Sunday, 26.03.2017

Comment by Hector Warnes

Hector Warnes’ comment on Thomas A. Ban’s From Melancholia to Depression: A History of Diagnosis and Treatment

I was in awe reading your E-Book. I could not agree more that there is a “pharmacological heterogeneity of depressive illness” and that “it is not possible to predict which patient will respond to treatment and which patient will remain refractory”. I also appreciate very much your CODE or Composite Diagnostic Evaluation, about which I would like to learn more.  I recall that Jules Angst studied families of depressed patients who responded to the same drug as did other members of the family who also had affective disorders, but not to others (pharmacogenetics), which you seem to support by citing Steven Paul’s computational structural biology as an important marker.

One problem that has blurred boundaries proposed by Kraepelin is quantifying the symptomatology and the intensity of depression, which is addressed by Pierre Pichot (see P. Kielholz, editor: Depressive Illness. Hans Huber Publishers, Switzerland, 1972). Pichot stated that we can divide up the patients on the basis of symptomatology and aetiology using either factorial analysis or typological analysis. Further, we can measure the changes in symptomatology using a global measurement of severity and finally, we can search for prognostic indicators based on the response to treatment.  I have followed in my clinical praxis the nosology proposed by Paul Kielholz of somatogenic, endogenous and more socio-psychogenic depression, including neurotic depression, chronic characteropathy and reactive depression. In this classification, exhaustion (Erschöpfung) depression is compatible with the chronic fatigue syndrome and with the stress theories of Selye. In the same book edited by Kielholz, the chapter by Juan J. López Ibor on masked depression and depressive equivalents brings together psychosomatic pathology with clinical psychiatry and the neurosciences.  He writes: “I put forward the thesis that certain forms of anxiety neurosis and so-called psychosomatic disease were superimposed on a phasic alteration in the endothymic background of the patient’s personality”, which has been accepted as of late by many studies of risk factors in most illnesses, particularly, cardiovascular ones. Masked depression is equivalent to larviert depression and latent depression. Already, Griesinger described a frontal headache as a “frontal dysthymia”.

López Ibor isolated a meralgia paresthetica, thymopathic vertigo, cardiac arrhythmias and nuchal pain and even Groen’s “syndrome shift” in psychosomatic disorders as compatible with depressive equivalents. HBM Murphy noted in cross-cultural studies that African patients are more likely to have somatizations while western patients are more likely to suffer from guilt and self-laceration (Murphy HBM, Wittkower ED and Chance NA- Cross cultural inquiry into the symptomatology of depression. International Journal of Psychiatry1967; 3: 6-22).

A masterful chapter in the Comprehensive Textbook of Psychiatry (eds. Harold Kaplan and Benjamin Sadock, William and Wilkins, Baltimore, 1985 vol. I) was published by Heinz E. Lehmann. In this monumental treatise, he set the criteria for a classification based  on the outcome, the periodicity (chronopathology),  the signs of endogenous (particularly  severe anhedonia,  loss of libido, retardation, early awakening and diurnal fluctuation) versus reactive depression, the symptoms (retarded or anxious depression), the biological markers and the treatment response. Lehmann includes the ‘vital depression’ proposed by Kurt Schneider in 1920, which was associated with an endogenous depression and masked depression, in which dysphoria is overshadowed or masked by obvious somatic symptoms such as pain proneness, alcoholism, somatizations and finally the ‘underground’ depressions or untergrund-depressionen, which are prone to addictions (suchtgefährdet). It was a mind-opening chapter because Lehmann covers the historical, descriptive, phenomenological, representational and even cartographical aspects.

I noticed that you did not include in your E-Book the names of Kretschmer, Freud and Akiskal.  The first one, regarding pyknic constitution or body build (Korperbau) and cyclothymic temperament (Körperbau u. Charakter. Berlin-Göttingen-Heildelber: Springer 1955). In 85 cases of manic-depressive illness, Kretschmer found that 68.2% were “pyknic” body build.

 Freud distinguished neurasthenia or actual neurosis (an entity introduced by G.M Beard in 1869), which in my mind is akin to neurovegetative dystonia and consists in fatigability, aches, pains, paresthesias, insomnia, pathological bodily sensations, etc. from anxiety neurosis; and he even wrote about a neurasthenic melancholia, see vol. III, Freud’s paper: “On the grounds for detaching a particular syndrome form neurasthenia under the description anxiety neurosis” (The Standard Edition-London-the Hogarth Press, 1973). Angstneurose was a diagnosis first used by Freud.  I have treated a few patients with classical neurasthenia, a diagnosis that still prevails in China.

Freud also distinguished mourning from melancholia (see Trauer und Melancholie-The Standard Edition vol. XIV) and E. Lindemann   (Symptomatology and management of acute grief. American J. of Psychiatry 1944; 101: 141-8) went further in studying the cases of pathological grief. 

Finally, H.S. Akiskal and O. Pinto (The soft bipolar spectrum: footnotes to Kraepelin on the interface of hypomania, temperament and depression. In: A. Marneros and J. Angst, Eds.  Bipolar Disorder- Manic-Depressive Insanity. Dordrecht: Kluwer Academic Publishers; 2000, pp. 37-62), studied the so-called soft spectrum of bipolarities. He included an erratic personality and a cyclothymic personality within about 12 subtypes. In another publication, Psychiatric Developments (1983; 2: 123-160), he refined the identification of subtypes based on categories, dimensions and biological markers (DST, REM latency, Test of TRH-TSH, Test of urinary excretion of MHPG, catechol-O-methyl-transferase, etc. This attempt of sorting out more and more subtypes to the point that there are even sub-clinical types reminds me of the complicated nosology of Wernicke-Kleist-Leonhard.

In my own clinical work, still there are many patients who cannot be fitted in any diagnostic category and one has to wait sometimes for 10 years to be able to understand their diagnostic formulation.  A case in mind is an alcoholic patient. who was admitted with delirium tremens, later developed a chronic delusional psychosis treated with depot neuroleptics and finally after 20 years, he became hypomanic and I treated him with  aripiprazole and lamotrigine with excellent result.  The delusional psychosis just did not enter into the picture. Another case of a woman with chronic dysthymia, which started at puberty and at the age of 40, ended up in a major depression.  Kraepelin wrote about a woman with melancholia who did not react to the death of her husband but she did years later to the death of her dog. It is not easy to be as emphatic as Germán Berrios from Cambridge regarding reactive or minor depressions versus endogenous or major and primary versus secondary depression. He clarified the area of neurotic depression in a masterful lecture in Buenos Aires. I recommend his work bearing on the hermeneutical aspects of psychopathology (Berrios, GE and Porter R. The history of clinical psychiatry- Athlone Press, London, 1995 and Berrios GE. Aetiology. In the Great Notions of Psychiatry: A conceptual history: Oxford University Press, London, 2000).

 Minor or neurotic depressions are in my mind a misnomer because the so called minor which is the opposite of major may be quite severe and may lead to suicide while the major or endogenous depression may have occasionally less severity and may respond better to treatment.  Weitbrecht wrote about endoreactive depression, which you mentioned and probably would be equivalent to double depression.

                      I am sorry for the elimination of neurotic disorders, which are often chronic. You refer to Raskin’s “poor premorbid personality”. I don’t know what “poor” means in this nosological construct. Kurt Schneider listed at least 10 premorbid personalities.  I had a colleague in Lima, Peru who had a hypomanic personality and another in Montreal who had a depressive personality and eventually died of Parkinson’s Disease. The DSM5 preserves the three main grouping of personality disorders, namely A: the paranoiac, schizoid and schizotypic; B: the histrionic, narcissistic, anti-social and borderline; and group C: the obsessive-compulsive, dependent and avoidant. In my mind, many of these disorders blur the boundaries between trait and state, between psychopathology proper and premorbid personality and finally many overlap one with the other.

You did not discuss the issue of combination pharmacological therapy, which Leslie Solyom dared to implement in refractory depression by combining MAOI and tricyclic antidepressants. In Argentina, a well-known psychiatrist in this area is Eduardo Kalina.  I, myself, have used combination of psychopharmacologic agents without complications in refractory depression, which as you know, are on the rise despite neuropsychopharmacology.  I have used escitalopram and duloxetine with excellent results. By the way, in your list of antidepressants, duloxetine is not included. I like the simplicity of Esquirol’s classification: lypemania, monomanía and mania which you mentioned. 

                      E. Stengel published (Bulletin World Health Organization 1959; 21:601-63) a monograph on comparative classifications of mental disorders, which was amazing because it included the Russian, Chinese, German, English, French, etc. I don’t think that DSM-5 is the end of the story.  It is quite shocking that Leonhard and Henri Ey were largely ignored in the USA. I heard that they refused a translation into English of Ey’s Ëtudes Psychiatriques, which was published in three volumes by Desclée de Brouwer, Paris in 1950 with an amazing theoretical and clinical wealth reaching across all national boundaries.

I enjoyed reading your E-Book very much!


Hector Warnes

March 5, 2015