Judgment towards emotions as a mediator of the relationship between emotional eating and depression symptoms in bariatric surgery candidates.

PURPOSE: Emotional eating is common in bariatric surgery candidates, and often is associated with depression and poorer weight loss outcomes following surgery. However, less is known about other modifiable risk factors that may link depression and emotional eating. The aim of the current study was to examine facets of mindfulness as potential mediators of the relationship between emotional eating and depression severity in bariatric surgery candidates. METHODS: Bariatric surgery candidates (n = 743) were referred by their surgeons for a comprehensive psychiatric pre-surgical evaluation that included self-report questionnaires assessing depression severity, emotional overeating, and facets of mindfulness. Mediation effects were examined for each mindfulness facet based on prior research. RESULTS: Only the nonjudging mindfulness facet significantly mediated the relationship between emotional eating and depression, suggesting that greater emotional eating may be associated with greater depression severity through higher levels of judgement towards thoughts and emotions. A reverse mediation analysis showed that depression severity was not a significant mediator of the relationship between nonjudging and emotional eating. CONCLUSION: Fostering a nonjudgmental stance towards thoughts and feelings may be helpful in improving eating habits that would support greater post-surgical success. Other clinical and research implications are discussed. LEVEL OF EVIDENCE: Level V, descriptive study.

Exploring the Optimal Factor Structure of the Five Facet Mindfulness Questionnaire: Associations Between Mindfulness Facets and Dimensions of Psychopathology.

Recent studies of the Five Facet Mindfulness Questionnaire (FFMQ) and its condensed version (FFMQ-SF) fail to replicate the initially proposed five-factor structure in clinical samples. Failure to adequately understand the dimensionality of common mindfulness measures within clinical samples, therefore, represents an important gap in the current literature. The increasing popularity of mindfulness-based interventions warrants further investigation of differential associations between facets of mindfulness and different forms of psychopathology. We examined (a) the underlying structure of the FFMQ and FFMQ-SF, and (b) associations between FFMQ and FFMQ-SF facets and dimensions of psychopathology (i.e., internalizing and substance use disorders) in two large clinical samples (N = 2,779). Results from bass-ackwards analyses suggested similarly defensible five- and six-factor model solutions in terms of fit. The five-factor model was optimal when factoring in parsimony. Exploratory structural equation modeling revealed that all FFMQ facets with the exception of observe were negatively associated with the internalizing factor. Associations with substance use disorders were more complex. In both samples, five-factor FFMQ and FFMQ-SF models were determined to best represent these data. Whereas deficits in all FFMQ facets with the exception of observe correspond with lower internalizing psychopathology, a more nuanced association was observed with substance use disorders.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study.

BACKGROUND: Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD. METHODS: Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128). RESULTS: Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations. CONCLUSIONS: Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Emotion regulation accounts for associations between mindfulness and depression across and within diagnostic categories.

BACKGROUND: Previous research shows that mindfulness and emotion regulation (ER) are highly related to each other. Preliminary evidence in small clinical populations show that ER may partially account for the relationship between mindfulness and depressive symptoms. The present study aimed to investigate which diagnostic categories were associated with depressive symptoms after controlling for ER in a heterogeneous sample of treatment-seeking patients. METHODS: A large sample of psychiatric outpatients (N = 911) completed the Structured Clinical Interview for DSM-IV (SCID), Five Facet Mindfulness Questionnaire (FFMQ), Difficulties in Emotion Regulation Scale (DERS), and Clinically Useful Depression Outcome Scale (CUDOS). Partial correlations were conducted to evaluate to what degree the relationship between depression scores and facets of mindfulness were accounted for by ER scores. RESULTS: When controlling for baseline mindfulness, the relationship between emotion dysregulation and depression symptoms remained significant for all data points; however, when controlling for baseline emotion dysregulation, the association between mindfulness and depression was not significant in the majority of cases. Nonjudging was most resistant to this result. CONCLUSIONS: Although mindfulness is negatively associated with depressive symptoms, this association may be better accounted for by emotion dysregulation.

Principal Diagnoses in Psychiatric Outpatients With Posttraumatic Stress Disorder: Implications for Screening Recommendations.

In this study, we examined the prevalence of posttraumatic stress disorder (PTSD) in 3800 psychiatric outpatients with different principal diagnoses. For all disorders identified as a principal diagnosis, we compared patients' odds ratios of PTSD to all other patients in the sample. Approximately one-sixth of the sample (n = 663, 17.4%) was diagnosed with PTSD, including 417 patients with current PTSD and 246 with PTSD in partial remission. Patients with principal bipolar disorder and major depressive disorder (MDD) demonstrated higher rates of PTSD compared with those without principal bipolar and MDD. For most psychiatric outpatients with PTSD, the principal diagnosis for which they seek treatment is not PTSD, but rather a mood disorder. This highlights the importance of screening for PTSD, particularly in patients with a principal diagnosis for which the prevalence of PTSD is relatively high, namely, MDD, bipolar disorder, panic disorder, and borderline personality disorder.

Applying the inclusion/exclusion criteria in placebo-controlled studies to a clinical sample: A comparison of medications.

BACKGROUND: We previously compared the inclusion/exclusion criteria in the studies of vortioxetine to other antidepressants and found that they were significantly more restrictive in the vortioxetine studies. In the present study, we tested the hypothesis that the differences in psychiatric inclusion/exclusion criteria used in the studies of some antidepressants resulted in differences in generalizability to clinical samples. METHODS: We applied the inclusion and exclusion criteria used in 161 antidepressant efficacy trials to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation. We compared the percentage of patients that would be excluded in studies of different medications. RESULTS: The percentage of patients that would have been excluded was significantly higher in the vortioxetine studies than other medications. For the 15 medications that were included in at least 5 trials, we computed the mean percentage of patients that would be excluded. The values ranged from 76.0% (for fluoxetine) to 99.1% (for quetiapine). LIMITATIONS: While our calculations were based on the exclusion criteria stated in the published articles, we have no way of knowing how these criteria were actually applied. CONCLUSION: Studies of different medications vary in how representative the samples are of patients in clinical practice. The variability in the inclusion/exclusion criteria used to select samples for antidepressant efficacy trials, and the evidence that studies of different medications vary in their generalizability, makes it more difficult to interpret network analyses comparing the relative efficacy of medications.

Understanding the severity of depression: do nondepressive symptoms influence global ratings of depression severity?

OBJECTIVE: Almost all depression measures have been developed without discussing how to best conceptualize and assess the severity of depression. It is therefore not surprising that measures differ in both how items are rated and item content. The question that we address in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is whether a measure of depression severity should include symptoms that are frequent in depressed patients but are defining features of other disorders (eg, anxiety, irritability). METHODS: Patients were evaluated with a semi-structured interview and severity ratings were made of each symptom of major depressive disorder (MDD) as well as anxiety, irritability, and somatization. Patients were also rated on the Clinical Global Index of severity (CGI). RESULTS: Three of the 5 nondepressive symptoms (psychic anxiety, somatic anxiety, and subjective anger) were significantly correlated with the CGI. The correlation between the sum of all 5 nondepressive symptoms and the CGI was significantly lower than the correlation between the sum of the depressive symptom severity ratings (0.12 vs 0.52, z = 11.0, p < .001). The partial correlation between the CGI and the nondepressive symptom severity ratings (after controlling for the total depressive symptom ratings) was nonsignificant. DISCUSSION: After accounting for the severity of depressive symptoms, the severity of the nondepressive symptoms was not associated with global ratings of depressive severity. These findings raise questions regarding the appropriateness of including ratings of anxiety, irritability, and somatization on a measure that purportedly assesses the severity of depression.

Symptom presence versus symptom intensity in understanding the severity of depression: Implications for documentation in electronic medical records.

BACKGROUND: Data mining efforts have been applied to research data bases to develop statistical models for predicting outcomes. Electronic medical records have the potential to enable efforts to apply statistical techniques to mine large clinical data bases. Of course, such prediction algorithms will only be as good as the data that is available to input. The question that we address in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is how much information might be gained from dimensional ratings of symptom severity over and above that which is accounted for when determining symptom presence. Such results could have implications for how medical record documentation should be established. METHODS: Patients were evaluated with a semi-structured interview, and the presence of each symptom of major depressive disorder (MDD) was recorded. Patients were also rated on the Clinical Global Index of Severity (CGI-S). RESULTS: A multiple regression analysis entering the presence of MDD symptoms as predictors of the CGI had a cumulative R2 of 0.26. A multiple regression analysis entering all symptom severity ratings as predictors of the CGI had a cumulative R2 of 0.40. LIMITATIONS: The study was based on patients presenting for outpatient treatment to a single clinical practice. Symptoms that are not diagnostic criteria for MDD were not examined. DISCUSSION: Research institutions interested in using data mining statistical approaches of electronic medical records should consider having the clinicians rate whether symptoms are mild, moderate or severe and not just whether they are present or absent.

Have Treatment Studies of Depression Become Even Less Generalizable? Applying the Inclusion and Exclusion Criteria in Placebo-Controlled Antidepressant Efficacy Trials Published over 20 Years to a Clinical Sample.

BACKGROUND: Antidepressants are amongst the most frequently prescribed medications. More than a decade ago, our clinical research group applied a prototypic set of inclusion/exclusion criteria used in an antidepressant efficacy trial (AET) to patients presenting for treatment in our outpatient practice and found that most patients would not qualify for the trial. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we apply the psychiatric inclusion/exclusion criteria used in 158 placebo-controlled studies to a large sample of depressed patients who presented for outpatient treatment to determine the range and extent of the representativeness of samples treated in AETs and whether this has changed over time. METHOD: We applied the inclusion and exclusion criteria used in 158 AETs to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation. RESULTS: Across all 158 studies, the percentage of patients that would have been excluded ranged from 44.4 to 99.8% (mean = 86.1%). The percentage of patients that would have been excluded was significantly higher in the studies published in 2010 through 2014 compared to the studies published from 1995 to 2009 (91.4 vs. 83.8%, t(156) = 3.74, p < 0.001). CONCLUSIONS: Only a minority of depressed patients seen in clinical practice are likely to be eligible for most AETs. The generalizability of AETs has decreased over time. It is unclear how generalizable the results of AETs are to patients treated in real-world clinical practice.

Should childhood conduct disorder be necessary to diagnose antisocial personality disorder in adults?

BACKGROUND: Antisocial personality disorder (ASPD) is the only DSM personality disorder that requires a diagnosis of conduct disorder (CD) during childhood. Previous research comparing adults diagnosed with ASPD with adults who meet all ASPD criteria except for a history of CD (referred to in this study as adult antisocial syndrome [AAS]) have reported mixed results. This study sought to clarify the differences among adults with ASPD, adults with AAS, and a large psychiatric outpatient control group. METHODS: A series of semi-structured interviews were conducted with 2,691 psychiatric outpatients. We compared groups on demographic variables, psychiatric comorbidity, symptom presentation, parental history, and psychosocial morbidity. RESULTS: Significant differences were found among ASPD, AAS, and controls in regard to demographic variables, comorbidity, symptom presentation, and parental history. The ASPD and AAS groups were similarly impaired with respect to global functioning, occupational and social functioning, and suicidality. CONCLUSIONS: Findings suggest that by including a history of CD in ASPD criteria, our diagnostic system excludes an important group of later-onset patients who also require attention and resources. Implications, limitations, and future directions are discussed.

Screening for Borderline Personality Disorder in Psychiatric Outpatients With Major Depressive Disorder and Bipolar Disorder.

OBJECTIVE: Borderline personality disorder (BPD) is a serious illness that is frequently underdiagnosed. A previous psychometric analysis of the 9 BPD criteria in DSM-IV/DSM-5 found that the affective instability criterion functioned well as a screen for the disorder. A limitation of that initial study was that the performance of the BPD criteria was examined in a diagnostically heterogeneous sample, including those with a low likelihood of having BPD. The present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project examined the operating characteristics of the BPD criteria in patients with major depressive disorder (MDD) and bipolar disorder. METHODS: From December 1995 to April 2014, 3,674 psychiatric outpatients were evaluated with a semistructured diagnostic interview for DSM-IV BPD. The operating characteristics of the BPD criteria were examined in 3 nonoverlapping groups of patients: those with a principal diagnosis of MDD, those with a principal diagnosis of bipolar disorder, and all remaining patients. RESULTS: The sensitivity and negative predictive value of the affective instability criterion were greater than 90% in patients with MDD, bipolar disorder, or other diagnoses. Of the 9 BPD criteria, the affective instability criterion achieved the highest sensitivity and negative predictive value in all 3 diagnostic groups. CONCLUSIONS: Despite the phenomenological overlap between BPD and mood disorders, inquiry about affective instability functions well as a clinically useful screen for BPD in patients with MDD and bipolar disorder. In patients presenting for the treatment of MDD or bipolar disorder, clinicians should screen for BPD in the same way that they screen for other comorbid psychiatric disorders-by inquiring about a single feature of the disorder (ie, affective instability), the presence of which captures almost all patients with the disorder and the absence of which rules out the disorder.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder: A Replication and Extension.

The authors' group previously reported that patients who screened positive on the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, were as likely to be diagnosed with borderline personality disorder (BPD) as with bipolar disorder. A limitation of that study was that the authors examined the performance of the MDQ in patients presenting for various psychiatric disorders, including depression. The recognition of bipolar disorder and its differential diagnosis with BPD is of greatest clinical relevance in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors attempted to replicate their initial findings in a new sample of psychiatric outpatients, and they also examined the performance of the MDQ in depressed patients. The results of the present study were consistent with the original report, thereby indicating that the MDQ is not effective in helping distinguish bipolar disorder from BPD.

Differentiating borderline personality from bipolar disorder with the Mood Disorder Questionnaire (MDQ): A replication and extension of the International Mood Network (IMN) Nosology Project.

INTRODUCTION: Vöhringer et al. identified a triad of items on the Mood Disorder Questionnaire (MDQ) that best discriminated between borderline personality disorder (BPD) and bipolar disorder (BD) in a tertiary mood clinic setting [23]. The present study aimed to replicate and extend these findings by examining the performance of the triad across a range of cut-off scores and comparing the operating characteristics of the triad to the full MDQ. METHODS: Patients presenting for treatment were assessed with the Structured Clinical Interview for DSM-IV (SCID) and the BPD module of the Structured Interview for DSM-IV Personality (SIDP-IV). The present report is based on 476 depressed patients who had a principal diagnosis of major depressive disorder or BD and who completed the MDQ. RESULTS: Fifty-seven patients were diagnosed with BD and fifty-four patients were diagnosed with BPD. Both the triad and full MDQ significantly predicted BD diagnosis (p < .001), but the triad had optimal operating characteristics, particularly at a cut-off of two. CONCLUSION: Within a sample of depressed patients, the MDQ triad is a better screener for BD than the full MDQ, particularly if a positive triad screen is indicated by the presence of any two items. The triad is particularly good for differentiating between BD and BPD, whereas the full MDQ does a poorer job of differential diagnosis. Future studies should administer the triad as a stand-alone scale.

Understanding the severity of depression: Which symptoms of depression are the best indicators of depression severity?

BACKGROUND: In DSM-5, all symptoms of depression are considered equal representations of severity. In ICD-10, the type of symptom is considered in classifying severity. It is important to better understand if the defining symptoms of depression are differentially associated with overall severity so that severity categorization in diagnostic systems is most valid. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the individual diagnostic criteria for major depressive disorder (MDD) and global ratings of depression severity. We thus examined whether there is support for the ICD-10 approach in which some symptoms are better indicators of severity than are other symptoms. METHODS: Patients were evaluated with a semi-structured interview and the presence of each symptom of MDD was recorded. Patients were also rated on the Clinical Global Index of severity (CGI-S). RESULTS: All 9 DSM-5 criteria were significantly correlated with the CGI with suicidality having the highest correlation. A regression analysis found that all 9 criteria were significant predictors of the CGI. At the symptom level, 15 of the 17 symptoms were significantly correlated with the CGI (all except increased appetite and increased weight). DISCUSSION: There were differences between the symptoms of depression in their association with severity with suicidal ideation, depressed mood, and anhedonia having the highest correlations with severity whereas some symptoms were not significantly associated with severity distinctions. Future descriptions of the severity of depression should not consider all criteria as equal representations of severity.

The role of emotion regulation difficulties in the connection between childhood emotional abuse and borderline personality features.

In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the role of emotion dysregulation as a mediator between childhood abuse and borderline personality disorder (BPD) feature severity among a sample of 964 adults presenting for treatment at an outpatient clinic. A structural equation model suggested that emotional abuse relates to BPD features both directly and through difficulties with emotion regulation, whereas physical abuse showed only a weak indirect relation with BPD features. There was no link between sexual abuse and BPD feature severity in the model. Results add specificity to etiological theories of BPD and suggest that future research in treatment should focus on developing and strengthening emotion regulation strategies in clinical populations with a history of emotional abuse. Clinicians should be sure to assess the presence of childhood emotional abuse in addition to sexual and physical abuse. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Depression and substance use disorders in the offspring of depressed parents as a function of the parent's borderline personality disorder symptomatology.

BACKGROUND: Parental major depressive disorder (MDD) and borderline personality disorder (BPD) are associated with increased risk of offspring psychopathology. It is unclear whether BPD in depressed parents infers greater risk than depression alone. We hypothesized that BPD features in depressed parents would be associated with higher morbid risk of offspring MDD and substance use disorders (SUDs). METHODS: Participants included 912 psychiatric outpatients with a principal diagnosis of MDD. Semi-structured interviews determined diagnoses of parents and their 2,011 reported offspring. We compared the offspring's morbid risk of MDD and SUDs based on whether their parents had BPD, ≥1 BPD criteria, and by each criterion. RESULTS: Offspring of parents with ≥1 BPD criteria had higher morbid risk of MDD and SUDs. Differences were insignificant when comparing by BPD diagnosis. Anger and impulsivity were associated with increased risk of MDD, and emptiness was associated with increased risk of SUDs. CONCLUSIONS: Results suggest that BPD features confer additional risk to offspring beyond that of parental depression alone. Parental anger and impulsivity may be particularly important in determining risk of MDD, and parental feelings of emptiness may be particularly important for risk of SUDs. Limitations, future directions, and treatment implications are discussed.

Suicide attempts and emotion regulation in psychiatric outpatients.

BACKGROUND: Suicidal behavior has been associated with maladaptive strategies for emotion regulation; however, limited research has explored this association after controlling for diagnosis. This study aims to explore this connection across diagnoses. We hypothesized that patients who reported greater difficulty with emotion regulation would be more likely to have made suicide attempts. METHOD: Participants included 1046 psychiatric outpatients. Diagnoses and information about suicide history were determined using semi-structured interviews. Patients also completed the Difficulties in Emotion Regulation Scale (DERS). Analyses were conducted to determine the relationships between emotion regulation difficulties and lifetime suicide attempts. RESULTS: Emotion regulation difficulties did not independently predict suicidal behavior. After controlling for the contribution of emotion dysregulation on lifetime suicide attempts, diagnoses of borderline personality disorder and posttraumatic stress disorder were the only disorders independently associated with a history of suicidal behavior. LIMITATIONS: The generalizability of our findings may be limited based on the sample's demographic characteristics and low base rate of suicide attempts. This study was cross-sectional in nature; therefore, the predictive capacity of either DERS scores or psychiatric diagnoses in terms of future suicidal behavior could not be determined. CONCLUSIONS: The independent effect of emotion dysregulation on suicidal behavior was negated after controlling for psychiatric diagnosis. Individuals with certain disorders tend to make suicide attempts for reasons that are distinct from emotion dysregulation, whereas emotion dysregulation may be at the core of suicidality for individuals with other clinical presentations.

The Importance of Assessing for Childhood Abuse and Lifetime PTSD in Bariatric Surgery Candidates.

For bariatric surgery candidates, history of child abuse and PTSD may be under-recognized or under-reported at pre-surgical evaluation. On a range of clinically relevant factors, we studied 3045 candidates for bariatric surgery: (1) those with a history of childhood abuse compared to those without such history; and (2) among candidates with a history of abuse, those with a lifetime diagnosis of PTSD compared to those without that diagnosis. We compared them on current and lifetime eating disorders, physical health problems, health behaviors, physical functioning, psychosocial functioning, psychiatric disorders, emotional wellness, body satisfaction, and self-esteem. We hypothesized that patients with a history of childhood abuse, and within that group, those with a lifetime PTSD diagnosis, would display greater overall impairment. Patients were interviewed with semi-structured interviews and completed self-report questionnaires. Results showed that (1) patients with a history of childhood abuse exhibited significantly greater impairment than those without abuse; and (2) among candidates with a history of abuse, those with a lifetime history of PTSD displayed significantly greater impairment than those without a PTSD diagnosis. The findings suggest that a history of both childhood abuse and lifetime PTSD should be thoroughly assessed for at pre-surgical evaluation, and that greater attention be paid to the experience of PTSD symptoms in abuse survivors presenting for bariatric surgery.

Principal diagnoses in psychiatric outpatients with borderline personality disorder: Implications for screening recommendations.

BACKGROUND: In the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how often borderline personality disorder (BPD) is the principal diagnosis in patients presenting for outpatient psychiatric treatment. To inform clinicians when it is most productive to screen for BPD, we examined the prevalence of BPD in psychiatric outpatients with different principal diagnoses. METHODS: In this study, 3,674 psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD. RESULTS: Slightly ≥10% of the sample was diagnosed with BPD (n = 390, 10.6%). For 80 (20.5%) patients with BPD, the chief concern was related to a feature of BPD; therefore, BPD was designated as a comorbid diagnosis. The highest rate of BPD as a principal diagnosis was found among patients with bipolar disorder. The rate of BPD in patients with principal diagnoses of adjustment disorder, dysthymic disorder, and generalized anxiety disorder was significantly lower than in patients without these principal diagnoses. CONCLUSIONS: For the majority of psychiatric outpatients with BPD, the principal diagnosis for which they seek treatment is not BPD but, rather, a mood or anxiety disorder. This highlights the importance of screening for BPD.

Has the symptom severity inclusion requirement narrowed the definition of major depressive disorder in antidepressant efficacy trials?

BACKGROUND: The inclusion criteria of all placebo-controlled studies of antidepressants have required a minimum level of severity on standardized measures of symptoms of depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between scores on the Hamilton Depression Rating Scale (HAMD) and the number of criteria met for MDD, as well as the impact of different HAMD cutoff scores on the distribution of the number of DSM-IV criteria met. We speculated that the use of a minimum symptom severity score (MSSS) for inclusion in an antidepressant efficacy trial (AETs) disproportionately excludes patients who are at or just above the diagnostic threshold for MDD, whereas patients who are well above the diagnostic threshold are not excluded. METHODS: Seven hundred forty outpatients with current MDD were evaluated with a semi-structured diagnostic interview. We compared the distribution of DSM-IV MDD criteria scores in patients who scored at or above or below the 3 cutoff scores on the HAMD most commonly used for inclusion in an AET. RESULTS: The distribution of the number of DSM-IV MDD symptom criteria met was significantly associated with HAMD scores. Compared to patients scoring below 18 on the HAMD the patients scoring 18 and above were less likely to report 5 MDD criteria (13.9% vs. 43.7%, χ2=82.2, p<0.001; RR 0.32 [95% C.I. 0.24-0.41]) and more likely to report 9 criteria (9.3% vs. 0.3%, χ2=27.6, p<0.001; RR 28.7 [95% C.I. 4.0-207.5]). The pattern was similar when comparing patients scoring above and below the cutoffs of 20 and 22. At a cutoff of 22 on the HAMD more than 85% of the patients meeting 5 or 6 MDD criteria would be excluded from a trial. In contrast, less than 10% of the patients meeting 8 or 9 criteria would be excluded based on a HAMD cutoff of 18. LIMITATIONS: The present study was conducted in a single outpatient practice in which the majority of patients were white, female, and had health insurance. Although the study was limited to a single site, a strength of the recruitment procedure was that the sample was not selected for participation in a treatment study, and exclusion and inclusion criteria did not reduce the representativeness of the patient groups. CONCLUSIONS: While there is not a perfect relationship between the HAMD score and the number of DSM MDD criteria present, the results of the current study suggest that HAMD scores can be thought of as a proxy for the number of DSM diagnostic criteria. Thus, the recruitment strategy for AETs has increasingly redefined the MDD diagnostic category by requiring a greater number of criteria than that required in the DSM.