From: Clinical classification in mental health at the cross-roads: which direction next?
Clear goals | Consequences for diagnoses related to major depression |
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1. Focus primarily on enhancing clinical practice | 1. Abandon use of the single term ‘major depression’ as on its own it does not predict response to specific psychological or physical treatments [62]; |
2. Only use in association with specifiers that predict likely response to specific treatments - for example, major depression with psychotic features; melancholia associated with psychomotor changes [63–65]; depression following manic episode [62]; | |
3. Differentiate other risk or comorbidity factors from the diagnosis itself - notably risk of self-harm or suicide or misuse of alcohol and other substances [66–69]. | |
2. Link directly to objective markers of pathophysiological processes | Require the cross-sectional and longitudinal recording of objective markers that may predict response to treatment or risk of recurrence: |
• Neurohormonal - for example, presence of non-suppression to dexamethasone [70]; | |
• Circadian or sleep - for example, actigraphic evidence of phase-delay [58, 60, 71]; | |
• Psychomotor change - for example, observer or automated measures [63–65]; | |
• Neuropsychological - for example, neuropsychological evidence of delayed reaction time [72–75]; | |
• Brain imaging - for example, presence of subcortical white matter changes [59, 74, 76–82]. | |
3. Incorporate known facts about developmental paths, environmental risk factors, course of illness or family history | 1. Differentiate early-onset (<30 years) from late-onset (>50 years) forms [83–87]; |
2. Differentiate first major episode from recurrence, relapse or chronicity [21, 22, 52, 88]; | |
3. Record clear environmental (for example, seasonal onset, exposure to traumatic events) or medical illness (for example, post-stroke) exposures that are concurrent with depression [89]; | |
4. Record clear earlier (notably childhood) phenotypes such as childhood anxiety; | |
5. Record clear family history data related to presence of psychosis, mania or suicide in first-degree relatives [35, 37, 90–95]; | |
6. Record clear history of exposure to social adversity or interpersonal stressors or ongoing evidence of major socio-economic, interpersonal or other relevant social circumstances [96–98]. | |
4. Be consistent with data from family, twin or genetic studies | 1. Restrict the diagnosis to those sub-categories with strong evidence of high heritability - for example, depression in those with previous mania; depression in those with psychotic features [35, 37, 38, 99–101]; |
2. Support the concepts of depressive disorders preceded by childhood anxiety or early- versus late-onset depressive disorders [66, 84–86, 102]. | |
5. Capture key aspects of illness stage | Use a clinical staging format for depressive disorders that differentiates early stages that are strongly linked to other childhood and adolescent phenotypes (for example, anxiety, phase-delay in sleep and circadian systems, fatigue, hypomania, mood instability) from later early adult or mid-adult stages (which may also be associated with different phenotypes such as psychomotor change, phase-advance in sleep and circadian systems) [21, 22, 58–61, 88, 102]. |
6. Best predict future illness course or response to specific treatments. | Use known factors about response/non-response to specific treatments - for example, for acute episode: classify as selective serotonin reuptake inhibitor responder or non-responder; classify as responder or non-responder to cognitive behavioral therapy [103–105]. |