Modelling and Managing the Depressive Disorders

Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Front...
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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

Modelling and Managing the Depressive Disorders A Clinical Guide

This book will interest clinicians, researchers and inquiring readers. The authors argue that the current modelling of depressive disorders compromises research and clinical management and present an alternative approach to sub-typing and managing the mood disorders. Prof Gordon Parker is Scientia Professor of Psychiatry at the University of New South Wales and Executive Director of the Black Dog Institute which is a research, clinical, education and training facility for mood disorders. He is an active researcher and, in 2003, was awarded a Citation Laureate for being the most highly cited Australian in the fields of Psychiatry and Psychology. Dr Vijaya Manicavasagar is a Senior Clinical Psychologist and Senior Research Fellow with the Black Dog Institute, and a conjoint Senior Lecturer within the School of Psychiatry in the Faculty of Medicine at the University of New South Wales. She has had a long-standing interest in the psychological treatment of mood disorders.

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

Modelling and Managing the Depressive Disorders A Clinical Guide

Gordon Parker Scientia Professor University of New South Wales Executive Director, Black Dog Institute Sydney, Australia

Vijaya Manicavasagar Director of Psychology Education Black Dog Institute Sydney, Australia

© Cambridge University Press

www.cambridge.org

Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

CAMBRIDGE UNIVERSITY PRESS

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo CAMBRIDGE UNIVERSITY PRESS

The Edinburgh Building, Cambridge CB2 2RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521671446 © Cambridge University Press 2005 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2005 Printed in the United Kingdom at the University Press, Cambridge A record for this publication is available from the British Library ISBN-13 978-0-521-67144-6 paperback ISBN-10 0-521-67144-2 paperback Library of Congress in Publication data (copy to follow) Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

Contents

Acknowledgements Introduction Part I

vii ix

The current model for depressive disorders and its impact on clinical management

1

A declaration of independence Defining and diagnosing depression Depression sub-typing: independence and interdependence

3 14 21

The diagnosis and management of melancholic and psychotic depression

29

Management of melancholic depression Management of psychotic depression Bipolar melancholic or psychotic depression

31 42 47

Part III

An introduction to non-melancholic depression

51

7 8 9 10 11 12

Our model of non-melancholic depression Self-esteem Personality style and functioning Identifying the constructs to non-melancholic depression: stress Resilience and vulnerability Psychological interventions for non-melancholic depression

53 64 70 85 89 95

Part IV

Modelling and managing the non-melancholic depressive disorders

105

Acute stress-related non-melancholic depression Acute stress-related non-melancholic depression: ‘key and lock’ model Chronic stress-related non-melancholic depression The perfectionist personality style and non-melancholic depression

107 117 123 131

1 2 3 Part II 4 5 6

13 14 15 16 v

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

vi

Contents

17 18 19 20 21 22 23 24

Irritability and non-melancholic depression Anxious worrying and non-melancholic depression Social avoidance and non-melancholic depression Personal reserve and non-melancholic depression Rejection sensitivity and non-melancholic depression Self-focused personality style and non-melancholic depression Self-criticism and non-melancholic depression Natural and alternative treatments for non-melancholic depression

143 154 164 174 183 193 202 212

Appendix 1 Appendix 2 Appendix 3

The DMI-18 and the DMI-10 The CORE system of measuring psychomotor disturbance The temperament and personality measure

224 226 228

References Index

229 236

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

Acknowledgements

This book marks the culmination of a number of clinical research projects spanning several years and involving many of our colleagues at the Black Dog Institute. These include Psychiatrists Philip Mitchell, Kay Wilhelm, Marie-Paule Austin, Gin Malhi and our statistical adviser, Dusan HadziPavlovic, who are all co-Chief Investigators on our current National Health and Medical Research Council (NHMRC) Program Grant. Other key research staff involved in many of the studies considered in this book include Gemma Gladstone, Kay Parker, Joanna Crawford, Lucy Tully, Tania Perich, Therese Hilton, Gabbi Heruc, and Amanda Olley. In addition, we have been extremely appreciative of assistance from Christine Boyd, who has supervised data entry, and Yvonne Foy for preparation of this manuscript. We are particularly grateful for the cogent advice of Kerrie Eyers who commented on several drafts and helped us improve the book’s ‘readability’, and to Kathryn Fletcher for editing assistance. We are also extremely appreciative of the creativity shown by the Sydney graphic artist, Aurah Wood, in capturing nuances of the ‘psychotransmitter model’. Much of our research was undertaken at the Mood Disorders Unit, a tertiary referral facility established in 1985, and which was incorporated into the Black Dog Institute in 2002. The Institute is based at Prince of Wales Hospital, housing a research team together with clinical services, education and training facilities, as well as a consumer and community resource centre, and allowing iteration between these components. This structure advances our long-standing model of seeking to have clinical observation inform research hypotheses and, in turn, research findings inform modifications to clinical practice as well as to education and training. Our web site (www.blackdoginstitute.org.au) provides additional information about the organisational structure and how research studies have historically evolved. Our research would not have been able to be undertaken without longstanding support from Australia’s NHMRC for funding our research over the last 15 years. We are also indebted to the Centre for Mental Health, NSW Department of Health, for providing Infrastructure Grant funding to vii

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

viii

Acknowledgements

enable research to be pursued actively. We are particularly appreciative of assistance from the many patients who have willingly allowed us to assess them in some detail for our research studies while undertaking their clinical assessment. We thank Cambridge University Press’ Richard Barling, Richard Marley, and Betty Fulford for their great assistance and professionalism in taking this project forward. We are also deeply grateful to our partners, Heather Brotchie and Stephen Mackie, for their patience and support.

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

Introduction

There are major problems in modelling the depressive disorders and in evaluating available treatments. In the last few decades, the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1994) model has dominated the classification of depression. It shares its largely dimensional model with the World Health Organisation’s International Classification of Diseases (ICD-10) (World Health Organization, 1992) recent classificatory system. Thus, the current dominant model for conceptualising the depressive disorders is a dimensional or continuum view – with depression essentially seen as a single condition varying by severity. We have long argued for a differing paradigm: one that allows (on the basis of specific clinical features) categorical status to certain expressions of depression such as melancholia and psychotic depression. However, once these more categorical conditions are excluded from the broad landscape of ‘depressive disorders’, there are difficulties in modelling the heterogeneous residue of non-melancholic conditions, as they are not categorical, vary in their status (as disorders, conditions, and stress responses) and are often multi-axial. For these, we favour a ‘spectrum’ model: viewing them as reflecting an interaction between salient life stresses and personality style. In addition to challenging current diagnostic models we also challenge the ‘evidence base’ for evaluating antidepressant therapies. We question the reliability or ‘gold standard’ value offered by evidence-based approaches, at least as currently undertaken. We do not dispute the ideal – whereby judgements about the effectiveness of available antidepressant treatments benefit from randomised control trials (or RCTs) – when such data provide objective, impartial, systematic, and valid information. However, we note a number of intrinsic limitations to both the design and to the actual conduct of such trials and the ‘meaninglessness’ of the derived information. Much of the consequences include clinicians relying more on their own ‘pattern analyses’ rather than being able to trust results from the RCTs – a clearly unsatisfactory scenario. ix

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Cambridge University Press 0521671442 - Modelling and Managing the Depressive Disorders: A Clinical Guide Gordon Parker and Vijaya Manicavasagar Frontmatter More information

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Introduction

Our alternative classificatory model allows that ‘depression’ can exist as a disease, a disorder, a syndrome and even as a ‘normal reaction’, and therefore requires a mix-and-match model for capturing both categorical and dimensional depressive disorders. Our model components are strongly weighted to clinical pattern analysis or what has been described by anthropologists as ‘thick description’, a base camp approach pursued by our team of clinical researchers before moving up the testing slopes of formal studies. After establishing the Mood Disorders Unit in 1985, we spent nearly a decade seeking to distinguish psychotic and melancholic depression from the non-melancholic disorders. In the following decade, we have focused on developing the most appropriate model for conceptualising and differentiating the non-melancholic disorders from each other, with study results re-shaping our clinical approach to patients. Integral components of the model are tested in ‘clinical effectiveness’ studies, where we seek to define the most appropriate treatments for managing differing depressive disorders with increasing precision. We have cut our cloth on the iteration between clinical observation and research testing, and now we seek to persuade others to ‘feel’ its quality. This book then reports a series of models and makes a number of treatment recommendations for managing the principal depressive conditions. As we considered melancholia and psychotic depression in considerable detail in a previous monograph (Parker & Hadzi-Pavlovic, 1996) this present volume gives greater attention to modelling and managing the nonmelancholic disorders. We argue against an eclectic, and for a pluralistic approach to managing depressive conditions. This is best illustrated in regard to the non-melancholic disorders, where we seek to detail the impact of salient life events on predisposing personality styles, specifying the vulnerability points and arguing for pluralistic intervention strategies that we identify within our ‘psychotransmitter model’. Thus, the book ranges from polemical to practical, and from provocative to precise. The identified models should not be seen as immutable, and we would welcome readers’ responses, particularly if they could advance any of our current treatment strategies – and even coin a superior term to describe the ‘non-melancholic’ disorders. The book is presented in three sections. Part I details the limitations to the current dimensional model for depressive disorders and the impact on clinical management. Part II considers the phenomenological definition and distinction of both psychotic depression and melancholic depression, and provides treatment recommendations based on published clinical effectiveness studies.

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Introduction

Part III & Part IV presents our principal focus and aspirations for this book – how best to model and manage the non-melancholic depressive disorders. The ‘diagnostic model’ is rooted in clinical observation but, as noted, also respects a rich tradition of viewing these conditions as reflecting interactions between life events and vulnerable personality styles. The ‘aetiological’ model (termed a ‘psychotransmission model’) is partly metaphorical but, like all metaphors, seeks to advance communication – here, by identifying vulnerability processes for more rational pluralistic treatment approaches. At this stage, the ‘evidence base’ for the clinical effectiveness of the psychotransmitter model is not available beyond systematic clinical observation. We are currently testing its utility in ‘real world’ effectiveness studies, and we have some confidence in offering it as a logical model in managing these common conditions. Its logic emerges from combining the literature base with clinical observation, in avoiding therapeutic eclecticism (where a favoured therapy is applied non-specifically), and in promoting therapeutic pluralism in a commonsense and rational manner. We hope that readers judge it of value. Gordon Parker Vijaya Manicavasagar

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