Depression is not a consistent syndrome: an investigation of unique symptom patterns in the STAR*D study

By Eiko I. Fried, R. Nesse. Journal of Affective Disorders, 2014

900 citations recorded by the source corpus.

Background The DSM-5 encompasses a wide range of symptoms for Major Depressive Disorder (MDD). Symptoms are commonly added up to sum-scores, and thresholds differentiate between healthy and depressed individuals. The underlying assumption is that all patients diagnosed with MDD have a similar condition, and that sum-scores accurately reflect the severity of this condition. To test this assumption, we examined the number of DSM-5 depression symptom patterns in the "Sequenced Treatment Alternatives to Relieve Depression" (STAR*D) study. Methods We investigated the number of unique symptom profiles reported by 3,703 depressed outpatients at the beginning of the first treatment stage of STAR*D. Results Overall, we identified 1,030 unique symptom profiles. Of these profiles, 864 profiles (83.9%) were endorsed by five or fewer subjects, and 501 profiles (48.6%) were endorsed by only one individual. The most common symptom profile exhibited a frequency of only 1.8%. Controlling for overall depression severity did not reduce the amount of observed heterogeneity. Limitations Symptoms were dichotomized to construct symptom profiles. Many subjects enrolled in STAR*D reported medical conditions for which prescribed medications may have affected symptom presentation. Conclusions The substantial symptom variation among individuals who all qualify for one diagnosis calls into question the status of MDD as a specific consistent syndrome and offers a potential explanation for the difficulty in documenting treatment efficacy. We suggest that the analysis of individual symptoms, their patterns, and their causal associations will provide insights that could not be discovered in studies relying on only sum-scores.

Subfields: Clinical Psychology, Experimental and Cognitive Psychology, Pharmacology

View Paper: https://www.semanticscholar.org/paper/9179e65b3e2f1372489527684304aa91482b464e

How researchers see this paper

The researchers whose trusted networks rank it highest, strongest advocate first. Every researcher gets a different order.

In Clinical Psychology

1. Eiko I. Fried
2. A. Cramer
3. R. Nesse
4. Roi Reichart
5. Christa S. C. Asterhan
6. Tim Dalgleish
7. Sacha Epskamp

In Experimental and Cognitive Psychology

1. Eiko I. Fried
2. A. Cramer
3. R. Nesse
4. Sacha Epskamp
5. Roi Reichart
6. Christa S. C. Asterhan
7. D. Johnston
8. Tim Dalgleish

In Pharmacology

1. Eiko I. Fried
2. R. Nesse
3. A. Cramer

Citations in the corpus

• The Hitchhiker’s Guide to Computational Linguistics in Suicide Prevention (2021, background): “Two individuals who suffer from major depression, for example, a well-recognized risk factor for suicide, may share very little, if any, joint symptoms and yet be eligible to the same diagnosis according to the DSM (Fried, 2017; Fried & Nesse, 2015).”
• The Turker Blues: Hidden Factors Behind Increased Depression Rates Among Amazon’s Mechanical Turkers (2020, background): “This difference in diagnoses is partially because different self-report questionnaires may result in different clusters of symptoms (Fried, 2017) and fail to encompass the heterogenic psychosocial nature of depression (Fried & Nesse, 2015).”
• Transdiagnostic Approaches to Mental Health Problems: Current Status and Future Directions (2020, background): “Indeed, when we account for all of the subsymptoms and directional qualifiers, there are 16,400 different symptom profiles that all qualify as MDD (Fried & Nesse, 2015).”
• Moving Forward: Challenges and Directions for Psychopathological Network Theory and Methodology (2017, background): “As we discussed in more detail above, there is considerable heterogeneity within diagnoses such as PTSD and MD, and patients may exhibit very different problems (Fried & Nesse, 2015a; Galatzer-Levy & Bryant, 2013; Olbert et al., 2014).”
• Depression sum-scores don’t add up: why analyzing specific depression symptoms is essential (2015, methodology): “While the DSM has a hierarchical structure that features two core symptoms, and while symptoms have to cause significant distress or impairment in important areas of functioning for a diagnosis, these criteria are not accounted for in such scales, further increasing the heterogeneity of depressed sa”