Diagnostic issues

So far only depressive onsets in the general population, almost entirely of a 'neurotic' kind, have been considered. In the Camberwell patient enquiry, while events were rather less frequent before 'melancholic' depression than before 'neurotic' depression, there was considerable overlap between the types of depression. This lack of a clear link between the presence of a provoking life event and diagnosis had been reported earlier (39) and also in several subsequent studies.(4 1!>

A recent study of North London psychiatric patients has thrown possible light on this somewhat unexpected picture. When episode number was taken into account, those patients with both a melancholic/psychotic diagnosis and a prior episode of depression had a much smaller chance of experiencing a severe event before onset.(42> A patient series from Pittsburgh produced consistent findings. (43> These results, if confirmed, may also help to explain inconsistencies in published results since the proportion with a melancholic/psychotic picture and a prior episode is bound to vary by type of treatment centre.

It is of interest that the smaller number with provoking events as episode number rises has also been found to relate to the course of bipolar conditions where there is some evidence for a sensitization or kindling mechanism.(44) It is also of note that this same London study concluded that, despite detailed questioning, as many as one-tenth of patients with a 'neurotic' depressive disorder gave no hint of being provoked by social adversity of any kind. (42>

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