Thursday, November 18, 2010

Grading Depression

I recently posted a five-part (and counting) series, Are Antidepressants Bad for You? For a good many, the answer is yes. A lot of it has to do with our antiquated diagnostic criteria for depression, which treats virtually all depressions as the same. This encourages one-size-fits all treatments that turn out to fit very few and harm a good many.

In Feb, the American Psychiatric Association released a draft of an updated DSM, which would perpetrate the mistakes of the past. In light of my most recent series, it's appropriate here to re-run three of my critiques in this one post. Without further ado ...

Grading Depression - Part I

This is the first in a series of report cards that grades the homework turned in last week 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.

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 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, as well.

How this fits into unipolar depression is unclear. On one hand, the workgroup expressly rules out unipolar depression if the patient had ever experienced a mixed episode. On the other hand,
with no explanation, the workgroup adds the specifier, “with mixed features.” Huh?

There is good evidence that many individuals with unipolar depression experience mania/hypomania symptoms in their depressions, not enough to rate a diagnosis of bipolar, but enough to raise their levels of distress and make their depressions more difficult to treat.

On this very important issue, the DSM-5 workgroup has not handed in its homework.

Grade: Incomplete.

Grading Depression - Part II

Part I began issuing grades on the homework handed in last week by the DSM-5 Task Force concerning its proposed revisions to depression. To recap:

The symptom checklist
- “So why change it? This was the approach adopted by the workgroup.” Grade: F-minus.

Mixed anxiety depression
-  “The recognition of anxious-depression is long-overdue.” Grade: C.

Mixed depression-mania episodes
- “On this very important issue, the DSM-5 workgroup has not handed in its homework.” Grade: Incomplete.

Moving on ...

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.


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).

It also places 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 Mood Disorders  workgroup is currently investigating a variety of measures.

Grade: Incomplete.

The Specifiers

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.


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.

Grading Depression - Part III


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.

PMDD. Are you kidding me? We still hide “women’s problems” in the 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 three-part DSM-5 Depression Report Card. Here are the subjects and my grades:
  • Symptom Checklist: F-minus
  • Mixed Anxiety Depression: C
  • Mixed Episodes: Incomplete
  • Chronic and Recurrent Depression: F
  • Severity: Incomplete
  • 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 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?

The other main problem is “paradigm freeze,” which I will get to in a future blog piece.  

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet.


Smitty said...

I'd like to see more on Insel. Especially now that he has an article in Nature, and a blog on the NIMH website, finally admitting (in the most delicate of ways).... that the medication model for treating psychosis was ineffective and we are ready to use new tools. This is a huge paradigm shift.

Am I too optimistic? I sense true hope at last for treatment of schizophrenia and all of psychiatry. Yet I must also ask how this will affect those who have been told a mistruth about the need for lifelong medications, paid for by Uncle Sam. And how they'll get back on a path of meaning and purpose?

Thank God, we are here at last! Maybe NOW we can get to the bottom of why EACH patient has psychosis, and thereby help them to understand how to prevent it.

Smitty said...

Sharing just a highlight or two of my journey: I devoted only seven years of my life, holding my ground against for health that could move away from medications. What a travesty of a system it has been! I had to do my own advocacy. In my court, were two old school therapists who had insight and faith in me. Also I have a husband who listened to me and did not simply tell me to "take my meds", when my body told me they were not what was getting me well.

It took me a few years to trust that my scientific background was the strength that could help me get away from medication, under the doctor's watchful eye.

I knew that there had to be a reason for my repeat psychoses.

For years, I fought this battle, getting quietly educated, teasing out my risk factors. I did not read Whitaker's first book until 2005, but that book helped me to take back my power.

I did not believe the medications did anything for me, except restore sleep. Turns out I was right. My repeat bouts showed me that the antianxiety meds were best at shutting off the alarm that kept me psychotic.

Another obvious truth the doctors don't admit is that big hormonal fluctuations in perimenopause can set off alarms in the brain, that can involve psychosis. I had to tell my doctor that this was the case for me! And by the time I really knew it, it was too late to get data. I was in menopause. And I was dealing with unresolved story and dysfunctional beliefs that I had learned from a parent who fits all the criteria for Borderline Personality Disorder. These are huge physical health factors, too, that I am glad I was able to discern for myself.