Melancholia: The diagnosis, pathophysiology, and treatment of depressive illness

561 Pages·2006·2.483 MB·English

by  Taylor, Michael Alan, Fink, Max

Melancholia
This book provides a comprehensive review of melancholia as a severe disorder of mood,
associated with suicide, psychosis, and catatonia. The syndrome is defined with a clear
diagnosis, prognosis, and range of management strategies, diVerentiated from other similar
psychiatric, neurological, and general medical conditions. It challenges accepted doctrines in
the classification and biology of the mood disorders and defines melancholia as a treatable
mental illness. Described for millennia in medical texts and used as a term in literature and
poetry, melancholiawas included within early versions of the major diagnostic classification
systems, but lost favor in later editions. This book updates the arguments for the diagnosis,
describesitscharacteristicsindetail,andpromotestreatmentandprevention.ThebookoVers
greathopetothosewithadisordertoooftenmisdiagnosedandoftenfatal.Itshouldbereadby
allthoseresponsibleforthemanagementofpatientswithmooddisorders.
Michael Alan Taylor is Professor of Psychiatry Emeritus at Rosalind Franklin University of
MedicineandScience,NorthChicago,ILandAdjunctClinicalProfessorofPsychiatryatthe
UniversityofMichiganSchoolofMedicine,AnnArbor,MI,USA.
Max Fink is Professor of Psychiatry and Neurology Emeritus at the State University of New
YorkatStonyBrook,USA.

Melancholia
The diagnosis, pathophysiology, and
treatment of depressive illness
Michael Alan Taylor, M.D.
ProfessorofPsychiatryEmeritusatRosalindFranklin
UniversityofMedicineandScience,NorthChicago,IL,
andAdjunctClinicalProfessorofPsychiatryatthe
UniversityofMichiganSchoolofMedicine,
AnnArbor,MI,USA
Max Fink, M.D.
ProfessorofPsychiatryandNeurologyEmeritus,
StateUniversityofNewYorkatStonyBrook,USA
CAMBRIDGEUNIVERSITY PRESS
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Cambridge University Press
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Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521841511
© M. A. Taylor and M. Fink 2006
This publication is in copyright. Subject to statutory exception and to the provision of
relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published in print format 2006
ISBN-13 978-0-511-22105-7 eBook (NetLibrary)
ISBN-10 0-511-22105-3 eBook (NetLibrary)
ISBN-13 978-0-521-84151-1 hardback
ISBN-10 0-521-84151-8 hardback
Cambridge University Press has no responsibility for the persistence or accuracy of urls
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Contents
List of patient vignettes page ix
Preface xi
Acknowledgments xv
1 Melancholia: a conceptual histor y 1
Origins of the concept 2
The psychodynamic interruption 6
The recognition ofmelancholia in psychiatricclassification 7
Notes 10
2 Melancholia defined 15
Melancholy 15
Manic-depressiveillness 18
Psychoticdepressionis melancholia 24
Depressionwith catatoniaor stupor is severemelancholia 30
Melancholiadefined bya specificevent 32
Notes 37
3 Defining melancholia by psychopatholog y 45
DSMdepressioncategories anddiagnosticcriteria 46
Consensus and empirical approaches defining a syndrome 51
Psychopathologydata supporting the validityof melancholia 53
The natureofmelancholia 56
Conclusions 58
Notes 59
4 Defining melancholia: laborator y tests 62
Neuroendocrine measuresin mood disorders 62
The hypothalamic–pituitary–adrenal axis 64
The hypothalamic–pituitary–thyroid axis 72
Electrophysiologicmeasures 72
v
vi Contents
Conclusions 76
Notes 78
5 Examination for melancholia 85
Examination strategy 86
Examining mood 87
Examining psychomotor functioning 88
Examining for vegetativesigns 88
Examining for psychotic features 89
Examining for suicidal thoughts 90
Examining cognition 90
Examining for personalitydisorder 91
Rating scales of depression 91
Notes 95
6 The di Verential diag nosis of melancholia 97
Non-melancholicdepressivemood disorders 97
Melancholia in childrenandadolescents 103
Melancholia in theelderly 104
Melancholia in a patient with a psychoticdisorder 106
Distinguishing melancholiafrom anxiety and
obsessive-compulsivedisorders 108
Distinguishing melancholiafrom drug-related depressive-likestates 109
Melancholia associated with general medical illnesses 110
Avolitional, apathetic, and bradykinetic syndromes 112
Neurologicdisease associated with apathyand
depression-likesyndromes 113
Notes 118
7 Suicide in melancholia 125
Errorsin suicide prevention 126
Suiciderisk assessment 134
The eV ect of specific treatments onsuiciderates 139
Management of thesuicidal melancholic patient 143
Notes 146
8 Electroconv ulsive therapy for melancholia 153
ECTin melancholia 155
ECT for psychoticdepression 157
ECTandsuiciderisk 159
ECT forcatatonia and depressivestupor 161
ECTin pregnancy andpostpartum depression 163
ECTin childrenand adolescents 165
ECTin the elderly 170
ECTandcharacterological conditions 171
vii Contents
ECTin unipolar andbipolardepression 172
Conclusion 174
Notes 174
9 Achiev ing e Vective ECT 181
Patient selection 181
Technical considerations 183
Conclusions 190
Notes 190
10 The validity of the phar macotherapy literature in melancholia 196
Industry influenceundermines conclusions about newer agents 197
Head-to-head comparisons arebiased tofavornewerdrugs 199
Antidepressantdrug eY cacy: TCAversuspureSSRI 201
Antidepressantdrug eY cacy: pureSSRIscompared tonon-TCAagents 204
Conclusions 206
Notes 207
11 Basic phar macotherapy for melancholic patients 211
Acute treatment 212
Combiningdrugs and psychotherapy 218
Continuation and maintenancetreatment 219
Pharmacotherapy formelancholia 220
Treatmentof severemelancholia 222
Optimizing treatments for manic-depressiveillness 229
Notes 231
12 Phar macotherapy for melancholic patients in
complicating circumstances 239
Melancholiain pregnancy andbreast-feeding 239
Melancholiain childhood and adolescence 244
Melancholiain old age 250
Melancholiawith co-occurring alcoholordrug abuse 255
Melancholiawith co-occurring neurologicdisease 257
Melancholiaco-occurring with general medical conditions 261
Melancholiawith co-occurring personalitydisorder 265
Summary recommendations 266
Treatment-resistant depression 268
Notes 273
13 Proposed treatments for melancholia 284
Lighttherapy 284
Transcranial magneticstimulation 286
Magnetic seizuretherapy (MST) 288
Vagal nerve stimulation(VNS) 289
viii Contents
Glucocorticosteroid receptoragonists 289
Targetedneurotransmitter system agents 290
Hormones 291
Herbal remedies 292
Notes 294
14 The pathophysiolog y of melancholia 298
Geneticpredisposition 299
Environmental factors 303
Abnormal stressresponse 307
Abnormal neurochemical functioning 311
Abnormal brain structure 317
Abnormal brain metabolism 318
Electrophysiologic abnormalities 320
Cognitivedeficits 327
Why some melancholic patientshavemanicepisodes 328
Conclusions 330
Notes 333
15 Future directions 346
Changing theDSMclassification ofdepression 347
Changing theDSMdiagnosticcriteria formelancholia 348
Changing thestandardsof pharmacotherapy research 349
Changing treatment guidelines: endlessdrug trials elicit chronicity 351
Improving theeducation of medical practitioners in mood disorders 351
Studies ofthe mechanismof convulsivetherapy 353
Preventiveapproaches toreduce theburdenof melancholia 354
Pharmacogenetics 359
The pathophysiologyof melancholia 360
Coda 364
Notes 365
References 371
Index 522
Patient vignettes
2.1 Awomanwith melancholia (Hopewell-Ash) page 17
2.2 Awomanwith melancholia (Hopewell-Ash) 17
2.3 A manwith melancholia (Hopewell-Ash) 17
2.4 Awomanwith melancholia (Hopewell-Ash) 17
2.5 Awomanwith cycloid psychosis(Hopewell-Ash) 22
2.6 A manwith a psychoticmelancholia (DSM-IVCasebook) 28
2.7 A manwith psychotic melancholia(Fink) 28
2.8 Awomanwith Cotardsyndrome (HansenandBolwig) 29
2.9 Awomanwith melancholia (Taylor) 30
2.10 Acatatonic womanwith psychoticmelancholia (Kalhbaum) 31
2.11 A 15-year-old girlwith psychotic melancholiaand catatonia (Hoch) 32
2.12 Awomanwith a postpartum melancholia (Protheroe) 35
2.13 Awomanwith postpartummelancholia (Hamilton) 35
3.1 A manwith an apathetic frontal lobe syndrome meeting criteriafor major
depression (Vaidyaand Taylor) 49
5.1 A melancholic manwith a psychoticdepression (Taylor) 89
6.1 An epileptic manwith brief depressions (Taylor) 116
7.1 An 87-year-old womanwith apsychoticdepression(Taylor) 128
7.2 A 44-year-old melancholic man misdiagnosed with PTSD who committed
suicide (Taylor) 130
7.3 A hospitalized depressedwomanwith asuicideplan (Taylor) 131
7.4 A melancholic womanwho receivedpoor treatment (Taylor) 132
7.5 A 30-year-old manwith a ‘‘postpartum’’melancholia (Taylor) 133
7.6 A manwho refused hospitalization and committed suicide (Taylor) 133
7.7 A 70-year-old manwho hanged himself(Taylor) 137
7.8 A 21-year-old womanwhomadea suicide attemptfollowinga
psychodynamic interview (Taylor) 145
8.1 A 66-year-old womanwith melancholia (Fink) 157
8.2 Aprofessorof surgerydescribes his psychoticdepression(Nuland) 158
8.3 A former medical schooldean describes his depression (Rosenberg) 160
8.4 A 58-year-old womanwith melancholia and catatonia misdiagnosed as
having Alzheimer’sdisease (Fink) 162
ix