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Eiko Fried University of Leuven

What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis. Eiko Fried University of Leuven. Network Analysis Approach to Psychopathology and Comorbidity ABCT, November 14, 2015. Diagnosis of Major Depression (MD).

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Eiko Fried University of Leuven

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  1. What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis Eiko Fried University of Leuven Network Analysis Approach to Psychopathology and Comorbidity ABCT, November 14, 2015

  2. Diagnosis of Major Depression (MD) • Reliablediagnosisis essential tostudyandtreat mental disorders • Reliablediagnosisof MD isdifficult: biomarkershavevery limited explanatory power, and MD was amongthe least reliablediagnosis in DSM-5 fieldtrials (kappa = 0.28) • Currentstate: wemeasuredepressionsymptomstoindicatethepresenceof MD. Weaddthemto a sum-score, andsupposethisadequatelyrepresentsdepressionseverity

  3. Common causemodel s1 s2 M s3 s4 s5

  4. Common causemodel s1 Red eyes s2 M s3 s4 s5

  5. Common causemodel s1 Red eyes Fever s2 M s3 s4 s5

  6. Common causemodel s1 Red eyes Fever s2 M Runny nose s3 Koplik's spots s4 s5 Cough

  7. Common causemodel s1 Red eyes Fever s2 Runny nose s3 Koplik's spots s4 s5 Cough

  8. Common causemodel • Thereis a specificrelationshipbetweensymptomsof a disorderandthedisorderitself (commoncausemodel) s1 Red eyes Fever s2 M Runny nose s3 Koplik's spots s4 s5 Cough

  9. Common causemodel • Thereis a specificrelationshipbetweensymptomsof a disorderandthedisorderitself (commoncausemodel) • Symptoms aresomewhatinterchangeable s1 Red eyes Fever s2 M Runny nose s3 Koplik's spots s4 s5 Cough

  10. Common causemodel • Thereis a specificrelationshipbetweensymptomsof a disorderandthedisorderitself (commoncausemodel) • Symptoms aresomewhatinterchangeable s1 Red eyes Fever s2 M Runny nose s3 Koplik's spots s4 s5 Cough

  11. Common causemodel • Thereis a specificrelationshipbetweensymptomsof a disorderandthedisorderitself (commoncausemodel) • Symptoms aresomewhatinterchangeable • Symptoms areunrelatedbeyondtheircommoncause s1 Red eyes Red eyes Fever Fever s2 M Runny nose Runny nose s3 Koplik's spots Koplik's spots s4 s5 Cough

  12. Common causemodel • Thereis a specificrelationshipbetweensymptomsof a disorderandthedisorderitself (commoncausemodel) • Symptoms aresomewhatinterchangeable • Symptoms areunrelatedbeyondtheircommoncause • A 'good' symptomisonethatindicatesthe latent diseasewell s1 Red eyes Fever s2 M Runny nose s3 Koplik's spots s4 s5 Cough

  13. Psychiatry • Common causemodelubiquitous in psychiatry s1 s2 D s3 s4 s5

  14. Measuring Major Depression • Common causemodel s1 s2 MD Insomnia s3 Fatigue s4 Concentration problems s5 Psychomotor problems Weight loss

  15. Measuring Major Depression • Common causemodel • Wemeasuresymptomstoindicatethedisorder • Add symptomsto total-score toindicateseverity s1 s2 MD Insomnia s3 Fatigue s4 Concentration problems s5 Psychomotor problems Weight loss

  16. Measuring Major Depression • Common causemodel • Wemeasuresymptomstoindicatethedisorder • Add symptomsto total-score toindicateseverity • Symptoms roughlyinterchangeable • Wewanttotreatthedisease so symptomsdisappear s1 s2 MD Insomnia s3 Fatigue s4 Concentration problems s5 Psychomotor problems Weight loss

  17. Measuring Major Depression • Common causemodel(overlysimplistic) • Wemeasuresymptomstoindicatethedisorder • Add symptomsto total-score toindicateseverity • Symptoms roughlyinterchangeable • Wewanttotreatthedisease so symptomsdisappear s1 s2 MD Insomnia s3 Fatigue s4 Concentration problems s5 Psychomotor problems Weight loss

  18. Measuring Major Depression • Problem: thereis a dramatic lack ofconsensuswhatdepressionsymptoms(orgooddepressionsymptoms) are. Different depressioninstrumentsmeasurevery different things. s1 s2 MD Insomnia s3 Fatigue s4 Concentration problems s5 Psychomotor problems Weight loss

  19. Whatare 'good' depressionsymptoms? • DSM-5: 9 symptoms • None ofthecommonratingscalesofdepressionmeasure all DSM symptoms; all ofthemmeasure a numberofsymptoms not featured in the DSM • BDI: irritability, pessimism, feelings of being punished, … • HRSD: anxiety, genital symptoms, hypochondriasis, insights into the depressive illness, paralysis, … • CESD: frequent crying, talking less, perceiving others as unfriendly, … • As a result, thereislittleconsistencyacrossdepressionstudiesbecausepatientsareenrolledbased on very different criteria

  20. Measurement of depression • "The measurement of depression of depression is as confused as the basic construct of the state itself."

  21. Network model • Symptoms co-occur due totheircommoncause

  22. Network model • Symptoms co-occurbecausetheycauseeachother Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  23. Network model • Symptoms co-occurbecausetheycauseeachother • Symptoms areroughlyequallyimportantindicators Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  24. Network model • Symptoms co-occurbecausetheycauseeachother • Symptoms aredistinctentitieswith different characteristics Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  25. Network model • Symptoms co-occurbecausetheycauseeachother • Symptoms aredistinctentitieswith different characteristics • Reinforcingfeedbackloops(attractorstate) Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  26. Network model • Importantnewquestionsarise: whatsymptomsaremostcentraltodriving depressive processes? Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  27. Network model • Importantnewquestionsarise: whatsymptomsaremostcentraltodriving depressive processes? Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  28. Network model • Importantnewquestionsarise: whatsymptomsaremostcentraltodriving depressive processes? Concentration problems s5 s2 Fatigue Insomnia s1 s3 Psychomotor problems s4 Weight loss

  29. What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis Journal of Affective Disorders Eiko I. Fried Sacha Epskamp Randolph M. Nesse Francis Tuerlinckx Denny Borsboom

  30. Research questions • Whatisthenetworkstructureofdepression? • DSM symptoms • A large numberofsymptomsaboveandbeyondthe DSM criteria • Whatsymptomsaremostcentral, i.e. mostconnected in thenetwork?

  31. Sample • 3463 depressedoutpatientsfromtheenrollmentstageofthe STAR*D study • Meanage 41 years (SD=13), 63% female • IDS-C: 28-item questionnairethatcovers 15 disaggregated DSM symptomsand 13 common non-DSM symptoms (e.g., anxiety, irritability) • Network estimation • Gaussiangraphicalmodel (specialcaseofthePairwise Markov Random Field): edgesare partial correlationcoefficients • Regularization via least absolute shrinkage and selection operator (lasso); very small edges set exactly to 0, results in a conservative (sparse) network

  32. Network structureof MD • Estimation • Edgesequal partial correlations • Sparsenetwork • Interpretation • Heterogeneousnetwork • Someclustersemerge DOI| 10.1016/j.jad.2015.09.005

  33. Symptom importance DOI| 10.1016/j.jad.2015.09.005

  34. Symptom importance DOI| 10.1016/j.jad.2015.09.005

  35. Full IDS symptomnetwork • Permutation testtoexaminedifferences in centralitybetween DSM and non-DSM symptoms: • Betweenness centrality: p= 0.12 • Closeness centrality: p= 0.64 • Node strength: p= 0.03 (0.08) • Controlling for outliers: • Betweenness centrality: p = 0.28 • Closeness centrality: p = 1 • Node strength: p = 0.13 • DSM symptomsare not morecentralthan non-DSM symptoms DOI| 10.1016/j.jad.2015.09.005

  36. Robustnessanalysis

  37. Conclusions • Core assumptionsofthecommoncausemodel do not seemremotelytenablefordepression • "Depression sum-scoresdon'taddup: whyanalyzingspecificdepressionsymptomsis essential" (Fried & Nesse, 2015) • Centrality measures may provide new insights regarding the clinical significance of specific depression symptoms. These insights likely have major clinical implications and suggest new approaches that may better predict outcomes such as the course of illness, probability of relapse, and treatment response.

  38. Limitations • STAR*D population • Cross-sectional (indegreevsoutdegreecentrality) • Heterogeneityofdepression • Topologicaloverlap

  39. Thank you

  40. Eiko Fried University of Leuven University of Amsterdam eiko-fried.com eiko.fried@gmail.com

  41. Discussion • Robustness: • DSM and non-DSM symptoms do not differ regarding means (W = 121, p = 0.30) or SD (W = 89, p = 0.72) • 10 disaggregated symptoms not more central than the other 18 symptoms (node strength: p = 0.86; betweenness and closeness: p = 1)

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