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

Does One Treatment Fit All? Effectiveness of a Multicomponent Cognitive Behavioral Therapy Program in Data-Driven Subtypes of Perinatal Depression

Background: Current diagnostic systems of mental disorders are criticized for their poor validity and reliability, owing to the within disorder heterogeneity and between disorder homogeneity. The issue is important if treatments for mental disorders are to be tailored to individual needs. There is little information in this area on perinatal depression (PND), a highly prevalent condition globally. Aims: i) Quantify heterogeneity attributable to the polythetic diagnostic framework for PND and, ii) present evidence for the effectiveness of a multicomponent and low-intensity cognitive behavioral Thinking Healthy Programme (THP) across the heterogeneous presentations of PND. Methods: This investigation presents secondary analyses of a cluster randomized controlled trial, conducted in Kallar Syedan, Pakistan. A total of 903 pregnant women were randomized to an intervention group receiving the THP intervention or control group receiving enhanced usual care. Principal component analyses and clustering algorithm were utilized to identify heterogenous subtypes of PND. Linear mixed effects models were used to assess effectiveness of the intervention across the identified subtypes of PND. Results: Four different clusters of PND were identified: mixed anxiety-depression, somatic depression, mild depression, and atypical depression. All clinical phenotypes responded well to the THP intervention. Compared to their counterparts in the control group, mothers with mild depression in the treatment group yielded lowest risk ratios 0.24 (95% CI: 0.15 to 0.37), followed by mothers with anxiety-depression 0.50 (95% CI: 0.37 to 0.68), atypical depression 0.51 (95% CI: 0.27 to 0.99) and somatic depression 0.59 (95% CI: 0.42 to 0.83). Conclusion: The Thinking Healthy Programme was found to be effective in reducing severity of depressive symptoms and disability across the four subtypes of PND.

Frequency and network analysis of depressive symptoms in patients with cancer compared to the general population

BACKGROUND

The use of sum scores of depressive symptoms has been increasingly criticized and may be particularly problematic in oncological settings. Frameworks analyzing individual symptoms and their interrelationships such as network analysis represent an emerging alternative.

METHODS

We aimed to assess frequencies and interrelationships of 9 DSM-5 symptom criteria of major depression reported in the PHQ-9 questionnaire by 4020 patients with cancer and 4020 controls from the general population. We estimated unregularized Gaussian graphical models for both samples and compared network structures as well as predictability and centrality of individual symptoms.

RESULTS

Depressive symptoms were more frequent, but less strongly intercorrelated in patients with cancer than in the general population. The overall network structure differed significantly between samples (correlation of adjacency matrices: rho=0.73, largest between-group difference in any edge weight: 0.20, p < 0.0001). Post-hoc tests showed significant differences in interrelationships for four symptom pairs. The mean variance of symptoms explained by all other symptoms in the same network was lower among cancer patients than in the general population (29% vs. 43%).

LIMITATIONS

Cross-sectional data do not allow for temporal or causal inferences about the directions of associations and results from population-based samples may not apply to clinical psychiatric populations.

CONCLUSIONS

In patients with cancer, both somatic and cognitive/affective depression symptoms are less likely to be explained by other depressive symptoms than in the general population. Rather than assuming a consistent depression construct, future research should study individual depressive symptom patterns and their potential causes in patients with cancer.

The centrality of DSM and non-DSM depressive symptoms in Han Chinese women with major depression

INTRODUCTION

We compared DSM-IV criteria for major depression (MD) with clinically selected non-DSM criteria in their ability to represent clinical features of depression.

METHOD

We conducted network analyses of 19 DSM and non-DSM symptoms of MD assessed at personal interview in 5952 Han Chinese women meeting DSM-IV criteria for recurrent MD. We estimated an Ising model (the state-of-the-art network model for binary data), compared the centrality (interconnectedness) of DSM-IV and non-DSM symptoms, and investigated the community structure (symptoms strongly clustered together).

RESULTS

The DSM and non-DSM criteria were intermingled within the same symptom network. In both the DSM-IV and non-DSM criteria sets, some symptoms were central (highly interconnected) while others were more peripheral. The mean centrality of the DSM and non-DSM criteria sets did not significantly differ. In at least two cases, non-DSM criteria were more central than symptomatically related DSM criteria: lowered libido vs. sleep and appetite changes, and hopelessness versus worthlessness. The overall network had three sub-clusters reflecting neurovegetative/mood symptoms, cognitive changes and anxiety/irritability.

LIMITATIONS

The sample were severely ill Han Chinese females limiting generalizability.

CONCLUSIONS

Consistent with prior historical reviews, our results suggest that the DSM-IV criteria for MD reflect one possible sub-set of a larger pool of plausible depressive symptoms and signs. While the DSM criteria on average perform well, they are not unique and may not be optimal in their ability to describe the depressive syndrome.

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.

The relationships between dysfunctional attitudes, rumination, and non-somatic depressive symptomatology in newly diagnosed Asian cancer patients

BACKGROUND

Given the high prevalence of cancer patients with comorbid depression, the present study sought to elucidate the relationships between two vulnerability factors, dysfunctional attitudes and rumination, and their influence on non-somatic depressive symptomatology in an Asian cohort of cancer patients. It was hypothesized that all variables of interest would be inter-correlated, and that both dysfunctional attitudes and rumination would mediate one another in influencing non-somatic depressive symptoms.

METHODS

A total of 194 recently diagnosed mixed-cancer patients in Singapore (Mage=49.2±9.2years; 68% women; 61% ethnically Chinese), without any comorbid psychiatric diagnosis, completed the Dysfunctional Attitudes Scale Form A, Rumination Responses Scale (comprising brooding and reflective rumination), and Hospital Anxiety and Depression Scale.

RESULTS

Correlational analyses revealed that all variables were inter-correlated (rhos[194]=.35-.52). Bootstrapping mediation analyses controlling for gender and treatment received revealed that both brooding and reflective rumination mediated the relationship between dysfunctional attitudes and non-somatic depressive symptoms, and that dysfunctional attitudes also mediated the relationship between both brooding and reflective rumination and non-somatic depressive symptoms.

CONCLUSIONS

Findings suggest that, in cancer patients, both dysfunctional attitudes and rumination seem to act upon one other, in a feedback loop, to influence non-somatic depressive symptomatology. Clinicians may therefore have a wider range of treatments to choose from in managing cancer patients with depressive symptomatology.

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.

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.

The impact of individual depressive symptoms on impairment of psychosocial functioning

Previous studies have established that scores on Major Depressive Disorder scales are correlated with measures of impairment of psychosocial functioning. It remains unclear, however, whether individual depressive symptoms vary in their effect on impairment, and if so, what the magnitude of these differences might be. We analyzed data from 3,703 depressed outpatients in the first treatment stage of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Participants reported on the severity of 14 depressive symptoms, and stated to what degree their depression impaired psychosocial functioning (in general, and in the five domains work, home management, social activities, private activities, and close relationships). We tested whether symptoms differed in their associations with impairment, estimated unique shared variances of each symptom with impairment to assess the degree of difference, and examined whether symptoms had variable impacts across impairment domains. Our results show that symptoms varied substantially in their associations with impairment, and contributed to the total explained variance in a range from 0.7% (hypersomnia) to 20.9% (sad mood). Furthermore, symptoms had significantly different impacts on the five impairment domains. Overall, sad mood and concentration problems had the highest unique associations with impairment and were among the most debilitating symptoms in all five domains. Our findings are in line with a growing chorus of voices suggesting that symptom sum-scores obfuscate relevant differences between depressed patients and that substantial rewards will come from close attention to individual depression symptoms.

Which symptoms are indicative of depression in epilepsy settings? An analysis of the diagnostic significance of somatic and non-somatic symptoms

BACKGROUND

Depression is a common psychiatric co-morbidity in epilepsy. However, there have been no previous studies which have investigated the validity of individual symptoms for comorbid depression in epilepsy, in particular the diagnostic value of somatic and non-somatic symptoms.

METHODS

Patients with epilepsy diagnosed in a specialist epilepsy clinic were approached and completed several self-reported mood scales, prior to or immediately after their neurology outpatient consultations. Symptoms of depression were elicited using PHQ-9, BDI-II and HADS scales, comprising a total of 44 self report questions. 266 patients returned complete questionnaires of whom 18.0% met criteria for DSM-IV major depression according to the WHO Major Depression Inventory.

RESULTS

Against DSM-IV major depressive disorder (MDD), both somatic and non-somatic symptoms were valuable. The top five most useful questions relating to a diagnosis of MDD in epilepsy were "Moving or speaking so slowly that other people could have noticed" "Little interest or pleasure in doing things" "Feeling down depressed or hopeless" "Trouble concentrating on things such as reading" and "Feeling tired or having little energy." Four of these symptoms were rated as excellent initial screening questions for depression namely, "Moving or speaking so slowly that other people could have noticed" "Little interest or pleasure in doing things" "Feeling down depressed or hopeless" "Trouble concentrating on things such as reading." The item "Moving or speaking so slowly that other people could have noticed" from the PHQ9 was endorsed in about 90% of depressed patients with epilepsy but only about 6% of non-depressed patients.

CONCLUSION

These findings suggest that both somatic and non-somatic symptoms can be valuable when diagnosing depression in epilepsy and should be considered when designing scales for depression in epilepsy. Specific psychological symptoms and specific somatic symptoms are indicative of depression in epilepsy.

Depressive dimensions and item response analysis of the Hamilton Depression Rating Scale-17 in eating disorders

BACKGROUND

Most patients having eating disorders (EDs) experience depressive symptoms. To date, there have been few reports about the different depressive dimensions in EDs.

OBJECTIVE

The aim of this study was to investigate the dimensions of depressive symptoms and highlight the distribution of the symptoms. The psychometric properties of these measures were tested using item response theory methods.

METHODS

A total of 103 consecutively admitted inpatients and outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition, criteria for anorexia nervosa, bulimia nervosa, and EDs not otherwise specified were rated with the Hamilton Depression Rating Scale (HDRS-17). A factor analysis of the HDRS-17 was carried out with the Cf-varimax rotation.

RESULTS

Factor analysis showed 2 independent and clinically interpretable factors corresponding to "anxious depression" and "somatic complaints" that constituted the core of depression. For the HDRS-17, item response theory analyses revealed that most of the items were maximally related to the core concept of depression and provided a good functioning. The 17 items were distributed in almost the same way as in the factor analyses found by other authors with different clinical groups. We conclude therefore that for the sample of EDs, 2 factors constitute the core symptoms of depression and most of the items provided a good functioning.

Which symptoms are indicative of DSMIV depression in cancer settings? An analysis of the diagnostic significance of somatic and non-somatic symptoms

BACKGROUND

There have been few studies that have attempted to examine the phenomenology of comorbid depression, in particular the diagnostic value of individual somatic and non-somatic symptoms when attempting to diagnose depression following cancer.

METHODS

We approached 279 patients up to three times within 9 months of first presentation with a diagnosis of cancer, and collected data following a total of 558 contacts. 176 contacts (31%) were in a palliative stage. Symptoms were elicited by self-report PHQ9 and HADS-D scales. The prevalence of major depression was 12.7% but 29.6% had major or minor depression (any depressive disorder) according to modified DSMIV criteria.

RESULTS

All symptoms of depression were significant more common in depressed versus non-depressed cancer patients regardless of stage. Against broadly defined any depressive disorder (ADD) the most accurate diagnostic symptoms were all somatic (namely trouble falling or staying asleep or sleeping too much; feeling tired or having little energy; poor appetite or overeating; trouble concentrating on things such as reading). Indeed the optimal symptom insomnia had good case-finding properties and screening properties used alone. A two step combination of three questions give a sensitivity of 100% and specificity of 91.6% against ADD. Against major depressive disorder (MDD) both somatic and non-somatic symptoms were valuable (including but not limited to the PHQ2 stem questions). Only low energy was poorly discriminating which may suggest that the standard ICD10 criteria may not be optimal. When considering depression as defined by the HADS-D (≥ 11), then the three most influential symptoms were psychological closely followed by somatic symptoms. When looking for MDD and HADS-D depression, no single symptom was a good proxy for depression highlighting a possible shortcoming if clinicians attempt to rely on one single question. In a subset of palliative patients feeling bad about yourself and moving or speaking slowly were less influential and outperformed by poor appetite/overeating and feeling tired or having little energy.

CONCLUSION

This research suggests that most somatic symptoms remain influential when diagnosing depression in the context of cancer and hence should not be omitted indiscriminately, even in palliative stages. The optimal symptoms for diagnosing depression will depend on whether a narrow concept of depression or a broad concept of depression is considered clinically important.

Deconstructing major depression: a validation study of the DSM-IV symptomatic criteria

BACKGROUND

The DSM-IV symptomatic criteria for major depression (MD) derive primarily from clinical experience with modest empirical support.

METHOD

The sample studied included 1015 (518 males, 497 females) Caucasian twins from a population-based registry who met criteria for MD in the year prior to the interview. Logistic regression analyses were conducted to compare the associations of: (1) single symptomatic criterion, (2) two groups of criteria reflecting cognitive and neurovegetative symptoms, with a wide range of potential validators including demographic factors, risk for future episodes, risk of MD in the co-twin, characteristics of the depressive episode, the pattern of co-morbidity and personality traits.

RESULTS

The individual symptomatic criteria showed widely varying associations with the pattern of co-morbidity, personality traits, features of the depressive episode and demographic characteristics. When examined separately, these two criteria groups showed robust differences in their patterns of association, with the validators with the cognitive criteria generally producing stronger associations than the neurovegetative.

CONCLUSIONS

Among depressed individuals, individual DSM-IV symptomatic criteria differ substantially in their predictive relationship with a range of clinical validators. These results challenge the equivalence assumption for the symptomatic criteria for MD and suggest a more than expected degree of 'covert' heterogeneity among these criteria. Part of this heterogeneity is captured by the distinction between cognitive versus neurovegetative symptoms, with cognitive symptoms being more strongly associated with most clinically relevant characteristics. Detailed psychometric evaluation of DSM-IV criteria is overdue.

Fatigue in patients with diabetes: a review

OBJECTIVE

Fatigue is a common and distressing complaint among people with diabetes and likely to hinder the ability to perform daily diabetes self-management tasks. A review of the literature about diabetes-related fatigue was conducted with an eye toward creating a framework for beginning to conduct more focused studies on this subject.

METHODS

A literature search containing the terms diabetes, fatigue, tiredness, and symptoms was conducted to search for literature that addressed diabetes-related fatigue.

RESULTS

Diabetes presents many potential pathways for fatigue, but focused studies on this symptom are rare. Furthermore, research on diabetes-related fatigue is limited by fatigue's nonspecific symptoms and because fatigue researchers have yet to agree on standardized definition, measurement, or diagnostic criteria. Additionally, few diabetes randomized clinical trials included measurement of patient-reported outcomes, such as symptoms or health-related quality of life in their study designs, although one that did provided some meaningful finding that symptom-focused education improved self-management practices, Hb(A1c) levels, quality of life, and symptom distress.

CONCLUSION

There is a need to standardize the definition, measurement, and diagnostic criteria of fatigue in diabetes. We present a model that can guide focused studies on fatigue in diabetes. The model capitalizes on the multidimensional phenomena (physiological, psychological, and lifestyle) associated with fatigue in diabetes.

Diagnosing major depressive disorder XII: can a self-report depression questionnaire be used to examine questions about the DSM-IV diagnostic criteria?

This paper is the final one in our series examining the DSM-IV diagnostic criteria for major depressive disorder. The data collected were part of the Rhode Island Methods to Improve Diagnostic Assessment and Services project, a unique integration of a research assessment protocol into a community-based clinical practice. We were able to examine a number of psychometric and conceptual issues in the diagnosis of depression because we modified the diagnostic interview to inquire about all diagnostic criteria, as well as additional associated features, of all patients. The results reported in the papers published earlier in the series suggested that some changes in the diagnostic criteria might be warranted. However, before changes are made to the diagnostic nomenclature, the results of any single study should be replicated. The cost of conducting this type of research is high, thereby reducing the likelihood of replication. As part of the Methods to Improve Diagnostic Assessment and Services project, we developed the Diagnostic Inventory for Depression (DID), a self-report scale that was specifically designed to assess the DSM-IV diagnostic criteria for major depressive disorder; thus, this scale could potentially be used to study many of the same questions examined in the present series, though at a fraction of the cost. In the present report, we used the DID to examine questions that were addressed in three of the prior reports in this series. The results of the present analysis based on the DID replicated the previously reported findings based on the SCID. This suggests that a self-report measure such as the DID could be used in other settings to examine the issues studied in the present series of papers, thereby facilitating the compilation of a more substantial literature upon which decisions regarding criteria modification could be based.

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.

Diagnosing major depressive disorder IV: relationship between number of symptoms and the diagnosis of disorder

The symptom inclusion criteria for DSM-IV major depressive disorder (MDD) consist of a list of nine characteristic features of depression, at least five of which must be present. Two of the criteria for MDD, low mood and loss of interest or pleasure, are accorded greater importance than the remaining seven criteria in that one of these two features is required for the diagnosis. The implicit assumption underlying this organization of the criteria is that some individuals might meet five of the nine criteria without experiencing low mood or loss of interest or pleasure and thus be inappropriately diagnosed with major depression. We are not aware of any studies that have examined this assumption. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how many psychiatric outpatients meet five of the nine DSM-IV criteria for MDD without simultaneously experiencing either low mood or loss of interest or pleasure. If this pattern is rare or does not exist, then the method of counting criteria to diagnose major depression could be simplified to a straightforward five out of nine. Twenty-seven (1.5%) patients reported five or more criteria in the absence of low mood or loss of interest or pleasure. More than half (N = 16) of these 27 patients were diagnosed with MDD or bipolar disorder, depressed type, in partial remission (N = 14), bipolar disorder mixed type (N = 1), or bipolar disorder not otherwise specified (N = 1). Six of the remaining 11 patients were diagnosed with depressive disorder not otherwise specified. Thus, few patients who met five or more of the MDD criteria were not diagnosed with a depressive disorder. This suggests that the diagnostic criteria for MDD can be simplified to a straightforward symptom count without reference to the necessity of low mood or loss of interest or pleasure.