Elsevier

Journal of Affective Disorders

Volume 227, February 2018, Pages 739-744
Journal of Affective Disorders

Research paper
The centrality of DSM and non-DSM depressive symptoms in Han Chinese women with major depression

https://doi.org/10.1016/j.jad.2017.11.032Get rights and content

Highlights

  • Network analyses of major depression (MD) were conducted.

  • DSM-IV MD criteria are a subset of a larger pool of plausible depressive symptoms.

  • DSM-IV MD criteria are not unique in their ability to assess depression.

Abstract

Introduction

We compared DSM-IV criteria for major depression (MD) with clinically selected non-DSM criteria in their ability to represent clinical features of depression.

Method

We conducted network analyses of 19 DSM and non-DSM symptoms of MD assessed at personal interview in 5952 Han Chinese women meeting DSM-IV criteria for recurrent MD. We estimated an Ising model (the state-of-the-art network model for binary data), compared the centrality (interconnectedness) of DSM-IV and non-DSM symptoms, and investigated the community structure (symptoms strongly clustered together).

Results

The DSM and non-DSM criteria were intermingled within the same symptom network. In both the DSM-IV and non-DSM criteria sets, some symptoms were central (highly interconnected) while others were more peripheral. The mean centrality of the DSM and non-DSM criteria sets did not significantly differ. In at least two cases, non-DSM criteria were more central than symptomatically related DSM criteria: lowered libido vs. sleep and appetite changes, and hopelessness versus worthlessness. The overall network had three sub-clusters reflecting neurovegetative/mood symptoms, cognitive changes and anxiety/irritability.

Limitations

The sample were severely ill Han Chinese females limiting generalizability.

Conclusions

Consistent with prior historical reviews, our results suggest that the DSM-IV criteria for MD reflect one possible sub-set of a larger pool of plausible depressive symptoms and signs. While the DSM criteria on average perform well, they are not unique and may not be optimal in their ability to describe the depressive syndrome.

Introduction

The history of the symptoms and signs used as diagnostic criteria for major depression (MD) in DSM-III and subsequent DSM editions is relatively well understood ((Kendler et al., 2010) Table 1). They derive, with minimal changes, from those proposed for the Research Diagnostic Criteria (Spitzer et al., 1975), which in turn were based, with modest modifications, on those included in the Feighner Criteria (Feighner et al., 1972). The Feighner criteria for MD were themselves adapted from an earlier set of items proposed by Cassidy et al. (1957) who cite, as one key source, a set of criteria for MD proposed previously by Stone and Burris (1950). Some differences across these criteria were noteworthy. For example, Cassidy et al. (1957) included slowed thinking, decreased libido and constipation, none of which were included in DSM-III. DSM-III added worthlessness, a symptom not present in the earlier diagnostic formulations, and added appetite/weight gain, not present in either Cassidy et al. (1957) or Stone and Burris (1950).

A recent review provided a broader historical context within which to view the DSM criteria for MD (Kendler, 2016). Examining textbook descriptions of the depressive syndrome from 1900 to 1960, a good but imperfect correspondence was seen between symptoms and signs noted by historical experts and those incorporated into the recent DSM editions. Of the 18 depressive symptoms and signs frequently noted by these textbook authors, 10 were well covered by DSM MD criteria, two were partly covered and six were entirely absent (Kendler, 2016). For example, the historical experts noted that symptoms of anxiety were commonly present in depression but these were not included in any modern MD criteria. In describing the common cognitive changes in depression, the textbook authors noted a rather wide range of symptoms including hopelessness, pessimism and feelings of inadequacy, symptoms not entirely captured by the relevant single DSM criterion which assesses guilt and feelings of worthlessness. These results were recently extended further back in time to the critical period between 1880 and 1900 where expert descriptions of the depressive syndrome closely resembled those found from 1900 to 1960 (Kendler, 2017b).

These historical inquiries suggest that the specific criteria chosen for MD for the DSM-III and subsequent DSM editions reflect one subset of a broader number of plausible criteria that could have been chosen. This viewpoint is supported by evidence that common rating scales for depression differ widely in the symptoms they assess (Fried, 2016). From this perspective, it naturally becomes of interest to examine how the DSM criteria for MD might compare to a set of other plausible symptoms of depression not included in the DSM. Are there distinctive features which differentiate DSM-criteria for MD from these other depressive symptoms? Are the DSM-criteria more centrally placed in this structure of depression than are credible non-DSM depressive symptoms?

To address this question, we utilize a network approach with which we quantify – via the concept of centrality (Opsahl et al., 2010) – how closely interconnected each individual criterion is with all the other symptoms in the network. Specifically, we apply network analysis to 8 of the 9 DSM depressive criteria and 11 other depressive symptoms chosen for their research and clinical value. All these criteria were assessed at personal interview in Han Chinese women, ascertained in psychiatric treatment facilities, who met DSM-IV criterion for recurrent MD. We first describe the network formed by these 19 putative criteria and determine the degree to which the DSM and non-DSM criteria are part of a single network. Second, we explore the connectivity structure of these depressive symptoms as revealed by our network analysis to determine if the DSM criteria are more central to the network than are the non-DSM symptoms.

Section snippets

Sample

The analyses here reported were based on a total of 6008 female cases of MD recruited as part of the CONVERGE (China, Oxford, and VCU Experimental Research on Genetic Epidemiology) study from 57 mental health centers and psychiatric departments of general medical hospitals in 45 cities in 23 provinces in China. The primary focus of CONVERGE was a molecular genetic study of MD (CONVERGE consortium, 2015). Given evidence that the genetic effects on MD are different in the sexes (Kendler et al.,

Results

Table 1 depicts the frequency of endorsement of the 20 putative depressive criteria assessed during the worst lifetime episode. These rates varied from a low of 62.2% for worse in AM to a high of 99.6% for sad mood. The DSM criteria had, on average, higher endorsement rates than did the non-DSM criteria. A tetrachoric correlation matrix for these 20 criteria, along with the adjacency matrix (i.e. the numerical value of all connections) of the network depicted in Fig. 1, is presented in Appendix

Discussion

The major goal of this study was to examine, in a large, carefully assessed and ethnically homogeneous ascertained sample of severely depressed patients, the performance of the DSM criteria for MD compared to a selected set of non-DSM criteria judged by one of us (KSK) on the basis of clinical and research experience to be valuable in the evaluation of depressed patients. Using network analyses, we empirically investigated whether we could find support for or against the impressions gleaned

Conclusions

In a large sample of clinically depressed Han Chinese women, we performed a network analysis of DSM-IV criteria for MD along with a set of non-DSM depressive symptoms chosen for their clinical relevance. The resulting network has a structure that intermingled DSM and non-DSM symptoms. Furthermore, the “inter-connectedness” of the DSM criteria did not differ from the non-DSM symptoms. These results are consistent with the hypothesis, suggested by historical research, that the DSM criteria were

Acknowledgments

This work was funded by the Wellcome Trust (WT090532/Z/09/Z, WT083573/Z/07/Z, WT089269/Z/09/Z) and by NIH grant MH100549. KSK and JF are part of the CONVERGE consortium (China, Oxford and Virginia Commonwealth University Experimental Research on Genetic Epidemiology) and gratefully acknowledge the support of all partners in hospitals across China. Special thanks to all the CONVERGE collaborators and patients who made this work possible. DB and EIF are supported by the European Research Council

Location of where work was done

Department of Psychological Methods, University of Amsterdam and Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

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