Major depressive episode was diagnosed when at least 2 weeks of persistent depressed mood, anhedonia, or hopelessness occurred reported by self or observed by others , plus additional symptoms from criterion A, for a total of 5 of the 9 DSM-5 major depression criteria 26 and the clinical significance criterion. Lifetime DSM-5 MDD was defined as at least one lifetime major depressive episode without full DSM-5 manic, mixed, or hypomanic episodes, 26 , 28 excluding substance-induced and medical-induced disorders.
Those with at least one episode in the prior 12 months were classified as having month MDD. The DSM-5 does not state the number of MDD symptoms required for each severity level, so these levels were defined as follows: mild is 5 symptoms minimum for a diagnosis , moderate is 6 to 7 symptoms, and severe is 8 to 9 symptoms. The DSM-5 also states that distress and impairment should increase across levels but without clear definitions.
Therefore, we used the symptom count only, which is clear. The symptom count was based on the lifetime MDD episode when mood or anhedonia was the worst.
The DSM-5 defines this specifier as at least 2 of the following 5 anxiety or distress symptoms during an episode: feeling keyed up or tense, being unusually restless, having trouble concentrating due to worry, fearing something awful would happen, and thinking one might lose control of oneself.
These symptoms were required for at least 2 weeks during the episode when mood or anhedonia was the worst a lesser threshold than the actual DSM-5 definition, which requires symptoms on more days than not. The DSM-5 defines this specifier as at least 3 of the following symptoms during episodes not meeting criteria for mania or hypomania: elevated or expansive mood, inflated self-esteem or grandiosity, unusual talkativeness or pressure to keep talking, flight of ideas or racing thoughts, increased energy or goal-directed activity, involvement in activities eg, financial or sexual with potential for painful consequences, and decreased need for sleep rested despite sleeping less.
These symptoms were required for most days during at least one lifetime episode. In DSM-5 , the month or lifetime diagnoses of alcohol or drug disorders require at least 2 of 11 criteria within a month period. Impaired functioning was assessed with version 2 of the Item Short Form Health Survey SFv2 , a reliable, valid, widely used measure of impairment in the prior 30 days. Lower scores indicate poorer functioning.
Adjusted odds ratios aORs from multivariable logistic regressions were used to test associations of MDD with sociodemographic characteristics, controlling for all others, as was done previously in NESARC studies. Logistic regressions indicating the association between SFv2 scores and MDD were adjusted for sociodemographic characteristics and other psychiatric disorders.
The respective month and lifetime prevalences were Compared with respondents 65 years or older, odds of month MDD were greater for younger age groups. The associations between lifetime MDD and sociodemographic characteristics were similar Table 1. All disorders were significantly associated with month and lifetime MDD Table 2.
The aORs were larger for drug use disorder than for alcohol or nicotine use disorders and were larger for borderline than other personality disorders. Additional adjustment for other psychiatric disorders decreased all aORs some substantially , but most remained significant. Overall, a mean SE of 3. The median duration of lifetime longest or only episode was Treatment for MDD was reported by The mean age at first treatment for MDD was During the lifetime MDD episode when mood or anhedonia was at its worst, Lifetime and past-year suicide attempts were reported by Mental health, social functioning, role-emotional functioning, and mental component summary scores ranged from Moderate and severe cases had worse functioning, with scores for severe cases range, In participants whose only MDD episode extended into the prior 30 days Table 4 , scores were poorer overall range, When mood or anhedonia was at its worst during lifetime MDD Table 3 , Among those whose only MDD episode was in the prior 12 months, Of participants who ever had MDD, Both specifiers were significantly associated with earlier onset, number of episodes, longest duration, severity, MDD treatment overall and by type, suicidality, and poorer SFv2 scores.
Most of these correlates remained significant when controlling for sociodemographic characteristics and MDD severity.
Major depressive disorder was associated with other psychiatric disorders, especially generalized anxiety disorder and borderline personality disorder, associations found in previous studies. Few were mild; most were moderate or severe. Only among Major depressive disorder was associated with impaired functioning, especially in severe cases.
Demographic correlates were consistent with previous surveys. This study found association between low income and month MDD, consistent with other studies conducted within the last 3 years.
Major depressive disorder was associated with anxiety disorders, particularly panic disorder and generalized anxiety disorder, as well as with PTSD.
Associations were strongest with models adjusting only for sociodemographic characteristics. These findings reflect the underlying association of anxiety disorders with each other and MDD within the internalizing component of the transdiagnostic spectrum. Major depressive disorder was associated with SUDs, particularly drug disorders, as found previously for cannabis, 40 , 62 nonmedical prescription opioids, 5 , 57 , 63 and drug use disorders.
Evidence suggests that efforts to self-manage depression with cannabis are increasing 71 - 75 also Aaron L. Sarvet, MPH, written communication, January 2, despite lack of evidence that cannabinoids are effective for this purpose 76 , 77 ; prospectively, cannabis worsens the course of depressive disorders.
This study contributes novel information about the epidemiology of 2 new DSM-5 major depression specifiers. This study has limitations. The study was cross-sectional; associations do not necessarily indicate causal relationships. Lifetime associations of MDD with other psychiatric disorders may be influenced by recall bias, although this possibility is less likely for month findings, which were similar.
Therefore, all cases of MDD beginning shortly after the death of someone close and remitting in less than 2 months were characterized as bereavements, as was done in previous research.
Furthermore, we defined the DSM-5 severity specifier by MDD symptom counts, which are straightforward, transparent, and replicable. This approach enabled us to examine the association between these severity levels and SFv2 impairment scores. The DSM-5 also suggests incorporation of distress and impairment levels into the severity classifications but defines these vaguely.
Future studies should develop brief, psychometrically sound measures of these domains for epidemiologic studies. Also, a response rate greater than Increases between surveys can occur for many reasons, 90 including methodological eg, DSM changes and unspecified survey effects or substantive eg, true increases, perhaps due to growing economic insecurities 1 or other societal changes.
Studies examining methodological issues would be valuable but are beyond the present scope. The likelihood that NESARC-III indicates valid increases in prevalence is supported by the coherence of its results with 6 other reports showing national increases in depression indicators 1 , 2 also Katherine M. Keyes, PhD, written communication, January 2, and suicidality. This study on MDD prevalence, demographic and psychiatric correlates, disability, treatment use, and specifiers can inform policymakers, clinicians, and the public, as well as stimulate investigation in several areas.
While many with MDD receive treatment, others remain untreated. The high prevalence of MDD among US adults is a substantial concern given the personal, public health, and economic burdens that the disorder imposes.
Therefore, the need to reduce the prevalence of this disorder remains. Corresponding Author: Deborah S. Published Online: February 14, Author Contributions: Drs Hasin and Grant had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported.
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Table 1. View Large Download. Table 2. Table 3. Table 4. Table 5. Supplementary Material. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PubMed Google Scholar Crossref. The participants in the Non-depressed and Moderately depressed groups were selected based on matching demographic characteristics with the Severely depressed group.
Then, 46 controls and 46 moderately depressed patients were randomly selected to be analyzed Figure 1. Figure 1. Design of the study timeline. Age, percentage of females, years of education, and mini-mental state exam scores were calculated for the SD group. These demographic values were used to sample the other two groups ND and MD. Then, from the total number of subjects in the other two groups ND and MD , 92 subjects 46 MD and 46 ND were randomly selected to be included in the analyses.
It was administered by trained physicians that are familiar with the DSM-5 diagnostic criteria. Two trained raters independently scored each patient at the same interview.
Only patients who received equal scores from the two raters were included in the sample. It should be mentioned that high interrater reliability has been described previously 16 , 28 , The total score on the item HAMD ranges from 0 to 52, with higher scores representing greater severity of depression. All subjects gave written informed consent in accordance with the Declaration of Helsinki.
Quantitative variables are reported as absolute and relative frequencies, means M , and standard deviations. Table 1. Comparison of matched groups variables according to the Hamilton Depression Rating Scale.
Results will be presented for Non-depressed vs. Moderately Depressed, and Severely Depressed vs. Moderately Depressed. Then, the assumptions of the discriminant analyses were tested linearity, normality, multilinearity, equal variances, and multivariate normal distribution of the predictors.
Box's M -tests were performed to test the assumption of the homogeneity of covariance matrices. It should be mentioned that discriminant analysis is robust when the homogeneity of variances assumption is not met, provided the data do not contain important outliers.
For our data, the Box's M -test was interpreted in conjunction with the inspection of the log determinants. Considering our sample size and the absence of outliers, we concluded that the small deviations from homogeneity groups did not violate the assumptions of the discriminant analysis. For each case Non-depressed vs. Moderately Depressed and Severely Depressed vs. Moderately Depressed , the discriminant was created as a linear combination of the nine independent variables.
The standardized canonical coefficients of the discriminant function analysis were used to identify the most reliable variable for discriminating between Severely Depressed and Moderately Depressed groups as well as between Non-depressed and Moderately Depressed groups.
Then, the canonical discriminant function coefficients were calculated to obtain the Discriminant Function DF. Non-depressed, and Moderately Depressed vs.
Severely Depressed. For each case, the correspondent chi-squared was calculated to verify if the DF did better than the chance level of separating the two groups.
With the aid of the DF, the accuracy of the classification was measured for each case. Most participants were female sex The prevalence of MDE in this clinical sample was In the whole sample, 46 depressive patients were found to be severely depressed.
Severe depression was found to be more frequent in women In contrast, there was not an association between sex and moderate depression. The Non-depressed and the Moderately Depressed groups were matched considering the demographic variables of the Severely Depressed group Table 1. There was no statistically significant differences according to race Caucasians and non-Caucasians among the three groups. The human development index in our sample ranged from 0.
As expected, all the DSM-5 symptoms were found to be more frequent in Severely Depressed and Moderately Depressed groups as compared to the control Non-depressed group. Table 2. The relative frequencies of the DSM-5 criteria for major depressive episode among the groups. Group means were found to be significantly different for all DSM-5 criteria. Depressed mood was the most reliable variable for discriminating between groups, followed by sleep difficulties and poor concentration.
The smallest discriminant ability was found for suicidality. The pooled within-groups correlations Table 3 identified the large correlations with the full discriminant model: Depressed mood, sleep difficulties, poor concentration, and fatigue. The canonical discriminate function reached an eigenvalue of 6. Therefore, the DF significantly separated the two groups.
Table 3. Pooled within-groups correlations between discriminating variables and standardized canonical discriminant function: Non-depression vs. Severe depression. The highest value was fatigue. The analysis of the standardized canonical coefficients indicated that suicidality was the most reliable variable for discriminating between the groups, followed by anhedonia. The smallest discriminant ability was found for fatigue. The lowest was fatigue. The canonical discriminate function reached an eigenvalue of 0.
Figure 2. Summary of the results. Loss of interest or pleasure discriminates severely depressed SD group from MD. The ellipses represent the non-somatic DSM-5 items and the rectangles the somatic DSM-5 items, according to the factor structure described by Elhai et al.
DM, depressed mood; LI, loss of interest or pleasure; SD, sleep difficulties insomnia or hypersomnia ; C, diminished ability to think or concentrate; FE, fatigue or loss of energy; FW, feelings of worthlessness or excessive guilt; SU, suicidality; AW, appetite or weight disturbance; PAR, psychomotor agitation or retardation.
The two main diagnostic criteria for depression depressed mood and loss of interest or pleasure differ regarding their discrimination ability when the level of depression is considered: depressed mood is the most reliable DSM-5 symptom to discriminate moderate depression from non-depression whereas anhedonia emerges as an important criterion when depression becomes more severe.
Among the secondary DSM criteria, the somatic cluster shows high discriminant ability to separate non-depression from moderate depression.
For the discrimination of severe from moderate depression, the most reliable DSM-5 symptom is suicidality, followed by anhedonia, feelings of worthlessness and depressed mood.
In summary, the non-somatic DSM-5 criteria are found to distinguish moderate from severe depression reliably, while the somatic factors are useful for the discrimination between moderate and non-depression groups. The present data support a two-factor model of depression proposed by Elhai et al. Among the secondary DSM-5 symptoms, the somatic factors are related to moderate depression, whereas the non-somatic or cognitive-affective factors are related to severe depression.
The finding that the two main criteria for depression depressed mood and anhedonia exhibit distinct discrimination ability may reflect the possible differences between these two symptoms. Depressive mood is often associated with the presence of stressors 30 , often loss situations death, economic reversal, separation, illness, etc.
Thus, it is possible to speculate that depressed mood may be considered a compound factor indicating either a response to stressful situations somatic factor or a sadness feeling affective factor. Anhedonia may indicate either loss of interest motivational anhedonia or absence of an anticipatory pleasure from future activities or loss of pleasure in response to stimuli that were previously perceived as rewarding consummatory anhedonia Therefore, anhedonia is fully related to the affective factor while depressed mood might be related to both affective and somatic factors stressful situations.
This might explain why depressed mood is a good discriminator of moderate from non-depressed groups. However, another interpretation is that HAMD simply gives more importance to depressed mood items than to anhedonia 14 , 16 , In line with these findings, increased inter-lead QT interval differences on lead electrocardiography QT dispersion or reduced heart rate variability HRV has been reported in depressed patients 19 , 35 — Thus, both conditions may predispose individuals with depression to ventricular tachycardia, ventricular fibrillation, myocardial ischemia, and sudden cardiac death 44 — However, research on depression and HRV has been typically conducted in patients with cardiovascular disease 46 — Our findings are in agreement with the recent report by Benvenuti et al.
Here we demonstrated that moderately and severely depressed patients may express symptoms of low mood or distress through two distinct clusters of DSM-5 criteria.
The present study report that moderate depression is associated with the somatic cluster is in agreement with the previous finding of highest autonomic dysfunction in moderate depression as compared to all other groups, including control and severely depressed patients The somatic symptoms may be related to autonomic disturbances in depressed patients without known cardiovascular disease 52 , Likewise, the Mental Stress-Induced Myocardial Ischemia has already been described in a patient with normal coronary arteries and generalized anxiety disorder In this case, anxiety might be considered a somatic component of depression 54 — Decreasing serotonin may cause a decrease in parasympathetic activity 58 , and emotional response capabilities are marked peripherally by vagal efference to the heart 40 , Specifically, high parasympathetic tone helps to maintain heart stability and protect against possible adverse cardiac events 32 , Conversely, increased sympathetic tone increases the risk of malignant arrhythmias and sudden cardiac death Thus, a high degree of HRV provides cardioprotective effect whereas the reduction in HRV is associated with higher cardiovascular risk in depressed patients 43 , 51 , Although medication-free depressed patients already exhibit reductions in HRV 52 , the use of specific antidepressants e.
This poses an additional risk for the depressed patients. The finding that the somatic cluster is related to moderate depression indicates a decrease in parasympathetic activity leading to higher cardiovascular risk. Therefore, the present data suggest that the cluster of DSM-5 symptoms exhibited by the patient may guide the choice of the adequate antidepressant drug treatment.
In addition, severe depression was found to be linked to increased suicidality, highlighting the importance of needing clear markers of severe depression for clinicians to identify the patients are at risk for committing suicide In our study, the presence of the anhedonia main criterium indicates severe depression, especially when accompanied by feelings of worthless or excessive guilt, and thoughts of death.
Although serotonin has been the most studied neurotransmitter in depression, norepinephrine is also of importance in depressive disorders. An association of specific features and symptoms of depression and a deficiency or dysfunction of certain neurotransmitters has been proposed 65 — 67 : a serotonin deficiency is related to problems such as anxiety, obsessions, and compulsions whereas dysfunctional dopaminergic activity is implicated in problems of motivation and pleasure 66 — Accordingly, norepinephrine deficiency is associated with increased suicide risk 50 , 65 , A limitation of this study is the use of a clinical sample.
We choose a clinical sample because it maximizes the prevalence of depression. Although the DSM criteria do not require distinguishing between clinical and non-clinical populations, it is possible to speculate that specific clinical problems may bias both the Hamilton Depression Rating Scale e.
In addition, the study was done from a sample in Brazil, and some cultural factors could influence the symptoms. Therefore, it would be useful to add other scales to measure depression such as something that the patients could fill out to show if there is a relationship among the multiple instruments 73 — Another limitation is the lack of power to study sex differences. Although the DSM criteria do not distinguish men from women, men's experiences of depression may be different from women, such as higher rates of anger attacks and aggression in men compared to women It would be of interest to perform a confirmatory analysis using the equations derived from the present data controlling gender and using non- clinical samples.
From a clinical point of view, the present study suggests that somatic rather than cognitive-affective DSM-5 criteria are linked to moderate depression. To save favorites, you must log in. Creating an account is free, easy, and takes about 60 seconds.
Log In Create Account. The principal investigators of the study request that you use the official version of the modified score here.
Diagnoses major depressive disorder MDD. When to Use. Depressive symptoms. Depressed mood. Most of the day, nearly every day; may be subjective e. Weight loss or gain. Insomnia or hypersomnia. Psychomotor agitation or retardation. Nearly every day and observable by others not merely subjectively restless or slow. Nearly every day; guilt may be delusional; not merely self reproach or guilt about being sick. Decreased concentration. Nearly every day; may be indecisiveness; may be subjective or observed by others.
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