Improving the Diagnosis of Depression

The official guidelines for diagnosing depression are out of touch with current clinical knowledge. What would make them more useful for guiding treatment?

 Richard J. Metzner, M.D.

Clinical Professor 
Semel Institute for Neuroscience and Human Behavior at UCLA

The most influential guidelines for diagnosing depression come from the American Psychiatric Association's Diagnostic and Statistical Manual, 4th Edition, Text Revision. Many depression tests are based on these DSM-IV-TR criteria. Founded upon some of the early 20th century teachings of the German psychiatrist Emil Kraepelin, the DSM-IV-TR's depression codes make no distinction between too much or too little of any of the following critical functions: sleep, appetite, body weight, physical activity or mental activity. As long as sadness or loss of enjoyment are present, the overweight, excessively sleeping, apathetic and mute patient is given the same diagnostic code as the thin, irritable, agitated, sleepless patient. Is it really possible that when it comes to the central nervous system, excessive and diminished functioning represent the same disorder? Where else in the body do we equate too much with too little? Not with vital signs like blood pressure or pulse rate. Not with any other organ activity. Why then the brain?

Though of little utility, the DSM-IV-TR criteria do allow for feature specifiers, such as "with atypical features."  The "atypical" specifier requires "mood reactivity" and two of the following 1) weight gain or increased appetite, 2) excessive sleeping, 3) heavy, leaden feelings in arms or legs and 4) rejection hypersensitivity. This specifier might be useful to differentiate the two patients above, except that if the overeating patient's moods don't fluctuate (as they often don't), he can't receive the specifier. Few studies have validated the full atypical syndrome, but the association between excessive eating and sleeping has been replicated on a number of occasions. A new study on the comorbidity of obesity and depression by Levitan et al reports that atypical depressed patients with excessive eating and sleeping represent a significantly distinct populations from "classically" depressed patients whose appetite and sleep are diminished. Our own work corroborates this finding.

The APA worked for several years on DSM-5, the latest version of the manual, but the newly approved version is under attack from both inside and outside organization.  Allen Frances, MD, chairperson of the APA Committee that produced DSM-IV-TR  says there was not enough evidence to justify replacing his 12-year-old version. He's taken his case to the media. His successor, David Kupfer, MD, disagrees and stands behind his version.

Several of the proposed changes were withdrawn because of protests about "recklessly expanding" psychiatric diagnosis. Mixed anxiety/depression was one of the stillborn diagnoses. The fact that there are millions of people who fit the criteria for mixed anxiety/depression is part of the problem. Many people who don't yet have a potentially reimbursable psychiatric disorder would receive one. What is worse for insurance companies is that some evidence suggests antidepressants might help this problem.  To no one's surprise, psychologists have mounted a petition to stop the publication of DSM-V altogether. 

An interesting related story is the public apology issued by the psychiatrist considered by some most responsible for spearheading the modern DSMs, Dr. Robert L Spitzer. His apology was for having published a scientifically questionable study supporting the validity of reparative therapy for homosexuality. The negative publicity being generated by these stories doesn't reflect well on the mental health field. Woeful PR aside, it should remind those of us who study and treat emotional disorders that we can sometimes overstep our bounds. It is tempting to assume our training and experience gives us an omniscience we do not have. Presuming to lead when lacking the empirical data to support one's contentions is a dangerous mix of arrogance and folly.

Reading Kraeplin, one cannot help but be impressed with the diligence and powers of observation he brought to the enterprise of psychiatric diagnosis. Was he right in placing melancholia on the same spectrum with dementia? Depressive "stupor" on the same spectrum with mania? The answers might be a surprise, and I'll address them in an upcoming article on this website. Kraepelin's teachings were based on decades of careful scrutiny in the asylum. How different it is now. One of psychiatry's most esteemed contemporary researchers told me that it had been years since he had had contact with a patient. I suspect that the erroneous conclusions that he and other researchers have sometimes reached about their own data may reflect that lack of ongoing clinical experience. Kraepelin did not have the advantages of modern neuroscientific discoveries to guide him, but he definitely had boots on the ground where psychiatric patients battled their demons. Perhaps, if those attempting to follow in Kraepelin's footsteps had more of his experience in the trenches rather than the towers, depressed individuals agitated with apprehension would not be receiving the same diagnostic codes and treatment guidelines as those paralyzed by stupor.



Copyright 2012, Scaled Psychiatric Systems, Inc. All rights reserved.