The interplay of stress, gender and cognitive style in depressive onset

Major depression is more common in women than men, but the reasons for this difference have not been completely understood. We examine recent evidence investigating whether sex differences in exposure or response to stressful life events play an explanatory role in the sex differences found in onset of depression. We also explore the possibility that sexual dimorphism in depressive prevalence and response to events is related to sex differences in cognitive style. We conclude that differences between women and men in response to stressful life events and cognitive style are relevant to understanding sex differences in the onset of depression.

Gambling: an addictive behavior with health and primary care implications

Over the past several decades, and particularly during the last 10 to 15 years, there has been a rapid increase in the accessibility of legalized gambling in the United States and other parts of the world. Few studies have systematically explored the relationships between patterns of gambling and health status. Existing data support the notion that some gambling behaviors, particularly problem and pathological gambling, are associated with nongambling health problems. The purpose of this article is to provide a perspective on the relationship between gambling behaviors and substance use disorders, review the data regarding health associations and screening and treatment options for problem and pathological gambling, and suggest a role for generalist physicians in assessing problem and pathological gambling. A rationale for conceptualization of pathological gambling as an addictive disorder and a model proposing stress as a possible mediating factor in the relationship between gambling and health status are presented. More research is needed to investigate directly the biological and health correlates associated with specific types of gambling behaviors and to define the role for generalist physicians in the prevention and treatment of problem and pathological gambling.

Dysarthria During ECT Given for Parkinson's Disease and Depression

A patient with recurrent major depression, parkinsonism, and pseudobulbar symptoms underwent a course of electroconvulsive therapy. Although his depression and parkinsonian symptoms markedly improved, his dysarthria worsened, resulting in cessation of further treatments. Possible mechanisms are explored.

Examining structured representation and designated fiscal support for women's health in the U.S. Department of Health and Human Resources

The United States Department of Health and Human Services (DHHS) is committed to monitoring, protecting, and improving the health of the nation. We examine the structure established within DHHS to address the health of women; review initiatives generated by women's health offices, advisors, and coordinators within DHHS agencies; and contrast the budgets provided to women's health offices with those of the parent DHHS agencies. Data were obtained from DHHS and other public government documents, DHHS websites, contact with agency personnel, and literature review. Significant clinical, research, and educational efforts important to the health of women have resulted from representation for women's health within the DHHS. Yet, structured representation and designated fiscal support necessary to maintain and expand these efforts are variable and not guaranteed across agencies. Only one Office of Women's Health and one Senior Advisor position are supported by statute, one director's position for an Office of Women's Health has been downgraded in government rank, and two other women's health positions had their reporting structure changed, making them less centrally located in their respective agencies. During the last 4 years of unprecedented growth within DHHS, only one Office of Women's Health received consistent increases in budgeted dollars. There is a clear need to support and stabilize representation for women's health within DHHS in order to maintain current productive efforts, coordinate existing and developing initiatives, and integrate new topics of importance to women's health into each agency. This can be accomplished by establishing structured offices by statute and ensuring future funding commensurate with the mission of each office.

Sex differences in event-related risk for major depression

BACKGROUND

This study sought to determine if women are more likely than men to experience an episode of major depression in response to stressful life events.

METHOD

Sex differences in event-related risk for depression were examined by means of secondary analyses employing data from the Americans' Changing Lives study. The occurrence and time of occurrence of depression onset and instances of stressful life events within a 12-month period preceding a structured interview were documented in a community-based sample of 1024 men and 1800 women. Survival analytical techniques were used to examine sex differences in risk for depression associated with generic and specific stressful life events.

RESULTS

Women were approximately three times more likely than men to experience major depression in response to any stressful life event. Women and men did not differ in risk for depression associated with the death of a spouse or child, events affecting their relationship to a spouse/partner (divorce and marital/love problems) or events corresponding to acute financial or legal difficulties. Women were at elevated risk for depression associated with more distant interpersonal losses (death of a close friend or relative) and other types of events (change of residence, physical attack, or life-threatening illness/injury).

CONCLUSION

Stressful life events overall, with some exceptions among specific event types, pose a greater risk for depression among women compared to men.

Management of the adverse effects of clozapine

Clozapine has been found to be superior to traditional neuroleptics in the treatment of refractory schizophrenia and is increasingly being used to treat schizophrenia, affective disorders, some neurological disorders, and aggression. For many patients, clozapine offers new hope for the successful pharmacological management of a disabling mental disorder. However, up to 17 percent of patients must discontinue treatment with clozapine because of adverse effects, which also limit the rate at which the dose can be increased and the maximum dose that can be tolerated. This article reviews strategies for minimizing and managing the adverse effects of clozapine, including agranulocytosis, seizures, sedation, delirium, obsessive-compulsive symptoms, hypotension, tachycardia, weight gain, sialorrhea, elevated liver enzymes, constipation, nausea, enuresis, fever, and neuromuscular effects. Incidence and morbidity are presented first. Then, the known or hypothesized pathophysiology of the adverse effects are described. Finally, nonpharmacological and pharmacological interventions are reviewed. Under-standing the incidence, pathophysiology, and treatments of adverse effects is essential for a positive therapeutic outcome when prescribing clozapine.

Acute neuroleptic treatment in elderly patients without dementia

Low doses of neuroleptics are the standard for treating psychosis in elderly patients because of concern about inducing adverse effects. The authors found that fixed, low-dose neuroleptic treatment (0.15 mg/kg/day) for 10 days resulted in low perphenazine levels and low rates of acute response (25%) in elderly patients with primary psychotic illness (without dementia). Increase in initial dose did not speed acute response and induced adverse effects that were absent or minimal with low-dose treatment. With higher-dose treatment, drug blood levels rose disproportionately, and level-to-dose ratios were higher than those observed in non-elderly adults. Naturalistic follow-up suggested that response may take longer to develop than in non-elderly adults and that low doses for a longer duration may provide effective treatment.

Psychotogenic drug use and neuroleptic response

When fixed doses of haloperidol or perphenazine were used in two separate studies, we found that psychotic males with a prior history of psychotogenic drug use had a poorer early neuroleptic response even in the early stages of their psychotic disorder than psychotic males who had not previously used significant amounts of psychotogenic drugs. Relative neuroleptic refractoriness may be characteristic of some dual diagnosis patients at the beginning of their illness. Antecedent psychotogenic drug use may contribute to the development of psychosis and to relative neuroleptic refractoriness by means of effects upon dopaminergic mechanisms.

Cortical instability and the mechanism of mania: a neural network simulation and perceptual test

BACKGROUND

A previous neural network simulation suggested that manic states arise from excessive levels of noise that destabilize neural representations. The Necker cube stick figure provides a simple perceptual task that assesses stability of gestalt-type representations.

METHODS

A neural network was developed that included a simulation of the Necker cube task. Noise was added to induce maniclike jumps from one representation to another. A parallel study of Necker cube perception was conducted with 16 patients diagnosed with manic-spectrum disorder, 18 patients with schizophrenia, and 19 normal control subjects. Cognitive speed and rate of indiscriminate responses were assessed using an auditory continuous performance task.

RESULTS

During processing of the "Necker cube" stimulus, the reversal rate of the noise-destabilized "manic" network was increased by 30%. In the human subject study, the median score of Necker cube reversal rates for manic-spectrum patients was roughly twice that of normal control subjects and patients with schizophrenia. Accelerated reversal rates in the manic-spectrum group were not attributable to excessive cognitive speed or higher rates of indiscriminate responses.

CONCLUSIONS

The two studies, considered together, support the hypothesis that excessive cortical noise destabilizes neural representations in manic-spectrum patients.

Development and preliminary psychometric properties of an instrument for the measurement of childhood trauma: the Early Trauma Inventory

Research on the effects of childhood trauma has been limited by the lack of a comprehensive, reliable, and valid instrument that assesses the occurrence of early traumatic experiences. This paper presents the development and preliminary psychometric properties of an instrument, the Early Trauma Inventory (ETI), for the assessment of reported childhood trauma. The clinician-administered ETI is a 56-item interview for the assessment of physical, emotional, and sexual abuse, as well as general traumatic experience (including items which range from parental loss to natural disaster). For each item of the ETI, frequency of abuse/trauma by developmental stage, onset and termination of abuse/trauma, perpetrator of the abuse/trauma, and impact on the individual are assessed. Initial analyses indicate acceptable inter-rater reliability, test-retest reliability, and internal consistency for the ETI. Comparisons between the ETI and other instruments for the assessment of trauma, as well as instruments for the measurement of symptoms related to abuse, such as dissociation and PTSD, demonstrated good convergent validity. Validity was also demonstrated based on the ability of the ETI to discriminate patients with PTSD from comparison subjects. Based on these findings, the ETI appears to be a reliable and valid instrument for the measurement of reported childhood trauma.

Antidepressant-associated mania and psychosis resulting in psychiatric admissions

BACKGROUND

The safety and tolerability of the selective serotonin reuptake inhibitors and the newer atypical agents have led to a significant increase in antidepressant use. These changes raise concern as to the likelihood of a corresponding increase in adverse behavioral reactions attributable to these drugs.

METHOD

All admissions to a university-based general hospital psychiatric unit during a 14-month period were reviewed.

RESULTS

Forty-three (8.1%) of 533 patients were found to have been admitted owing to antidepressant-associated mania or psychosis.

CONCLUSION

Despite the positive changes in the side effect profile of antidepressant drugs, the rate of admissions due to antidepressant-associated adverse behavioral effects remains significant.

Gender differences in referral to cardiac rehabilitation programs after revascularization

BACKGROUND

This study examines the influence of gender on the healthcare provider's secondary prevention instruction and cardiac rehabilitation (CR) referral after coronary revascularization procedures such as balloon angioplasty/coronary stenting and coronary bypass surgery (CABG). Cardiac rehabilitation decreases mortality and morbidity, yet only a small percentage of women and men are referred to these programs. The patient population of our university-affiliated CR program consisted of 88% men and 12% women.

METHODS

In a matched case observational study, 80 patients (40 men, 40 women) who had undergone coronary revascularization procedures between 1997 and 1998 completed a questionnaire on secondary prevention instruction and written referral to CR programs. Patients were matched for age and coronary revascularization procedure.

RESULTS

Women were less likely to be instructed on secondary prevention strategies and CR or referred to CR as compared to men despite being matched for age and undergoing the same procedure. The data demonstrate a gender difference in hospital teaching and referral information for CR after revascularization (P < 0.001). Being a woman was associated with a decreased likelihood of receiving a physician referral to CR after revascularization (P < 0.001).

CONCLUSION

The instruction of patients concerning secondary prevention and CR postrevascularization procedures is poor. Within that group, women were far less likely to have CR discussed or referrals made by healthcare professionals. This study demonstrates the need for education initiatives of all healthcare providers on the comprehensive nature and benefits of CR in the secondary prevention of cardiovascular disease, with a particular emphasis on women.

Multidisciplinary Women's health research: the national centers of excellence in women's health

Contemporary research increasingly needs to consider the value of a multidisciplinary approach in answering critical health questions. The current article outlines the need for multidisciplinary investigations specifically in reference to women's health, and addresses issues related to generating and sustaining interest in such an approach. In addition, the importance of resources and environment for facilitating multidisciplinary research and advocacy efforts for obtaining funding for this approach are discussed. Methodological issues pertinent to the operationalization of multidisciplinary research in women's health are also addressed, and lessons learned from the National Centers of Excellence in initiating multidisciplinary research in women's health are reviewed.

Adverse life events and cognitive-personality characteristics in the prediction of major depression and antidepressant response

OBJECTIVE

Stressful life events are known to precipitate major depression. However, it remains unclear why some individuals who experience adverse events develop depression whereas others do not, and how the occurrence of life events affects treatment outcome. Emerging models posit that the effect of adverse life events varies by cognitive-personality style. This study examines the direct and interactive effects of stressful life events and cognitive-personality style in predicting 1) episode onset in patients with DSM-IV unipolar depression versus community comparison subjects and 2) depressive symptom severity at the completion of a 6-week standard antidepressant regimen.

METHOD

Multivariate models were used to test the effects of adverse life events, cognitive-personality style, and the congruence of event type (interpersonal versus achievement) with cognitive-personality style on depressive onset and treatment outcome in 43 patients with major depression and 43 healthy comparison subjects. Cognitive-personality characteristics were assessed by using Beck's measures of sociotropy (interpersonal dependency) and autonomy (need for independence and control).

RESULTS

Adverse life events, sociotropy, and an autonomy factor need for control were each significantly related to depressive onset and predicted group status for 88% of the subjects. Event types affected outcome differently, and specific life event types interacted with cognitive-personality styles in predicting response to treatment. A multivariate model accounted for 65% of the variance in predicting outcome.

CONCLUSIONS

Adverse life events are a potent factor in predicting depression. However, cognitive-personality characteristics also confer susceptibility to depression. Better outcome is associated with occurrence of adverse interpersonal events (e.g., death of a loved one) rather than adverse achievement events (e.g., loss of job) and occurs when the event type is congruent with cognitive-personality style.

Self-efficacy as a mediator between stressful life events and depressive symptoms. Differences based on history of prior depression

BACKGROUND

Self-efficacy, a characteristic that is protective against depressive symptoms, may be undermined by stressful life events.

AIMS

To estimate the effects of stressful life events on self-efficacy, and to examine self-efficacy as a mediator of the effect of stressful life events on symptoms of depression.

METHOD

Using a sample of 2858 respondents from the longitudinal Americans' Changing Lives study, path analyses were used to evaluate interrelationships between self-efficacy, life events and symptoms of depression controlling for a variety of potentially confounding variables. Separate models were estimated for those with and without prior depression.

RESULTS

For those with prior depression, dependent life events had a significant, negative impact on self-efficacy. For those without prior depression, life events had no effect on self-efficacy.

CONCLUSIONS

For those with prior depression, self-efficacy mediates approximately 40% of the effect of dependent stressful life events on symptoms of depression.

Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior

Relatives frequently accommodate patients' obsessive-compulsive symptoms and clinicians hypothesize that such accommodations adversely affect patient outcome. This study's purpose was to develop a valid and reliable measure, the Family Accommodation Scale for Obsessive-Compulsive Disorder (FAS), and to investigate the family accommodation construct. We administered the FAS and additional family and patient measures to 36 adult obsessive-compulsive patients and their primary caregivers. The FAS demonstrated excellent interrater reliability and good internal consistency and performed well on assessment of its convergent and discriminant validity. Family accommodation was significantly associated with patient symptom severity and functioning, and with relatives' own obsessive-compulsive symptoms. Although most relatives accommodated patient symptoms, many did not believe that such accommodations improved the patient's clinical status. The FAS will provide researchers and clinicians with a useful tool for assessing family accommodation and for identifying families who may benefit from interventions aimed at developing more adaptive coping strategies.

Childhood sexual abuse as a risk factor for depression in women: psychosocial and neurobiological correlates

OBJECTIVE

Depression is twice as common in women as in men, but the reason for this sexual dimorphism is unknown. This article reviews recent studies of the role of childhood sexual abuse in the subsequent development of major depressive disorder, and the biological and psychosocial mechanisms by which early stressors may contribute to adult-onset depression in women. Particular attention is paid to investigations of the long-term effects of early stress on hypothalamic-pituitary-adrenal (HPA) axis function.

METHOD

Studies were identified by means of computerized and manual searches; further references were obtained from the bibliographies of reviewed articles.

RESULTS

Childhood sexual abuse is associated with adult-onset depression in both men and women, and occurrence of such abuse is more common in girls than in boys. There is evidence from both animal and human studies that early stressors produce long-term dysregulation of the HPA axis similar to that seen in depressed patients and that such dysregulation results in a differential response to stressors in adulthood. In addition, it appears that the HPA axis in females may be more susceptible to stress-induced dysregulation, which might contribute to an increased vulnerability to depression in adulthood.

CONCLUSIONS

Childhood sexual abuse is an important early stressor that may predispose individuals to adult-onset depression by means of dysregulation of the HPA axis. Investigation of the mechanisms mediating the relationship between childhood sexual abuse and adult-onset depression, and the study of gender differences in exposure to this and other stressors, may improve our understanding of the etiology of depressive illness in general.

Selective speech perception alterations in schizophrenic patients reporting hallucinated "voices"

OBJECTIVE

The authors tested a model of hallucinated "voices" based on a neural network computer simulation of disordered speech perception.

METHOD

Twenty-four patients with schizophrenia spectrum disorders who reported hallucinated voices were compared with 21 patients with schizophrenia spectrum disorders who did not report voices and 26 normal subjects. Narrative speech perception was assessed through use of a masked speech tracking task with three levels of superimposed phonetic noise. A sentence repetition task was used to assess grammar-dependent verbal working memory, and an auditory continuous performance task was used to assess nonlanguage attention.

RESULTS

Masked speech tracking task and sentence repetition performance by hallucinating patients was impaired relative to both nonhallucinating patients and normal subjects. Although both hallucinating and nonhallucinating patients demonstrated auditory attention impairments when compared to normal subjects, the two patient groups did not differ with respect to these variables.

CONCLUSIONS

Results support the hypothesis that hallucinated voices in schizophrenia arise from disrupted speech perception and verbal working memory systems rather than from nonlanguage cognitive or attentional deficits.

Gender differences in the effects of bereavement-related psychological distress in health outcomes

BACKGROUND

This study examined whether traumatic grief, depressive and anxiety symptoms formed three distinct factors for widows and widowers. In addition, we examined whether high symptom levels of traumatic grief, depression and anxiety predicted different mental and physical health outcomes for widows and widowers.

METHOD

Ninety-two future widows and 58 future widowers were interviewed at the time of their spouse's hospital admission and then at 6 weeks, 6, 13 and 25 month follow-ups. Principal axis factor analyses tested the distinctiveness of traumatic grief, depressive and anxiety symptoms, by gender. Repeated measures ANOVA tested for gender differences and changes over time in mean symptom levels of traumatic grief, depression and anxiety. Linear and logistic regression models estimated the effects of high symptom levels of traumatic grief, depression and anxiety at 6 months on health outcomes at 13 and 25 months post-intake by gender.

RESULTS

Three distinct symptom clusters (i.e. traumatic grief, depressive and anxiety symptoms) were found to emerge for both widows and widowers. Widows had higher mean levels of traumatic grief, depressive and anxiety symptoms. High symptom levels of traumatic grief measured at 6 months predicted a physical health event (e.g. cancer, heart attack) at 25 months post-intake for widows. High symptom levels of anxiety measured at 6 months predicted suicidal ideation at 25 months for widowers.

CONCLUSIONS

The results suggest that there are gender differences in the levels of psychological symptoms resulting from bereavement and in their effects on subsequent mental and physical health for widows and widowers.

Do attitudes toward disclosure in donor oocyte recipients predict the use of anonymous versus directed donation?

OBJECTIVE

To compare the demographic and psychological characteristics of oocyte recipients and to determine whether the issue of disclosure about the use of a donor is a correlate of the decision to use an anonymous or directed donor.

DESIGN

Cross-sectional study.

SETTING

University teaching hospital.

PATIENT(S)

Ninety consecutive recipients of donated oocytes (64 of whom used anonymous donors and 26 of whom used directed donors).

INTERVENTION(S)

Pretreatment psychosocial evaluation.

MAIN OUTCOME MEASURE(S)

Recipient opinions and attitudes regarding the choice of donor type and disclosure to others as determined through a semistructured interview.

RESULT(S)

There were no statistically significant differences with regard to demographic characteristics between recipients who used anonymous and directed donors. There were statistically significant differences between the groups with regard to the issue of disclosure. Recipients who used directed donors were more likely to have told others about using an oocyte donor and were more likely to indicate that they intended to inform the child about the nature of his or her conception.

CONCLUSION(S)

Oocyte recipients who use known donors differ significantly from those who use anonymous donors with regard to the issue of disclosure to others. Further studies are needed to determine the causal direction of this relation.

Pretreatment plasma HVA predicts neuroleptic response in manic psychosis

Elevated pretreatment plasma free homovanillic acid (HVA) predicted acute response to neuroleptic treatment in patients with manic psychosis. These findings suggest that plasma HVA may be a useful predictor of a successful short-term response in manic as well as schizophrenic psychoses, and that elevated pre-synaptic dopaminergic release may play a role in more than one group of psychotic disorders.

Measurement of dissociative states with the Clinician-Administered Dissociative States Scale (CADSS)

The purpose of this study was to develop an instrument for the measurement of present-state dissociative symptoms, the Clinician Administered Dissociative States Scale (CADSS). Reported here are interrater reliability and internal consistency of the CADSS, validity as assessed by comparisons with other instruments for the assessment of dissociation, and sensitivity of the CADSS to discriminate patients with dissociative disorders from patients with other psychiatric disorders and healthy subjects. Initial analyses indicated good interrater reliability and construct validity for the CADSS. Scores on the CADSS discriminated patients with dissociative disorders from the other groups.

The expanding indications for clozapine

Clozapine is increasingly being used for clinical indications in addition to treatment-resistant schizophrenia; this article reviews the relevant literature. The first section reassesses the risks associated with clozapine treatment, particularly agranulocytosis. The next section discusses its use for schizophrenia in patients who are treatment resistant, not treatment resistant, and intolerant of traditional drug treatments. Subsequent sections address its use in mood disorders, neurologic conditions, comorbid substance abuse, aggressive behavior, and childhood schizophrenia. Each includes the initial rationale for the use of clozapine in the disorder, a critical evaluation of the relevant literature, and theories as to why clozapine's unique pharmacodynamic profile may be efficacious for the specific condition. This body of literature suggests clozapine may be an effective treatment for a wide range of disorders.

Chronic neuroleptic exposure in bipolar outpatients

BACKGROUND

Although the chronic use of neuroleptic medications is generally discouraged in patients with bipolar disorder, data on the actual extent of this practice are relatively scarce.

METHOD

All bipolar patients receiving treatment at the Connecticut Mental Health Center on September 1, 1994, were identified through a computerized administrative database; the medical record was then examined. Patients were included in the study if (1) the last two recorded diagnoses in the chart were concordant for bipolar disorder and (2) the patient had not been hospitalized in the past year.

RESULTS

Of 49 patients meeting review criteria, 33 (67%) met criteria for chronic neuroleptic exposure. The mean +/- SD continuous neuroleptic dosage for these 33 outpatients was 416 +/- 527 mg/day chlorpromazine (CPZ) equivalents. The dosage distribution was skewed, with 17 (52%) receiving < or = 200 mg/day CPZ [corrected] equivalents.

CONCLUSION

Chronic neuroleptic administration occurred frequently in our sample of nonhospitalized bipolar outpatients.

Recent life stressors and biological markers in newly admitted psychotic patients

The association of recent life stressor severity to putative biological markers of stress was examined in 34 newly admitted patients with acute psychosis. Of the biological variables examined, only pretreatment admission serum cortisol was correlated with stressor severity. Pretreatment serum prolactin, plasma homovanillic acid (HVA), and methoxyhydroxyphen-ethylglycol were not associated with severity of recent life stressors. We controlled for clinical and psychosocial variables that might affect the relationship of stressor severity to biological markers, and found that duration of psychotic symptoms was negatively correlated with stressor severity; however, when both cortisol and duration were entered in a stepwise multiple regression analysis, only pretreatment admission cortisol remained significantly and positively correlated with stressor severity. These findings suggest that serum cortisol may be a useful biological marker when investigating the relationship of life stress to episode onset. In addition, pretreatment HVA was correlated with early neuroleptic response but not with stressor severity, suggesting that HVA has value as a predictor of response independent of recent life stressors.

Possible acceleration of alcoholic cirrhosis in a patient with bulimia

We report the case of a 27-year-old Caucasian woman with a history of bulimia and alcohol abuse who developed cirrhosis at a rapid rate. We hypothesize that the patient's bulimia, in combination with other possible predisposing factors, potentially accelerated the development of her alcoholic cirrhosis and subsequent medical complications. The association between eating disorders and liver disease is discussed, and the importance of aggressive treatment of eating disorders in combination with alcohol abuse is highlighted.

Desipramine treatment of major depression in patients over 75 years of age

The authors investigated the relationship of desipramine concentrations in plasma to response, side effects, and dose in depressed patients over 75 years of age to determine if these "very old" patients were unusually sensitive to treatment. Thirty-four elderly patients consecutively hospitalized for nonpsychotic, unipolar major depression were treated with a fixed dose desipramine regimen for 4 weeks. Twelve nonresponding patients received a second trial at an increased dose. Comparisons were made with data from younger patients previously published by the authors. At comparable doses, steady-state desipramine concentrations in plasma in the elderly patients did not differ from those observed in younger patients. Response at levels in blood < 115 ng/ml was low, only 6 (21%) of 28 patient trials resulted in response. At levels > or = 115 ng/ml, 6 (46%) of 13 patient trials were effective. These rates were not significantly different. Inspection of the data revealed that a concentration in plasma of 105 ng/ml significantly separated responders and nonresponders (chi 2 = 3.93, df = 1, p < 0.05), but even at levels > or = 105 ng/ml, the response rate was still low relative to rates in prior studies of younger patients treated for a similar duration. The serious adverse reaction rate, 7 of 34, was similar to that previously observed in younger patients. This sample of "very old" elderly was not unusually "sensitive" to antidepressant drug treatment. In fact, the low rate of response observed at usually adequate levels in blood suggested "resistance" to treatment. The findings underscore the need for more effective drug treatments in the depressed elderly.

Assessment of extrapyramidal symptoms during acute neuroleptic treatment

BACKGROUND

Acute administration of traditional neuroleptic drugs is often accompanied by the emergence of extrapyramidal symptoms (EPS). The use of a standardized scale to measure EPS can assist the clinician in assessing the occurrence and severity of these adverse reactions. The current work presents the interrater reliability and validity of the Yale Extrapyramidal Symptom Scale (YESS)--an eight-item, easy-to-administer scale for assessing emergence, severity, and type of side effects that commonly occur during acute treatment.

METHOD

Interrater reliability (Study 1) and validity (Study 2) of the scale were studied using two independent samples of acutely psychotic patients treated with neuroleptic drugs. Study 1: Interrater reliability was assessed by comparing the YESS ratings of two clinicians blind to the other's rating and to the patient's drug regimen and dose. Study 2: Validity was studied by examining whether YESS items correlated with other EPS measures (convergent validity) but not with psychotic symptoms that may be confused with EPS (discriminant validity).

RESULTS

Interrater agreement between clinicians was good to excellent. YESS items correlated with assessments used to measure symptoms of Parkinson's disease and akathisia and generally showed low nonsignificant correlations with ratings of symptoms of psychosis.

CONCLUSION

The current work presents a brief EPS scale for the assessment of commonly occurring neuroleptic-induced extrapyramidal side effects. It was demonstrated that the YESS could be used reliably across clinician raters and that the YESS is a valid measure for assessing EPS during acute treatment.

DSM-III-R Axis IV: clinician reliability and comparability to patients' reports of stressor severity

Stress has long been considered an important precipitant to the development or exacerbation of psychopathology (Selye 1980). However, it has been difficult to reach agreement on how to measure stressors reliably, and whether stressors should be assessed using an objective clinical rating or a subjective appraisal (Mazure and Druss 1995). When the DSM-III multiaxial diagnostic system was derived, Axis IV was designed to provide a mechanism for objectively rating the severity of psychosocial stressors that contributed to the development or exacerbation of psychiatric disorders (Williams 1985). With the continued use of this nosological system, DSM-III-R Axis IV has become the most commonly used assessment of stressors in clinical settings today. The current work focuses on whether DSM-III-R Axis IV can be used reliably by clinicians generating objective ratings, and on whether these objective ratings reflect patients' appraisals of the severity of their psychosocial stressors. Based on this work, options for future use of Axis IV are discussed.

Similarities and differences between anonymous and directed candidates for oocyte donation

PURPOSE

To compare anonymous and directed candidates for oocyte donation within a single program.

METHODS

75 consecutive candidates for oocyte donation (49 anonymous and 26 directed) were studied using a semistructured interview to collect data on demographics, psychosocial history, motivation, and candidate views on disclosure to a potential child.

RESULTS

Donor groups were similar with regard to race, religion and education. Anonymous donors (mean age 27.33 years, SD 4.17) were significantly younger than directed donors (mean age 37.54 years, SD 4.94), (t = -4.83, df = 73, p < 0.001). Marital duration was significantly longer for directed donors (6.92 years, SD 5.64) versus (2.57 years, SD 3.96) for anonymous donors (t = -3.50, df = 38.47, p = .001). Forty-one percent of anonymous and 69% of directed donors had previous pregnancies (X2 = 4.60, p < .05). A greater percentage of anonymous donors (34.7%) felt that the potential child should be informed of his or her origins, compared to 19% of directed donors, but this difference fell short of statistical significance.

CONCLUSIONS

There were more similarities than differences among groups of potential donors with the exception of age, marital status, and previous pregnancies. Differing views about disclosure were suggested in both groups with anonymous donors tending to opt for disclosure.

The Yale-Brown-Cornell Eating Disorder Scale: development, use, reliability and validity

Patients with eating disorders present with a wide range of eating-related preoccupations and or rituals. Yet, eating disorder assessments traditionally have measured a finite number of specific eating-disordered thoughts or actions. The current work presents a new instrument, the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS), that does not limit assessment to a particular set of eating-related concerns or behaviors. Rather, it assesses the severity of illness associated with an individual's unique symptomatology. Reliability and validity of this new, clinician-rated instrument was tested in two independent samples of DSM-III-R eating disorder patients. The YBC-EDS eight-item scale assessing severity of preoccupations and rituals, and a set of six provisional items for assessing motivation for change were both frequently endorsed and found to have excellent interrater reliability. Internal consistency was shown to be good for the set of eight core items and the set of six items related to motivation for change. The eight-item scale demonstrated aspects of convergent validity with other assessments of eating disorder symptomatology. The set of six provisional items for assessing motivation for change was inversely related to measures to diet restriction, drive for thinness, and body dissatisfaction. This paper presents the eight-item Yale-Brown-Cornell Eating Disorder Scale for assessing illness severity in eating-disordered patients with an extensive range of symptomatology. An accompanying set of six provisional items for assessing motivation for change are also presented. Initial findings showed excellent reliability and indications of validity for both the eight-item YBC-EDS and the set of six provisional items.

Elevated plasma monoamine metabolites in eating disorders

Mean fasting plasma homovanillic acid (HVA) levels were elevated in females hospitalized with eating disorders (both anorexia and bulimia nervosa) compared with females hospitalized with adjustment disorder. Fasting plasma 3-methoxy-4-hydroxyphenylglycol (MHPG) was elevated in anorectic patients only. Five patients with eating disorder and psychosis had higher values for HVA and MHPG than the remainder of the patients with eating disorder.

Characteristics of desipramine-refractory depression

BACKGROUND

To determine the predictors of desipramine-refractory depression, the authors examined the outcome in patients with major depression who were admitted to a general hospital and treated with desipramine adjusted to an adequate blood level.

METHOD

Sixty-eight consecutive inpatients with DSM-III nonpsychotic unipolar major depression who had failed to respond to 1 week of hospitalization without drug treatment were studied. Outcome was assessed with the Yale Depression Inventory after a 4-week desipramine trial in which 24-hour plasma concentrations were used to rapidly achieve a therapeutic desipramine level.

RESULTS

Poor response to a therapeutic desipramine trial, which occurred in 15 of 50 patients, was significantly associated with definite personality disorder, prior treatment failure, near delusional status, age < or = 35 years, duration of depressive episode, recurrence of depression, dysthymia, and secondary depression. The first four items remained significantly correlated with poor response when the presence of the other items was accounted for using multiple regression. Drug response was not predicted by the diagnosis of melancholia (DSM-III and DSM-III-R) or initial severity of the depressive episode.

CONCLUSION

The four strongest correlates of outcome were highly predictive of drug response. In patients with two or more predictors, only 25% (4 of 16) responded, while in those with one or no predictors, 91% (31 of 34) responded.