Copyright 1993 by the American Psychological Association, Inc.

0021-843X/93/S3.00

Journal of Abnormal Psychology

1993, Vol. 102. No. 2, 197-205

The Symptoms of Major Depression

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Alexander M. Buchwald and David Rudick-Davis

The 8 symptoms of Criterion B for major depressive disorder (MDE) in the third edition of the
Diagnostic and Statistical Manual of Mental Disorders were studied in 107 cases and 57 noncases of
MDE (all had depressed mood or pervasive anhedonia for more than 2 weeks). Sleep change, loss of
energy, and appetite change were the most common symptoms, and psychomotor change and
feelings of worthlessness the least common, in MDE. Loss of energy and sleep change were the best
single symptoms and thoughts of death, feelings of worthlessness, and psychomotor change the
worst for both diagnoses. Psychomotor change was the best and thoughts of death the worst
indicator of MDE. Absence of sleep change and of loss of energy were the best and absence of
thoughts of death, psychomotor change, and feelings of worthlessness the worst indicators of
non-MDE. Results suggest that vegetative symptoms are more central to clinical depression than
feelings of worthlessness, self-reproach, or guilt.

DSM-III, the DSM-HI-R (American Psychiatric Association,

1987), has appeared since the study reported here was completed. The DSM-IH-R has eliminated the distinction between Criterion A and Criterion B. It adds depressed mood to
the list of eight symptoms and requires the presence of five of
the nine, including either depressed mood or pervasive loss of
interest or pleasure, for the diagnosis of MDE. Although there
are some changes in the specific wording of other individual
symptoms, the present study has essentially the same implications for the DSM-HI-R as for the DSM-III.

The third edition of the Diagnostic and Statistical Manual of

Mental Disorders (DSM-III; American Psychiatric Association,
1980) presents five explicit criteria for diagnosing a major depressive episode (MDE), a syndrome that may occur in major
depression or in bipolar disorder. Three of these are exclusion
criteria that prohibit the diagnosis of MDE under varying circumstances; the other two specify symptoms that must be present for the diagnosis to be made. Criterion A requires either
"dysphoric mood or loss of interest or pleasure in all or almost
all usual activities and pastimes" (p. 213). Criterion B lists eight
symptoms or groups of symptoms and requires the presence of
at least four of these for the criterion to be met. Thus, the
presence of any one of the eight symptoms can contribute to the
diagnosis of MDE, although no single one of them is needed for
the diagnosis to be made. Similarly, some subset of the symptoms must be present in each case of MDE, but no specific
symptom need be present in all cases. Criterion B, then, does
not completely determine the relationship between MDE and
each of its symptoms. The symptoms may vary in such matters
as the frequency with which they occur in cases of MDE and in
the extent to which their presence predicts MDE or their absence predicts its absence.
In the present study, we set out to investigate the relationships
between MDE and the individual symptoms of Criterion B.
The questions that were explored are presented and discussed
briefly in the succeeding paragraphs. A modified version of the

Description of Major Depressive Episodes

Heterogeneity of Cases of MDE
Criterion B permits cases of MDE to have anywhere from
four to eight of the symptoms listed in Criterion B. What is the
frequency distribution of the number of symptoms present?
Criterion B can be met by 163 different subsets (constellations)
of symptoms. Are cases of MDE distributed over a large number of constellations, or do they tend to pile up at one constellation, or perhaps at a few? The last-mentioned possibility would
fit with the idea that there are several distinguishable subtypes
of major depressive disorder.

Frequency of Occurrence of Individual Symptoms

How often does each symptom occur among cases of MDE?
Do all of the symptoms listed in Criterion B occur equally
often, or do some occur more often than others? If the symptoms do not occur equally frequently, which are the most common and which are the least common? Which pairs of symptoms are most and least common? The relative frequencies of
the various symptoms are of interest in amplifying the description of MDE and may also provide clues to the nature of severe
depression.
These questions can be answered by studying the symptoms
present in a group of cases of MDE. Although it would be
desirable to select cases independently of the symptoms being

Alexander M. Buchwald and David Rudick-Davis (now in private

practice at the University of Texas Southwestern Medical Center, Dallas, Texas), Department of Psychology, Indiana University.
This article was based on a doctoral dissertation by David RudickDavis under the direction of Alexander M. Buchwald.
We gratefully acknowledge the cooperation of Douglas Puryear, Director of Psychiatry, Emergency Service, Parkland Hospital, Dallas,
Texas, and of the second- and third-year class of psychiatry residents
and the psychology interns of 1984.
Correspondence concerning this article should be addressed to
Alexander M. Buchwald, Department of Psychology, Indiana University, Bloomington, Indiana 47405.
197

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198

ALEXANDER M. BUCHWALD AND DAVID RUDICK-DAVIS

studied, it is not possible to do so because there is no acceptable

basis for diagnosis of MDE except for symptoms. Note that
simply asking for global diagnostic judgments with no reference to Criterion B would be more likely to hide whatever circularity is involved in selection on the basis of DSM-HI criteria
than to eliminate it, because (at the time of the study) many
clinicians were used to making DSM-III diagnoses and their
judgments were likely to be affected by the DSM-HI criteria.
Accordingly, cases of MDE in the present study met all DSMIII criteria for the diagnosis.
To answer an additional set of questions, described subsequently, requires comparing cases of MDE with an appropriate
group of noncases. For the reasons just described, it also
seemed appropriate to select noncases on the basis of their
failure to meet the DSM-HI criteria. Such a contrast group
might be selected in any of several different ways. It might consist of cases with any DSM-III diagnosis except for MDE; that
would allow the two groups to be matched on the basis of
severity of disorder. Or the contrast group might consist of
cases with some specific diagnosis. Several investigators have
compared cases of depressive disorders and cases of anxiety
disorders, although usually not using Z>SM-///diagnostic criteria to select cases (Clark, 1989). Or the contrast group might
consist of cases that satisfied Criterion A (dysphoric mood or
pervasive anhedonia), and that met the exclusion criteria for
MDE, but did not have diagnoses of MDE because they did not
have enough Criterion B symptoms (cf. Clarkin, Widiger,
Frances, Hurt, & Gilmore, 1983). This last procedure was the
one used in the present study. It has two limitations that should
be noted. First, none of the noncases could have more than
three of the symptoms in Criterion B. Second, the contrast
group may differ from the MDE group in severity of disorder.
On the positive side, this procedure is the only one that selects a
contrast group consisting of cases matched with the MDE
group for the presence of depressive mood disturbance (Criterion A) and for the absence of conditions that would exclude the
diagnosis of MDE. Thus, differences between the two groups
are not confounded with presence versus absence of depressive
mood, and the contrast group consists of cases in which the
diagnosis of MDE is an obvious possibility and in which ruling
out its presence is important.

Descriptive Validity of Symptoms

Spitzer and Williams (1980) used the term descriptive validity
to refer to "the extent to which the characteristic features of a
mental disorder are unique to that category, relative to other
mental disorders and conditions" (p. 1037). Are all of the symptoms of Criterion B descriptively valid; that is, does each occur
more often among cases than noncases?
Clark (1989) has reviewed studies comparing symptoms in
depressive disorders and anxiety disorders. She reported that
depressed mood, loss of interest or pleasure, suicidal behavior,
and psychomotor retardation were the only symptoms that
were significantly more frequent in depressives in at least two of
three studies. In most of the studies Clark reviewed, however,
some symptoms that are grouped in Criterion B (e.g., psychomotor agitation and psychomotor retardation) were studied sep-

arately. Thus, the results do not provide firm evidence for lack
of descriptive validity.
It should be noted that the way in which subjects were assigned to the two groups in the present study means that the full
set of symptoms must occur more often in the MDE group than
in the contrast group; however, this need not be true for each
individual symptom. In the Clarkin et al. (1983) study, one of
the eight symptoms of borderline personality disorder (BPD)
did not occur significantly more often in cases of BPD than in
noncases (our calculation), even though the presence of five or
more symptoms was required for a diagnosis of BPD.

Diagnostic Efficiency of Symptoms

Meehl and Rosen (1955) identified three types of diagnostic
efficiency. In the present context, the positive hit rate (Hp) is the
conditional probability of MDE given the presence of a particular symptom; the negative hit rate (H,) is the conditional probability of non-MDE given the absence of the symptom; and the
total hit rate (Hj) is the probability that diagnoses based on the
presence versus absence of a symptom are correct. (The first
two are also referred to as positive predictive power and negative predictive power, respectively) Thus, these indices indicate
how well one could use the presence or absence of a specified
symptom to identify (or select) cases or noncases, or both. A
particular symptom may be more useful for one of these purposes than for another, and the relative efficiencies of two
symptoms need not be the same for each of these purposes.
The present study compared the efficiency of the various
symptoms for each diagnostic purpose. Are all symptoms
equally efficient? If not, which have the highest values and
which the lowest values for a given efficiency index? There are
no data currently available on this matter for MDE except in
contrast to anxiety disorders in which, as noted, many depressive symptoms do not differentiate cases of depression from
cases of anxiety.
Why study the diagnostic efficiency of the symptoms of Criterion B? Widiger, Frances, Warner, and Bluhm (1986) contended
that efficiency statistics are useful in developing better diagnostic criteria, especially when there is no external criterion for
a particular category. Morey and McNamara (1987) disagreed.
They argued that it makes no sense to study the diagnostic
efficiency of DSM-HI criteria unless the categories can be defined independently because using the criteria being studied to
identify cases renders the study of diagnostic efficiency circular. This argument is obviously true in regard to certain questions such as asking about the diagnostic efficiency of the entire
set of MDE criteria, but it does not apply to comparison of the
diagnostic efficiency of the individual symptoms because these
are not constrained by the DSM-III criteria. When both cases
and noncases meet all of the criteria for MDE except for Criterion B, the efficiency measures can be viewed as measures of
internal consistency. For example, the value of Hp for a particular symptom is the conditional probability of four or more
symptoms given the presence of the symptom in question.
Thus, the efficiency measures can be used to compare the extent to which each of the symptoms is linked to the full set of
symptoms and thus, presumably, to MDE.

199

SYMPTOMS OF MAJOR DEPRESSION

Method

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Subjects
The subjects were outpatients seeking psychiatric evaluation in a
county hospital in Dallas, Texas. The hospital, Parkland Memorial
Hospital, operates a 24-hr psychiatric emergency service for any individual who requests evaluation or is referred by court order. It serves a
wide variety of patients, but primarily those from lower socioeconomicstrata.
Subjects were selected for the present study from among 2,276 consecutive admissions (seen at all hours of the day or night) over a period
of 2.5 months. To be selected, individuals had to be at least 18 years old
and had to meet Criterion A for a DSM-III diagnosis of MDE: "dysphoric mood or loss of pleasure in all or almost all usual activities and
pastimes. . . [which is] prominent and relatively persistent" (American Psychiatric Association, 1980, p. 213). We added the restriction
that the mood disturbance must have lasted for at least 2 weeks.
Some subjects who might have met Criterion A were excluded from
this study as a result of certain screening rules. Patients who met Criterion A but who reported taking psychotropic medication at some time
during the 3 weeks prior to evaluation were excluded because medication may have eliminated some of their symptoms (n = 61). Similarly,
patients with a diagnosis of major affective disorder in remission (n =
4) were excluded because they would have fewer symptoms than during major depressive episodes. Patients diagnosed as suffering from
organic mental disorder (n = 40), or abuse of or dependence on alcohol
(n = 190) or other substances (n = 213), were also excluded unless any
depressive symptoms they might have had were clearly unrelated to the
use of the substance. Many of these patients were not fully evaluated
for depressive symptoms once these diagnoses were established because the diagnoses were known to be exclusion criteria for this study.
Furthermore, many of these patients were intoxicated on admission.
Patients were also excluded if their diagnoses did not permit clear
placement as cases or noncases of MDE. The latter included 9 patients
with a diagnosis of schizoaffective disorder and 4 cases of residual
schizophrenia that met the criteria for MDE and should thus be diagnosed as cases of atypical depression under the DSM-III. (The majority of these patients would have been excluded because they were
maintained on medication, in any case.) Finally, 193 patients classified
under the heading "additional codes" in the DSM-III were excluded.
These included two subgroups: (a) those who were so hostile (many
brought in on warrants) or so psychotic that the examiner believed that
accurate diagnostic data could not be obtained and (b) those judged to
have minor problems (often financial or social in nature) and to be free
of mental disorder.
After application of the screening rules, there were 168 cases that
met Criterion A and for which full information on depressive symptoms was available. Of these, 111 had a diagnosis of MDE, including
107 diagnosed as cases of major depression and 4 as cases of bipolar
disorder depressed (BP).1 (Data on the BP cases are not included in the
analyses because there were too few of them.) An additional 57 patients
met Criterion A but not Criterion B (non-MDE). The distribution of
diagnoses for the non-MDE group is shown in Table 1.
The sample was predominantly female (66%), White (58%), and between 20 and 40 years of age (75%). The MDE and non-MDE groups
did not differ significantly on any of these variables. For sex, 67% of
MDE and 63% of non-MDE cases were women, x2 (1, N= 164) = 0.284,
p > .50; for race, 55% of MDE and 63% of non-MDE cases were White,
X2(l, N= 164)= 0.978, p> .30; and forage, the means were 33.02 (SD =
10.04) years for MDE and 31.02 (SD = 10.32) for non-MDE, ;('62) =
1.31,p>.10.

Procedure
In the psychiatric emergency service, each patient is routinely evaluated by one or more psychiatric attending physicians, residents, or

Table 1
Frequency of Diagnoses in Non-MDE Subjects in Study
Sample (Principal Diagnosis Only)
Diagnosis
Substance use disorders
Schizophrenic disorders
Affective disorders
Other specific affective disorders
Dysthymic
Cyclothymic
Atypical affective disorders
Atypical depression
Anxiety disorders
Somatoform disorders
Psychosexual disorders
Adjustment disorders
V codes"

n
3.5
5.3

10
1

17.5
1.8

4
1
1
1
29
5

7.0
1.8
1.8
1.8
50.9

Note. MDE = major depressive episode.

" Conditions not attributable to a mental disorder.

psychology interns, and a DSM-III diagnosis is assigned. Evaluations

are done through clinical interviews that include current complaints,
personal and family history, and a complete mental status examination. Within the context of this interview, the clinicians evaluated any
patients meeting Criterion A for MDE (except as noted earlier) and
specifically documented the presence or absence of each of the eight
symptoms listed in Criterion B. They also checked for the presence of
features that would prohibit the diagnosis of MDE under the DSM-HI
exclusion criteria (American Psychiatric Association, 1980). (These
criteria were used as indicated by the DSM-HI in making diagnoses.)
Clinicians also assessed patients for any other features of Axis I or Axis
II disorders that might be relevant to the patient's diagnosis.
A total of 25 clinicians evaluated patients for this study; most of
them were 2nd- and 3rd-year psychiatry residents. Some clinicians
evaluated as many as 15 patients and some as few as 1.

Reliability Interviews
As a check on the reliability of assessments, 43 subjects (26% of the
sample) were evaluated by two clinicians, an initial interviewer and
David Rudick-Davis.2 The initial interviewer always began the interview alone, and, if she or he believed that the subject met Criterion A
for MDE, asked the second interviewer to join the interview if he was
available (n = 10) or, if not (n = 33), to conduct a second interview with
the subject on the same day. In conjoint interviews, either interviewer
could gather any needed information. In all instances, both interviewers had access to case records, observations of behavior by other
staff members, and reports of informants; if one interviewer had access
to information but the other did not, this was communicated to the
other clinician. Reliability interviews were conducted at random times
(to reflect day, evening, night, and weekend samples), and data were
recorded independently. Whenever possible, reliability interviews
were conducted to represent the relative proportion of a rater's contribution to the total sample; that is, raters with many subjects were in1

In instances in which multiple Axis I diagnoses were made, cases

were considered to be cases of major depression or of bipolar disorder
if one of these diagnoses was made.
2
At the time of thisstudy, David Rudick-Davis had 3 years of experience working in the setting, first as a psychology intern and later as a
coordinator of service.

200

ALEXANDER M. BUCHWALD AND DAVID RUDICK-DAVIS

volved in relatively more reliability interviews. Three subjects declined

to participate in the interviews. Those who did participate gave informed consent. Judgments made by the second interviewer were used
only for estimates of reliability and did not affect the data for the study.

Results and Discussion

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Reliability
For 39 of the 43 subjects (91 %), the second interviewer agreed
with the initial interviewer that Criterion A was met. Both interviewers agreed that none of the other 4 subjects could be
diagnosed with MDE because they all failed to meet Criterion
B. The disagreement found on Criterion A suggests that the
sample in this study may include some subjects who do not
meet Criterion A but who are most likely to be included in the
non-MDE group.
The two interviewers agreed on the diagnosis (MDE vs. nonMDE) in 38 of 43 cases (88%), K = .74, p < .001. This exceeds the
level (.70) that Spitzer (American Psychiatric Association, 1980)
described as "high" agreement. It should be noted that agreement on Criterion A and hence on overall diagnosis may be
spuriously high because the second interviewer knew that he
would not have been asked to participate in, or to conduct, an
interview unless the initial interviewer believed that the subject
met Criterion A.
Estimates of reliability were computed for each of the eight
symptoms of Criterion B and are reported in Table 2. The median percentage of agreement was 89% and the median K was
.732. Except for loss of interest or pleasure, which fell in the
"poor" range (<.40), all symptoms fell in the "good" (.60-74) or
the "excellent" (>.74) range of interrater reliability of specific
items using the terminology of Cicchetti and Sparrow (1981).

Heterogeneity of Cases
Table 3 shows the frequency distribution of number of symptoms per case. Overall, 65% of the subjects had four or more of
the symptoms of Criterion B and thus had cases of MDE. This
suggests that Criterion A, which was used to select the sample,
is a powerful screening criterion for the diagnosis of MDE, but
this must be qualified. The rate of MDE reflects the exclusions
made in selecting the sample of consecutive admissions and
may not apply to populations other than those seen at an emergency service. Within these limitations, simply knowing that a
person has a persistent and relatively prominent depressed
mood or pervasive anhedonia would enable a clinician to diagnose MDE and to be correct in 65% of instances.
The DSM-IH permits a diagnosis of MDE with as few as four
of the symptoms listed in Criterion B, but such cases are rare, at
least in the emergency service from which subjects were drawn.
Only 4 (4%) of 107 cases had four symptoms, as compared with
19 (18%) who had all eight symptoms and 81 (76%) who had six
or more. The modal number of symptoms in the MDE group
was 6 and the mean was 6.32. These figures can be compared
with data based on clinical examination of 486 routine admissions to inpatient and outpatient psychiatric services (Beck,
1967). We calculated means of 4.04, 5.94, and 6.94 for cases of
mild, moderate, and severe depression, respectively. Beck's
cases were grouped by ratings of depth of depression without

Table 2
Reliability of Individual Symptoms
Symptom

> Agreement

Appetite disturbance
Sleep disturbance
Psychomotor disturbance
Loss of interest or pleasure
Loss of energy
Feelings of worthlessness
Thinking difficulties
Thoughts of death or suicide

83
90
81
69
90
90
88
93

.642
.738
.619
.389
.757
.808
.121
.850

Note. Values are based on two interviewers' agreement on 42 cases.

Detailed data on 1 case were lost.
All kappa values have p < .005 (one-tailed) on the basis of the more
conservative model for calculating the standard error (specifically on
the last equation shown in Hubert, 1977, p. 293, column 1).

regard to formal psychiatric diagnosis, and there is no way of

knowing how many might have been diagnosed as MDE by
DSM-IH criteria. We also calculated means of 5.52 and 5.62,
respectively, from data reported by Nelson, Mazure, Quinlan,
and Jatlow (1984) and by Miller and Nelson (1987) on hospitalized cases of MDE diagnosed by DSM-IH criteria. All of the
means cited, especially the last two, probably underestimate
the frequency of symptoms because the presentation of data
separates symptoms listed together in single items in Criterion
B.3 (For example, in the two last-mentioned studies the frequency of each of several types of insomnia is reported, but no
overall frequency is given for sleep disturbance.) Thus, the mean
number of symptoms found for cases of MDE in the present
study is roughly comparable to those reported in earlier studies.
The group was very heterogeneous in terms of constellations
of symptoms present. Of the 163 possible constellations of four
or more symptoms, 42 were represented among the 107 cases of
MDE, 26 by single cases. The most frequent constellation of
symptoms was the one in which all eight symptoms were present. The next most frequent constellation, all symptoms present except for loss of interest or pleasure, was found in only 9
cases (8%).
In the non-MDE group, the modal number of symptoms was
3 and the mean was 2.23. Almost all of these subjects (95%) had
one or more of the Criterion B symptoms. In the entire sample
(both groups combined), only 2.4% had exactly four symptoms,
and many more had either three symptoms or five.

Frequency of Individual Symptoms

Single symptoms. Table 4 shows the proportion of cases of
MDE with each of the symptoms. Note that each symptom was
present in more than 60% of the cases of MDE. Thus, despite
variations in the frequency of individual symptoms, each symptom can be said to be characteristic of MDE. In contrast, studies of personality disorders have found some symptoms present
3
In instances in which frequencies are available only for separate
symptoms grouped together in Criterion B, the means shown are based
on the largest of these frequencies.

201

SYMPTOMS OF MAJOR DEPRESSION

Table 4
Frequency (Percentage) of Each Symptom
in Cases and Noncases ofMDE

Table 3
Number of Criterion B Symptoms per Case

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Major
depressive
disorder/
no. of symptoms
Cases
8
7
6
5
4
Noncases
3
2
1
0

MDE
Frequency

19
27
35
22
4

18
25
33
21
4

28
17
9
3

49
30
16
5

in less than half of the cases (Clarkin et al., 1983; Widiger et al.,
1986).
Although all of the symptoms were common among cases of
MDE, sleep disturbance (98%), loss of energy (93%), and appetite disturbance (86%) were especially common, and the three
occurred together in almost 80% of cases. At the other extreme,
psychomotor disturbance and feelings of worthlessness were
the least frequent symptoms, each occurring in less than 70% of
the cases. A Cochran Q test (Myers, DiCecco, White, & Borden,
1982) applied to the frequency data showed a significant variation in frequencies, Q(l) = 67.77, p < .00001. (Using the ultraconservative Greenhouse-Geisser strategy [see Myers et al.,
1982] to guard against heterogeneity of covariances yielded p <
.01.) Follow-up Tukey tests (Levy, 1979) of the frequencies of
pairs of symptoms showed that sleep disturbance was more
frequent (p < .05) than motor disturbance, feelings of worthlessness, thoughts of death or suicide, loss of interest or pleasure, and thinking difficulties. Loss of energy was significantly
more frequent than all of these save the last, and appetite disturbance was more frequent than motor disturbance and feelings of worthlessness.
The present results differ in several respects from those presented by Beck (1967) for cases with moderate depression and
cases with severe depression. In both groups, loss of interest
ranked second and feeling inadequate third in frequency, and
both were more frequent than their counterparts in the present
study.4 Sleep disturbance and loss of appetite ranked relatively
low in both groups, and fatigability ranked sixth in the severe
group but first in the moderate group. Thus, in general, the
so-called "vegetative" symptoms were less common in Beck's
cases than in the current study. Interestingly, motor retardation,
as manifested by a reduction in spontaneous activity in the
severe group (87%) and by slow speech, reduced verbal output,
and so forth in the moderate group (72%), was more frequent
than the corresponding item, psychomotor agitation or retardation, in the current study, although it ranked sixth in both
groups. It seems likely that the frequency of loss of pleasure was
underestimated in the present study. This symptom was identified with poor reliability, and, in the reliability sample, the first
interviewers marked its presence in only 50% of the cases as

Symptom

Cases
(n = 107)

Noncases
(n = 57)

K"

Appetite disturbance
Sleep disturbance
Motor disturbance
Loss of interest or pleasure '
Loss of energy
Feelings of worthlessness
Thinking difficulties
Thoughts of death or suicide

86
98
62
75
93
68
78
74

32
47
11
19
28
25
18
44

.55
.57
.45
.52
.67
.40
.57
.30

Note. MDE = major depressive episode. All differences between

cases and noncases were significant at .001 by chi-square test. Variations in frequencies among symptoms were significant at, or less than,
.01 (for cases) and .05 (for noncases) by the Cochran Q test.
a
Calculated from 2 x 2 tables of presence versus absence of a given
symptom and MDE versus non-MDE.

compared with the second interviewer's 6 8%. The other discrepancies between the present results and Beck's may stem from
differences between the symptoms used by Beck's examiners to
decide that patients were moderately or severely depressed and
the criteria for MDE given in the DSM-III.
The frequency data are also somewhat inconsistent with clinical descriptions. For example, Hamilton (1982) asserted that
depressed mood, feelings of guilt, and suicidal thoughts are all
present in severe cases but that depressed mood, loss of interest, and anxiety (not assessed here) are the most common symptoms, followed by difficulty in falling asleep, loss of appetite,
loss of energy, and suicidal thoughts. Neither guilt (included in
feelings of worthlessness, self-reproach, or excessive or inappropriate guilt) nor loss of interest were found as frequently as
Hamilton's remarks suggest (however, see the earlier comments
on the frequency of loss of interest). It is somewhat difficult to
compare the present results with Kraepelin's (1921) classical
description of depression because he described symptoms separately for several variant depressive states. In general, however,
his descriptions suggest that thinking difficulties and motor
disturbance (retardation or agitation) should be more common
than they were in the present study.
Data on the frequency of individual symptoms for the nonMDE group are also shown in Table 4. In contrast to cases of
MDE, none of the symptoms occurred in as many as half of the
noncases. Only two symptoms, sleep disturbance (47%) and

Nelson, Mazure, Quinlan, and Jatlow (1984) and Miller and Nelson
(1987) tabulated frequencies separately for the three alternatives of the
Criterion B item (loss of pleasure, loss of interest, and decreased sex
drive) but found that one of these occurred both relatively and absolutely more often than in the present study. In contrast, they reported
feelings of worthlessness occurring with approximately the same frequency as in the present study, although they tabulated guilt separately.
Because of the way they fragmented the items in Criterion B, further
meaningful comparison with the present data is impossible.

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202

ALEXANDER M. BUCHWALD AND DAVID RUDICK-DAVIS

thoughts of death (44%), occurred in more than a third of the

patients in this group, whereas each of the three least frequent
symptoms, loss of interest or pleasure, thinking difficulties,
and psychomotor disturbance, occurred in less than 20%.
Again, the Cochran test showed significant variation in frequencies, (?(7) = 30.2314, p < .0001 (p < .05 by the Greenhouse-Geisser strategy). Tukey tests showed that sleep disturbance was more frequent (p < .05) than motor disturbance,
thinking difficulties, and loss of interest and pleasure.
Thoughts of death or suicide was more frequent than motor
disturbance and thinking difficulties.
Combinations of symptoms. Table 5 shows the relative frequencies of pairs of symptoms in the MDE group. Most pairs
occurred frequently; 24 of the 28 pairs occurred in at least 50%
of the cases of MDE, and the median frequency of occurrence
was 61 %. The most frequent combinations involved either sleep
disturbance or loss of energy, the two most frequent individual
symptoms; the combination of these symptoms represented the
most frequent pair (91%). The least frequent combinations involved either psychomotor disturbance or feelings of worthlessness, the two least frequent symptoms; the combination of
these symptoms represented the least frequent pair (40%).
Descriptive Validity of Symptoms
Each symptom in Criterion B occurred more frequently in
the MDE group than in the non-MDE group (see Table 4).
Furthermore, differences between the groups were large, ranging from 30% for thoughts of death or suicide to 65% for loss of
energy, with six of the eight 50% or larger. For each symptom,
the relative frequencies in the two groups were compared using
chi-square tests; in all cases, the null hypothesis of equal frequencies for the two groups can be rejected at .001, x2(l, N =
164) = 14.40 to 73.74. These results indicate that each of the
symptoms is related to MDE in the population under study,
although this finding may be of limited generality (see later
discussion).
The degree of the relationship between each symptom and
M DE can be estimated by calculating kappa for each symptom,
treating diagnosis and symptom as if they were two diagnosticians.5 If a symptom were independent of a disorder, some predictions of one from the other would be correct, by chance, and
some incorrect. When a symptom is related to a disorder, some
proportion of the predictions that would otherwise be incorrect
will be correct. The kappa statistic shows that proportion. The
kappa values (shown in Table 4) ranged from .30 for thoughts of
death or suicide to .67 for loss of energy, but there is no way to
test whether the differences are due to sampling variation.
These kappas are lower than those often reported for reliability
of diagnostic judgments, but they do not measure reliability. In
the present usage, they are more akin to measures of validity,
which typically are much smaller than measures of reliability.
Diagnostic Efficiency of Symptoms

Overall diagnosis. Table 6 shows the value of H- for each

symptom. This index is the proportion of correct diagnoses of
M DE or non-M DE based on the presence or absence of a particular symptom. For a symptom to be efficient in overall diag-

noses, Hj- must exceed the base rate of the disorder or of its
absence, whichever is larger (Meehl & Rosen, 1955). In the present study, predicting MDE in all instances would result in 65%
of diagnoses being correct. Table 6 shows that all symptoms
have values of Hp greater than .65; however, in some, or all,
instances the difference between .65 and H- may be due to
sampling error. To evaluate this possibility, a series of chisquare tests was carried out in which the observed frequencies
of correct and incorrect diagnosis based on single symptoms
were tested against expected frequencies based on the base
rates. For five symptoms, the null hypothesis was rejected at
.005 (two-tailed) or better, X 2 (l, N = 164) = 9.71 to 29.29; feelings of worthlessness, thoughts of death or suicide, and psychomotor disturbance were not significant at p < .05.
As Table 6 shows, values of H,- ranged from .85 for the most
efficient symptom, loss of energy, to .68 for the least efficient
symptom, thoughts of death or suicide. A Cochran Q test calculated to analyze the significance of variations in Hp yielded
(2(7) = 23.97, p = .01, using the procedure recommended by
Myers et al. (1982) to adjust the critical value for violation of
assumptions. Follow-up Tukey tests showed that loss of energy
was significantly more efficient than thoughts of death or suicide (p < .01), feelings of worthlessness (p < .05), and psychomotor disturbance (p = .05). Sleep disturbance was significantly more efficient than thoughts of death or suicide (p <
.05), but no other differences were significant. It should be
noted that differing base rates may produce different absolute
and relative values of Hp, so the results cannot be generalized to
populations with different base rates.
Identification of cases of MDE. The proportion of subjects
with a specified symptom who have cases of MDE is given by
Hp. Values of Hp are shown in Table 6. All are greater than the
base rate for MDE in the present sample. It can be shown algebraically that the value of Hp for a given symptom will be
greater than the base rate of the disorder whenever the symptom is more frequent among cases of the disorder than among
noncases. Thus, the evidence for descriptive validity cited earlier also indicates that each symptom can be used to identify
cases of MDE at a rate above random selection.
The values shown in Table 6 suggest that psychomotor disturbance is the best single symptom to use in identifying cases
of MDE (Hp = .92) and thoughts of death or suicide (Hp = .76) the
worst; however, the range of values is small, indicating that the
symptoms do not vary much in their ability to select cases of
MDE. Unfortunately, there is no satisfactory way to test
whether differences in Hp values are due to sampling variation.
The Cochran test cannot be used because it requires that each
subject be observed under all conditions, but Hp for a given
symptom is based only on subjects who had that symptom.
Tests for differences among independent groups would also not
be appropriate.
Identification of noncases. Values of H also appear in Table
6. This index is the proportion of subjects without a given
symptom who do not have cases of MDE. In a random sample
from the present population, we would expect 35% to be noncases. Again, the evidence for descriptive validity allows the
* This use of kappa was suggested by an anonymous reviewer.

203

SYMPTOMS OF MAJOR DEPRESSION

Table 5
Conditional Probabilities and Percentages for a Diagnosis of Major Depressive Episode
(MDE) Given a Combination of Two Symptoms
MDE probabilityV% of MDE"

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Symptom
1.
2.
3.
4.
5.
6.
7.
8.

Appetite disturbance
92/84
Sleep disturbance
97/54
Motor disturbance
100/66
Loss of interest or pleasure
95/82
Loss of energy
91/55
Feelings of worthlessness
99/64
Thinking difficulties
Thoughts of death or suicide 91/63

94/61
95/72
98/43
92/91 100/59
100/68
98/40
94/78 100/50
87/74 98/46

96/72
96/48
95/56
97/54

97/62
96/74
95/67

97/55

88/55 94/58

'b Conditional probability of MDE given the presence of the two symptoms.
Percentage of cases of MDE with the two symptoms.
conclusion that the absence of any given symptom can be used
to select noncases of MDE at a rate above random selection.
The best symptoms for identifying noncases of MDE are
(absence of) sleep disturbance (94%), loss of energy (84%), and
appetite disturbance (72%). The poorest symptoms are (absence
of) thoughts of death or suicide (53%), psychomotor disturbance (55%), and feelings of worthlessness (56%). It is noteworthy that sleep disturbance is one of the poorest indicators of
MDE and absence of psychomotor disturbance one of the
poorest indicators of non-MDE.
Although the numerical values of Hp and HN depend on the
base rates, the rank order of the symptoms in terms of either
one of these indices does not. The rank of a symptom based on
how well it can select cases (Hp) depends only on the ratio of the
frequency of the symptom among cases of MDE (true positives)
to the frequency of the symptom among noncases (false positives). Therefore, the values of Hp shown in Table 6 tend to be
inversely related to the frequency of each symptom among noncases. Similarly, rank based on how well a symptom can select
noncases (H,) depends only on the ratio of the frequency of

Table 6
Diagnostic Efficiency of Single Criterion B Symptoms for
Identifying Presence (Hp) and Absence (H^ of Major Depressive
Episode and Total Correct Diagnoses (Hj-)
Symptom
Appetite disturbance*
Sleep disturbance*
Psychomotor disturbance
Loss of interest or pleasure*
Loss of energy*
Feelings of worthlessness
Thinking difficulties*
Thoughts of death or suicide

HN
.84
.80
.92
.88
.86
.84
.89
.76

.72
.94
.55
.63
.84
.56
.66
.53

.80
.82
.71
.77
.85
.71
.79

.68

" For HT, the number of correct diagnoses based on each symptom was
tested against the number of correct diagnoses (107) that would be
made if major depressive episodes were diagnosed in every case using
the chi-square test (two-tailed). The values of HT varied significantly,
among symptoms, at .01 using a Cochran Q test.
* p < .005.

absence of the symptom among noncases (true negatives) to the

frequency of absence of the symptom among cases (false negatives). Thus, the values of Hf, tend to be related to the frequency
of the symptoms among cases. This explains why the presence
of psychomotor disturbance is a strong predictor of MDE but
its absence is a weak predictor of non-MDE, whereas the absence of sleep disturbance predicts non-MDE better than its
presence predicts MDE.
Values of Hp were also calculated for combinations of two
symptoms. (Because such combinations occurred so infrequently in the non-MDE group, as compared with the MDE
group, it seemed unnecessary to calculate values of Hf, and H?)
Values of Hp for the 28 pairs of symptoms are shown in Table 5.
The values were high, with little variation in the values for
different symptom pairs. Only two combinations, thoughts of
death or suicide combined with sleep disturbance (87%) and
with feelings of worthlessness (88%), had Hp values less
than .90.
Although the lowest value of Hp for any single symptom was
.76, this does not mean that 76% or more of patients known to
have any one unspecified Criterion B symptom will have MDE.
As Table 3 shows, 107 cases of MDE and 54 noncases have one
or more symptoms. Thus, the conditional probability of having
a case of MDE given at least one symptom is .66 (107/161).
Similarly, the probability is .70 for any two symptoms and .79
for any three symptoms. The first two of these probabilities are
not significantly greater than the base rate of .65, x2(l, N =
161) = 0.11, and X 2 (l, N=\52) = 1.74, ps > .10, but the last is,
X2(l, N = 135) = 11.69, p < .001 (two-tailed). The seeming paradox arises because the values of Hp shown in Table 6 are conditional on the presence of a specified symptom, whereas the
value of .66 is conditional on the presence of any symptom
whatsoever. A case with k symptoms will be counted as a case
when evaluating Hp for each of the k symptoms; in calculating
the conditional probability of MDE given at least one (unspecified) symptom, each case is counted only once.
Comments
In interpreting the results of the present study, it is necessary
to bear in mind that they may not generalize to cases of MDE

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204

ALEXANDER M. BUCHWALD AND DAVID RUDICK-DAVIS

seen in mental health settings other than emergency rooms or

in non-mental health settings. For one thing, the relative frequencies of the various symptoms studied may reflect the setting in which subjects were seen. For example, the two symptoms most frequently found in noncases were sleep disturbance
and thoughts of death or suicide, either of which may be particularly likely to lead people to seek services on an emergency basis
from a facility that is open all night.
The way the contrast group was selected in the present study
may also have affected some of the results, most notably the
finding that each of the eight symptoms in Criterion B is descriptively valid for MDE. This is at odds with results of studies
comparing cases of depression and cases of anxiety (Clark,
1989) in which many of the symptoms of Criterion B did not
differ significantly for the groups. The reasons for these discrepant results are unclear because the studies differ in many respects, but the way the contrast group was chosen may have
played a role. The procedure used here ensures that cases of
MDE will have more Criterion B symptoms than noncases.
Although this does not force each symptom to be more frequent
in the MDE group than in the contrast group, it would tend to
inflate differences between the groups. On the other hand, the
fact that all cases in the non-MDE group met Criterion A
(mood disturbance) may have tended to increase the frequency
of the symptoms in this group and thus decrease differences
between groups because all of the symptoms studied are (it is
presumed) correlates of mood disturbance. It might also be
argued that the groups differ in severity of disorder inasmuch
as the contrast group included 5 cases diagnosed with V codes
(conditions not attributable to a mental disorder) and 29 cases
with adjustment disorder. The former, clearly, are less severely
disturbed than the MDE cases, but the latter may not be unless
severity is identified with either the number of Criterion B
symptoms or the absence of an identifiable stressor preceding
onset of the disorder. The DSM-IU forbids a diagnosis of adjustment disorder if the condition meets the criterion for a
specific disorder such as MDE, and all of the present cases of
adjustment disorder would have been diagnosed as cases of
MDE if they had had a sufficient number of symptoms.6
Implications for the Diagnostic Rule
Nothing in the present data suggests changing the rule that a
diagnosis of MDE should depend on the presence of four or
more of the symptoms of Criterion B. The data on frequency of
symptoms for cases and noncases, in fact, seem to suggest a
discontinuity, inasmuch as very few cases have exactly four
symptoms. There is no way of deciding, however, whether the
paucity of cases with exactly four symptoms represents a natural point of discontinuity or whether it is an artifact. In some
cases, diagnosticians who have noted the presence of four
symptoms (and hence MDE) may tend to interpret equivocal
signs as evidence for the presence of additional symptoms.
Conceptualization of the Disorder
The symptoms of Criterion B are heterogeneous. Four of
them consist of disturbances of bodily activities: sleep, appetite, energy, and motor aspects. Three consist of disturbances of

mental content or mental processes: feelings of worthlessness,

thoughts of death or suicide, and thinking difficulties. The
final one, loss of interest or pleasure or decrease in sexual drive,
may be either mental or bodily in nature. Despite this heterogeneity, there were no indications that there are two or more distinct syndromes among the cases of MDE. If major unipolar
depression is heterogeneous, then heterogeneity at the symptom level is either confined to symptoms that are not included
in Criterion B or evident only in mild cases (i.e., those with few
symptoms).
Are any of the symptoms in Criterion B so strongly associated with MDE that they ought to be considered core symptoms? To answer this question, it is necessary to consider what
measure should be used to identify possible core symptoms.
Morey and McNamara (1987) suggested that data on true positives (sensitivity) and true negatives (specificity) are more useful
for identifying the core of a disorder than measures of diagnostic efficiency, but true-positive rates and true-negative rates may
provide different answers. In terms of frequency of occurrence
among cases of MDE, sleep disturbance, loss of energy, and
perhaps appetite disturbance might be considered core symptoms. These symptoms, however, are also among the most frequent of the eight in noncases. When all symptoms are found in
a majority of cases, high true-negative rates (low frequency of
symptoms in noncases) might be considered more indicative of
the core of MDE. Psychomotor disturbances, thinking difficulties, and loss of interest or pleasure stand out on these
grounds. Perhaps the best procedure would be to combine information from cases and noncases; unfortunately, however,
there are several ways to do so. One approach is to find the
difference between the frequency of occurrence of a symptom
in cases and in noncases (the true-positive rate minus the falsepositive rate). On this basis, loss of energy (difference = 65%)
and thinking difficulties (difference = 60%) are most strongly
associated with MDE, whereas thoughts of death or suicide
(difference = 30%) and feelings of worthlessness (difference =
43%) are least associated with MDE. Another approach to combining information is to take ratios of frequency data for cases
and noncases. As just noted, ratios based on the presence of
symptoms (true positives/false positives) will be directly related
to values of Hp, and ratios based on the absence of symptoms
(true negatives/false negatives) will be directly related to values
of H,. Thus, symptoms with the highest values of Hp are those
most strongly associated with MDE using the first ratio measure, and symptoms with the highest values of H^ are those
most strongly associated with MDE using the second ratio
measure. The list of the four symptoms with the highest values
of Hp, and the four with the highest values of H,, includes all
symptoms except for thoughts of death or suicide and feelings
of worthlessness. Two of the other six, loss of energy and thinking difficulties, appear on both lists; these symptoms also have
the largest differences between true-positive and false-positive
rates, as well as the largest two kappa values. Thus, these two
6
The mean number of the symptoms for the cases of adjustment
disorder (2.34) is almost identical to the mean (2.35) for the balance of
the non-MDE group, omitting cases of V codes and adjustment disorders.

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SYMPTOMS OF MAJOR DEPRESSION

symptoms are most strongly associated with MDE, by several
criteria. If the present results hold true for cases of MDE recruited from settings other than an emergency service, special
weight should be accorded these symptoms in theoretical accounts of depression.
On the negative side, some comments should be made about
feelings of worthlessness, self-reproach, or excessive or inappropriate guilt. This collection of symptoms is related to constructs
that have been given an important position in several psychological accounts of depression, notably Beck's (1967) cognitive
theory, and the accounts by revisionist psychoanalysts that emphasize the role of low self-esteem (Mendelson, 1982). In the
present sample, these indicators of a negative view of the self
occurred relatively infrequently among cases of MDE. Only
psychomotor disturbance was less common. To put the matter
in quantitative terms, almost one third (32%) of cases of MDE
did not display feelings of worthlessness or allied symptoms,
although they were among the symptoms most reliably identified. In addition, the feature is not strongly associated with
MDE by any of the measures considered. Furthermore, the
data do not indicate that these symptoms are particularly common among patients who may be depressed but do not have an
MDE. Only one quarter of the noncases displayed the symptom, although all suffered from depressive mood disturbance.
Clearly, nothing in the present study supports the view that a
negative bias toward the self is a central feature of depression.

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Received November 19,1990
Revision received August 6,1992
Accepted August 7,1992