Obtaining a family psychiatric history: is it worth the effort?

The purpose of this study was to determine whether, for first-degree relatives of patients presenting to a mood disorders clinic, family history information on psychiatric conditions collected by a psychiatrist and incorporated into the patient's medical records is as informative as that gathered during an interview specifically designed to collect family history data. The study group consisted of 472 first-degree relatives of 78 randomly selected index cases from a large mood disorders genetic database. Family history of psychiatric disorders recorded in regular psychiatric medical records ("clinician history"), and data obtained by a genetic counsellor administering specific family psychiatric history questionnaires to patients and multiple family informants ("family history") were compared using a kappa statistic. Good agreement between the two methods on the presence or absence of a psychiatric disorder was found among first-degree relatives of index cases, but poor agreement was found with respect to the presence or absence of a specific mood disorder diagnosis(es) in a relative. The results suggest that a clinician-generated family psychiatric history is sensitive to the presence or absence of a psychiatric disorder when compared to a more structured detailed genetic interview. However, for research purposes, a clinician-generated family psychiatric history of a specific mood disorder diagnosis, without supporting collateral information, may not be reliable for use in supporting a mood disorder diagnosis in a patient and/or his relatives.

Depressive symptoms and family history in seasonal and nonseasonal mood disorders

OBJECTIVE

The authors' goal was to compare the symptoms and family history of seasonal affective disorder with those of nonseasonal mood disorders.

METHOD

From a subspecialty mood disorders clinic, 34 patients with major depression, seasonal pattern (seasonal affective disorder), diagnosed with DSM-III-R criteria, were matched in age, sex, and diagnostic subtype (recurrent unipolar, bipolar I, or bipolar II) to 34 patients with nonseasonal mood disorders. Data on symptoms during the most recent depressive episode were obtained by chart review and compared by using chi-square tests. Family history data for first-degree relatives of patients with seasonal and nonseasonal mood disorders were gathered by using the family history method, and diagnoses were based on Family History Research Diagnostic Criteria.

RESULTS

Patients with seasonal affective disorder reported significantly more hypersomnia, hyperphagia, and weight gain and reported less suicidal ideation and morning worsening of mood than the patients with nonseasonal mood disorders. No differences were found in family histories of mood disorders, other psychiatric disorders, and any psychiatric disorder between the groups with seasonal versus nonseasonal mood disorders. Alcoholism was found more frequently in the relatives of the patients with seasonal affective disorder.

CONCLUSIONS

Differences in symptoms between seasonal and nonseasonal mood disorders provide some support for seasonal affective disorder as a diagnostic subtype of mood disorders. However, the genetic loading for mood disorders (of unspecified seasonality), as determined by the family history method, is similar for seasonal and nonseasonal mood disorders.

The effects of ultraviolet-A wavelengths in light therapy for seasonal depression

Although light therapy is a recognized effective treatment for seasonal affective disorder (SAD), there has been little research into the critical wavelengths of light that produce the antidepressant effect. Previous studies found conflicting results for the importance of the ultraviolet (UV) spectrum in the therapeutic effect of light therapy. To assess the clinical effects of UV-A wavelengths (315-400 nm), we studied 33 depressed SAD patients diagnosed with structured interviews by DSM-IIIR criteria. Following a baseline week, patients underwent 2 weeks of 2500 lux light therapy for 2 h daily (06:00-08:00). Light therapy consisted of cool-white fluorescent light with the addition of a special UV-A fluorescent tube. Patients were randomized to wear glasses during light therapy that either blocked (UV-blocked condition) or passed (UV-A condition) wavelengths below 400 nm. Both treatments significantly reduced all depression ratings, but no differences were found between the UV-A and UV-blocked conditions. We conclude that the UV-A spectrum does not increase the antidepressant response of light therapy. Given the potential side effects of chronic UV exposure, clinical application of light therapy should use light sources that have the UV spectrum filtered.

Low electrooculographic ratios in patients with seasonal affective disorder

OBJECTIVE

Changes in retinal sensitivity to light have been hypothesized as etiological in seasonal affective disorder. This study was undertaken to investigate sensitivity to light in seasonal affective disorder using electrooculography (EOG), an objective measure of retinal light response.

METHOD

In a mood disorders clinic, 19 depressed, drug-free patients with seasonal affective disorder, diagnosed by DSM-III-R criteria, were compared with 19 age- and sex-matched normal comparison subjects. All subjects had identical EOG testing performed during the winter. EOG (Arden) ratios were calculated from the EOG data. RESULTS According to multivariate analysis of variance, the EOG ratios in the patients with seasonal affective disorder were significantly lower than those of the normal comparison subjects, although there was considerable overlap in EOG ratios between patients and comparison subjects.

CONCLUSIONS

These results suggest that seasonal affective disorder is associated with subtle retinal abnormalities at the level of the photoreceptor/retinal pigment epithelium complex, consistent with subsensitivity to light. A limitation of this study is that the retinal origins of the EOG response are nonspecific and still not completely elucidated.

Ultraviolet versus non-ultraviolet light therapy for seasonal affective disorder

Although light therapy has been shown to be effective in the treatment of seasonal affective disorder (SAD), little research has been done to determine which light wavelengths affect treatment outcome. In this triple crossover study the authors compared 1 week of light therapy in which bright (2500 lux), full-spectrum fluorescent light, with and without blockade of the ultraviolet (UV) spectrum, was used with a dim (500 lux) light control in 11 SAD patients. The dim light condition had no significant antidepressant effects as measured by the Hamilton Rating Scale for Depression (HAM-D), the Beck Depression Inventory (BDI), and an atypical depressive symptom (ATYP) score. The UV-light condition significantly reduced HAM-D, BDI, and ATYP scores, whereas the UV-blocked condition significantly reduced only the ATYP score. These results suggest that the UV-spectrum in light therapy may have a differential effect on typical and atypical symptoms in SAD.

Dichotic perception and memory following electroconvulsive treatment for depression

Verbal and visuospatial memory and dichotic listening performance were examined in 15 acutely depressed patients with no history of ECT, 17 depressed patients currently in remission, 15 remitted depressed patients who had received ECT six months or more in the past, and 20 normal controls. The neuropsychological functioning of an additional group of 10 acutely depressed patients was also studied before and two weeks after ECT. The results revealed some evidence of logical and autobiographical memory impairment two weeks following ECT, but no evidence that ECT impaired dichotic listening ability. Rather, a normalisation of hemispheric laterality was apparent on the dichotic listening task following ECT and the concomitant relief from depression. There was also no evidence of cognitive dysfunction on any task in individuals who were tested six months or more following their last ECT treatment.

Monoamine oxidase inhibitors: clinical review

Monoamine oxidase inhibitors (MAOIs) are effective antidepressant agents. They are increasingly and effectively used in a number of other psychiatric and non-psychiatric medical syndromes. Their potential for serious toxicity (i.e., hypertensive reaction) is far less than original reports suggest, and newer reversible substrate-specific MAOIs may offer even less toxicity. The author reviews the pharmacology, mechanism of action, clinical indications, and dosing strategies of MAOIs. The common MAOI side-effects (hypotension, weight gain, sexual dysfunction, insomnia, daytime sedation, myoclonus, and hypertensive episodes) are described and management techniques suggested. Recent clinical developments involving MAOIs are outlined.

Seasonal affective disorder

Seasonal affective disorder (SAD) is a recently described mood disorder characterized by recurrent winter depressive episodes and summer remissions. The symptoms of SAD include DSM III-R criteria for recurrent major depression, but atypical depressive symptoms predominate with hypersomnia, hyperphagia and carbohydrate craving, and anergia. Seasonal affective disorder is effectively treated by exposure to bright light (phototherapy or light therapy), a novel antidepressant treatment. The authors review the syndrome of SAD, hypotheses about its pathophysiology, and the use of phototherapy to treat the disorder.

Unnecessary delay in tricyclic antidepressant treatment of a patient with atrial fibrillation

Atrial fibrillation and other cardiac conduction disturbances are not contraindications for the use of tricyclic antidepressants. A case in which physician unfamiliarity with these facts led to an unnecessary delay in the antidepressant treatment of a patient with depression and long-standing atrial fibrillation is presented.

Effect of morphine on cortisol and prolactin secretion in anorexia nervosa and depression

Endogenous opioid peptides are involved in feeding regulation, and alterations in opioidergic regulation have been implicated in the pathophysiology of eating disorders. To investigate further this hypothesis, we conducted a placebo-controlled study of the effect of the opiate alkaloid morphine on cortisol and prolactin secretion in six patients with anorexia nervosa and six age-matched healthy volunteers, and compared the results with those obtained in nine depressed patients. Basal cortisol but not basal prolactin levels were elevated in patients with anorexia nervosa and patients with depression. Following the administration of morphine plasma concentrations of cortisol levels declined progressively and at a similar rate in all three groups. The prolactin response to morphine was attenuated significantly in patients with depression. Neither the cortisol and prolactin response to morphine in the anorectic patients nor the cortisol response in the depressed patients we observed in this study suggests altered opiate receptor sensitivity. However, the decreased prolactin response to morphine in depressed patients remains compatible with this hypothesis.

Reduction of post-ECT memory complaints through brief, partial restricted environmental stimulation (REST)

1. A previous paper (Suedfeld, et al. 1987) reported on preliminary results of placing patients into a room with substantially reduced environmental stimulation (REST) immediately after recovery from ECT. 2. Comparing two depressed patients who had undergone this experience with three who had instead returned to their own hospital room (Ward), Suedfeld et al. (1987) found that the former registered much fewer complaints concerning memory loss related to ECT administration than the latter. 3. The current report extends this finding to a total of 19 patients, of whom 13 completed four testing sessions. Once again, objective tests of memory showed no significant change as a function of ECT. Both groups of patients complained of substantial memory disruption after the first ECT. By the one-week follow-up, such complaints were minimal among REST patients but showed only a slight decline among the Ward group. This was the only significant intergroup difference.

Evening urine cortisol excretion and DST results in depression and anorexia nervosa

Cortisol determination in a single one-hour urine sample collected between 2200 h and 2300 h has been shown to identify accurately patients with Cushing's disease. To examine the usefulness of this procedure for identifying psychiatric patients with a pituitary-adrenal disturbance, we studied 17 drug-free depressed patients, 6 euthymic anorectic patients and 10 healthy volunteers. We found that there was good agreement between DST results and evening urine cortisol excretion in this sample (when cortisol levels were expressed as ng of cortisol per mg of creatinine), and that adopting as a criterion a urine cortisol value two standard deviations above the mean cortisol value of the controls predicts 74% of the dexamethasone suppression test (DST) results. We would like to suggest that this measure deserves further study as a potentially useful and simple alternative to the DST for identifying psychiatric patients with a pituitary-adrenal disturbance.

Common side effects associated with monoamine oxidase inhibitors

There is relatively little documentation on the common side effects associated with monoamine oxidase inhibitors (MAOI) and their frequency of occurrence. A retrospective chart review of patient records in a Mood Disorders Service was completed. Side effects of patients receiving phenelzine (N = 42) and tranylcypromine (N = 19) were rated as mild (resulting in no change in treatment), moderate (some modification in treatment plan necessary), and severe (definite change in treatment plan or drug discontinuation due to MAOI side effect). A total of 35 reports of side effects were noted in 15 of 19 tranylcypromine patients (1.84 per patients) and a total of 125 side effect reports were noted in 39 of 42 phenelzine patients (2.98 per patient). Only two severe tranylcypromine side effects occurred (resulting in drug cessation for one of these patients - hypotension), while 9 severe reactions occurred with phenelzine, resulting in drug discontinuation in 6 of these patients. The side effects for tranylcypromine and the number of reports were insomnia (N = 10), sedation (N = 8), hypotension (N = 5), sexual dysfunction (N = 3), hypomania (N = 3), weight gain/edema (N = 2), hypertensive episode (N = 2), and myoclonic jerking (N = 2). The number of reports of phenelzine side effects were insomnia (N = 26), hypomania/mania (N = 27; most common reason for drug cessation - 4), hypotension (N = 16; three cases considered severe), weight gain/edema (N = 15), sedation (N = 15), sexual dysfunction (N = 13), hypertensive episode (N = 6), and myoclonic jerking (N = 7).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment resistant depression: a clinical perspective

One hundred and fourteen patients with a diagnosis of "treatment resistant depression" (TRD) were assessed and treated at a Mood Disorders Clinic. Diagnostically, 52 (45.6%) subjects met criteria for bipolar disorder, 49 (42.9%) for recurrent depression, and 13 (11.4%) patients did not fulfill diagnostic criteria for affective disorder which explained their treatment resistance. With appropriate, individualized treatment, 59 of 98 (60.2%) patients had complete symptom remission based on clinical and psychometric ratings (initial Ham-D 26.7, final Ham-D 5.9). Eighteen of 98 patients had partial remission (final Ham-D 15.9) with vigorous pharmacological interventions, and 8 subjects exhibited "absolute" TRD (final Ham-D 23.4). The results suggest the value of specialized mood disorder services. The partial and absolute TRD's were more likely to be older, received more Axis II diagnoses, and had previous histories of drug or alcohol abuse.

Weight gain with antidepressants and lithium

Undesired weight gain is a common complaint of patients receiving pharmacological treatment for major affective disorders. It has been found to jeopardize patient compliance and may pose additional health hazards. A review of the literature on weight gain associated with tricyclic antidepressants, monoamine oxidase inhibitors, and lithium was carried out with the aim of deriving practical management strategies. Tricyclic antidepressants were found to stimulate appetite, carbohydrate craving, and a dose-dependent continuous weight gain of 0.57 to 1.37 kg per month of treatment. Proposed mechanisms include noradrenergic or antihistaminic inhibition of satiety and decreased metabolic rate. Novel serotonergic and dopaminergic antidepressants were found to be anorectic. Monoamine oxidase inhibitors may stimulate appetite and potentiate insulin-induced hypoglycemia. Lithium maintenance therapy stimulates weight gains of over 10 kg in 20% of patients. Documented mechanisms include insulin-like actions on carbohydrate and fat metabolism, polydipsia, and sodium retention. Recommendations regarding choice of antidepressant drug as well as dietary and behavioral strategies to prevent excessive weight gain are presented. Potential adjunctive drug approaches to severe weight gain are reviewed.

A comparison of the efficacy and safety of alprazolam and desipramine in depressed outpatients

Fifty-two adult depressed outpatients fulfilling Research Diagnostic Criteria for Definite Major Depressive Disorder were enrolled in a double-blind study comparing the antidepressant effects of alprazolam versus desipramine. Twenty-nine patients completed the seven week (one week placebo followed by six weeks of active drug) study. The mean daily dose of alprazolam and desipramine at study termination was 3.34 mg and 192 mg respectively. Based on psychometric ratings of depression (Hamilton Scale) and severity of illness (Clinical Global Impressions) there was no significant difference between alprazolam and desipramine at the end of six weeks of active drug treatment. Both medications were well tolerated with drowsiness being the most common side effect of alprazolam, and insomnia, dry mouth, and constipation, the complaints most associated with desipramine.

Neuroleptic malignant syndrome

The neuroleptic malignant syndrome (NMS) is a potentially fatal syndrome characterized by diffuse muscular rigidity, pyrexia, sweating, cardiovascular instability, and elevated serum creatinine phosphokinase. NMS occurs in 2% of all patients exposed to neuroleptics (antipsychotic drugs). A case of successfully treated NMS is presented, and the typical symptomatic presentation, etiology, pathogenesis, and treatment options of this syndrome are described.

The lateralization of atypical facial pain

Various theories have been proposed to explain the reported predominance of left-sided symptoms in patients with conversion disorders, psychogenic symptoms, and chronic pain. In a population of 110 patients with atypical facial pain (AFP), there were no significant differences in the side of pain or lateralization of pain between psychiatric and non-psychiatric patients. A non-significant trend to left-sided pain in psychiatric patients was found if only those patients with lateralized pain were examined. The significance of these results to etiological theories of chronic pain lateralization is discussed.

Anticholinergic side effects of tricyclic antidepressants and their management

Side effects associated with tricyclic antidepressant (TCA) therapy often leads to premature drug discontinuation. The most common side effects associated with TCA's are those related to the anticholinergic activity of these medicines. The peripheral anticholinergic complaints of dry mouth, constipation, ocular side effects and urinary hesitancy are described and specific clinical guidelines for their effective management are provided.