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Cited by 227Personality Disorders and PsychopathologyMental Health and PsychiatryAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

The severity of psychiatric disorders

Open access
Zimmerman, Mark, Morgan, Theresa A., Stanton, Kasey·2018·World Psychiatry
DOI 10.1002/wps.20569PMC PMC6127765
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Abstract

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM‐5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom‐defined disorders depends on factors extrinsic to those disorders, such as self‐efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

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  • Severity is typically conceptualized and measured through DSM-5-based scales that overlook broader functional and socio-structural dimensions.

    “This also raises questions about how severity is conceptualized and measured, typically through DSM-5-based scales that overlook broader functional and socio-structural dimensions [179].”

    From Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review (2025) · cites this paper as [179]

    The Conclusions (page unavailable) say depression severity is predominantly measured with symptom-rating scales, and the section on DSM-5 and ICD-10 depression severity says treatment studies generally do not consider functional impairment. But the paper does not characterize those instruments as DSM-5-based; it also says DSM-5 severity definitions include social and occupational impairment and that functioning is central to personality-disorder severity. It does not establish that severity scales generally overlook socio-structural dimensions. (LLM, conf=0.88)

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  • Current formal assessment strategies fail to capture most of the information about positive affects and their borders with elation and behavioral activation.

    “However, current formal assessment strategies fail to capture most of this information 49 .”

    From The pursuit of euthymia (2020) · cites this paper as [49]

    The section ‘Scales measuring the severity of depression’ discusses limitations in scale content and rating formats, and the Conclusions say that how best to measure severity has received little study. Neither passage addresses whether formal assessments fail to capture positive affect or its boundaries with elation and behavioral activation; searches for those terms found no relevant passage. Page numbers were not available in our copy. (LLM, conf=0.72)

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  • Patients with severe mental disorders report a greater desire to be involved in clinical decision-making and a need to have a say in the process of care than individuals receiving assistance for other medical conditions.

    “This has been especially highlighted in the case of patients with severe mental disorders who report a greater desire of being involved in clinical decision-making and a need to have a say in the process of care, as compared to individuals receiving assistance for other medical conditions [8–11].”

    From The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: A clinical review (2020) · cites this paper as [11]

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Research works printed but not linked: 4

  1. [67]67. Zimmerman M, Posternak M, Friedman M et al. Which factors influence psy- chiatrists' selection of an antidepressant? Am J Psychiatry 2004;161:1285-9.
  2. [87]87. Rush AJ, Gullion CM, Basco MR et al. The Inventory of Depressive Symp- tomatology (IDS). Psychol Med 1996;26:477-86.
  3. [142]142. Elkin I, Shea M, Watkins J et al. NIMH treatment of depression collabora- tive research program: general effectiveness of treatments. Arch Gen Psy- chiatry 1989;46:971-82.
  4. [160]160. Paris J. Dimensional diagnosis and the DSM-5. J Clin Psychiatry 2005;72: 1340.

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Authors
Zimmerman, M., Morgan, T. A., & Stanton, K.
Affiliations
Brown University (US)
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2018-09-07
Volume
17
Issue
3
Pages
258-275
ISSN
  • 1723-8617 (ISSN-L)
  • 2051-5545
DOI
10.1002/wps.20569
PMC
PMC6127765
OpenAlex
W2890739253
Cited by
227
References
200
Citations by year
2026: 23 · 2025: 32 · 2024: 28 · 2023: 28 · 2022: 49 · 2021: 25 · 2020: 32 · 2019: 9 · 2018: 1
FWCI
19.64
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • World Psychiatry (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
depression severity, personality disorders, DSM-5, functional disability, symptom rating scales, psychiatric disability, antidepressant efficacy, treatment outcome measures, quality of life

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