Depression: The Shroud of Heterogeneity
Abstract
Over the past several decades, depression has emerged as a major public health problem. Yet depression has not always represented such a prominent psychiatric condition, and the term depression has harbored different meanings over time. One widely agreed upon way of explaining such variation in what depression implies has been to describe depression as being heterogeneous. In the present article, depression is examined in relation to different types of heterogeneity, particularly with regard to the concept of a syndrome. The consequences of various meanings of heterogeneity for understanding the nature of depression are then explored. Finally, we speculate on the implications for the future of depression research and practice.
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The heterogeneity of depression is evident from the multiple ways in which symptoms combine to produce a variety of clinical phenotypes.
“The heterogeneity is evident, however, from the multiple ways in which symptoms combine to produce a variety of clinical phenotypes. 6”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [6]
Cites
Diagnostic and Statistical Manual of Mental Disorders
American Psychiatric Association (2013) · doi:10.1176/appi.books.9780890425596 · Cited by 116,369 · see citing works
Diagnostic and Statistical Manual of Mental Disorders
American Psychiatric Association (2022) · doi:10.1176/appi.books.9780890425787 · Cited by 23,476 · see citing works
Network analysis: An integrative approach to the structure of psychopathology
Borsboom, D., & Cramer, A. O. J. (2013) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-050212-185608 · Cited by 4,359 · see citing works
Horwitz, A. V., & Wakefield, J. C. (2007) · doi:10.1093/oso/9780195313048.001.0001 · Cited by 1,019 · see citing works
Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanczyk, G., & Poulton, R. (2010) · Psychological Medicine · doi:10.1017/s0033291709991036 · Cited by 938 · see citing works
The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder
(2009) · PsycEXTRA Dataset · doi:10.1037/e671332011-001 · Cited by 752 · see citing works
Overview of Recent Research in Depression
Akiskal, H. S. (1975) · Archives of General Psychiatry · doi:10.1001/archpsyc.1975.01760210019001 · Cited by 548 · see citing works
Healy, D. (1998) · DigitalGeorgetown (Georgetown University Library) · Cited by 415 · see citing works
Constructing constructs for psychopathology: The NIMH research domain criteria.
Cuthbert, B. N., & Kozak, M. J. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0034028 · Cited by 364 · see citing works
Jackson, S. W. (1986) · Yale University Press eBooks · doi:10.2307/j.ctt1xp3stn · Cited by 335 · see citing works
Psychiatric Diagnosis as Reified Measurement
Mirowsky, J., & Ross, C. E. (1989) · Journal of Health and Social Behavior · doi:10.2307/2136907 · Cited by 276 · see citing works
Melancholia and depression during the 19th century: a conceptual history
Berrios, G. E. (1988) · British Journal of Psychiatry · doi:10.1192/bjp.153.3.298 · Cited by 123 · see citing works
Wakefield, J. C., & Schmitz, M. F. (2013) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.12184 · Cited by 82 · see citing works
Neurasthenic Nation: America's Search for Health, Happiness, and Comfort, 1869-1920
Shorter, E. (2012) · Journal of American History · doi:10.1093/jahist/jas281 · Cited by 72 · see citing works
The classification of depression: are we still confused?
Cole, J. H., McGuffin, P., & FARMER, A. E. (2008) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.107.039826 · Cited by 37 · see citing works
American melancholy: constructions of depression in the twentieth century
(2010) · Choice Reviews Online · doi:10.5860/choice.47-3484 · Cited by 26 · see citing works
Is major depression that major?
Parker, G. B. (2013) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.12189 · Cited by 3 · see citing works
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Sorted by citations
Time for united action on depression: a Lancet–World Psychiatric Association Commission
Herrman, H., Patel, V., Kieling, C., Berk, M., Buchweitz, C., Cuijpers, P., Furukawa, T. A., Kessler, R. C., Kohrt, B. A., Maj, M., et al. (2022) · The Lancet · doi:10.1016/s0140-6736(21)02141-3 · Cited by 1,104 · see citing works
Major Depression and Its Recurrences: Life Course Matters
Monroe, S. M., & Harkness, K. L. (2022) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-072220-021440 · Cited by 608 · see citing works
Self-citationClashing diagnostic approaches: DSM-ICD versus RDoC
Lilienfeld, S. O., & Treadway, M. T. (2016) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-021815-093122 · Cited by 275 · see citing works
Khazanov, G. K., & Ruscio, A. M. (2016) · Psychological Bulletin · doi:10.1037/bul0000059 · Cited by 240 · see citing works
Beijers, L., Wardenaar, K. J., van Loo, H. M., & Schoevers, R. A. (2019) · Molecular Psychiatry · doi:10.1038/s41380-019-0385-5 · Cited by 240 · see citing works
Forbes, C. N. (2020) · Clinical Psychology Review · doi:10.1016/j.cpr.2020.101860 · Cited by 88 · see citing works
Modelling mood disorders: An ACE solution?
Malhi, G. S., Irwin, L., Hamilton, A., Morris, G., Boyce, P. M., Mulder, R., & Porter, R. (2018) · Bipolar Disorders · doi:10.1111/bdi.12700 · Cited by 80 · see citing works
Role of trazodone in treatment of major depressive disorder: an update
Fagiolini, A. M., González-Pinto, A. M., Miskowiak, K. W., Morgado, P. F., Young, A. H., & Vieta, E. (2023) · Annals of General Psychiatry · doi:10.1186/s12991-023-00465-y · Cited by 65 · see citing works
MRI predictors of pharmacotherapy response in major depressive disorder
Gerlach, A. R., Karim, H. T., Peciña, M., Ajilore, O., Taylor, W. D., Butters, M. A., & Andreescu, C. (2022) · NeuroImage: Clinical · doi:10.1016/j.nicl.2022.103157 · Cited by 57 · see citing works
Lilienfeld, S., Watts, A. L., Murphy, B. A., Costello, T. H., Bowes, S. M., Smith, S. F., Latzman, R. D., Haslam, N., & Tabb, K. (2019) · Journal of Personality Disorders · doi:10.1521/pedi.2019.33.5.577 · Cited by 42 · see citing works
Default mode network activity in depression subtypes
Borserio, B. J., Sharpley, C. F., Bitsika, V., Sarmukadam, K., Fourie, P. J., & Agnew, L. L. (2021) · Reviews in the Neurosciences · doi:10.1515/revneuro-2020-0132 · Cited by 40 · see citing works
Beltz, A. M. (2022) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2022.101037 · Cited by 39 · see citing works
Beijers, L., Wardenaar, K. J., Bosker, F. J., Lamers, F., van Grootheest, G., de Boer, M. K., Penninx, B. W. J. H., & Schoevers, R. A. (2018) · Psychological Medicine · doi:10.1017/s0033291718001307 · Cited by 37 · see citing works
Social expectations in depression
Kirchner, L., Κube, T., Berg, M., Eckert, A.-L., Straube, B., Endres, D., & Rief, W. (2024) · Nature Reviews Psychology · doi:10.1038/s44159-024-00386-x · Cited by 31 · see citing works
Lloyd, A., Broadbent, A., Brooks, E., Bulsara, K., Donoghue, K., Saijaf, R., Sampson, K. N., Thomson, A. C., Fearon, P. R. M., & Lawrence, P. J. (2023) · BJPsych Open · doi:10.1192/bjo.2023.545 · Cited by 28 · see citing works
Gendered Mechanisms Underlie the Relation Between Pubertal Timing and Adult Depressive Symptoms
Beltz, A. M. (2018) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2017.12.019 · Cited by 26 · see citing works
Modeling Heterogeneous Brain Dynamics of Depression and Melancholia Using Energy Landscape Analysis
Regonia, P. R., Takamura, M., Nakano, T., Ichikawa, N., Fermin, A. S. R., Okada, G., Okamoto, Y., Yamawaki, S., Ikeda, K., & Yoshimoto, J. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.780997 · Cited by 21 · see citing works
Christen, M., Domingo‐Ferrer, J., Draganski, B., Spranger, T. M., & Walter, H. (2016) · Law, governance and technology series · doi:10.1007/978-3-319-33525-4_9 · Cited by 20 · see citing works
Nielsen, K., & Ward, T. J. (2020) · Theory & Psychology · doi:10.1177/0959354320906462 · Cited by 18 · see citing works
Improving Depression Severity Prediction from Passive Sensing: Symptom-Profiling Approach
Akbarova, S., Im, M., Kim, S. H., Toshnazarov, K. E., Chung, K., Chun, J., Noh, Y., & Kim, Y.-A. (2023) · Sensors · doi:10.3390/s23218866 · Cited by 17 · see citing works
Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome
Burton, M. S., Cooper, A. A., Mello, P. G., Feeny, N. C., & Zoellner, L. A. (2021) · Behavior Therapy · doi:10.1016/j.beth.2020.12.005 · Cited by 17 · see citing works
Smit, A. C., Helmich, M. A., Bringmann, L. F., Oldehinkel, A. J., Wichers, M., & Snippe, E. (2025) · Clinical Psychological Science · doi:10.1177/21677026241305136 · Cited by 17 · see citing works
Anderson, S. F., Monroe, S. M., Rohde, P., & Lewinsohn, P. M. (2015) · Clinical Psychological Science · doi:10.1177/2167702615591951 · Cited by 17 · see citing works
Self-citationThe Association Between Juvenile Onset of Depression and Emotion Regulation Difficulties
Visted, E., Sørensen, L., Vøllestad, J., Osnes, B., Svendsen, J. L., Jentschke, S., Binder, P., & Schanche, E. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02262 · Cited by 15 · see citing works
Beijers, L., van Loo, H. M., Romeijn, J., Lamers, F., Schoevers, R. A., & Wardenaar, K. J. (2020) · Psychological Medicine · doi:10.1017/s0033291720002846 · Cited by 15 · see citing works
Avaliando "depressões": dos critérios diagnósticos às escalas psicométricas
Baptista, M. N. (2018) · Revista Avaliação Psicológica · doi:10.15689/ap.2018.1703.14265.03 · Cited by 14 · see citing works
Piccin, J., Viduani, A. C., Buchweitz, C., Pereira, R. B., Zimerman, A., Amando, G. R., Cosenza, V., Ferreira, L. Z., McMahon, N. A. G., de Melo, R. F., et al. (2023) · JAACAP Open · doi:10.1016/j.jaacop.2023.11.002 · Cited by 14 · see citing works
Vieira, R., Coelho, A., Reis, J. S., Portugal‐Nunes, C., Magalhães, R. J. D. S., Ferreira, S., Moreira, P. S., Sousa, N., & Bessa, J. M. (2021) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2021.693109 · Cited by 14 · see citing works
Lewis, L. R., Benn, A., Dwyer, D. M., & Robinson, E. S. J. (2019) · Behavioural Brain Research · doi:10.1016/j.bbr.2019.112051 · Cited by 14 · see citing works
Hakulinen, C. A., Böckerman, P., Pulkki-Råbäck, L., Virtanen, M., & Elovainio, M. J. (2020) · Occupational and Environmental Medicine · doi:10.1136/oemed-2020-106660 · Cited by 13 · see citing works
Ramos, S. D., Vincent, W., Siconolfi, D. E., Pollack, L. M., Horvath, K. J., Campbell, C. K., Tebbetts, S., Kegeles, S. M., & Storholm, E. D. (2023) · AIDS and Behavior · doi:10.1007/s10461-023-04186-x · Cited by 12 · see citing works
Ahorsu, D. K., & Tsang, H. W. H. (2018) · Neuropsychiatry · doi:10.4172/neuropsychiatry.1000451 · Cited by 12 · see citing works
Dang, K., Ritvo, P., Katz, J. D., Gratzer, D., Knyahnytska, Y., Ortiz, A., Walters, C., Attia, M., Gonzalez‐Torres, C., Lustig, A., et al. (2023) · Interactive Journal of Medical Research · doi:10.2196/46419 · Cited by 11 · see citing works
Depressive symptoms are associated with reduced positivity preferences in episodic memory in aging
James, T., & Duarte, A. (2022) · Neurobiology of Aging · doi:10.1016/j.neurobiolaging.2022.10.006 · Cited by 11 · see citing works
Depression, Chemical Imbalances, and Feminism
Schultz, W., & Hunter, N. (2016) · Journal of Feminist Family Therapy · doi:10.1080/08952833.2016.1235523 · Cited by 10 · see citing works
Shahar, G. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.721746 · Cited by 10 · see citing works
Cheung, H., Asgarabad, M. H., Ho, W., Zibetti, M., Li, S.-T.-K., Stella, W. Y. C., & Williams, J. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-06161-9 · Cited by 7 · see citing works
Alsalloum, G. A., Dalibalta, S., & Hadijat, Y. (2025) · Frontiers in Digital Health · doi:10.3389/fdgth.2025.1654745 · Cited by 9 · see citing works
An active inference approach to interpersonal differences in depression
Kirchner, L., Eckert, A.-L., Berg, M., Endres, D., Straube, B., & Rief, W. (2024) · New Ideas in Psychology · doi:10.1016/j.newideapsych.2024.101092 · Cited by 9 · see citing works
The (Suicidal-) Depressive Position: A Scientifically Informed Reformulation
Shahar, G. (2018) · Psychodynamic Psychiatry · doi:10.1521/pdps.2018.46.2.265 · Cited by 8 · see citing works
Bailey, R., Clemens, K., Portela, B., Bowrey, H. E., Pfeiffer, S. N., Geonnotti, G., Riley, A., Sminchak, J., Kevo, S. L., & Naranjo, R. R. (2024) · Psychiatry Research Communications · doi:10.1016/j.psycom.2024.100200 · Cited by 6 · see citing works
Cheung, H. N., Williams, J. M., Chan, Y. S., & Chan, S. W. Y. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.04.035 · Cited by 6 · see citing works
The computational psychopathology of emotion
Erdman, A., & Eldar, E. (2023) · Psychopharmacology · doi:10.1007/s00213-023-06335-5 · Cited by 6 · see citing works
Using the NIMH Research Domain Criteria (RDoC) in human and nonhuman primate research
Dario Maestripieri, A., & Lilienfeld, S. O. (2016) · Psychophysiology · doi:10.1111/psyp.12552 · Cited by 6 · see citing works
Zhou, J., Zhou, J. L., Feng, Y., Feng, L., Xiao, L., Xu, C., Feng, Z., Yang, J., & Wang, G. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.12.005 · Cited by 5 · see citing works
Bayer, J., van Velzen, L. S., Pozzi, E., Davey, C. G., Han, L. K. M., Bauduin, S., Bauer, J., Benedetti, F., Berger, K., Bonnekoh, L. M., et al. (2025) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2025.03.17.643677 · Cited by 5 · see citing works
Chen, S., Zhang, J., Wu, G., Ouyang, X., Liu, Z., Lv, D., Han, Z., Xiang, Y., Chen, T., Xu, C., et al. (2025) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2025.05.010 · Cited by 4 · see citing works
Sharpley, C. F., Bitsika, V., Arnold, W. M., Shadli, S. M., Jesulola, E., & Agnew, L. L. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1194318 · Cited by 4 · see citing works
Will Adults’ Happiness be Affected by Childhood Parental Divorce? Evidence From China
Liu, Y., & Ren, Z. (2023) · Journal of Family Issues · doi:10.1177/0192513x231194292 · Cited by 4 · see citing works
Sharpley, C. F., Bitsika, V., Sarmukadam, K., & Agnew, L. L. (2019) · Archives of Depression and Anxiety · doi:10.17352/2455-5460.000039 · Cited by 3 · see citing works
Henry, L. M., Pandya, U., Malone, E. P., Miller, C., Agyemang, S., Tandilashvili, E., Lewis, K., Haeffner, C. E., Lee, K., Livinski, A. A., et al. (2026) · NPP—Digital Psychiatry and Neuroscience · doi:10.1038/s44277-026-00058-z · Cited by 2 · see citing works
Valentini, F., Baptista, M. N., & Filho, N. H. (2021) · Paidéia (Ribeirão Preto) · doi:10.1590/1982-4327e3129 · Cited by 2 · see citing works
An Exploratory Comparison of Alpha and Beta Network Connectivity Across Four Depression Subtypes
Sharpley, C. F., Evans, I. D., Bitsika, V., Vessey, K. A., Odierna, G. L., Jesulola, E., & Agnew, L. L. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14155295 · Cited by 2 · see citing works
Remmers, C., Zimmermann, J., Topolinski, S., Richter, C., Zander-Schellenberg, T., Weiler, M., & Knaevelsrud, C. (2020) · Clinical Psychology in Europe · doi:10.32872/cpe.v2i4.2593 · Cited by 2 · see citing works
Zhang, Y., Wang, N., Lin, X., Wang, J., & Luo, F. (2022) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2022.924319 · Cited by 2 · see citing works
Zapetis, S. L., Li, J., Xu, E. P., Ye, Z., Phanord, C. S., Trull, T. J., Schneider, S., & Stange, J. P. (2024) · Depression and Anxiety · doi:10.1155/da/9193159 · Cited by 2 · see citing works
The Task of Explanation (and the Beginnings of Treatment)
Nielsen, K. (2023) · Palgrave Studies in the Theory and History of Psychology · doi:10.1007/978-3-031-29164-7_6 · Cited by 1 · see citing works
EFFECTIVENESS OF THRESHOLD-LEVEL VAGUS NERVE STIMULATION IN MODULATING PSYCHOEMOTIONAL STATES
Gachshenko, Y., Zhadigerova, A., Vysokov, N. V., Kuzembayeva, Y., Ferreira, J. M. A., Palamar, B. I., & Тукаєв, С. (2026) · Clinical and Preventive Medicine · doi:10.31612/2616-4868.2.2026.04 · Cited by 1 · see citing works
Ross, C., McBride, O., Henderson, E. M., & Adamson, G. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.121213 · Cited by 1 · see citing works
Helmich, M. A. (2022) · doi:10.33612/diss.200101721 · Cited by 1 · see citing works
Fleshing Out the Concept, and Questions of Classification
Nielsen, K. (2023) · Palgrave Studies in the Theory and History of Psychology · doi:10.1007/978-3-031-29164-7_5
Koivisto, H., Smolander, H., Honkalampi, K. M., Pakarinen, M., Ruusunen, A. A., & Valkonen‐Korhonen, M. (2025) · Psykologia · doi:10.62443/psykologia.v58i1.112900
Villalobos-Gallegos, L., Trejo, S., Cruz, D. M., Toledo-Fernández, A., & González-García, D. A. (2025) · Psychiatry International · doi:10.3390/psychiatryint6040126
Additional file 1 of Role of trazodone in treatment of major depressive disorder: an update
Fagiolini, A., González-Pinto, A., Miskowiak, K. W., Morgado, P., Young, A. H., & Vieta, E. (2024) · Figshare · doi:10.6084/m9.figshare.26614498
Xu, C., Lu, W., Zheng, Y., Chen, S., Xiang, Y., Tan, C., Xu, X., Zheng, L., Cong, P., Feng, J., et al. (2026) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-026-02210-4
Stigmatisation de soi dans la schizophrénie : une série d’études en population générale et clinique
Violeau, L. (2020) · theses.fr (ABES) · doi:10.70675/caaf6820z23bfz4661za926z5f5f1262d79a
Relations among daily symptoms of depression
Quinn, M. E., Kleinman, M. E., Standring, J. P., & Liu, Q. (2026) · British Journal of Psychology · doi:10.1111/bjop.70072
Saillart, E., Jacobs, K., Claes, S. J., & Vergaelen, E. (2026) · Brain Behavior & Immunity - Health · doi:10.1016/j.bbih.2026.101334
Saleem, S., & Anjum, R. (2026) · International Journal of Advanced Psychiatric Nursing · doi:10.33545/26641348.2026.v8.i9a.293
- Authors
- Monroe, S. M., & Anderson, S. F.
- Affiliations
- University of Notre Dame (US)
- Venue
- Current Directions in Psychological Science
- Publisher
- SAGE Publications
- Published
- 2015-06
- Volume
- 24
- Issue
- 3
- Pages
- 227-231
- ISSN
- 0963-7214 (ISSN-L)
- 1467-8721
- OpenAlex
- W2210298535
- Cited by
- 68
- References
- 17
- Citations by year
- 2026: 6 · 2025: 7 · 2024: 6 · 2023: 12 · 2022: 8 · 2021: 6 · 2020: 6 · 2019: 5 · 2018: 6 · 2016: 5 · 2015: 1
- FWCI
- 30.60
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Current Directions in Psychological Science (publishedVersion)
- Topics
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- depression, depression heterogeneity, history of depression, psychiatric classification
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