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Objective: To differentiate clinical and non‐clinical depression via a set of symptoms. Methods: A sample of 140 patients attending a clinical service for those with mood disorders together with 40 subjects denying ever experiencing a clinical episode of depression were compared, with participants completing a questionnaire capturing many symptoms of depression as well as illness correlates. Results: A latent class analysis of symptom data identified two classes and with class assignment corresponding strongly with initial clinical vs. non‐clinical assignment. Univariate analyses identified the extent to which individual symptoms contributed to differentiation. Study data suggested DSM criteria that would benefit from re‐writing or of reassignment. Two models for classifying clinical depression were generated. The first involved individuals feeling hopeless and also being suicidal or at risk of self‐harm. The second involved a symptom set corresponding to DSM‐5 criteria but with only five making significant independent contributions to diagnostic differentiation. Conclusion: The study is heuristic in offering a strategy for more precisely differentiating clinical and non‐clinical depression in more representative samples, so allowing resolution of key features, and determining whether a monothetic or polythetic diagnostic symptom criterion model is optimal. [ABSTRACT FROM AUTHOR]

Objective: To determine the level of agreement across a set of evidence‐based guidelines for management of the unipolar depressive disorders and with a focus on physical treatments. Method: A literature search was undertaken using the terms ‘depression’, ‘depressive’ and ‘guidelines’, using PubMed, Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. Twelve national psychiatric or professional guideline‐producing organizations were identified from the period 2007–2017, with guidelines qualitatively reviewed by two assessors. Results: For major depressive disorder (MDD), there was general consensus to use an antidepressant (AD) in cases of greater severity, although disagreement on AD use in mild to moderate depression. There was some agreement on choice of AD class in first‐line treatment recommendations, though great variability in second‐ and third‐line management particularly in recommended augmentation and combined AD strategies. Electroconvulsive therapy was considered in all but one guideline, with other neurostimulation treatments being less consistently covered and with variable recommendations. Finally, there was low consistency in the management of dysthymia, persistent depressive disorder and treatment resistant depression. Conclusion: Our review identifies varying levels of consistency in guideline recommendations. Strategies to improve reliability in guideline formulation should also improve their validity. [ABSTRACT FROM AUTHOR]

Objective To examine the level of agreement across professionally auspiced evidence-based guidelines for managing the bipolar disorders. Methods A literature search in PubMed, the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews and PsycInfo was undertaken using the search terms 'bipolar disorder' and 'guidelines', generating 11 evidence-based guidelines published by professional organisations over the 2002-2015 period. Each guideline was reviewed by two independent reviewers and key themes extracted via qualitative analyses. Results There was agreement on issues such as the first-line treatment of mania where mood-stabilising and/or an antipsychotic medication together with tapering or ceasing antidepressant medications was most commonly recommended. Differences included the extent to which (i) the different bipolar disorders were defined or not, (ii) there were separate recommendations for bipolar I and bipolar II disorders vs. non-differentiating general bipolar management strategies, (iii) 'general' vs. severity-based recommendations were made, and (iv) narrow vs. broad sets of candidate medications were nominated, while there was variable consideration of treatments such as electroconvulsive therapy ( ECT). Conclusions While there was some consistency across guidelines on key recommendations, there was also substantial inconsistencies, limiting the generation of any 'meta-consensus' model for managing the bipolar disorders. [ABSTRACT FROM AUTHOR]

Objective To detail limitations to the construct of 'major depression', argue for repositioning it as a proxy for 'clinical depression' and then operationalize it and its principal constituent depressive subtypes, while preserving the DSM criteria-based format. Method We summarize limitations to major depression being viewed as a diagnostic entity. Data from 391 clinically depressed patients were analysed to identify high-prevalence non-specific depressive symptoms to define 'clinical depression' as well as the features showing specificity to a melancholic depressive subtype. Results We identified a set of high-prevalence and generalized symptoms for defining clinical depression and with many being current criteria for major depression. We also developed a refined set of melancholic features and with their underlying distributions generating two classes that correlated strongly with clinical diagnoses of a melancholic or non-melancholic depression, thus validating its capacity to so differentiate. We append criteria sets for diagnosing clinical depression and its principal diagnostic subtypes (psychotic, melancholic and non-melancholic). Conclusion This heuristic study reframes and modifies major depression's criteria set to define a domain of clinical depression with additional criteria and then allowing the delineation of three diagnostic subtypes. If this paradigm shift is accepted and further refined, greater precision in diagnosis, treatment and research would be anticipated. [ABSTRACT FROM AUTHOR]

BackgroundEstablishing an evidence-based diagnostic system informed by the biological (dys)function of the nervous system is a major priority in psychiatry. This objective, however, is often challenged by difficulties in identifying homogeneous clinical populations. Melancholia, a biological and endogenous subtype for major depressive disorder, presents a canonical test case in the search of biological nosology.MethodWe employed a unique combination of naturalistic functional magnetic resonance imaging (fMRI) paradigms – resting state and free viewing of emotionally salient films – to search for neurobiological signatures of depression subtypes. fMRI data were acquired from 57 participants; 17 patients with melancholia, 17 patients with (non-melancholic) major depression and 23 matched healthy controls.ResultsPatients with melancholia showed a prominent loss of functional connectivity in hub regions [including ventral medial prefrontal cortex, anterior cingulate cortex (ACC) and superior temporal gyrus] during natural viewing, and in the posterior cingulate cortex while at rest. Of note, the default mode network showed diminished reactivity to external stimuli in melancholia, which correlated with the severity of anhedonia. Intriguingly, the subgenual ACC, a potential target for treating depression with deep brain stimulation (DBS), showed divergent changes between the two depression subtypes, with increased connectivity in the non-melancholic and decreased connectivity in the melancholic subsets.ConclusionThese findings reveal neurobiological changes specific to depression subtypes during ecologically valid behavioural conditions, underscoring the critical need to respect differing neurobiological processes underpinning depressive subtypes. [ABSTRACT FROM PUBLISHER]

Objective To detail the disconnect between the quantified efficacy of the mood stabilizer lamotrigine in its registration controlled trials and its later judged clinical effectiveness and consider some determinants of disconnects between some efficacy trial findings and 'real-world' clinical effectiveness judgments. Method Published articles considering lamotrigine as a treatment for the bipolar I or II disorders were selected for review. While randomized controlled trials were weighted, we also consider open trials and effectiveness observations from clinician researchers and demonstrate that lamotrigine has been quite variably judged over time. Results We suggest that the early trials evaluating lamotrigine for acute bipolar disorder depression focused on a suboptimal clinical target, and in so doing, ensured less lamotrigine efficacy compared with trials of bipolar disorder preventative treatment. Moreover, a number of additional methodological limitations compromised analyses. We also detail variable reporting of actual study results. The initial sharp disconnect (between efficacy and effectiveness judgments) has narrowed as lamotrigine has been evaluated and progressively taken up as a maintenance mood stabilizer. Conclusion The lamotrigine disconnect story provides a number of salutary lessons that are salient to evaluating the effectiveness and ecological niche of any psychotropic medication. The lamotrigine story presented here argues strongly for the wisdom of encouraging an iterative process between efficacy studies and clinical observation. [ABSTRACT FROM AUTHOR]

Background Studies suggest that differentiating melancholic from non-melancholic depressive disorders is advanced by use of illness course as well as symptom variables but, in practice, potentially differentiating variables are generally positioned as having equal value. Judging that differentiating features are more likely to vary in their signal intensity, we sought to determine the number of features required to effect differentiation and their hierarchical order. Methods The 24-item clinician-rated Sydney Melancholia Prototype Index (SMPI-CR) was completed for 364 unipolar depressed patients. The sample was divided into two cohorts according to the recruitment period. An RPART classification tree analysis identified the most discriminating SMPI items in the development sample of 197 patients, and examined the sensitivity and specificity of the diagnostic decisions, then sought to replicate findings in a validation sample of 169 patients. Results Independent analyses of putative SMPI items identified only seven items as required to discriminate those with clinically-diagnosed melancholic or non-melancholic depression when the conditions were examined separately. An RPART analysis considering differentiation of melancholic and non-melancholic depression in the total samples retained five of those items in the classification tree, three of which were non-symptom items, and with 92% sensitivity and 80% specificity in the development sample. This reduced item set showed 93% sensitivity and 82% specificity in the validation sample. Limitations Our clinical judgment of melancholic or non-melancholic depression may not correspond with the clinical logic employed by other clinicians. Conclusion Only five SMPI items were required to derive a succinct and efficient decision tree, comprising high sensitivity and specificity in differentiating melancholic and non-melancholic depression. Current study findings provide an empirical model that could enrich clinicians׳ approach to differentiating melancholic and non-melancholic depression. [ABSTRACT FROM AUTHOR]

Objective There has been increasing concern about extensions to the definition of 'clinical' depression, but little evident investigation as to how clinical and non-clinical depressive states might best be differentiated. This review considers the potential of many candidate symptom and non-symptom parameters. Method We overview representative concerns and theories about the nature of psychiatric disorders before reviewing the potential utility of candidate parameters for differentiating clinical and non-clinical depressive states. Results While we detail limitations to all candidate parameters designed to distinguish between clinical and non-clinical depression, their actual utility may only be able to be judged by empirical testing across appropriate comparison groups. Conclusion We argue for initial comparisons being made between prototypically defined categorical (i.e. psychotic, melancholic and bipolar) depressive disease states and residual non-melancholic clinical depressive states, before considering how each of those two clinical subsets might differ from non-clinical depressive mood states. [ABSTRACT FROM AUTHOR]

Objective We sought to determine whether putative depressive diseases could be differentiated categorically from clinical depressive disorders and non-clinical mood states. Method We interviewed volunteers who reported or denied any lifetime depressive mood state and analyzed data from the former group reporting on their 'most severe' depressive episode. We employed latent class analysis (LCA) to determine whether a two-class solution was supported and the contribution of individual variables to class allocations. Results All variables were significant predictors of class allocation. LCA-assigned Class I participants reported more depressive symptoms, had more distressing episodes and more lasting consequences, were more likely to view their depression as 'like a disease', and as being both disproportionately more severe and persistent in relation to any antecedent stressor. Validation involved comparison of LCA assignment with DSM-IV diagnosis for their most severe depressive episode. Of those assigned to Class I, 89% had a DSM diagnosis of melancholic, psychotic or bipolar depression. Class II had all those failing to meet criteria for a depressive episode and the majority of those with a non-melancholic depressive condition. Conclusion Despite not including individual depressive symptoms, study variables strongly differentiated putative depressive diseases from a composite of clinical depressive conditions and subclinical depressive states. [ABSTRACT FROM AUTHOR]

Objective We tested the hypothesis that abnormal levels of omega-3 and omega-6 polyunsaturated fatty acids ( PUFAs) during late pregnancy are associated with antenatal and post-natal depression. Method We interviewed a sample of more than 900 women in late pregnancy. We assessed whether they met criteria for depression on a standardized measure of post-natal depression [the Edinburgh Post-natal Depression Scale ( EPDS)] and met DSM- IV criteria for major depression and/or were in receipt of antidepressant medication. Blood was collected at that time to generate data on nine PUFA variables. Sample members were re-interviewed post-natally to determine depressive experience in the 3 months following the birth of their baby. Results Univariate associations were demonstrated between pre-natal depression categorized using DSM criteria and measures of blood fatty acids including total omega-3, the ratio of omega-6 to omega-3, docosahexaenoic acid ( DHA) omega-3 and DHA plus eicosapentaenoic acid ( EPA) omega-3. Such associations were not found post-natally, but different associations were quantified between EPDS-diagnosed depression and total omega-6, total omega-3 and EPA omega-3. In multivariate analyses, slight associations were maintained between EPDS and lower omega-3, lower EPA and higher omega-6 when neuroticism, stress during pregnancy, a lifetime episode of depression and older age were included in the analysis. Conclusion Findings in such a large sample indicate that PUFA status in late pregnancy is only slightly linked with the risk of post-natal depression when depression was quantified by the EPDS. There were no associations between post-natal depression diagnosed by DSM criteria and any fatty acid variables. [ABSTRACT FROM AUTHOR]

Abstract: Background: In arguing for the need to distinguish clinical depression from sadness, Horwitz and Wakefield argued for weighting consideration to nuances of life event stressors. Their definition of clinical depression corresponds to the concept of endogenous depression or melancholia, while their model would position reactive (or context specific) non-melancholic depressive disorders more as manifestations of ‘sadness’ rather than as clinical depression. Method: We test their postulate by examining the extent to which 141 clinically diagnosed melancholic and non-melancholic depressed patients reported episodes as being preceded by a life event stressor or not — and the salience of any life stressor to episode onset and severity. Results: While melancholic patients were more likely than non-melancholic patients to report episodes coming ‘out of the blue’ and to be more severe than might be expected from the severity of antecedent stressors, differences were more ones of degree and not absolute. Such context variables appeared, however, to differentiate melancholic and non-melancholic patients more consistently than depression symptom variables. As depression severity and impairment levels did not differ across the melancholic and non-melancholic patients, findings were unlikely to be artefacts of such factors. Conclusions: The study finds some support for the Horwitz and Wakefield hypothesis of clinical (or, at least melancholic) depression requiring independence of context or an antecedent stressor, but with precision likely to be compromised by nuances intrinsic to assessment of life event stressors and their contribution to depression onset, difficulties in defining valid ‘melancholic’ and ‘non-melancholic’ depressive sub-groups and the parsimony of the hypothesis. [Copyright &y& Elsevier]

Parker G, Brotchie H. Mood effects of the amino acids tryptophan and tyrosine. Objective: Reflecting increased scientific interest in any nutritional contribution to the onset and treatment of mood disorders, we overview research into two neurotransmitter precursors - the amino acids tryptophan and tyrosine - particularly examining whether any deficiency increases risk to depression and whether those amino acids have any antidepressant properties. Method: The theoretical relevance of the two amino acids was overviewed by considering published risk and intervention studies, technical papers and reviews. Results: There is some limited evidence, suggesting that depressed patients, especially those with a melancholic depression, have decreased tryptophan levels. Whether such findings reflect a causal contribution or are a consequence of a depressed state remains an open question. There is a small database supporting tryptophan preparations as benefitting depressed mood states. There is no clear evidence as to whether tyrosine deficiency contributes to depression, while the only randomized double-blind study examining tyrosine supplementation did not show antidepressant benefit. Conclusion: Acute tryptophan depletion continues to provide a research tool for investigating the relevance of serotonin to depression onset. There is limited evidence that tryptophan loading is effective as a treatment for depression through its action of increasing serotonin production. Most clinical studies are dated, involve small sample sizes and/or were not placebo controlled. The development of the new serotonin reuptake inhibitor drugs seemingly signalled an end to pursuing such means of promoting increased serotonin as a treatment for depression. The evidence for tyrosine loading promoting catecholamine production as a possible treatment for depression appears even less promising, and depletion studies less informative. [ABSTRACT FROM AUTHOR]

Parker G, Brotchie H. 'D' for depression: any role for vitamin D?. Objective: While there has long been interest in any nutritional contribution to the onset and treatment of mood disorders, there has been increasing scientific evaluation of several candidate nutritional and dietary factors in recent years. In this paper, we overview research into any vitamin D insufficiency and deficiency contribution to depression. Method: The relevant literature was reviewed. Results: Cross-sectional studies have identified associations between depression and low vitamin D levels, but studies have failed to clarify whether vitamin D deficiency is an antecedent cause, correlate or consequence of depression. While vitamin D deficiency and insufficiency have been linked with seasonal affective disorder, suggested associations have not been rigorously tested. There has been insufficient research to establish whether and when vitamin D supplementation should be considered as an augmentation strategy with antidepressant drugs. Conclusion: There is currently insufficient evidence to argue strongly for vitamin D supplementation in patients with depression, but such a strategy is worthy of consideration in depressed patients whose lifestyle and geographical residence may indicate a risk of vitamin D insufficiency - or where low vitamin D levels have been quantified. [ABSTRACT FROM AUTHOR]

Hegarty BD, Parker GB. Marine omega-3 fatty acids and mood disorders - linking the sea and the soul. While there has long been interest in any nutritional contribution to the onset and treatment of mood disorders, there has been increasing scientific evaluation of several candidate nutritional and dietary factors in recent years. In this inaugural study of our 'Food for Thought' series, we will overview the evidence for any role of omega-3 fatty acids (FA) in regulating mood. Relevant literature was identified through online database searches and cross-referencing. Plausible mechanisms exist by which omega-3 FA may influence neuronal function and mood. Cross-sectional studies demonstrate an association between omega-3 fatty acid deficiency and both depressive and bipolar disorders. Studies investigating the efficacy of omega-3 fatty acid supplementation for mood disorders have however provided inconsistent results. The proportion of treatment studies showing a significant advantage of omega-3 supplementation has dropped over the last 5 years. However, the vast heterogeneity of the trials in terms of constituent omega-3 FAs, dose and length of treatment makes comparisons of these studies difficult. More research is required before omega-3 supplementation can be firmly recommended as an effective treatment for mood disorders. Whereas increased omega-3 FA intake may alleviate depressive symptoms, there is little evidence of any benefit for mania. [ABSTRACT FROM AUTHOR]

Abstract: Background: We report on the assessment and outcome of the first 1000 patients referred to a tertiary referral depression clinic established to assess the utility of diagnostic sub-typing on clinical course of illness. Methods: Diagnostic, treatment recommendations, prognostic judgments and 12-week outcome data were examined. Results: Nearly 40% of those with a primary mood disorder were diagnosed with bipolar disorder, of whom three-quarters received such a diagnosis for the first time. Alternative diagnoses or formulations were provided for 68% of the total sample, with the therapeutic paradigm altered for the majority (86%) of patients. Improvement rates were indicative of a higher level of improvement in those diagnosed with bipolar disorder (some 70%) compared to those with unipolar disorders (some 60%). Overall, however, rates of ‘full remission’ were low, being 2% and up to 12% for bipolar and unipolar patients respectively and perhaps reflecting the tertiary nature of the assessing clinical facility. Baseline clinician predictions were in the order of 60% accuracy in predicting outcome, irrespective of diagnostic grouping. Limitations: Anticipation factors (e.g. attending a specialist tertiary referral service) may have contributed non-specifically to outcome. Use of clinician-derived diagnoses rather than strict DSM-IV criteria limits comparisons to other studies. Conclusions: The high rates of a first-time bipolar diagnosis suggest that detection and diagnosis of this condition continues to be problematic. Low remission rates underline the chronic nature of many mood disorders, and the need for ongoing management given the high risk of relapse. Our findings offer support for the importance of identifying bipolar disorder and distinguishing depressive sub-types in order to shape more targeted treatments, a task that might be advanced by the establishment of more tertiary referral services. [Copyright &y& Elsevier]

Objective: We examine the depressive symptom profile of bipolar II disorder patients compared with a comparator (composite) group of those with unipolar depression, with stratification by melancholic and non-melancholic subtypes. Method: Out-patients ( n = 394) attending a specialist depression clinic comprised the sample. Data on severity and prototypic status of depressive symptoms were analysed. Results: Age-matched analyses revealed minimal differentiation between bipolar II and composite unipolar groups. Stratified analyses suggested that ‘bipolar II depression’ more closely approximated melancholic depression in terms of psychomotor and cognitive slowing. Severity-based analyses and prototypic symptom patterns yielded differing results, suggesting that definition of bipolar II depression is influenced by rating strategies, and age. Conclusion: We found limited differentiation of bipolar II depression from unipolar, melancholic and non-melancholic depression. Differences suggested previously may reflect age, gender and severity differences, highlighting the need for appropriately matched groups in defining bipolar II depression. [ABSTRACT FROM AUTHOR]

Background. Melancholia has long resisted classification, with many of its suggested markers lacking specificity. The imprecision of depressive symptoms, in addition to self-report biases, has limited the capacity of existing measures to delineate melancholic depression as a distinct subtype. Our aim was to develop a self-report measure differentiating melancholic and non-melancholic depression, weighting differentiation by prototypic symptoms and determining its comparative classification success with a severity-based strategy. Method. Consecutively recruited depressed out-patients (n=228) rated 32 symptoms by prototypic or ' characteristic ' relevance (using the Q-sort strategy) and severity [using the Severity-based Depression Rating System (SDRS) strategy]. Clinician diagnosis of melancholic/non-melancholic depression was the criterion measure, but two other formal measures of melancholia (Newcastle and DSM-IV criteria) were also tested. Results. The prevalence of ' melancholia ' ranged from 20.9% to 54.2% across the subtyping measures. The Q-sort measure had the highest overall correct classification rate in differentiating melancholic and non-melancholic depression (81.6 %), with such decisions supported by validation analyses. Conclusions. In differentiating a melancholic subtype or syndrome, prototypic symptoms should be considered as a potential alternative to severity-based ratings. [ABSTRACT FROM AUTHOR]

Objective: The study aimed to review the conclusion of a previously published meta-analysis which quantified distinct superiority of cognitive therapy to antidepressant drug-therapy ( P < 0.0001). Method: We sought to include all studies used in the original meta-analysis. Adopting both that study’s inclusion criteria and additional criteria resulted in a reduced set of studies. We analysed both ‘completer’ and ‘intention to treat’ data, using effect size and odds ratio quantification. Results: There was an overall trend for cognitive therapy to be superior to antidepressant drug-therapy, but this was significant for only one of the four meta-analyses (an intention to treat analysis). We demonstrated considerable heterogeneity between studies, and a significantly higher drop-out rate in the antidepressant groups. Conclusion: The previous interpretation – cognitive therapy being distinctly superior to antidepressant medication – cannot be sustained from the currently analysed data set. [ABSTRACT FROM AUTHOR]

Objective: While Cognitive Behaviour Therapy (CBT) and Interpersonal Therapy (IPT) have been positioned as first-line evidence-based treatments for depression, we suggest that limitations to the ‘evidence’ deserve wider appreciation. Method: A systematic literature search was undertaken, and limitations to the evidence base discussed. Results: The review suggests that the specificity of CBT and IPT treatments for depression has yet to be demonstrated and details likely reasons. Conclusion: The superiority of CBT and IPT may well be able to be demonstrated across defined rather than universal circumstances. To achieve this aim, outcome research should move away from testing treatments as if they have universal application for heterogeneous disorder categories. Findings have distinct implications for the clinical management of depressive disorders, and particularly in relation to the utility of psychotherapy. [ABSTRACT FROM AUTHOR]

Objective: Traditional cross-sectional clinician-rated measures have limited use in clinical trials of bipolar disorder. We examine the validity and usefulness of patients’ daily ratings of mood and functional impairment during a treatment trial. Method: Ten subjects with bipolar II disorder completed daily ratings of depression severity, depression, hypomania and functional impairment over a 9-month trial. Ratings were correlated with clinician-rated measures at nine time points to determine validity. Mood ratings were contrasted with cross-sectional data for one subject to determine usefulness of such fine-grained data. Results: Moderate to large correlations were found between patients’ and clinicians' ratings of mood and impairment for most of the nine time points. The utility of the patients’ ratings relative to clinician-rated cross-sectional measures was also illustrated. Conclusion: Results support the validity and usefulness of patients’ daily mood ratings. [ABSTRACT FROM AUTHOR]

Objective: To argue that melancholia is a categorically distinct depressive condition, able to be differentiated from other depressive conditions by a neuropathological marker [observable psychomotor disturbance (PMD)] and having a differential response to various antidepressant treatments. Method: The above statements are addressed by review of a wide body of research, which identified observable PMD as the cardinal marker of melancholia and developed the CORE measure as a strategy for assessing PMD and its severity. Properties of the CORE measure, including reliability, validity and treatment prediction, are overviewed. Results: A case is made for defining melancholia and a strategy for establishing its probability. Conclusion: Melancholia is positioned as a categorical entity capable of being circumscribed by its cardinal feature of PMD. [ABSTRACT FROM AUTHOR]

Objective: To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression. Method: One hundred and seventy-six patients (74 male, 102 female) aged 16–82 years (M = 42, SD = 14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression. Results: Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness. Conclusion: A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies. [ABSTRACT FROM AUTHOR]

Objective: As deliberate self-harm (DSH) is a common concomitant of depressive disorders, we undertook a study examining the relevance of possible determinants and correlates of DSH. Method: Three separate samples of depressed outpatients were studied to determine consistency of identified factors across samples, with principal analyses involving gender, age and diagnosis-matched DSH and non-DSH subjects. Results: Across the samples, some 20% of subjects admitted to episodes of DSH. Women reported higher rates and there was a consistent trend for higher rates in bipolar patients. Univariate analyses examined the relevance of several sociodemographic variables, illicit drug and alcohol use, past deprivational and abusive experiences, past suicidal attempts and disordered personality functioning. Multivariate analyses consistently identified previous suicide attempts and high ‘acting out’ behaviours across the three samples, suggesting the relevance of an externalizing response to stress and poor impulse control. Conclusions: Results assist the identification and management of depressed patients who are at greater risk of DSH behaviours. [ABSTRACT FROM AUTHOR]

Objective: To better define treatment-resistant depression (TRD) so as to assist clinical management and refine treatment guidelines. Method: In this study, we examine a broad range of clinical variables in depressed patients ( n = 196) referred to a tertiary referral Mood Disorders Unit (MDU). Information was collected from patients, referrers and assessors over a period of 32 months and included evaluations of treatments, treatment resistance and related variables. Data were analysed across trichotomized ‘high’, ‘low’ and ‘no’ treatment resistance groupings of patients. Results: A significantly greater proportion of patients with melancholia were amongst the high TRD group, and this was consistent across different strategies for evaluating melancholia. Conclusion: Melancholia perhaps provides a prototypic TRD subset that perhaps reflects some innate aspects of melancholic depression or factors such as the impact of ageing. Research into TRD is needed to both replicate this finding and perhaps explicate it further. [ABSTRACT FROM AUTHOR]

Parker G, Malhi G, Mitchell P, Wilhelm K, Austin M-P, Crawford J, Hadzi-Pavlovic D. Progressing a spectrum model for defining non-melancholic depression.Acta Psychiatr Scand 2005: 111: 139–143.© Blackwell Munksgaard 2005.To further develop a‘spectrum model’ for non-melancholic disorders that encompasses underlying personality styles and clinical patterning.In a sample of patients with non-melancholic depression, we studied four personality constructs influencing risk to depression, assessing associational strength and specificity between personality scores and symptom and coping response patterns.Analyses refined four personality dimensions (anxious worrying, irritability, social inhibition, and self-centredness) for testing the model. For all dimensions, personality style was specifically linked with a mirroring‘coping’ response. Quantification of specific links allowed development of a spectrum model for the non-melancholic depressive disorders in which underpinning personality style showed some specific links with the clinical‘pattern’ of symptoms and coping repertoires.The model has the capacity to assist clinical assessment, identify aetiological personality influences and allow specific treatment effects for the heterogeneous non-melancholic depressive disorders to be determined. [ABSTRACT FROM AUTHOR]

Malhi GS, Parker GB, Greenwood J. Structural and functional models of depression: from sub-types to substrates.Acta Psychiatr Scand 2005: 111: 94–105.© Blackwell Munksgaard 2005.To present a functional model of depression facilitating research and clinical understanding.The authors conducted a systematic literature search and reviewed articles pertaining to the neurochemistry and pathophysiology of depressive disorders, focusing on the contribution made by the principal monoamines to three differing depressive structural sub-types (i.e. psychotic, melancholic and non-melancholic).We suggest that the three structural depressive subtypes appear functionally underpinned by differential contributions of serotonergic, noradrenergic and dopaminergic neurotransmitters, so influencing phenotypic distinction (our structural model) and allowing an aetiological model to be derived with treatment specificity implications.The functional model logically iterates with the structural model of depression and provides a useful framework for conceptualizing the depressive disorders. This model provides a logic for distinguishing between principal depressive subtypes, pursuing their functional underpinnings and explaining treatment differential effects across the three sub-types. [ABSTRACT FROM AUTHOR]

Objective: To review critically alternative models of depression. Method: Contrasting historical models are noted and some results of a study overviewing a temperament-based model for the non-melancholic disorders are presented. Results: Limitations to all models are considered. Conclusion: As depression can present as a mood state, a syndrome, a disorder and as a disease, it is unwise to assume that a single model will suffice. A pure temperament diathesis model of non-melancholic depression is unlikely to be sufficient and would benefit from testing of additional personality constructs. [ABSTRACT FROM AUTHOR]

Objective: Depression is currently modelled dimensionally, along severity, duration and recurrency dimensions. An alternative model allows dimensional expressions of temperament and personality to influence risk to onset as well as persistence. Here, we examine the utility of a temperament model. Method: A questionnaire assessing temperament dimensions and a number of depression variables was administered to a large routine general practice sample and with the temperament measure also completed by a small clinical sample. Results: `Anxious worrying' and `irritable' dimensions were identified as internalizing and externalizing expressions of a trait anxiety dimension, three other `temperament' dimensions (i.e. `introversion', `self-centred' and `obsessive') were refined, while a `self-blame' dimension intruded into the factor analytic solution. High scores on the `anxious worrying' dimension were associated with all depression parameters. The `irritable', `introversion' and `self-blame' dimensions were less clearly linked with depression variables, while higher scores on the `self-centred' and `obsessional' dimensions did not appear to increase the chance of depression onset, persistence or recourse to treatment. Conclusion: A temperament-based approach appears to have some conceptual utility in modelling depression, and particularly, the non-melancholic disorders. It is likely, however, to require complementing with refined at-risk personality dimensions. [ABSTRACT FROM AUTHOR]

Objective: To examine gender differences in depression risk and coping factors in a clinical sample of patients with a diagnosis of DSM-IV major depression. Method: Patients were assessed for substance use and abuse, family history of psychiatric disorder, interpersonal depressogenic factors and lifetime history of anxiety disorders. Trait anxiety, coping styles when depressed, parental bonding, marital features and personality style were also measured. Patients were reassessed at 12-month follow-up. Results: There were few gender differences in experience of depression (either in duration, type or severity prior to treatment) in a group with established episodes of major depression but women reported more emotional arousability when depressed. Women reported higher rates of dysfunctional parenting and childhood sexual abuse, and rated their partners as less caring and as more likely to be a depressogenic stressor. Men were more likely to have a generalized anxiety disorder at assessment, to use recreational drugs prior to presentation. Men were rated as having a more rigid personality style and `Cluster A' personality traits both at assessment and follow-up. Conclusion: There were few gender differences in severity or course of established episodes of major depression. Gender differences were related to levels of arousal, anxiety disorders, and repertoires for dealing with depression, rather than depressive symptoms per se . [ABSTRACT FROM AUTHOR]

Objective: We suggest that the identification of depression in the medically ill (DMI) might be improved by focussing on cognitive features. Method: We recruited 302 patients to complete our provisional cognitive-based measure. Subsets also completed one of two comparator screening measures, either the Hospital and Anxiety Depression Scale (HADS) or the Beck Depression Inventory for Primary Care (BDI-PC). One hundred and sixty patients were then assessed by a psychiatrist who estimated whether they were `clinically depressed' and who also administered a standardized interview for depression (the CIDI). Results: Analyses identified items discriminating clinically depressed and non-depressed individuals, allowing development of brief (10-item) and extended (18-item) measures. The two new measures were compared with the HADS and the BDI-PC in discriminating depressed and non-depressed medically ill patients. Conclusion: A cognitive construct-based approach to assessing depression in the medically ill appears strongly supported. We provide brief (DMI-10) and extended (DMI-18) measures that appear to have utility as screening instruments. Consideration of the discriminating items may also assist clinical decision making. [ABSTRACT FROM AUTHOR]

Objectives Studies comparing older and younger depressed patients have variably identified differing and similar clinical feature patterns, an inconsistency requiring clarification and explanation. If influential, age may have a true phenotypic effect or be a secondary influence reflecting depressive sub-type differences. If age is primarily influential, then, after controlling for depressive sub-type differences its effect should impact on clinical features — even in non-western regions. Methods We therefore undertook a study in Singapore, comparing 42 elderly and 28 younger patients of a Singapore psychiatric hospital, and with the diagnostic sub-type profile similar across the age-based groups. Results Despite the elderly group being some 35 years older, both at first episode and when surveyed, and having a distinctly higher rate of physical disorders, few clinical differences were identified. While the elderly group reported a less severe depressed mood and more ‘somatic’ symptoms, analyses indicated that such differences were accounted for by education and language factors, and were compatible with the view that Chinese subjects historically report depression more ‘somatically’. Conclusion We conclude that, in a non-western, largely Chinese sample of depressed patients, few differences in the phenotypic expression of depression were identified, perhaps reflecting similar distributions of depressive sub-types across the groups, an issue which may have muddied interpretation of western studies. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: National community studies consistently identify higher rates of both depressive and anxiety disorders in women. The female preponderance in depression could be primary or, alternatively, a sex difference in anxiety could determine the differential depression rates. We therefore pursue whether the female preponderance in depression is secondary to a female preponderance in anxiety disorders in a community sample. Method: We analyse relevant data from the National Comorbidity Study (NCS) database, examining in particular whether sex differences in anxiety (here those meeting criteria for panic disorder, agoraphobia without panic disorder, generalized anxiety and social phobia) influenced sex differences in the prevalence of both major depression and dysthymia. Results: Survival analyses indicated that, for both major depression and dysthymia, and within subsamples of those with early onset and late onset depression, both female sex and a preceding anxiety disorder made significant contributions, with preceding anxiety making the consistently stronger contribution of the two. Conclusion: A proportion of the female preponderance in major depression and dysthymia in the general community appears determined by a primary sex difference in anxiety. [ABSTRACT FROM AUTHOR]

Parker G. Differential effectiveness of newer and older antidepressants appears mediated by an age effect on the phenotypic expression of depression. Acta Psychiatr Scand 2002: 106: 168–170. © Blackwell Munksgaard 2002. Objective: A possible mechanism whereby the serotonin reuptake inhibitor (SSRI) antidepressants may not (overall) be as effective as the tricyclic (TCA) antidepressants is explored. Method: Clinical psychiatrists rated the effectiveness of past antidepressant medications in a clinical panel study of patients with a major depressive disorder, with 200 having previously received a TCA and 219 an SSRI. Results: Analyses indicated decreased SSRI effectiveness with age in those with the melancholic subtype. TCA effectiveness appeared uninfluenced by age and depressive subtype. Conclusion: Findings suggest why the broader-based TCAs may be more effective than the SSRIs in implicating age and depressive subtype influences. [ABSTRACT FROM AUTHOR]

Abstract: Background: The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in “at risk” women have used a “psychoeducational” intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period. Method: Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4. Results: Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women “completing” the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 “completers” showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups. Limitations: A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself. Conclusion: While a modest reduction in depression scores was noted in study “completers”, both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention. [Copyright &y& Elsevier]