Abstract
ObjectivesThe melancholic and atypical specifiers for a major depressive episode (MDE) are supposed to reduce heterogeneity in symptom presentation by requiring additional, specific features. Fried et al. (2020) recently showed that the melancholic specifier may increase the potential heterogeneity in presenting symptoms. In a large sample of outpatients with depression, our objective was to explore whether the melancholic and atypical specifiers reduced observed heterogeneity in symptoms.MethodsWe used baseline data from the Inventory of Depression Symptoms (IDS), which was available for 3,717 patients, from the Sequenced Alternatives to Relieve Depression (STAR*D) trial. A subsample met criteria for MDE on the IDS (“IDS-MDE”; N =2,496). For patients with IDS-MDE, we differentiated between those with melancholic, non-melancholic, atypical, and non-atypical depression. We quantified the observed heterogeneity between groups by counting the number of unique symptom combinations pertaining to their given diagnostic group (e.g., counting the melancholic symptoms for melancholic and non-melancholic groups), as well as the profiles of DSM-MDE symptoms (i.e., ignoring the specifier symptoms).ResultsWhen considering the specifier and depressive symptoms, there was more observed heterogeneity within the melancholic and atypical subgroups than in the IDS-MDE sample (i.e., ignoring the specifier subgroups). The differences in number of profiles between the melancholic and non-melancholic groups were not statistically significant, irrespective of whether focusing on the specifier symptoms or only the DSM-MDE symptoms. The differences between the atypical and non-atypical subgroups were smaller than what would be expected by chance. We found no evidence that the specifier groups reduce heterogeneity, as can be quantified by unique symptom profiles. Most symptom profiles, even in the specifier subgroups, had five or fewer individuals.ConclusionWe found no evidence that the atypical and melancholic specifiers create more symptomatically homogeneous groups. Indeed, the melancholic and atypical specifiers introduce heterogeneity by adding symptoms to the DSM diagnosis of MDE.
Highlights
Experiences of depressed mood or low positive affect can range from states of transient sadness to highly debilitating, chronic, and recurrent patterns of symptoms [1, 2]
The optimal classification of major depressive disorder (MDD), the diagnosis most commonly associated with a major depressive episode (MDE) [4], has been one of the major challenges in the history of psychiatry [1, 5,6,7,8,9,10,11,12,13,14]
We present basic descriptive data on the categorical endorsement of all the symptoms we are studying, which include the symptoms from the DSM MDE criteria, the symptoms from the melancholic specifier, and the symptoms from the atypical specifier
Summary
Experiences of depressed mood or low positive affect can range from states of transient sadness to highly debilitating, chronic, and recurrent patterns of symptoms [1, 2]. The DSM diagnostic criteria for a MDE are a polythetic set (i.e. there are more symptoms than necessary for a diagnosis). There can be considerable heterogeneity in the symptom presentation of MDD to the point that two individuals with the diagnosis may not overlap on any one symptom [15, 16]. Counting compound criteria as a single symptom, there are 227 possible ways of meeting criteria for a MDE [15, 16]. Perhaps more accurate, in counting the compound symptoms as distinct symptoms, there are as many as 10,377 ways of meeting the MDE criteria [17]. In a sample of 3,703 outpatients, Fried & Nesse [15] had symptom data that allowed for up to 4,096 possible profiles of the symptoms. Underscoring the importance of attending to heterogeneity in symptoms are findings that symptoms have different relations to validators like impairment [18] co-morbidity and temperamental vulnerabilities [5, 19] as well as to biological vulnerabilities [20]
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