Chapter 7 Depressive illness

• Introduction 224
  
• Historical perspective 226
  
• Diagnosis 1: symptoms 228
  
• Diagnosis 2: caseness and subtypes 230
  
• Diagnosis 3: other clinical presentations 232
  
• Epidemiology 234
  
• Aetiology 236
  
• Differential diagnosis 238
  
• Investigations 239
  
• Course and prognosis 240
  
• Management principles and outpatient treatment 241
  
• Hospital admission 242
  
• Treating depressive illness (without psychotic features) 244
  
• Treating depressive illness (with psychotic features) 246
  
• An approach to treatment-resistant depression 248
  
• Atypical depressive episode 249
  
• Seasonal affective disorder (SAD) 250
  
• Dysthymia (ICD-10)/dysthymic disorder (DSM-IV) 251
  
• Antidepressants 252
  
• Tricyclic antidepressants (TCAs) 254
  
• Monoamine oxidase inhibitors (MAOIs) and reversible monoamine oxidase inhibitors (RIMAs) 258
  
• Selective serotonin reuptake inhibitors (SSRIs) 260
  
• Other antidepressants 1 262
  
• Other antidepressants 2 264
  
• ECT 1: background and indications 266
  
• ECT 2: problems and treatment course 268
  
• ECT 3: work-up and administration 270
  
• ECT 4: notes on treatment 272
  
• Psychosurgery/neurosurgery for mental disorder (NMD) 274
  
• Other physical treatments 276
  

1 Post F (1994) Creativity and psychopathology. A study of 291 world-famous men. BJP, 165, 22–34.

1 For an exhaustive critique of conceptual ideas see: Jackson SW (1987) Melancholia and depression: from Hippocratic times to modern times. New Haven, Yale University Press.

1 Parker G, Hadzi-Pavlovic D, Roussos J, et al. (1998) Non-melancholic depression: the contribution of personality, anxiety and life events to subclassification. Psychological Medicine, 28, 1209–19.[CrossRef][Web of Science][Medline]

1 Brown GW and Harris TO (1978) Social origins of depression: a study of psychiatric disorders in women. London, Tavistock Publications.

1 It should be noted that many patients do spontaneously improve without active antidepressant treatment. The Medical Research Council Clinical Psychiatry Committee 1965 clinical trial of the treatment of depressive illness found that outcomes (Patients with no or only slight symptoms) for different treatments were: ECT (71%), imipramine (52%), that outcomes (patients phenelzine (30%), and placebo (39%).

2 Recently published NICE guidelines (see p. 266) do not allow for some of these uses of ECT. However, NICE guidance does not override the individual responsibility of health professionals to make decisions appropriate to the circumstances of a specific patient (such action should be discussed, documented in the notes, and, where appropriate, validated by a second opinion).

1 ‘Rejection sensitivity’ (to both real and imagined rejection) adds to the difficulty of managing atypical depression, as the patient may have had adverse experiences with doctors in the past, been labelled as ‘personality disordered’, and may find the idea of a therapeutic alliance alien.

1 In the last 15 years, there have been 6 studies on ECT effectiveness, demonstrating the efficacy of ECT over and above any placebo effect in 5/6 studies (the one study showing a negative result had small numbers and used unilateral brief pulse stimulus).

2 Wechsler H, Grosser GH and Greenblatt M (1965) Research evaluating antidepressant medications on hospitalized mental patients: a survey of published reports during a five-year period. Journal of Nervous and Mental Disease, 141, 231–9.[Web of Science][Medline]

1 Alexander GE, Crutcher MD and DeLong MR (1990) Basal ganglia-thalamocortical circuits: parallel substrates for motor, oculomotor, ‘prefrontal’ and ‘limbic’ functions. Progress in Brain Research, 85, 119–46.[Medline]

2 CRAG Working Group (1996) Neurosurgery for mental disorder. Scotland, HMSO (J2318 7/96).

1 Rosenthal NE, Sack DA, Gillin JC et al. (1984) Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy. Archives of General Psychiatry, 41, 72–80.[Abstract/Full Text]

2 Holtzheimer PE III, Russo J and Avery DH (2002) A meta-analysis of repetitive transcranial magnetic stimulation in the treatment of depression. Psychopharmacology Bulletin, 35, 149–69.

3 Lisanby SH, Schlaepfer TE, Fisch HU and Sackeim HA (2001) Magnetic seizure therapy of major depression. Archives of General Psychiatry, 58, 303–5.[Full Text]

4 George MS, Sackeim HA, Rush AJ et al. (2000) Vagus nerve stimulation: a new tool for brain research and therapy. Biol Psychiatry, 47, 287–95.[CrossRef][Web of Science][Medline]