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The DSM-IV definition of severity of major depression: inter-relationship and validity

  • V. Lux (a1), S. H. Aggen (a2) (a3) and K. S. Kendler (a2) (a3) (a4)
  • DOI:
  • Published online: 08 January 2010

Severity is an important characteristic of major depression (MD) and an ‘episode specifier’ in DSM-IV classifying depressive episodes as ‘mild’, ‘moderate’ or ‘severe’. These severity subtypes rely on three different measures of severity: number of criteria symptoms, severity of the symptoms and degree of functional disability. No prior empirical study has evaluated the coherence and validity of the DSM-IV definition of severity of MD.


In a sample of 1015 (518 males, 497 females) Caucasian twins from a population-based registry who met criteria for MD in the year prior to interview, factor analysis and logistic regression were conducted to examine the inter-relationships of the three severity measures and their associations with a wide range of potential validators including demographic factors, risk for future episodes, risk of MD in the co-twin, characteristics of the depressive episode, the pattern of co-morbidity, and personality traits.


Correlations between the three severity measures were significant but moderate. Factor analysis indicated the existence of a general severity factor, but the factor was not highly coherent. The three severity measures showed differential predictive ability for most of the validators.


Severity of MD as defined by the DSM-IV is a multifaceted and heterogeneous construct. The three proposed severity measures reflect partly overlapping but partly independent domains with differential validity as assessed by a wide range of clinical characteristics. Clinicians should probably use a combination of severity measures as proposed in DSM-IV rather than privileging one.

Corresponding author
*Address for correspondence: Dr K. S. Kendler, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Box 980126, Richmond, VA23298-0126, USA. (Email:
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GS Alexopoulos , ML Bruce , J Hull , JA Sirey , T Kakuma (1999). Clinical determinants of suicidal ideation and behavior in geriatric depression. Archives of General Psychiatry 56, 10481053.

J Angst , R Amrein , M Stabl (1995). Moclobemide and tricyclic antidepressants in severe depression: meta-analysis and prospective studies. Journal of Clinical Psychopharmacology 15, S16S23.

AT Beck , RA Steer , R Ball , W Ranieri (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment 67, 588597.

AT Beck , CH Ward , M Mendelson , J Mock , J Erbaugh (1961). An inventory for measuring depression. Archives of General Psychiatry 4, 561571.

PM Bentler (1990). Comparative fit indexes in structural models. Psychological Bulletin 107, 238246.

MB Blom , P Spinhoven , T Hoffman , K Jonker , E Hoencamp , PM Haffmans , R van Dyke (2007). Severity and duration of depression, not personality factors, predict short term outcome in the treatment of major depression. Journal of Affective Disorders 104, 119126.

TJ Carmody , AJ Rush , I Bernstein , D Warden , S Brannan , D Burnham , A Woo , MH Trivedi (2006). The Montgomery Asberg and the Hamilton ratings of depression: a comparison of measures. European Neuropsychopharmacology 16, 601611.

SBG Eysenck , HJ Eysenck , P Barrett (1985). A revised version of the psychoticism scale. Personality and Individual Differences 6, 2129.

KO Fagerström (1978). Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addictive Behaviors 3, 235241.

C Faravelli , P Servi , JA Arends , WK Strik (1996). Number of symptoms, quantification, and qualification of depression. Comprehensive Psychiatry 37, 307315.

DL Foley , MC Neale , C Gardner , A Pickles , KS Kendler (2003). Major depression and associated impairment: same or different genetic and environmental risk factors? American Journal of Psychiatry 160, 21282133.

RD Gibbons , DC Clark , DJ Kupfer (1993). Exactly what does the Hamilton Depression Rating Scale measure? Journal of Psychiatric Research 27, 259273.

M Hamilton (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 5662.

MA Hamilton (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 6, 278296.

T Hiroe , M Kojima , I Yamamoto , S Nojima , Y Kinoshita , N Hashimoto , N Watanabe , T Maeda , TA Furukawa (2005). Gradations of clinical severity and sensitivity to change assessed with the Beck Depression Inventory-II in Japanese patients with depression. Psychiatric Research 135, 229235.

RM Hirschfeld (1999). Efficacy of SSRIs and newer antidepressants in severe depression: comparison with TCAs. Journal of Clinical Psychiatry 60, 326335.

FY Huang , H Chung , K Kroenke , RL Spitzer (2006). Racial and ethnic differences in the relationship between depression severity and functional status. Psychiatric Services 57, 498503.

RW Iannuzzo , J Jaeger , JF Goldberg , V Kafantaris , ME Sublette (2006). Development and reliability of the HAM-D/MADRS interview: an integrated depression symptom rating scale. Psychiatric Research 145, 2137.

S Kasper , M Zivkov , KC Roes , AG Pols (1997). Pharmacological treatment of severely depressed patients: a meta-analysis comparing efficacy of mirtazapine and amitriptyline. European Neuropsychopharmacology 7, 115124.

KS Kendler , CA Prescott (1999). A population-based twin study of lifetime major depression in men and women. Archives of General Psychiatry 56, 3944.

N Kennedy , R Abbott , ES Paykel (2004). Longitudinal syndromal and sub-syndromal symptoms after severe depression: 10-year follow-up study. British Journal of Psychiatry 184, 330336.

T Kitamura , Y Nakagawa , S Machizawa (1993). Grading depression severity by symptom scores: is it a valid method for subclassifying depressive disorders? Comprehensive Psychiatry 34, 280283.

K Kroenke , RL Spitzer , JBW Williams (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16, 606613.

RW Licht , S Qvitzau , P Allerup , P Bech (2005). Validation of the Bech–Rafaelsen Melancholia Scale and the Hamilton Depression Scale in patients with major depression; is the total score a valid measure of illness severity? Acta Psychiatrica Scandinavica 111, 144149.

TK Melartin , HJ Rytsala , US Leskela , PS Lestela-Mielonen , TP Sokero , ET Isometsa (2004). Severity and comorbidity predict episode duration and recurrence of DSM-IV major depressive disorder. Journal of Clinical Psychiatry 65, 810819.

R Mojtabai (2001). Impairment in major depression: implications for diagnosis. Comprehensive Psychiatry 42, 206212.

SA Montgomery , M Äsberg (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry 134, 382389.

BF Rodriguez , SE Bruce , ME Pagano , MB Keller (2005). Relationships among psychosocial functioning, diagnostic comorbidity, and the recurrence of generalized anxiety disorder, panic disorder, and major depression. Journal of Anxiety Disorders 19, 752766.

PP Roy-Byrne , P Stang , HU Wittchen , B Ustun , EE Walters , RC Kessler (2000). Lifetime panic-depression comorbidity in the National Comorbidity Survey. Association with symptoms, impairment, course and help-seeking. British Journal of Psychiatry 176, 229235.

LV Rubenstein , NR Rayburn , EB Keeler , DE Ford , KM Rost , CD Sherbourne (2007). Predicting outcomes of primary care patients with major depression: development of a depression prognosis index. Psychiatric Services 58, 10491056.

DA Santor , JC Coyne (2001). Examining symptom expression as a function of symptom severity: item performance on the Hamilton Rating Scale for Depression. Psychological Assessment 13, 127139.

S Scheibe , C Preuschhof , C Cristi , RM Bagby (2003). Are there gender differences in major depression and its response to antidepressants? Journal of Affective Disorders 75, 223235.

DV Sheehan , K Harnett-Sheehan , BA Raj (1996). The measurement of disability. International Clinical Psychopharmacology 11 (Suppl. 3), 8995.

JS Strauss , WT Carpenter Jr. (1978). The prognosis of schizophrenia: rationale for a multidimensional concept. Schizophrenia Bulletin 4, 5667.

M Zimmerman , CJ Ruggero , I Chelminski , D Young , MA Posternak , M Friedman , D Boerescu , N Attiullah (2006). Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life. Journal of Clinical Psychiatry 67, 15361541.

S Zisook , AJ Rush , A Albala , J Alpert , GK Balasubramani , M Fava , M Husain , H Sackeim , M Trivedi , S Wisniewski (2004). Factors that differentiate early vs. later onset of major depression disorder. Psychiatric Research 129, 127140.

WW Zung (1965). A Self-Rating Depression Scale. Archives of General Psychiatry 12, 6370.

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