Abstract
This is an important book for all psychiatrists. It details careful and admirable, clinically based research carried out by Gordon Parker and his associates at the Mood Disorders Unit at Prince Henry Hospital, Sydney, over many years. The research has a long pedigree and builds on work carried out by Professor Kiloh, among others, which focused on the separation of endogenous depression, or melancholia, from other forms of depression.
The book begins with an historical review of important controversies in the classification of mood disorders, which, in itself, is a valuable corrective to the stultifying effect that the DSM-III classification has had on thinking in this area. The authors' bias is made clear. They believe that there is a dichotomy between melancholia and other forms of depression. They come to the conclusion that clinical signs of psychomotor disturbance (PMD) define the core of melancholia although several other symptoms also contribute. They developed a measure of PMD and these symptoms called the CORE measure. They demonstrated that this was a reliable measure and improved its sophistication as the research developed. There are valuable chapters that detail discussions of the sophisticated, statistical approaches employed.
Using the CORE measure to diagnose melancholia, they proceeded to establish a number of important correlations. There were correlations between melancholia, outcome and response to treatment. The findings suggested that response to antidepressants and electroconvulsive therapy was better for patients with melancholia. Good correlations with non-suppression on the dexamethasone suppression test were established for melancholia but not for other forms of depression. Melancholia was found to be associated more commonly with neurological disorders such as Parkinson's disease and Huntington's chorea as well as abnormalities on neuroimaging. The authors suggest that melancholia could well be considered a neurological disorder resulting from the dysfunction of a number of parallel, frontal-subcortical neural networks.
This is not an easy book to read. I found it made a poor summer companion at the beach or while watching cricket; however, it is well worth the effort.
The points it makes are often complex and are made with great care, as indeed they need to be. The implications are major. I believe that the authors have established that any research into mood disorders, which does not take their findings into account, must be regarded as flawed. Clinically, all psychiatrists will need to consider afresh the dichotomy between melancholia and other forms of depression, in deciding how best to help their patients. They will need to focus on psychomotor disturbances in arriving at their diagnoses. The CORE measure itself or some simplified form could usefully be employed in routine clinical practice. I hope that this book and its findings reach the widest possible audience and have the impact they deserve.