Premorbid social competence and the effectiveness of early neuroleptic treatment

The relationship of premorbid social competence to early psychotic symptom resolution was examined in 84 (44 male, 40 female) acutely psychotic inpatients given fixed-dose neuroleptic treatment. Patients with a substantial reduction in psychotic symptomatology at 10 days had higher overall social competence scores and higher scores on the indices of occupation, marital status, age, and employment history than did patients with little symptom resolution. Sex and diagnosis were not related to degree of psychotic symptom resolution. The results suggest that early symptom resolution with neuroleptic treatment represents yet another instance of outcome being related to premorbid social competence. The findings likewise accord with the view that social competence reflects underlying developmental differences.

Lithium in combination with perphenazine: effect on plasma monoamine metabolites

The addition of lithium to perphenazine altered the pattern of plasma homovanillic acid (HVA) during the course of treatment for acute psychosis. In the perphenazine-treated group plasma HVA declined significantly by days 7-9 of treatment, whereas in the perphenazine-plus-lithium group plasma HVA tended to increase. The pattern for plasma methoxyhydroxyphenethyl-glycol (MHPG) was not significantly different for the two groups. The addition of lithium to a neuroleptic may enhance the metabolism of dopamine.

Comparison of ovarian response in the same women with the same or different lots of human menopausal gonadotropin

A variation in the bioactivity of different production lots of human menopausal gonadotropin (hMG) has been suggested. Therefore, we evaluated ovarian response to hMG in 14 women during three separate IVF cycles. The first two cycles were performed with the same lot (#03310027; Cycles A1 and A2); the third cycle utilized different lots of hMG (Cycle B). In all cycles, hMG was administered 3 ampules/day beginning cycle Day 3 and continued for at least 6 days. Estradiol and ultrasound evaluations were performed on Day 3, and then daily, beginning on cycle Day 8. Fourteen women completed all three cycles. There were no significant differences in baseline estradiol and ultrasound. Estradiol levels on Day 8 (A1, 754 +/- 130; A2, 700 +/- 107; B, 520 +/- 80 pg/ml, analysis of variance p greater than 0.5) and on Day 9 (A1, 1051 +/- 144; A2, 1140 +/- 155; B, 840 +/- 124 pg/ml, p greater than 0.05) were similar as well. The number of small (1.0-1.4 cm) follicles, large (greater than or equal to 1.5 cm) follicles, and total follicles (Day 8: total A1, 5.5 +/- 0.9; A2, 4.0 +/- 0.7; B, 4.5 +/- 0.9, p greater than 0.05; Day 9: total A1, 6.7 +/- 0.9; A2, 6.9 +/- 0.8; B, 6.9 +/- 0.9, p greater than 0.05) in all three cycles were also similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug-responsive symptoms during early neuroleptic treatment

Identification of symptoms that are directly responsive to neuroleptic drugs at progressive phases of treatment is important for monitoring drug response and understanding the relationship between neurochemical mechanisms of drug action and disordered behavior. Using multiple regression analyses that controlled for pretreatment severity, we identified those symptoms that improved in direct relation to serum concentrations of perphenazine after 10 days of treatment. Improvement in two positive symptoms of psychosis--hallucinations and conceptual disorganization--appears to be related to perphenazine level and useful for assessment of early drug response.

Plasma free homovanillic acid (HVA) as a predictor of clinical response in acute psychosis

The relationship of plasma free homovanillic acid (HVA) and methoxyhydroxyphenylglycol (MHPG) to early clinical response was prospectively studied in a new series of acutely psychotic inpatients given a fixed dose of perphenazine elixir for 10 days. Elevated pretreatment plasma HVA but not MHPG was significantly associated with good response. Change in HVA was correlated with a favorable response and a significant decline in MHPG was found in responders. Results suggest that HVA can provide a useful clinical predictor of response, and that both dopamine metabolism and noradrenergic functioning, as measured by plasma HVA and MHPG, are reduced in effective neuroleptic treatment.

A preliminary, open study of the combination of fluoxetine and desipramine for rapid treatment of major depression

Prompted by a recent study suggesting that the combination of desipramine hydrochloride and fluoxetine down-regulates beta-adrenergic receptors more rapidly than either drug alone, we administered both desipramine and fluoxetine to 14 inpatients with major depression in an open, 4-week trial. Desipramine plasma levels drawn 24 hours after an initial standardized dose were used to rapidly adjust desipramine dosage and compensate for the interactive effects of fluoxetine on desipramine levels in the blood. Responses were retrospectively compared with those of 52 inpatients who were descriptively similar and previously treated in the same setting with desipramine alone. Response was significantly more rapid in the group that received both drugs. One week after treatment began, the mean change in Hamilton Depression Rating Scale scores was 42% in the group that received both drugs and 20% in the group that received desipramine alone (Mann-Whitney U test, P = .007). Two weeks after administration of the drugs, the mean change in scores of the group that received both drugs was 60%, while a 30% change was noted in the patients treated with desipramine alone (P = .001). Ten (71%) of the 14 patients in the group that received both drugs completely remitted (change in Hamilton Depression Rating Scale score of greater than 75%, and final score of less than 7) within 4 weeks, while few patients treated with desipramine alone met these criteria within 4 weeks. This preliminary study suggests that treatment with both desipramine and fluoxetine is a rapid and effective strategy for treatment of major depression, and supports recent hypotheses of noradrenergic-serotonergic synergism.

Value of the DST for predicting response of patients with major depression to hospitalization and desipramine

The authors examined the value of the dexamethasone suppression test (DST) for predicting response of patients with unipolar, nonpsychotic major depression to 1 week of hospitalization without antidepressant drugs and to a 4-week trial of desipramine at a fixed plasma level. The rates of response to hospitalization without drug treatment (defined as a score of 12 or less on the Hamilton Rating Scale for Depression) were not significantly different for the patients with a positive DST and those with a negative DST. This finding differs from those of prior studies of the DST and response to placebo. The responses of the DST-positive and DST-negative patients to desipramine also did not differ, a finding that replicates those in some prior reports.

The relationship between blood perphenazine levels, early resolution of psychotic symptoms, and side effects

Serum perphenazine concentrations and early resolution of psychosis were examined to determine if blood level monitoring could be used to maximize drug efficacy while limiting extrapyramidal side effects (EPS). Sixty-six acutely psychotic inpatients were given perphenazine 0.5 mg/kg/day for 10 days, and their response was rated blind to blood level. Although 36 of 66 patients showed resolution of psychosis, neither perphenazine nor N-dealkylated perphenazine levels were related to global response or to Brief Psychiatric Rating Scale (BPRS) totals. Improvement in two individual BPRS items (hallucinations and conceptual disorganization) was related to serum perphenazine levels and suggestive of a lower therapeutic threshold of 0.8 ng/mL. Perphenazine level was not correlated with EPS; but benztropine, given only if required for serious EPS, was more likely to be used when perphenazine levels were elevated. The data suggest that higher perphenazine levels were no more effective than moderate levels but that higher levels may be associated with increased EPS; the data also suggest that individual symptoms rather than global response were associated with a lower therapeutic perphenazine threshold.

A scale for rating tricyclic response in major depression: the TRIM

We describe the construction and validation of the TRIM, an empirically derived scale designed to rate tricyclic antidepressant response in major depression. Symptoms selected were those that improved in direct association with therapeutic desipramine plasma levels, were frequently present, were substantially correlated with the scale total, could be reliably rated, and for which interview ratings were concordant with observed behavior. Eight symptoms met these criteria and were included. The sensitivity of the TRIM was tested and compared with the Hamilton Rating Scale for Depression (HAM-D) and the Montgomery Asberg Depression Scale (MADS) in a new 4-week prospective desipramine study of nonpsychotic unipolar inpatients with major depression. TRIM 4-week totals were significantly associated with total desipramine plus hydroxydesipramine plasma concentrations, r = -0.32, p less than 0.05, but HAM-D and MADS scores were not. Using multiple regression to control for pretreatment severity, TRIM scores were significantly associated with desipramine plus hydroxydesipramine levels, while HAM-D and MADS scores were not. The data appear to validate the sensitivity of the TRIM and illustrate that scales designed for drug response may detect drug effects that global scales do not.

Predictors of hospital outcome without antidepressants in major depression

Fifty-two consecutive inpatients with nonpsychotic unipolar major depression were assessed for response to 1 week of hospitalization without antidepressants. Each was rated at admission and at 1 week using the Hamilton Rating Scale for Depression (HRSD). Fifteen of 52 responded (HRSD score less than or equal to 12), 10 of whom improved by greater than or equal to 50% change in the HRSD score. Five variables were correlated with lack of hospital response: DSM-III melancholia, panic disorder, the DSM-III-R item "absence of personality disorder," admission severity, and age. Multiple regression showed an independent association between hospital outcome and the first three variables. Response to 1 week of hospitalization was found in 70% (14 of 20) of the patients who had none of the three identified predictors: melancholia, panic, and absence of personality disorder. In patients with one or more of these predictors, only 3% (1 of 32) responded.

Does melancholia predict response in major depression?

We examined the value of the melancholic distinction for predicting response to 1 week of hospitalization without antidepressant drugs and to a 4-week fixed plasma level desipramine (DMI) trial in patients with unipolar non-psychotic major depression. Both DSM-III and III-R criteria were tested. Response to hospitalization (HDRS less than or equal to 12) was much less common in DSM-III melancholic than in non-melancholic patients (1 of 19 vs. 18 of 37, chi 2 = 8.69, df = 1, P less than 0.001) and severity did not account for this association. DSM-III-R melancholia criteria were also associated with poor hospital response but slightly less predictive. Melancholic patients, however, diagnosed with either set of criteria, were not more likely to respond to drug treatment on any of the measures examined.

Depression in late life: age of onset as marker of a subtype

Late-onset depression may be pathogenetically and prognostically distinct from early-onset, recurrent affective disorder. The authors reviewed records of 94 consecutively admitted unipolar major depressives over the age of 60 years, divided subjects into groups based on their age of onset, and examined demographic and clinical features. Late-onset elderly depressives had a lower incidence of family history of affective illness, longer hospital stay, and more residual symptoms at discharge. However, there was no demonstrable relationship between age of onset and presence of psychosis, melancholia, medical illness, symptom severity at admission, or indicators of neuropathology. Although late-onset elderly depressives did less well than those with early-onset illness, the data do not support the notion of late-onset depression as a distinct pathological process.

Psychological studies of in vitro fertilization/embryo transfer participants

During the last decade, reproductive endocrinology has provided new technologies for treatment of infertility--one of which is in vitro fertilization/embryo transfer (IVF/ET). The use of this technology has been accompanied by considerable interest in understanding the psychology of those seeking IVF/ET and in understanding psychological reactions during and after IVF/ET. This paper reviews the psychological research within the IVF/ET literature as divided into three major areas: first, psychological profiles of women and their partners requesting IVF/ET; second, clinical reports which describe the psychological experience of IVF/ET and provide recommendations for counseling both before and during IVF/ET; and third, follow-up studies of IVF/ET participants. This paper is designed to highlight initial findings in these three areas of research and thus provide a context for future research directions. Specific suggestions for future study include redirecting research effort from investigations of psychopathology to detecting stress which may affect IVF/ET outcome.

Elderly patients admitted to the psychiatric unit of a general hospital

Elderly psychiatric patients who are cared for in general hospital psychiatric settings have not been clearly characterized in the literature in terms of demographics, primary diagnoses, hospital course, and outcome. The authors reviewed charts of 168 patients over the age of 60 years admitted to a general hospital inpatient psychiatry unit over a 5-year period in order to develop a demographic and clinical profile of this patient population. Results indicated that the large majority of patients had affective syndromes; dementia was the second most common diagnosis. Length of stay correlated with severity of depressive illness, while a diagnosis of dementia was associated with a shorter hospitalization. Outcome measures showed favorable response to treatment in three-fourths of this population of elderly psychiatric patients. These data suggest that the general hospital acute inpatient setting is well suited to care for the combined medical and mental illnesses of elderly psychiatric patients.

Lithium augmentation in psychotic depression refractory to combined drug treatment

In this retrospective study the authors determined the efficacy of lithium added to a combined antipsychotic-antidepressant drug regimen in 21 psychotically depressed patients who had been refractory to combined drug treatment. Response to lithium was then compared with response rates of 15 patients to ECT, the established treatment for nonresponsive delusional depression. Lithium was effective in eight of nine patients with bipolar depression but in only three of 12 patients with unipolar depression; ECT was effective in nine of 15 patients with unipolar depression. Lithium augmentation appeared to be a realistic treatment alternative for refractory bipolar patients but was disappointing in unipolar patients.