Research paperThe centrality of DSM and non-DSM depressive symptoms in Han Chinese women with major depression
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.
References (37)
- et al.
Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study
Psychiatr. Clin. North Am.
(2003) - et al.
What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis
J. Affect. Disord.
(2016) - et al.
Node centrality in weighted networks: generalizing degree and shortest paths
Social. Netw.
(2010) Diagnostic and Statistical Manual of Mental Disorders
(1994)- et al.
Cognitive Therapy of Depression
(1980) - et al.
Revealing the dynamic network structure of the Beck Depression Inventory-II
Psychol. Med.
(2015) - et al.
Clinical observations in manic-depressive disease: a quantitative study of one hundred manic-depressive patients and fifty medically sick controls
J. Am. Med. Assoc.
(1957) Sparse whole-genome sequencing identifies two loci for major depressive disorder
Nature
(2015)- Epskamp, S., Borsboom, D., Fried, E.I., 2017. Estimating Psychological Networks and their Accuracy: A Tutorial Paper....
- et al.
qgraph: network visualizations of relationships in psychometric data
J. Stat. Softw.
(2012)
Diagnostic criteria for use in psychiatric research
Arch. Gen. Psychiatry
The 52 symptoms of major depression: Lack of content overlap among seven common depression scales
J. Affect. Disord.
Graph drawing by force-directed placement
Softw.: Pract. Exp.
What are the clinical implications of new onset or worsening anxiety during the first two weeks of SSRI treatment for depression?
Depress. Anxiety
Overt irritability/anger in unipolar major depressive episodes: past and current characteristics and implications for long-term course
JAMA Psychiatry
The phenomenology of major depression and the Representativeness and nature of DSM criteria
Am. J. Psychiatry
DSM disorders and their criteria: how should they inter-relate?
Psychol. Med.
Cited by (47)
A network analysis of post-traumatic stress among youth aging out of the foster care system
2022, Children and Youth Services ReviewCitation Excerpt :Internal consistency for the network was very high (Cronbach’s alpha = 0.891). In the partial correlation network, the edges link conditionally dependent symptoms together and any two symptoms that lack an edge between them are conditionally independent (Kendler et al., 2018). The strength and direction of associations noted above remained the same in the graphical LASSO network.
A bibliometric analysis of 10 years of research on symptom networks in psychopathology and mental health
2022, Psychiatry ResearchCitation Excerpt :However, it is worth mentioning that NA is not free of criticism, such as the debate related to replicability (Forbes et al., 2017; Borsboom et al., 2017), as well as the invariance found in networks developed by modifying certain variables (P.J. Jones et al., 2018; Schweren et al., 2018; van Loo et al. 2018). Other studies find that the network obtained, for example in depression, presents the same core symptoms as those proposed in the DSM 5 (Kendler et al., 2018), questioning the approach's contributioncontribution of the approach. This highlights the need to (i) develop more rigorous analytical methods to explore the reliability of the networks (Contreras et al., 2019), (ii) undertake studies focused on the comparison and analysis of commonalities (Dejonckheere et al., 2017), and (iii) give greater weight to the hypotheses and not so much to the exploratory analyses with little theoretical supportThis highlights the need to develop more rigorous analytical methods to explore the reliability of the networks (Contreras et al., 2019), as well as to carry out studies focused on the comparison and analysis of commonalities (Dejonckheere et al., 2017), and to give greater weight to the hypotheses and not so much to the exploratory analyses with little theoretical support (Wichers et al., 2017).
Comparison of depression and anxiety symptom networks in reporters and non-reporters of lifetime trauma in two samples of differing severity
2021, Journal of Affective Disorders ReportsCitation Excerpt :Furthermore, the criteria of moderate symptoms used to identify participants were based on total scores, and did not require the endorsement of specific symptoms. This meant that endorsement rates for core symptoms were not artificially inflated in the analytic sample, and did not need to be excluded from analyses, as they have been in previous studies (Kendler et al., 2018; van Loo et al., 2018). However, combining two measures that are psychometrically distinct with high internal consistency may have increased associations with core symptoms, as they are likely to be highly correlated with other items from the same measure, but not with items from the other measure.
Symptom networks in major depression do not diverge across sex, familial risk, and environmental risk
2021, Journal of Affective DisordersCitation Excerpt :This finding is relevant for clinical practice and warrants vigilance for suicidality in patients with early-onset MD. We found that non-DSM symptoms exhibited similar centrality as DSM symptoms, in line with other studies (Kendler et al., 2018). Recognizing the role of these symptoms is important, as they might also provide opportunities for precision treatment.