Bipolar affective disorder in old age

In a retrospective study of 67 elderly bipolar patients the first manic attack occurred at about age 60, often after a long period from the time of the first affective episode, after which further depressive episodes occurred. This calls into question Perris' criteria for unipolar diagnosis. Among the men, a preponderance of cerebral-organic disorders was found. The evidence for sub-classification of bipolar disorders into secondary or symptomatic manias is discussed. The recurrent nature of the illness in old age stresses the need for further evaluation of lithium prophylaxis.

Averaged evoked responses in relation to cognitive and affective state of elderly psychiatric patients

Averaged cortical evoked responses to auditory and somatosensory stimuli were recorded in elderly depressives, dements, patients with a combination of depression and dementia and normal elderly controls. The subjects were also given a battery of cognitive tests and clinical ratings at stated intervals. The latency of the auditory response was significantly longer in dements than in controls. Depressives had intermediate latencies which did not return to normal after recovery. Although somatosensory stimulu produced the results that pointed in the same direction, the mean response latencies were not statistically significant. Mixed cases were too few for separate statistical analysis but their latencies fell between those of the dements and those of the depressives. Significant correlations emerged between latencies of auditory responses and some cognitive tests, but not with measures of depressive symptomatology. The delay in response to auditory stimuli may be a useful adjunct to diagnosis: in depressives it may reflect organic cerebral change playing a part in the emergence of depressive symptoms in old age.

Then and now

Dr Post has been known to generations of students of psychiatry passing through The Maudsley Hospital, London, as a clinician and clinical teacher. He retired in July 1978.

Psychological test performance and sedation thresholds of elderly dements, depressives and depressives with incipient brain change

As expected, dements, depressives and patients with a mixed psychopathology were differentiated from one another on the sedation threshold measure and on a number of psychological tests. In depressives responding to treatment significant changes in physiological and psychological measures, which had been reported in an earlier study could not be replicated except for an increase of psychomotor speed. In the present sample of patients there were significant correlations between various psychological measures and between them and the levels of the sedation threshold, suggesting that sedation thresholds and psychological tests measured related cerebral functions. Evidence obtained from the earlier investigations to the effect that cerebral age changes short of those occurring in dementia may facilitate the occurrence of depression in late life was only weakly confirmed by the replication study.

The effect of cyclandelate in depressed and demented patients: a controlled study in psychogeriatric patients

In a double-blind clinical trial the effects of the vasodilator drug cyclandelate (in a dose of 1200 mg daily) were studied in a group of patients with depressive illnesses or dementing conditions. The measures used before treatment and after six weeks' treatment were: clinical rating, psychometric tests (Paired Associate Learning Test, Digit Copying Test, Digit Substitution Test, and Serial Learning Test), cortical evoked potentials, the sedation threshold and the Gresham Questionnaire. In the depressive group there were no significant differences in the changes in scores at six weeks in three groups: those who received cyclandelate plus amitriptyline, those who received placebo plus amitriptyline, and those who received neither placebo nor cyclandelate. In the demented group there were significant changes in favour of the placebo on two measures (Digit Copying test, and one component of the auditory evoked response). The results do not support the previously reported views claiming, in a number of studies, a significant improvement in the performance of both demented and normal elderly subjects treated with cyclandelate. The significance of these findings is discussed.

The use of an interactive computer terminal in the assessment of cognitive function in elderly psychiatric patients

The use of a teaching machine is the assessment of mental function has been described by Gredye and his colleagues. This report concerns its use in testing 56 elderly patients suffering from functional psychiatric disorders of dementia. After a diagnostic interview patients were tested on the teaching machine as well as on the Mill Hill, Progressive Matrices, Paired Associate Learning Test and Digit Copying Test. After a fixed period all tests were repeated and clincal progress rated. Results showed a significant correlation (P less than 0.01) between teaching-machine scores and those on the standard psychological tests. The correlation between the machine scores on the two occasions was high (r equals 0.58) but this was complicated by practice effects and by low 'ceiling' of the test. It is concluded that the test provided a relatively reliable and valid measure of cognitive function but that its value would be increased by providing a parallel form and by extending its level of difficulty.

Comparison of self-ratings of psychiatric patients with ratings made by a psychiatrist

A large part of the data gathered in psychiatric and clinical psychological research consists of ratings carried out by various members of the clinical team. A set of clinical ratings consists essentially of a questionnaire that is completed by someone who is familiar with the patient. Data of this kind provide information about the way in which members of the clinical team think about their patients; but not necessarily about the ways in which the patients themselves actually behave, feel and think. One would of course expect to find a relationship between the two kinds of data, and both are of psychological interest.

Barbiturate tolerance and psychological functioning in elderly depressed patients

Increases in barbiturate tolerance and in scores on certain cognitive tests were found to have occurred after the treatment of elderly depressives. These changes were related to original severity of illness and to the extent of improvement, as well as to a number of other clinical features including age at first attack. The reported findings lent support to theories linking depressive illness with reduction in cortical arousability.

The management and nature of depressive illnesses in late life: a follow-through study

Since the long-term results of the treatment of elderly depressives admitted to the writer's care between 1949 and 1951 were communicated (1962), further experiences (e.g. Colwell and Post, 1959; Post, 1968) have confirmed that affective illnesses in late life are associated with much subsequent mental invalidism and needs for further treatment. It was hoped that these needs might be met by increased use of out-patient and community care as well as by the introduction of thymoleptic drugs. A follow-up investigation of a further consecutive series of depressives over the age of 60 receiving inpatient treatment from the same psychiatrist in the same hospital during the years 1966–67 was undertaken with the following aims in view:

Firstly, it was intended to test the proposition that the less reluctant use of electro-convulsive therapy in old persons, as well as the introduction of antidepressant drugs and of more active after-care measures, had improved the long term outlook in the affective illnesses of late life. It was realized that a comparison of two series of patients separated from one another by some 15 years might be vitiated by differences between the samples other than those due to changed methods of treatment. It would, however, have been unethical to withhold the new forms of management from a control group.

Schizo-affective symptomatology in late life

Kasanin (10) seems to have been the first author to use the term 'schizo-affective psychosis'. He drew attention to Lange's observations of catatonic features in mania, and to Claude's concept of 'schizomanie’. The case records of his young and acutely ill patients make one wonder, however, whether Kasanin had been sufficiently ready to recognize mixed manic-depressive states. Arising from the study of more prolonged illnesses, the Kleist-Leonhard school attempted to construct a number of sub-categories of schizophrenia in order to accommodate ‘cycloid’ cases. In this country, the term 'schizo-affective’ is at the present time in bad odour. Aubrey Lewis (11), employing very searching criteria, discovered schizophrenic symptoms in 23 of his 61 patients with affective psychoses, but derived them from hereditary and personality factors. Both Batchelor (2) and Mayer-Gross, Slater, and Roth (13), while admitting the occasional co-existence of manic-depressive and schizophrenic psychoses largely ascribed to mixed inheritance, have indicated that the schizo-affective label could be avoided by a more rigorous diagnostic approach and follow-up. These were employed recently by Clayton et al. (6), and of 39 schizo-affective patients 33 were re-assessed after at least one year; only 13 were still ill; and although 5 of them continued to show some schizophrenic symptoms, the authors interpreted their findings to indicate that schizophrenic deterioration was not a usual result of schizo-affective illness. Moreover, the family histories suggested a very strong relationship with ordinary affective illnesses rather than with schizophrenia or schizo-affective psychoses. These workers did not, therefore, confirm the claims of others (e.g. those arising from Mitsuda's (14) twin studies) to the effect that atypical psychoses were in a genetically different category from schizophrenia and manic-depression. The concept of 'schizo-affective’ has been devastatingly criticized by Foulds and Caine (7) on logical grounds.

An evaluation of bimedial leucotomy

An attempt is reported here to evaluate the results of a modified form of leucotomy. Subjects of the investigation were 64 consecutively operated patients, for all of whom the same technique of bimedial leucotomy was employed. This operation is similar to the full division of white matter (as described by Poppen, 1948) through a superior frontal approach, but the cut is limited to the medial 2 cm. (Greenblatt and Solomon, 1952). The operation is carried out under direct vision through two 4 cm. trephine openings placed immediately anterior to the coronal suture on either side of the midline. The plane of the cut is found with a brain needle and extends from the middle of the trephine opening (2 cm. in front of the coronal suture) to the line of the sphenoidal ridge. The white matter is cut with a metal sucker for a width of about 2 cm. subjacent to grey matter medially and inferiorly. The incision skirts the front of the lateral ventricles and divides the thalamo-frontal bundle, thereby isolating the cortex of the frontal pole and also interfering with the fibres to the remaining anterior prefrontal areas which lie in the midcentral segment of white matter. This cut does not necessarily extend sufficiently far back to interfere with all the fibres related to area 13, but is free from the disadvantages of misplacement into the septal area.