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Diversity in mood disorders

Australian & New Zealand Journal of Psychiatry, 46(11) Several of the papers in this month’s issue have a common thread—the boundaries and diverse presentations of mood disorders. Continuing a theme explored in previous articles in the Journal (Rosenman and Anderson, 2011, 2012), Rosenman and Nasti (2012) provide a philosophical analysis of the use of psychiatric language, using the diagnostic label of depression as a specific example. They argue that this label is used in diverse ways according to its context and purpose and that, because of this diversity, depression cannot be reduced to an underlying process, whether it be genetic, physiological, psychological or social. This issue of boundaries also arises in Kuiper et al.,’s (2012) editorial on the expansion of the concept of bipolar disorder from bipolar I to bipolar II and then to a broader bipolar spectrum. This type of diagnostic boundary creep has been seen with a number of psychiatric diagnoses in recent times. Kuiper et al., (2012) put up a clear warning sign that the concept may have been stretched too far, resulting in poor reliability and validity and no clear treatment pathway. Bipolar boundaries also appear in the paper by Bauer et al., (2012), which presents data on daily monitoring of mood from a large sample of bipolar patients. They find that brief depressive episodes lasting for a few days are common and, in fact, account for more days of depression than depressive episodes. These subsyndromal depressive symptoms were equally common in both bipolar I and bipolar II disorders. A number of contributions this month deal with the diverse presentations of depression. Zaroff et al., (2012) review the literature on whether Chinese people are more likely to have somatic presentations of depression and anxiety. They argue that the oft-cited view that Chinese people are more likely to somatise is an over-simplification. When comparable assessment methods are used, no actual difference is found. Rather, the apparent difference reflects the way illness needs to be presented to the services available in China and the stigma involved in reporting various types of symptoms. We also have reports on the presentations of mood disorders in both their earliest phases and, at the other end of the spectrum, their recurrent and treatment-resistant forms. These reports are relevant to the notion of clinical staging, which has been particularly championed by McGorry and colleagues (2006) and featured in many contributions to this Journal. Batterham et al., (2012) test the idea that sleep problems are early indicators of depression and anxiety disorders. They indeed find that sleep problems are predictive; however, in the case of depression, this association disappears when personality traits are controlled, suggesting that these traits reflect a common predisposition to both depression and sleep problems. By contrast, the latter did seem to be a specific early indicator of anxiety disorders. At the other end of staging, Magalhães et al., (2012) examine outcomes for people with bipolar disorder who vary in the number of previous episodes. One of the promises of a staging approach is that treatments might be tailored to be appropriate to the stage of illness. Magalhães et al., (2012) found that the number of previous episodes predicted outcome following acute depression, but unfortunately this did not predict responsiveness to antidepressant treatment. Finally, we have a paper by Quinn et al., (2012) examining another theme that has recurred over many years in the Journal—the subtyping of depression. They present data supporting the distinction between melancholic and non-melancholic forms, showing different patterns of impairment in each, rather than a simple difference in severity.