risk factors varies substantially across DSM depression criterion symptoms. As symptoms are etiologically heterogeneous, considering individual symptoms in addition to depression diagnosis might offer important insights obfuscated by symptom sum scores.

Associations of Alcohol Consumption and Chronic Diseases With Sleep Apnea Among US Adults

BACKGROUND

Sleep apnea (SA) is a common sleep disorder among US adults. Associations of SA with alcohol consumption and some chronic diseases have been inconsistent.

OBJECTIVES

This study aimed to estimate prevalence of SA and examine its associations with potential factors including alcohol consumption, asthma, diabetes, and hypertension.

PATIENTS AND METHODS

This was a cross-sectional study on 823 adults with SA and 38,638 controls from the 2011 National Survey on Drug Use and Health Data. Weighted univariate and multiple logistic regression analyses were used to examine the associations of SA with the potential factors.

RESULTS

The prevalence of SA was higher in males (4.01%) than in females (2.61%), while the prevalence increased with age (0.86%, 3.50%, and 4.47% for age groups of 18-25, 26-64, and ≥ 65, respectively). Univariate analysis revealed that all factors except for income and education were associated with SA (P < 0.05). In multivariable analyses, participants who were current and past alcohol consumers had significantly higher odds of having SA (OR = 1.52, 95% CI = 1.03-2.23; OR = 1.65, 95% CI = 1.09-2.49, respectively) than non-alcohol drinker. Furthermore, asthma (OR = 2.77, 95% CI = 2.04-3.75), diabetes (OR = 2.89, 95% CI = 2.19-3.83), and hypertension (OR = 2.42, 95% CI = 1.91-3.07) were significantly associated with SA.

CONCLUSIONS

Age, alcohol consumption, asthma, diabetes, and hypertension, were positively associated with SA. More efforts should be directed to promoting screening for SA and finding possible treatments for SA among these vulnerable groups.

Sleep problems among women with noncancerous gynecologic conditions

OBJECTIVE

To estimate the prevalence of and identify factors associated with poor sleep quality and short sleep duration among women with noncancerous gynecologic conditions.

STUDY DESIGN

We conducted a cross-sectional analysis of 838 pre-menopausal women aged 31-54 who enrolled in a study of pelvic problems, hysterectomy and intervention alternatives in 2003/2004. Primary outcomes were poor sleep quality and short sleep duration (six or less hours on average) in the four weeks preceding the interview; hypothesized correlates included sociodemographic characteristics, pelvic problem impact, measured by the Pelvic Problem Impact Questionnaire (PPIQ), and depression, measured by the Patient Health Questionnaire (PHQ).

RESULTS

One-third (33.7%) of the participants reported having poor sleep quality and nearly half (46.8%) reported short sleep duration. In multivariable models, women with major depressive disorder were more likely than those who were not depressed to experience poor sleep quality (adjusted odds ratio (aOR) 4.15, 95% confidence interval (CI) 2.36-7.28, p < 0.001). Women with higher PPIQ scores also were more likely to experience poor sleep quality (aOR 1.59, 95% CI 1.27-1.98, p < 0.001) and short sleep duration (aOR 1.37, 95% CI 1.11-1.69, p < 0.003). Finally, women who self-identified as African-American (aOR 2.81, 95% CI 1.83-4.32, p < 0.001) or Asian/Pacific Islander (aOR 2.32, 95% CI 1.32-4.09, p < 0.003) were more likely than White women to have short sleep duration.

CONCLUSIONS

Sleep problems are prevalent among women with noncancerous gynecologic conditions, and are associated with depression and high pelvic problem impact. Providers should be proactive in inquiring about and offering solutions for sleep difficulties experienced by their patients.

Major depressive disorder and sleep disturbance in patients with chronic pain

BACKGROUND

Disturbed sleep is a common problem in both chronic pain and major depressive disorder (MDD). Moreover, many patients with chronic pain are depressed.

OBJECTIVES

To examine the effects of depression on the sleep behaviour of chronic pain patients by comparing patients who did or did not meet diagnostic criteria for MDD.

METHODS

A total of 60 patients with chronic musculoskeletal pain underwent structured diagnostic interviews for MDD and insomnia, and completed questionnaires assessing pain severity, disability, sleep quality, beliefs and attitudes about sleep, and sleep hygiene. For four consecutive days, they also completed a sleep diary, and reported on sleep hygiene practices and presleep arousal.

RESULTS

Thirty-three patients (55%) met diagnostic criteria for MDD, most of whom (n=32 [97%]) also fulfilled criteria for insomnia disorder. Insomnia was also common among patients without MDD (21 of 27 [78%]). Participants with MDD had higher self-reports of pain, disability, dysfunctional beliefs about sleep, and, on a prospective basis, greater presleep arousal and poorer sleep hygiene. However, diary assessments of specific sleep parameters (eg, sleep onset latency, total sleep time, sleep efficiency) did not differ between the groups.

DISCUSSION

Chronic pain patients with comorbid MDD exhibited more dysfunctional beliefs about sleep, poorer sleep hygiene practices and greater presleep arousal; however, diary-recorded sleep characteristics may not differ from those of patients without MDD. Chronic pain itself may disturb sleep so extensively that MDD introduces little additive effect.

CONCLUSION

MDD in chronic pain may be related to the cognitive and behavioural aspects of insomnia, rather than to an incremental disturbance in the initiation or maintenance of sleep.

Prevalence and Clinical Correlates of Insomnia in Depressive Disorders: The CRESCEND Study

OBJECTIVE

To investigate the prevalence, clinical manifestations, and clinical correlates of insomnia in a large cohort of Korean patients with depressive disorders.

METHODS

We recruited 944 patients with depressive disorders from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Psychometric scales were used to assess depression (HAMD), anxiety (HAMA), psychotic symptoms (BPRS), global severity (CGI-S), and functioning (SOFAS). Insomnia levels were determined by adding the scores for all items on the HAMD insomnia subscale. The clinical characteristics of the patients with 'low insomnia' (summed score ≤3 on the HAMD subscale) and 'high insomnia' (score ≥4) were compared using statistical analyses. A logistic regression model was constructed to identify factors associated with 'high insomnia' status.

RESULTS

Symptoms of insomnia were present in 93% of patients, while simultaneous early, middle, and late insomnia affected 64.1%. The high insomnia patients were characterized by significantly greater age, higher symptom levels (including core, gastrointestinal somatic and anxiety symptoms, and suicidal ideation), higher global severity and incidence of physical disorders, and greater insight. Explanatory factors of 'high insomnia' status were older age, higher gastrointestinal somatic and anxiety symptom levels, higher global severity, and greater insight.

CONCLUSION

In clinical psychiatry, insomnia has been significantly underdiagnosed and undertreated. It affects most patients with depressive disorders, and is indicative of the global severity of depression. Active efforts to diagnose and treat insomnia in patients with depressive disorders should be strongly encouraged. Further research is needed to improve the diagnosis and treatment of insomnia in depressive patients.

Validity and clinical utility of the current operational characterization of major depression

The operational definition of major depression has remained more or less the same in the past 40 years. An appraisal of currently available research data leads to the conclusion that further evidence is needed about (1) where to fix the boundary between cases and non-cases in order to improve the clinical utility of the diagnosis, (2) the validity and clinical utility of the construct of melancholia as a qualitatively distinct subtype of depression, and (3) the validity and clinical utility of a 'contextual' exclusion criterion. Furthermore, we need a more precise description of individual depressive symptoms, an exploration of the predictive value of these symptoms and of clusters of them, especially concerning clinical outcome and treatment response, and a clearer operationalization of the impairment criterion.

Are increased weight and appetite useful indicators of depression in children and adolescents?

During childhood and adolescence, physiological, psychological, and behavioral processes strongly promote weight gain and increased appetite while also inhibiting weight loss and decreased appetite. The Diagnostic and Statistical Manual-IV (DSM-IV) treats both weight-gain/increased-appetite and weight-loss/decreased-appetite as symptoms of major depression during these developmental periods, despite the fact that one complements typical development and the other opposes it. To disentangle the developmental versus pathological correlates of weight and appetite disturbance in younger age groups, the current study examined symptoms of depression in an aggregated sample of 2307 children and adolescents, 47.25% of whom met criteria for major depressive disorder. A multigroup, multidimensional item response theory model generated three key results. First, weight loss and decreased appetite loaded strongly onto a general depression dimension; in contrast, weight gain and increased appetite did not. Instead, weight gain and increased appetite loaded onto a separate dimension that did not correlate strongly with general depression. Second, inclusion or exclusion of weight gain and increased appetite affected neither the nature of the general depression dimension nor the fidelity of major depressive disorder diagnosis. Third, the general depression dimension and the weight-gain/increased-appetite dimension showed different patterns across age and gender. In child and adolescent populations, these results call into question the utility of weight gain and increased appetite as indicators of depression. This has serious implications for the diagnostic criteria of depression in children and adolescents. These findings inform a revision of the DSM, with implications for the diagnosis of depression in this age group and for research on depression.

Development and validation of the current concept of major depression

The operational diagnostic criteria for major depression have remained more or less the same in the past 40 years. However, the threshold for the diagnosis fixed by operational definitions has been criticized for either being too high, excluding many depressive states which do not differ from currently defined major depression on several variables, or too low, so that the milder cases receiving the diagnosis do not respond to antidepressants better than to placebo. Furthermore, it has been stated that current operational criteria do not convey anymore the gestalt of the depressive syndrome, and that they lead to the inclusion under the heading of depression of several homeostatic responses to adverse life events. This paper reviews the development and validation of the current concept of major depression and identifies priorities for future research.

An item response analysis of the DSM-IV criteria for major depression: findings from the Australian National Survey of Mental Health and Wellbeing

BACKGROUND

This study examines the psychometric properties and presence of gender bias in the major depression criteria using data from the Australian general population.

METHODS

Data came from a subsample of respondents from the 1997 National Survey of Mental Health and Wellbeing (NSMHWB; n=2061). A two-parameter logistic model was employed to yield severity and discrimination parameters, and the IRT log-likelihood-ratio test for differential item functioning (IRTLRDIF) procedure was utilized to evaluate gender bias.

RESULTS

DIF analyses indicated that the psychomotor difficulties criterion was endorsed at lower levels of severity by males than females. In general, the criteria were arrayed along a continuum of depression severity. Discrimination was greatest for concentration difficulties/indecision and lowest for death/suicidal thoughts and worthlessness/guilt. Worthlessness/guilt, psychomotor difficulties, and death/suicidal thoughts tapped the severe end of the depression continuum, whereas concentration difficulties/indecision and sleep disturbance tapped the mild range.

LIMITATIONS

The inclusion of stem questions precluded examination of two core symptoms of depression (depressed mood and loss of interest).

CONCLUSIONS

Collectively, the criteria performed well in defining a latent continuum of major depression. Few gender differences were observed, with the exception of the psychomotor difficulties criterion. Quantitative and qualitative analyses collectively hold promise of providing a scientifically rigorous basis for empirically-based modifications to the psychiatric classification system.

Impact of obesity on the psychometric properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depressive disorder

Obesity is associated with several symptoms that are components of the diagnostic criteria for major depressive disorder (MDD). Compared with nonobese individuals, obese individuals report more fatigue, sleep disturbance, and overeating. Obesity might, therefore, impact the psychometric properties of the MDD criteria. The goal of the present report from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services project was to examine the impact of obesity on the psychometric characteristics of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom criteria for major depression. Two thousand four hundred forty-eight psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all symptoms of depression for all patients. The mean sensitivity of the 9 criteria in the nonobese and obese patients was nearly identical (74.6% vs 74.3%). The mean specificity was slightly higher in the nonobese patients (82.0% vs 79.5%). No symptom was more specific in the obese than the nonobese patients, whereas the specificity of increased appetite, increased weight, and fatigue was more than 5% lower in the obese patients. Increased appetite, increased weight, hypersomnia, and fatigue had a higher sensitivity in the obese than the nonobese patients, whereas decreased appetite, weight loss, and diminished concentration had a higher sensitivity in the nonobese than the obese patients. Thus, although there were small differences between obese and nonobese patients in the operating characteristics of some symptoms, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for MDD generally performed equally well for obese and nonobese patients.

Anhedonia associated with stimulant use and dependence in a population-based sample of American adults

Prior research suggests an association between anhedonia--diminished interest or pleasure in rewarding activities--and stimulant use in selected samples. However, it is unclear whether this association generalizes to the overall population and is consistent across stimulant drug types (amphetamine vs. cocaine) and outcome characteristics (any lifetime use vs. dependence). Questions also remain as to whether the anhedonia-stimulant relationship is unique from covariance with depressed mood, psychiatric disorders, and nonstimulant substance use. The current study addressed these questions by examining anhedonia-stimulant relationships in a cross-sectional population-based sample of 43,093 American adults. Results indicated that lifetime anhedonia and depressed mood each were positively associated with lifetime stimulant use and lifetime dependence among those who reported stimulant use. Anhedonia-stimulant relationships were consistent across amphetamine- and cocaine-related outcomes and distinct from covariance with depressed mood, which exhibited no association over and above the effect of anhedonia. After adjusting for demographic, psychiatric, and nonstimulant substance use characteristics, anhedonia-stimulant associations remained significant, although effect sizes were partially attenuated. Lifetime anhedonia was also more prevalent among respondents who initiated use but did not eventually progress to dependence in comparison with individuals who never once used a stimulant drug. Anhedonia appears to be uniquely associated with lifetime use of cocaine and amphetamines and lifetime progression from use to dependence in the American population. Albeit cross-sectional in nature, these findings add further support to the generalizability and specificity of the anhedonia-stimulant relationship. Future research utilizing longitudinal and experimental designs are warranted to clarify the underpinnings of this association.

Insomnia in patients with depression: a STAR*D report

INTRODUCTION

Insomnia symptoms, which are common in depression, have a significant impact on function and quality of life. However, little is known about the prevalence and associated features of insomnia symptoms in representative treatment-seeking patients with depression.

METHODS

Data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were analyzed. STAR*D recruited 3,743 adult outpatients diagnosed with nonpsychotic major depressive disorder (MDD) from primary (n=18) and psychiatric care (n=23) clinics across the United States. Baseline sociodemographic and clinical features were compared between those with insomnia symptoms (84.7%) and those without (15.3%).

RESULTS

The most common presentation was the simultaneous presence of sleep onset, mid-nocturnal, and early morning insomnia symptoms (27.1%). Of these three types of insomnia symptoms, mid-nocturnal insomnia symptoms were the most commonly found alone (13.5%) and in combination with one or more other types (82.3%). Insomnia symptoms were associated with several indicators of a more severe depressive illness. Only a small proportion of participants with insomnia symptoms were receiving treatment for sleep disturbances at study initiation, and the vast majority of those receiving treatment still reported having insomnia symptoms.

CONCLUSION

In outpatients who seek treatment for nonpsychotic MDD in typical clinical settings, insomnia symptoms are very common, undertreated, and indicative of a more severe depression.

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.

The importance of functional impairment to mental health outcomes: a case for reassessing our goals in depression treatment research

Outcomes in depression treatment research include both changes in symptom severity and functional impairment. Symptom measures tend to be the standard outcome but we argue that there are benefits to considering functional outcomes. An exhaustive literature review shows that the relationship between symptoms and functioning remains unexpectedly weak and often bidirectional. Changes in functioning often lag symptom changes. As a result, functional outcomes might offer depression researchers more critical feedback and better guidance when studying depression treatment outcomes. The paper presents a case for the necessity of both functional and symptom outcomes in depression treatment research by addressing three aims-1) review the research relating symptoms and functioning, 2) provide a rationale for measuring both outcomes, and 3) discuss potential artifacts in measuring functional outcomes. The three aims are supported by an empirical review of the treatment outcome and epidemiological literatures.

Classification of depressive disorders in the DSM-V: proposal for a two-dimension system

The number of categories and specifiers for mood disorders has increased with each successive edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM). Many of these categories and specifiers can be viewed as an effort to map the various permutations of severity and chronicity that characterize the depressive disorders. However, this has resulted in a system that (a) is unnecessarily complex and unwieldy, (b) has created problems with artificial distinctions between categories and artifactual comorbidity, and (c) at the same time obscures what may be more fundamental distinctions. A potentially useful and more parsimonious approach to capturing much of the heterogeneity of depressive disorders is to classify the depressive disorders along 2 dimensions, 1 reflecting severity and the other, chronicity. Considerations in the development of these dimensions are discussed, and a set of examples is presented. Although further research and discussion are needed to determine the optimal form of these dimensions, the next edition of the DSM should consider replacing many of the existing categories and specifiers for depressive disorders with the simpler approach of classifying depressive disorders using the 2 dimensions of severity and chronicity.

Gender differences in the symptoms of major depressive disorder

Data from the Canadian Community Health Survey 1.2 were used for a gender analysis of individual symptoms and overall rates of depression in the preceding 12 months. Major depressive disorder was assessed using the Composite International Diagnostic Interview in this national, cross-sectional survey. The female to male ratio of major depressive disorder prevalence was 1.64:1, with n = 1766 having experienced depression (men 668, women 1098). Women reported statistically more depressive symptoms than men (p < 0.001). Depressed women were more likely to report "increased appetite" (15.5% vs. 10.7%), being "often in tears" (82.6% vs. 44.0%), "loss of interest" (86.9% vs. 81.1%), and "thoughts of death" (70.3% vs. 63.4%). No significant gender differences were found for the remaining symptoms. The data are interpreted against women's greater tendency to cry and to restrict food intake when not depressed. The question is raised whether these items preferentially bias assessment of gender differences in depression, particularly in nonclinic samples.

Sleep and circadian rhythms in mood disorders

OBJECTIVE

Self-reported sleep disturbances are present in over 80% of patients with depression. However, sleep electroencephalography (EEG) findings, based on overnight polysomnography have not always differentiated depressed patients from healthy individuals.

METHOD

The present paper will review the findings on sleep EEG studies in depression highlighting how recent technological and methodological advances have impacted on study outcomes.

RESULTS

The majority of studies, including our own work, do indicate that sleep homeostasis and sleep EEG rhythms are abnormal in depression, but the sleep disturbances were strongly moderated by gender and age. Melancholic features of depression correlated significantly with low slow-wave activity in depressed men, but not in depressed women. Women with depression showed low temporal coherence of sleep EEG rhythms but the presence or absence of melancholic features did not influence correlations.

CONCLUSION

Diagnostic classification schemas and clinical features of depression may influence sleep EEG findings, but gender may be a more important consideration.

Diagnosing major depressive disorder XI: a taxometric investigation of the structure underlying DSM-IV symptoms

Psychopathologists have long debated the latent structure of mental disorders, and a number of researchers have suggested that depression may be best characterized as a continuous, rather than categorical, phenomenon. Nonetheless, attention has been drawn to limitations permeating existing research and the need for studies using more appropriate statistical methods developed expressly to tease apart taxonic (categorical) and dimensional (continuous) structural models. The present study examined the structure underlying the DSM-IV symptoms of major depressive disorder in a large outpatient sample rigorously assessed using semistructured clinical interviews. The results of a series of taxometric procedures and consistency tests supported a taxonic structural model, consistent with the only previous taxometric study of DSM-IV symptoms in an adult outpatient sample. In addition to the need for further replication and clarification, these results have implications for the assessment and diagnosis of major depressive disorder. Suggestions for several additional avenues of research are discussed.