Whither Melancholia?

By Arline Kaplan | January 8, 2010

^a Coauthors of the position paper are Gordon Parker, MD, PhD; Max Fink, MD; Edward Shorter, PhD; Michael Alan Taylor, MD; Hagop Akiskal, MD, German Berrios MD; Tom Bolwig, MD; Walter A. Brown, MD; Bernard Carroll, MB, PhD; David Healy, MD; Donald F. Klein, MD, DSc; Athanasios Koukopoulos, MD; Robert Michels, MD; Joel Paris, MD; Robert T. Rubin, MD, PhD; Robert Spitzer, MD; and Conrad Swartz, MD. They represent clinicians from the United States, Australia, Canada, Denmark, Italy, and the United Kingdom.

Mood Disorders Work Group

Fawcett was asked about the work group’s process for considering changes.

“People proposing changes to the DSM are thinking of the positives of what they are proposing, but we have to be sure that if we make the change, it is going to result in clarification for clinicians, usability for clinicians, and better treatments for patients,” he said.

The work group, he added, has to consider not only the positives but also the negatives and the implications of making changes.

“We are trying to change things where there are good arguments for the change and good evidence. The question is whether the evidence from Dr Parker, Dr Fink, and their colleagues is at the highest level to create a new diagnosis. It is the same issue with premenstrual dysphoric disorder and extended grief, among others,” he said.

Stability over time is an important validator of a diagnosis, Fawcett said. Parker has been asked to provide follow-up data on this issue, along with data on the specificity of laboratory tests for melancholia.

Unintended consequences are also a consideration. “The major depression criteria have been used in research for years, and there is a huge body of research on major depression,” Fawcett said. “If you change the criteria to accommodate melancholia as a separate entity, what are the unintended consequences?”

More generally, the work group is exploring the possibility of adding external dimensions to diagnoses rather than changing diagnostic criteria, Fawcett said. “Dimensional specifications carry more information, but we are stuck with categories to line up with medicine,” he said.

Kupfer in a recent American Psychiatric Association (APA) press statement noted that draft changes to DSM will be posted on the DSM-V Web site in January 2010. Comments will be accepted for 2 months and reviewed by the relevant DSM-V work groups in each diagnostic category. Field trials for testing proposed changes will be conducted in 3 phases.

To allow more time for public review, field trials, and revisions, APA president Alan Schatzberg, MD, just announced that the anticipated release date for the DSM-V has been moved from 2012 to May 2013. The extension will also permit DSM-V to better link with the US implementation of the ICD-10-CM codes for all Medicare or Medicaid claims reporting, scheduled for October 1, 2013, he added.

Pages: 1 2 3

Engraving by Albrecht Dürer, 1514

References

1. Rush AJ, Weissenburger JE. Melancholic symptom features and DSM-IV. Am J Psychiatry.1994;151:489-498.
2. Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. Cambridge, UK: Cambridge University Press; 2006.
3. Melancholia: Beyond DSM, Beyond Neurotransmitters. Proceedings of a conference, May 2006, Copenhagen, Denmark. Acta Psychiatr Scand Suppl.2007;115(433):4-183.
4. Parker G, Fletcher K, Hyett M, et al. Measuring melancholia: the utility of a prototypic symptom approach. Psychol Med. 2009;39:989-998.

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