To my Teachers and Students Depression and its Treatment John Pollitt, MD MRCP DPM Physician in Psychological Medicine St. Thomas's Hospital, London William Heinemann Medical Books London First published 1965 © John Pollitt 1965 Printed in Great Britain by The Whitefriars Press Ltd London and Tonbridge Preface In planning this book for clinicians important decisions had to be made. Much of current terminology is out-dated, there is no satisfactory classification, and existing theories do not cover the breadth of know­ ledge which has recently accumulated. There is no proper framework in which to place important discoveries or on which to plan basic research. The choice lay between a brief review of hypotheses and the use of accepted, but inadequate terminology, or suggestions for a new physio­ logical theory with a concordant classification. I decided to pursue the latter boldly and simply, while including as many useful facts as possible. I am indebted to Dr Raymond Greene and Dr William Sargant for their help and encouragement, and I would like to thank my teachers and all those, including many friends at Harvard, who by their helpful criticism have brought my ideas into better perspective. I am particu­ larly grateful to Dr Marjery Moncrieff and Dr Harry Buckland for their help in reading and moulding the manuscript. J. P. Introduction The subject of depressive illness is of prime importance not only to psychiatrists, but to general practitioners, medical students and special­ ists in other fields. It is important because of its high incidence, the large morbidity rate, its world-wide distribution and disrupting effects upon work, social activities and family life. For these reasons alone, it is probably true that to know depressive illness is to understand three- quarters of psychiatry. Depression is the commonest reaction seen by psychiatrists. It is common at all ages in adult life, and it afflicts mostly those who are reliable, capable and conscientious. Although frequently deceptive in its clinical manifestations, the various guises in which the reaction presents can be penetrated; straightforward methods of treatment will be found effective in a large number of apparently difficult cases. Almost all depressive illnesses are potentially dangerous, because, whether patho­ logical or not, most suicides are associated with them; suicides in this country numbering over 5000, and in the United States 18,000, per year. From this point of view, untreated depression has the worst prognosis of any psychiatric illness. An equally serious aspect is that if the illness is left untreated, or treated improperly, there is a danger of psychosis. Both the development of psychosis and the possibility of suicide may lead to hospital admission, time off work, loss of income and dis­ organisation of important social relationships. Methods of treatment for depression have been developing over the last twenty years. Present methods include those of the simplest kind such as drugs to be taken by mouth, and range to electro-convulsive therapy, the technique of which has been improved enormously. In addition, ways of preventing complications which were commonly seen thirty years ago, are readily available. Research into mental illness, particularly depression, is advancing more rapidly than ever before. Investigation of clinical and social aspects, brain physiology, bio­ chemistry of the nervous system, cybernetics, psychopharmacology, and psychotherapy have progresssed at a rate which has brought the problem into much better focus. Diagnosis is particularly important because early treatment can often resolve the illness before any degree of incapacity has occurred. How­ ever severe its manifestations, it is almost always reversible. Good therapeutic results can be achieved rapidly, and once the depressive process has cleared, the patient's mental integrity is unimpaired and there is no resulting personality change, thus its identification and treatment can be one of the most rewarding processes in medicine for both patient and doctor. Several fallacies about depression are still held; one is that depression ÷ Introduction is commoner among those who are unfortunate in their social and economic status. Depression does not spare class, station or soul, and it is not surprising that a number of eminent men have suffered from it. Occasionally it has ended or interrupted their creative lives long before their talents have been expended by age. Mozart's depression at the age of thirty-four, and Edgar Allen Poe's recurrent attacks of depression which so coloured his writings, consisted of patterns of reaction similar to those seen throughout the world today. Although the content of symptoms and their form of expression by the patient vary widely and challenge the art of medicine, depression remains a constant pattern of mental disturbance. This book is concerned with depression in all its forms. The first aim is to present a physiological basis for physical symptoms, possible mechanisms for the purely psychological features and a new classifica­ tion. The varieties of depression, including deceptive pictures, are des­ cribed as the clinician sees them. Common errors of judgement in depressives are emphasised as a knowledge of these is helpful in pre­ venting the implementation of irremediable decisions which the patient regrets as soon as he is well. The relevant chemistry of the nervous system, the chemical changes occurring in depression, and the ways of correcting and modifying these by modern methods are reviewed. The second aim of the book is to give the principles and details of the techniques used in treatment. The indications for use of older methods and the ways of using the more recent anti-depressant drugs are given. Particular attention is paid to ways of helping the patient with chronic illness in which all usual methods of treatment have been tried without result. Although much less common nowadays, the physical complications, and ways of avoiding them, are described. The greater interest shown in mental disorder by parliament and public, and the increasing use of mass media to educate all in the mechanisms and treatment of mental disorder, demand that the medical profession as a whole should be well acquainted with one of the chief illnesses for which now, there can be so much help. There is no branch of clinical medicine in which depressive illness does not play some part; and with this in mind, an attempt has been made to give a comprehen­ sive account of depression for all engaged in clinical practice. So much knowledge has been gained only during the past decade that inevitably the majority of doctors have had no opportunity, during their early clinical training, to learn this at the bedside or in the lecture theatre. It is hoped that they, particularly, will find it helpful in focusing those principles which it is believed will always govern and influence treatment. Chapter I Concept and Classification of Depression "Tell us pray, what devil this melancholy is, which can transform Men into monsters." John Ford 1629 In everyday conversation the word depression refers to misery, sadness, hopelessness or unhappiness, and it is implied that the emotion is justi­ fied by the circumstances in which the individual concerned finds him­ self. In clinical psychiatry the term depression means much more than this, for not only do patients suffer from prolonged or severe emotional reactions justified by unpleasant or traumatic circumstances, but they more commonly present with a specific disease entity affecting both body and mind which is not easily understood in terms of a simple emotional reaction. The latter may be precipitated by physical as well as psychological stress and occasionally appears in the absence of a detectable cause. These two types of depression have different natural histories, prognoses and complications, and require different forms of treatment. Both involve functional changes, probably biochemical, but not organic lesions in the brain (some brain lesions may produce depressive symptoms in addition to neurological changes, but these are not under review). There are many clinical types of depression, and as feelings of depres­ sion are occasionally absent, even in the severe states, it is more explicit to refer to depressive "illness" or "reaction" and to reserve "depressive mood" for the feeling of misery which is but one symptom. Depressive illness is classified as an affective emotional disorder, because in most examples depressive mood is the presenting complaint. Mania and hypomania form the other category of affective disorder, and demon­ strate changes of mental and physical kinds opposite to those seen in the depressive reactions, the presenting features (rarely a complaint) being of high spirits and elation. Classification of depressive illnesses Depression, whatever its type, is always a result of changes in the internal or external environment on the nervous system of the sufferer. Certain bodily changes or external events, or both, precipitate depres­ sion, the clinical state produced being dependent on the constitution, personality, physical state and upbringing of the individual affected. Current classifications of depression, mainly descriptive, but partly etiological, do not embrace all varieties of the illness; they overlap and bear no relation to treatment or changes in the nervous system. In view 1 2 Depression and its Treatment of these deficiencies, a new, simple classification is given. In some instances terms have been applied in the currently accepted sense. New terms have been introduced only when old ones could not be used in a comprehensive classification. A critique of the old terminology and the relationship of new concepts to older descriptions is given in Appendix 1. The present classification attempts to relate terminology with treat­ ment methods available at the present time, and to present a rational approach to the many types of depressive illness. The importance of classification lies in the need to identify the different types of depression in order to apply appropriate variations in treatment. There is no universal formula, and only by careful identification can the method of treatment most likely to help the patient be selected. Depressive illness can be roughly divided into two main groups, which for reasons to be given later, may be labelled as "psychological" and "physiological". Psychological depression The phrase "psychological" depression applies to the development of feelings of sadness, depression, hopelessness or despondency which are entirely related to, and justified by, adverse external circumstances in which the patient finds himself and of which he is fully aware. The environmental conditions may be overwhelming, or the individual's personality may be inadequate to deal with current problems, however mild they seem to others. The patient has full insight into his difficulties and, secondarily to his complaint of misery, he confesses inadequacy to deal with his present life situation. The subjective mood is similar in quality to normal feelings of depression arising from disappointments, but the reaction is heightened or prolonged beyond normal expectation. The mental state is, at least from the patient's point of view, justified and the symptoms and complaints are limited to the psychological or mental level. For brevity, "psychological" depression will be referred to occasionally as Type /(justified). No delusions or hallucinations, and none of the physiological changes to be described as part of "physio­ logical" depression are found. Physiological depression "Physiological" depression is distinguished by symptoms and signs of characteristic bodily changes dependent on persisting altered function in the central nervous system. The pathognomonic features are somatic manifestations, and it is therefore referred to as Type S. The nervous and bodily changes have been collectively termed the "depressive functional shift" (Pollitt (28)), and the explanation of this phrase and its scientific justification are outlined below. The chief clinical features are early morning waking and inability to fall asleep Concept and Classification of Depression 3 again, feeling worse in the early part of the day and better as the day wears on, loss of appetite, loss of weight, loss of sexual desire, secondary impotence or frigidity, constipation, pallor, poor emotional expression in the face, inability to cry, dry mouth, coldness of the extremities and dryness of the skin. These symptoms and signs, listed in order of their frequency and importance, indicate that the illness is of pathological degree regardless of the depth of depressive mood accompanying it. They indicate also that the illness is not solely related to the circum­ stances, however traumatic, which precipitated it. In addition to the physiological changes, mental phenomena take on a characteristic pattern in that feelings of guilt, unworthiness, inferiority and inadequacy develop. In more severe examples these ideas reach delusional strength. Whereas almost all these features will be found in severe cases, it is common to find only a few represented in the majority of milder ill­ nesses. The group of symptoms exhibited depends largely on the constitution, family history, personality and age of the patient. Thus several patients with entirely different clinical pictures may be suffering from the same illness and require similar treatment. While mental retardation, anxiety, agitation and paranoid ideas are very commonly seen in "physiological" depression, the distinction from Type J depres­ sion can be made in their absence. At this stage a direct tabular comparison between the major types may be helpful in emphasising the main differences. Psychological Physiological Depression (Type J) Depression (Type S) PHYSIOLOGICAL SYMPTOMS Early waking Absent Present Feeling worse in the mornings Absent Present Appetite change Absent Present Weight change Absent Present Sexual desire changes Absent Present PSYCHOLOGICAL SYMPTOMS Depression Present Usually present Retardation Absent Often present Feelings of unworthiness Absent Often present guilt Absent Often present „ inadequacy Absent Often present Delusions Absent Occasionally present Concern about current life situation Always Frequently AETIOLOGY Environmental stresses Always in some degree Frequently Physical stresses Absent Frequently PERSONALITY Inadequacies Frequently present Occasionally present Having determined the main type of depressive illness, further identification is necessary, but before discussing this, a scheme to show 4 Depression and its Treatment the place of the two types of depression in a general classification of mental disorder may be helpful. DISORDERS OF CHARACTER Psychopathy NEUROSES Anxiety states Obsessional neuroses Hysteria Depression Type J Depression Type S (mild) PSYCHOSES Depression Type S (severe) Mania Schizophrenia ORGANIC MENTAL REACTIONS Acute, e.g. Toxic confusional states Chronic, e.g. Dementia PSYCHOSOMATIC REACTIONS e.g. Psychogenic asthma Type S depression is classified both as a neurosis and as a psychosis according to severity. In advanced states the patient lacks insight and becomes psychotic, whereas in milder cases full insight is common. Psychological depression (Type J) This type of depression may be broadly described as follows: Acuteness: 1. Acute, e.g. acute grief reaction. 2. Chronic, e.g. chronic domestic difficulties. Type of situation: As the situations likely to cause unhappiness are legion, and as each set of circumstances must be studied in detail in psychological depression, nothing is gained by a rigid classifica­ tion. Nevertheless, to aid the search for important factors when examining a patient, the following groups may be helpful: Social, marital, sexual, domestic, bereavement, occupational, physical incapacity. Personality: 1. Good, well adjusted prior to development of traumatic situation. 2. Specific inadequacy in relation to current situation. 3. Chronic and general inadequacy as shown by frequent past depressive reactions to similar, or less severe stresses. The importance of personality structure will be discussed later; at this stage only broad groups are reviewed. Physiological depression (Type S) Having, with reference to the depressive functional shift, determined that the depressive reaction is of this type, further subdivision provides more precise clinical information. In describing these, some well known descriptive terms will be used where they are of value. These terms are not derived from a unitary classification, they are not mutually ex-