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Psychiatry's Main Method to Preve= nt Mistaken Diagnoses of Depression Doesn't Work: Study
=ScienceDaily (Feb. 25, 2010) — A study in the March edition of the American Journal of = Psychiatry senior-authored by Jerome C. Wakefield, a professor at t= he Silver School of Social Work at New York University with Mark Schmitz= of Temple University and Judith Baer of Rutgers University, empirically= challenges the effectiveness of psychiatrists' official diagnostic manu= al in preventing mistaken, false-positive diagnoses of depression.
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The findings concerning the American Psychiatric Association's Diagno= stic and Statistical Manual of Mental Disorders' (DSM) criteria for diag= nosing depression rebuts recent criticism of earlier research by Wakefie= ld. That earlier research suggested that misdiagnoses of depression are = widespread, and touched off considerable controversy.
According to the DSM, the diagnosis of major depression requires the = presence -- for two weeks -- of at least five possible symptoms out of a= list of nine, which include, for example, sadness, loss of interest in = usual activities, lowered appetite, fatigue, and insomnia. However, thes= e symptoms can also occur in normal responses to loss and stress. False = positive diagnoses occur when someone reacting with intense normal sadne= ss to life's stresses is misdiagnosed as having major depressive disorde= r. Recent studies suggest that a very large percentage of people have su= ch symptoms for two weeks or longer at some point in their lives; theref= ore, how many of these individuals really are afflicted by a mental diso= rder or are responding within normal limits to loss or stress has been a= matter of debate.
The journal article examines the primary method by which the official= diagnostic criteria for depression -the Clinical Significance Criterion= (CSC) -- are supposed to distinguish normal from disordered cases and t= hereby prevent false positive diagnoses. The CSC was added to the sympto= m and duration criteria in the DSM's fourth edition in 1994 (DSM-IV) in = the wake of criticism that too many of the listed symptoms -- loss of ap= petite, say, or sadness, insomnia, or fatigue -- were being identified a= s evidence of major depressive disorder even when they were mild and pos= sibly normal responses to distress arising from such events as the loss = of a job, the dissolution of a marriage, or other triggers for sadness, = and that such errors might be contributing to the very high reported rat= es of untreated depression in the American population drawn from epidemi= ological surveys.
Under the 1994 DSM revision, in addition to the two weeks of sadness = and other depressive symptoms, a specified minimal "clinically sign= ificant" threshold in the form of harm due to distress or role impa= irment (in occupational, family, or interpersonal contexts) must have re= sulted from the symptoms in evidence before they could be considered sig= ns of depression. Researchers have subsequently assumed -- without defin= itive evidence -- that the CSC eliminates substantial numbers of false p= ositives.
In a 1999 article in American Journal of Psychiatry, Wakefie= ld and co-author Robert Spitzer, the originator of the modern DSM sympto= m-based approach to diagnosis, argued that the CSC would not eliminate f= alse-positive diagnoses of major depression because anyone having the sp= ecified symptoms -- even an individual experiencing a normal intense rea= ction to loss -- would be likely to experience distress or role impairme= nt. Thus, they asserted, the CSC was redundant with the symptom criteria= and could not distinguish normal from disordered symptoms -- a claim th= at has come to be known as the "redundancy hypothesis." The re= searchers' argument was purely conceptual, and largely ignored.
The issue of whether the redundancy hypothesis is correct became sudd= enly more important after Wakefield senior-authored a much-discussed 200= 7 article in Archives of General Psychiatry. The article argued that the= re were indeed large numbers of false-positive diagnoses of major depres= sion in community surveys of mental disorder -- possibly as high as 25% = to 33%. However, that study used data from a national survey that was co= nducted before the DSM-IV's addition of the CSC to the major depression = diagnostic criteria. Thus, there was no CSC in the criteria that Wakefie= ld and his team used to identify cases of major depression at the time.<= /p>
Critics of that study argued that the lack of a CSC was fatal to the = argument because if the CSC had been used, then the supposed false-posit= ive diagnoses that Wakefield and his group identified would likely have = been eliminated as cases too mild for diagnosis. For example, one noted = psychiatrist argued that Wakefield's results were due to a "glitch&= quot; in the diagnostic criteria Wakefield used, and that the diagnosed = individuals identified by Wakefield as having normal reactions would hav= e been eliminated from the depression category if current diagnostic cri= teria including the CSC were used.
A paper later submitted by Wakefield that built on the 2007 article w= as rejected for publication partly based on a reviewer's assertion that = if the CSC had been included in the earlier study, the supposed false po= sitives likely would have been eliminated. So, the issue of whether the = CSC is in fact redundant or actually eliminated many false-positive majo= r depression diagnoses became key to the debate, which is still ongoing,= about the prevalence of depressive disorder.
The latest study, coming in the American Journal of Psychiatry, offers an empirical demonstration, based on nationally representativ= e data, that the Critical Significance Criterion fails to distinguish no= rmal from disordered conditions. In this analysis, Wakefield undertook t= o evaluate independently the impact of the CSC on epidemiological survey= estimates of major depressive disorder by using data from a later surve= y that included a carefully worked out CSC criterion for depression whos= e inclusion, according to the claims of its authors, was an effective wa= y of eliminating former false positives. Wakefield then compared estimat= es of depressive disorder with and without the use of the CSC.
Confirming the redundancy hypothesis put forward a decade earlier, he= found that the CSC eliminated virtually no one from diagnosis -- in fac= t, even among those who experienced prolonged sadness without meeting ot= her diagnostic criteria for depression, about 94% of them satisfied the = CSC just on the basis of the "distress" component alone. Thus = the Clinical Significance Criterion, according to Wakefield and his co-a= uthors, is not doing what it is supposed to do -- reducing the over-diag= nosis of normal mood fluctuations as depression -- and the issue of prev= enting false positives needs to be revisited. And contrary to critics' s= peculations, the earlier findings suggesting many false positives in com= munity surveys cannot be dismissed on the basis of the CSC.
The results take on further importance, Wakefield says, in light of p= roposals for changes to the DSM in a revision currently taking place tha= t will lead to DSM-V. Concern about increasing false positives is at the= heart of criticisms of the proposals that have been put forward by lead= ing psychiatrists, including Allen Frances, the Editor of DSM-IV. Moreov= er, some of the proposals seem to rely heavily on the CSC to justify dia= gnosis of disorder even when symptoms are minimal -- when in fact the cu= rrent research underscores that normal distress can easily satisfy the C= SC.
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=Adapted from materials provided by New York U= niversity.=
=
Journal Reference:
- Jerome C. Wakefield, Mark F. Schmitz, Judith C. Baer. Does t= he DSM-IV Clinical Significance Criterion for Major Depression Reduce Fa= lse Positives? Evidence From the National Comorbidity Survey Replication= . American Journal of Psychiatry, 2010; DOI: 10.1= 176/appi.ajp.2009.09040553
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