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History & Concepts of Psychiatry
This course will review the evolution of beliefs regarding mental illnesses and their treatments, beginning in ancient Greece and moving forward into the 19th and 20th centuries. Focus will be put on central figures or ideas that have persisted to the present day.
Receive 10 hours of CME or CEU credits for 10 one hour lectures. Physicians, Registered Nurses, Nurse Practitioners and Physician Assistants can accept AMA PRA Category 1 Credits. Psychologists can receive credits in most states also (check with your state board).
The practice gap that is being addressed is that psychiatric practitioners often do not have extensive knowledge about the scientific or conceptual basis of the most common psychiatric diagnoses. This limited knowledge leads to notable misdiagnosis rates or to misuse of diagnoses.
What is bipolar depression? What is melancholia?
MDI means bipolar illness plus unipolar depression. Unipolar depression does not mean non-bipolar depression, because there are other depressive conditions that are neither unipolar nor bipolar, meaning they are not part of MDI. MDI is a disease of severe mood episodes that being early in life. Another depression is mild and chronic (not severe and episodic), called neurotic depression. Another depression is severe and chronic and late in age of onset, called in the past “involutional melancholia.” That’s the difference between melancholia as part of bipolar or unipolar depression (MDI), and involutional melancholia. Melancholia as part of MDI is episodic – it has episodes that come and go and last about 3-6 months. Melancholia as part of chronic involutional melancholia is chronic – it has no end; once it begins later in life, it is present all the time. So the difference is in the course, not the symptoms.
“Bipolar depression” is as false as “major depressive disorder”: it has no meaning by itself, but rather consists of melancholic depressive episodes, or mixed depressive episodes, or pure depressive episodes. So it is melancholia if it meets melancholia definitions, which includes but is not limited solely to psychomotor retardation (also anhedonia and lack of mood reactivity).
How do you treat melancholic depression?
Kraepelin used the phrase “involutional melancholia” to describe middle age and later onset severe depression. It was chronic in its course, ie, it didn’t come and go, it just stayed. Our view is that it likely reflects what now is called vascular depression, which has middle and later onset and is chronic. The “melancholic” features are not central in our view of that condition, and in Kraepelin’s era, all depression was melancholic because otherwise, it didn’t lead to hospitalization, which is where Kraepelin saw his patients.
Regarding the treatment of melancholia with “activating” agents like venlafaxine or duloxetine, you may be right, but the proof is greater for older tricyclic antidepressants. Why not just use them? Venlafaxine has major cardiac risks if that’s a reason to avoid TCAs. Further, the efficacy is short-term. Long-term use of venlafaxine or duloxetine for melancholia may not be necessary if the melancholia is episodic, as opposed to chronic. In that case, when the episode resolves, the antidepressants can be stopped and long-term prevention of episodes can occur with standard-dose, not low-dose, lithium, or possibly other mood stabilizers.
Of course, ECT is the most effective treatment for melancholia, although again short-term for the actual episode, not long-term for prevention, which is disproven.
What is a disease-modifying drug?
Clinically, DM means altering the course of the illness, and especially improving morbidity and mortality, not just improving symptoms.
About two decades ago, Frederick Goodwin and I linked the available literature on second messengers to the concept of long-term course benefits. We didn’t know think of the concept of disease modification versus symptomatic effects at that time in an explicit way, but we had a similar idea in mind.