Report of the DSM-V Mood Disorders Work Group
April 2009
Jan Fawcett, M.D.
The 13 member Mood Disorders Workgroup has continued to work in a configuration of subworkgroups dealing with Major Depression and related disorders, Bipolar Disorders, Anxiety in Depression, Suicide, Pre-Menstrual Dysphoric Disorder( PMDD), and Seasonal Affective Disorder (SAD). The process has continued to be an iterative process based on literature reviews, review of data from secondary analyses, and input from eight advisors with expertise in specific areas as well as input from four liaison participants in areas that overlap with other workgroups (e.g. the psychosis workgroup regarding schizoaffective disorder).
Each subworkgroup has continued its work on conference calls ranging in frequency from every two weeks to every month. The entire work group has a conference call about once monthly to keep every member abreast of what each subworkgroup has reviewed and any decisions that subworkgroups wish to present to the workgroup for endorsement for presentation to the Task Force for approval. The workgroup has agreed that a proposal for any significant additions or deletions from DSM-IV will be presented to the group by a sponsoring individual who will present a reason for the change, advantages of a proposed change and anticipated unintended consequences of the change, backed up by a literature review and/or data for secondary analyses of supporting data. The greater the change, the more in depth data will be required by the group.
The major depression (MDD) subworkgroup, is reviewing secondary analyses of symptom severity of the 9 symptoms plus hopelessness and irritability validated by impairment measures and severity measures to decide whether there is sufficient data to support adding or removing symptoms that are currently criteria for major depression. This subworkgroup also has reviewed the literature on the clinical outcomes of major depression with and without the bereavement specifier and will request and consider input from investigators who study the treatment of patients with complicated bereavement before coming to a final recommendation. The literature showing that subthreshold manic symptoms predict a switch to a bipolar diagnosis over time in patients originally diagnosed with major depression together with the evidence that a delay of up to eight years is reported in making a bipolar diagnosis is being reviewed. Since classifying all such patients could result in up to 30% of major depression diagnoses being converted to bipolar diagnoses, the committee is cautiously examining thresholds based on available data to better differentiate this boundary or possible spectrum, since major treatment implications are involved. A bipolar features specifier added to the diagnosis of major depression is being considered. This issue is being discussed with the bipolar subworkgroup. The MDD subworkgroup is also considering data on subthreshold depression that show that two or three depressive symptoms are also found to be correlated with significant disability and risk of suicidal behavior. The issue is where and how to draw a boundary of caseness so that community rates of depression don’t soar to unbelievable levels, while at the same time reducing the use of the NOS diagnosis which conveys little clinical information, and ensuring that those in need of treatment can be identified. Finally, the MDD subworkgroup has received a review of SADS and is awaiting another review to reach a decision whether SADS is better considered a diagnostic category or a specifier in DSM-V.
The Bipolar subworkgroup is considering the issue of mixed states which in the DSM-IV requires full criteria for major depression and for mania, therefore limiting a mixed episode to only a bipolar I disorder. It is believed based on literature and clinical experience that this criterion is too stringent and those patients who do not meet criteria for Bipolar I disorder, such as Bipolar II patients, frequently display and require treatment for mixed hypomanic or depressive states. A mixed episode specifier requiring 2-3 symptoms of either major depression or mania is being considered, based on data provided by an advisor who has worked extensively in this area. The lower boundaries of caseness of bipolar disorder are being reviewed in various data bases and the literature in an attempt to provide an alternative for the Bipolar NOS diagnosis, which provides very little clinical information. The Bipolar subworkgroup has also been discussing the issue of the criteria for the diagnosis of Pediatric Bipolar Disorder. Members are working with a liaison from the Child and Adolescent Disorders work group and an advisor to develop strategies to enhance accurate diagnosis of the disorder in this age group.
The suicide sub-workgroup is working on a suicide risk scale. This scale, as currently conceptualized, is not a simple severity dimension because it has to deal with the clinically important distinction of chronic high suicide risk versus acute or immediate suicide risk. The former requires clinical watchfulness but no immediate action, while the latter requires that decisions be made to try to intervene in order to prevent suicide. We are reviewing the data to support the various risk levels covered by the scale in order to provide support for the clinician in reaching this assessment. This is an assessment that each clinician needs to consciously make when treating patients at any level of risk for suicide, and we believe being asked to record the conclusions of this assessment will help the clinician consciously go through this process and decide whether any action is necessary or could become necessary in a patients management. It will also provide documentation that the clinician made a conscious assessment.
The Work group has discussed the usefulness of dimensionally assessing various behavioral domains across the mood disorders diagnostic categories. The literature and a secondary data analysis has shown that anxiety, substance abuse and suicide risk have the most impact on outcome and therefore should be considered as valuable assessments for the mood disorders. The workgroup is also discussing and pursuing literature on an appropriate overall severity dimension for mood disorders. The question of whether a dimension such as found in the CGI would suffice across both major depression and bipolar disorders is being addressed.
Another specific issue under consideration is whether a separate diagnostic category of Anxious Depression or Mixed Anxiety-Depression is warranted. Will the use of an anxiety severity dimension across all mood disorders categories meet the needs for documenting subthreshold combinations of mixed anxiety-depression--often found in primary care practice--as well as the equally important condition of full syndrome major depression with severe anxiety--which has been shown to predict poor treatment response, suicide attempts, and suicide?
The PMDD subworkgroup, is accumulating evidence as to whether PMDD can be discriminated from other diagnoses such as other mood disorders, and looking at validators ( biological, course, impairment, treatment response, familial transmission) as well as evidence for caseness such as impairment and distress to determine whether the evidence supports a recommendation that it be deemed a diagnosis in DSM-V.
The Mood Disorders Workgroup prepared a basic outline for two field trials. One is focused on manic/hypomanic symptoms in patients with Major Depression, and the other on criteria for differentiating pediatric bipolar disorder from childhood attention deficit disorder, oppositional defiant disorder and conduct disorder. Specific methods and parameters as well as possible combination possibilities for these studies are under consideration and discussion.