BMJ  2003;327:869-870 (11 October), doi:10.1136/bmj.327.7419.869-b

Letter

Separation of anxiety and depressive disorders

New tools will lead to more valid classification system

EDITOR—Shorter and Tyrer's comments about the implications of separating depressive and anxiety disorders in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) are perplexing, but not enlightening.¹

Implying that this separation is impeding the development of new antidepressants, the authors cite an inverse relation between the number of patented new drugs and the number of DSM categories, then acknowledge that this association may not be causal. They call for companies to develop drugs targeting the heterogeneous category of mixed anxiety and depression but ignore the added cost resulting from the huge sample sizes of patients that would be needed to see even small drug effects.

Finally, the authors incorrectly assert that the drug industry significantly influences the diagnostic revision process. No facet of the DSM-IV revision process entailed any pharmaceutical company support.

We contend that the Food and Drug Administration's approval of compounds for multiple, diagnosis specific indications reflects their broad spectrum of efficacy and has no bearing on the pace of new drug development. Moreover, adopting broadly defined indications could encourage over-prescribing by blurring the diagnostic threshold that separates "normal" depression and anxiety from pathological states.

Certainly the biggest hindrance to both successful new drug development and the utility of the DSM classification is our current lack of understanding of the underlying pathophysiology of psychiatric disorders. New tools ranging from neuroimaging to functional genomics will help to elucidate the pathophysiology of mood and anxiety disorders, leading to a more valid classification system and, in turn, accelerated development of new medications.

Columbia University, 1051 Riverside Drive, Unit 60, New York, NY 10032, USA mbf2{at}columbia.edu

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209, USA

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Competing interests: MBF was editor of text and criteria for DSM-IV and DSM-IV-TR. DAR is director of APA Division of Research, which oversees the development of the DSM.

References

1. Shorter E, Tyrer P. Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease. BMJ 2003;327: 158-60. (19 July.)[Free Full Text]

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Relevant Article

Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease

Edward Shorter and Peter Tyrer
BMJ 2003 327: 158-160. [Extract] [Full Text] [PDF]