Depression: Recent Concepts

Depression: Recent Concepts
   Starting in the middle third of the twentieth century, the diagnosis of depression increased many-fold.
   Though some of this increase was owing to the systematic marketing of the diagnosis by pharmaceutical companies, other elements of the increase involved refocusing the psychiatric nosology as such. Classic diagnoses such as "hysteria," "neurasthenia," and "nervousness" started to go out of style. Psychoanalysis popularized "neurotic depression" or "depressive neurosis" as workaday diagnoses, and the great relabeling of psychiatric diagnoses that occurred with DSM-III in 1980 elevated "major depression" to prominence. By the end of the twentieth century, "depression" had come to represent more than half of all psychiatric diagnoses made in clinical practice. "Vegetative" depression (1949). There was a tradition of associating affective disorders with autonomic disturbances that went back to Max Rosenfeld’s (1871–1956) 1906 article in the Central Journal for Nervous Diseases (Centralblatt für Nervenheilkunde). Rudolf Lemke (1906–1957), professor of psychiatry at Jena University in East Germany, alluded to it in 1949, proposing in the newly founded journal Psychiatrie, Neurologie und Medizinische Psychologie the diagnosis "vegetative depression," characterized by an anxious-depressed mood and autonomic symptoms. It differed from such diagnoses as "vegetative dystonia" (see HYSTERIA: "vegetative dystonia" [1934]) in that the patients were at risk of suicide.
   Lopez Ibor’s "anxious thymopathy" (timopatia ansiosa) (1950). Departing from the Kraepelinian tradition of seeing anxiety as part of manic-depressive disorder, in 1950 Juan J. Lopez Ibor (1907–1991), a member of the department of psychiatry of the University of Madrid and a former student of Karl Jaspers and Kurt Schneider, argued that anxiety and anguish represented an autonomous disease of an entirely "endogenous" nature; anxious thymopathy possessed deeply somatic roots and was not at all psychogenic. It came from the "vital" level of the body; in his book La Angustia Vital (Patologia General Psicosomatica), published in 1950, he proposed the term "vital anguish" (la angustia vital) for the whole complex. (Thymo- is derived from the Greek, meaning mind or will; in modern parlance, however, "thymopathy" refers to diseases of the thymus.*) He believed it to be part of a "circular" disorder ("el circulo timopatico") and said it might overlap in some patients with endogenous depression, giving rise to "idiopathic anxious depression."
   * As Eugen Bleuler wrote in 1916 in his Textbook of Psychiatry (in the English translation [1924] by New York psychoanalyst Abraham Arden Brill [1874–1948]—an early translator of Freud’s work as well), "Since the affective dispositions fluctuate greatly in different people, they also most readily cross the borderline of the ‘normal.’ The so-called psychopaths are really nearly all exclusively or mainly thymopaths" (translation of the fourth German ed. of Lehrbuch der Psychiatrie, 1923, p. 117).
   Kraepelin’s manic-depressive illness seems to consist of separate diseases: bipolar and unipolar disorders (1957). See Manic-Depressive Illness (1957).
   Atypical depression (1959). William Sargant’s group in the department of psychological medicine at St. Thomas’s Hospital in London found that a certain subset of depressive patients responded readily to the drug iproniazid (Marsilid), an inhibitor of brain monoamine oxidase. The subset was characterized by patients who did not have the classic picture of endogenous depression, with self-reproaches and earlymorning worsening, but rather were highly anxious, phobic, and greatly fatigued. Sargant’s "registrars" (the British term for resident) Eric Douglas West (M.B. 1951) and Peter John Dally (M.B. 1953) published on this in the British Medical Journal in 1959, then Sargant himself co-wrote several subsequent follow-up articles, saying for example in 1960 in Psychosomatics that, "[These patients] may . . . have become bad tempered, irritable, hyperreactive and aggressive, quite unlike so many of the more endogenously depressed patients" (p. 15). Sargant’s work represents one of the first attempts to identify a subclass of depression patients differentially responsive to a given drug. Marsilid was subsequently withdrawn from the market as toxic.
   Tellenbach’s "melancholic type" (1961). Hubert Tellenbach (1914–), associate professor and head of the department of clinical psychopathology at Heidelberg, postulated in his book Melancholie (1961) that a certain "melancholic type" of character exists that predisposes individuals to clinical melancholy. Its main characteristic is a highly developed sense of orderliness (Ordentlichkeit) that leads to "exceptionally high demands regarding one’s own achievements." Said Tellenbach: "The melancholic individual wants to achieve much, and to do so regularly. But he wants to maintain his achievements at a level that is simultaneously a ceiling." Thus, the melancholic is interested only in the "possible," while anything "that might appear impossible is never even aspired to. That is probably the reason that melancholic types almost never achieve a high social position" (pp. 53–54). Although the diagnosis was never taken up in American psychiatry, it has remained influential in Central Europe.
   Vital depression vs. personal depression (1965). Herman van Praag (1929–) and co-workers, then at the Dijkzigt Hospital in Rotterdam, contrasted these two forms of depression as the equivalents of endogenous vs. reactive depression, with the difference that the latter set of terms implied causation of some kind (constitutional vs. external events), whereas Van Praag considered the causes of depression to be unknowable. The defining characteristic of vital depression was its "motiveless" nature, or inexplicable onset, coming out of the blue. Also, the patient may not necessarily feel sad, but rather physically dragged down. "One might speak of a continuous hangover, or, with Schneider (Clinical Pathology [Klinische Pathologie], 1959), of a depressio sine depressione." The article appeared in Psychiatria, Neurologia, Neurochirurgia, a Dutch medical journal (quote, p. 331). Van Praag was first to devise a scale for measuring vital depression.
   "Primary vs. secondary" depression (1969). Drawing on the work of Robert Woodruff (1934–) and colleagues, St. Louis school members Eli Robins and Samuel Guze proposed in 1969, at a large National Institute of Mental Health conference on "the psychobiology of the depressive illnesses," the division of affective disorders (depression and mania) into primary and secondary forms; "primary" meaning patients with no previous history of psychiatric illness and "secondary" patients who had "a preexisting, diagnosable psychiatric illness, other than a previous primary affective disorder" (p. 292 of the proceedings of the conference, edited by Thomas A. Williams and others, published in 1972). The authors found this classification superior to the other conventional classifications of affective disorders: endogenous vs. reactive, and neurotic vs. psychotic.
   Psychotic depression as an independent entity (1975 and after). There was a European tradition of treating all serious depressions as "psychotic." The study of psychotic depression goes back at least to Kahlbaum’s work on catatonia in 1874, when he described patients with catatonia who were depressed and psychotic. (See Schizophrenia: Emergence: catatonia [1874].) During the years, the observation was commonly made that depressed patients who displayed symptoms such as catatonia and delusions did less well than other kinds of depressed patients. Yet, in the absence of specific treatments or a common family history for such patients, little was made of the finding. Also, these depressions responded equally well to electroconvulsive therapy, so it did not really matter what the subgroups were.
   Then, starting in 1975, it began to become apparent that a subgroup clearly existed—with psychotic delusional symptoms—that did poorly on standard antidepressants, as Alexander Glassman (1934–) and associates at the New York State Psychiatric Institute, linked to Columbia University, reported in the American Journal of Psychiatry; these patients also responded much better to ECT, as David Avery (1946–) and Aldo Lubrano (1950–) at the Palo Alto Veterans Administration Hospital found in a reanalysis of an earlier Italian study that had compared ECT to the tricyclic antidepressant imipramine (American Journal of Psychiatry, 1979). In 1992, Alan F. Schatzberg (1944–) and Anthony J. Rothschild (1953–), at the time in the department of psychiatry of Harvard Medical School, asked in an article in the American Journal of Psychiatry, "Psychotic (Delusional) Major Depression: Should It Be Included as a Distinct Syndrome in DSM-IV?" They answered yes. "[The data] point to both the rationale and the need for designating psychotic major depression as a distinct syndrome in DSM-IV" (p. 743). ("Severe with psychotic features" continued, however, in the Manual to be just a specifier for "major depressive episode.")
   The concept of psychotic "depression" would cause misgivings in researchers who believe that catatonia, a brutal slowing, is not the same as the retardation of depression. Thus, a psychotic depression that included catatonia caused some international eyebrow-raising. Under the leadership of Max Fink, the treatment of psychotic depression with ECT became well defined. (See Georgios Petrides [1957–] and Max Fink, Journal of ECT, 2001.)
   See "Feighner Diagnostic Criteria" (1972)
   The introduction of "major depression" (1978). Continuing the work of the St. Louis school (see also "Feighner Diagnostic Criteria" [1972]), in 1978 Robert L. Spitzer and psychologist Jean Endicott (1936–) of the New York State Psychiatric Institute and department of psychiatry of Columbia University, together with Eli Robins, extended their nosology—which they were now calling the Research Diagnostic Criteria (RDC)—to 25 principal diagnostic categories, including "major depressive disorder" (which had 11 subtypes) and "minor depressive disorder with significant anxiety." This article in the Archives of General Psychiatry became part of the intellectual scaffolding of DSM-III.
   Atypical depression (revived) 1979. In searching for treatment-specific depression subtypes, a group of researchers led by Frederic Quitkin (1937–) and Michael Liebowitz (1945–) and including Donald Klein and Arthur Rifkin (1937–), of the department of psychiatry of Columbia University and the New York State Psychiatric Institute, identified a subset of patients whom they believed especially responsive to monoamine oxidase inhibiting drugs (monamine oxidase inhibitors, or MAOIs) (see Iproniazid). The patients, who were given the diagnosis "atypical depression" (with reference to the earlier English work of William Sargant), had the following characteristics: some degree of dysphoria on the basis of Research Diagnostic Criteria, plus "mood reactivity" (patient gets better when things change), plus two or more of the following symptoms: overeating, gaining weight, oversleeping, sensation of leaden fatigue, taking rejection poorly. In 1979, Quitkin and colleagues began to publish on this in the Archives of General Psychiatry; Liebowitz and colleagues wrote another key article in the Journal of Clinical Psychology in 1984. Atypical depression was accepted as an official psychiatric diagnosis ("atypical features specifier") in DSM-IV (1994).
   DSM-III enshrines "major depression" and revives "dysthymia" (1980). In 1980, the Task Force on Nomenclature and Statistics of the American Psychiatric Association, led by Robert Spitzer, published the third edition of its Diagnostic and Statistical Manual of Mental Disorders. Among the many disorders to be reconfigured were the depression diagnoses ("affective disorders"), but in a manner sharply different from the Research Diagnostic Criteria of 1978 (see above). DSM-III created three new disease labels in the mood area: (1) "major depression" (anticipated in 1978), which was a mixture of psychotic and nonpsychotic depressive conditions; (2) "dysthymic disorder" (a term coined by Flemming in 1844; see Depression: Emergence), which was a new label for what had been known as "neurotic depression"; and (3) "adjustment disorder with depressed mood" for minor depressions supposedly treatable with psychotherapy alone (as the correspondence of the drafters indicates). Manic-depressive illness, for which the DSM drafters adopted Karl Kleist’s label "bipolar disorder" (see Wernicke–Kleist–Leonhard Pathway) remained intact. DSM adopted the Kahlbaum label "cyclothymic disorder" for less serious manic-depressive illness (see Manic-Depressive Illness [1882]). As in the Feighner article (see "Feighner Diagnostic Criteria" [1972]), "operational criteria" were stipulated for the granting of each of these diagnoses. Thus, to meet the criteria for major depressive episode, the patient had to have a dysphoric mood for a certain period of time plus four of a list of eight other criteria that included such symptoms as poor appetite, insomnia, and loss of pleasure in formerly pleasurable activities. (The drafters did not use the term "anhedonia.") Subsequent editions of DSM did not change significantly the nature of the affective diagnoses.
   The new DSM diagnosis of "major depressive disorder," with its checklist of heterogeneous symptom pictures and absence of reference to the patient’s past history, was not without critics. As Bernard James ("Barney") Carroll (1940–), then professor of psychiatry at Duke University, said in 1982 at a conference in Berlin on The Origins of Depression that Jules Angst (1926–) of Zurich had convened, the concept of major depressive disorder was far too nonspecific. Also, "These criteria are deficient in another important respect—they give a flat, two-dimensional view of the patient’s illness because they ignore features that earlier clinicians placed much weight upon—family history, for example, previous episodes, responses to previous treatments, and a history of hypomanic or manic phases" (p. 166). Nonetheless, "major depression" went on to become the single most important diagnosis in psychiatry.
   Double depression (1982) Martin B. Keller (1946–), then in the department of psychiatry of the Massachusetts General Hospital, and Robert W. Shapiro (1938–1980), whose name was added posthumously, characterized double depression as the overlapping of two Research Diagnostic Criteria depression categories (see above): a patient having, at the same time, major depressive disorder superimposed on an underlying chronic depression ("dysthymic disorder"). The article, in the American Journal of Psychiatry, thus aired publicly an overlapping that DSM insiders had discussed throughout the drafting. Keller and Shapiro argued that the prognosis for patients with double depression was worse than for those with major depression alone.
   "Seasonal affective disorder" (SAD) (1984). The existence of a certain kind of depression that routinely worsens in the winter months was proposed and named in 1984 by Norman E. Rosenthal—himself a sufferer—and co-workers at the National Institute of Mental Health in the Archives of General Psychiatry. Bright light was said to have "a marked antidepressant effect" upon SAD. The concept was incorporated in DSM-III-R in 1987 as a "specifier" for major depression (see above) and for bipolar disorder (see Manic-Depressive Illness), defined as "a regular cyclic relationship between onset of the mood episodes and a particular 60-day period of the year," especially the time from early October to late November. Despite international misgiving about the diagnosis, it reappeared in DSM-IV (1994).
   Recurrent, brief depression (1985). In the context of a longitudinal study of a cohort of young adults in Zurich, Jules Angst (1926–), chair of the research department of the Psychiatric University Hospital in Zurich (Burghölzli), realized that many of the patients suffered recurrent bouts of depression too brief to qualify as "major depression" or "dysthymia" in DSM terminology. In the European Archives of Psychiatry in 1985, Angst proposed the diagnosis "recurrent, brief depression" (RBD) as a subtype of affective disorder. (The series of articles in which they suggested the diagnosis began in 1984.)

Edward Shorter. 2014.

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