What are the strengths and weaknesses of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and International Classification of Diseases, Eleventh Revision (ICD-11) in diagnosing other specified depressive disorder?

Diagnostic Strengths and Weaknesses of DSM-5-TR and ICD-11 for Other Specified Depressive Disorder

DSM-5-TR Strengths

The DSM-5-TR's categorical framework provides clear diagnostic boundaries that facilitate insurance reimbursement and treatment justification, making it the preferred system when administrative clarity is required. 1

• The categorical approach allows clinicians to make definitive distinctions between primary depressive disorders and those due to other medical conditions or substances, which is essential for billing and treatment authorization 1
• The system maintains operational definitions that reduce ambiguity when communicating diagnoses across healthcare settings 2

DSM-5-TR Weaknesses

Both DSM-5-TR and ICD-11 suffer from fundamental weakness in defining symptoms clearly enough to separate depression from normal mood variations, leading to medicalization of normal individuals. 3

• The categorical approach obscures partial and atypical presentations that don't fit neatly into defined categories, particularly problematic for "other specified" diagnoses 1
• Neither system has biological validation, resulting in biologically heterogeneous groups within the same diagnostic category 4
• The purely categorical classification misses nuances in symptom presentation, especially when medical conditions complicate the clinical picture 1
• Relying solely on categorical diagnosis at initial presentation is problematic because longitudinal reassessment is necessary to determine whether mood episodes persist independently 1

ICD-11 Strengths

ICD-11's dimensional framework allows rating symptom severity across six domains on a 4-point scale, providing superior flexibility for capturing partial and atypical presentations that categorical diagnosis misses. 2, 1

• Field studies with 928 clinicians demonstrated that 82.5% to 83.9% rated ICD-11 as quite or extremely easy to use, accurate, clear, and understandable 2, 1, 5
• The dimensional qualifiers for depressive episodes include melancholic features, anxiety symptoms, panic attacks, and seasonal pattern, allowing detailed clinical characterization beyond categorical diagnosis 2
• Depressive episodes can be described according to severity (mild, moderate, or severe) and remission status (partial or full remission), with psychotic symptoms indicated for moderate and severe episodes 2
• The system enables documentation of symptom severity across positive, negative, depressive, manic, psychomotor, and cognitive domains at each assessment, helping establish causality over time 1
• Diagnostic accuracy, time required to reach diagnosis, and perceived clinical utility were more favorable for ICD-11 compared to ICD-10 2

ICD-11 Weaknesses

When excluding entirely new diagnostic categories, ICD-11 showed no significant difference in diagnostic accuracy, goodness of fit, clarity, or time required for diagnosis compared to ICD-10, with advantages largely limited to new categories rather than improvements in existing ones. 2, 5

• Interrater reliability was high for psychotic disorders but only moderate for mood disorders in ecological field studies, with reliability for dysthymic disorder noted as "improvable" 2, 5
• Field study samples may be biased toward practitioners positive about ICD-11, particularly in online studies where participants registered voluntarily 2
• Vignette studies used prototypic cases that might not accurately reflect real-life clinical complexity, and behavior in field studies might not reflect diagnostic decision-making in routine care 2
• Further ecological field studies under regular clinical conditions are needed to validate how well ICD-11 performs in actual practice 2

Optimal Clinical Approach

Use ICD-11's dimensional framework to document symptom severity across all six domains at each assessment while maintaining DSM-5-TR's categorical distinction for insurance and treatment justification purposes. 1

• Rate severity on the 4-point scale (not present, present and mild, present and moderate, present and severe) for each domain: positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive symptoms 2, 1
• Document episodicity (first episode, multiple episodes, or continuous course) and current clinical status (currently symptomatic, partial remission, full remission) to capture longitudinal patterns 2, 5
• Plan for longitudinal reassessment rather than making definitive distinctions between primary and secondary depression at initial presentation, as the diagnosis frequently evolves over time 1, 4

Critical Pitfalls to Avoid

• Never rely solely on categorical diagnosis when medical conditions are present, as this approach misses partial and atypical presentations that dimensional assessment captures 1
• Avoid making definitive diagnostic distinctions at initial presentation without longitudinal follow-up to determine whether symptoms persist independently of potential contributing factors 1
• Do not assume that meeting categorical criteria alone provides sufficient information for treatment planning in complex presentations—dimensional severity ratings across multiple domains are essential 1, 5