Unitary or binary nature of classification of depressive illness and its implications for the scope of manic depressive disorder

Roth, Sir Martin

doi:10.1016/s0165-0327(00)00237-8

Cited by 16 publications

(9 citation statements)

References 67 publications

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“…On the one hand, it has been argued that depressive disorders can be understood as dimensional – the so-called unitary position that led to the DSM-III categories "minor depression" and "major depression"; from this perspective, mood disorders can be differentiated by the severity of the syndrome alone. Others have posited qualitative differences between different depressive states (for an overview, see Faravelli et al, 1996; Parker, 2005; Roth, 2001). Unfortunately, there has been limited success in identifying external validators for such qualitative subtypes (Davidson, 2007; Melartin et al, 2004; Pae et al, 2009; Young et al, 1987), and the debate about the number and nature of depression subtypes continues (Baumeister et al, 2011; Lichtenberg and Belmaker, 2010; van Loo et al, 2012).…”

Section: Discussionmentioning

confidence: 99%

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

Fried¹,

Nesse²

2015

Journal of Affective Disorders

772

534

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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 3,703 depressed outpatients at the beginning of the first treatment stage of STAR*D. Results Overall, we identified 1,030 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.

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Section: Discussionmentioning

confidence: 99%

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

Fried¹,

Nesse²

2015

Journal of Affective Disorders

772

534

View full text Add to dashboard Cite

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“…It might be argued that major depression and anxiety disorders should not be considered ‘disease-like’, as these conditions are frequently accompanied by long-standing personality vulnerabilities (Roth et al 1972; Bienvenu et al 2004, 2009). Major depression is probably a heterogeneous condition, including a more disease-like ‘endogenous’ form and a less disease-like ‘neurotic’ form (Roth, 2001; Shorter, 2009). Although some studies suggest that endogenous features are associated with higher heritability (Leckman et al 1984 a , b ; McGuffin et al 1996), aspects of depressive illness that are particularly salient for heritability include the related features recurrence, early onset, and perhaps short duration (Kendler et al 2007).…”

Section: Discussionmentioning

confidence: 99%

Psychiatric ‘diseases’versusbehavioral disorders and degree of genetic influence

2010

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No systematic relationship exists between the disease-like character of a psychiatric disorder and its heritability; many behavioral disorders seem to be more heritable than conditions commonly construed as diseases. These results suggest an error in 'common-sense' assumptions about the etiology of psychiatric disorders. That is, among psychiatric disorders, there is no close relationship between the strength of genetic influences and the etiologic importance of volitional processes.

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“…Especially the rise of biological psychiatry fostered the notion of mental disorders as discrete conditions. Once the DSM-III was established, clinical trials demanded strict diagnostic criteria leading to homogeneous groups of patients, with the aim of developing specific treatments for particular disorders, and of finding specific underlying biological abnormalities ( Roth, 2001 ). Such beliefs in the categorical nature of mental disorders are also reflected in more recent developments like the DSM-5 ( Lilienfeld, 2014 ).…”

Section: The Current Depression Schemamentioning

confidence: 99%

Problematic assumptions have slowed down depression research: why symptoms, not syndromes are the way forward

2015

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Major depression (MD) is a highly heterogeneous diagnostic category. Diverse symptoms such as sad mood, anhedonia, and fatigue are routinely added to an unweighted sum-score, and cutoffs are used to distinguish between depressed participants and healthy controls. Researchers then investigate outcome variables like MD risk factors, biomarkers, and treatment response in such samples. These practices presuppose that (1) depression is a discrete condition, and that (2) symptoms are interchangeable indicators of this latent disorder. Here I review these two assumptions, elucidate their historical roots, show how deeply engrained they are in psychological and psychiatric research, and document that they contrast with evidence. Depression is not a consistent syndrome with clearly demarcated boundaries, and depression symptoms are not interchangeable indicators of an underlying disorder. Current research practices lump individuals with very different problems into one category, which has contributed to the remarkably slow progress in key research domains such as the development of efficacious antidepressants or the identification of biomarkers for depression. The recently proposed network framework offers an alternative to the problematic assumptions. MD is not understood as a distinct condition, but as heterogeneous symptom cluster that substantially overlaps with other syndromes such as anxiety disorders. MD is not framed as an underlying disease with a number of equivalent indicators, but as a network of symptoms that have direct causal influence on each other: insomnia can cause fatigue which then triggers concentration and psychomotor problems. This approach offers new opportunities for constructing an empirically based classification system and has broad implications for future research.

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Unitary or binary nature of classification of depressive illness and its implications for the scope of manic depressive disorder

Cited by 16 publications

References 67 publications

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

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

Psychiatric ‘diseases’versusbehavioral disorders and degree of genetic influence

Problematic assumptions have slowed down depression research: why symptoms, not syndromes are the way forward

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