By Carlos A. Morra
Depression is one of the earliest diagnoses identified by mankind, and its roots can be traced to Hippocrates and the concept of melancholia (Black bile). However, earlier descriptions are present in ancient documents, such as the Bible (the Book of Job) (Adams 1929). Nonetheless, despite the longstanding tradition, several questions still arise about its nosological validity, etiopathology and even clinical manifestations (Kendler 2016; Heckers 2008).
Finding the natural categories of this disease has been the holy grail of depressive disorders research, but many seemingly useful classifications were quickly excluded from international classifications before clinical researchers could even test their validity. One of the factors that triggered the development of the CODE system by Thomas A. Ban was the recognition that “vital depressions” completely disappeared in consensus-based classifications, such as the DSM-III (American Psychiatric Association 1980). This subtype of depression is characterized by “corporization,” “disturbance of vital balance” and the “feeling of loss of vitality.” Although it was clearly identified and treated, it vanished from international classifications together with many other distinct disorders (Schneider 1920, 1950, 1959).
The prototype of the Composite Diagnostic Evaluation System (CODE System) is the CODE for Depressive Disorders or CODE-DD, developed by Ban and published in 1989 (Ban 1989). It consisted of a 90-item vocabulary, a structured interview, a 40-item severity subscale and 25 diagnostic decision trees (algorithms). In addition, the computer version was developed together with Olaf Fjetland and allowed to easily process patient’s results and obtain the diagnoses (Ban 1989).
The methodology started from a structured interview; then the presence of each symptom or sign (variable) was derived from processing the patient’s answers using symptom algorithms. At the end of this process, the presence, or absence of the symptoms and signs were analyzed using the diagnostic algorithms of all the classifications included in the system, resulting in up to 25 distinct diagnoses for the same patient (Ban 1989).
This system showed an inter-rater agreement of 87.8% in the first reliability study that included 239 patients (Morey 1991). In the further studies, inter-rater agreement ranged from 97.2-100% (Ban, Fjetland, Kutscher and Morey 1993). This system was used in a series of clinical studies in the early development of reboxetine, a selective NE re-uptake blocker (Ban, Gaszner, Aguglia et al. 1998).
In the late 1990s, when Tom A. Ban and Carlos Morra were writing a book on psychopathology, they started to talk about the need for testing some of the current subtypes of depression and they agreed to review CODE-DD to update it to include the DSM-IV, DSM IV-TR and ICD-10. Then, CODE-DD was revised and renamed CODE-UD, with English and Spanish versions, the vocabulary varied from 90 to 220 variables and the number of diagnostic algorithms increased from 25 to 84. The new version included all major diagnostic concepts and classifications of melancholia/depression from Hippocrates (460-377 BC) to the DSM-IV (American Psychiatric Association 1994). In addition, CODE-UD includes several types of clinical interviews, self-rating interviews and five severity scales. Its structure is compatible with artificial intelligence and predictive models and could help analyze the results of studies on biomarkers at a significant scale (Belsher, Smolenski, Pruitt et al. 2019; Morra and Kreiker 2020).
The practical applications of this composite diagnostic instrument were not fully explored and include clinical psychopharmacological, nosological, research and education.
Based on the possible academic applications we will be presenting on our weekly postings all the English components of the CODE-UD.
Adams F. Genuine Works of Hippocrates. Translated from the Greek. New York: William Wood & Co; 1929.
American Psychiatric Association. DSM-III. Diagnostic and Statistical Manual of Mental Disorders. Third Edition; 1980.
American Psychiatric Association. DSM-IV. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition; 1994.
Ban TA. CODE-DD. Composite Diagnostic Evaluation of Depressive Disorders. Nashville: JM Productions; 1989.
Ban TA, Fjetland OK, Kutscher M, Morey LC. CODE-DD development of a diagnostic scale for depressive disorders. In: Hindmarch I, Stonier PD, editors. Human Psychopharmacology. Measures and Methods. Vol. 4. Chichester: John Wiley& Sons; 1993, pp. 73-85.
Ban TA, Gaszner P, Aguglia E, Batista R, Castillo A, Lipcsey A, Macher J-P, Torres-Ruis A, Vergara L. Clinical efficacy of reboxetine: a comparative study with desipramine with methodological considerations. Human Psychopharmacology 1998;13(Suppl. 1):29-39.
Belsher BE, Smolenski DJ, Pruitt LD, Bush NE, Beech EH, Workman DE, Morgan RL, Evatt DP, Tucker J, Skopp NA. Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiatry 2019;76(6):642-51.
Heckers S. Making progress in schizophrenia research. Schizophrenia bulletin 2008;34(4):591–4.
Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry 2016;173(8):771-80.
Morey L. Reliability considerations in the development of CODE-DD. In: Aguglia E, Ban TA, editors. Functional Psychoses Today. Rome: Jon Libbey; 1991, pp. 297-304.
Morra C, Kreiker M. General Psychopathology 21. (Thomas A. Ban: Towards a clinical methodology for neuropsychological research). inhn.org.centraloffice. December 3, 2020.
Schneider K. Die Schichtung des emotionalen Lebens und der Aufbau der Depressionszustände. Z Ges Neurol Psychiatr 1920;59:281-5.
Schneider K. Klinische Psychopathologie. 3 Aufl. Stuttgart; Thieme; 1950.
Schneider K. Clinical Psychopathology (translated by Mary W. Hamilton). New York: Grune & Stratton; 1959.
September 1, 2022