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

Department of Psychology, Free University Berlin, Germany.
Psychological Medicine (Impact Factor: 5.94). 10/2010; 40(10):1679-90. DOI: 10.1017/S0033291709992157
Source: PubMed


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

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    • "Consistent with the majority of the literature, our findings provide strong evidence against the common assumption that depression sum-scores adequately represent the severity of one underlying disease; the routine reflective latent variable interpretation of depression as a latent disease that is responsible for the covariation among symptoms is questionable. This, in turn, implies that symptoms are unlikely to be measurements of one underlying disorder (Borsboom, 2008;Fried, 2015), which is consistent with research documenting that individual depression symptoms differ in important dimensions such as their risk factors (Fried, Nesse, Zivin, Guille, & Sen, 2014;Lux & Kendler, 2010), impact on impairment of psychosocial functioning (), antidepressant response (Hieronymus, Emilsson, Nilsson, & Eriksson, 2015), and genetic as well as neuroimaging correlates (Kendler, Aggen, & Neale, 2013;Myung et al., 2012;Webb et al., 2015) (for a review, seeFried & Nesse, 2015b). To put it differently, it seems unlikely that depression symptoms are interchangeable measurements of one depression construct due to their pronounced differences in relation to important constructs. "
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    ABSTRACT: In depression research, symptoms are routinely assessed via rating scales and added to construct sum-scores. These scores are used as a proxy for depression severity in cross-sectional research, and differences in sum-scores over time are taken to reflect changes in an underlying depression construct. To allow for such interpretations, rating scales must (a) measure a single construct, and (b) measure that construct in the same way across time. These requirements are referred to as unidimensionality and measurement invariance. We investigated these 2 requirements in 2 large prospective studies (combined n = 3,509) in which overall depression levels decrease, examining 4 common depression rating scales (1 self-report, 3 clinician-report) with different time intervals between assessments (between 6 weeks and 2 years). A consistent pattern of results emerged. For all instruments, neither unidimensionality nor measurement invariance appeared remotely tenable. At least 3 factors were required to describe each scale, and the factor structure changed over time. Typically, the structure became less multifactorial as depression severity decreased (without however reaching unidimensionality). The decrease in the sum-scores was accompanied by an increase in the variances of the sum-scores, and increases in internal consistency. These findings challenge the common interpretation of sum-scores and their changes as reflecting 1 underlying construct. The violations of common measurement requirements are sufficiently severe to suggest alternative interpretations of depression sum-scores as formative instead of reflective measures. We discuss the possible causes of these violations such as response shift bias, restriction of range, and regression to the mean. (PsycINFO Database Record
    Full-text · Article · Jan 2016 · Psychological Assessment
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    • "Major Depressive Disorder (MDD) is a burdensome disorder with heterogeneous symptomatology (Lux and Kendler, 2010; Widiger and Clark, 2000; Widiger and Samuel, 2005) and course trajectories (Penninx et al., 2011; Wardenaar et al., 2014). This heterogeneity is a likely reason for the persistent lack of comprehensive etiological models for depression (Luyten et al., 2006). "
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    ABSTRACT: Atypical response behavior on depression questionnaires may invalidate depression severity measurements. This study aimed to identify and investigate atypical profiles of depressive symptoms using a data-driven approach based on the item response theory (IRT). A large cohort of participants completed the Inventory of Depressive Symptomatology self-report (IDS-SR) at baseline (n=2329) and two-year follow-up (n=1971). Person-fit statistics were used to quantify how strongly each patient׳s observed symptom profile deviated from the expected profile given the group-based IRT model. Identified atypical profiles were investigated in terms of reported symptoms, external correlates and temporal consistency. Compared to others, atypical responders (6.8%) showed different symptom profiles, with higher 'mood reactivity' and 'suicidal ideation' and lower levels of mild symptoms like 'sad mood'. Atypical responding was associated with more medication use (especially tricyclic antidepressants: OR=1.5), less somatization (OR=0.8), anxiety severity (OR=0.8) and anxiety diagnoses (OR=0.8-0.9), and was shown relatively stable (29.0%) over time. This is a methodological proof-of-principal based on the IDS-SR in outpatients. Implementation studies are needed. Person-fit statistics can be used to identify patients who report atypical patterns of depressive symptoms. In research and clinical practice, the extra diagnostic information provided by person-fit statistics could help determine if respondents׳ depression severity scores are interpretable or should be augmented with additional information. Copyright © 2015 Elsevier B.V. All rights reserved.
    Full-text · Article · Jul 2015 · Journal of Affective Disorders
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    • "The course of MC symptoms was expected to be specifically predicted by cognitive vulnerability and the tendency to experience negative emotions. The neuroticism and extraversion scales of the Neuroticism-Extraversion-Openness- Five-Factor-Inventory (NEO-FFI; Costa and McCrae, 1992) were included as these were previously shown to be associated with MC-type symptomatology (Lux and Kendler, 2010). In addition, cognitive vulnerability was assessed through the mastery scale (Pearlin and Schooler, 1978) (assessing locus-of-control) and the Rosenberg self-esteem scale (Rosenberg, 1965). "
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    ABSTRACT: The course-heterogeneity of Major Depressive Disorder (MDD) hampers development of better prognostic models. Although latent class growth analyses (LCGA) have been used to explain course-heterogeneity, such analyses have failed to also account for symptom-heterogeneity of depressive symptoms. Therefore, the aim was to identify more specific data-driven subgroups based on patterns of course-trajectories on different depressive symptom domains. In primary care MDD patients (n=205), the presence of the MDD criterion symptoms was determined for each week during a year. Weekly 'mood/cognition' (MC) and 'somatic' (SOM) scores were computed and parallel processes-LCGA (PP-LCGA) was used to identify subgroups based on the course on these domains. The classes׳ associations with baseline predictors and 2-/3-year outcomes were investigated. PP-LCGA identified four classes: quick recovery, persisting SOM, persisting MC, and persisting SOM+MC (chronic). Persisting SOM was specifically predicted by higher baseline somatic symptomatology and somatization, and was associated with more somatic depressive symptomatology at long-term follow-up. Persisting MC was specifically predicted by higher depressive severity, thinking insufficiencies, neuroticism, loneliness and lower self-esteem, and was associated with lower mental health related quality of life and more mood/cognitive depressive symptomatology at follow-up. The sample was small and contained only primary care MDD patients. The weekly depression assessments were collected retrospectively at 3-month intervals. The results indicate that there are two specific prototypes of depression, characterized by either persisting MC or persisting SOM, which have different sets of associated prognostic factors and long-term outcomes, and could have different etiological mechanisms. Copyright © 2015 Elsevier B.V. All rights reserved.
    Full-text · Article · Mar 2015 · Journal of Affective Disorders
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