The DSM-5 classification of mood disorders: some fallacies and fault lines

The clinical utility and relevance in clinical practice of DSM-5 specifiers for major depressive disorder: A Delphi expert consensus study

Major depressive disorder (MDD) is a heterogeneous syndrome, associated with different levels of severity and impairment on the personal functioning for each patient. Classification systems in psychiatry, including ICD-11 and DSM-5, are used by clinicians in order to simplify the complexity of clinical manifestations. In particular, the DSM-5 introduced specifiers, subtypes, severity ratings, and cross-cutting symptom assessments allowing clinicians to better describe the specific clinical features of each patient. However, the use of DSM-5 specifiers for major depressive disorder in ordinary clinical practice is quite heterogeneous. The present study, using a Delphi method, aims to evaluate the consensus of a representative group of expert psychiatrists on a series of statements regarding the clinical utility and relevance of DSM-5 specifiers for major depressive disorder in ordinary clinical practice. Experts reached an almost perfect agreement on statements related to the use and clinical utility of DSM-5 specifiers in ordinary clinical practice. In particular, a complete consensus was found regarding the clinical utility for ordinary clinical practice of using DSM-5 specifiers. The use of specifiers is considered a first step toward a "dimensional" approach to the diagnosis of mental disorders.

Combining predominant polarity and affective spectrum concepts in bipolar disorder: towards a novel theoretical and clinical perspective

This is an overview of recent advances on predominant polarity conceptualization in bipolar disorder (BD). Current evidence on its operationalized definitions, possible contextualization within the affective spectrum, along with its epidemiological impact, and treatment implications, are summarized. Predominant polarity identifies three subgroups of patients with BD according to their mood recurrencies: (i) those with depressive or (ii) manic predominance as well as (iii) patients without any preponderance ('nuclear' type). A predominant polarity can be identified in approximately half of patients, with similar rates for depressive and manic predominance. Different factors may influence the predominant polarity, including affective temperaments. More generally, affective disorders should be considered as existing on a spectrum ranging from depressive to manic features, also accounting for disorders with 'ultrapredominant' polarity, i.e., unipolar depression and mania. While mixed findings emerge on its utility in clinical practice, it is likely that the construct of predominant polarity, in place of conventional differentiation between BD-I and BD-II, may be useful to clarify the natural history of the disorder and select the most appropriate interventions. The conceptualization of predominant polarity seems to reconcile previous theoretical views of both BD and affective spectrum into a novel perspective. It may provide useful information to clinicians for the early identification of possible trajectories of BD and thus guide them when selecting interventions for maintenance treatment. However, further research is needed to clarify the specific role of predominant polarity as a key determinant of BD course, outcome, and treatment response.

A phenomenologically grounded specification of varieties of adolescent depression

Researchers are increasingly acknowledging that psychopathological conditions usually grouped together under the generic label "depression" are highly diverse. However, no differential therapeutic approach currently exists that is sensitive to the varieties of depression afflicting young people. In fact, the discussion is missing something much more fundamental: a specification of the types of adolescent depression. Recent research that has aimed to classify different kinds of depression has mainly studied adult populations and predominantly used technically complicated measurements of biological markers. The neglect of the potential particularities of dysphoric disorders affecting youths is unfortunate, and the exclusive focus on biological parameters unnecessarily restrictive. Moreover, this one-sidedness obfuscates more directly available sources of clinically relevant data that could orient conceptualization efforts in child and adolescent psychiatry. Particularly, clues for discriminating different types of adolescent depression may be obtained by analyzing personally articulated accounts of how affected young people experience changes in their relation to the world and to themselves. Thus, here we present and discuss the findings of a study that explored the possibility of specifying types of adolescent depression in a phenomenological way. The study investigated the association between these types and the vicissitudes of personality development. In accounts given by youths diagnosed with depression during semi-structured interviews, we identified themes and examined their phenomenological centrality. Specifically, our qualitative analyses aimed to determine the relative importance of certain themes with respect to the overall intelligibility of the described changes to the relational space. Based on the findings of these analyses, we differentiate three specifiers of adolescent depression and suggest an association between particular types of experiences and the trajectory of affected adolescents' personality development. To our knowledge, this is the first phenomenologically grounded specification of types of adolescent depression with potential therapeutic significance. Thus, based on this contribution, we propose that modes of scientific exploration that are close to phenomenological philosophy-which have been ignored in the context of developmental psychopathology-could offer a foundation to theories developed in the field of child and adolescent psychiatry.

Association of the plasma complement system with brain volume deficits in bipolar and major depressive disorders

BACKGROUND

Inflammation plays a crucial role in the pathogenesis of major depressive disorder (MDD) and bipolar disorder (BD). This study aimed to examine whether the dysregulation of complement components contributes to brain structural defects in patients with mood disorders.

METHODS

A total of 52 BD patients, 35 MDD patients, and 53 controls were recruited. The human complement immunology assay was used to measure the levels of complement factors. Whole brain-based analysis was performed to investigate differences in gray matter volume (GMV) and cortical thickness (CT) among the BD, MDD, and control groups, and relationships were explored between neuroanatomical differences and levels of complement components.

RESULTS

GMV in the medial orbital frontal cortex (mOFC) and middle cingulum was lower in both patient groups than in controls, while the CT of the left precentral gyrus and left superior frontal gyrus were affected differently in the two disorders. Concentrations of C1q, C4, factor B, factor H, and properdin were higher in both patient groups than in controls, while concentrations of C3, C4 and factor H were significantly higher in BD than in MDD. Concentrations of C1q, factor H, and properdin showed a significant negative correlation with GMV in the mOFC at the voxel-wise level.

CONCLUSIONS

BD and MDD are associated with shared and different alterations in levels of complement factors and structural impairment in the brain. Structural defects in mOFC may be associated with elevated levels of certain complement factors, providing insight into the shared neuro-inflammatory pathogenesis of mood disorders.

Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

The World Health Organization’s 11^th revision of the International Classification of Diseases (ICD-11) including the chapter on mental disorders has come into effect this year. This review focuses on the “Bipolar or Related Disorders” section of the ICD-11 draft. It describes the benchmarks for the new version, particularly the foremost principle of clinical utility. The alterations made to the diagnosis of bipolar disorder (BD) are evaluated on their scientific basis and clinical utility. The change in the diagnostic requirements for manic and hypomanic episodes has been much debated. Whether the current criteria have achieved an optimum balance between sensitivity and specificity is still not clear. The ICD-11 definition of depressive episodes is substantially different, but the lack of empirical support for the changes has meant that the reliability and utility of bipolar depression are relatively low. Unlike the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5), the ICD-11 has retained the category of mixed episodes. Although the concept of mixed episodes in the ICD-11 is not perfect, it appears to be more inclusive than the DSM-5 approach. Additionally, there are some uncertainties about the guidelines for the subtypes of BD and cyclothymic disorder. The initial results on the reliability and clinical utility of BD are promising, but the newly created diagnostic categories also appear to have some limitations. Although further improvement and research are needed, the focus should now be on facing the challenges of implementation, dissemination, and education and training in the use of these guidelines.

Clinical Course in Patients With Melancholic and Nonmelancholic Bipolar Depression

The aim of the current study was to compare the longitudinal clinical course of patients with a history of melancholic and nonmelancholic bipolar depression. Seventy-seven euthymic outpatients with bipolar disorder were categorized as melancholic or nonmelancholic through the clinician-rated Sydney Melancholia Prototype Index. Clinical course was assessed for a period longer than 48 months by time spent ill, density of affective episodes, severity and duration of depressive episodes, and time to depressive recurrence. The mean follow-up time was 69.05 months. Patients with melancholic depressions had more severe and longer depressive episodes during follow-up, whereas patients with nonmelancholic depressions had a shorter time to depressive recurrence and more subsyndromal depressive symptoms and affective instability. These findings highlight the heterogeneity inherent to the current construct of bipolar depression and position melancholia as an interesting target for comparison with nonmelancholic depressions in other external validators in the field of bipolar disorder.

New Mental Health Diagnosis as a Prognostic Factor for Muscle-Invasive Bladder Cancer

BACKGROUND

To examine differences in survival outcomes for muscle-invasive bladder cancer patients stratified by new mental health diagnosis.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified patients diagnosed with muscle-invasive bladder cancer between 2008 and 2014. Our primary outcome was cancer-specific and overall hazards of mortality. As a secondary outcome, we reported predictors of developing a new mental health diagnosis after bladder cancer diagnosis. We used Cox proportional hazards models to determine the impact of palliative care and mental health diagnoses on survival outcomes after adjusting for grade, stage, comorbidity index, and baseline demographics.

RESULTS

Of the 3794 patients who met inclusion criteria, 1193 (31%) were diagnosed with a mental health illness after their bladder cancer diagnosis during the 6 years in the study period. The most common diagnoses were depression (13%), alcohol and drug abuse (12%), and anxiety (11%). Patients with a post-bladder cancer mental health diagnosis had a 57% higher hazard of overall mortality (HR 1.57, P = .048) and an 80% higher hazard of bladder cancer-specific mortality (HR 1.81, P = .037) CONCLUSIONS: New mental health diagnoses are associated with worse survival in patients with muscle invasive bladder cancer. This suggests that a multimodal approach to bladder cancer treatment should include addressing the non-oncologic needs of the patient to optimize survival outcomes.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations

OBJECTIVES

The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided-a critical gap which the current update aims to address.

METHOD

Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion.

RESULTS

No agents met threshold for first-line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second-line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second-line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first-line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second-line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first-line, and lithium and olanzapine identified as second-line options.

CONCLUSION

The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state.

Bipolar Depression: A Historical Perspective of the Current Concept, with a Focus on Future Research

The aim of this narrative review is to trace the origin of the concept of bipolar depression and to expose some of its limitations. Bipolar depression is a broad clinical construct including experiences ranging from traditional melancholic and psychotic episodes ascribed to "manic-depressive insanity," to another heterogeneous group of depressive episodes originally described in the context of binary models of unipolar depression (e.g., psychogenic depression, neurotic depression). None of the available empirical evidence suggests, however, that these subsets of "bipolar" depression are equivalent in terms of clinical course, disability, family aggregation, and response to treatment, among other relevant diagnostic validators. Therefore, the validity of the current concept of bipolar depression should be a matter of concern. Here, we discuss some of the potential limitations that this broad construct might entail in terms of pathophysiological, clinical, and therapeutic aspects. Finally, we propose a clinical research program for bipolar depression in order to delimit diagnostic entities based on empirical data, with subsequent validation by laboratory or neuroimaging biomarkers. This process will then aid in the development of more specific treatments.

Research Domain Criteria: Cutting Edge Neuroscience or Galen's Humors Revisited?

The Research Domain Criteria (RDoC) scheme has guided the research agenda of the National Institute of Mental Health for the past decade. The essence of RDoC is its dimensional conception of mental illness, with the assumption that psychopathology is a manifestation of extremes along axes of neuropsychological variation. Research, it follows, should emphasize normal neuropsychological function and its associated neurocircuitry. We argue that RDoC, dressed in terms of modern neurobiology, is in fact a return to the humoral theory of Galen, a dimensional approach in which physical and mental health requires a balance of the four basic bodily humors (blood, black bile, yellow bile, and phlegm). The RDoC/Galenic approach may be useful in understanding those conditions best understood as extremes along a continuum, such as personality disorders. However, we contend that for the most severe psychiatric disorders - categorically defined diseases such as schizophrenia, bipolar disorder, and autism - RDoC's Galenic dimensionalism is a retreat from the biomedical approach that seeks to find rational therapeutic targets by identifying etiologic factors and pathogenic pathways. Abandoning this medical model now, in the context of remarkable advances in genetics, neuroimaging, and neuroscience, is a major setback for the advancement of scientific psychiatry.

Targeting and transforming major depression

OBJECTIVE

To detail limitations to the construct of 'major depression', argue for repositioning it as a proxy for 'clinical depression' and then operationalize it and its principal constituent depressive subtypes, while preserving the DSM criteria-based format.

METHOD

We summarize limitations to major depression being viewed as a diagnostic entity. Data from 391 clinically depressed patients were analysed to identify high-prevalence non-specific depressive symptoms to define 'clinical depression' as well as the features showing specificity to a melancholic depressive subtype.

RESULTS

We identified a set of high-prevalence and generalized symptoms for defining clinical depression and with many being current criteria for major depression. We also developed a refined set of melancholic features and with their underlying distributions generating two classes that correlated strongly with clinical diagnoses of a melancholic or non-melancholic depression, thus validating its capacity to so differentiate. We append criteria sets for diagnosing clinical depression and its principal diagnostic subtypes (psychotic, melancholic and non-melancholic).

CONCLUSION

This heuristic study reframes and modifies major depression's criteria set to define a domain of clinical depression with additional criteria and then allowing the delineation of three diagnostic subtypes. If this paradigm shift is accepted and further refined, greater precision in diagnosis, treatment and research would be anticipated.

Cleaving depressive diseases from depressive disorders and non-clinical states

OBJECTIVE

We sought to determine whether putative depressive diseases could be differentiated categorically from clinical depressive disorders and non-clinical mood states.

METHOD

We interviewed volunteers who reported or denied any lifetime depressive mood state and analyzed data from the former group reporting on their 'most severe' depressive episode. We employed latent class analysis (LCA) to determine whether a two-class solution was supported and the contribution of individual variables to class allocations.

RESULTS

All variables were significant predictors of class allocation. LCA-assigned Class I participants reported more depressive symptoms, had more distressing episodes and more lasting consequences, were more likely to view their depression as 'like a disease', and as being both disproportionately more severe and persistent in relation to any antecedent stressor. Validation involved comparison of LCA assignment with DSM-IV diagnosis for their most severe depressive episode. Of those assigned to Class I, 89% had a DSM diagnosis of melancholic, psychotic or bipolar depression. Class II had all those failing to meet criteria for a depressive episode and the majority of those with a non-melancholic depressive condition.

CONCLUSION

Despite not including individual depressive symptoms, study variables strongly differentiated putative depressive diseases from a composite of clinical depressive conditions and subclinical depressive states.

DSM-5 and Mental Disorders in Older Individuals: An Overview

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the changes in DSM-5 relative to earlier versions.• Evaluate the implications of the DSM-5 for practicing geriatric psychiatrists.

ABSTRACT

About every 20 years, the American Psychiatric Association revises its official classification of mental disorders. The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2013, prompting considerable commentary, debate, and criticism. This article briefly describes the process leading up to DSM-5 and the main changes from the previous version (DSM-IV) that would be of interest to a geriatric psychiatrist. The changes in the areas of schizophrenia, bipolar disorder, depressive disorders, and anxiety disorders have been many, but the majority of them are minor and unlikely to have major treatment implications. The classification of neurocognitive disorders, however, has seen a major revision and elaboration in comparison to DSM-IV; of special note is the introduction of "mild and major neurocognitive disorders," the latter equated with dementia. A common language has also been introduced for the criteria for the various etiological subtypes of neurocognitive disorders. All physicians treating patients with neurocognitive disorders should familiarize themselves with these criteria. Their use in research has the potential to harmonize the field.