Validation of a new prototypic measure of melancholia Gordon Parker a,b, ⁎ , Stacey McCraw a,b , Kathryn Fletcher a,b , Paul Friend b , Shulamit Futeran b a School of Psychiatry, University of New South Wales, Sydney, Australia b Black Dog Institute, Sydney, Australia Abstract Multiple approaches have been adopted in an attempt to effectively identify and discriminate melancholic and non-melancholic depressive subtypes. We recently developed the Sydney Melancholia Prototype Index (SMPI) which incorporates antecedent and illness course variables as well as symptoms, with clinician-rated and self-rated SMPI versions, and with the former having been shown to have superior sensitivity and specificity in discriminating melancholic from non-melancholic depression. The aim of this study was to further evaluate the capacity of the SMPI to identify melancholia in comparison to DSM-based and clinician-judged assignments. The sample comprised 214 patients diagnosed with melancholic or non-melancholic depression according to a detailed clinical assessment and by the Mini International Neuropsychiatric Structured Interview (MINI) assessing formal DSM-IV melancholia criteria. DSM-IV assignment to melancholic versus non-melancholic depression was contrasted with clinician-judged allocation, the combination of these two strategies (“concordant diagnoses”), and to the SMPI (CR or clinician-rated and SR or self-report versions), with the likely validity of each approach examined against historical ascriptions for melancholia. DSM-IV criteria assigned the highest percentage of the sample with a melancholic diagnosis (64%), whereas the SMPI-SR assigned the smallest percentage with a melancholic diagnosis (37%). DSM-IV assignment was associated with the fewest number of validating variables, whilst SMPI-CR and independent clinician diagnosis were associated with the greatest number of differentiating variables including negative childhood experiences, past and recent stressors, satisfaction with life and perceived social support. These comparative analyses provide further support for the SMPI-CR in identifying and discriminating melancholic depression from non-melancholic depression. Replication of these findings in other samples with independent raters is recommended. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Depression has historically been conceptualized from either a binary or unitary perspective. Originally, the binary view described an autonomous or “endogenous” depressive sub-type that ran its own course once precipitated as against other depressions that were “reactive” to the environment. The unitary view (of depression being a single entity varying by severity) gained momentum in the late 1920's, when Mapother concluded that, since he was unable to determine any differences between diagnosed endogenous and non- endogenous depressive conditions with regard to causation, prognosis and treatment (“a complete graduation”), it was pointless to distinguish between them and argued for all neurosis to be placed on a continuum. This dimensional view has subsequently largely prevailed. Currently, the distinction between depressive subtypes is not “sharp”; however, knowledge has advanced and with clearer distinctions emerging through analysis of illness course as well as symptom variables. Reviews of melancholic depression [1,2] have suggested a number of ascriptions and differential features. For example, melancholic depression— in comparison to a residual group of non-melancholic depressive conditions—is weighted to a greater prevalence or likelihood of certain symptoms and signs including vegetative features (decreased appetite and weight loss), early morning awakening, psychomotor disturbance, diurnal variations in mood and energy, and an anhedonic and non- reactive mood. It also differs in illness course and treatment response relative to other (non-melancholic) depressions in a way suggesting the greater relevance of genetic and other biological determinants compared to psychosocial factors, with episodes being less likely to spontaneously remit and with selective response to physical treatments such as broad action antidepressant medication and electroconvulsive therapy (ECT) [3]. Conversely, we position [4,5] the “non- Available online at www.sciencedirect.com ScienceDirect Comprehensive Psychiatry 54 (2013) 835 – 841 www.elsevier.com/locate/comppsych ⁎ Corresponding author. Black Dog Institute, Prince of Wales Hospital, Randwick 2031, Sydney, Australia. E-mail address: g.parker@unsw.edu.au (G. Parker). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.02.010