My DSM-5 Report Card - Grading Depression
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Hint - Expect liberal use of the sixth letter of the alphabet.
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DSM-5 and Depression. This is the first in a series of report cards that grades the homework turned by the DSM-5 Task Force. Our first assignment: Depression.
First, some background ...
According to statistics cited on the NIMH website, major depression is the leading cause of disability in the US and affects 6.7 percent of Americans in any given year. Plus major depression is a major component to bipolar disorder, affecting another 2.6 percent of the US population each year. In addition, dysthymia (major depression lite) accounts for an additional 1.5 percent.
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An illness of this dimension literally comes equipped with its own gravitational field. Thus, few psychiatric diagnoses make sense without some reference to depression, be it anxiety or schizophrenia or borderline personality disorder.
This means that if the people responsible for coming up with a new version of DSM depression get it wrong, then the whole document - together with the whole field of diagnostic psychiatry - is going to be out of alignment.
Fortunately, everyone knows what depression is, right? Um, not exactly. Early versions of the DSM recognized the highly complex nature of the illness at the expense of confusing just about everyone and thus influencing no one. The DSM-III of 1980 and its successors (the DSM-III-R, the DSM-IV, and the DSM-IV-TR) went for simplicity and clarity, which seemed to please just about everyone, except maybe patients.
The major knock on depression as we know it is that it is a catch-all diagnosis for all manner of things going wrong. But this is its major appeal, as well. One one hand, not enough patients are getting better on meds and therapies designed to combat this simultaneously mysterious and obvious entity called depression. On the other hand, just enough are.
At issue for the DSM-5’s Mood Disorders Work Group is how these major contradictions can be reconciled.
Time to start grading ...
The DSM Symptom Checklist
This was a masterstroke from those who brought us the DSM-III. So much so, that we tend to think of the checklist as something that existed since before the dawn of time and that is based on pure science rather than being pulled out of thin air. Even though the current DSM recognizes several different forms of depression, everything originates from this (five of) nine-item menu.
Critics have identified a number of major problems with the list, namely:
- It is biased toward identifying depression in women rather than men (such as “appears tearful”).
- It fails to identify the patient’s predominant state of mind. For instance, it is possible to check off “feeling depressed,” followed by “significant weight loss,” “insomnia,” “psychomotor agitation,” and “fatigue.” Voila! Major depression, but what does that tell us? Is one vague mental symptom followed by four physical ones truly depression?
- It fails to identify the patient’s predominant state of mind (again). Sad? Agitated? Unmotivated? Feeling hopeless? Overthinking things? Excruciating psychic pain? Yes, we know it’s depression. But what is really going on?
On the other hand, the list has been in service for 30 years. It may not be perfect, but it does give us a reasonable approximation of a condition that so profoundly lays waste to so many. So why change it? This was the approach adopted by the workgroup.
Unfortunately, this was the safe option that gave us nothing to think about, that squelched a conversation that we badly need to be having, and that put the interests of monied stake-holders (such as the insurance industry) over the needs of patients.
Grade: F-minus.
Mixed Anxiety/Depression
This is a wholly new and separate diagnosis, distinct from major depression. The workgroup recognized that nearly 60 percent of those with major depression also experience anxiety, which adversely affects patient outcomes.
The new diagnosis would acknowledge that one need not experience full-blown major depression or full-blown anxiety to wind up seriously distressed and incapacitated. A little bit of each will do. Thus, Mixed Anxiety/Depression calls for just three or four depression symptoms (one which must include either feeling depressed or loss of pleasure), plus “anxious distress” which involves such things as “irrational worry.”
The recognition of anxious-depression is long-overdue, but since it was already listed in the DSM-IV appendix as deserving of future consideration, one cannot give the current workgroup credit for putting the issue on the table. Moreover, there is no mention of how “agitated depression” and other types of “mixed states” may fit into the picture.
Grade: C.
Mixed Episodes
The current DSM only recognizes mixed depression-mania states as occurring in bipolar I, and only in the ridiculously limited context of full-blown mania combined with full-blown depression. The DSM-5 would restore a measure of sanity by acknowledging that mixed states can occur in bipolar II and in unipolar depression, as well, but perpetuates the absurd notion that both depression and (hypo)mania must be evident in full measure.
Thus, no full depression with a bit of (hypo)mania. Not a little bit of depression with a little bit of (hypo)mania.
The DSM-5 disingenuously states the condition must be "predominately depressed," but - hello? - how is this possible with equal quantities of depression and mania? Moreover, if full-blown mania is going on, clearly this a bipolar condition and doesn't belong in unipolar depression.
Finally, what does a mixed depression look like? Most likely an "agitated" or "energized" depression characterized by intense psychic unease, but we shouldn't have to fill in the blanks, ourselves.
Let's put it this way: By acknowledging depressive mixed states, the DSM hit the equivalent of a triple with the possiblity of stretching it into an inside-the-park home run. But by forgetting to step on second base, the DSM-5 effectively tagged itself "out."
Grade: C-minus.
Chronic and Recurrent Depression
These are two entirely different animals. For the first time, the DSM would fully acknowledge the chronic variety (“chronic depressive disorder” with an episode lasting at least two years). The new diagnosis would subsume dysthymia and change its threshold to include major depression as well as low grade depression.
Gone is the “chronic” specifier to a major depressive episode.
The DSM-IV criteria for recurrent depression would stand, namely two or more major depressive episodes (lasting at least two weeks) at least two months apart. No provision is made, however, for the reality of highly-recurrent depressions that come and go at a faster rate.
Recurrent depression - and the highly-recurrent variety in particular - may have more in common with bipolar depression than unipolar depression, or at least may occupy common ground in dire need of mapping. Somewhere, somehow, on some level, the rather obvious overlap between unipolar and bipolar needs to be recognized and dealt with. On this vital issue, the workgroup looked the other way.
Grade: F.
Severity
The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would obviate the rather arbitrary and clumsy distinction the current DSM makes between major depression and dysthymia (which the workgroup proposes eliminating).
In theory, this would place less emphasis on the symptom checklist. Thus, someone with all nine depression symptoms who is nevertheless able to hold down a job and keep his or her marriage going is in much better shape than someone with only four symptoms who technically does not meet the threshold for major depression but hasn’t been able to get out of bed in six months.
The obvious way to do this is to rate each symptom according to severity (ie from "normal" to "extreme") then add up the numbers. Another is for the physician to globally make a determination. The "Severity of Illness Rating" is one approach mentioned by the DSM-5. The catch is any measure of severity is based on a flawed symptom checklist, which raises one of those Zen koan questions:
If we cannot adequately define the illness to begin with, how can we tell how severe it is?
Grade: C
The Specifiers to Depression
The current DSM uses these to parse out different types of major depression, thus major depression with: psychotic features, catatonic features, melancholic features, atypical features, postpartum onset.
The DSM-5 would leave this list intact with two exceptions. “Chronic” is removed as a specifier and upgraded to a diagnosis, and “mixed features” is added with no explanation. In addition some changes are added to the psychotic features specifier to account for severity as well as type (“congruent” or “incongruent”).
The problem with specifiers in this context is they are only as good as the symptom checklist they are supposed to be specifying. There must be a better way, for instance, of distinguishing an agitated depression from a vegetative one or a mainly sad state of mind from one characterized by the lack of ability to care.
Think of depression as too much emotion on one hand and not enough on the other. Factor in too much or not enough thinking, and you can see that the experts charged with this brief had their work cut out them. They didn’t put in the work.
Grade: F.
Reactive Depression
The DSM-II of 1968 distinguished between what it saw as biologically-based depression (endogenous) and depression seen as a reaction to stressful events (exogenous). The DSM-III and its successors wisely ditched speculating about cause and effect and stuck to categorizing observable symptoms.
Thirty years later, however, advances in brain science suggest some merit in going back to the future, but with this ironic twist: Although current brain science does not yet support diagnostic descriptions based on underlying biology, one can make a good biological case for supposedly non-biological reactive depression.
Not only that, we already know that managing stress is a key to managing one’s depression. Stress Junction is where Freud, brain science, and common sense meet. The DSM-5 workgroup missed the bus.
Grade: F-minus.
Personality
Can persistent and treatment-resistant depression be looked upon as a personality disorder? Consider this assignment extra credit. Neither the Mood Disorders nor the Personalities Disorders workgroups took up the challenge.
No grade.
PMDD
The initial draft had premenstrual dysphoric disorder stuck in the NOS closet. The current version has it out in the open, where it belongs. But this was hardly a stoke of genius or boldness worthy of an A.
Grade: C for competency and common sense.
NOS
Is there a place in your house you dread looking into? The attic? The crawl space? A certain closet? The bottom of your refrigerator? The current DSM contains its own version of the dreaded place. It is called NOS - not otherwise specified - and accompanies 41 listed diagnoses.
The draft DSM-5 would continue the practice. I peeked in and, suffice to say, experienced every traumatic flashback involving attics, crawl spaces, closets, and refrigerators, and then some. Some background:
If you’re a DSM editor and don’t know what to do with a certain type of symptom or behavior, you create an NOS closet (or refrigerator) and stick the weird stuff in and close the door. Maybe you’ll figure out what to do with it later.
It you’re a doctor and don’t know how to diagnose a certain patient, you write up NOS and find the appropriate closet (or refrigerator), shut your eyes, stick it in, and close the door. Maybe you’ll come up with the correct diagnosis later.
The trouble is NOS is a black hole. What, for instance, does “Depression NOS” mean? Imagine “Cardiovascular NOS” and you can see that the practice is unacceptable, whether one is practicing medicine or writing a diagnostic manual. Moreover, the practice is highly abused. A background paper put out by the DSM-5 mood disorders workgroup cited an unpublished study that found that the specialist and nonspecialist clinicians in the sample employed “NOS” in 37-38 percent of their primary diagnoses for depression.
The DSM-5 would change NOS to CNEC (conditions not otherwise classified). I opened the freshly painted closet door to find ...
Subsyndromal depressive CNEC. This would include patients in obvious distress who somehow don’t meet the formal diagnostic criteria for depression. Given the extremely wide view of depression the DSM already employs and its generously low thresholds it’s hard to imagine such a group. Certainly there are those who must put up with residual symptoms once the worst is over, but can’t we find a better way of defining this category? Out in broad daylight?
Major depressive disorder superimposed on a psychotic disorder. What the hell is something this major doing buried away in a closet?
Recurrent brief depressive disorder. So THAT’s where they stuck highly recurrent depression! I was looking all over for it. Nope, not out with recurrent major depressive disorder, where it belongs. Nope, not red-flagged as a type of depression closely related to bipolar. Nope, stuck away in a closet.
The sad thing is the things lurking in the DSM-5 CNEC closet are nearly identical versions of those still gathering dust in the DSM-IV NOS refuse bin.
Grade: F-minus.
To Sum Up
Thus concludes my Depression Report Card. Here are the subjects and my grades:
- Symptom Checklist: F-minus
- Mixed Anxiety Depression: C
- Mixed Episodes: C-minus
- Chronic and Recurrent Depression: F
- Severity: C
- The Specifiers: F
- Reactive Depression: F-minus
- Personality (extra credit): No grade
- NOS: F-minus
Overall grade: F
Concluding Remarks
One of the ironies in issuing this report card is that I owe much to virtually all of the members of the DSM-5 mood disorders workgroup. I have read their articles. I have heard them speak at conferences. I have asked them questions face-to-face. In some cases, I found myself seated at the same breakfast or luncheon or dinner table.
My dealings with these individuals have been extremely productive and beneficial. To a person, they are as dedicated to their work as they have been gracious to me. Moreover, a good deal of what I know about mood disorders can be attributed to them and their colleagues. Many of my key Aha! moments are a direct result of the wisdom they have shared with me, their professional colleagues, and with patients and family members.
So, what went wrong?
For one, DSM-5 operating parameters were far too restrictive, involving an onerous burden of proof for new inclusions. Too often, the necessary empirical data was lacking. We may “know” for instance that depression is bound up in personality, but can we “prove” it?
Scientists need to “validate” their claims with scientific evidence. But what if the incomplete and fragmented picture they produce is inaccurate and misleading and leads to the kind of absurd results I've brought up this series? No acknowledgment of the obvious relation and overlap between depression and bipolar? C'mon!
My concern is with "credibility," which the DSM-5 sacrificed in its obsessive over-pursuit of "validity." As a result, the DSM-5 is failing in its key mission of aligning psychiatric authority to our clinical reality.
Nevertheless, everyone has a stake in the status quo - Pharma, the insurance companies, the clinical-research establishment, perhaps even patient advocacy groups. Credible or not, the DSM pays the bills. Thus, no one is about to stand up and say the DSM-5 is a piece of shit. Okay, I just did, but who listens to me?
First published as a series of blogs, April 2010, reshaped as an article Jan 3, 2011, updated, April 20, 2011.
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