Melissa Barrett

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 Black Dog Institute Depression Clinic: a subtyping model in practice.

Objective: The new Black Dog Institute Depression Clinic adopts a novel clinical service model that argues for the importance of clinically defining separate mood disorders in order to apply specific management strategies. This paper describes clinic nuances and the impact on diagnosis and management for the first 100 patients assessed. Method: Patients are assessed via a computerized structured self-report program, a semistructured interview undertaken by a psychiatrist and a colloquium involving several practitioners where diagnostic decisions are formulated. A detailed report with treatment recommendations, incorporating psychiatric and psychological perspectives, is sent to the referring clinician. Such data are examined in this report. Results: We offered a differing diagnostic and treatment paradigm for nearly 90% of those diagnosed with a primary mood disorder. Difficulties encountered by referring practitioners are highlighted and the need for an alternative diagnostic and management model is discussed. Conclusions: A subtyping diagnostic management model has the capacity to advance treatment outcome, but requires validation. Our future research will assess the comparative utility of the subtyping model in clinical and research arenas.

Outcome in a Specialist Referral Clinic for Mood Disorders: A Qualitative and Quantitative Review

Objective: The aim of this study was to determine whether short-term outcome for those referred with a depressive disorder could be predicted from baseline clinical assessment and identify factors contributing to outcome in a clinic operating to a subtyping diagnostic and aetiologically weighted management model. Method: This pilot study involved a consecutive series of 85 patients referred to the Depression Clinic at the Black Dog Institute. Results: Globally assessed baseline prediction was associated with short-term outcome. Comparably high rates of improvement were evident in those with bipolar, melancholic and non-melancholic subtypes, and somewhat lower in those diagnosed with a ‘secondary depression’. Qualitative and quantitative analyses established that outcome was most clearly associated with referral source, degree of take up of recommendations and implementation of psychotropic drug strategies. Conclusions: Study results encourage more definitive and comparative study designs to be derived.