18 results
Contributors
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- By Waiel Almoustadi, Brian J. Anderson, David B. Auyong, Michael Avidan, Michael J. Avram, Roland J. Bainton, Jeffrey R. Balser, Juliana Barr, W. Scott Beattie, Manfred Blobner, T. Andrew Bowdle, Walter A. Boyle, Eugene B. Campbell, Laura F. Cavallone, Mario Cibelli, C. Michael Crowder, Ola Dale, M. Frances Davies, Mark Dershwitz, George Despotis, Clifford S. Deutschman, Brian S. Donahue, Marcel E. Durieux, Thomas J. Ebert, Talmage D. Egan, Helge Eilers, E. Wesley Ely, Charles W. Emala, Alex S. Evers, Heidrun Fink, Pierre Foëx, Stuart A. Forman, Helen F. Galley, Josephine M. Garcia-Ferrer, Robert W. Gereau, Tony Gin, David Glick, B. Joseph Guglielmo, Dhanesh K. Gupta, Howard B. Gutstein, Robert G. Hahn, Greg B. Hammer, Brian P. Head, Helen Higham, Laureen Hill, Kirk Hogan, Charles W. Hogue, Christopher G. Hughes, Eric Jacobsohn, Roger A. Johns, Dean R. Jones, Max Kelz, Evan D. Kharasch, Ellen W. King, W. Andrew Kofke, Tom C. Krejcie, Richard M. Langford, H. T. Lee, Isobel Lever, Jerrold H. Levy, J. Lance Lichtor, Larry Lindenbaum, Hung Pin Liu, Geoff Lockwood, Alex Macario, Conan MacDougall, M. B. MacIver, Aman Mahajan, Nándor Marczin, J. A. Jeevendra Martyn, George A. Mashour, Mervyn Maze, Thomas McDowell, Stuart McGrane, Berend Mets, Patrick Meybohm, Charles F. Minto, Jonathan Moss, Mohamed Naguib, Istvan Nagy, Nick Oliver, Paul S. Pagel, Pratik P. Pandharipande, Piyush Patel, Andrew J. Patterson, Robert A. Pearce, Ronald G. Pearl, Misha Perouansky, Kristof Racz, Chinniampalayam Rajamohan, Nilesh Randive, Imre Redai, Stephen Robinson, Richard W. Rosenquist, Carl E. Rosow, Uwe Rudolph, Francis V. Salinas, Robert D. Sanders, Sunita Sastry, Michael Schäfer, Jens Scholz, Thomas W. Schnider, Mark A. Schumacher, John W. Sear, Frédérique S. Servin, Jeffrey H. Silverstein, Tom De Smet, Martin Smith, Joe Henry Steinbach, Markus Steinfath, David F. Stowe, Gary R. Strichartz, Michel M. R. F. Struys, Isao Tsuneyoshi, Robert A. Veselis, Arthur Wallace, Robert P. Walt, David C. Warltier, Nigel R. Webster, Jeanine Wiener-Kronish, Troy Wildes, Paul Wischmeyer, Ling-Gang Wu, Stephen Yang
- Edited by Alex S. Evers, Washington University School of Medicine, St Louis, Mervyn Maze, University of California, San Francisco, Evan D. Kharasch, Washington University School of Medicine, St Louis
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- Book:
- Anesthetic Pharmacology
- Published online:
- 11 April 2011
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- 10 March 2011, pp viii-xiv
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9 - Achieving effective ECT
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 181-195
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Summary
Practice makes perfect.
Remission of melancholia is achieved in 80–95% of patients treated with electroconvulsive therapy (ECT). Lesser remission rates, however, are commonly reported. What accounts for the differences in clinical outcome?
The technical practice of ECT is complex and not all treatment courses are optimized to assure the maximum therapeutic benefit. Inappropriate frequency and inadequate numbers of treatments, energies too low to assure an effective seizure, elevated seizure thresholds, inefficient electrode placements, and missed or incomplete seizures result in courses of treatment with limited benefit.
Patient selection
Convulsive therapy relieves depressive mood disorders, yet the benefits are best established in those with melancholia. The relief of severe disorders in mood was discovered early in ECT history. In patients with both the depressed and manic phases of “manic-depressive insanity” and “involutional depression,” the introduction of ECT was quickly identified as a life-saving treatment. To assure proper selection of patients, an intensive search for predictors of good response examined identifiable symptoms and syndromes, demographic features, severity of illness, and duration of illness. An excellent and rapid clinical response found in melancholia of recent onset with severe vegetative signs, suicide intent, and delusional thinking occurred in older rather than younger patients. A poor outcome was associated with chronic illness, limited impairment that allowed sustained employment, comorbid personality disorder, “neurotic symptoms” (pervasive anxiety, dysthymia, hypochondriasis), and substance abuse. Specific behavior-rating scales designed as predictors were developed.
10 - The validity of the pharmacotherapy literature in melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 196-210
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Summary
… my few hours of sleep were usually terminated at three or four in the morning, when I stared up into yawning darkness, wondering and writhing at the devastation taking place in my mind and awaiting the dawn, which usually permitted me a feverish, dreamless nap
Melancholia is a severely debilitating illness with a high death rate and high potential for suicide. Its consequences were so dire that the introduction of even so intrusive a treatment as induced seizures was hailed as a remarkable advance. Over the past half-century, medications effective in ameliorating melancholia were developed and the fears that melancholia engendered in earlier centuries lessened.
Our present therapeutic ideal is to select treatments based on scientific study, defined as evidence-based medicine. Randomized controlled clinical trials form the foundation of evidence-based medicine, and the literature assessing the benefits of antidepressant and mood-stabilizing drugs is widely accepted. Reviews of this evidence conclude that all antidepressant medications have equal efficacy for major depression, differing only in side-effects. These conclusions influence clinical guidelines.
Present teaching, as expressed by an expert National Institutes of Mental Health (NIMH) panel states that: “The SSRIs [selective serotonin reuptake inhibitors] are clearly the drug treatment of choice for all forms of depression in the United States … These drugs are approximately equivalent to each other and to TCAs [tricyclic antidepressants] in efficacy … The SSRIs have a much more benign side effect profile than TCAs and, largely for this reason, have replaced TCAs as first line therapy.”
List of patient vignettes
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp ix-x
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1 - Melancholia: a conceptual history
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 1-14
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Summary
Depression, most people know, used to be termed “melancholia”… Melancholia would still appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a major illness …
The Swiss-born psychiatrist Adolf Meyer had a tin ear for the finer rhythms of English and therefore was unaware of the semantic damage he had inflicted by offering “depression” as a descriptive noun for such a dreadful and raging disease. Nonetheless, for over seventy-five years the word has slithered innocuously through the language like a slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.
A scientific classification of behavior disorders is still an unreachable goal. The efforts in the past two centuries are reminiscent of the many attempts to bring order into the universe of plants and animals before the singular rules of Linnaeus and Mendel allowed meaningful classifications to emerge. The maladaptive variations in human mood, thought, and motor behavior observed over the millennia offer a myriad of images that have captured the attention of one observer or another who attempted to formulate these observations into an understandable framework.
5 - Examination for melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 85-96
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Summary
I began to sense the onset of the symptoms at mid afternoon or a little later – gloom crowding in on me, a sense of dread and alienation and, above all, stifling anxiety. Rational thought was usually absent from my mind at such times, hence trance.
I can think of no more appropriate word for this state of being, a condition of helpless stupor in which cognition was replaced by that positive and active anguish.
The bedrock of psychiatric clinical research is the structured interview. It is designed to collect large amounts of information in a form suitable for multivariate analysis. To achieve reliability, questions are asked in a specific form and sequence. The opportunity for follow-up questioning, clarification, and discussion with the patient is limited. Experienced clinicians recognize the artificial nature of these instruments. Kendell commented on the exaggerated value given to structured interviews and rating scales, and the tendency to disregard the validity of a well-done clinical examination.
For most of medical history, syndromes have been identified intuitively by gifted physicians on the basis of their experience. They saw a pattern where others saw only confusion, or they saw a different pattern than had their predecessors.
The art of the medical examination is learned at the bedside. It is not taught from books alone. It remains the bedrock of clinical psychiatric diagnosis.
Clinical diagnosis, however, is simplified when depressive mood disorders are considered a single state differing only in severity.
14 - The pathophysiology of melancholia
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 298-345
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Summary
I am gall, I am heartburn. God's most deep decree
Bitter would have me taste: my taste was me;
Bones built in me, flesh filled, blood brimmed the curse.
Self yeast of spirit a dull dough sours. I see
The lost are like this, and their scourge to be
As I am mine, their sweating selves; but worse
The biological components of depressive mood disorders are the theme of thousands of articles. Despite recognition that mood disorders are clinically and physiologically heterogeneous, few studies assess the biology of different forms of depressive illness. Our knowledge about melancholia is therefore limited, and is based largely on interpolation from hospital samples or patients identified as “severely depressed,” the groups most likely to include an abundance of melancholic patients. This chapter examines the neurobiology of melancholia. The association of melancholia with vegetative, psychomotor, and mood disturbances that result from the characteristic hypothalamic–pituitary–adrenal (HPA) axis dysfunction are the basis for the clinical features of melancholia. Their usefulness as diagnostic criteria is discussed in Chapter 4. Biological studies picture a mood disorder as an abnormal physiologic stress response. The neurochemical, electrophysiologic, and cognitive deviations are considered secondary to an abnormal stress response. Melancholic patients also demonstrate abnormal brain metabolism and structure that worsen with increasing numbers of episodes. Most abnormalities, however, resolve with proper treatment. When prolonged, the risk increases for future episodes of the illness.
A genetic predisposition for melancholia has been sought in genomic mapping.
11 - Basic pharmacotherapy for melancholic patients
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 211-238
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Summary
I, who have always seen him so serene, so completely the master of his wonderful emotional instrument … so sensitive to human contacts and yet so secure from them; I could hardly believe it was the same James who cried out to me his fear, his despair, his craving for the “cessation of consciousness,” and all his unspeakable loneliness and need of comfort, and inability to be comforted! “Not to wake – not to wake –” that was his refrain; “and then one does wake, and one looks again into the blackness of life, and everything ministers to it.”
Among the interventions for the relief of melancholia, electroconvulsive therapy (ECT) is the most effective and should be considered in the treatment of every melancholic patient. Although superior to medications in the treatment of depressive illness, ECT is intrusive, not widely available, and most psychiatrists are not trained to prescribe or administer it. ECT has been so stigmatized that it is widely considered the treatment of last resort. The cost per treatment is substantial. The efficacy and optimal use of ECT are discussed in Chapters 8 and 9.
Melancholia is an illness that requires acute treatment to resolve the episode of depression, continuation treatment to preserve the remission and prevent relapse, and long-term treatment to reduce the risk of recurrence.
The basic pharmacotherapy for adult melancholic patients in uncomplicated circumstances warrants simplified algorithms.
12 - Pharmacotherapy for melancholic patients in complicating circumstances
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 239-283
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Summary
A mood of lassitude and dejection took possession of his spirits. He lost all pleasure in society, would sit for hours at his table, unable to bring himself to work at anything … His sleep was troubled by dreams, his waking hours by accusing voices … His shaken nerves could muster up no power of resistance … Melancholy swelled to obsession, obsessions to delusion … Once again he tried to kill himself
Melancholia that is identified early and is treated vigorously by the available methods resolves rapidly. Treatment becomes challenging, however, when the patient has a comorbid general medical or neurologic condition that affects its delivery, or is very young or very old. The presence of psychosis or a history of a manic-depressive course are also complicating circumstances, but acute treatment of a melancholic episode in these circumstances is often straightforward and is discussed in Chapter 11. So-called “treatment-resistant depression” is discussed here.
Melancholia in pregnancy and breast-feeding
From 5 to 10% of women become clinically depressed during pregnancy. A depressive mood disorder is a risk factor for obstetrical difficulties, low infant birth weight, newborn irritability, retarded child development, and neurological deficits. Depressive moods and abnormal vegetative signs during pregnancy anticipate postpartum depression.
Women with mood disorders during the childbearing years and while sexually active need to be educated about the risks for the fetus of the illness and its treatments. They and their partners need a long-range treatment plan.
3 - Defining melancholia by psychopathology
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 45-61
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Summary
And the mind's canker in its savage mood,
When the impatient thirst of light and air
Parches the heart; and the abhorred grate,
Marring the sunbeams with its hideous shade,
Works through the throbbing eyeball to the brain
With a hot sense of heaviness and pain
The descriptions of melancholia over millennia by medical authorities, writers, and public figures have face validity. The recognition led to the inclusion of “melancholia” in some form in all psychiatric classification systems. This heritage regards melancholia as a disorder in mood accompanied by perturbations in circadian and ultradian rhythms. Psychomotor disturbance is always present, expressed as agitation or inactivity, slowness of movement and speech, catatonia, or stupor. Ruminations of despondency and death dominate the sufferer's waking thoughts. Suicide is all too frequent.
Melancholia is the classic depressive mood disorder. Psychotic depression, manic-depressive depression, puerperal depressions, and abnormal bereavement are part of the melancholia picture. Diverse disease processes, such as endocrinopathies and seizure disorder, induce it. It is recognized worldwide and at all ages, becoming most prominent in older adults. Melancholia is less recognized in young children, but that omission may be a distortion of classification.
Despite its long history, the position of melancholia in psychiatric taxonomy is unclear. Traditionally it was considered a distinct illness. More recently it has been viewed as a stage of illness, not fundamentally different in pathophysiology from other depressive illnesses. Which view is correct?
Acknowledgments
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp xv-xvi
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13 - Proposed treatments for melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 284-297
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Summary
There is a woman in this town who had lost three of four foetuses from epileptic attacks immediately after birth … It is clear that those foetuses died from a taint in the blood transmitted to the brain … In dealing with her next three children, immediately at birth, we had a fontanelle inserted in the neck and leeches applied behind the ears in order to drain off the impurities from the brain; they completely escaped epilepsy and still do to this day.
It is fair to say that most treatments prescribed today have little evidence to support their efficacy
Novel treatments for depression have been proposed. Some derive from observations of the neurobiology of mood disorders (e.g., light therapy (LT)) while others are opportunistic applications of new technologies (e.g., transcranial magnetic stimulation (TMS)). None has proven efficacy. Commonly promoted alternatives to standard treatments are discussed here.
Light therapy
Evidence for a seasonality in the incidence of mood disorders with higher incidence in the winter months encouraged thoughts that reductions in hours of sunlight affected brain neuroendocrine mechanisms and elicited mood disorders. The description of a seasonal affective disorder (SAD) (winter depression) and its inclusion in the psychiatric classification system encouraged extensive studies of LT. LT has also been assessed in patients with non-seasonally related depression.
This intervention presents high-intensity light from light boxes for varying lengths of time to subjects. Exposure time is 30–60 min daily for two weeks or more, typically between 6 and 9 a.m.
4 - Defining melancholia: laboratory tests
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 62-84
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Summary
The lesson of the history of psychiatry is that progress is inevitable and irrevocable from psychology to neurology, from mind to brain, never the other way round. Every medical advance adds to the list of diseases which may cause mental derangement. The abnormal mental state is not the disease, nor its essence or its determinant, but an epiphenomenon. This is why psychological theories and therapies, which held out such promise at the turn of the century when so much less was known of localization of function in the brain, have added so little to understanding and treatment of mental illness, despite all the time and effort devoted to them.
The serological identification of syphilis is the model of a specific laboratory test for a general medical disorder. The test separates the behavioral syndrome of neurosyphilis from phenotypically similar but etiologically diverse conditions of mood and psychotic disorders. No such assessment exists for psychiatric disorders, despite more than a century of effort. A major hurdle in this quest has been the inability to define syndromes with biological homogeneity, thus confounding samples and eliciting conflicting findings. The dexamethasone suppression test (DST) was positive (non-suppression) in about 50% of depressed patients but was deemed unsuitable as a laboratory test in depressive illness, despite the evidence that samples of depressed patients were heterogeneous. Severely depressed patients, however, have substantial perturbations in their neuroendocrine functioning and measures of the endocrine system remain the best laboratory-based opportunity to demarcate mood disorders.
15 - Future directions
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 346-370
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Summary
The madness of depression is … a storm of muck. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained
Melancholia, a severe disturbance of mood, movement, and thought, has been recognized for millennia. It is a brain disease with abnormalities in neurochemical, neurohormonal, metabolic, and electrophysiologic processes.
The syndrome is considered moderately heritable. Under circumstances of stress at critical phases of development, the genetic predisposition is expressed, and the mood disorder develops. A prominent feature of melancholia is an “abnormal stress response state.” Recognizing melancholia is a clinical judgment that combines a signature psychopathology with identifiable hormonal and neurophysiologic perturbations.
Melancholia is well defined in the literature of medicine. Its characteristic psychopathology and laboratory testing are established in evidence, if not yet by consensus. Guidelines for the examination of melancholic patients and the differential diagnosis of depressive syndromes derive from the clinical experience and investigations of many authors. Suicide is a special risk for sufferers of melancholia, and prevention strategies are established.
Two effective treatment modalities for melancholic patients have been developed. Convulsive therapy is the oldest and the most effective intervention; guidelines for its effective application are well known. Medications are also delineated from the evidence, but the therapeutics has been distorted by the pharmaceutical industry. An objective consensus is needed. The efficacy of psychotherapies and other proposed treatment interventions has yet to be substantiated.
6 - The differential diagnosis of melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 97-124
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Summary
But when the melancholy fit shall fall
Sudden from heaven like a weeping cloud,
That fosters the droop-headed flowers all,
And hides the green hill in an April shroud;
Then glut thy sorrow on a morning rose,
Or on the rainbow of salt sand-wave,
Or on the wreath of globed peonies,
Or if thy mistress some rich anger shows
Imprison her soft hand, and let her rave,
And feed deep, deep upon her peerless eyes
We have defined melancholia as a depressive mood disorder characterized by psychomotor retardation and agitation, disturbances in vegetative functions, loss of interest, impaired concentration and memory, delusional thoughts, and preoccupation with suicide. Psychotic depression, depression that is part of a manic-depressive course, depression with catatonia, puerperal depression, and abnormal bereavement are melancholic illnesses. The evidence for including these conditions as melancholic disorders is discussed in Chapter 2.
Many other depressive disorders are delineated in psychiatric classifications that may or may not meet the criteria for melancholia. Atypical depression, dysthymia, seasonal affective disorder (SAD), adjustment disorder with depression, and similar syndromes are poorly defined. They encompass heterogeneous samples of patients who are best considered as having a non-melancholic mood disorder (Table 6.1).
Non-melancholic depressive mood disorders
Non-melancholic “major depression”
Cluster and latent class analyses identify depressed patients who do not exhibit melancholic features (Table 6.2). The studies do not indicate whether this group can be divided further.
Preface
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
- Print publication:
- 01 June 2006, pp xi-xiv
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Summary
O Lord, all my desire is before you;
From you my groaning is not hid.
My heart throbs; my strength forsakes me;
The very light of my eyes has failed me.
My friends and neighbors stand back
Because of my affliction;
My neighbors stand afar off.
Psalm 38At any point in time on this planet, almost two and a half times as many persons are depressed as are demented. Counting all variations on the theme, about 10% of men and 20% of women are at lifetime risk for experiencing a depressive illness. Based on numbers of persons affected, the World Health Organization estimates that depressive illnesses are the fourth highest cause of medical disability and premature death worldwide in years of illness, treatments required, lost productivity during episodes, and death rates.
Ten to 15% of depressed persons die by suicide. This rate translates into about one million persons annually, worldwide, and 30 000–90 000 persons annually in the USA. The first figure is the accepted count and the latter figure is estimated from analyses that acknowledge underreporting. In the USA, suicide is the 11th leading cause of death. Most persons over age 50 have known at least one individual who has committed suicide. Among depressed persons, sufferers of melancholia have the highest suicide rates.
Depressive illness is increasing in frequency among persons born closer to the present (a period effect), and first episodes are occurring at younger ages (a cohort effect).
7 - Suicide in melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
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- 14 August 2009
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- 01 June 2006, pp 125-152
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Summary
I want to die. I can't believe I feel like this. But it's the strongest feeling I know right now, stronger than hope or faith or even love. The aching relentlessness of this depression is becoming unbearable. The thoughts of suicide are becoming intrusive. It's not that I want to die. It's that I'm not sure I can live like this anymore.
Persons with mood disorders are at the greatest risk for suicide, with 50–70% of persons who kill themselves doing so during an episode of depressive illness. Melancholic patients who are agitated and anxious, psychotic, or who have been hypomanic are at the greatest risk. Studies of suicide, however, do not typically identify the melancholic patients in their samples, and so the evidence for risk is mostly indirect. Patients who are severely depressed, or who have abnormal hypothalamic–pituitary–adrenal functioning are likely to be melancholic, but studies associating these factors of increased risk rarely define the form of depressive illness. An exception is a study that compared suicide attempts in a large sample of melancholic and non-melancholic patients. After controlling for severity and baseline characteristics as covariates, the melancholic patients were more likely to have had prior serious suicide attempts and to make more attempts during the follow-up period. Although the cited studies refer to severe depression, it is likely that the majority of patients meet criteria for melancholia.
In early estimates of suicide risk, 15–19% of depressed patients committed suicide.
8 - Electroconvulsive therapy for melancholia
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- By M. D. Michael Alan Taylor, University of Michigan School of Medicine, M. D. Max Fink, State University of New York at Stony Brook
- Michael Alan Taylor, University of Michigan, Ann Arbor, Max Fink, State University of New York, Stony Brook
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- Book:
- Melancholia
- Published online:
- 14 August 2009
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- 01 June 2006, pp 153-180
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Summary
Diseases desperate grown
By desperate appliance are relieved,
Or not at all.
ShakespeareAmong the more remarkable medical discoveries of the twentieth century, convulsive therapy is an unheralded success. At a time when the only effective treatment for a major psychiatric disorder was fever therapy for neurosyphilis, the reports that the induction of seizures relieved the psychosis of dementia praecox were rapidly and widely accepted. Seizures were first induced by intramuscular injections of camphor by Ladislas Meduna, a Hungarian neuropsychiatrist. Within a year, he described the benefits of intravenous pentylenetetrazol, known commercially as Cardiozol and Metrazol. The benefit of convulsive therapy in patients with mood disorders was quickly recognized, but nowhere is its efficacy more striking than in the relief of melancholia. When and how was this association made?
The first detailed reports on the effects in manic-depressive disorders appeared in 1938: “The facility with which so many diverse reactions were influenced by cardiozol fits led me … to experiment with emotional and conduct disorders of non-schizophrenic type.” Cook described four manic patients whose excitement and psychosis were quickly relieved. An agitated psychotic depressed patient recovered; of three depressed patients with severe psychomotor retardation, two recovered; and a postpartum depressed patient became hypomanic and left the hospital much improved. Simultaneous reports were made by Bennett, who reported relief within two weeks in 21 seriously depressed patients treated with Metrazol-induced seizures and by Küppers (1939), who described the augmentation of insulin coma by Metrazol seizures.