1 Boring Old Man

^{An Aside: I’m starting this with a bias. In 2012, I think the diagnosis Major Depressive Disorder used in the 1980 DSM-III and since has been a maelstrom – an egregious error with multiple negative consequences. So my looking back on its roots is not just a casual jaunt into history. It’s more in the vain of "how did this happen?"}

Several investigators have developed structured interview schedules which  an interviewer uses n his examination of the patient … These techniques provide for a standardized sequence of topics, and ensure that variability among clinicians in how they conduct their interviews and what topics they cover is kept to a minimum…

With respect to improving the nomenclature, the St.Louis group has offered a system limited to 16 diagnoses for which they believe strong validity evidence exists, and for which specified requirements are provided. Whereas in the standard system the clinician determines to which of the various diagnostic stereotypes his patient is closest, in the St. Louis system the clinician determines whether his patient satisfies explicit criteria…

A Diagnostic Interview: The Schedule for Affective Disorders and Schizophrenia
^{by Jean Endicott, PhD and Robert L. Spitzer, MD}
Archives of General Psychiatry. 1978 35:837-844.
[full text on-line]

SUMMARY SCALE SCORES FOR THE CURRENT SECTION OF THE SADS

There are a number of items in the current section of the SADS that are descriptive of specific dimensions of psychopathology. An initial scoring system has been developed through the assignment of items to eight larger summary dimensions. The item assignment was based on knowledge of factor analytic work of scales with similar item content, consideration of the major clinical distinctions usually made in research studies of affective and schizophrenic disorders, and a desire to have a smaller number of clinically meaningful measures on which to compare individual subjects over time or groups of subjects with each other. The names of the summary scales and the item contents are shown in Table 2. The two syndromal scales, which have considerable overlap, were developed to describe features of the depressive syndrome that are frequently associated with depressive mood. The first, Endogenous Features, is limited to those items descriptive of symptoms that have traditionally been considered characteristic of an "endogenous" depressive episode. The other scale, Depressive Associated Features, is broader and includes both the "endogenous" items and some additional items generally assumed to be part of the depressive syndrome…

Research Diagnostic Criteria: Rationale and Reliability
^{by Robert L. Spitzer, MD; Jean Endicott, PhD; and Eli Robins, MD}
Archives of General Psychiatry. 1978 35:773-792.
[full text on-line]

Abstract:

A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria…

Reliability:

The reliability of the RDC categories with psychiatric inpatients has been tested in three studies. The first two involved joint interviews whereby one rater conducted the interview and the other merely observed. Both made independent ratings. The third study involved a more rarely used procedure, whereby two independent raters interviewed the patient at different times [test-retest]. The kappa coefficients of reliability for these three studies are shown in Table 3…

Study B used the first edition of the RDC and involved pairs of raters at four facilities participating in a Pilot Study of the Psychobiology of the Depressive Disorders sponsored by the Clinical Research Branch of NIMH; the New York State Psychiatric Institute; Renard and Barnes Hospitals, Washington University School of Medicine; Iowa Psychiatric Hospital, University of Iowa Medical School, and Massachusetts General Hospital, Harvard Medical School. The subjects were newly admitted inpatients who met screening criteria for a depressive or manic syndrome. The SADS was used to interview the patients and an RDC diagnosis was made afterwards…

Relationship Among Alternative Classifications of Depressive Disorders:

One of the main purposes of the RDC approach to psychiatric diagnosis is to facilitate the comparison of alternative classification systems for depressive disorders. Table 7 gives the joint classification of diagnoses for 90 patients with a current diagnosis of major depressive disorder (study B). The table should be read across so that the frequency with which subjects given a diagnosis on the left indicates how often they were also given a diagnosis listed on the right. Some of the cell sizes are quite small; therefore, this table is presented primarily for illustrative purposes.

Frequently, there is an assumption that the more commonly used methods for classifying depressed patients are equivalent and that the results of studies using these different systems can be easily compared. For example, it is often assumed that episodes of primary depressive disorder would almost always meet the criteria for endogenous depressive disorder and rarely meet the criteria for situational [reactive] depressive disorder. However, only 64% of patients with a diagnosis of primary depressive disorder also met the criteria for endogenous phenomenology, while 51% of them met the criteria for situational depressive disorder. Similarly, it is often assumed that situational [reactive] depressive episodes would rarely meet the criteria for endogenous depressive disorder whereas they actually met those criteria 42% of the time…

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I admit to not being totally clear about how Table 7 was derived. It’s from Study B, in which one person did the interview using the SADS protocol and the other was an observer. I gather that under Major Depressive Disorder, the raters could chose multiple diagnoses.

…thus accounting for the large % numbers. But the point of the table and the last paragraph quoted from the article above is clear. The table says that the categories we thought of as separate conditions at the time did not separate well in the Study B – for example Endogeneous Depression and Situational Depression [overlapping 37% and 42% depending on which came first]. It’s obvious, given the etiological implications of those names, that the names were not exactly candidates for the purely descriptive DSM-III being constructed. Don Klein had even suggested a cause-neutral term "endogenomorphic" to replace "endogenous." I presume "situational" was associated with "neurotic," a causal term that had to go. But while the terms and their former implications were problems, that could’ve easily been surmounted. I suspect that the values in Table 7 suggested that previous distinctions were not real, mythological, and supported the "lumping" of all of the categories under the one roof – Major Depressive Disorder.

Looking over and over this latter paper, and the SADS interview used to gather this data, I couldn’t get close enough to what they actually did to assess it. The details were just too obscure and I haven’t located the criteria they used for the subclasses. But I was suspicious that those numbers in Table 7 were not an accurate picture. They don’t fit my experience or that of many others. But beyond that, there’s another consideration that seems ignored. Even if they couldn’t find the reliable separation in the varieties of depression, that means to me back to the drawing board, not that those distinctions are necessarily mythic. And it for sure doesn’t mean that all significantly depressed people have the same "Disorder." Lumping, in this case, wasn’t just a passive act. It was an active declaration of unity without any backing of its own – one that had enough negative consequences to deserve the term maelstrom.