Melancholic versus non-melancholic depression: A longitudinal study protocol

BMC Psychiatry published an interesting article on the difference between melancholic and non-melancholic depression in terms of cognitive function, and the authors have offered a research design and protocol to test their hypothesis.

It's an open source publication, so the PDF is free to read.

Melancholic versus non-melancholic depression: differences on cognitive function. A longitudinal study protocol

Saray Monzon , Margalida Gili , Margalida Vives , Maria JESUS Serrano , Natalia Bauza , Rosa Molina , Mauro Garcia-Toro , Joan Salva , Joan Llobera and Miquel Roca

BMC Psychiatry 2010, 10:48doi:10.1186/1471-244X-10-48

Published: 17 June 2010

Abstract (provisional)

Background

Cognitive dysfunction is common among depressed patients. However, the pattern and magnitude of impairment during episodes of major depressive disorder (MDD) through to clinical remission remains unclear. Heterogeneity of depressive patients and the lack of longitudinal studies may account for contradictory results in previous research.

Methods

This longitudinal study will analyze cognitive differences between CORE-defined melancholic depressed patients (n=60) and non-melancholic depressed patients (n=60). A comprehensive clinical and cognitive assessment will be performed at admission and after 6 months. Cognitive dysfunction in both groups will be longitudinally compared, and the persistence of cognitive impairment after clinical remission will be determined.

Discussion

The study of neuropsychological dysfunction and the cognitive changes through the different phases of depression arise a wide variety of difficulties. Several confounding variables must be controlled to determine if the presence of depression could be considered the only factor accounting for group differences.

Here is the beginning of the article, offering some definitions and background for the study. Essentially, the authors are proposing that studies on major depression have been flawed in terms of defining subjects. They propose using melancholia ("a disorder with definable clinical signs") which describes a depression in physical symptoms are predominant. This is contrasted by a "reactive or non-melancholic form of depression" which we might generally define as situational or as sadness ("the presence of low mood and tearfulness is frequent and biological markers are not predominant").

Background
Over the last years cognitive dysfunction has increasingly been recognized as a core feature of major depressive disorder (MDD). Clinical studies have focused on the pattern and magnitude of impairment during and between episodes of MDD as well as the neuropsychological domains affected and the origin of these abnormalities [1]. However, results from neuropsychological and neuroimaging studies are still controversial. These contradictory results could be explained mainly by two methodological factors. The first factor is the absence of homogeneity in clinical samples. The heterogeneity of patients evaluated in clinical studies may derive from the different criteria (DSM, ICD) currently used to diagnose MDD and its subtypes. Some authors have pointed out that these criteria poorly identify samples for clinical and outcome studies [2,3]. The second factor explaining controversial results is related to the lack of longitudinal studies that focus on the changes on cognitive function produced through the clinical course of depression. Whether cognitive impairment manifested during periods of depression is long lasting or improves after remission and recovery remains a central issue of study [4]. The cognitive domains affected have neither been clearly identified [5].

To overcome the limitation derived from the first methodological factor, a more accurate selection of depressed patients is required. A pattern of cognitive dysfunction may be more evident in a form of depression characterized by biological markers than in more heterogeneous depressed samples. Melancholia is a disorder with definable clinical signs that identifies more specific populations than the DSM-IV [3]. It describes episodes in which physical symptoms are predominant and is opposed to a reactive or non-melancholic form of depression in which the presence of low mood and tearfulness is frequent and biological markers are not predominant [6].

Overcoming the limitation derived from the lack of longitudinal data imply the development of cohort studies. Longitudinal assessment of cognitive functions seems to be a potentially powerful method of identifying and distinguishing state-related from trait-related cognitive deficits [4]. Previous studies report residual neuropsychological deficits in melancholic patients despite improvement in their depressive symptomatology [7]. Particularly, persisting executive functions and memory disturbances have been observed. This would indicate that some cognitive dysfunction may not be simply secondary to mood disturbances in depression but may represent trait vulnerability markers for MDD. Deficits in other domains of cognitive performance appear to be more state-dependent [8]. The high risk of relapse in depression makes it important to analyze the existence of persisting cognitive impairments during remission, recovery and the euthymic phase of depression. A better understanding of these issues is crucial as it has been suggested that cognitive impairment worsens for every episode of depression and that the observed cognitive impairment in a nonsymptomatic phase of depression may be related to the number of previous episodes [9].

The course of cognitive changes through to clinical improvement in samples of depressed participants with and without melancholia has scarcely been longitudinally studied [6]. The present study aims to analyze longitudinally the cognitive performance of a homogeneous sample of depressed patients. Results of this study can have relevant implications for treatment and neuropsychological rehabilitation.

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Tags: Melancholic, non-melancholic, depression, longitudinal study protocol, differences, cognitive function, Saray Monzon et al, BMC Psychiatry, cognitive impairment, major depressive disorder, biological markers, sadness, low mood, tearfulness, neuroscience, neuroimaging, DCM-IV, ICD-10, Psychology, brain, research

Dr. Ronald Pies - The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective

This is an excellent articles from Dr. Pies, who is "Professor of Psychiatry and Lecturer on Bioethics and Humanities at S.U.N.Y. Upstate Medical University in Syracuse, New York, and Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is the author of The Ethics of the Sages (Rowman & Littlefield) and Everything Has Two Handles: The Stoic's Guide to the Art of Living (Hamilton Books) as well as several textbooks on psychopharmacology (see Handbook of Essential Psychopharmacology). He is interested in the connection between mental health care and various spiritual traditions." Oh yeah, and he is the editor of Psychiatric Times.

I have had the pleasure of conversing a bit with Dr. Pies through this blog, and I am a fan of his objectivity and open-mindedness. What appeals to me about this article is that he seeks to make a phenomenological analysis of sorrow and depression. In doing so, he identifies distinct and yet partly similar "lifeworlds." More importantly, he examines these ideas through the relational (sorrow is more relational, depression is intrapersonally focused), temporal (in sorrow, we know it will pass, but there is a slowing of time in depression), dialectical (sorrow generates intrapersonal conversation, depression does not), and intentional (we are overtaken by depression, but give ourselves over to sorrow) perspectives.

The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective

Ronald Pies:

Department of Psychiatry, S.U.N.Y. Upstate Medical University, Syracuse, NY, USA
Tufts University School of Medicine, Boston MA, USA

Philosophy, Ethics, and Humanities in Medicine 2008, doi:10.1186/1747-5341-3-17

The electronic version of this article is the complete one and can be found online at: http://www.peh-med.com/content/3/1/17

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

There is considerable controversy, both within and outside the field of psychiatry, regarding the boundaries of normal sadness and clinical depression. Furthermore, while there are frequent calls for a "pluralistic", comprehensive approach to understanding depression, few writers have tried to integrate insights from the spiritual, philosophical, and neurobiological literature. The author proposes that such a synthesis is possible, and that our understanding of ordinary sorrow and clinical depression is enriched by drawing from these disparate sources. In particular, a phenomenological analysis of sorrow and depression reveals two overlapping but distinct "lifeworlds". These differ in the relational, temporal, dialectical, and intentional realms. Recent brain imaging studies are also beginning to reveal the neurobiological correlates of sorrow and depression. As we come to understand the neurobiology of these states, we may be able to correlate specific alterations in "neurocircuitry" with their phenomenological expressions.

Introduction

The field of psychiatry has always sought to incorporate insights from disciplines outside the realm of biology, notwithstanding the widespread notion that "biological psychiatry" is now the field's dominant paradigm. To be sure, recent advances in neurobiology–particularly in the area of mood disorders–have cast a bright light on the molecular and neurochemical bases of psychiatric illnesses.

To some degree, this has come at the expense of other modes of understanding. Indeed, some have upbraided modern-day psychiatry for ignoring the psychological, social and spiritual dimensions of emotional disorders. These attacks, in my view, distract us from the overriding task of integrating biological discoveries with a broader philosophy of emotional dysfunction. Insights from both the Western and Eastern spiritual traditions can help illuminate important aspects of ordinary sadness and pathological depression. A phenomenological analysis of these mood states can further enrich our understanding. Ultimately, I believe that a pluralistic view of mood disorders will aim at "mapping" experiential aspects of depression, such as hopelessness or self-deprecation, on to specific areas of brain dysfunction. In this paper, I try to provide a broad outline of such an integrated understanding of mood.

A brief spiritual history of sorrow and depression

Psychiatrists and psychologists are hardly the only ones who have recognized the difference between clinical depression and "normal" sadness or sorrow. The distinction seems to be as old as recorded history. Surprisingly, in the Old Testament, the figure of King David presents us with portraits of both severe depression and normal bereavement. In Psalm 38, conventionally ascribed to David, the psalmist is lamenting his sins. He tells us that "There is no soundness in my flesh...no health in my bones because of my sin...my wounds grow foul and fester because of my foolishness, I am utterly bowed down and prostate; all the day I go about mourning...I groan because of the tumult of my heart." [1]. Modern diagnosticians would see in this description a picture quite consistent with an episode of major depression. In contrast, after the death of his beloved friend, Jonathan, the very same King David is far from "bowed down and prostrate". Rather, after a brief period of weeping and fasting, David is moved to write a passionately stirring dirge, known as "The Lament of the Bow" (2 Samuel 1:17–27), addressed to his lost friend: "How have the mighty fallen...I grieve for you, my brother Jonathan, you were most dear to me..." [1]. There is no trace, in David's lament, of the self-loathing and bodily decay found in Psalm 38. David's period of mourning after Jonathan's death represents roughly what modern-day mental health professionals would call "bereavement"–not clinical depression.

That life brings with it certain unavoidable or at least "expectable" sorrows is a concept found in Eastern religious thought, as well. In Buddhism, for example, we are told there are two roots of unhappiness in human existence: dukha and tanha. Dukha comprises the "...inevitable occasions of unhappiness" that come with human suffering, frailty, disease, loss of loved ones, and of course, death. Then there is tanha, which is translated as "blind demandingness": that part of our nature "...which leads us to ask of the universe...more than it is ready or even able to give." [2] Very roughly, we can see the precursors of normal and pathological sadness, respectively, in dukhaand tanha.

Similarly, the 14^th century monk, Thomas ΰ Kempis (1380–1471) recognized that sorrow is sometimes appropriate. "Levity of heart and neglect of our faults," he wrote, "make us insensible to the proper sorrows of the soul." [3] Thomas asks, "Is there anyone who enjoys everything as he wishes? Neither you, nor I, nor anyone else on earth. There is no one in the world without trouble or anxiety, be he King or Pope."[3] Indeed, like many medieval theologians, Thomas saw this earthly existence as a vale of tears. He believed that, "...we often engage in empty laughter when we should rightly weep." [3]

Four centuries after Thomas ΰ Kempis, several Hassidic masters also distinguished between normal and abnormal degrees of sorrow. Rabbi Levi Yitzchak of Berditchev (1740–1810) wrote,

"There are two kinds of sorrow...When a man broods over the misfortunes that have come upon him... [and] cowers in a corner and despairs of help–that is a bad kind of sorrow..." In contrast, "...the other kind is the honest grief of a man who knows what he lacks." [4]

Similarly, writing at roughly the same time, Rabbi Simcha Bunam of Pshis'cha (1767–1827) recognized the distinction between "a broken heart" and what he termed "dejection":

"For it is a good thing to have a broken heart, and pleasing to God, as it is written: 'The sacrifices of God are a broken spirit...' [Psalm 51:19]...God does not entirely heal those who have broken hearts. He only eases their suffering, lest it torment and deject them. For dejection is not good and not pleasing to God. A broken heart prepares man for the service of God, but dejection corrodes service. We must distinguish as carefully between the two as between joy and wantonness..." [[4], p. 115, italics added].

Surprisingly, Rabbi Bunam seems to have foreseen not only our distinction between normal grief and clinical depression, but perhaps also that between normal joy and hypomania or mania ("wantonness").

Of course, it is not always easy to tell "proper sorrows" from intense grief, "pathological" grief, or clinical depression. Indeed, it is very doubtful that these are strictly delineated categories. Furthermore, the nature of the putative "cause" or precipitating event is not a reliable predictor of where, on this emotional continuum, a given individual may end up. The loss of a loved one, for example, ordinarily provokes sorrow and a finite period of grief and mourning. Most mourners do not develop a severe, intractable clinical depression. Indeed, in the Judaic tradition, it is expected that after the seven days of mourning known as shiva, the bereaved will generally be ready to resume some "everyday" activities (while refraining, however, from any kind of celebration) [5].

There are, of course, many exceptions to the generally self-limited course of mourning; in principle, there are as many kinds of mourning as there are mourners. The great medieval philosopher, Moses ben Maimon (Maimonides, 1135–1204), appears to have developed a profound and prolonged depression, after the death of his beloved brother, David, in a shipwreck. Maimonides writes, in a letter dated from 1176,

"On the day I received that terrible news [of David's death], I fell ill and remained in bed for about a year, suffering from a sore boil, fever, and depression, and was almost given up. About eight years have since passed, but I am still mourning and unable to accept consolation...all joy has gone...whenever I see his handwriting or one of his letters, my heart turns upside down and my grief awakens again." [6]

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Tags: Psychology, grief, depression, sorrow, Philosophy, sadness, The anatomy of sorrow, spiritual, phenomenological, neurological perspective, Ronald Pies, relational, temporal, dialectical, intentional