[Stress and panic. Immunologic aspects]

Stress induces an imbalance of neuroimmunomodulation, a phenomenon involving the immune, central nervous and endocrine systems. Receptors to substances involved in stress reactions and anxiety, like adrenaline, acetylcholine, histamine, endomorphines, ACTH and several neuropeptides, are present on lymphocytes and lymphocytes can secrete various hormones and neuropeptides. Peripheral and central, cortical and subcortical nervous structures influence immune response. Steroids play a dose dependent inhibitory role perhaps via GIF (Glucocorticoid Increasing Factor) and cytokines (IL 1). In rats, stress induces an increase of corticosterone levels and a lymphopenia depending on the presence of adrenals and pituitary, whereas functional responses to mitogens appear decreased in animals even after surgical removal of adrenals and/or pituitary. Immune response vary according to the degree of control over stressors, to the type of stressor and the animal species. Chronic or repeated stress tends to stimulate immune reaction, contrary to acute stress. In man grief reactions, terminal illness of a spouse, divorce, examinations, caregiving to Alzheimer patients have been used as models of stress, with immune consequences. Pathological anxiety has been less studied, with only few anomalies reported in DSM III-R panic disorder. The immune system participation in the adaptive response to stress is reviewed.

[Effect of psychotropic drugs on vigilance and motor performances]

This review paper deals with the impact of psychotropic drugs on vigilance, awakening and motricity. Antidepressants can be divided into 3 categories, depending on the subject's awakening: sedatives with a strong anticholinergic component, compounds devoid of positive or negative impact on cognition and stimulating antidepressants. The principal effect of lithium is to lengthen the reaction time. Taken acutely, neuroleptics produce alterations of fine motor gestures, but when taken chronically they spare the functioning of cognition. Benzodiazepines act on vigilance in various ways, depending on their half-life and on their plasma peak time after oral administration. The effect of anticonvulsants on cognition is more pronounced with phenytoin and barbiturates than with carbamazepine or valproate sodium. The problems of comparative analysis in this field and the trends in current studies are underlined.

Natural autoantibodies in schizophrenia

Autoantibodies reacting with cell constituents other than antinuclear antibodies have seldom been reported in the literature on schizophrenia. Serum of 41 DSM-III-R schizophrenic patients was examined for the presence of various autoantibodies and compared with that of healthy volunteers (n = 10) and hospitalized controls. Titers of IgG, IgA and IgM autoantibodies directed against actin, tubulin, myosin, DNA, thyroglobulin, elastin, albumin, DNA and trinitrophenyl groups were determined using enzyme immunoassay. IgG and IgA titers were significantly decreased in schizophrenic patients. These results contrast with those obtained with various other autoimmune and nonautoimmune diseases in which titers are either unchanged or increased. A significant increase of various autoantibody levels was observed in the paranoid subgroup of schizophrenics compared with the disorganized subgroup. These autoantibodies possess characteristics similar to those of natural autoantibodies, which seem to play several biological roles.

[Schizophrenia and immunity]

In schizophrenia, various modifications of the immune system have been reported. A decrease of interleukin-2 production by T lymphocytes and an increase of IL-2 receptors were observed by several authors. Not only cellular but humoral immunity seems to be modified: apart from the viral hypothesis, an auto-immune hypothesis holds that auto-antibodies may play a role in the biology of schizophrenia. Natural auto-antibodies, preexisting any antigenic stimulation, may also be involved, particularly in the response to neuroleptic drugs.

[Somatic and biological factors predicting a response to antidepressive agents]

In order to assess the predictive value of somatic and biological factors in antidepressant trials, non specific parameters, i.e. natural course of illness, life events, placebo effect ... have to be controlled by means of studies vs placebo. Among somatic factors, retardation seems to predict a positive response to antidepressants. The predictive value of other endogenous signs--like insomnia or weight loss--is still questioned. Few biochemical parameters appear relevant when metabolites of central monoamines, their precursors and the enzymatic processes involved are considered. The serotoninergic system is the focus of many studies. Among the neuroendocrine indices, the DST proved too poorly specific of depression. Among the physiological parameters, some characteristics of sleep EEG, like a shortening of REM latency, seem promising. Pharmacological challenges, for instance response to stimulant drugs, gave inconsistent results and should be discussed on ethical grounds. Many studies have been undertaken but presently no routine reliable biological index is available to predict a response to antidepressants.

Diagnostic and therapeutic value of testing stimulation of thyroid-stimulating hormone by thyrotropin-releasing hormone in 100 depressed patients

The thyrotropin-releasing hormone (TRH) test was performed in 100 depressed patients, including 73 patients with a major depressive episode (MDE) according to DSM-III. Thirty-one patients subsequently received an antidepressant with a predominant serotoninergic action (indalpine or citalopram), and 27 patients received a noradrenergic antidepressant (maprotiline). The diagnostic value of the TRH test was not conclusive for any of the subgroups of depressed patients: MDE, MDE with melancholia or MDE in bipolar patients. Similarly, the value of the TRH test in the choice of antidepressant treatment according to the monoaminergic action was not convincing. These results are discussed in the light of the data of the international literature.

[Towards the rehabilitation of maintenance electroconvulsive therapy?]

ECT is a reliable treatment of serious affective disorders more efficacious than antidepressants either used alone or combined with mood stabilizers or neuroleptics. Recurrent affective disorders refractory to all treatments presently available have been tentatively treated by prophylactic ECT since the beginning of ECT. In this study, 16 cases of recurrent affective disorders treated with maintenance ECT are discussed. Six continue to show a good response to maintenance ECT. Six remain improved although they discontinued ECT. ECT failed to improve 4 patients. Indications and inclusion criteria of maintenance ECT are defined. Good responses in cases refractory to all other treatment strategies are promising but still require prospective studies, difficult to implement, in order to confirm the efficacy of maintenance ECT.

[Cognition disorders in obsessive disorder]

The authors present a critical overview of the multiple studies of cognitive functions of patients with obsessive compulsive disorder. First are mentioned some correlations between neurological diseases and obsessive compulsive disorder. Then, the authors analyse the results obtained by the patients in WAIS, in the tactual perception memory test, in visual memory and orientation and in verbal memory. Verbal behaviour, performances in sensory perception tests, motor performances, attention and, lastly, troubles in information processing are reviewed. With these results, the authors try to develop the relevant theories about the mechanisms in obsessive compulsive disorder: dysfunction of the dominant hemisphere and abnormality of the serotoninergic system.

Aberrant T cell-mediated immunity in untreated schizophrenic patients: deficient interleukin-2 production

The authors examined the immune status at the cellular and humoral levels of 16 untreated schizophrenic patients. No abnormality in the distribution of T cell subsets (CD4+, CD8+) was detected. The proliferative response to the T cell mitogen phytohemagglutinin was normal. No increase in the number of T cells showing activation markers, such as human leukocyte antigens and interleukin-2 receptors, was noted. Conversely, function studies revealed a clear deficiency in interleukin-2 production by purified T cells. This lower production was probably intrinsic to the patients' T cells, since interleukin-2 production showed normal sensitivity to prostaglandin E2-mediated down-regulation by autologous monocytes.

Free and conjugated plasma homovanillic acid in schizophrenic patients

It has recently been suggested that the plasma level of homovanillic acid (HVA) may provide an index of central dopaminergic activity in humans. Clinical studies have shown that in schizophrenic patients, plasma HVA levels increase with the severity of psychopathology. However, these studies only considered the plasma free HVA fraction whereas investigations on conjugated HVA in humans are sparse and results remain controversial. The aim of this study was to measure both plasma free and conjugated HVA in healthy volunteers and drug-free schizophrenic patients. The mean values and the ranges of plasma free HVA in volunteers and patients were similar to those described in the literature. A substantial and significant increase in plasma free HVA was observed in schizophrenic patients compared with normal subjects. In contrast, plasma conjugated HVA was significatively decreased in schizophrenics. The plasma total HVA was nevertheless higher in schizophrenics compared with controls. No significant correlations were observed between plasma HVA levels and the clinical features of schizophrenic patients rated by various psychiatric scales. These findings suggest that there is an imbalance between plasma free and conjugated HVA in schizophrenic patients, who present an increase in total HVA when compared with controls. Paranoid schizophrenic patients, who present mainly positive symptoms, show the most marked plasma free/conjugated HVA imbalance.

[Chemotherapy in the treatment of bulimic behaviors]

Bulimia has been treated with various drugs. MAOI and heterocyclic non MAOI antidepressants have proved efficacious in controlled studies. Whereas Benzodiazepines, Lithium and antiepileptic medications appear less promising or have not yet been widely assessed in methodologically valid studies. Serotoninergic compounds are particularly specific of bulimic disorders. The links of bulimia with depressive states are briefly discussed.

Lack of correlation between DST results and urinary MHPG in depressed inpatients

Abnormalities of noradrenaline metabolism and of the activity of hypothalamic-pituitary adrenal axis (HPA) have been reported in depression. To study the possible relationship between these 2 parameters, urinary excretion of 3-methoxy-4-hydroxy-phenylethyleneglycol (MHPG) and Dexamethasone Suppression Test (DST) were analyzed in 58 depressed patients. A positive correlation was found between the age of depressed patients and 24-h urinary excretion of MHPG. Twenty-two patients (38%) were DST non suppressors. Pre-DST plasma cortisol levels were significantly higher in non suppressors than suppressors. No difference was found however between urinary MHPG levels in suppressors and non suppressors. There was no correlation between pre-DST plasma cortisol and levels of urinary excretion of MHPG. These results do not support the hypothesis of a relationship between these 2 parameters. However, when depressed patients were separated into two groups according to urinary excretion of MHPG ("high MHPG" and "low MHPG"), the "high MHPG" group included significantly more non suppressors then the "low MHPG" one. This result is not sufficient to demonstrate of link between HPA system activity and central noradrenaline metabolism.

[Value of maintenance electroshock therapy in recurrent depression. Apropos of 4 cases]

Four cases of recurrent affective disorders received a long term treatment by maintenance ECT in order to control relapses which were not otherwise controlled by antidepressant or mood stabilizing drugs. The efficacy of maintenance ECT makes it possible to use this therapeutic method under certain conditions.

[Epileptogenic action of fluvoxamine. Apropos of a case]

A case of status epilepticus with transient motor deficit is reported in a 66 year old male treated with fluvoxamine. Fluvoxamine is supposed to induce few epileptic seizures. The patient had no previous history of epilepsy. Two factors seem to have favoured the occurrence of epilepsy: presence of an incipient arteriopathic impairment, cortical and subcortical brain atrophy and perhaps drug overdosage causing a tremor in the days before the epileptic fit.

[Cognitive therapies of depression]

Among brief psychotherapies of depression, cognitive therapy, a theoretical model which was proposed by A.T. Beck as early as the sixties, holds that depression comes from a distorted view of the environment: depressed patients view themselves, the world and the future negatively (cognitive triad). This conception is based upon cognitions, preconscious schemes and faulty information processing, that cognitive therapy corrects, using in a pragmatic way cognitive and behavioral techniques requiring an active collaboration of the patient. Cognitive therapy is indicated, alone or combined with anti-depressants, in neurotic depressions (DSM-II) and in most of major depressions (DSM-III) treated on an outpatient basis. Comparative outcome studies prove the effectiveness of cognitive therapy.