Abstract
Having been coined by William Cullen in 1969, the concept of neurosis was greatly expanded by psychoanalytic theorists (Chessick, 2002). The success with which the term entered popular and scientific consciousness was ultimately its downfall. It was eliminated by the DSM-III (Diagnostic and Statistical Manual of Mental Disorders, Third Edition) (Silverstein et al., 1982), largely because it expanded to encompass such a broad range of psychic phenomena that the precision and therefore utility of the concept was lost. Is the same happening with depression? This issue of the Journal dwells extensively on the boundaries of the major nosological categories in the DSM-5, particularly depression. There is currently considerable disquiet regarding the heterogeneity and imprecision of the term depression (Baumeister and Parker, 2010; Ghaemi et al., 2012). Given that it refers to one of the most critical psychic phenomena with a myriad of consequences and that management decisions rest on the assumed sensitivity and specificity of the term, this is no small matter for the field. The current DSM-IV definition of depression is already a broad one encompassing a diverse array of phenotypes, severities and patterns. It is agnostic to formulation, which is argued as a significant blinker to clinical utility (Macneil et al., 2012).
In this issue, Bastiampillai and colleagues (2013) present an intriguing model whereby emotions can spread throughout communities in a manner not unlike the spread of infectious diseases. These authors propose that the social contagion theory of emotion can highlight aetiological patterns of depression as well as propose management strategies at a population health level. In the context of this issue of the Journal, however, the term depression is used more akin to distress or dysphoria, highlighting the diffuse nature of the word. Jacob (2013) makes the point that normal people under severe stress, individuals who struggle to cope with the rough and tumble of life, and those who manifest melancholic-type symptoms in the context of a biological illness can all fall under the depression rubric. Crucially, they also argue that this poor diagnostic sensitivity and specificity undermines our ability to detect and develop useful treatments. The paper argues that a public health understanding of depression could usefully incorporate inputs from a range of disciplines including social sciences, medicine, politics, finance, law and engineering. Lastly, Porter and colleagues (2013) debate the deletion of bereavement as an exclusion criterion for major depression. While the loss of this criterion will broaden an already very broad group, they argue that this criterion was relatively unhelpful inasmuch as depression does not always need treatment, particularly pharmacotherapy, and that clinicians would generally make reasonable judgements despite this criterion’s presence or absence. However, this debate further emphasises the intense confusion over the boundaries of depression and its terminology.
One of the potential solutions to this dilemma comes from the paper by Frey and colleagues (2013). This position paper of the International Society for Bipolar Disorders examined potential biomarkers including neuroimaging, genetics and peripheral markers including neurotrophins, inflammation and oxidative stress markers. These have the potential to serve as biomarkers of vulnerability, disease expression, illness course and treatment response. Whether this promise will be fulfilled is the subject of a large number of active projects. These are exemplified by the studies by Das et al. (2013), who utilised magnetic resonance imaging spectroscopy to detect patterns of metabolite changes in the cingulate cortex of depressed people taking N-acetylcysteine or placebo, and Vierck et al. (2013) examining binocular rivalry as a marker for bipolar disorder.
Looi et al. (2013) argue for an increased emphasis on the ethos of research in psychiatry. They reason that the practical wisdom gleaned by understanding the process whereby skills and knowledge are generated play a critical role in enhancing clinical skills, especially amongst young trainees. They note that despite increasing recognition of this imperative, the resources available, particularly to younger trainees, are limited and that, compared to other disciplines, mental health research (AUD$60m per year) lags behind cancer (AUD$180m), prevention (AUD$150m), cardiovascular (AUD$110m) and diabetes (AUD$70m) research, despite mental health being a stated main priority. Their arguments for enhanced and additional support to boost research capacity can only be welcomed by the field. Sadly, Christensen et al. (2013) note that even within mental health, there is a divergence between disease burden and funding, with the gap greatest for affective disorders and dementia, and smallest for violence and eating disorders.