Kerrie Eyers

Melancholia : a disorder of movement and mood : a phenomenological and neurobiological review

This is an important book for all psychiatrists. It details careful and admirable, clinically based research carried out by Gordon Parker and his associates at the Mood Disorders Unit at Prince Henry Hospital, Sydney, over many years. The research has a long pedigree and builds on work carried out by Professor Kiloh, among others, which focused on the separation of endogenous depression, or melancholia, from other forms of depression. The book begins with an historical review of important controversies in the classification of mood disorders, which, in itself, is a valuable corrective to the stultifying effect that the DSM-III classification has had on thinking in this area. The authors’ bias is made clear. They believe that there is a dichotomy between melancholia and other forms of depression. They come to the conclusion that clinical signs of psychomotor disturbance (PMD) define the core of melancholia although several other symptoms also contribute. They developed a measure of PMD and these symptoms called the CORE measure. They demonstrated that this was a reliable measure and improved its sophistication as the research developed. There are valuable chapters that detail discussions of the sophisticated, statistical approaches employed. Using the CORE measure to diagnose melancholia, they proceeded to establish a number of important correlations. There were correlations between melancholia, outcome and response to treatment. The findings suggested that response to antidepressants and electroconvulsive therapy was better for patients with melancholia. Good correlations with non-suppression on the dexamethasone suppression test were established for melancholia but not for other forms of depression. Melancholia was found to be associated more commonly with neurological disorders such as Parkinson’s disease and Huntington’s chorea as well as abnormalities on neuroimaging. The authors suggest that melancholia could well be considered a neurological disorder resulting from the dysfunction of a number of parallel, frontal–subcortical neural networks. This is not an easy book to read. I found it made a poor summer companion at the beach or while watching cricket; however, it is well worth the effort. The points it makes are often complex and are made with great care, as indeed they need to be. The implications are major. I believe that the authors have established that any research into mood disorders, which does not take their findings into account, must be regarded as flawed. Clinically, all psychiatrists will need to consider afresh the dichotomy between melancholia and other forms of depression, in deciding how best to help their patients. They will need to focus on psychomotor disturbances in arriving at their diagnoses. The CORE measure itself or some simplified form could usefully be employed in routine clinical practice. I hope that this book and its findings reach the widest possible audience and have the impact they deserve.Introduction Classification and research: Historical and theoretical aspects 1. Issues in classification: Part I. Some Historical Aspects: 2. Issues in classification: Part II. Classifying Melancholia: 3. Issues in classification Part III. Utilizing Behavioral Constructs in Melancholia Research: 4. Issues in classification: Part IV. Some Statistical Aspects: Development and Validation of a Measure of Psychomotor Retardation as a Marker of Melancholia: 5. Psychomotor change as a feature of depressive disorders: historical overview and current assessment strategies 6. Development and structure of the CORE system 7. Reliability of the CORE measure 8. Validity of the CORE: Part I. A Neuroendocrinological Strategy: 9. Validity of the CORE: Part II. Neuropsychological Tests: 10. Validity of the CORE Part III. Outcome and Treatment Prediction: 11. Phenotypic expression of melancholia contrasted for those with bipolar and unipolar illness courses 12. Psychotic depression: clinical definition, status and the relevance of psychomotor disturbance to its definition 13. A clinical algorithm for defining melancholia: comparison with other sub-typing measures 14. Rating the CORE: a users guide The Neurobiology of Melancholia: 15. Melancholia as a neurological disorder 16. Melancholia and the aging brain 17. Magnetic resonance imaging in primary and secondary depression 18. Functional neuroimaging in affective disorders 19. Summary and conclusions Appendix The CORE measure: procedural recommendations and rating guidelines Bibliography.

PSYCHOTIC DEPRESSION : A REVIEW AND CLINICAL EXPERIENCE

We review research literature on psychotic (delusional) depression, including demographic, illness pattern, clinical, biological marker and treatment issues. Secondly, we report a study of a consecutive sample of 137 patients meeting criteria for DSM-III melancholia, RDC definite endogenous depression and our “clinical” criteria for endogenous depression, of whom there were 35 “psychotic depressives” (PDs). The PDs were contrasted with the remaining 76 depressives (EDs) and with an age and sex-matched subset (MEDs). The PDs were distinctly older than the EDs at assessment and at initial onset of any affective disorder. Compared to the MEDs, they tended to have longer illnesses, were more likely to be hospitalised (and to have longer stays), to receive (in the past and for the current episode) combination antipsychotic/antidepressant medication and/or ECT, and to have a poorer course over the following year. They were no more likely to have a bipolar pattern, a family history of depressive disorder, schizophrenia or alcoholism, or vegetative depressive features. Developmental psychosocial stressors and antecedent life event stressors were not over-represented. Most of the PDs had delusions, one-fifth reported hallucinations and psychomotor disturbance was marked. Other differential clinical findings were sustained mood disturbance, constipation, and the absence of a diurnal variation in mood and energy.

Patient Satisfaction with a Mood Disorders Unit: Elements and Components

Patient satisfaction is an indicator of effective service provision and may influence compliance with treatment. Of 265 patients attending a specialised mood disorders unit and surveyed at least two years after their initial contact, 221 (83%) replied. Characteristics of responders and non-responders were compared on demographic and clinical information from index assessment and follow-up. Sixty-four percent of responders were very satisfied and 21% partly satisfied with their management. Components of satisfaction included perceived competence of clinical management; the units administrative and after-treatment accessibility; and the support of staff and other patients. Those with a more adequate personality and melancholic depression at baseline assessment were more satisfied. A low current mood state at time of survey was associated with lower satisfaction in non-melancholies only. There were interactions between improvement in condition, diagnosis, personality and satisfaction. The survey provided a framework for formulating treatment programmes and was a useful quality assurance tool.

Depression Sub-Typing: Unitary, Binary or Arbitrary?

The strongest statistical support for the binary view of depression has been provided by factor (principal components) analytic studies which delineate a bipolar factor with features interpreted as reflecting “endogenous depression” and “neurotic depression” at opposing poles. We review the seminal studies to suggest instead that the bipolar factor has generally polarised depression and anxiety, and that no such entity or symptom complex of “neurotic depression” has been isolated. Instead, “neurotic depression” has been defined principally by features of anxiety and personality style. We argue that the suggested entity is, in fact, a pseudo-entity, being no more than a residual group of non-depressive features without any significant intrinsic depressive characteristics. We support our interpretation by showing comparable solutions in published studies of depressives alone, contrasted with separate analyses of anxious and depressed patients. We also report two studies in which the “neurotic depressive” pole is made to appear and disappear by the inclusion and exclusion of anxiety items. As factor analytic studies have defined the “residual” pole so variably, we argue that some features held to distinguish neurotic depression are of no utility and that such a diagnosis is meaningless. We suggest that the clinician should not proceed (after excluding endogenous depression) to conclude that the default option is necessarily an entity “neurotic depression” and that instead a heterogeneous group of options (e.g. anxiety, personality disorder) require review. If the “neurotic depressive” type of the multivariate analytic studies is a pseudo-entity, then a modified unitary view of depression may be valid.

Development of a measure profiling problems and needs of psychiatric patients in the community.

Abstract We argue the advantages of a measure profiling common problems faced by psychiatric patients in the community and indicating a likely need for service recognition, review and possible assistance. We describe the development of such a measure, the 35-item Profile of Community Psychiatry Clients (PCPC), and the identification of four relevant domains. Component scales assess coping limitations, behavioural problems, levels of social support and organic problems. High test-retest reliability was established, and a number of tests of the measures validity were undertaken. Discriminant validity was established by demonstrating that those case managed by a community mental health service returned significantly higher scale scores than a comparison group who, while having a similar diagnostic profile, were not case managed. Additionally, scale scores were associated with a number of categorical and dimensional validators reflecting aspects of service need, and distinctly with service costs. We demonstrate that PCPC scores correspond with scores generated by the Life Skills Profile (LSP), a measure of disability, and examine the extent to which PCPC scales correspond to those contained in the Health of the Nation Outcome Scales (HoNOS). We argue for the scales capacity to provide both a profile of central problems faced by patients and their likely need for community-based service assistance.

What the Doctor Ordered? Referrer Satisfaction with a Mood Disorders Unit

Assessment of referrers needs, patterns and satisfaction ratings with a psychiatric service provides both a clinical and service performance indicator. This study explored referrer satisfaction with a tertiary referral mood disorders unit (MDU). The 147 responders comprised 75 psychiatrists, 59 general practitioners and 13 others. Thirty-two percent of referrers were “very satisfied” and 42%“quite satisfied” with their contact with the unit. Components of satisfaction were defined by piincipal components analysis as“technical competence”; “adequate information and follow-up support” and “access” to the facility, dimensions confirmed by responses to open-ended questions. Differences were established between the referral needs of psychiatrists and general practitioners, suggesting different treatment emphases. Such surveys provide a framework which can facilitate review and restructuring of important service components of any psychiatric facility.

Defining the personality disorders: description of an Australian database.

Objective: We seek to improve the definition and classification of the personality disorders (PDs) and derive a large database for addressing this objective. Method: The paper describes the rationale for the development of a large set of descriptors of the PDs (including all DSM-IV and ICD-10 descriptors, but enriched by an additional 109 items), the design of parallel self-report (SR) and corroborative witness (CW) measures, sample recruitment (of 863 patients with a priori evidence of personality disorder or disturbance) and preliminary descriptive data. Results: Analyses (particularly those comparing ratings on molar PD descriptions with putative PD dimensions) argue for acceptable reliability of the data set, while both the size of the sample and the representation of all PD dimensions of interest argue for the adequacy of the database. Conclusions: We consider in some detail current limitations to the definition and classification of the PDs, and foreshadow the analytic techniques that will be used to address the key objectives of allowing the PDs to be modelled more clearly and, ideally, measured with greater precision and validity.

Waggish excerpts from ‘Tracking the Black Dog’

It was my first day as a locum consultant in addiction psychiatry. A nurse from the team (a community drug team) kindly showed me around and as we passed the drug testing room, he narrated an interesting incident. Doing urine drug screens (for illicit psychoactive substances) was routine for him in his many years work in the field. On one such occasion, a patient provided him with a rather odd-looking (in its colour and appearance) urine specimen. Although it tested positive for methadone (on an on-site dipstick test ), and despite the patient reassuring him that all was well, his suspicion was not allayed. Hence, to ensure that it was not a manufactured specimen, and also to rule out any genuine pathology (such as blood in urine), the nurse sent off the sample to the lab. Dismayed at the test result – that it was not human urine! – he confronted the patient at next review. The patient admitted he had provided a sample of his dog’s urine (to which he had added some of his prescribed methadone). He had been using heroin on top of the prescribed methadone, but wanted to provide a clean sample (with only methadone and no heroin) to be seen to comply with the treatment order. The nurse said to me you think you’ve seen it all, don’t you? – well, welcome.