The impact of individual depressive symptoms on impairment of psychosocial functioning

Eiko I Fried, Randolph M Nesse, Eiko I Fried, Randolph M Nesse

Abstract

Previous studies have established that scores on Major Depressive Disorder scales are correlated with measures of impairment of psychosocial functioning. It remains unclear, however, whether individual depressive symptoms vary in their effect on impairment, and if so, what the magnitude of these differences might be. We analyzed data from 3,703 depressed outpatients in the first treatment stage of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Participants reported on the severity of 14 depressive symptoms, and stated to what degree their depression impaired psychosocial functioning (in general, and in the five domains work, home management, social activities, private activities, and close relationships). We tested whether symptoms differed in their associations with impairment, estimated unique shared variances of each symptom with impairment to assess the degree of difference, and examined whether symptoms had variable impacts across impairment domains. Our results show that symptoms varied substantially in their associations with impairment, and contributed to the total explained variance in a range from 0.7% (hypersomnia) to 20.9% (sad mood). Furthermore, symptoms had significantly different impacts on the five impairment domains. Overall, sad mood and concentration problems had the highest unique associations with impairment and were among the most debilitating symptoms in all five domains. Our findings are in line with a growing chorus of voices suggesting that symptom sum-scores obfuscate relevant differences between depressed patients and that substantial rewards will come from close attention to individual depression symptoms.

Trial registration: ClinicalTrials.gov NCT00021528.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Relative importance coefficients of depressive…
Figure 1. Relative importance coefficients of depressive symptoms on overall impairment.
Relative importance coefficients of depressive symptoms on overall impairment, including bootstrapped confidence intervals. Each value represents the unique shared variance between a symptom and impairment, controlling for age and sex. Estimates are adjusted to sum to 100%.
Figure 2. Associations between depressive symptoms and…
Figure 2. Associations between depressive symptoms and impairment domains.
The arrows represent standardized regression coefficients of the 14 QIDS-16 depression symptoms (s1–s14) on the five WSAS impairment domains (D1–D5). Thickness of arrows indicates strength of regression weights.

References

    1. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association.
    1. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, et al. (2003) The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA: the journal of the American Medical Association 289: 3095–3105 10.1001/jama.289.23.3095
    1. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K (1995) Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Archives of general psychiatry 52: 11–19 10.1001/archpsyc.1995.03950130011002
    1. Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine 3: e442 10.1371/journal.pmed.0030442
    1. Murray CJL, Lopez A (1996) Global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge MA: Harvard School of Public Health.
    1. Hirschfeld RM, Dunner DL, Keitner G, Klein DN, Koran LM, et al. (2002) Does psychosocial functioning improve independent of depressive symptoms? A comparison of nefazodone, psychotherapy, and their combination. Biological psychiatry 51: 123–133.
    1. Judd LL, Paulus MP, Wells KB, Rapaport MH (1996) Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. The American journal of psychiatry 153: 1411–1417.
    1. McKnight PE, Kashdan TB (2009) The importance of functional impairment to mental health outcomes: a case for reassessing our goals in depression treatment research. Clinical psychology review 29: 243–259 10.1016/j.cpr.2009.01.005
    1. Ostergaard SD, Jensen SOW, Bech P (2011) The heterogeneity of the depressive syndrome: when numbers get serious. Acta psychiatrica Scandinavica 124: 495–496 10.1111/j.1600-0447.2011.01744.x
    1. Katschnig H, Pakesch G, Egger-Zeidner E (1986) Life stress and depressive subtypes: A review of present diagnostic criteria and recent research results. In: Katschnig H, editor. Life events and psychiatric disorders: Controversial issues.Cambridge MA: Cambridge University Press.
    1. Lichtenberg P, Belmaker RH (2010) Subtyping major depressive disorder. Psychotherapy and psychosomatics 79: 131–135 10.1159/000286957
    1. Baumeister H, Parker JD (2012) Meta-review of depressive subtyping models. Journal of affective disorders 139: 126–140 10.1016/j.jad.2011.07.015
    1. Coryell W, Winokur G, Shea T, Maser JD, Endicott J, et al. (1994) The long-term stability of depressive subtypes. The American journal of psychiatry 151: 199–204.
    1. Oquendo MA, Barrera A, Ellis SP, Li S, Burke AK, et al. (2004) Instability of symptoms in recurrent major depression: a prospective study. The American journal of psychiatry 161: 255–261 10.1176/appi.ajp.161.2.255
    1. Lux V, Kendler KS (2010) Deconstructing major depression: a validation study of the DSM-IV symptomatic criteria. Psychological medicine 40: 1679–1690 10.1017/S0033291709992157
    1. Bollen KA (1989) Structural Equations with Latent Variables. New York: Wiley.
    1. Schmittmann VD, Cramer AOJ, Waldorp LJ, Epskamp S, Kievit RA, et al. (2013) Deconstructing the construct: A network perspective on psychological phenomena. New Ideas in Psychology 31: 43–53 10.1016/j.newideapsych.2011.02.007
    1. Hasler G, Drevets WC, Manji HK, Charney DS (2004) Discovering endophenotypes for major depression. Neuropsychopharmacology 29: 1765–1781 10.1038/sj.npp.1300506
    1. Cramer AOJ, Waldorp LJ, van der Maas HLJ, Borsboom D (2010) Comorbidity: a network perspective. The Behavioral and brain sciences 33: 137–50 discussion 150–93 10.1017/S0140525X09991567
    1. Borsboom D, Cramer AOJ (2013) Network analysis: an integrative approach to the structure of psychopathology. Annual review of clinical psychology 9: 91–121 10.1146/annurev-clinpsy-050212-185608
    1. Fried EI, Nesse RM, Zivin K, Guille C, Sen S (2013) Depression is more than the sum score of its parts: individual DSM symptoms have different risk factors. Psychological medicine: 1–10. doi:10.1017/S0033291713002900.
    1. Keller MC, Nesse RM (2005) Is low mood an adaptation? Evidence for subtypes with symptoms that match precipitants. Journal of affective disorders 86: 27–35 10.1016/j.jad.2004.12.005
    1. Keller MC, Nesse RM (2006) The evolutionary significance of depressive symptoms: different adverse situations lead to different depressive symptom patterns. Journal of personality and social psychology 91: 316–330 10.1037/0022-3514.91.2.316
    1. Keller MC, Neale MC, Kendler KS (2007) Association of different adverse life events with distinct patterns of depressive symptoms. The American journal of psychiatry 164: 1521–9; quiz 1622. doi:10.1176/appi.ajp.2007.06091564.
    1. Cramer AOJ, Borsboom D, Aggen SH, Kendler KS (2011) The pathoplasticity of dysphoric episodes: differential impact of stressful life events on the pattern of depressive symptom inter-correlations. Psychological medicine 42: 957–965 10.1017/S003329171100211X
    1. Jang KL, Livesley WJ, Taylor S, Stein MB, Moon EC (2004) Heritability of individual depressive symptoms. Journal of affective disorders 80: 125–133 10.1016/S0165-0327(03)00108-3
    1. Myung W, Song J, Lim S-W, Won H-H, Kim S, et al. (2012) Genetic association study of individual symptoms in depression. Psychiatry research 198(3): 400–406 10.1016/j.psychres.2011.12.037
    1. Kendler KS, Aggen SH, Neale MC (2013) Evidence for Multiple Genetic Factors Underlying DSM-IV Criteria for Major Depression. American Journal of Psychiatry 70(6): 599–607 10.1001/jamapsychiatry.2013.751
    1. Tweed DL (1993) Depression-related impairment: estimating concurrent and lingering effects. Psychological Medicine 23: 373–386 10.1017/S0033291700028476
    1. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Association.
    1. Rush AJ, Fava M, Wisniewski SR, Lavori PW, Trivedi MH, et al. (2004) Sequenced treatment alternatives to relieve depression (STAR*D): rationale and design. Controlled clinical trials 25: 119–142 10.1016/S0197-2456(03)00112-0
    1. Fava M, Rush AJ, Trivedi MH, Nierenberg A, Thase ME, et al. (2003) Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study. The Psychiatric clinics of North America 26: 457–494.
    1. Hamilton M (1960) A rating scale for depression. Journal of neurology, neurosurgery, and psychiatry 23: 56–62.
    1. Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, et al. (2003) The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): A Psychometric Evaluation in Patients with Chronic Major Depression. Biological Psychiatry 54(5): 573–583 10.1016/S0006-3223(03)01866-8
    1. Rush AJ, Bernstein IH, Trivedi MH, Carmody TJ, Wisniewski S, et al. (2006) An Evaluation of the Quick Inventory of Depressive Symptomatology and the Hamilton Rating Scale for Depression: A Sequenced Treatment Alternatives to Relieve Depression Trial Report. Biological psychiatry 59: 493–501 10.1016/j.biopsych.2005.08.022
    1. Marks IM (1986) Behavioural Psychotherapy. Bristol: John Wright.
    1. Mundt JC, Marks IM, Shear MK, Greist JH (2002) The Work and Social Adjustment Scale: a simple measure of impairment in functioning. The British Journal of Psychiatry 180: 461–464 10.1192/bjp.180.5.461
    1. Heiberger RM, Holland B (2004) Statistical Analysis and Data Display: An Intermediate Course with Examples in S-PLUS, R, and SAS. Springer.
    1. Grömping U (2006) Relative Importance for Linear Regression in R: The Package relaimpo. Journal of Statistical Software 17: 1–27.
    1. Johnson JW, Lebreton JM (2004) History and Use of Relative Importance Indices in Organizational Research. Organizational Research Methods 7: 238–257 10.1177/1094428104266510
    1. Kruskal W, Majors R (1989) Concepts of Relative Importance in Recent Scientific Literature. The American Statistician 43: 2–6.
    1. Grömping U (2007) Estimators of Relative Importance in Linear Regression Based on Variance Decomposition. The American Statistician 61: 139–147 10.1198/000313007X188252
    1. Muthén BO, Muthén L (2012) Mplus User's Guide, seventh edition. Los Angeles: Muthén & Muthén.
    1. R Development Core Team (2008) R: A language and environment for statistical computing.
    1. Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, et al. (2013) DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses. The American journal of psychiatry 170(1): 59–70 10.1176/appi.ajp.2012.12070999
    1. Pigott HE, Leventhal AM, Alter GS, Boren JJ (2010) Efficacy and effectiveness of antidepressants: current status of research. Psychotherapy and psychosomatics 79: 267–279 10.1159/000318293
    1. Fitzgerald PB, Laird AR, Maller J, Daskalakis ZJ (2008) A meta-analytic study of changes in brain activation in depression. Human brain mapping 29: 683–695 10.1002/hbm.20426
    1. Tansey KE, Guipponi M, Perroud N, Bondolfi G, Domenici E, et al. (2012) Genetic predictors of response to serotonergic and noradrenergic antidepressants in major depressive disorder: a genome-wide analysis of individual-level data and a meta-analysis. PLoS medicine 9: e1001326 10.1371/journal.pmed.1001326
    1. Hek K, Demirkan A, Lahti J, Terracciano A (2013) A Genome-Wide Association Study of Depressive Symptoms. Biological psychiatry 73(7): 667–678 10.1016/j.biopsych.2012.09.033
    1. Dew MA, Reynolds CF, Houck PR, Hall M, Buysse DJ, et al. (1997) Temporal profiles of the course of depression during treatment. Predictors of pathways toward recovery in the elderly. Archives of general psychiatry 54: 1016–1024.
    1. Pigeon WR, Hegel M, Unützer J, Fan M-Y, Sateia MJ, et al. (2008) Is insomnia a perpetuating factor for late-life depression in the IMPACT cohort? Sleep 31: 481–488.
    1. Lichstein K, Wilson N, Johnson C (2000) Psychological treatment of secondary insomnia. Psychology and aging 15: 232–240 10.1037//0882-7974.I5.2.232
    1. Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski E (2002) Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychology and Aging 17: 288–298 10.1037//0882-7974.17.2.288
    1. Zimmerman M, McGlinchey JB, Young D, Chelminski I (2006) Diagnosing major depressive disorder III: can some symptoms be eliminated from the diagnostic criteria? The Journal of nervous and mental disease 194: 313–317 10.1097/01.nmd.0000217806.16329.ff
    1. Judd LL, Schettler PJ, Coryell W, Akiskal HS, Fiedorowicz JG (2013) Overt Irritability/Anger in Unipolar Major Depressive Episodes: Past and Current Characteristics and Implications for Long-term Course. JAMA psychiatry 92093. doi:10.1001/jamapsychiatry.2013.1957.
    1. Fava M, Rush AJ, Alpert JE, Balasubramani GK, Wisniewski SR, et al. (2008) Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report. The American journal of psychiatry 165: 342–351 10.1176/appi.ajp.2007.06111868

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