Existential depression: A meaningful diagnostic entity?

OBJECTIVE: To examine the construct of existential depression and whether it represents a distinct diagnostic entity. METHOD: Descriptive psychopathology and phenomenology are used to define the characteristics of existential depression and for comparison with other presentations of low mood. RESULTS: Existential depression can be differentiated from other forms of depression by careful appraisal of symptomatology. Drawing attention to this, and likewise other distinguishable yet under-recognised forms of depression, may help stimulate interest in further research on the classification of mood disorders with the prospect of greater diagnostic specificity and more precise treatment matching. CONCLUSION: Existential depression is a clinically discernible diagnostic entity.

On what basis should we select treatment in clinical psychiatry: a question too obvious to ask?

OBJECTIVE: Given the differences between our profession and the broader set of medical disciplines, a review of the factors to be considered in treatment planning was conducted. CONCLUSION: Treatment planning in psychiatry is inherently more complicated than in other medical disciplines for various reasons including: a broader range of conceptual models of mental illness and treatment; greater complexities around nosology and diagnosis; the greater limitations of the research evidence base and clinical practice guidelines; and the more substantial impacts of patients' subjectivity and contextual aspects. Diagnosis is generally neither a sufficient nor necessarily the most useful criterion for treatment planning in psychiatry, with a number of other considerations to help guide treatment being outlined.

Are we missing dementia with Lewy bodies?: a case report.

OBJECTIVES: We aim to explore the importance of early diagnosis of dementia with Lewy bodies in order to facilitate effective psychiatric management. We present a case where delayed diagnosis stemming from an atypical presentation illustrates the complex issues involved in identifying and treating this type of dementia. CONCLUSIONS: We discuss the difficulty of diagnosis of this disorder in the absence of obvious memory dysfunction or parkinsonian symptoms. We use the case to draw attention to the limited availability of certain investigations and treatment options in Australia.

A review of the concepts, terminologies and dilemmas in the assessment of decisional capacity: a focus on alcoholism.

OBJECTIVE: The formal assessment of a person's capacity for making reasoned decisions is an infrequent and usually unappealing clinical task. The purpose of this paper is to dissect the task, consider the component parts, clarify those aspects that can be problematic and highlight those that remain so. METHOD: The paper reviews the concepts, terminologies and dilemmas around alcoholism, insight, lack of insight, denial, judgement, will, decisional capacity and competence. CONCLUSION: Assessments of patients suffering from alcoholism (or any other dyscontrol problem such as deliberate self-harm, problem gambling or eating disorders) are likely to evoke unease because of the interweaving of potentially disputable phenomenological, clinical, ethical, semantic and legal aspects. Familiarity with the concepts and terms around decisional capacity helps to orientate clinicians in their work. There remain some particular conceptual issues that are in need of further scholarly attention.

A nosological review of depressive disorders based on observations in clinical practice, Part 2: a working typology for clinicians.

OBJECTIVE: The purpose of this paper is to examine the essential nosological differentiation between melancholic and non-melancholic forms of depression with a view to promoting a meaningful, working typology for clinicians. The paper primarily comprises observations and reflections drawn from clinical practice. CONCLUSIONS: The most specific symptoms of melancholic depression are described, as are the main varieties of non-melancholic 'depression', including demoralisation, grief, loneliness, existential depression and depressive personality.

A nosological review of depressive disorders based on observations in clinical practice, part 1: Terminology and phenomenology.

OBJECTIVE: The purpose of this paper is to describe the problems with the contemporary nosology of 'depression' and to discuss the key linguistic and phenomenological aspects that are essential prerequisites for a clinically meaningful typology of depressive disorders. The paper comprises observations and reflections drawn from clinical work. CONCLUSIONS: First, the use of the unqualified, stock term 'depression' is counterproductive, as are the diagnostic non-entities of 'major depression' and 'dysthymia'. Second, the core psychopathology in melancholic depression is a loss of self-confidence, which helps explain the frequent co-occurrence of 'anxiety' with 'depression'. Third, descriptive, non-technical terms such as 'demoralisation' and 'grief' are most helpful in formulating non-melancholic forms of depression and thus useful in differential diagnosis.

Disconcerting aspects in the everyday professional life of the mental health clinician: a brief overview.

OBJECTIVE: To collate and briefly outline some commonly encountered sources of unease in the professional life of mental health clinicians. METHOD: This paper is based on observations from a range of workplace settings, personal reflection and ideas drawn from the professional literature. CONCLUSION: There is considerable room for reducing work-related feelings of unease in mental health clinicians, such as through arriving at a better understanding of: the limitations of the academic literature with regard to clinical work and low predictability of treatment outcomes, the almost inevitable presence of patients' ambivalence toward treatment, the rather personal nature of the work, the issues around ownership over patients' difficulties and decisions pertaining to treatment, and clinicians cultivating a capacity for circumspection about 'fixing' patients and in so doing reduce their own levels of performance anxiety.

Walking on thin ice: the use of triple antidepressant combinations in refractory melancholic depression.

OBJECTIVE: To report on the outcome of cases of refractory depression treated with a combination of three antidepressant agents. METHOD: Retrospective case series. RESULTS: Three of the four patients made a good recovery. One patient developed transient increased agitation and exacerbation of pre-existing confusion. CONCLUSION: The use of a triple antidepressant combination may be a treatment option, albeit unorthodox and inelegant, in very specific circumstances such as for patients with refractory melancholic depression who have only partially responded to vigorous pharmacological treatment with combined antidepressants and are unwilling to use, or are unsuitable for, established treatments, such as lithium augmentation or electro-convulsive therapy (ECT).

A Pilot Investigation of the Operationalized Predicaments of Suicide (OPS) Framework.

BACKGROUND: Suicide may be conceptualized as an escape from intolerable predicaments, in particular, mental illness and environmental stressors. The operationalized predicaments of suicide (OPS) is a 4 category framework designed to assist in the classification of suicide. The objective was to examine whether this framework is potentially useful. METHODS: 18 psychiatrists from 6 different countries examined 12 written coroners' reports of suicide and rated each report according to the OPS. 16 of these raters then also completed a qualitative questionnaire regarding the framework. RESULTS: In 89.8% of cases the raters where able to make a decision regarding the drivers which led to the suicides. The respondents displayed modest inter-rater correlation (Kappa = 0.42; P < 0.0001). In the qualitative section, respondents supported the face validity of OPS and considered it potentially useful. Feedback allowed improved wording of the OPS instructions. CONCLUSION: The OPS has potential as a useful framework. The OPS instructions have been improved and further studies are justified.

Beyond diagnosis- and therapy-centred therapy: the case for incorporating contextual factors in psychotherapy treatment planning.

OBJECTIVE: The purpose of this paper is to outline a basic approach to psychotherapy treatment selection, with an emphasis on the role of contextual factors. METHOD: Observations and suggestions are based on clinical work and reading of the psychiatric literature. CONCLUSION: It is preferable to organize psychotherapy treatment selection around a consideration of case formulation and contextual factors rather than just diagnosis or a general preference for a purportedly superior type of therapy.

Pharmacological treatment of behavioural and psychological symptoms of dementia in psychogeriatric inpatient units.

OBJECTIVE: This study involved an examination of the current patterns of pharmacological treatment of patients with behavioural and psychological symptoms of dementia (BPSD) in psychogeriatric inpatient units. METHOD: An audit was conducted of discharge medications of patients with BPSD who were hospitalized at three separate inpatient units in Perth, Western Australia over a 1-year period. RESULTS: Prescribing patterns were found to be relatively similar across the three units. Dementia-specific drugs such as choline-esterase inhibitors and memantine comprised a minority of prescribed medication. Antipsychotics, benzodiazepines and sodium valproate were the most commonly prescribed drugs. Cyproterone acetate was used in a small number of patients at each of the three units. CONCLUSIONS: The broad range of medications used to treat BPSD, the relatively modest place of dementia-specific drugs in this patient group, and the co-prescribing of more than one psychotropic agent in the majority of patients support the prevailing impressions that BPSD are difficult to treat and that there is no consistently effective or superior medication or drug group.

An empirical categorization of psychosocial factors for clinical case formulation and treatment planning.

OBJECTIVE: The purpose of this paper is to assemble a basic, empirically derived set of psychosocial 'linchpin' factors for use in case formulation and treatment planning. METHOD: Observations are drawn from clinical work and the psychiatric literature. CONCLUSION: A generic set of psychosocial factors can be useful in providing reference points for case formulation and treatment planning. Such a categorization of factors might be useful for trainees and could help promote discourse toward a 'common language' in psychotherapeutic formulation.

Patients' performance anxiety and related aspects as factors in resistance to change.

OBJECTIVE: The purpose of this paper is to touch on some aspects of patients' potentially ambivalent attitude toward change in the early stages of treatment. METHOD: A de-identified case study is used as a springboard for discussing these issues. CONCLUSION: A range of factors can affect a person's confidence in, commitment to, and results from their treatment. Some of these include: the patient feeling that the nature of their problem--including any ambivalence to change--has been adequately understood; the clinician expressing reassurance or encouragement only after due consideration; the clinician and patient discussing their respective expectations at the outset so as to minimize any subsequent disenchantment; and recognizing the possible presence of a patient's performance anxiety around fearing he or she may fail to respond to treatment and disappoint not only him- or herself but others as well.

A brief, descriptive typology of depressed mood.

OBJECTIVE: The purpose of this paper is to consider the potential clinical utility of a descriptive typology of negative mood states that can present as, and tend to get loosely subsumed under, the broad ranging term, 'depression'. METHOD: Information and ideas from clinical practice and the existing literature have been brought together with a view to compiling a provisional, brief, descriptive typology of depressed mood. CONCLUSION: A qualitative typology of various kinds of depressed mood has heuristic value in engaging, formulating and planning treatment for people presenting with 'depression'.

Writing a letter to patients.

OBJECTIVE: This paper considers the potential utility in clinical practice of writing a letter to patients. CONCLUSION: Letters written by psychiatrists to patients may be helpful in some clinical situations.