Severity of complicated versus uncomplicated subthreshold depression: New evidence on the "Monotonicity Thesis" from the national comorbidity survey.

BACKGROUND: "Complicated" subthreshold depression (CsD) includes at least one of six pathosuggestive "complicated" symptoms: >6 months duration, marked role impairment, sense of worthlessness, suicidal ideation, psychotic ideation, and psychomotor retardation. "Uncomplicated" subthreshold depression (UsD) has no complicated features. Whereas studies show that complicated (CMDD) versus uncomplicated (UMDD) major depression differ substantially in severity and prognosis, UsD and CsD severity has not been previously compared. This study evaluates UsD and CsD pathology validator levels and examines whether the complicated/uncomplicated distinction offers incremental concurrent validity over the standard number-of-symptoms dimension as a depression severity measure. METHODS: Using nationally representative community data from the National Comorbidity Survey, seven depression lifetime history subgroups were identified: one MDD screener symptom (n=1432); UsD (n=430); CsD (n=611); UMDD (n=182); and CMDD with 5-6 symptoms (n=518), 7 symptoms (n=217), and 8-9 symptoms (n=291). Severity was evaluated using five concurrent pathology validators: suicide attempt, interference with life, help seeking, hospitalization, and generalized anxiety disorder. RESULTS: CsD validator levels are substantially higher than both UsD and UMDD levels, and similar to mild CMDD, disconfirming the "monotonicity thesis" that severity increase with symptom number. Complicated/uncomplicated status predicts severity, and when complicatedness is controlled, number of symptoms no longer predicts validator levels. LIMITATIONS: Diagnoses were based on respondents' fallible retrospective symptom reports during a lay-administered structured interview, which may not yield diagnoses comparable to clinicians' assessments. CONCLUSION: CsD is more severe than UsD and comparable to mild MDD. Complicated status more validly indicates depression severity than the standard number-of-symptoms measure.

Symptom quality versus quantity in judging prognosis: Using NESARC predictive validators to locate uncomplicated major depression on the number-of-symptoms severity continuum.

BACKGROUND: Uncomplicated major depressive disorder (UMDD) is defined as MDD that does not include any of six pathosuggestive features: more than six months duration, marked functional impairment, sense of worthlessness, suicidal ideation, psychotic ideation, and psychomotor retardation. Complicated MDD (CMDD) includes all episodes containing one or more of these features. UMDD has been shown to be lower than CMDD and indistinguishable from no-MDD-history on predictive pathology validators. This study's purpose is to establish where on the number-of-symptoms depressive continuum UMDD is located, using the criterion of predictive validity. METHODS: Using two-wave longitudinal community data, seven baseline depression history subgroups were identified: no MDD symptoms (n=23,214), one MDD screener symptom (n=609), subthreshold or "minor" depression (mD; 2-4 MDD symptoms; n=2,623), UMDD (n=505), and complicated MDD with 5-6 symptoms (n=1,106), 7 symptoms (n=1,200), and 8-9 symptoms (n=2,408). Predictive validity was evaluated by four follow-up variables: major depressive episode; generalized anxiety disorder; suicide attempt; and manic/hypomanic episode. RESULTS: UMDD predictive pathology validator rates are not significantly different from rates for subthreshold mD but significantly different from those for all other depression categories; UMDD is higher in symptoms but lower in validator levels than 5-6 symptom CMDD. LIMITATIONS: Baseline and follow-up diagnoses were based on respondents' fallible retrospective symptom reports in response to a lay-administered structured questionnaire, which may not yield diagnoses comparable to clinicians' assessments. CONCLUSION: Uncomplicated MDD's follow-up outcomes resemble subthreshold depression, not CMDD, even when CMDD has less symptoms. Clinical decisions should reflect the relatively benign prognosis of uncomplicated MDD.

Addiction Vulnerability and Binge Eating in Women: Exploring Reward Sensitivity, Affect Regulation, Impulsivity & Weight/Shape Concerns.

Almost 40% of individuals with eating disorders have a comorbid addiction. The current study examined weight/shape concerns as a potential moderator of the relation between the hypothesized latent factor "addiction vulnerability" (i.e., impairments in reward sensitivity, affect regulation and impulsivity) and binge eating. Undergraduate women (n=272) with either high or low weight/shape concerns completed self-report measures examining reward sensitivity, emotion regulation, impulsivity and disordered (binge) eating. Results showed that (1) reward sensitivity, affect regulation and impulsivity all loaded onto a latent "addiction vulnerability" factor for both women with high and with low weight/shape concerns, (2) women with higher weight/shape concerns reported more impairment in these areas, and (3) weight/shape concerns moderated the relation between addiction vulnerability and binge eating. These findings suggest that underlying processes identified in addiction are present in individuals who binge eat, though weight/shape concerns may be a unique characteristic of disordered eating.

The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates.

AIMS: To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity. DESIGN: DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data. SETTING: United States. PARTICIPANTS: National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54 years (wave 1, n = 29 673; wave 2, n = 24 244). MEASURES: NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group. FINDINGS: Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group. CONCLUSIONS: Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.

How Many People have Alcohol Use Disorders? Using the Harmful Dysfunction Analysis to Reconcile Prevalence Estimates in Two Community Surveys.

Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.

When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds.

High community prevalence estimates of DSM-defined major depressive disorder (MDD) have led to proposals to raise MDD's diagnostic threshold to more validly distinguish pathology from normal-range distress. However, such proposals lack empirical validation. We used MDD recurrence rates in the longitudinal 2-wave Epidemiologic Catchment Area Study to test the predictive validity of three proposals to narrow MDD diagnosis: a) excluding "uncomplicated" episodes (i.e., episodes that last no longer than 2 months and do not include suicidal ideation, psychotic ideation, psychomotor retardation, or feelings of worthlessness); b) excluding mild episodes (i.e., episodes with only five to six symptoms); and c) excluding nonmelancholic episodes. For each proposal, we used lifetime MDD diagnoses at wave 1 to distinguish the group proposed for exclusion, other MDD, and those with no MDD history. We then compared these groups' 1-year MDD rates at wave 2. A proposal was considered strongly supported if at wave 2 the excluded group's MDD rate was not only significantly lower than the rate for other MDD but also not significantly greater than the no-MDD-history group. Results indicated that all three excluded groups had significantly lower recurrence rates than other MDD (uncomplicated vs. complicated, 3.4% vs. 14.6%; mild vs. severe, 9.6% vs. 20.7%; nonmelancholic vs. melancholic, 10.6% vs. 19.2%, respectively). However, only uncomplicated MDD's recurrence rate was also not significantly greater than the MDD occurrence rate for the no-MDD-history group (3.4% vs. 1.7%, respectively). This low recurrence rate resulted from an interaction between uncomplicated duration and symptom criteria. Multiple-episode uncomplicated MDD did not entail significantly elevated recurrence over single-episode cases (3.7% vs. 3.0%, respectively). Uncomplicated MDD's general-distress symptoms, transient duration, and lack of elevated recurrence suggest it may generally represent nonpathologic intense sadness that should be addressed in treatment guidelines and considered for exclusion from MDD diagnosis to increase the validity of the MDD/normal sadness boundary.

The roles of affect dysregulation and positive affect in non-suicidal self-injury.

Non-suicidal self-injury (NSSI) is a prevalent behavior, yet little is known about associated affective mechanisms. Research has focused on the role of negative affect in NSSI, with positive affect receiving relatively less attention. This study examined affect dysregulation, emotional reactivity, and the experience of positive and negative affect in NSSI. Path analyses revealed that emotional reactivity predicted positive and negative affect after NSSI. Positive affect, in turn, predicted more lifetime acts of NSSI. The results demonstrate the importance of examining multiple facets of affect regulation, as well as the roles of both negative and positive affect in NSSI.

Recurrence of depression after bereavement-related depression: evidence for the validity of DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study.

The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (≤ 2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920-928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity?: evidence from the National Comorbidity Survey.

The DSM's major-depression "bereavement exclusion" eliminates bereavement-related depressive episodes (BRDs) from diagnosis unless they are "complicated" by prolonged duration or certain severe symptoms. The exclusion was substantially narrowed in DSM-IV to decrease false-negative diagnoses, but the impact of this change remains unknown. We divided BRDs in the National Comorbidity Survey into uncomplicated versus complicated categories using broader DSM-III-R and narrower DSM-IV exclusion criteria. Using 6 pathology validators (symptom number, melancholic depression, suicide attempt, interference with life, medication for depression, and hospitalization for depression), we compared the validity of the 2 exclusion criteria sets using 2 tests: (1) which criteria set yielded less pathological uncomplicated cases or more pathological complicated cases; (2) which yielded the largest separation between uncomplicated and complicated pathology levels. Results of both tests indicated that the narrower DSM-IV criteria substantially decreased the exclusion's validity. These results suggest caution regarding the current proposal to eliminate the bereavement exclusion in DSM-5.

Does the DSM-IV clinical significance criterion for major depression reduce false positives? Evidence from the National Comorbidity Survey Replication.

OBJECTIVE: To reduce false positive diagnoses, DSM-IV added a clinical significance criterion to many diagnostic criteria sets requiring that symptoms cause significant distress or impairment. The DSM-V Task Force is considering whether clinical significance should remain a diagnostic threshold or become a separate dimension, as it is in ICD. Yet, the criterion's effectiveness in validly reducing the prevalence of specific disorders remains unclear. Critics have argued that for some categories, notably major depression, the criterion is redundant with symptoms, which are inherently distressing or impairing. The authors empirically evaluated the criterion's effect on the prevalence of major depression in the community. This report also considers more broadly the relationship of symptoms to impairment in diagnosis. METHOD: Subjects were respondents, aged 18 to 54 years, who participated in the National Comorbidity Survey Replication (N=6,707). The effect of the clinical significance criterion's distress and impairment components on major depression was assessed in this sample. Distress questions were administered to all respondents reporting persistent sadness (> or = 2 weeks) or the equivalent. Questions pertaining to role impairment were asked of all respondents satisfying major depression symptom-duration criteria. RESULTS: Of 2,071 individuals reporting persistent sadness or the equivalent, 97.2% (N=2,016) satisfied criteria for distress. Of 1,542 individuals satisfying depression symptom-duration criteria, 96.2% (N=1,487) satisfied criteria for impairment. CONCLUSIONS: These findings support the redundancy thesis. Distress is virtually redundant with symptoms of persistent sadness, even in the absence of major depression, and impairment is almost always entailed by major depression-level symptoms. Thus, the clinical significance criterion does not substantially reduce the prevalence of major depression in the community. The DSM-V Task Force should consider eliminating the criterion and explore alternative ways to identify false positives in the diagnosis of depression. The criterion's status for other disorders should be evaluated on a disorder-by-disorder basis because the diagnostic relationship between symptoms and impairment varies across categories.

The Hyperemesis Beliefs Scale (HBS): a new instrument for assessing beliefs about severe nausea and vomiting in pregnancy.

OBJECTIVE: The purpose of this research was to validate the Hyperemesis Beliefs Scale (HBS), a new instrument for assessing patient perception factors of hyperemesis gravidarum (HG) that influence reported patient satisfaction with medical care. METHODS: Patients' beliefs and their perception of their physicians' beliefs about the causal explanations of HG, seriousness of the illness, and the impact of the illness upon patients' daily lives were determined using a newly developed hyperemesis beliefs scale (HBS) in a sample of 96 women. Exploratory factor analyses of the patient and physician versions of the HBS were performed separately using principal factor analysis extraction and oblique rotation in SPSS. RESULTS: Exploratory factor analyses of patient and physician versions of the HBS demonstrated broad support for the hypothesized factor structure. However, two key differences appeared in the two versions of the HBS. First, the patient items exhibited two causal factors (general and personal), whereas the physician items showed only a single causal factor. Second, in the patient version, items assessing the impact of HG on the babies' health loaded separately from the rest of the items in the HBS, whereas the analyses of the corresponding physician items indicated that the baby items loaded well on the degree of seriousness factor. CONCLUSION: This scale may be of value in facilitating further research on HG illness representations, patient-physician relationship and patient satisfaction. Specifically, the HBS design provides data to show whether patient-physician agreement on particular measures is associated with better patient satisfaction outcomes.

Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey.

CONTEXT: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder (MDD) but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity. OBJECTIVE: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses. DESIGN: Community-based epidemiological study. PARTICIPANTS: From the National Comorbidity Survey (NCS) of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement (n = 157) or other loss (n = 710). Intervention We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms. MAIN OUTCOME MEASURES: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables. RESULTS: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators. CONCLUSION: The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.

Hyperemesis gravidarum and patient satisfaction: a path model of patients' perceptions of the patient-physician relationship.

OBJECTIVE: To examine the relationship between patients' perceptions of the patient-physician relationship and patients' satisfaction with the overall medical care received from their physicians in the treatment of hyperemesis gravidarum (HG). METHODS: This study investigated patients' beliefs and their views of their physicians' beliefs about the causal explanation of HG, the seriousness of the illness, and the impact of the illness upon patients' daily lives. Also examined were the extent to which patients' beliefs were congruent with their perception of their physicians' beliefs, and patients' ratings of the humanistic characteristics of physicians they deemed important. Ninety-six respondents who had experienced at least one hospitalization from January 1993 through April 1997 responded to interview questions focusing on their HG illness experience. Using both quantitative and qualitative methodological approaches, a path model of patient perception factors associated with patient satisfaction was tested. RESULTS: Perceived shared beliefs about the etiology of HG for a particular patient's illness were more important direct contributing factors of satisfaction than were the specific causal explanations. The length of the patient-physician relationship provided important indirect effects on patient satisfaction; three key mediating variables were patients' perceptions about physician humanism and perceived agreement about the cause and impact of HG. Pertinent qualitative findings are provided as additional sources of information to supplement the quantitative results. CONCLUSION: Knowledge of the patient-physician relationship factors that influence HG women's satisfaction can be used to enhance service delivery and may ultimately improve perinatal outcomes.

Rethinking twins and environments: possible social sources for assumed genetic influences in twin research.

A central sociological problem is the extent to which genetics and the environment influence human behavior. Studies of twins are a core method in attempts to disentangle and to determine the comparative strength of genetic and environmental influences on psychosocial outcomes. A critical assumption of twin studies is that both monozygotic "identical" twins and dizygotic "fraternal" twins share common social environments. Therefore, any greater similarity of monozygotic than dizygotic twins is attributed to genetic influences. This paper tests the equal environment assumption by examining the extent to which greater concordance of adolescent monozygotic compared to dizygotic twins results from social, as well as genetic, influences. Bivariate comparisons indicate that monozygotic twins show greater similarity than dizygotic twins in socially-based characteristics including physical attractiveness, time spent in each other's company, the overlap in friendship networks, and friends' use of alcohol. Multivariate analyses indicate that measures of the social environment sometimes reduce or eliminate apparent genetic effects. In comparison with genetic indicators, social variables are usually stronger predictors of depression and alcohol use and abuse. These findings suggest that past twin studies could overstate the strength of genetic influences because some similarities in behavior among monozygotic compared to dizygotic twins stem from social influences.

Double vision: reply to Freese and Powell.

Freese and Powell make a number of critiques of the theoretical assumptions, statistical methods, and use of variables in our paper, which raises questions about the typical use of the equal environments assumption in twin research. We do not find that any of their critiques modify our conclusion that the equal environments assumption cannot be taken for granted but must be subjected to empirical testing. We hope that our paper and the resulting exchange will lead sociologists to become more actively involved in the debate regarding the extent of genetic and environmental influences on social behaviors.