Howe Synnott

Inching toward Bethlehem: Mapping melancholia

BACKGROUND As melancholia has resisted symptom-based definition, this report considers possible explanations and options for moving forward. Clinician-assigned melancholic and non-melancholic groups were initially compared to refine a candidate set of differentiating symptoms alone for examination against a set of non-clinical validators. Analyses then examined the capacity of both the refined symptom and validator sets to discriminate the assigned melancholic and non-melancholic subjects. METHODS Subjects completed measures assessing symptoms and correlates (putative validators) of diagnostic sub-type, and were assessed independently by two psychiatrists. RESULTS Analyses identified 14 severity-based symptoms as discriminating clinically-diagnosed groups - with melancholic subjects differing significantly from non-melancholic subjects across a number of validators. Such symptom-based discrimination was superior to DSM-IV and Newcastle Index assignment in a study sub-set. While the refined symptom set had an overall accurate classificatory rate of 68%, use of the combined sets of refined symptoms and validators improved classification to 80%. CONCLUSIONS Melancholia definition is improved by the use of correlates in addition to depressive symptoms, suggesting that melancholia may be mapped more precisely by use of multiple co-ordinates or data sources.

The duration of undiagnosed bipolar disorder: effect on outcomes and treatment response.

INTRODUCTION There are commonly long delays between the onset of bipolar disorder (BP), seeking of treatment and acquiring a bipolar disorder diagnosis. Whether a longer duration of undiagnosed bipolar disorder (DUBP) leads to an inferior treatment response is unclear in the literature. METHOD We conducted two studies with independent samples of BP patients who had received a first-time diagnosis of BP - first investigating whether DUBP was related to clinical and social outcomes at the time of assessment (n=173) and, second, whether response to mood stabiliser medication was affected by DUBP when assessed three months following assessment and intervention (n=64). RESULTS Participants׳ mean DUBP was 18-20 years (from the onset of mood episodes). After controlling for age, a longer DUBP was associated with employment difficulties, whereas a shorter DUBP was associated with a history of engaging in self-harm behaviours, as well as a reduced likelihood of experiencing social costs as consequence of the mood disorder. The majority of study variables were statistically unrelated to DUBP. In a multivariate analysis, age was the only predictor variable to make a significant contribution to the DUBP (33%). Across the 3-month intervention period, participants improved significantly on all but one outcome measure. The participants׳ likelihood to improve, become worse or experience minimal/no change over the study period was not significantly related to the DUBP. LIMITATIONS Self-reporting poses a risk to measurement precision. Being a naturalistic observation, no specific dose of medication was prescribed. The small sample of BP I patients provided insufficient statistical power to undertake meaningful separate analyses of the BP I and BP II participants. CONCLUSION Early detection and intervention remains important for helping to reduce morbidity and risks associated with untreated BP. However, the variation in DUBP was mostly a function of age and did not substantially affect clinical status at assessment, or lead to an inferior response to mood stabilising medication.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study

To pursue the previously long‐standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone.

Screening for bipolar disorder: does gender distort scores and case-finding estimates?

BACKGROUND Gender differences in rates of bipolar disorder have been described, with most studies reporting males as over-represented in those diagnosed with a bipolar I disorder and females over-represented in those diagnosed with a bipolar II disorder. This could reflect true differences in prevalence or measurement error emerging from screening or case-finding measures. We examine the possible contribution of the latter by examining one screening measure-the Mood Swings Questionnaire (MSQ). METHODS We analyse MSQ data from a large sample of age- and gender-matched bipolar I and bipolar II patients (and their composite group). Gender differences were examined in terms of prevalence and severity of MSQ symptoms, MSQ sub-scales scores and total MSQ scores, employing univariate and differential item functioning (DIF) analyses. RESULTS Both male and female bipolar I patients reported higher total MSQ and higher mysticism MSQ sub-scale scores than their male and female bipolar II counterparts. There were no gender differences when bipolar I, bipolar II and composite bipolar groups were separately examined on both total and sub-scale MSQ scores, suggesting that gender does not impact on MSQ scoring. When item analyses of bipolar I and II groups were undertaken separately, a number of differences emerged, but as few were consistent across bipolar sub-types such differences could reflect chance and failure to control for multiple comparisons. The over-representation of some items in females and some in males may have contributed to the comparable total and sub-scale scores. LIMITATIONS Large sample size and only one measure (i.e. MSQ) examined. CONCLUSION As total and sub-scale MSQ scores were uninfluenced by gender we can conclude that this screening test is not confounded by gender and, if representative of other such screening measures, would indicate that any differential prevalence of the bipolar disorders identified in community studies possibly reflects gender differences in their occurrence rather than artefactual consequences of screening measures having a gender bias.