Amy A. F. Lutz: The Rise and Fall of the Dexamethasone Suppression Test: Stability, Consensus, Closure.

Barry Blackwell’s comment

       This essay on the fate of the DST is an informative and entertaining reprise on the recurring theme of hoping and failing to find a definitive biological marker to distinguish melancholia from the mélange of Major Depression in DSM-III and beyond (Blackwell 1992).

       Fortunately, that distinction rests on substantive clinical criteria documented by 17 distinguished clinicians taking issue with the DSM 5 category of Major Depression, a dimensional model based entirely on severity that ignores the psychopathology described by Hippocrates (OED: Gr.melan:black & khole: bile), Kraepelin and Schneider.

       According to Lutz, expert’s proposed additional features include 21 symptoms under five headings: persistent depression, psychomotor disturbance, cognitive impairment, vegetative dysfunction and psychotic features. Her paper includes additional comments on the therapeutic approaches.

       In the back of the DSM there are lists of “specifiers” that suggest features that may influence the major definitions. Melancholic features include eight of those named in the critical editorial but there is no mention of treatment. The APA appears to have made no substantive response to that criticism.

       When Roland Kuhn, an astute Swiss psychiatrist and director of a busy asylum, discovered imipramine in 1947 he described the kind of melancholic depression that responded: “It consists of tiredness, a feeling of heaviness and dejection or depression, slowed or obstructed thinking, decision making and interaction, loss of ability to enjoy oneself and sustain interests and daily fluctuations with worsening in the morning.” This description was borrowed from Kurt Schneider, the brilliant German psychopathologist who coined the term “vital depression.” The change with imipramine was especially dramatic because it contrasted with the only existing alternative treatment: tincture of opium increased slowly, drops at a time over weeks or months, but complicated by constipation and concerns about dependency.

       Two things stand in the way of timely and accurate diagnosis of melancholia, (endogenous depression): lack of interest and knowledge of psychopathology and its virtual absence in cavalier use of the DSM system.

       What is the price paid in terms of human suffering and what is the prognosis of untreated melancholia?

       Classical nosology is lacking because before effective treatments the focus was on diagnosis and less on outcome. Late in my career and retired, from a distance, I watched a close colleague in another country suffer from an illness that began precisely as Kuhn described but who never received either imipramine or ECT and who failed to benefit from any of the second-generation drugs in popular use prescribed by psychiatrists trained and practicing with DSM as their bible. Slowly and progressively his biologically induced illness morphed into a dementia, his wife, a medical professional could no longer cope, and he ended his days in a memory care unit.

       If I were no longer retired and a lot younger, I would want to find out how many of those admitted to memory care had a history of poor or inadequately treated melancholia, the logical outcome of a biological disorder.

Reference:

Blackwell B. Biological Formulations. In: Sperry L, Gudeman JE, Blackwell B, Faulkner LR, editors. Psychiatric Case Formulations. Washington DC, American Psychiatric Press; 1992, pp. 49-65.

July 29, 2021