DEPRESSION. The disorder and its associations

Transcription

1 DEPRESSION The disorder and its associations

2 DEPRESSION The disorder and its associations by B. Mahendra Consultant Psychogeriatrician, Hope Hospital (University of Manchester School of Medicine) Salford and Prestwich Hospital, Manchester M.TP PRESS LIM.ITED... ~ ~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP.. LANCASTER I BOSTON I THE HAGUE I DORDRECHT.1IIIIIIII

3 Published in the UK and Europe by MTP Press Limited Falcon House Lancaster, England British Library Cataloguing in Publication Data Mahendra, B. Depression: the disorder and its associations. 1. Depression, Mental I. Title '27 RC537 Published in the USA by MTPPress A division of Kluwer Academic Publishers 101 Philip' Drive Norwell, MA 02061, USA Library of Congress Cataloging-in-Publication Data Mahendra, B. (Bala), Depression: the disorder and its associations. Bibliography: p. Includes index. 1. Depression, Mental. I. Title. [DNLM: 1. Depression. WM 171 M214d]. RC537.M ' ISBN- 13: e-isbn-13: : / Copyright 1987 MTP Press Limited Softcover reprint of the hardcover 15t edition 1987 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers. Typeset by Witwell Ltd, Liverpool

4 Contents Acknowledgments Preface 1 Depressed minds, discursive thoughts: From melancholia to depression: a brief historical sketch 2 Depressed minds, distressed folk: The nature and onset of depression 3 Depressed mind, disordered brain - I: The neurobiology of depression 4 Depressed mind, disordered brain - II: The neuropsychiatry of depression 5 Depressed minds, disputed cures: The management of depression 6 Depressed minds, disordered cells: Malignancy and depression 7 Depressed minds, dastardly acts: Violence and depression 8 Depressed minds, diverse souls: Transcultural aspects of depression 9 Depressed mind, distinguished art: A pathography of depression References vi vii Index v 271

5 Acknowledgements The material for this book has been collected over nearly 10 years, and during that time it has been my good fortune to be able to avail myself of the services of several libraries. I would like to express my thanks to the Librarians and staff of the Institute of Psychiatry Library at the Maudsley Hospital, the St Bartholomew's Hospital Medical Library at West Smithfield, the John Squires Library at the Clinical Research Centre at Northwick Park Hospital, the Royal Cornwall Hospital Library in Truro, the County Library at Morpeth, Northumberland and, most recently, the Prestwich Hospital Library in Manchester. Without the material they obtained for me, this book would not have been feasible. Dr J. M. Brewis, Acquisitions Editor, of MTP Press Ltd, Lancaster, commissioned this book and also undertook to arrange the thankless task of having the manuscript typed. I must thank him and his staff for their assistance and for the expeditious result they have brought about. vi

6 Preface The purpose of this book is to acknowledge the universality of depression, to throw some light on those aspects of depression which are neglected in the more conventional treatments of the subject and also to attempt to provide a synthesis between the biological and socio-environmental factors which lead to the onset of depression and modify its course. A book devoted to depression has the advantage that it has the space at its disposal to explain and clarify concepts and promising ideas that a chapter in even a comprehensive textbook does not have. A single author writing about all the relevant aspects of a subject brings with him the merit of uniformity, continuity and lack of repetition. He is also more fallible in some areas than others, which finds an exact parallel in the experience of clinicians in their practice. A multi-author, multi-specialist work portrays an air of omniscience and omnicompetence which many clinicians find dispiriting. It is likely a considerable number of practising clinicians will have a greater knowledge and experience in some areas of the subject of this book. than I have and will feel emboldened to approach others. The entire work is informed by historical considerations. The lesson of history is to be open-minded and not to judge too harshly those that have gone before. The proper reading of history should induce a salutary humility, and impress upon one the need to distance oneself from even the most alluring theories, which sadly are too often to be found in psychiatry. Nature is said to abhor a vacuum, and that which has been created by the decline of magic and conventional religion appears occasionally to be filled by some psychological doctrine or other. In this book depression has been presented as a medical subject having considerable social and environmental overtones. There is no medical subject which is free of social and environmental considerations. The distinction between general medicine and psychiatry, in this respect, is therefore, falsely made, and the subject of depression is dealt with here as one which ~ o interested s t medical practitioners can study if they set their vii

7 DEPRESSION minds to it. The practical importance of this is that a very large number of depressed patients in medical and surgical wards, and in the community, can have their conditions recognized, understood and effectively treated by non-psychiatrists. It is an enduring source of mystery that doctors who can fathom, say, the classification of epilepsy and the mysteries of the EEG, are apparently bemused by something considerably more straightforward as depression. Part of the reason may lie in the attempts of some in the psychiatric profession to project depression as something mysterious requiring arcane knowledge to unravel it, which is.. further evidence that vacuums can be filled by pseudo-priests, too. Despite what the books might say, our knowledge of depression is far from complete and any dogmatic certainty is unwarranted. For instance, the alarums and excursions surrounding various classification schemes appear to be really a sophisticated version of 'blind man's buff'. Depression may appear to be the final common pathway of events that occur in the mind and, as the evidence reveals to an increasing extent, may also be due to subtle changes in the brain. To create elaborate schema on the basis of what are only superficially observed phenomena is something akin to amateur weather forecasting, amusing and satisfying to a band of enthusiasts but of little use to farmers, controllers of air and shipping traffic and others who rely on the fruits of a more exact knowledge of basic processes. This book encourages the pursuit of knowledge and speculation, but with a critical and sceptical spirit. Trainee psychiatrists preparing for both parts of their membership examination will find there is sufficient material for that purpose, but one hopes some of them can be induced to wander down the by-lanes of the subject. The more senior psychiatrist who wishes to refresh his memory, the research worker who needs an overview of subjects other than his own, the interested general practitioner who nowadays is likely to treat more and more depressed patients, and the medical student who wonders what it is all about may find this book of some value. As with my earlier work on dementia, the chapters on history and pathography may be of some interest to the general reader. Having studied depression for over 10 years in a variety of settings - university departments, district general hospitals, a specialized psychiatric hospital, mental hospitals and in community practice both in urban, inner city and rural areas - in Britain and a Third World country, the book also reflects my personal experience of the subject. Manchester, July 1986 B. Mahendra viii