DEPRESSION AND ANXIETY 25:274–281 (2008)

Research Article
CLASSIFICATION OF ANXIETY AND DEPRESSIVE
DISORDERS: PROBLEMS AND SOLUTIONS
G. Andrews, MD, T.M. Anderson, PhD, T. Slade, PhD, and M. Sunderland, BPsychol

The American Psychiatric Association and the World Health Organization

have begun to revise their classifications of mental disorders. Four issues related
to these revisions are discussed in this study: the structure of the classifications, the
relationship between categories and dimensions, the sensitivity of categorical
thresholds to definitions, and maximizing the utility and validity of the diagnostic
process. There is now sufficient evidence to consider replacing the present
groupings of disorders with an empirically based structure that reflects the actual
similarities among disorders. For example, perhaps the present depression
and anxiety disorders would be best grouped as internalizing disorders.
Most mental disorders exist on a severity dimension. The reliability and validity
of the classification might be improved if we accepted the dimensional nature
of disorders while retaining the use of categorical diagnoses to enhance clinical
utility. Definitions of the thresholds that define categories are very susceptible
to detail. In International Classification of Diseases-11(ICD-11) and Diagnostic
and Statistical Manual of Mental Disorders-V (DSM-V), disorders about
which there is agreement should be identically defined, and disorders in
which there is disagreement should be defined differently, so that research can
identify which definition is more valid. The present diagnostic criteria are too
complex to have acceptable clinical utility. We propose a reduced criterion set that
can be remembered by clinicians and an enhanced criterion set for use
with decision support tools. Depression and Anxiety 25:274–281, 2008.
& 2008 Wiley-Liss, Inc.

Key words: DSM-V; ICD-11; classification structure; dimensionality; clinical

utility

The American Psychiatric Association and the World
Health Organization have begun the process of
revising DSM-IV and ICD-10. [American Psychiatric
Association, 1994; World Health Organization, 1992,
1993.] We have participated in meetings of both
organizations. In this study we have used data from
the Australian National Survey of Mental Health and
Well-being to illustrate four issues. There are 16 major
categories and 160 diagnoses defined by four-digit
numbers in DSM-IV, many more if you use the five-
digit classification. The four-digit diagnoses, for
instance, do not differentiate between agoraphobia,
social phobia, and specific phobia, or between general-
ized anxiety disorder and panic disorder, whereas the
fifth-digit diagnoses do. In ICD-10 there are 10 major
categories and a similar number of diagnoses. Both are
complex classifications that might be simplified by
using major clusters that also folded disorders of
children and personality disorders into the appropriate
World Health Organization Collaborating Centre for Classifi-
cation in Mental Health, School of Psychiatry, UNSW at St
Vincent’s Hospital, Sydney, Australia
Correspondence to: Andrews G, World Health Organization
Collaborating Centre for Classification in Mental Health, School of
Psychiatry, UNSW at St Vincent’s Hospital, Sydney, Australia.
Received for publication 22 February 2008; Revised 22 February
2008; Accepted 25 February 2008
DOI 10.1002/da.20489
Published online in Wiley InterScience (www.interscience.wiley.
com).

r 2008 Wiley-Liss, Inc.

 Research Article: Classification of Anxiety and Depressive Disorders
cluster. This study is concerned with the internalizing
disorders cluster. These classifications serve a variety of
different purposes: primarily they define illness to
determine treatment and they provide for communica-
tion between clinicians, but they also define casedness
for research purposes, they can have legal ramifica-
tions, they can legitimize compensation, and they can
justify fee-for-service payments to clinicians. This
study will focus mostly on the primary uses, ‘‘defining
illness to determine treatment’’ and ‘‘communication
between clinicians’’ [Mellsop et al., 2007]. There are,
however, four issues to consider before we begin to
revise these nomenclatures for DSM-V and ICD-11.
GETTING THE STRUCTURE
CORRECT
Are the individual depressive and anxiety disorders in
Diagnostic and Statistical Manual of Mental Disorders-IV
(DSM-IV) distinct? If this were the case then the rates
of co-occurrence among these disorders would occur at
chance levels. However, the rates of co-occurrence
among these mental disorders are considerably higher
than would be expected [Andrews et al., 1990, 2002]. It
has been suggested that such rates could reflect the
existence of higher-order dimensions of psychopathol-
ogy. A number of studies have examined this and found
very similar groupings of mental disorders [Cox et al.,
2002; Kendler et al., 2003; Kessler et al., 2005;
Krueger, 1999, Krueger et al., 1998, 2001, 2003;
Vollebergh et al., 2001]. Using methodology originally
outlined in Krueger [1999] one recent study [Slade and
0.81/
Major depression 0.80
0.82/
Dysthymia 0.78
0.83/
0.69
Posttraumatic stress disorder
0.85/
0.85
Generalized anxiety disorder
0.75
Neurasthenia
0.82/
Social phobia 0.80
0.83/
Panic disorder 0.70
0.83/
0.90
Agoraphobia 0.78/
0.73
Obsessive compulsive disorder
0.72/
Alcohol dependence 0.80
0.70/
0.71
Drug dependence
Figure 1. Best fitting model of the structure of 10 common DSM-IV and 11 common ICD-10 mental disorders from the Australian
National Survey of Mental Health and Well-being, 1997. All parameter estimates (DSM-IV/ICD-10) are standardized and significant at
Po.05. All parameter estimates, except for Neurasthenia, relate to DSM-IV/ICD-10. The single parameter estimate for Neurasthenia
relates to ICD-10 only.
275
Watson, 2006] identified a hierarchical three-factor
structure as the best fit to 10 common DSM-IV and 11
common ICD-10 mental disorders. This structure was
characterized by correlated distress and fear factors
(which were best considered lower-order facets of a
broader internalizing factor) as well as an externalizing
factor. As can be seen in Figure 1, the individual mental
disorders that were characteristic of the distress factor
were major depression, dysthymia, generalized anxiety
disorder (GAD), posttraumatic stress disorder (PTSD),
and neurasthenia. In DSM-IV, neurasthenia would be
coded as Undifferentiated Somatoform Disorder
300.81. The mental disorders that were characteristic
of the fear factor were social phobia, agoraphobia,
panic disorder, and obsessive–compulsive disorder
(OCD). In this study the externalizing factor was best
characterized by drug and alcohol dependence.
SOLUTION
It had been supposed that as genetic and brain
functioning information became more precise it would
support the existence of categories of mental disorders.
This has not proved to be the case. The genetic
underpinnings of depression and anxiety disorders are
probably more related to the higher-order dimensions
of psychopathology than to individual syndromes
[Hettema et al., 2006]. On the basis of latent structure
data, Watson [Clark and Watson, 2006; Watson, 2005]
argues that there is now sufficient evidence to replace
the present grouping of disorders with an empirically
based structure that reflects the actual similarities
among disorders. Following such a model it might be
Distress 0.94/
0.88
Internalizing
0.93/
Fear 0.99
0.65/
0.61
Externalizing
Depression and Anxiety
276 Andrews et al.
possible to reduce the 10 categories of ICD and the 16
categories of DSM to a small number of clusters—one
of which would be internalizing disorders.
DISORDERS CAN BE BOTH
CATEGORIES AND DIMENSIONS
A diagnosis of major depression is made when there
are five or more of the nine symptoms specified in
Criterion A. This prompts an important question: is
there any evidence of a natural break in the distribution
of symptoms at or around this threshold? This issue
has been explored in a number of ways. Ustun and
Sartorius [1995] reported a study of 5,000 primary-care
attendees in 14 countries and found a linear relation-
ship between the number of depression symptoms and
disability. Kessler et al. [1997] using data from the
National Comorbidity Survey examined the relation-
ship between groups, defined by the number of
depressive symptoms, and risk of multiple clinical
correlates including parental history of mental illness,
number and duration of depressive episodes and
comorbidity. They found no natural break, the risk of
these clinical correlates increased simply with increas-
ing numbers of symptoms. Sakashita et al. [2007]
selected all people who endorsed the symptoms of
either ‘‘sadness or loss of interest’’ in the Australian
National Survey of Mental Health and Well-being
(NSMHWB) and examined the distribution of the
remaining seven possible symptoms of depression as
predictors of four measures of impairment. The
relationship between the number of symptoms and all
measures of impairment was linear, with no evidence of
any natural discontinuity that would support the use of
five of nine symptoms as a critical diagnostic threshold.
These studies examine the manifest or observable
relationship between severity as typified by the number
of depressive symptoms and suggested validators of
disease. However, recent focus has shifted to investiga-
tion of the latent structure. These latter studies
concentrate on the internal relationship between
symptoms and how these relationships give rise to
surface expression of symptomatology. Slade and
Andrews [2005] examined the latent structure of
depression using taxometric analysis, a statistical
technique designed specifically to determine whether
a given construct is best conceptualized by two latent
discrete categories or one latent continuous dimension.
They concluded, as had Ruscio and Ruscio [2000]
before them, that depression is best conceptualized,
measured, and classified as a continuously distributed
syndrome rather than as a discrete diagnostic entity.
One of the implications of this finding is that the
decision to offer treatment can be made at any level on
the continuum.
This does not necessarily mean that depression is
normally distributed throughout the population.
Although measures of psychological distress are
Depression and Anxiety
normally distributed, measures of depression may not
be. In the Australian NSMHWB the distribution of the
frequency of symptoms endorsed is, once the no-
symptom group is removed, normally distributed, in
part helped by the gateway symptoms of ‘‘depression’’
and ‘‘loss of interest’’ but probably an indication that in
addition to being a dimension, the symptoms refer to a
dimension of abnormal affect that indicates major
depressive disorder.
The situation in the anxiety disorders is similar, most
appear to be dimensional. The inclusion criteria for all
anxiety disorders specify either a count of the number
of key symptoms above which the diagnosis is made
and/or a duration of symptoms requirement. In this
sense the criteria are more complex than that for
depression. Taxometric analyses support dimensional-
ity. In OCD, taxometric analysis favored a dimensional
model for most subtypes [Haslam et al., 2005]. In
GAD, results of a taxometric analysis provided
evidence for the dimensionality of worry [Ruscio
et al., 2001]. In PTSD, taxometric analysis converged
on a dimensional solution that PTSD reflects the upper
end of stress–response continuum [Ruscio et al., 2002].
In social phobia, taxometric analysis produced evidence
of a dimensional latent structure [Kollman et al., 2006].
To quote Kraemer [2007] a ‘‘diagnosis of a disorder is
an expert opinion that the disorder is present.’’ Clearly,
the disorder was present before the expert clinician
made the diagnosis and will still be present when
treatment has reduced the symptoms on which the
diagnosis was based. When the disorder began it was
probably mild and would not have satisfied the formal
diagnostic criteria, after effective treatment it probably
does not satisfy the criteria any longer but it would be
specious to argue that the disorder changed simply
because it failed to match the threshold required for the
formal diagnosis. The purpose of a diagnostic system
such as DSM-IV is simply to describe common
presentations of a disorder in ways that might help a
clinician to recognize the disorder, educate the patient,
and apply an effective treatment to produce a better
outcome.
SOLUTION
Dimensionality can inform clinical practice [Helzer
et al., 2007]. Patients and therapists already know that
it is the progress along the dimension toward being
well that is important. Funders, the media, and lawyers
also have progress as their underlying goal. Most think
in dimensions but use categories as shorthand for
communication. The DSM/ICD revisions might there-
fore consider the dimensional nature of mental
disorders, and endorse measures that clinicians can
use to aid treatment planning and to measure outcome.
We have argued elsewhere [Andrews et al., 2007] that
the Patient Health Questionnaire (PHQ-9) could meet
this role in depression and await more evidence that the
GAD-7 [Kroenke et al., 2007] will do likewise in
 Research Article: Classification of Anxiety and Depressive Disorders
anxiety disorders. Although there are literally hundreds
of symptom measures in the literature, these two
currently have the advantage of being brief question-
naires in the public domain that are specifically linked
to the present classification.
DEFINING THRESHOLDS
IS CRITICAL
It is seldom realized how sensitive the diagnostic
criteria are to the exact words used. One method of
examining the sensitivity of the diagnostic thresholds to
changes in detail is to compare the positive cases
generated by a fully structured diagnostic instrument,
such as the Composite International Diagnostic Inter-
view, scoring the same interview according to ICD-10
and DSM-IV criteria. We report data from the
Australian NSMHWB. The interview in this survey
used CIDI v2.1 and addressed each and every criterion
in the two classifications. It was administered by an
interviewer from a computer that controlled the logic
and skips in the interview. The interviewer’s memory
was not a factor. The results were generated by
predetermined scoring algorithms.
The text descriptions in ICD-10 and DSM-IV of the
common affective disorders, major depression, GAD,
and PTSD, describe similar constructs so thatconcor-
dance is very good and both classifications are equally
valid. In Table 1 we present the 12-month prevalences
of the two sets of diagnoses together with
the concordance. Concordance is the percentage of
people positive on either classification or who were
positive on both.
The agreement in depression was good. The
prevalences were similar and 83% of those who met
the criterion on either classification met criterion on
both. The discrepancies in major depressive disorder
were related to the higher threshold of 5 of 9 symptoms
required in DSM-IV as against the 4 of 10 symptoms
required in ICD-10; and to the need for at least 2 of 3
critical symptoms being required in ICD-10 as against
at least 1 of 2 critical symptoms in DSM-IV. The
TABLE 1. The 12-month prevalences of the two sets of
diagnoses in the respondents in the Australian National
Survey of Mental Health and Well-being together with
the concordance—the percentage of people positive on
either classification who were positive on both
Prevalence in Prevalence in Percent
Disorder ICD-10 (%) DSM-IV (%) concordant
Major depressive 6.7 6.3 83
disorder
Generalized 3.7 3.6 41
anxiety
disorder
Posttraumatic 3.3 1.3 32
stress disorder
277
concept of major depressive disorder (MDD) is similar
in both classifications, the differences are trivial, and
need not have occurred.
In GAD the prevalences in the two classifications
were similar but only 41% met criteria on both
classifications when the exclusion criteria were oper-
ationalized [Slade and Andrews, 2001]. Fifty-five
percent of the DSM-IV cases failed to meet the ICD
criteria, half because they did not endorse more than 4
of 22 symptoms of autonomic arousal and half because
they did not meet the ICD exclusion criteria of panic/
agoraphobia, social phobia, or OCD. Sixty two percent
of ICD-10 cases did not meet the DSM criteria because
the worry was not identified as excessive and because
the clinical significance criteria were not endorsed. As a
result DSM cases were more disabled than the ICD
cases. The text descriptions are similar, worry is
described as excessive (DSM), and generalized and
persistent (ICD). In the ICD diagnostic criteria for
research ‘‘generalized and persistent’’ was changed to
‘‘prominent,’’ and many respondents who accepted that
their worry was ‘‘prominent’’ did not regard it as
‘‘excessive,’’ whereas it would seem reasonable that if
ICD had asked whether the worry was ‘‘generalized and
persistent’’ most endorsing that would then have
endorsed the ‘‘excessive’’ requirement in DSM. It was
the detail of the words describing the thresholds that
lead to dissonance. Although the prevalence rates are
almost identical, these classification systems are diag-
nosing different groups of people.
In PTSD both classifications regarded the disorder
as due to persisting memories and distress after a
traumatic experience, yet the agreement between ICD
and DSM was only 32%. The prevalence of ICD-10-
defined cases was more than double the prevalence of
DSM-IV-defined cases. There does not appear to be a
basic disagreement between DSM and ICD text
descriptions about the characteristics of PTSD but in
the ICD diagnostic criteria numbing was omitted and
the clinical significance criteria not applied. These
differences account for the higher prevalence in ICD.
Again the criteria could have been identical. We
conclude that defining a threshold on a continuum of
symptoms to establish a category is very sensitive to the
actual definition of the threshold.
SOLUTION
Kendell [1991] argued that there would be consider-
able attractions in making entire sections in DSM-IV
and ICD-10 identical. He said that if there were to be
differences, they should be substantial so that research
could lead to a rational choice between the alternatives.
The worst outcome, he said, would be for the two
classifications to be littered with trivial differences,
none rooted in important conceptual differences.
The dissonance between the DSM and ICD classi-
fications is not the issue. What is important is that this
comparison shows that quite small changes in words
Depression and Anxiety
278 Andrews et al.
describing the same criteria can have a substantial
effect on people being identified as cases. Thus,
revisions in the transition from DSM-IV to V and
from ICD-10 to 11 will have to be made with care.
Successful field trials in which clinicians use the new
system will not suffice. Before the new classifications
are ratified we should embed both systems in a fully
structured interview delivered to a population sample
to determine the effect of the changes.
SIMPLIFYING THE DIAGNOSTIC
CRITERIA TO IMPROVE
CLINICAL UTILITY
One problem for clinicians is the difficulty in
remembering the criteria. Humans can routinely recall
no more than five–nine items on a list unless they
develop a schema to aid memory. In DSM-IV the
diagnosis of major depression requires 20 pieces of
information to satisfy the five criteria, and PTSD
requires 25 pieces of information for six criteria, and
GAD 25 pieces of information to satisfy the six criteria.
ICD-10 is equally complex; for instance, GAD requires
34 pieces of information. Few clinicians can remember
to ask about such detail, and in a busy clinic there is no
time to consult a reference book.
Zimmerman et al. [2006] reviewed evidence that
even the nine symptoms in Criterion A in major
depression were poorly recalled. There is little research
on the ability of experienced mental health clinicians
to remember the details of the DSM-IV classifications,
but there is research on primary-care and trainee
clinicians. Rapp and Davis [1989] asked 49 primary-
care residents and 25 mental health residents to list
the nine Criterion A symptoms of depression in
DSM-III-R. The appetite/weight change symptom
was recalled best by 85% of the residents, and the
psychomotor changes least by 21% residents. The
cardinal symptoms, depression, and loss of interest
were recalled by 21 and 46% respectively. Similarly,
Krupinski and Tiller [2001] found that only one
quarter of general practitioners could list even five
symptoms, Medow et al. [1999] found that their
internal medicine residents did better, two-thirds could
list five or more symptoms of DSM-IV, but few could
list all. Depression is a common disease that all
physicians should be able to screen for. It is difficult
to screen for a disease if you can not remember the
symptoms.
If remembering the criteria is hard, there are no
penalties for not remembering them. For example, the
likelihood of high functioning, minimally impaired
clients receiving a depressive disorder NOS diagnosis is
positively associated with the need to ensure insurance
payment [Pomerantz and Segrist, 2006]. Lowe et al.
[2007] replicated this work in subclinical social phobia
and attention deficit hyperactivity disorder. One group
reports that 99.9% of claims for depressive disorder
Depression and Anxiety
NOS diagnosis are paid without challenge
(Mid America Coalition accessed 2007). There
are studies to show that the diagnosis of Depressive
Disorder NOS is used as commonly as the diagnosis of
MDD in both primary and speciality care [Busch,
2002; Frank and Blevins, 2004; Horn, 2003; Hu and
Rush, 1995]. A similar situation may exist for
anxiety disorder NOS [Frank and Blevins, 2004]
and for eating disorders NOS [Fairburn and Bohn,
2004]. This is not what the authors of DSM-IV
intended, an NOS diagnosis contains no clinical
information and neither informs treatment or assists
communication. Winter et al. [1991] reported that
70% of people receiving a DSM-III-R diagnosis of
depressive disorder NOS in primary care qualified for
specific diagnoses when Research Diagnostic Criteria
were applied. Thus, there may be some utility in
simplifying the main diagnostic criteria to facilitate
more accurate diagnosis. Clinicians could then re-
member and ask about a restricted symptom list and
have less need to use the NOS option, particularly if
the data required for the NOS diagnoses were
increased to be more complex, such as those required
by the DSM-IV decision trees.
SOLUTION
The present diagnostic criteria are complex. There
are two questions about increasing clinical utility;
whether decision support tools that allow all disorders
to be screened are practical for everyday use, and if not,
whether a simplified criteria would identify the same
people as the present criteria. One advantage of a
simplified system is that the full classification could
then include additional features.
Decision Support Tools. There is a range of
decision support tools that can be used to produce
provisional diagnoses. They range from paper-based
checklists to computer–based checklists, fully struc-
tured, diagnostic interviews. All help to increase the
accuracy of the clinical interview process. DSM-IV
contains diagnostic decision trees, the use of which
increases diagnostic accuracy and decreases diagnostic
time [Morgan et al., 2000]. Despite this advantage, they
are seldom used, presumably because they interfere
with the usual empathic taking of the clinical history
that tends to focus on the patient’s predicament as
much as the diagnosis and treatment plan.
There are many screening questionnaires that
patients can complete earlier to the interview with
the clinician, some paper based that will need scoring
and some computer based that can display the probable
diagnosis to inform the traditional diagnostic interview.
The paper-based PHQ-9 has been used to screen for
depression and has been shown to improve clinician
decision making [Andrews et al., 2007]. Zimmerman
[2003] reports on a broad self-administered diagnostic
screening questionnaire with good psychometric prop-
erties. Again usage is not widespread.
 Research Article: Classification of Anxiety and Depressive Disorders
There are many semistructured and fully structured
diagnostic interviews, both paper based and computer-
ized. Miller et al. [2001] compared three methods of
making a diagnosis (a traditional unstructured clinical
interview, a Structured Clinical Interview for DSM
(SCID), and a computer-aided diagnostic interview) to
the results of Spitzers [1983] ‘‘LEAD’’ standard . Both
structured interviews agreed and were better than the
traditional unstructured interview. In a subsequent
study, the computer-aided diagnostic interview was
associated with benefits: a reduced length of stay, more
accurate treatment, and considerable cost savings
[Miller, 2002]. Kashner et al. [2003] had nurses
administer the SCID to new patients and showed that
physicians treating patients who received SCIDs,
compared to physicians whose patients did not, were
more likely to order tests, update and change diagnoses
and medication in accord with the SCID results.
Thienemann [2004] reported on the use of a structured
diagnostic interview in a child and adolescent anxiety
disorder clinic. Consumer satisfaction and cooperation
increased, and the use of anxiety disorder NOS
decreased. Decision support tools that focus on
diagnostic validity have been widely available for 15
years but their use outside academic environments
remains small.
A Simplified Criterion Set To Improve Clinical
Utility. If decision support tools are not likely to be
widely used, would the traditional clinical interview
become more informative if it were possible to simplify
the diagnostic criteria without significant loss of
validity? Zimmerman et al. [2006], in an analysis of
their total clinic data set (n2000), concentrated on the
five psychological symptoms contributing to Criterion
A for major depression (depression, poor interest,
worthlessness, poor concentration, and thoughts of
death) and found that almost all patients who had met
criteria for five or more of the nine traditional
symptoms met the new criteria for three of the five
psychological symptoms and almost all who had not
met the old criteria failed to meet the new criteria. We
used data from the Australian NSMHWB and repli-
cated this finding, the agreement in our data between
the five of nine and three of five symptom sets was 97%
(Table 2). Diagnostic validity of Criterion A was
maintained in the restricted symptom set and there
seems little utility in maintaining the full symptom set
for clinical use [Andrews et al., 2007].
That Criterion A for major depression could be
simplified without loss of validity is understandable,
but could the multiple criteria that form a diagnosis be
simplified? Again we used CIDI v2.1 data from the
Australian NSMHWB to explore this issue. The CIDI
contains many skips and hidden rules and is not ideal
for this purpose. In depression, six pieces of informa-
tion—Criterion A of five significant symptoms (judged
to be clinically significant and not due to drugs or
alcohol, or physical disorders or injury) combined with
no history of mania or hypomania—identified many of
279
TABLE 2. Comparison of full and restricted DSM-IV
Criterion A of major depression in respondents meeting
criteria for any anxiety, affective, or substance use
disorder in the Australian National Survey of Mental
Health and Well-being (n 5 1,013)
Full criteria
Restricted criteria Met criteria44/9 Did not meet44/9 Total
Met criteria42/5 315 8 323
Did not meet42/5 24 666 690
Total 339 674 1,013
Sensitivity 92.9; specificity 98.8; overall agreement 96.8.
the same people as had the full criteria that required 20
pieces of information, agreement 0.95. In social
phobia, Criteria A and D together identified many of
the same people as the complete criteria, agreement
0.93. In GAD the data compromised the skip rules but
two pieces of information (Criterion A1 ‘‘excessive
worry’’ combined with C1 ‘‘keyed up’’) identified many
of the same people as had the full criteria requiring 25
pieces of information. PTSD was even more proble-
matic as Criterion A ‘‘experiencing an event’’ was not a
characteristic of the disorder just a necessary precondi-
tion. We combined four pieces of information (Criter-
ion A1, B1 ‘‘intrusive recollections,’’ and C1 or C2
‘‘avoidance of recollection,’’ or ‘‘avoidance of situa-
tion’’) and together they corresponded well with the
full criteria that required 25 pieces of information.
The restricted criteria above are based on the first
examination of one epidemiological data set, but they
do suggest that such an approach could be feasible. A
review of the literature on the simplification of
individual criteria is warranted. If the present position
is supported, that between two and six pieces of
information might be sufficiently valid to improve the
clinical utility of the present classifications, the next
step, before the DSM-V and ICD-11 drafting commit-
tees begin work, would be to examine a number of
different epidemiological data sets and a number of
different clinic data sets to define the fewest number of
characteristics that had the greatest correspondence
with the current full diagnostic criteria. These re-
stricted criteria might define the diagnoses at a level
suitable for general clinical use. Just what would be an
acceptable level of agreement between restricted and
full criteria remains to be determined. When the form
of the new diagnostic criteria for DSM-V and ICD-11
is known, the exercise would need to be repeated to
ensure that the clinical classification had the closest
correspondence to the research classification.
Implications: A Two Tier Classification. DSM-
IV combined clinical descriptions and diagnostic
criteria but the latter are too complex for clinicians to
remember without a decision support system. We, like
others [Watson and Clark, 2006], would advocate a
two-tier classification, one focused on clinical utility,
Depression and Anxiety
280 Andrews et al.
the other on clinical validity, with clinical utility criteria
identifying people for treatment, and clinical validity
criteria subdividing the same people according to
additional criteria required for research or when
response to treatment has not occurred.
CONCLUSIONS
The problems with the current DSM-IV and ICD-
10 classifications of anxiety and depressive disorders
stem from two sources, a level of complexity that makes
the classifications difficult to remember during a
traditional patient interview, and inadequate control
over detail defining the thresholds and exclusion
criteria for many diagnoses. There is new information
on the meta-structure of mental disorders that could
inform the revisions. There is growing agreement
about the dimensional nature of these disorders, and
methods to incorporate measurement of the severity
dimension within each disorder should be developed.
The problem of complexity could be managed by
ensuring the widespread use of decision support tools
that allow much more detailed enquiry than presently
used when clinicians diagnose patients, or by simplify-
ing the classification for use in traditional patient
interviews or both. A mechanism for the development
of a two-tier classification is proposed
Acknowledgments. Dr. Andrews is a member of
the WHO International Advisory Group for the
Revision of ICD-10 Mental and Behavioral Disorders.
Dr. Andrews has been a member of five APA groups
working toward DSM-V and Dr. Slade a member of
one such group; the views expressed in the study are
their own and cannot be construed to be the views of
WHO or the APA or of any of the groups. The authors
appreciate critical comments from Ayelet Ruscio,
David Watson, and Mark Zimmerman.
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