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

Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA.
Journal of Nervous & Mental Disease (Impact Factor: 1.81). 07/2006; 194(6):450-3. DOI: 10.1097/01.nmd.0000221425.04436.46
Source: PubMed

ABSTRACT 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.

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    • "An accurate analysis of these two symptoms was not possible ; nor was it possible to examine respondents who might endorse symptoms of depression without these two symptoms. A study by Zimmerman et al. (2006) using a skip-free diagnostic assessment found that almost all patients (98.5 %) who endorsed five or more symptoms of MDE, therefore meeting the DSM-IV symptom criteria, indicated at least low mood or lack of interest/pleasure as one of their symptoms. Therefore, although an accurate analysis of the first two symptoms could not be attained, we are confident that the sample examined in this study is representative of a subpopulation at greater risk of developing MDE. "
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    • "An accurate analysis of these two symptoms was not possible ; nor was it possible to examine respondents who might endorse symptoms of depression without these two symptoms. A study by Zimmerman et al. (2006) using a skip-free diagnostic assessment found that almost all patients (98.5 %) who endorsed five or more symptoms of MDE, therefore meeting the DSM-IV symptom criteria, indicated at least low mood or lack of interest/pleasure as one of their symptoms. Therefore, although an accurate analysis of the first two symptoms could not be attained, we are confident that the sample examined in this study is representative of a subpopulation at greater risk of developing MDE. "
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    ABSTRACT: Large community-based epidemiological surveys have consistently identified high co-morbidity between major depressive episode (MDE) and generalized anxiety disorder (GAD). Some have suggested that this co-morbidity may be artificial and the product of the current diagnostic system. Because of the added direct and indirect costs associated with co-morbidity, it is important to investigate whether methods of diagnostic classification are artificially increasing the level of observed co-morbidity. The item response theory (IRT) log-likelihood ratio procedure was used to test for differential item functioning (DIF) of MDE symptoms between respondents with and without a diagnosis of GAD in the 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC). The presence of GAD significantly increased the chances of reporting any symptom of MDE, with odds ratios ranging from 2.54 to 5.36. However, there was no indication of significant DIF of MDE symptoms in respondents with and without GAD. The lack of any significant DIF indicates that cases with GAD do not present with a distinct MDE symptom profile, one that is consistent with the endorsement of symptoms that are conceptually similar in nature between the two disorders, compared to cases without GAD. This does not support the hypothesis that co-morbidity between MDE and GAD is artificially inflated because of the similar symptom criteria required by the current diagnostic system. Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait.
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    • "Sucrose intake is a measure of hedonia, which is widely used for the assessment of an animal's sensitivity to reward (the ability to experience pleasure) (Mathews & Forbes, 1995; Willner & Mitchell, 2002). Decreased sucrose consumption (or preference), that is, anhedonia, is considered to be a well-validated index of depressivelike state in animals (Willner & Mitchell, 2002), homologous to that of depressed patients (Zimmerman et al., 2006). In the sucrose preference test, animals were exposed to both the test solution (20% sucrose) and drinking water for a period of 1 h following 23 h of food and water deprivation (Sarkisova et al., 2007). "
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    ABSTRACT: The WAG/Rij strain of rats, a well-established model for absence epilepsy, has comorbidity for depression. These rats exhibit depression-like behavioral symptoms such as increased immobility in the forced swimming test and decreased sucrose intake and preference (anhedonia). These depression-like behavioral symptoms are evident in WAG/Rij rats, both at 3-4 and 5-6 months of age, with a tendency to aggravate in parallel with an increase in seizure duration. Here we investigated whether the behavioral symptoms of depression could be prevented by the suppression of absence seizures. Ethosuximide (ETX; 300 mg/kg/day, in the drinking water) was chronically applied to WAG/Rij rats from postnatal day 21 until 5 months. Behavioral tests were done before the cessation of the treatment. Electroencephalography (EEG) recordings were made before and after cessation of treatment to measure seizure severity at serial time-points. ETX-treated WAG/Rij rats exhibited no symptoms of depression-like behavior in contrast to untreated WAG/Rij rats of the same age. Moreover, treated WAG/Rij rats did not differ from control age-matched Wistar rats. ETX treatment led to almost complete suppression of spike-wave discharges (SWDs) in 5-6 month old WAG/Rij rats. Discontinuation of chronic treatment was accompanied by a gradual emergence of SWDs; however, a persistent reduction in seizure activity was still present 47 days after discontinuation of the chronic treatment. The results suggest that seizure activity is necessary for the expression of depression-like behavioral symptoms and confirm that epileptogenesis can be prevented by early and chronic treatment.
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