Mark F. Schmitz

When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds

High community prevalence estimates of DSM‐defined major depressive disorder (MDD) have led to proposals to raise MDDs diagnostic threshold to more validly distinguish pathology from normal‐range distress. However, such proposals lack empirical validation. We used MDD recurrence rates in the longitudinal 2‐wave Epidemiologic Catchment Area Study to test the predictive validity of three proposals to narrow MDD diagnosis: a) excluding “uncomplicated” episodes (i.e., episodes that last no longer than 2 months and do not include suicidal ideation, psychotic ideation, psychomotor retardation, or feelings of worthlessness); b) excluding mild episodes (i.e., episodes with only five to six symptoms); and c) excluding nonmelancholic episodes. For each proposal, we used lifetime MDD diagnoses at wave 1 to distinguish the group proposed for exclusion, other MDD, and those with no MDD history. We then compared these groups’ 1‐year MDD rates at wave 2. A proposal was considered strongly supported if at wave 2 the excluded groups MDD rate was not only significantly lower than the rate for other MDD but also not significantly greater than the no‐MDD‐history group. Results indicated that all three excluded groups had significantly lower recurrence rates than other MDD (uncomplicated vs. complicated, 3.4% vs. 14.6%; mild vs. severe, 9.6% vs. 20.7%; nonmelancholic vs. melancholic, 10.6% vs. 19.2%, respectively). However, only uncomplicated MDDs recurrence rate was also not significantly greater than the MDD occurrence rate for the no‐MDD‐history group (3.4% vs. 1.7%, respectively). This low recurrence rate resulted from an interaction between uncomplicated duration and symptom criteria. Multiple‐episode uncomplicated MDD did not entail significantly elevated recurrence over single‐episode cases (3.7% vs. 3.0%, respectively). Uncomplicated MDDs general‐distress symptoms, transient duration, and lack of elevated recurrence suggest it may generally represent nonpathologic intense sadness that should be addressed in treatment guidelines and considered for exclusion from MDD diagnosis to increase the validity of the MDD/normal sadness boundary.

Does the DSM-IV Clinical Significance Criterion for Major Depression Reduce False Positives? Evidence From the National Comorbidity Survey Replication

OBJECTIVE To reduce false positive diagnoses, DSM-IV added a clinical significance criterion to many diagnostic criteria sets requiring that symptoms cause significant distress or impairment. The DSM-V Task Force is considering whether clinical significance should remain a diagnostic threshold or become a separate dimension, as it is in ICD. Yet, the criterions effectiveness in validly reducing the prevalence of specific disorders remains unclear. Critics have argued that for some categories, notably major depression, the criterion is redundant with symptoms, which are inherently distressing or impairing. The authors empirically evaluated the criterions effect on the prevalence of major depression in the community. This report also considers more broadly the relationship of symptoms to impairment in diagnosis. METHOD Subjects were respondents, aged 18 to 54 years, who participated in the National Comorbidity Survey Replication (N=6,707). The effect of the clinical significance criterions distress and impairment components on major depression was assessed in this sample. Distress questions were administered to all respondents reporting persistent sadness (> or = 2 weeks) or the equivalent. Questions pertaining to role impairment were asked of all respondents satisfying major depression symptom-duration criteria. RESULTS Of 2,071 individuals reporting persistent sadness or the equivalent, 97.2% (N=2,016) satisfied criteria for distress. Of 1,542 individuals satisfying depression symptom-duration criteria, 96.2% (N=1,487) satisfied criteria for impairment. CONCLUSIONS These findings support the redundancy thesis. Distress is virtually redundant with symptoms of persistent sadness, even in the absence of major depression, and impairment is almost always entailed by major depression-level symptoms. Thus, the clinical significance criterion does not substantially reduce the prevalence of major depression in the community. The DSM-V Task Force should consider eliminating the criterion and explore alternative ways to identify false positives in the diagnosis of depression. The criterions status for other disorders should be evaluated on a disorder-by-disorder basis because the diagnostic relationship between symptoms and impairment varies across categories.

Recurrence of depression after bereavement-related depression: evidence for the validity of DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study.

Abstract The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (⩽2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920–928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

Did Narrowing the Major Depression Bereavement Exclusion From DSM-III-R to DSM-IV Increase Validity?: Evidence From the National Comorbidity Survey

The DSMs major-depression “bereavement exclusion” eliminates bereavement-related depressive episodes (BRDs) from diagnosis unless they are “complicated” by prolonged duration or certain severe symptoms. The exclusion was substantially narrowed in DSM-IV to decrease false-negative diagnoses, but the impact of this change remains unknown. We divided BRDs in the National Comorbidity Survey into uncomplicated versus complicated categories using broader DSM-III-R and narrower DSM-IV exclusion criteria. Using 6 pathology validators (symptom number, melancholic depression, suicide attempt, interference with life, medication for depression, and hospitalization for depression), we compared the validity of the 2 exclusion criteria sets using 2 tests: (1) which criteria set yielded less pathological uncomplicated cases or more pathological complicated cases; (2) which yielded the largest separation between uncomplicated and complicated pathology levels. Results of both tests indicated that the narrower DSM-IV criteria substantially decreased the exclusions validity. These results suggest caution regarding the current proposal to eliminate the bereavement exclusion in DSM-5.

Latino Cultural Differences in Maternal Assessments of Attention Deficit/Hyperactivity Symptoms in Children.

Many aspects of attention deficit/hyperactivity disorder (ADHD) are likely influenced by culture, particularly the differences in perceptions of child behavior and the demands of the environment in homes, schools, and communities of people from different ethnic and cultural groups. In particular, ADHD-related behaviors must be understood within the context of cultural environments and expectations. This study examined differences in parental evaluations of ADHD-related child behaviors in the following three Latino ethnic populations: Mexican (n = 81), Mexican American (n = 179), and Puerto Rican (n = 60). Overall, results indicate an important role for acculturation in mothers’ perceptions of ADHD-related behaviors but only in the measures of hyperactivity and not in the attention deficit aspects of the disorder. Mothers from different Latino cultures and at different levels of acculturation differentially assess specific symptoms of ADHD, indicating the need for careful reassessment of the validity of the disorder for Latino families.

Normal vs. disordered bereavement-related depression: are the differences real or tautological?

Objective:  To evaluate whether the DSM distinction between uncomplicated (normal) and complicated (disordered) bereavement‐related depression (BRD) has discriminant validity on a range of pathology indicators. The DSM’s major depression bereavement exclusion (BE) excludes BRDs from diagnosis when they are uncomplicated (defined by brief duration, non‐severe impairment, and lack of certain pathosuggestive symptoms) but classifies all other (“complicated”) BRDs as major depression. A previous report seemed to support the uncomplicated/complicated distinction’s discriminant validity. However, those arguing for eliminating the BE from DSM‐5 dismiss the findings as ‘tautological,’ attributing the validator differences to definitional biases (e.g. ‘uncomplicated’ requires ‘no suicidal ideation,’ yet ‘lifetime suicide attempt’ was a validator). This study empirically tests whether the uncomplicated/complicated differences are real or tautological.

The Roles of Affect Dysregulation and Positive Affect in Non-Suicidal Self-Injury

Non-suicidal self-injury (NSSI) is a prevalent behavior, yet little is known about associated affective mechanisms. Research has focused on the role of negative affect in NSSI, with positive affect receiving relatively less attention. This study examined affect dysregulation, emotional reactivity, and the experience of positive and negative affect in NSSI. Path analyses revealed that emotional reactivity predicted positive and negative affect after NSSI. Positive affect, in turn, predicted more lifetime acts of NSSI. The results demonstrate the importance of examining multiple facets of affect regulation, as well as the roles of both negative and positive affect in NSSI.

Predictive validation of single-episode uncomplicated depression as a benign subtype of unipolar major depression.

To evaluate the predictive validity of a proposed benign major depressive disorder (MDD) subtype, single‐episode ‘uncomplicated MDD’, defined as MDD that remits within 6 months and lacks severe impairment, psychotic ideation, suicidal ideation, psychomotor retardation, and feeling worthless.

Relation between duration and severity in bereavement‐related depression

Wakefield JC, Schmitz MF, Baer JC. Relation between duration and severity in bereavement‐related depression.

Influence of Social and Family Contexts on Self-Esteem of Latino Youth.

The study presented here examines the influence of social and family contexts on the self-esteem of Mexican (n = 287), Mexican American (n = 558), and Puerto Rican (n = 212) children. Using data from the National Longitudinal Surveys of Youth, tests of a longitudinal path model show significant social and family effects on the cognitive stimulation and emotional support in the home environment and on academic self-esteem. However, the home environment was not predictive of child global self-esteem and thus did not support the proposed mediator hypothesis. These results indicate that socioeconomic status and family structure influence the presence of a cognitively stimulating and emotionally supportive home environment, but these aspects of the home environment do not influence the development of child self-worth and scholastic self-perception.