Impact of dysfunctional parenting, affective temperaments, and stressful life events on the development of melancholic and non-melancholic depression: A path analysis study.

BACKGROUND: The influence of psychosocial factors on differentiating between melancholic depression (MEL) and non-melancholic depression (NMEL) remains unclear. In this study, we aimed to investigate the interrelationship between dysfunctional parenting, personality traits, stressful life events, and the diagnosis of MEL and NMEL among patients with major depressive disorder (MDD). METHODS: Ninety-eight patients with MDD completed the following self-administered questionnaires: the Parental Bonding Instrument (PBI) for dysfunctional parenting, the short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A) for affective temperaments, and the Life Experiences Survey (LES) for stressful life events. The data were analyzed using single and multiple regression analyses and path analysis. RESULTS: Dysfunctional parenting did not have a significant direct effect on MEL. However, paternal care had a significant indirect effect on MEL through depressive temperament. The total indirect effect of paternal care on MEL was significant (indirect path coefficient = 0.161, p <0.05). In other words, low levels of paternal care were associated with the development of NMEL via increased depressive temperament. None of the paths from paternal care to MEL via negative change scores of the LES were significant. LIMITATIONS: This study used cross-sectional data, so the possibility that current depressive status may affect the assessment of LES and TEMPS-A cannot be ruled out. CONCLUSIONS: We found that low levels of paternal care did not directly affect the development of NMEL, but affected the development of NMEL through the mediation of depressive temperament rather than stressful life events.

Affective Temperaments in Differentiation Between Melancholic and Nonmelancholic Depression: A Case-Control Study.

ABSTRACT: The association between major depressive disorder (MDD) and personality traits has been extensively studied. However, differences in personality traits between patients with melancholic MDD (MEL) and nonmelancholic MDD (NMEL) remain unclear. In this study, we aimed to determine whether neuroticism, which has been associated with MDD, and the five affective temperament subtypes assessed by the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A) can be used to distinguish MEL and NMEL. A total of 106 patients with MDD (MEL, n = 52; NMEL, n = 54) and 212 age- and sex-matched healthy controls answered the Eysenck Personality Questionnaire-revised and the short version of TEMPS-A. In hierarchical logistic regression analysis, only depressive temperament scores were identified as a statistically significant feature distinguishing NMEL from MEL. Depressive temperament scores assessed by the short version of TEMPS-A were found to be significantly higher in NMEL patients than in MEL patients.

Identifying Subjective Symptoms Associated with Psychomotor Disturbance in Melancholia: A Multiple Regression Analysis Study.

PURPOSE: Melancholia has recently been re-evaluated, because patients with major depressive disorder (MDD) were found to be heterogeneous. However, the DSM-5 criteria for melancholia (DSM-MEL) have been criticized, because of the difficulty in clearly distinguishing between melancholic and non-melancholic depression using DSM-MEL. Psychomotor disturbance (PMD) is one of the most important, as well as one of the only measurable symptoms of melancholia. Parker et al developed the CORE measure, which assesses PMD as a behavioral characteristic. The aim of our study was to objectively identify the subjective symptoms of melancholia by analyzing the symptoms associated with PMD. PATIENTS AND METHODS: A total of 106 participants with MDD were examined by psychiatrists. Multiple regression analysis was performed in which the total CORE score was the dependent variable, and items of the DSM-MEL and historically suggested melancholic features were independent variables. RESULTS: The following five independent variables were able to predict the total CORE score: 1) feelings of having lost feeling, 2) depressive delusions, 3) perplexity, 4) indecisiveness, and 5) no aggression against others. These five variables were more strongly associated with the total CORE score than the DSM-MEL. LIMITATION: The major limitation of this study was that when choosing non-DSM melancholic signs and symptoms, we did not comprehensively evaluate and select the symptoms but chose items that are clinically important. CONCLUSION: We identified five subjective symptoms that were associated with PMD. These five symptoms may be clinically useful as diagnostic criteria for melancholia.

[Rethinking the theory of melancholia (Tellenbach): its construction process and theoretical significance].

In 1961, Tellenbach published the concept of "Typus melancholicus" (melancholic type) to illustrate the complementary relationship between premelancholic (predepressive) situations and a premorbid personality. The melancholic type is often considered to be a non-universal type that is localized in Germany and Japan; however, this belief is increasingly considered to be incorrect. When referring to papers written in the United States around the time that Tellenbach's monograph was published, it is now possible to identify some personalities corresponding to the melancholic type. In the early 20th century in Germany, the precipitating events and premorbid personalities of manic-depressive illness were frequently reported by Kraepelin and other researchers. They identified a conscientious, punctual, and orderly character that is analogous to the melancholic type. However, they ignored the relationships between events and personality. For them, the etiologies of endogenous psychoses, such as schizophrenia and manic-depressive illness, should not be sought from exogenous factors, such as precipitating events and environmental factors, but from endogenous and constitutional factors. After the end of the Second World War, the traditional view of a reactive (exogenous)-endogenous dichotomy of depression increasingly began to be deemed no longer valid. Consequently, it gradually became clear that many patients develop endogenous and autonomous depression after a psychological precipitating event. Tellenbach tried to resolve the impasse in the reactive-endogenous dichotomy of depression through creation of the concept of the "endon" in place of the "endogenous" concept. Tellenbach considered the endon not as cryptogenic but as transcending the dichotomy between the somatogenic and psychogenic. The endon is represented phenomenologically as transformations of arising rhythms, transformations of form of movement, the globalism of transformations, binding to a maturing process, and reversibility. According to Goethe's morphology. Tellenbach placed the endon in the ideal and phenomenological (empirical) realms simultaneously. The essential feature of the melancholic type is orderliness, which manifests in the following three areas: work, behavior, and conscientiousness. The interpersonal relationships of people with the melancholic type are described as "Being-for-others", which is analogous to altruism. People with the melancholic type think highly of common sense and duty. Furthermore, they cannot lower their level of aspiration even if the quality and quantity of their work is beyond their abilities or their capacities are weakened. In these premelancholic situations, pre-melancholic persons are forced to choose either quality or quantity and are plunged into the depths of despair, which means a hiatus or onset of melancholia. Thus, Tellenbach analyzed the complementary relationship between premelancholic situations and a premorbid personality at the beginning of melancholia. However, Tellenbach failed to explain why people with the melancholic type do not develop any illnesses other than melancholia or contradict the possibility that people with non-melancholic type personalities could have melancholia. In Japan, the melancholic type originated from Hirasawa's viewpoint that he had shifted the essential feature of Shimoda's Immodithymie (Shuuchaku Seikaku) from enthusiasm to orderliness. Subsequently, Kasahara developed the Japanese concept of the melancholic type, which remains in the empirical and descriptive realm and its essential feature is "orderliness underlying the altruism." In the United States, although the melancholic type probably existed, the concept was infrequently discussed because there were few psychiatrists who knew the concept of endogenous depression very well. Moreover, in DSM-III, the difference between endogenous and reactive depression was eliminated according to the "atheoretical" policy. Consequently, Tellenbach's theory of melancholia lost significance. The value of the theory of endon, which constitutes Tellenbach's theory of melancholia in empirical medicine, is considered to be restrictive. However, the discovery of the melancholic type concurrently in Germany, the United States, and Japan is of marked significance. It is now possible to reappraise the importance of the melancholic type and premelancholic situations.

[The difference between depression and melancholia: two distinct conditions that were combined into a single category in DSM-III].

In DSM-III (1980), depressive states of neurosis and those of manic-depressive illness (melancholia or endogenous depression) were combined into the single category "major depression," which is the progenitor of "major depressive disorder" in DSM-IV-TR (2000). According to Hamilton, the word "depression" is used in three different ways. In common speech, it is used to describe the state of sadness that all persons experience when they lose something of importance to them. In psychiatry, the word is used to signify an abnormal mood, analogous to the sadness, unhappiness, and misery of everyday experiences. Moreover, the depression discussed in psychiatry often has another quality that makes it distinctive, and this quality appears to be related to an inability to experience any pleasure (anhedonia) regardless of experience. Accordingly, we classify these three uses of the term "depression" into sadness, depression, and melancholia in order of appearance within this paper. According to DSM-IV-TR criteria for major depressive disorder, depression corresponds closely to A1 "depressed mood", while melancholia is roughly compatible with A2 "markedly diminished interest or pleasure." Depression and melancholia differ in terms of origin, psychopathology, and therapy. Before DSM-III, depression had not been considered as a diagnosis, but was a ubiquitous symptom that was seen in such conditions as neurasthenia, psychasthenia, nervousness, and neurosis. Melancholia has a history that reaches back to Hippocratic times. Its modern meaning was established based on Kraepelin's manic-depressive illness. Depression is a deepened or prolonged sadness in everyday life, but melancholia has a distinct quality of mood that cannot be interpreted as severe depression. In modern times, depression has been treated with a diverse range of methods, including rest, talk therapy, amphetamines (1930s), meprobamate (1950s), and benzodiazepines (1970s). Melancholia has primarily been treated with somatic therapy, such as electroconvulsive therapy, and tricyclic antidepressants. When preparing diagnostic criteria for DSM-III, Spitzer referred not to DSM-II but to Feighner's (1972) criteria as a model because Feighner's operational criteria were considered to be effective in establishing inter-rater reliability. At the outset, Spitzer established Research Diagnostic Criteria (RDC, 1975), which he revised in 1978. In the first edition of RDC, Spitzer adopted most of the Feighner criteria, including essential criteria A "dysphoric mood" and eight optional criteria (B1-B8). However, he reduced the minimal morbid duration for diagnosis. Moreover, for the purpose of excluding neurosis from the diagnostic criteria, Spitzer eliminated the distinction between primary and secondary depression, which had been used to differentiate melancholia from depression. In the revised RDC, Spitzer upgraded optional criteria B5 "loss of pleasure or interest" to one of the essential criteria A with "dysphoric mood." This revision reflects the fact that "loss of pleasure or interest" has been designated as an essential feature of Klein's concept of "endogenomorphic depression" (1974), which is equivalent to melancholia or endogenous depression. At that time, depression and melancholia were completely amalgamated into a single category. DSM-III followed almost all of the revisions in the revised RDC and accepted the bipolar-unipolar dichotomy. However, Klein's endogenomorphic depression was downgraded to the specifier "with melancholia", which has been used only rarely. Thus, as depression and melancholia were fused into major depressive disorder, we have only limited evidence of the efficacy of pharmacotherapy and psychotherapy. DSM-IV divided major depression into major depressive disorder and bipolar II disorder. Consequently, some depression and some melancholia were moved from unipolar depression to bipolar disorder, although the bipolar-unipolar dichotomy was proposed for manic-depressive illness and recurrent unipolar melancholia, but not depression. Therefore, we suspect that we will not obtain strong therapeutic evidence for bipolar II disorder as well. Our proposals are as follows: give up the unitarian view of depression and melancholia and accept the binarian view; and restrict the bipolar-unipolar dichotomy to manic-depressive illness and unipolar melancholia.

[The modern concept of atypical depression: four definitions].

This report describes and compares four current concepts and definitions of atypical depression. Since its emergence, atypical depression has been considered a depressive state that can be relieved by MAO inhibitors. Davidson classified the symptomatic features of atypical depression into type A, which is predominated by anxiety symptoms, and type V, which is represented by atypical vegetative symptoms, such as hyperphagia, weight gain, oversleeping, and increased sexual drive. Features that are shared by both subtypes include: early onset, female predominance, outpatient predominance, mildness, few suicide attempts, nonbipolarity, nonendogeneity, and few psychomotor changes. Based on these features, bipolar depression can also be defined as atypical depression type V. Herein, we examine and classify four concepts of atypical depression according to the endogenous-nonendogenous (melancholic-nonmelancholic) and unipolar-bipolar dichotomies. The Columbia University group (see Quitkin, Stewart, McGrath, Klein et al.) and the New South Wales University group (see Parker) consider atypical depression to be chronic, mild, nonendogenous (nonmelancholic), unipolar depression. The former group postulates that mood reactivity is necessary, while the latter asserts the structural priority of anxiety symptoms over mood symptoms and the significance of interpersonal rejection sensitivity. For the Columbia group, the significance of mood reactivity reflects the theory that mood nonreactivity is the essential symptom of "endogenomorphic depression", which was proposed by Klein as typical depression. Thus, mood reactivity is not related to overreactivity or hyperactivity, which are often observed in atypical depressives. However, Parker postulates that psychomotor symptoms are the essential features of melancholia, which he recognizes as typical depression; therefore, the New South Wales group does not recognize the significance of mood reactivity. The New South Wales group accepts the relationship between anxiety symptoms and interpersonal rejection sensitivity, while the Columbia group does not recognize the importance of anxiety symptoms because they could not identify a relationship between such symptoms and the efficacy of MAO inhibitors. The concept of atypical depression proposed by the New South Wales group overlaps considerably with that of hysteroid dysphoria, which was proposed by Klein et al., and was the progenitor of Columbia group's concept of atypical depression. The Pittsburgh University group (see Himmelhoch, Kupfer, Thase et al.) and the soft bipolar spectrum group (see Akiskal, Perugi, Benazzi et al.) regard atypical depression as a depressive state that can be observed in bipolar disorder. The former groups takes into account reversed vegetative symptoms and lethargy as signs of bipolar disorder, while the latter recognizes that atypical depression shares features with bipolar II disorder or soft bipolar spectrum disorder. The soft bipolar spectrum group maintains their unique concept of bipolar disorder, which regards some unipolar depressions as bipolar disorder, while the Pittsburg group continues to share the conventional concept of a unipolar-bipolar dichotomy with other groups. The fundamental pattern of atypical depression is represented by chronic mild depressions, which are characterized by a younger age at onset, female predominance, interpersonal rejection sensitivity, and mood lability, which are difficult to distinguish from a characterological pathology. Patients who present with such patterns are frequently diagnosed with borderline, histrionic, or avoidant personality disorders; therefore, we must recognize the significance of atypical depression as a concept that can suggest the utility of medication for these patients. For such patients, however, various groups have proposed different kinds of definition and therapeutic guidelines that are difficult to synthesize and utilize in clinical settings. Moreover, some features of atypical depression outlined in the Columbia University criteria, such as a younger age at onset, chronicity, mildness, and female predominance, were excluded from DSM-IV. Consequently, the concept of atypical depression has become overextended and gradually lost its construct validity. Therefore, the diagnostic criteria for atypical depression should be reconsidered in reference to various definitions and concepts and refined through accumulated clinical research.

[The debate concerning the classification of depression that predominantly occurred in the United Kingdom from 1926 to 1957: the discovery and reappraisal of "mild endogenous depression"].

Herein, the author reassesses the intense debate concerning the classification of depression which predominantly occurred from 1926 to 1957 in the United Kingdom as either unitarian or binarian. The main issue under debate was whether all depressions, which vary from severe cases in psychiatric hospitals to mild cases in general practices, should be considered symptomatically hetero- or homogeneous. The former is related to the binarian perspective, which was represented by Kraepelin and was adopted mainly in continental Europe, while the latter, the unitarian perspective proposed by Meyer, was adopted in the United States. In contrast, in the United Kingdom, there was vigorous debate as to whether the Meyerian or Kraepelinian perspective should be adopted. In 1926, Mapother asserted that the unitarian concept was the most appropriate because there were no qualitative symptomatic differences between manic-depressive psychosis and neurasthenia, only quantitative differences in severity. In opposition to Mapother, Gillespie proposed the binarian perspective, which shifted the essential feature of manic-depressive psychosis or melancholia from etiological ("no precipitating event") to symptomatic ("mood-nonreactivity"). However, subsequent to Mapother, Lewis proposed that, in clinical practice, we must refer to other dimensions, such as etiology, constitution, and environment, rather than only symptoms. Furthermore, he related severity with acuteness for psychosis, and mildness with chronicity for neurosis. Consequently, Lewis's unitarian concept and relationships became tacit assumptions in psychiatry until the 1950s. With progress in somatic therapies in psychiatry, the binarian perspective gradually came to the forefront. In the mid-1940s, a new method of reexamining psychiatric diagnosis in accordance with the specific efficacy of convulsion therapy was developed. Mayer-Gross asserted the importance of the symptomatic distinction of endogenous depression in clinical practice and noticed, similarly to Gillespie's idea, that "mood-nonreactivity" was a symptomatic feature of endogenous depression, and suggested the application of somatic therapies. For Mayer-Gross, the term "endogenous depression" did not necessarily indicate severe forms of depression. In 1957, the concept of "mild endogenous depression" was proposed in a paper by Watts, who was not a psychiatrist but a general practitioner. Prior to the publication of his paper, Watts had already stated in 1956 that "Endogenous depression is a condition that is often overlooked," and "Not more than one-quarter of the cases are seen by a psychiatrist. Endogenous depression is essentially a disease of general practice." Consequently, it was "discovered" that a substantial portion of patients with mild depression who had formerly been assigned to receive psychotherapy, had actually required somatic therapies, and many of them had sought help from general practitioners, not psychiatrists. In addition, it was also "discovered" in the sense that physicians had been released from a fixed preoccupation with the equivalence of mildness and neurosis. In the same year, Kuhn confirmed the marked effects of imipramine on vital forms of depression, eventually equivalent to endogenous depression. Subsequently, the focus of this debate shifted from clinical intuition to statistical methods, such as factor and cluster analyses. However, some methodological and technical flaws were identified by Eysenck; thereafter, statistical research on the symptomatic classification of depression began to decrease over time. In contrast, the unitarian perspective continued to prevail in the United States despite some interesting research by binarians such as Klein, who proposed the concept of "endogenomorphic depression" and insisted that the existence of mild endogenous depression supported the rejection of the unitarian perspective. At present, the unitarian perspective dominates operational diagnostic criteria, such as those in the DSM and ICD, and little attention is focused on the significance of mild endogenous depression; however, it should be reappraised as a concept that can help to avoid the over-diagnosis of depression and provide guidance for the appropriate prescription of antidepressants.