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Definitions and Distinctions Among Depressive Syndromes and Symptoms: Implications for a Better Understanding of the Depression–Cardiovascular Disease Association

From the Columbia College of Physicians and Surgeons, New York, NY (K.W.D.); the Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY (K.W.D.); and the Department of Psychiatry, Mount Sinai School of Medicine, New York, NY (N.R., M.A.R.).

Address correspondence and reprint requests to Karina W. Davidson, PhD, Medicine, Columbia University College of Physicians and Surgeons, 622 W. 168th St., PH9 Center, Room 948, New York, NY 10032. E-mail: kd2124{at}columbia.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
Objective: A prognostic role for depressive disorder presence and/or elevated depressive symptoms in the onset and recurrence of cardiovascular disease has been largely supported. Depression is a multifaceted disorder, encompassing a wide range of somatic, cognitive, and mood symptoms; it varies in intensity, duration, frequency, course, and family history; it can be assessed continuously or categorically; it can be obtained by interview or by self-report; and importantly, the cardiac prognostic impact of these distinctions may vary. We provide an overview of definitions and possible assessment of depression, and we discuss key assessment distinctions.

Conclusion: Examining the predictive ability of these key distinctions of depression for acute coronary syndrome recurrence would be of benefit to future research in this field.

Key Words: depression • cardiovascular disease • assessment • behavioral medicine

Abbreviations: CVD = cardiovascular disease; ACS = acute coronary syndrome; MDD = major depressive disorder; SCID = Structured Clinical Interview for DSM-IV; DIS = Diagnostic Interview Schedule; DISH = Depression Interview and Structured Hamilton.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
Elevated depressive symptoms appear to be a robust risk and prognostic marker of cardiovascular disease (CVD) and all-cause mortality (1–4). The predominantly positive prospective associations reported have led to conjectures that depression is a causal CVD risk factor, and that depression treatment may alter the course of CVD (5,6).

However, depression is a term that is used for a variety of phenomena, often rendering comparisons of these studies impossible. We provide definitions of depression as provided in the standard psychiatric diagnostic system, and we provide depression assessment methods as commonly used in prospective and intervention studies of CVD patients. The aim of this article is to review key characteristics of both depression definitions and assessments and to discuss the implications of the differences among these characteristics for the study of the CVD/depression association.

	DEPRESSION AS PSYCHIATRIC DISORDER

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
Many researchers assume that depression is a categorical disorder, and that those who have symptoms typically associated with depression have a disorder qualitatively different from everyday distress (7,8). Consequently, they consider that a cluster of depressive symptoms should be viewed as one of a series of psychiatric disorders, as described within the DSM-IV (9). These disorders are predominantly based on the subjective experience of mood and other psychological and somatic symptoms that are evaluated along continua of intensity, duration, frequency, and impairment/distress.

A differential depression disorder diagnosis is based on the duration of the symptoms, the number of symptoms present, and the presumed etiology of the syndrome—all of which are key characteristics or distinctions that should be reported when investigating the link between depression and CVD. Major depressive disorder (MDD) is the most commonly studied clinical diagnosis in relation to CVD. It is characterized by clinically significant impairment in at least five areas such as appetite or sleep that have persisted for at least 2 weeks, plus the presence of depressed mood or the loss of pleasure/interest for most of the day during those 2 weeks. In contrast, dysthymia is reserved for a cluster of symptoms that have persisted over a longer period. The number of symptoms (at least two) needed to diagnose dysthymia is less than in MDD, but persistent depressed mood has to be present throughout 2 years. Both MDD and dysthymia can be further specified according to the presence or absence of atypical symptoms such as reactive mood, hyperphagia (i.e., excessive eating), hypersomnia, leaden paralysis, or long-standing interpersonal rejection sensitivity.

The diagnosis of mood disorder due to a general medical condition describes a significant disturbance in mood that is directly related to the presence of a medical condition known to cause depression, as long as the mood symptoms do not meet criteria for other DSM-IV categories of depression. Although there is a high prevalence of elevated depressive symptoms after an acute coronary syndrome (ACS) event, no one to our knowledge has proposed that ACS may cause these symptoms; however, it seems plausible to assume that depressive symptoms can result from cerebrovascular disease (10).

Another relevant disorder from the DSM-IV is adjustment disorder, characterized by the development of clinically significant emotional and/or behavioral symptoms in response to an identifiable psychological stressor, and this deserves mention in the context of CVD morbidity. The symptoms must develop within 3 months after the onset of the stressors and must resolve within 6 months of the termination of the stressor (11). Severe physical events, such as an onset of an ACS (myocardial infarction or unstable angina), can be a precipitant of an adjustment disorder with depressed mood. Thus, adjustment disorder, as a consequence of an ACS, could play a role in the prediction of recurrent ACS events. Depression not otherwise specified (NOS) allows the classification of less severe syndromes of depression (with fewer symptoms) of a shorter duration (less than 2 weeks) that do not meet criteria for MDD or dysthymia. In addition, the DSM-IV has proposed an exploratory, research category, minor depression, that is to be employed when the patient has only two to four symptoms of MDD, one of which again has to be depressed mood or loss of interest/pleasure. Researchers have also used the term subsyndromal depression interchangeably with minor depression. Both minor and subsyndromal depression are associated with significant impairment in social or occupational functioning (12). However, the term subsyndromal was originally coined to imply a form of depression that is even less severe than a DSM-IV minor depression, but that applies only to patients with a history of MDD (13) to reflect fluctuations in the longitudinal course of this mood disorder. In addition, the term subthreshold depression is commonly used to define clusters of symptoms that do not fulfill criteria for major depression or dysthymia, regardless of whether a history of MDD is present (14).

Interestingly, minimal elevations in self-reported depressive symptoms have been found to predict the recurrence of ACS (15,16), but it is unclear whether this level of depression is indicative of minor depression, depression NOS, subsyndromal depression, or some other form of a depressive disorder. Thus, the longitudinal course of a full depressive syndrome, as well as the course of subthreshold depression, should be carefully assessed to determine whether one or both are critical to adverse ACS prognosis.

Studies more recently have addressed the problem of comorbid anxiety and depressive disorders as classified by the DSM-IV (17). According to the US National Comorbidity Survey (18), as many as 58% of patients with a lifetime diagnosis of MDD may suffer from anxiety disorders, suggesting that the psychiatric disorders' underlying pathophysiology may not respect DSM boundaries. The broad implications of this highly prevalent comorbidity are that etiologies (19), neuroendocrine mechanisms (20), and sequelae may be common to both psychiatric disorders, so future research on depression should consider carefully the implications of these recent findings.

Common assessment tools for a reliable diagnosis of depressive disorders for CVD patients include the Structured Clinical Interview for DSM-IV (SCID; 21) and the Diagnostic Interview Schedule (DIS; 22).¹ The SCID is a semistructured interview designed for administration by a clinician or trained mental health professional to provide a basis for accurate DSM-IV diagnoses. A research version is available that is modifiable, and research assistants without a clinical degree can reliably administer this version after extensive training. In addition to an earlier version based on DSM-II-R criteria, the new SCID allows for a detailed coding of past mood episodes and provides information on minor depression and a mixed anxiety–depression diagnosis. Test-retest reliability of the SCID ranges widely according to setting and study population (24). Its validity has not been extensively studied mostly because of the lack of a gold standard for psychiatric diagnoses. In contrast, the SCID itself is widely used as the gold standard against which the sensitivity and specificity of self-report measures are evaluated.

Trained nonclinician interviewers can also administer the DIS. The answers are completely precoded, which enhances reliability; however, the DIS is rather inflexible, and some have argued that it is insensitive to change (25). The DIS served as one basis for the development of the Depression Interview and Structured Hamilton (DISH; 25), a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease study.

The DISH was designed to assess the severity of depressive symptoms using the 17-item Hamilton Rating Scale for Depression (26), and to enable trained interviewers to make a DSM-IV MDD, minor depression, and dysthymia diagnosis in medically ill patients. Furthermore, the lifetime and family history of these diagnoses is assessed. The DISH was validated against the SCID (88% diagnostic overlap), and in the Enhancing Recovery in Coronary Heart Disease study, clinicians agreed with 93% of diagnoses made by research nurses (25).

	SELF-REPORT DEPRESSION QUESTIONNAIRES

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
When professionally trained interviewers are not available and/or it is not feasible to conduct psychiatric diagnostic interviews, reliance on self-report measures of depression for categorical classification has been common, despite objections to this use (27–29). They are also used in the presence of a clinical depression diagnosis to assess the severity of specific symptoms within a syndrome. Finally, their most common use is as a continuously (as opposed to a categorically) distributed assessment of depressive symptoms. There are many such measures, each with its own merits, and some are available in updated and/or shortened versions. Each of these self-report measures has been tested for its ability to detect depressive disorders in various populations (such as primary care patients, older adults, or population-based samples), and each demonstrates item consistency, split-half reliability, and stability to varying but generally satisfactory degrees (27,28).

Two of the most frequently used self-report scales with CVD patients—the Beck Depression Inventory²(30,31) and the Center for Epidemiological Studies—Depression scale (32)—have shown good predictive validity to ACS events (1,33,34). However, of concern in choosing any of these self-report measures for use in a depression–CVD study is their sensitivity and specificity for depressive disorder detection in older patients with comorbid medical illnesses who have recently undergone a life-threatening medical crisis (35). Total scores on questionnaires such as the Beck Depression Inventory reflect the number and severity of depression symptoms, but even moderately high scores do not guarantee that the patient meets the criteria for a DSM-IV depressive disorder. Among patients who do have DSM-IV depressive disorders, there are no Beck Depression Inventory or Center for Epidemiological Studies—Depression subscale cutoff scores that accurately differentiate between major and minor depressive disorders (36).

	WHAT ARE WE TRYING TO ASSESS WITH DEPRESSION SELF-REPORT MEASURES?

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
We may have predictive ability for ACS incidence and recurrence from these self-report measures, but because of serious concerns about these measures' sensitivity and specificity in detecting depressive disorders (8,37–39), we may not be confident about what it is that we are measuring in post-ACS patients. In addition, this lack of certainty about what is assessed by self-report depressive symptom measures in post-ACS patients is problematic. One solution to this problem would be to ascertain MDD sensitivity and specificity norms for these self-report measures in the post-ACS patient populations—and, for that matter, for the other depressive disorders as well. Sensitivity and specificity studies could help clarify the usefulness of these self-report measures for detecting depressive disorders in post-ACS patients.

	CONCLUSIONS AND FUTURE DIRECTIONS

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
We propose that a broader assessment of depression symptoms, including the assessment of specific type of symptoms, course, etiology, and the characterization of diagnostic status, will enable us to improve our understanding of the association of depression and the recurrence of ACS. Post hoc analyses of extant data sets in which some of the dimensions listed—such as depression symptom type—have been assessed could greatly aid our field in understanding which aspects of depression are good predictors of ACS incidence and recurrence. Such research would enable us to develop hypotheses about potential mechanisms linking depression and ACS recurrence, and this in turn could inform depression prevention and intervention studies. Further, any existing data set with lifetime psychiatric depressive disorder history or current psychiatric disorder presence or both should be similarly mined for ACS associations. Ideally, we would have a population-based sample, with complete ACS outcome data, in which multiple measures of depressive symptoms, syndromes, and psychiatric characterization (both present and past) were also available. This type of study would help determine which characteristics of depression, or which depressive disorders, are worthy of further investigation and possible intervention for those at risk or with ACS.

	NOTES

TOP ABSTRACT INTRODUCTION DEPRESSION AS PSYCHIATRIC... SELF-REPORT DEPRESSION... WHAT ARE WE TRYING... CONCLUSIONS AND FUTURE... NOTES REFERENCES

 
¹ Another structured interview commonly used to diagnose depressive disorders according to the DSM-IV is the Composite International Diagnostic Interview, which was developed by the World Health Organization (23). However, this has not been used in studies with CVD patients.

² A trademarked inventory—both versions I and II.

The preparation of this article was supported by #HC-25197 and #HL-04458 from the National Heart, Lung, and Blood Institute.

DOI:10.1097/01.psy.0000162257.19266.fc

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