Psychiatry Research, 12, 173-174 Elsevier

Letters

Diagnosing RDC Endogenous Depression and DS’W4.1 Melancholia

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To the Editors:

In their recent article comparing clinically referred depressed outpatients and depressed symptomatic volunteers recruited with media announcements, Thase et al. (1984) found that the two groups did not significantly differ in the frequency of patients diagnosed as suffer- ing from endogenous depression according to the Research Diagnostic Criteria (RDC) (Spitzer et al., 1978) or melancholia according to DSM-III (American Psychiatric Associa- tion, 1980). These diagnoses were made retro- spectively, based on detailed case material. In another article, Thase et al. (1983) used these retrospectively derived diagnoses to validate a Hamilton rating subscale for endogenomor- phic depression. We have reservations about the retrospective application of these criteria sets to case material, and the data reported by Thase et al. reinforce our concerns.

For their entire sample of 125 depressed patients, 23 (18.4%) were diagnosed RDC def- inite endogenous depression and 33 (26.470) were diagnosed melancholic according to DSM-III. Thus, at least 10 of the 33 (30.3%) patients meeting DSM-III criteria for melan- cholia did not meet the RDC for definite endogenous depression. This is surprising in light of Williams and Spitzer’s (1982) sugges- tion that the DSM-Illcriteria for melancholia were intended to reduce the heterogeneity within the RDC endogenous depressive group.

Table 1 shows a side-by-side comparison of the two sets of criteria. The algorithms to arrive at each diagnosis are slightly different. There are two necessary criteria to be diag- nosed melancholic (pervasive or near perva- sive anhedonia and lack of reactivity), where- as there are no necessary criteria to be diag- nosed endogenous depression. Each of the eight criteria used to diagnose melancholia are also used to diagnose RDC endogenous de- pression. Of note, anhedonia appears in two places as part of the RDC criteria-in part A it must be pervasive in order to be scored, whereas in part B it is scored even if it is not pervasive. The minimum number of symp-

toms to be diagnosed melancholic is five. The only way a patient can be diagnosed melan- cholic but not RDC definite endogenous depression is to have the minimum number of five melancholic symptoms, and the patient must have lost interest in almost all activities, but not all of them.

We have recently completed a study of 271 depressed inpatients, all of whom met DSM- III criteria for major depressive disorder. Diagnoses were made during the first week of the patient’s hospitalization, and they were based on semistructured interviews. We found that all 110 melancholies also met RDC for definite endogenous depression. This finding is in marked contrast to the finding of Thase et al. that almost one-third of the patients meet- ing criteria for melancholia did not meet crite- ria for definite endogenous depression.

This may or may not be a major issue with respect to the comparison of depressed clinic referrals (it is possible that the nonsignificant trend in which clinic referrals were more fre- quently diagnosed endogenous depression and melancholic would have been a significant dif- ference if a more accurate methodology had been employed); however, it is certainly criti- cal when one is attempting to validate a new subscale to diagnose endogenomorphic depres- sion (Thase et al., 1983).

References

American Psychiatric Association. DSM-III: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. APA, Washington, DC (1980).

Spitzer, R.L., Endicott, J., and Robins, E. Research Diagnostic Criteria. New York State Psychiatric Institute, New York (1978).

Thase, M.E., Hersen, M., Bellack, A.S., Himmelhoch, J.M., and Kupfer, D.J. Valida- tion of a Hamilton subscale for endogeno- morphic depression. Journalof Affective Dis- orders, 5,267 (1983).

0165-1781/84/503.00 @ 1984 Elsevier Science Publishers B.V.

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Table 1. DSM-//I criteria for melancholia and RDC criteria for endogenous depression

Melancholia: Loss of pleasure in all or almost all activities, lack of reactivity to usual pleasurable stimuli (doesn’t feel much better, even temporarily, when something good happens), and at least

three of the following:

(a) Distinct quality of depressed mood, i.e., the depressed mood is perceived as distinctly different from the kind of feeling experienced following the death of a loved one.

(b) The depression is regularly worse in the morning. (c) Early morning awakening (at least 2 hours before usual time of awakening).

(d) Marked psychomotor retardation or agitation. (e) Significant anorexia or weight loss. (f) Excessive or inappropriate guilt.

Endogenous depression: From groups A and B a total of at least four symptoms for probable, six for definite, including at least one symptom from group A.

A. (1) Distinct quality to depressed mood, i.e., depressed mood is perceived as distinctly different from the kind of feeling he would have or has had following the death of a loved one.

(2) Lack of reactivity to environmental changes (once depressed doesn’t feel better, even

temporarily, when something good happens). (3) Mood is regularly worse in the morning. (4) Pervasive loss of interest or pleasure (some loss in all areas).

8. (1) Feelings of self-reproach or excessive or inappropriate guilt. (2) Early morning awakening or middle insomnia. (3) Psychomotor retardation or agitation (more than mere subjective feeling of being slowed

down or restless).

(4) Poor appetite. (5) Weight loss (2 pounds a week over several weeks or 20 pounds in a year when not dieting). (6) Loss of interest or pleasure (may or may not be pervasive) in usual activities or decreased

sexual drive.

Thase, M.E., Last, C.G., Hersen, M., Bel- lack, AS., and Himmelhoch, J.M. Sympto- matic volunteers in depression research: A closer look. Psychiatry Research, 11, 25 (1984).

Williams, J.B.W., and Spitzer, R.L. Research Diagnostic Criteria and DSM-III: An annotated comparison. Archives of General Psychiatry, 39, 1283 (1982).

Mark Zimmerman, B.A. Dalene Stangl, M.A. Bruce M. Pfohl, M.D. William Coryell. M D. University of Iowa Department of Psychiatry Iowa City, IA 52242, USA

March 9, 1984