Diurnal Mood Variation in Outpatients With Major Depressive Disorder: Implications for DSM-V From an Analysis of the Sequenced Treatment Alternatives to Relieve Depression Study Data

David W. Morris, PhD; A. John Rush, MD; Shailesh Jain, MD, MPH; Maurizio Fava, MD; Stephen R. Wisniewski, PhD; G. K. Balasubramani, PhD; Ahsan Y. Khan, MD; Madhukar H. Trivedi, MD

J Clin Psychiatry 2007;68(9):1339-1347

Article Abstract

Objective: Diurnal mood variation (DMV) with early morning worsening is considered a classic symptom of melancholic features in The Diagnostic and Statistical Manual of Mental Disorders (DSM) as well as The International Classification of Diseases (ICD) criteria for somatic major depressive disorder (MDD). Using the unique opportunity afforded by the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study data, we examined whether DMV with afternoon or evening worsening, in addition to classic early morning worsening, was related to other symptom constructs to determine whether the exclusive reliance on morning worsening is justified in defining melancholic features.

Method: Baseline demographic and clinical characteristics, as well as depressive symptoms, including DMV, were evaluated in 3744 outpatients with nonpsychotic MDD enrolled in the STAR*D study.

Results: DMV in at least one of the time periods was reported by 22.4% (N = 837) of the sample. Only 3.3% (N = 28) of these 837 patients with DMV attributed it to environmental factors. Of the 809 participants (96.7%) with DMV unrelated to environmental events, only 31.9% (N = 258) reported morning worsening, while 19.5% (N = 158) and 48.6% (N = 393) reported afternoon and evening worsening, respectively. Minimal distinctions in demographic characteristics, clinical features, and depressive symptoms were found between participants with morning worsening and those with either afternoon or evening worsening. More importantly, other melancholic symptom features were associated with DMV regardless of time of worsening.

Conclusion: DMV was meaningfully related to other melancholia criteria regardless of when the DMV occurred. If replicated, these findings suggest that DMV as a component of melancholic features might be expanded to include any DMV, not simply early morning worsening.