DSM-III Criteria Research Articles

Campbell's 1953 Book on “Manic-Depressive Disease”

Abstract The DSM-III symptomatic criteria for major depression (MD) were derived from those proposed by Feighner and colleagues in 1972, which closely resembled those published by Cassidy in 1957. I here present a counter-factual history in which Feighner carefully read a key reference in Cassidy, a large 1953 follow-up study by Campbell of depressed patients with detailed tables of depressive signs and symptoms. In this alternative timeline, the Feighner criteria for MD were modified by Campbell's results, which then changed DSM-III and subsequent MD criteria sets. The historical pathway to the current DSM MD criteria was contingent on a range of historical events and could easily have been different. This story is not meant to criticize DSM MD criteria that perform well. Rather, it suggests that these criteria represent a useful but fallible set of symptoms/signs that index but do not constitute MD and therefore are not to be reified.

Association of Psychotic Experiences and Incident Depression in a Longitudinal Population-Based Community Survey.

The present study aims to determine if psychotic experiences in a general population sample are a risk factor for depressive disorders at a 15-year follow-up visit. A longitudinal population cohort of adults over age 18 from East Baltimore were followed from 1981 to 1996 with 1409 participants included in analyses. Delusions and hallucinations and depressive disorders were assessed using DSM-III criteria. Odds ratios were obtained using logistic regression with psychotic experiences modeled both dichotomously and as count variables as predictors of major and minor depressive disorders at wave three. Age, race, and sex were included as covariates in the model. Both delusions and hallucinations were associated with an increased odds of incident depressive disorders. Delusions, but not hallucinations, were associated with increased odds of major depressive disorder (adjusted odds ratio, 3.04 [95% CI=1.29-7.13]) and both delusions and hallucinations were associated with increased odds of minor depressive disorder (adjusted odds ratios, 4.6 [95% CI=2.11-10.04] and 3.93 [95% CI=2.11-7.32]). There was a dose-response relationship in number of psychotic experiences reported and odds of depressive disorders. Lifetime psychotic experiences, particularly delusions, in the absence of mental disorders, are associated with later depressive disorders. Results persist in a dose-response manner. Future research should determine whether transitory versus persistent psychotic experiences have a differential effect on later depression.

Prevalence of Autism Spectrum Disorder (ASD) in all Individuals Diagnosed with Down Syndrome (DS): A Systematic Review and Meta-analysis Protocol

Background: Traditionally, autism spectrum disorder in people with Down syndrome was believed to be uncommon. This misconception is rooted in the challenges that a dual diagnosis poses. In fact, evidence indicates that children with Down syndrome are at risk for autism spectrum disorder with a potentially higher prevalence than the typically developing population. The purpose of this review is to determine the reported prevalence rate of autism spectrum disorder in all individuals with Down syndrome in comparison to the prevalence rate of autism spectrum disorder in the typical population when specific diagnostic tools are used. Methods: A systematic review will be conducted of the prevalence and incidence data and perform a meta-analysis of these results. This study will consider all studies that reported on children and adults with an existing diagnosis of Down syndrome and diagnosed by the standardized assessments for autism spectrum disorder. The diagnoses made by team assessment (psychologist, psychiatrist & developmental pediatrician) will also be considered according to DSM-III, DSM-IV or DSM-V criteria for diagnosing autism spectrum disorder or if they use autism spectrum disorder screeners. Studies will be considered from all countries that have data reporting prevalence on this topic. The language restrictions will not be applied attempting to translate studies that are not in English. The five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL) will be searched. Two reviewers will conduct all screening and data extraction independently. The articles will be categorized according to key findings and a critical appraisal performed. Discussion: The results of this review will bring increased awareness of the presence of autism spectrum disorder in individuals with Down syndrome. In doing so, this may facilitate a recommendation for screening and diagnosis of autism spectrum disorder in all individuals with Down syndrome. Based on the research demonstrating the benefits of early identification and intervention on the outcomes of children with autism, we anticipate similar benefits in this population. This will guide the allocation of resources and direct future research.

A brief young adult alcohol problems screening test: Short form development using combinatorics

Objective: To develop a shortened form of the Young Adult Alcohol Problems Screening Test 1 (YAAPST; original length = 27 items) using a novel combinatorial approach. Participants: 489 college freshmen, half of whom were above average risk for alcohol use disorder based upon family history, attending a large, Midwestern University followed prospectively for 16–17 years across 7 measurement occasions (waves). Methods: Using an exhaustive combinatorial approach, we evaluated all possible combinations of questions and questionnaire length. Each candidate short-form was evaluated using part-whole correlations, alpha coefficients, and polyserial correlations with DSM-III criteria. Results: The 12-item scale, the Brief-YAAPST, was chosen as the best candidate short-form as this scale had the fewest items while maintaining strong reliability and validity. Conclusions: Complete enumeration optimization effectively produced a 12-item short form with minimal loss of reliability and validity making the Brief-YAAPST a desirable assessment alternative when there are concerns about participant or client burden.

Deconstructing childhood conduct and adult antisocial criteria for the diagnosis of antisocial personality disorder

Antisocial personality disorder (ASPD) is a serious psychiatric disorder that can be incapacitating and costly to individuals and society. The ASPD diagnosis has 2 main components, childhood conduct problems and adult antisocial behaviors, with specific age requirements. The nosological effects of these criteria on population subgroups defined by these aspects of the criteria have not been fully explored. Data for ASPD were analyzed for 3,498 individuals in the St Louis, Missouri, site of the Epidemiologic Catchment Area study of general population psychiatric disorders collected in the early 1980s using structured diagnostic interviews for DSM-III criteria. Effects of the criteria on population subgroups defined by various combinations of the criteria were examined. Earlier-onset conduct disorder was more severe than later-onset childhood conduct disorder, with more total childhood and adult symptoms and negative psychosocial adult outcomes (substance use disorders, criminality, and homelessness). Three subgroups with adult antisocial behaviors (differentiated by no conduct disorder, later-onset conduct disorder, and earlier-onset conduct disorder meeting ASPD criteria) were similar in numbers of adult antisocial symptoms, but the ASPD subgroup had more negative psychosocial adult outcomes. These findings provide evidence for and against reconsideration of the 15-year age-of-onset requirement for conduct symptoms in ASPD criteria.

Reproducibility on science: Challenges and advances in Brazilian alcohol surveys

BackgroundReproducibility in Science is challenging and may be hard to achieve in alcohol research. Previous general population surveys in Brazil have estimated the prevalence of alcohol dependence to be around 10%. We aim to estimate alcohol use and dependence using different methods and definitions. MethodsThe 3rd Brazilian Household Survey on Substance Use (BHSU-3) was a nationwide, probability sample survey that interviewed 16,273 individuals. DSM-IV-TR criteria were used to determine alcohol dependence. In the BHSU-2 (covering only Brazil’s 108 largest municipalities), alcohol dependence was defined as fulfilling 2/6 DSM-III criteria. Using the BHSU-3 data, alcohol use was estimated at: [1] the national level, [2] BHSU-2 municipalities, taking into consideration the sample design, and [3] BHSU-2 municipalities, ignoring the sample design. Alcohol dependence was calculated using: BHSU-3 and BHSU-2 definitions, two denominators ([A] population and [B] 12-month drinkers), and [1], [2], [3]. ResultsLifetime alcohol use ranged from 66.4% (95%CI:64.8–68.0 [1]) to 70.1% ([95%CI:69.1–71.0], [3]). The estimated population presenting with alcohol dependence ranged from N = 2.3 million (BHSU-3 definition, [1]) to N = 4.3 million (BHSU-2 definition, [1]). In the first case, the prevalence among the general population [A] and drinkers [B] was 1.5% (95%CI:1.2–1.8) and 3.5% (95%CI:2.8–4.2), respectively. In second case, prevalence was 2.8% (95%CI:2.4–3.3, [A]) and 6.6% (95%CI:5.6–7.6, [B]). ConclusionsPrevalence of alcohol dependence may vary as much as 4.3 times, analyzing the same dataset in different ways. Brazilian research on alcohol is funded by governmental research and policy-making agencies, providing subsidies for alcohol policy in the country. It is crucial that sufficient methodological information is provided in order to guarantee reproducibility and consistency over time.

An empirical study of five sets of diagnostic criteria for delusional disorder

BackgroundThe diagnosis of paranoia/delusional disorder has been significantly modified and redefined from DSM-III to DSM-5, which in turn also meaningfully differ from the ICD-10 criteria. In this study we examined the degree to which these diagnostic systems differ on external variables. MethodTwo-hundred and eighty-six subjects diagnosed of paranoia/delusional disorder according to DSM-III, DSM-III-R, DSM-IV, DSM-5 or ICD-10 criteria were examined for a number of validators including risk factors, premorbid features, illness-related variables and psychosocial functioning. The prevalence rates of the diagnostic criteria and their concordance level were examined, such as the degree to which the criteria sets and their main diagnostic features were differentially related to the validators. ResultsDiagnostic criteria showed poor to fair concordance. The most inclusive system was the DSM-5 (n = 274) and the most restrictive the DSM-III (n = 187). Compared with subjects fulfilling other diagnostic criteria, those with a DSM-III diagnosis showed more and stronger associations with the validators: presence of cluster A personality disorders, insidious illness onset, poor response to treatment, chronic illness course and poor psychosocial functioning. This association pattern was mainly due to the 6-month duration criterion. Stability of delusions, type of delusions and the ICD-10 3-month duration criterion were poorly related to the validators. ConclusionsDiagnostic criteria for delusional disorder are not interchangeable. DSM-III criteria for paranoia may identify a more severe disorder mainly because the 6-month duration criterion. Type of delusions had a small impact on the validators across diagnostic systems. These findings have implications for future classifications of delusional disorder.

Childhood sexual abuse, poly-victimization and internalizing disorders across adulthood and older age: Findings from a 25-year longitudinal study

BackgroundWe aimed to investigate associations between childhood sexual abuse and maltreatment and internalizing disorders (anxiety, depression, PTSD) across adulthood. MethodsFollowing a postal survey of 2220 women, a subsample was selected to participate in an interview. The subsample included 276 women reporting childhood sexual abuse and 221 women with no reported history of childhood sexual abuse. Interviews were repeated six and 25 years following the first interview. Internalizing disorders were assessed using ICD-8 and DSM-III criteria. ResultsThere was a lower probability of having an internalizing disorder at older ages than younger ages for all women, regardless of maltreatment history. Latent class analysis was used to define three classes (no/low maltreatment, sexual abuse, poly-victimisation). Compared with no/low maltreatment, a history of childhood sexual abuse was associated with almost double the risk of an internalizing disorder and a history of poly-victimisation was associated with over four times the risk of an internalizing disorder. Childhood sexual abuse and poly-victimisation remained associated with an elevated risk of a disorder in older age. LimitationsFindings are limited by attrition (39% participated at Time 3), low prevalence of severe physical abuse, and changes in assessment practice of childhood maltreatment and mental disorder in the past 30 years. ConclusionsScreening and treatment for internalizing disorders in women with histories of childhood maltreatment remains important in older aged populations.

Why They Say No: Foundational Precises and Techniques for Managing Resistance

Why do they say no? Practitioners often have agonized with, and mulled over, this question when faced with a familiar, yet vexing problem of many youth: managing their resistance. Youth who display challenging behaviors are often perceived to be noncompliant, disobedient to directions, uncooperative, and oppositional. Serious noncompliant is one of the most frequent reasons young children are referred for psychiatric services (Kuczynski, Kochanska, Radke-Yarrow, & Gimius-Brown, 1987). Noncompliance serves as a gateway behavior for children developing serious antisocial (Walker, Colvin, and Ramsey, 1995). It can lead to tantrums, uncooperativeness, aggression, then stealing, and ultimately delinquency. In some instances, engendering compliance can prevent children from developing more serious antisocial (Walker et al., 1995). Compliance typically has been conceptualized as obedience to adult directives and prohibitions, cooperation with requests and suggestions, and willingness to accept suggestions in teaching situations (Rocissano, Slade, & Lynch, 1987). Severe oppositional behaviors have become so pervasive that they were classified as a psychiatric disorder about 20 years ago in the third edition of the Diagnostic and Statsitical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). The DSM-III criteria required the presence of at least two of the following symptoms over a 6-month period: violations of minor rules, temper tantrums, argumentativeness, provocative behavior, and stubbornness. The term oppositional-defiant disorder first appeared in the revised version of the third edition (DSM-III-R; APA, 1987). The current diagnostic criteria appearing in the.fourth edition (DSM-IV; APA, 1987). requires a pattern of negativistic, hostile, and defiant lasting 6 months in which at least four of the following eight symptoms are present: temper outbursts, arguing with adults, refusing to follow adult requests, deliberately annoying people, blaming others for own mistakes, touchy or easily annoyed by others, angry and resentful, and spiteful or vindictive.

Separation anxiety among birth-assigned male children in a specialty gender identity service.

Previous research suggested that separation anxiety disorder (SAD) is overrepresented among birth-assigned male children clinic-referred for gender dysphoria (GD). The present study examined maternally reported separation anxiety of birth-assigned male children assessed in a specialty gender identity service (N=360). SAD was determined in relation to DSM-III and DSM-IV criteria, respectively. A dimensional metric of separation anxiety was examined in relation to several additional factors: age, ethnicity, parental marital status and social class, IQ, gender nonconformity, behavioral and emotional problems, and poor peer relations. When defined in a liberal fashion, 55.8% were classified as having SAD. When using a more conservative criterion, 5.3% were classified as having SAD, which was significantly greater than the estimated general population prevalence for boys, but not for girls. Dimensionally, separation anxiety was associated with having parents who were not married or cohabitating as well as with elevations in gender nonconformity; however, the association with gender nonconformity was no longer significant when statistically controlling for internalizing problems. Thus, SAD appears to be common among birth-assigned males clinic-referred for GD when defined in a liberal fashion, and more common than in boys, but not girls, from the general population even when more stringent criteria were applied. Also, the degree of separation anxiety appears to be linked to generic risk factors (i.e., parental marital status, internalizing problems). As such, although separation anxiety is common among birth-assigned male children clinic-referred for GD, it seems unlikely to hold unique significance for this population based on the current data.

The Berlin Inventory of Gambling behavior \u2013 Screening (BIG-S): Validation using a clinical sample

BackgroundPublished diagnostic questionnaires for gambling disorder in German are either based on DSM-III criteria or focus on aspects other than life time prevalence. This study was designed to assess the usability of the DSM-IV criteria based Berlin Inventory of Gambling Behavior Screening tool in a clinical sample and adapt it to DSM-5 criteria.MethodsIn a sample of 432 patients presenting for behavioral addiction assessment at the University Medical Center Mainz, we checked the screening tool’s results against clinical diagnosis and compared a subsample of n=300 clinically diagnosed gambling disorder patients with a comparison group of n=132.ResultsThe BIG-S produced a sensitivity of 99.7% and a specificity of 96.2%. The instrument’s unidimensionality and the diagnostic improvements of DSM-5 criteria were verified by exploratory and confirmatory factor analysis as well as receiver operating characteristic analysis.ConclusionsThe BIG-S is a reliable and valid screening tool for gambling disorder and demonstrated its concise and comprehensible operationalization of current DSM-5 criteria in a clinical setting.

Bipolar disorder prevalence: a systematic review and meta-analysis of the literature.

Bipolar disorder (BD) is common in clinical psychiatric practice, and several studies have estimated its prevalence to range from 0.5 to 5% in community-based samples. However, no systematic review and meta-analysis of the prevalence of BD type 1 and type 2 has been published in the literature. We carried out a systematic review and meta-analysis of the lifetime and 1-year prevalence of BD type 1 and type 2 and assessed whether the prevalence of BD changed according to the diagnostic criteria adopted (DSM-III, DSM-III-R vs. DSM-IV). We searched MEDLINE, Scopus, Web of Science, PsycINFO, and the reference lists of identified studies. The analyses included 25 population- or community-based studies and 276,221 participants. The pooled lifetime prevalence of BD type 1 was 1.06% (95% confidence interval [95%CI] 0.81-1.31) and that of BD type 2 was 1.57% (95%CI 1.15-1.99). The pooled 1-year prevalence was 0.71% (95%CI 0.56-0.86) for BD type 1 and 0.50% (95%CI 0.35-0.64) for BD type 2. Subgroup analysis showed a significantly higher lifetime prevalence of BD type 1 according to the DSM-IV criteria compared to the DSM-III and DSM-IIIR criteria (p < 0.001). This meta-analysis confirms that estimates of BD type 1 and type 2 prevalence are low in the general population. The increase in prevalence from DSM-III and DSM-III-R to DSM-IV may reflect different factors, such as minor changes in diagnostic operationalization, use of different assessment instruments, or even a genuine increase in the prevalence of BD.

An Investigation of Adherence to Diagnostic Criteria, Revisited: Clinical Diagnosis of the DSM-IV/DSM-5 Section II Personality Disorders.

In an initial investigation by Morey and Ochoa (1989), adherence to DSM-III personality disorder diagnostic criteria was examined as an agreement rate between clinician (global) diagnoses and diagnoses algorithmically generated from DSM-III criteria rules. Morey and Ochoa (1989) findings suggested significant clinician-criterion diagnostic incongruity, a result that cross-validated in a DSM-III-R replication performed by Blashfield and Herkov (1996). The current study examined such adherence, utilizing DSM-IV decision rules, in a national sample of 337 clinicians and their target patients. The results of the current study are largely consistent with the earlier findings, with clinician-criterion agreement rates comparable to those commonly reported for interdiagnostician reliability. Ramifications for the future of personality disorder diagnostic classification are discussed.

Duration of untreated psychosis (DUP) and the course of schizophrenia in a 20-year follow-up study

Our aims were to analyze the relationship between the duration of psychosis (DUP) and short- and long-term outcomes of treatment, and to determine the cut-off point between short and long DUP at which differences in treatment outcomes are most significant. We assessed 80 participants with schizophrenia at the point of their first hospitalization. Fifty participated in all four follow-ups over 20 years. DUP was divided into short (up to 6 months) and long (over 6 months). ANOVA and Chi-square tests were employed to identify significant differences in both clinical and social indicators of functioning. ROC curves were used to estimate the best DUP division point. Significant differences favoring the short-DUP group were found for: GAF, total severity of symptoms and severity of positive symptoms, social functioning measured according to DSM-III criteria, employment, and social contacts. The optimal cut-off point for DUP was the 23rd week. We concluded that: (1) the relationship between longer DUP and worse overall treatment outcomes was sustained throughout the 20 years, (2) a positive correlation between DUP and the severity of psychopathological symptoms was observed over the first 12 years of illness, (3) the results indicate the efficacy of early therapeutic interventions in psychosis.

The Epidemiology of Delirium: Challenges and Opportunities for Population Studies

Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective.

Response to Hasin et al. Letter

Response to Hasin et al. Letter

2650 – Validation of a diagnostic questionnaire based on DSM-IV criteria for gambling

Different questionnaires were formulated in order to assess the severity of gambling. The most used questionnaire is the South Oaks Gambling Screen (SOGS), based on DSM-III criteria for gambling, even though it has poor specificity, because overestimates the prevalence of the disorder when used in general population. Try to overcome SOGS limits using a questionnaire based on DSM-IV criteria for gambling. Validate the questionnaire based on DSM-IV criteria, using as gold standard the clinical interview developed through the SOGS. The sample used is formed by 71 subjects, 58 men (81.7%) and 13 women (18.3%), recruited from the Psychiatric Department of Gemelli General Hospital in Rome, who were asked to fill out both questionnaires. The sensitivity of our questionnaire was 93% (compared to 100% in the SOGS); the specificity was 100% (97.1% in the SOGS). False negatives were 7%, while they were absent in the SOGS ; false positives were absent in the DSM-IV questionnaire, while they were 2.9% in the SOGS. We also determined the prevalence of each item of DSM-IV questionnaire in all gamblers identified (66 subjects): the most relevant item was “chasing one's losses”(item6), instead the least one was “committing illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling”(item8). Our data confirm the greater specificity of the questionnaire of DSM-IV criteria for gambling compared to the SOGS. We suggest its use for the identification of gamblers in a sample formed by general population.

Exploratory Analyses of Efficacy Data From Schizophrenia Trials in Support of New Drug Applications Submitted to the US Food and Drug Administration

There has been concern about a high rate of placebo response and a decline in treatment effect over time in schizophrenia trials as well as the implications of increasing conduct of such trials outside North America. This report explores differences in efficacy data over an 18-year period from randomized placebo-controlled trials submitted in support of new drug applications (NDAs) for the treatment of schizophrenia and differences in results between trials conducted in North America and elsewhere. Clinical trial data that were submitted to the US Food and Drug Administration (FDA) as part of NDAs for the indication of schizophrenia between 1991 and 2009. Efficacy data were compiled from 32 clinical trials with 11,567 evaluable patients with schizophrenia. Data from completed, randomized, multicenter, double-blind, placebo-controlled, 4- to 8-week clinical trials in adult patients diagnosed with schizophrenia according to DSM-III or DSM-IV criteria were included. Baseline demographic and disease characteristics, including mean Positive and Negative Syndrome Scale (PANSS) total scores, were summarized and compared between North American and multiregional trials. Mean change from baseline to endpoint in PANSS total scores was utilized as the primary outcome of interest. We explored differences in treatment effect and success rate of these trials based on when and where the studies were conducted, sample size, trial duration, and baseline patient characteristics. Twenty-one of the 32 trials were conducted solely in North America, and 11 were carried out in multiple regions. Of those 11 multiregional trials, 2 were conducted exclusively in foreign countries. Although the observed responses (change from baseline) in placebo and drug-treated groups in multiregional trials tended to be larger than in North American trials, the treatment effects (drug-placebo difference) were -9 and -8 PANSS units for North American and multiregional trials, respectively. When time of trial conduct was taken into account, an increasing placebo response and a diminishing treatment effect over time were observed in North American trials from -10.8 PANSS units for the first period (1991-1998) to -6.0 PANSS units for the later period (1999-2008). The overall trial success rate over the almost 2 decades was 78%, declining slightly in trials conducted after 1999, the time period during which multiregional trials were first conducted (74% for 1999-2008 vs 85% for 1991-1998), despite increasing sample sizes in the later period. The mean baseline PANSS total score was in the range of 87-100 for most of these trials. Trials in patients with higher mean baseline PANSS total scores tended to show larger treatment effects than those in patients with lower scores. The mean body weight and body mass index (BMI) were higher in patients in North American trials and North America-predominant multiregional trials compared to those in foreign-predominant multiregional trials (mean body weights of 85 kg and 81 kg vs 72 kg, and BMIs of 29 and 27 vs 25, respectively). Treatment effects decreased as body weights increased, especially in North American trials. In foreign-predominant multiregional trials, there were higher proportions of women than in North American trials and North America-predominant multiregional trials (40% vs 22% and 27%, respectively) and a relatively larger proportion of Asians (21% vs 1% and 8%, respectively). A high and increasing placebo response and a declining treatment effect are of great concern in schizophrenia trials conducted in North America. In this era of global clinical trials, close attention is needed to the design and conduct of these trials.

A practical prototypic system for psychiatric diagnosis: The ICD-11 Clinical Descriptions and Diagnostic Guidelines

A practical prototypic system for psychiatric diagnosis: The ICD-11 Clinical Descriptions and Diagnostic Guidelines

Can People With Nonsevere Major Depression Benefit From Antidepressant Medication?

Several meta- or mega-analyses suggest antidepressant medications should be given only to severely depressed patients. In our experience, mild depression benefits from medication. We reanalyzed 1 clinic's randomized placebo-controlled antidepressant studies, limiting analyses to patients with major depressive disorder (MDD) without severe illness, to determine whether nonsevere depression responds to antidepressant medication. Archives of the Depression Evaluation Service outpatient clinic of the New York State Psychiatric Institute were searched for randomized, placebo-controlled antidepressant studies that were conducted between 1977 and 2009 and included patients having MDD and pretreatment Hamilton Depression Rating Scale (HDRS) scores < 23. Six placebo-controlled studies were found, including 8 active treatment arms and 1,440 patients. 825 patients were randomized and had MDD and an HDRS score < 23. DSM-III, DSM-III-R, or DSM-IV diagnostic criteria contemporary to each study were employed. Treatments were compared within study and via a patient-level meta-analysis using analysis of covariance (ANCOVA) of HDRS end point scores adjusted for pretreatment score. The number needed to treat (NNT) was calculated from remission rates (HDRS end point score ≤ 7), which were compared by χ². Effect sizes were calculated from change in HDRS scores. Secondary analyses investigated the effect of chronicity and atypical features on treatment response. Three of 6 studies showed significant (P < .001) treatment effects by ANCOVA, and 4 of 6 studies showed significant (P < .04) differences in remission. The NNT ranged from 3 to 8. Effect sizes ranged from -0.04 to 0.8, with 4 of 8 greater than 0.4. The patient-level meta-analysis confirmed these results; neither chronicity nor atypical features significantly affected outcome. Secondary analyses utilizing global ratings and self-report mimicked the main findings. Several studies demonstrated significant antidepressant efficacy for patients having nonsevere MDD. Efficacy was not trivial, as NNT ranged from 3 to 8, a range accepted by researchers as sufficiently robust to recommend treatment. These findings suggest mild-moderate MDD can benefit from antidepressants, contrary to findings by several other meta- or mega-analyses.