Clarification of ambiguity regarding the time frame for the Major Depressive Disorder specifiers
An important use of the Diagnostic and Statistical Manual of Mental Disorders, Fouth Edition (DSM-IV) diagnostic codes is to facilitate analysis of psychiatric practice patterns and quality of care. For example, data from the American Psychiatric Association's (APA's) Practice Research Network was analyzed to examine the use of neuroleptic medication in psychotic mood disorders. During this analysis, an ambiguity was noted in the interpretation of the 5th digit severity codes for mood episodes, specifically regarding the time frame for the application of these severity modifiers. Take, for instance, the modifier “severe with psychotic features,” which is codable by indicating “4” in the 5th digit of the diagnostic code for Major Depressive Disorder or Bipolar I Disorder. There are three possible interpretations:
- it indicates that the person is currently experiencing psychotic symptoms
- that at some time during the current episode (for which the person's mood disturbance still meets criteria) the person had psychotic features
- the person had psychotic features during his or her most recent episode of depression.
Although all three of these scenarios are potentially worth noting in the clinical case record, they each have very different treatment and prognostic implications. The first scenario suggests active use of antipsychotic medication (or electroconvulsive therapy [ECT]), whereas the second and third scenarios indicate risk of developing future psychotic symptoms during depressive episodes, with the second scenario being at higher risk than the third.
Since the first scenario (i.e., the specifier “severe with psychotic features” indicates that psychotic symptoms are currently present) is most consistent with DSM-IV conventions on application of the severity specifiers, the text (and criteria sets) have been rewritten to indicate that the specifiers “mild,” “moderate,” “severe without psychotic features” and “severe with psychotic features” apply only if the criteria are currently met for a Major Depressive Episode and serve to indicate the current severity. If criteria are no longer met, then “in partial remission” or “in full remission” must be applied instead of “mild,” “moderate” or “severe.”
In a related vein, when specifiers such as “with melancholic features” or “with atypical features” are applied to a Major Depressive Episode in partial or full remission, it is understood that the specifier applies to the most recent Major Depressive Episode. For example, the diagnosis “Major Depressive Disorder, Recurrent, in Full Remission, With Melancholic Features” indicates that when the individual was last in a Major Depressive Episode, melancholic features were present when the episode was at its worst. Ambiguity exists, however, in the time frame for application of the criteria for atypical features for past episodes. The diagnostic criteria for “atypical features” indicate that the atypical features specifier applies if the criteria are met during the “most recent two-week period.” While this two-week time frame makes sense for current episodes, it is less meaningful for a past episode (i.e., there is nothing particularly special about the last two weeks of past Major Depressive Episode). Thus, to resolve this ambiguity, it has been clarified that a past episode is atypical if the criteria were met for any two-week period during the episode.