Evaluating the first 1000 patients referred to a specialist depression clinic: a case for tertiary referral facilities

BACKGROUND

We report on the assessment and outcome of the first 1000 patients referred to a tertiary referral depression clinic established to assess the utility of diagnostic sub-typing on clinical course of illness.

METHODS

Diagnostic, treatment recommendations, prognostic judgments and 12-week outcome data were examined.

RESULTS

Nearly 40% of those with a primary mood disorder were diagnosed with bipolar disorder, of whom three-quarters received such a diagnosis for the first time. Alternative diagnoses or formulations were provided for 68% of the total sample, with the therapeutic paradigm altered for the majority (86%) of patients. Improvement rates were indicative of a higher level of improvement in those diagnosed with bipolar disorder (some 70%) compared to those with unipolar disorders (some 60%). Overall, however, rates of 'full remission' were low, being 2% and up to 12% for bipolar and unipolar patients respectively and perhaps reflecting the tertiary nature of the assessing clinical facility. Baseline clinician predictions were in the order of 60% accuracy in predicting outcome, irrespective of diagnostic grouping.

LIMITATIONS

Anticipation factors (e.g. attending a specialist tertiary referral service) may have contributed non-specifically to outcome. Use of clinician-derived diagnoses rather than strict DSM-IV criteria limits comparisons to other studies.

CONCLUSIONS

The high rates of a first-time bipolar diagnosis suggest that detection and diagnosis of this condition continues to be problematic. Low remission rates underline the chronic nature of many mood disorders, and the need for ongoing management given the high risk of relapse. Our findings offer support for the importance of identifying bipolar disorder and distinguishing depressive sub-types in order to shape more targeted treatments, a task that might be advanced by the establishment of more tertiary referral services.

Ductility Enhancement and Mechanical Properties of Ibad Ceramic thin films

Thin ceramic films (A12O3 ZrO2, Si3N4, and BN) have been prepared by ion beam assisted deposition (IBAD) and their mechanical properties examined. The films exhibit extreme ductility and adhesion, with the former property possibly attributed to the very fine grained, quasi-amorphous grain structure noted for low temperature IBAD coatings.

Rehabilitation as a conservation tool: a case studyusing the common wombat

Wildlife rehabilitation seeks to return healthy animals back to their natural habitat with good survival prospects,and hence contribute to the persistence of their populations. However, the effectiveness of rehabilitation remains largelyundocumented, and its utility as a conservation tool is unclear. In this paper, we document the rehabilitation successof a large, herbivorous marsupial, the common wombat (Vombatus ursinus), and use the findings as a case study toevaluate the contribution that rehabilitation can make to wildlife conservation. Using a database of 54 orphaned wombatsmonitored for up to eight years, we found that 81.5% of young survived to release and, of those, 77.3% were alivein the wild by the end of the study. Survival during rehabilitation was greater for larger, older animals, but influencedalso by problems during care, reaction to human contact following weaning and, in particular, the responses ofindividuals to treatment. No factors associated with rescue condition, rehabilitation or release affected survival of animalsonce returned to the wild, suggesting that wombats were not disadvantaged by their progression through rehabilitation.We provide brief recommendations to improve rehabilitation success for wombats. We conclude that rehabilitation isan under-recognized but potentially valuable conservation tool, and suggest that it is timely to consider its contributionto wildlife management more generally.

Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment

BACKGROUND AND PURPOSE

FD technology enables reconstructive repair of otherwise difficult-to-treat intracranial aneurysms. These stentlike devices may induce progressive aneurysm thrombosis without additional implants and may initiate complete reverse vessel remodeling. The associated vascular biologic processes are as yet only partially understood.

MATERIALS AND METHODS

From 12 different centers, 13 cases of delayed postprocedural aneurysm rupture were recorded and analyzed. Symptom, aneurysm location and morphology, and the time elapsed from treatment until rupture were analyzed.

RESULTS

There were 10 internal carotid and 3 basilar artery aneurysms. Mean aneurysm diameter was 22 ± 6 mm. Eleven patients were symptomatic before treatment. A single FD was used for all saccular aneurysms, while fusiform lesions were treated by using multiple devices. A supplementary loose coiling of the aneurysm was performed in 1 patient only. Ten patients developed early aneurysm rupture after FD treatment (mean, 16 days; range, 2-48 days); in 3 patients, rupture occurred 3-5 months after treatment. In all cases, most of the aneurysm cavity was thrombosed before rupture. The biologic mechanisms predisposing to rupture under these conditions are reviewed and discussed

CONCLUSIONS

FDs alone may modify hemodynamics in ways that induce extensive aneurysm thrombosis. Under specific conditions, however, instead of reverse remodeling and cicatrization, aggressive thrombus-associated autolysis of the aneurysm wall may result in delayed rupture.

Social communication deficits in disruptive primary-school children

BACKGROUND

Parent and teacher data, from questionnaire surveys, suggest that school-identified disruptive children often have pragmatic language deficits of an autistic type.

AIMS

This replication study aimed to confirm earlier findings, using individual clinical assessment to investigate traits of autism-spectrum disorder in disruptive children.

METHOD

Persistently disruptive children (n = 26) and a comparison group (n = 22) were recruited from primary schools in a deprived inner-city area. Measures included standardised autism diagnostic interviews (with parents) and tests of IQ, social cognition, theory of mind and attention (with children).

RESULTS

The disruptive children possessed poorer pragmatic language skills (P<0.0001) and mentalising abilities (P<0.05) than comparisons. Nine disruptive children (35%) met ICD-10 criteria for atypical autism or Asperger syndrome.

CONCLUSIONS

Many persistently disruptive children have undetected disorders of social communication, which are of potential aetiological significance.

Do the old psychostimulant drugs have a role in managing treatment-resistant depression?

OBJECTIVE

As the authors have observed clinical benefit from the psychostimulants methylphenidate and dexamphetamine for treating resistant melancholic and bipolar depression, those drugs were evaluated in a consecutively recruited sample of 50 such patients.

METHOD

Patients (27 bipolar, 23 unipolar) received either methylphenidate (n = 44) or dexamphetamine (n = 6), with 30 having it prescribed as an augmenting drug and 20 as monotherapy. At the final review, ranging from 6 weeks to 62 months (mean 57 weeks), 52% were still receiving their psychostimulant.

RESULTS

Thirty-four per cent reported the psychostimulant as distinctly improving their depression, 30% reported some level of improvement and 36% reported no improvement and/or side-effects. For improvers, the modal dose of methylphenidate was 20 mg. Significant side-effects were reported by 18% (including one manic response), switching was rare and limited to the bipolar subjects, and most side-effects were minor. Any positive response occurred rapidly and loss of efficacy was rare. Testing of tricyclic levels in some patients suggested that stimulant drugs may raise tricyclic levels in those who are rapid metabolizers.

CONCLUSION

Although this study was not controlled, the high success rate in a diagnostically refined sample implies that the psychostimulants may be efficacious for patients with melancholic and bipolar depression who have failed to respond to orthodox antidepressant drugs.

Atypical depression: retrospective self-reporting of treatment effectiveness

OBJECTIVE

Earlier studies demonstrated that those with atypical depression show a differentially superior response to monoamine oxidase inhibitor (MAOI) antidepressants. This study compares ratings of effectiveness for a range of treatments, amongst depressed subjects with and without atypical features.

METHOD

In an on-line survey, individuals experiencing likely clinical depression rated symptoms experienced when depressed, including 'atypical features' and the effectiveness of previous treatments. Mean treatment effectiveness ratings were compared amongst those with 'atypical depression' (n = 338) and 'non-atypical depression' (n = 377).

RESULTS

There were few significant differences between the 'atypical depression' and 'non-atypical depression' groups in effectiveness ratings for drug treatments, and none for psychological treatments. The 'atypical depression' group had significantly lower mean effectiveness ratings for some selective serotonin reuptake inhibitor antidepressants. Few respondents had trialed MAOIs.

CONCLUSION

While MAOIs are rarely prescribed, a range of non-MAOI drug and psychological treatments are of some perceived benefit for depressed patients with atypical features.

REDUCED LITTER SIZES FOLLOWING 48-H OF PRENATAL EXPOSURE TO 5 nT TO 10 nT,0.5 HZ MAGNETIC FIELDS: IMPLICATIONS FOR SUDDEN INFANT DEATHS

To test the hypothesis that a narrow intensity band of geomagnetic activity contributes to Sudden Infant Death, 32 pregnant rats were exposed for two to three days before expected parturition either to a coil that generated 0.5 Hz sine-wave, 5 to 10 nanoTesla magnetic fields, or to a reference coil (<1 nT) in the same room. The field was off for 30 min every 4 h during the exposure. The orientation of the coils was perpendicular in space and activated alternately in four blocks of experiments. The litters born to the exposed mothers contained significantly fewer pups (M = 14.1,SD= 2.1) than those exposed to the control conditions (M = 16.2, SD = 2.7). There were significantly fewer numbers of males and fewer numbers of females in litters exposed to the fields generated in the east-west and north-south directions, respectively. These results support the hypothesis that a specific temporal configuration of brief periods of geomagnetic activity can produce an increased incidence of nonvital fetuses, neonates, or infants.

Measuring melancholia: the utility of a prototypic symptom approach

BACKGROUND

Melancholia has long resisted classification, with many of its suggested markers lacking specificity. The imprecision of depressive symptoms, in addition to self-report biases, has limited the capacity of existing measures to delineate melancholic depression as a distinct subtype. Our aim was to develop a self-report measure differentiating melancholic and non-melancholic depression, weighting differentiation by prototypic symptoms and determining its comparative classification success with a severity-based strategy.

METHOD

Consecutively recruited depressed out-patients (n=228) rated 32 symptoms by prototypic or 'characteristic' relevance (using the Q-sort strategy) and severity [using the Severity-based Depression Rating System (SDRS) strategy]. Clinician diagnosis of melancholic/non-melancholic depression was the criterion measure, but two other formal measures of melancholia (Newcastle and DSM-IV criteria) were also tested.

RESULTS

The prevalence of 'melancholia' ranged from 20.9% to 54.2% across the subtyping measures. The Q-sort measure had the highest overall correct classification rate in differentiating melancholic and non-melancholic depression (81.6%), with such decisions supported by validation analyses.

CONCLUSIONS

In differentiating a melancholic subtype or syndrome, prototypic symptoms should be considered as a potential alternative to severity-based ratings.

Pain during depression and relationship to rejection sensitivity

OBJECTIVE

Approximately 50% of patients with depression report symptoms of pain, yet the clinical and biological mechanisms underlying this association remain unclear. Recent neuroimaging studies, however, support the contention that depression, as well as pain distress and rejection distress, share the same neurobiological circuits. In this study, we aimed to examine the hypothesis that perception of increased pain during depression is related to increased rejection sensitivity.

METHOD

The present study analysed data from a study of 186 treatment-resistant depressed patients who met DSM-IV criteria for depression and had completed a self-report questionnaire regarding currently perceived pain and rejection sensitivity.

RESULTS

A major increase in the experience of pain during depression was predicted by a major increase in rejection sensitivity during depression.

CONCLUSION

The experience of increased pain during depression is related to increased rejection sensitivity. Research to further elucidate this relationship is required.

Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial

BACKGROUND

The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period.

METHOD

Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4.

RESULTS

Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups.

LIMITATIONS

A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself.

CONCLUSION

While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.

Perception of rejecting and neglectful parenting in childhood relates to lifetime suicide attempts for females--but not for males

OBJECTIVE

To examine the hypothesis that lifetime suicide attempts in a sample of depressed individuals is greater among those who remember their parents as rejecting or neglecting in childhood.

METHOD

Database analyses of patients referred to a public hospital Mood Disorders Unit in Sydney, over a consecutive 10-year period. Patients met DSM-IV criteria for depression, had completed a self-report questionnaire regarding perception of parental rearing, and had responded to a probe question assessing lifetime suicide attempts (n = 343).

RESULTS

Female patients who perceived themselves as rejected/neglected by either parent in childhood had a greater chance of making at least one lifetime suicide attempt. No such associations were found for males.

CONCLUSION

Perception of rejecting/neglectful parents was associated with lifetime suicide attempts in females only, inviting research explicating any such gender specificity.