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  OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA) Volume 12, Number 2June 2013   W  orld P sychiatry  ISSN 1723-8617 IMPACT FACTOR: 6.233 EDITORIAL “Clinical judgment” and the DSM-5 diagnosis 89of major depressionM. M AJ SPECIAL ARTICLES The DSM-5: classification and criteria changes92D.A. R EGIER , E.A. K  UHL , D.J. K  UPFER Future perspectives on the treatment of cognitive99deficits and negative symptoms in schizophreniaD.C. G OFF PERSPECTIVES Cognitive and social factors influencing clinical108judgment in psychiatric practiceH.N. G ARB The past, present and future of psychiatric 111diagnosisA. F RANCES Beyond DSM and ICD: introducing “precision113diagnosis” for psychiatry using momentaryassessment technology J. VAN O S , P. D ELESPAUL , J. W  IGMAN , I. M YIN -G ERMEYS , M. W  ICHERS FORUM - PEDIATRIC PSYCHOPHARMACOLOGY: TOO MUCH OR TOO LITTLE?  Pediatric psychopharmacology: too much or118too little? J.L. R APOPORT Commentaries  Pediatric psychopharmacology: too much124 and  too littleE. T AYLOR  What’s next for developmental psychiatry?125 J.F. L ECKMAN Prescribing of psychotropic medications 127to children and adolescents: quo vadis ?C.U. C ORRELL , T. G ERHARD , M. O LFSON Child neuropsychopharmacology: good news. . . 128the glass is half fullC. A RANGO From too much and too little towards stratified130psychiatry and pathophysiologyF.X. C ASTELLANOS A European perspective on paedo-psychiatric131pharmacoepidemiologyH.-C. S TEINHAUSEN Do we face the same dilemma on pediatric132psychopharmacology in low and middleincome countries?L.A. R OHDE Child psychopharmacology: how much have 133 we progressed?S. G ROVER , N. K  ATE Psychopharmacological treatments in 135children and adolescents. Adequate use or abuse?H. R EMSCHMIDT RESEARCH REPORTS The efficacy of psychotherapy and 137pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisonsP. C UIJPERS , M. S IJBRANDIJ , S.L. K  OOLE , G. A NDERSSON , A.T. B EEKMANETAL Early childhood sexual abuse increases suicidal 149intent  J. L OPEZ -C ASTROMAN , N. M ELHEM , B. B IRMAHER , L. G REENHILL , D. K  OLKOETAL Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions 155G. G ERLINGER , M. H AUSER , M. D E H ERT , K. L ACLUYSE , M. W  AMPERSETAL Priorities for mental health research in Europe: 165a survey among national stakeholders’ associations within the ROAMER projectA. F IORILLO , M. L UCIANO , V. D EL V ECCHIO , G. S AMPOGNA , C. O BRADORS -T ARRAGO ´ ETAL LETTERS TO THE EDITOR 171 WPA NEWS The International Study on Career Choice in181Psychiatry: a preliminary reportD. B HUGRA , ON B EHALFOFTHE S TEERING G ROUP (K. F AROOQ , G. L YDALL , A. M ALIKAND R. H OWARD ) WPA educational activities181E. B ELFORT  WPA scientific meetings182T. O KASHA  WPA contribution to the development of the 183chapter on mental disorders of the ICD-11: an updateU. V OLPE  The World Psychiatric Association (WPA) The WPA is an association of national psychiatric societiesaimed to increase knowledge and skills necessary for work inthe field of mental health and the care for the mentally ill. Itsmember societies are presently 135, spanning 117 differentcountries and representing more than 200,000 psychiatrists.The WPA organizesthe World Congress of Psychiatryevery three years. It also organizes international and regionalcongresses and meetings, and thematic conferences. It has 66scientific sections, aimed to disseminate information and pro-mote collaborative work in specific domains of psychiatry. Ithas produced several educational programmes and series of books. It has developed ethical guidelines for psychiatricpractice, including the Madrid Declaration (1996).Further information on the WPA can be found on the web-site WPA Executive Committee President – P. Ruiz (USA)President-Elect – D. Bhugra (UK)Secretary General – L. Küey (Turkey) Secretary for Finances – T. Akiyama (Japan)Secretary for Meetings – T. Okasha (Egypt)Secretary for Education – E. Belfort (Venezuela)Secretary for Publications – M. Riba (USA)Secretary for Sections – A. Javed (UK) WPA Secretariat Geneva University Psychiatric Hospital, 2 Chemin du PetitBel-Air, 1225 Chêne-Bourg, Geneva, Switzerland. Phone:+41223055737; Fax: +41223055735; E-mail: World Psychiatry World Psychiatry is the official journal of the WorldPsychiatric Association. It is published in three issues per yearand is sent free of charge to psychiatrists whose names andaddresses are provided by WPA member societies and sec-tions.Research Reports containing unpublished data are wel-come for submission to the journal. They should be subdividedinto four sections (Introduction, Methods, Results, Discussion).References should be numbered consecutively in the text andlisted at the end according to the following style: 1. Bathe KJ, Wilson EL. Solution methods for eigenvalueproblems in structural mechanics. Int J Num Math Engng1973;6:213-26. 2. McRae TW. The impact of computers on accounting.London: Wiley, 1964. 3. Fraeijs de Veubeke B. Displacement and equilibrium modelsin the finite element method. In: Zienkiewicz OC, HollisterGS (eds). Stress analysis. London: Wiley, 1965:145-97.All submissions should be sent to the office of the Editor. Editor – M. Maj (Italy). Associate Editor – P. Ruiz (USA). Editorial Board – D. Bhugra (UK), L. Küey (Turkey), T.Akiyama (Japan), T. Okasha (Egypt), E. Belfort (Venezuela), M.Riba (USA), A. Javed (UK). Advisory Board – H.S. Akiskal (USA), R.D. Alarcón (USA), J.A. Costa e Silva (Brazil), J. Cox (UK), H. Herrman (Austra-lia), M. Jorge (Brazil), H. Katschnig (Austria), F. Lieh-Mak(Hong Kong-China), F. Lolas (Chile), J.J. López-Ibor (Spain), J.E. Mezzich (USA), D. Moussaoui (Morocco), P. Munk- Jorgensen (Denmark), F. Njenga (Kenya), A. Okasha (Egypt), J. Parnas (Denmark), V. Patel (India), N. Sartorius (Switz-erland), C. Stefanis (Greece), M. Tansella (Italy), A. Tasman(USA), S. Tyano (Israel), J. Zohar (Israel).Office of the Editor – Department of Psychiatry, University of Naples SUN, Largo Madonna delle Grazie, 80138 Naples, Italy. Phone: +390815666502; Fax: +390815666523; E-mail: World Psychiatry  is indexed in PubMed, Current Contents/Clinical Medicine, Current Contents/Socialand Behavioral Sciences, Science Citation Index, and EMBASE.All back issues of World P    sychiatry  can be downloaded free of charge from the PubMed system(  EDITORIAL “Clinical judgment” and the DSM-5diagnosis of major depression M ARIO  M AJ Department of Psychiatry, University of Naples SUN, Naples, Italy The introduction of “explicit diagnostic criteria” in psy-chiatry – initially only for research purposes and sub-sequently, with the DSM-III, also for use in ordinaryclinical practice – had a main objective: to overcome the“vagueness and subjectivity inherent in the traditional diag-nostic process” (1, p. 85), and in particular the variability inthe inclusion and exclusion criteria used by clinicianswhen summarizing patient data into psychiatric diagnoses(“criterion variance”), which was regarded as the mainsource of the poor reliability of those diagnoses (2).From the very beginning, however, there was some am- bivalence in mainstream American psychiatry about theconstraints that the use of fixed diagnostic criteria wouldpose to the exercise of clinical judgment. Spitzer et al (3),in an early paper reporting on the development of theDSM-III, acknowledged that “the use of specified criteriadoes not, of course, exclude clinical judgment”. Theyqualified this statement by adding that “the proper use of such criteria requires a considerable amount of clinical ex-perience and knowledge of psychopathology”, thus givingthe impression that clinical judgment was regarded as justinstrumental to the proper use of the explicit diagnosticcriteria. However, they also stated that “in any case, thecriteria that may be listed in DSM-III would be ‘suggested’only, and any clinician would be free to use them orignore them as he saw fit” (3, p. 1191).Spitzer et al’s prediction that operational criteria wouldappear in the DSM-III “under the heading ‘suggestedcriteria’” (3, p. 1190) did not come true. However, theDSM-III introduction emphasized that those criteria wereprovided as “guides for making each diagnosis”, in ordernot to leave the clinician “on his or her own in definingthe content and boundaries of the diagnostic categories”(4, p. 8). As Spitzer commented later on (5, p. 403), theDSM-III diagnostic criteria were intended “as guides, notas rigid rules”.This is further clarified in the DSM-IV introduction,where it is stated that explicit diagnostic criteria “aremeant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbookfashion” (6, p. xxiii). The example is provided of a diagno-sis which is made through the exercise of clinical judg-ment although the clinical presentation falls just short of meeting the full criteria. So, clinical judgment does notonly inform the use of explicit criteria; it may also lead thepsychiatrist to “force”, to a limited extent, those criteria if he finds this appropriate.The text of the DSM-IV also mentions clinical judgmentwhen it comes to the assessment of clinical significance,required for the diagnosis of several disorders: “assessingwhether this criterion is met, especially in terms of rolefunction, is an inherently difficult clinical judgment” (6,p. 7). The chair of the DSM-IV Task Force, A. Frances,emphasized that “this appeal to clinical judgment is areminder to evaluate not only the presence of the symptomsin the criteria set, but also whether they are severe enoughto constitute mental disorder”, though he acknowledgedthat an evaluation of clinical significance by using clinical judgment “contains the seeds of tautology” (7, p. 119).As pointed out by Spitzer and Wakefield (8), there is noreference in the DSM-IV to the exercise of clinical judg-ment in the differential diagnosis between depression andthe “normal” response to a significant loss. The text is veryclear in stating that the diagnosis of major depressionshould be made whenever the severity, duration and dis-tress/impairment criteria for that condition are met, even if thedepressivestateistheunderstandableresponsetoapsy-chosocialstressor(6,p.326).Theonlyexceptionisbereave-ment: if the depressive state follows the loss of a loved one,the diagnosis of major depression should not be made evenif the diagnostic criteria are fulfilled, unless some furtherelements are present (the symptoms persist for longer than2 months, or are characterized by marked functionalimpairment,morbidpreoccupationwithworthlessness,sui-cidal ideation, psychotic symptoms, or psychomotor retar-dation). So, in any case – whether depression is related to bereavement or not – explicit criteria are provided, and nomentionismadeoftheuseofclinicaljudgment.Actually,whenJ.Wakefieldproposedtoexclude“normal”responses to psychosocial stressors from the diagnosis of major depression, leaving to the clinician the decision onwhether the depressive response was proportional or notto the preceding stressor (8,9), the rebuttal by K. Kendler,a protagonist of mainstream American psychiatry (and of the process of development of the DSM-5), was straight-forward: this return to “what at basis will be the subjectivecriteria proposed by Jaspers in his old idea of ‘under-standability’” would represent “more a step backwardthan forward for our field” (10, pp. 149–150).This “step backward” has to some extent been made inthe DSM-5 (11). A note included in the DSM-5 criteriafor major depressive disorder states that “responsesto a significant loss (e.g., bereavement, financial ruin,losses from a natural disaster, a serious medical illness or 89  disability)mayincludethefeelingsofintensesadness,rumi-nation about the loss, insomnia, poor appetite and weightloss noted in Criterion A, which may resemble a depressiveepisode”, and that the decision about whether a majordepressive episode (or just a normal response to the loss) ispresent“inevitablyrequirestheexerciseofclinicaljudgment based on the individual’s history and the cultural norms fortheexpressionofdistressinthecontextofloss”(11,p.161).This solution adopted by the DSM-5 Task Force should be seen within the context of the debate, taking place in both the scientific and the lay press (e.g., 12,13), about theelimination of the bereavement exclusion in the diagnosisof major depression. This development, announced on theDSM-5 website very early in the process (14), raised con-cerns about a possible trivialization of the concept of depression and consequently of mental disorder, since adepressive response to the death of a significant loved oneis normative in several cultures (e.g., 15). It was alsopointed out that, contrary to what reported on the DSM-5website, the ICD-10 does exclude “bereavement reactionsappropriate to the culture of the individual concerned”from the diagnosis of depression, and this exclusion islikely to be kept in the ICD-11 (16). The introduction of anote emphasizing the role of clinical judgment in thedifferential diagnosis between depression and a “normal”response to a significant loss has thus been regarded as away to mitigate the consequences of the elimination of the bereavement exclusion and to facilitate the harmonization between the DSM-5 and the ICD-11.As a matter of fact, this re-emphasis on clinical judgmentislikelytobewelcome bymanyclinicians worldwide,beingperceived as a remarkable acknowledgement of the limita-tionsoftheoperationalapproach,whicharguably“doesnotreflect the complex thinking that underlies decisions inpsychiatric practice” (17, p. 182). Indeed, in a large inter-national WPA-World Health Organization (WHO) surveyof practicing psychiatrists (18), more than two-thirds of respondents expressed the opinion that, for maximum util-ity in clinical settings, diagnostic manuals should containflexible guidance allowing for clinical judgment rather thanfixeddiagnosticcriteria.So, the DSM-5 note does not come out of the blue, andcan be seen as a further step in the articulated (and some-what ambivalent) approach of mainstream American psy-chiatry to the issue of clinical judgment.However, the note leaves several questions open. Is itcorrect to assume that clinical judgment will have priorityover operational criteria in determining whether theresponse to a significant loss is normal or pathological? Inother terms, will it be possible not to make the diagnosis of major depression – in cases in which the severity, durationand distress/impairment criteria are completely fulfilled – because the depressive state appears, on the basis of whatthe clinician knows of the individual and his/her cultural background, a “normal” response to the loss? Or should weassume that the diagnosis of major depression will have to be made whenever the full criteria are met, and the exerciseof clinical judgment be limited to doubtful or subthresholdcases? This is presently unclear, and this uncertainty islikelytointroduce an“interpretation variance” inthe appli-cation of the DSM-5 criteria for major depression which,added to the variance certainly produced by the exercise of clinical judgment, may substantially reduce the reliabilityof that diagnosis, already found to be “questionable”(kappa 5 0.20-0.35) in DSM-5 field trials (19) when usingan early version of the criteria not including the note.Furthermore, what will become of epidemiologicalresearch using lay interviewers, who by definition areunable to exercise clinical judgment when exploringwhether a person has (or has had in the past) a period of “normal” sadness or a depressive episode? Can we affordusing two different definitions of major depression, onefor clinical purposes and the other for community epide-miological studies? Should we assume that currentlyavailable epidemiological data on the prevalence of majordepression are biased, due to the fact that clinical judg-ment was not exercised in the diagnosis?On the other hand, the emphasis on the role of clinical judgment in the distinction between depression and“normal” responses to psychosocial stressors is likely toincrease the burden of responsibility on clinicians in somecontexts (e.g., community settings in areas heavily struck by the economic crisis) in which borderline cases are fre-quent and traditional differential diagnostic skills have become insufficient (see 20). The second note introducedin the DSM-5 definition of major depression – describingdifferential features between “normal” grief and depression– may be viewed as an attempt to support professionals inthe exercise of clinical judgment. No similar guidance,however, is provided for the distinction between a depres-sive episode and “normal responses” to other psychosocialstressors, so that the clinician may be left again “on his orher own” (4, p. 8), exposed to several biases (see 21), whenmaking a crucial and often delicate differential diagnosis.Specifyingthose aspectsofmentaldisorderwhich “areatpresent left to the uncertainties of clinical judgment” rep-resentsachallengeforpsychiatry,since“relianceuponclini-cal skills implies that some aspects of psychiatric disorderare impossible at the moment to specify in an explicit man-ner” (22, p. 978). The term “clinimetrics” (23) has indeed been introduced to indicate “a domain concerned with themeasurementofclinicalissuesthat donot find room incus-tomary clinical taxonomy” (17, p. 177). One could arguethat the DSM-5 re-emphasis on clinical judgment may rep-resent a stimulus to consider and develop this research line,whichmaybeparticularlyrelevantinthecaseofdepression. References 1. Blashfield RK. The classification of psychopathology. New York:Plenum, 1984. 90  WorldPsychiatry12:2- June2013
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