Depression Sub-Typing: Unitary, Binary or Arbitrary?

Abstract

The strongest statistical support for the binary view of depression has been provided by factor (principal components) analytic studies which delineate a bipolar factor with features interpreted as reflecting “endogenous depression” and “neurotic depression” at opposing poles. We review the seminal studies to suggest instead that the bipolar factor has generally polarised depression and anxiety, and that no such entity or symptom complex of “neurotic depression” has been isolated. Instead, “neurotic depression” has been defined principally by features of anxiety and personality style. We argue that the suggested entity is, in fact, a pseudo-entity, being no more than a residual group of non-depressive features without any significant intrinsic depressive characteristics. We support our interpretation by showing comparable solutions in published studies of depressives alone, contrasted with separate analyses of anxious and depressed patients. We also report two studies in which the “neurotic depressive” pole is made to appear and disappear by the inclusion and exclusion of anxiety items. As factor analytic studies have defined the “residual” pole so variably, we argue that some features held to distinguish neurotic depression are of no utility and that such a diagnosis is meaningless. We suggest that the clinician should not proceed (after excluding endogenous depression) to conclude that the default option is necessarily an entity “neurotic depression” and that instead a heterogeneous group of options (e.g. anxiety, personality disorder) require review. If the “neurotic depressive” type of the multivariate analytic studies is a pseudo-entity, then a modified unitary view of depression may be valid.