Lack of stability of the RDC endogenous subtype in consecutive episodes of major depression

doi:10.1016/0165-0327(87)90006-1

Journal of Affective Disorders

Volume 12, Issue 2, March–April 1987, Pages 139-143

https://doi.org/10.1016/0165-0327(87)90006-1 Get rights and content

Abstract

The stability of the endogenous subtype of major depressive disorder was examined within individuals across consecutive episodes. The subjects were 119 probands from the NIMH Collaborative Depression Study who experienced at least two episodes of unipolar major depressive disorder within a two-year period of biannual evaluations. Structured data collection methods and Research Diagnostic Criteria were employed. The inter-episode stability of subtype diagnosis was low, never producing a kappa of greater than 0.25. This result was not attributable to threshold for diagnosis, time between episodes, differences in severity, or changes in raters.

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Citation Excerpt :
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). In addition to theory-driven approaches, there is a vast literature on different data-driven techniques that have aimed to cluster individuals with MDD or depression symptoms into smaller and more homogeneous groups.
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.
We investigated the number of unique symptom profiles reported by 3703 depressed outpatients at the beginning of the first treatment stage of STAR*D.
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.
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.
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.
Severe depression: Genes and the environment
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Les patients souffrant d’un épisode dépressif avec des antécédents familiaux sont généralement considérés comme plus endogènes, de sévérité plus marquée, et donc de plus mauvais pronostic (par exemple pour le risque de récurrence). L’opposition classique entre les dépressions « névroticoréactionnelles » et les dépressions « endogènes » est ici remise en question, du fait des aspects confusionnants de l’âge de début et des biais de sélection. L’existence d’une interaction entre les gènes de vulnérabilité (G) d’une part, et des facteurs de risque tels les événements de vie stressants (E) d’autre part, est considérée comme particulièrement intéressante, évitant une opposition bien artificielle entre ces deux sources de vulnérabilité. L’approche G*E requiert des échantillons encore plus importants et accroît encore un peu plus le risque de faux positifs, mais ne peut que séduire du fait d’être plus proche de la réalité des mécanismes impliqués dans la dépression.
Depressed patients with a familial history of depression are usually considered as more endogenous, with higher severity, therefore with a worst prognosis (regarding for example recurrence risk). The opposition between « neurotic-stress linked depression » and « endogeneous-genetically related depression » is being challenge in the present review. Indeed, differences in age at onset and selection bias are probably important confusing factors. The existence of an interaction between the involved vulnerability genes (G) and the triggering stressful events (E) was considered as providing meaningful insight for the respective parts of genetics and the environment. Although this approach is even more fragile regarding required sample sizes (larger) and the problem of false positive results (increased), the G*E approach is seducing as closer to reality, the onset of complex disorders being usually explained by those two risk factors.
Restoring melancholia in the classification of mood disorders
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The present DSM criteria for major depression poorly identify samples for treatment selection, prognosis, and assessments of pathophysiology. Melancholia, in contrast, is a disorder with definable clinical signs that can be verified by laboratory tests and treatment response. It identifies more specific populations than the present system and deserves individual identification in psychiatric classification. Its re-introduction will refine diagnosis, prognosis, treatment selection, and studies of pathophysiology of a large segment of the psychiatrically ill.
Severe melancholic depression is more vulnerable than non-melancholic depression to minor precipitating life events
2006, Journal of Affective Disorders
The present study examines the moderating role of global depression severity on the relation of melancholic versus non-melancholic depression to severe and non-severe levels of stress.
A community sample of 50 women with unipolar major depressive disorder, of which 54% met Research Diagnostic Criteria for melancholic depression, were interviewed regarding stressful life events experienced prior to onset. Events were coded as severe or non-severe based on the rigorous Bedford College contextual rating system.
Greater severity of depression was related to a higher likelihood of a severely stressful event prior to onset only for women with non-melancholic major depression. By contrast, greater severity of depression was related to a higher likelihood of a non-severe, more minor, stressful event prior to onset only for women with melancholic major depression.
The present study was limited by its use of a female volunteer sample, which might not be entirely representative of the population of individuals with major depression. In addition, the study employed a cross-sectional design, which limits conclusions relating to the causal relation of stress to melancholic versus non-melancholic depression.
Far from being autonomous of stress, individuals with severe melancholic depression may be especially sensitive to stress, such that their episodes are influenced by more minor stressors than those of individuals with non-melancholic depression.
First-episode major depressive and dysthymic disorder in childhood: Clinical and sociodemographic factors in recovery
1997, Journal of the American Academy of Child and Adolescent Psychiatry
To characterize the temporal pattern of depressive disorder in childhood, the first episode of depression was examined, focusing on recovery and its baseline predictors.
The sample includes 112 clinically referred 8- to 13-year-olds with first-episode major depressive or dysthymic disorder participating in a naturalistic follow-up study. Psychiatric diagnoses were based on standardized interviews and operational criteria. Recovery was modeled by multivariate procedures using baseline clinical and demographic predictors.
Recovery rates were 86% and 7% for major depression and dysthymia, respectively, 2 years after onset. Median duration of major depression was 9 months and was predicted only by underlying dysthymia. Median duration of dysthymic disorder was 3.9 years and was predicted only by comorbid externalizing disorder. In post hoc analyses, no positive treatment effects were detected.
First-episode depression in youths is persistent, it generally appears to run its own course, and its naturalistic treatment requires scrutiny. However, because comorbid externalizing disorder apparently affects duration of dysthymia, intervention for behavior problems may shorten this type of depression.
The reproducibility of depressive and hypomanic symptoms across repeated episodes in patients with rapid-cycling bipolar disorder
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The purpose of this study is to determine the stability of symptoms of hypomania and depression across repeated affective episodes in patients with rapid-cycling bipolar disorder. Nine patients had a total of 30 depressive episodes and 31 hypomanic episodes during the period of observation. Standardized observer ratings indicated that the three symptoms most consistently reported during depressive episodes were fatiguability, decreased work activities and hypersomnia. These results as well as those from the standarized observer ratings of hypomania indicate that depression in this population consists of a lethargic, hypoactive state while hypomania may be a heightened state of activation. The clinical and theoretical implications of these findings are discussed.

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^☆: From the National Institute of Mental Health-Collaborative Program on Depression-Clinical Studies, conducted with the participation of the following investigators: G.L. Klerman, M.D. (Chairperson), R.M.A. Hirschfeld, M.D. (Project Director and Co-Chairperson) and P. Griffith, Ph.D. (Washington, D.C.); M.B. Keller, M.D. and P. Lavori, Ph.D. (Boston); J.A. Fawcett, M.D. and W.A. Schneftner, M.D. (Chicago); N.C. Andreasen, M.D., W. Coryell, M.D., G. Winokur, M.D., and P. Wasek, B.A. (Iowa City); J. Endicott, Ph.D., P. McDonald-Scott, M.A. and J.E. Loth, M.S.W. (New York); J. Rice, PhD., T. Reich, M.D. and D. Altis, B.A. (St. Louis). Other contributors include: P.J. Clayton, M.D., M.M. Katz, Ph.D., E. Robins, M.D., R.W. Shapiro, M.D. and R. Spitzer, M.D.

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Lack of stability of the RDC endogenous subtype in consecutive episodes of major depression☆

Abstract

J. Psychiatr. Res.

Diagnostic and Statistical Manual

Concepts, diagnosis and classification

Assessment of reliability in multicenter collaborative research with a video tape approach

Am. J. Psychiatry

The validation of the concept of endogenous depression: A family study approach

Arch. Gen. Psychiatry

Diagnostic consistency and change in a follow-up study of 1215 patients

Br. J. Psychiatry

A coefficient of agreement for nominal tables

Educ. Psychol. Measurement

Diagnostic change in a longitudinal study of psychiatric patients

Br. J. Psychiatry

A diagnostic interview: The schedule for affective disorders and schizophrenia (SADS)

Arch. Gen. Psychiatry

The Global Assessment Scale: A procedure for measuring the overall severity of psychiatric disturbance

Arch. Gen. Psychiatry