Clinical and psychosocial predictors of recurrence in recovered bipolar and unipolar depressives: a one-year controlled prospective study

Unipolar and bipolar patients with a chronic illness pattern were investigated to evaluate the relevance of clinical and psychosocial risk factors to predict subsequent recurrence. Self-esteem, social adjustment, social support and attributional style were assessed in 27 recovered bipolar patients, 24 recovered unipolar patients maintained on lithium or antidepressant prophylaxis and 26 healthy controls. They were further interviewed every 2 months in a 1-year period in order to diagnose affective episodes according to Research Diagnostic Criteria. Survival analyses and Cox's regressions demonstrated that being a unipolar patient and showing poor social adjustment were the strongest predictors of the occurrence of affective episodes. Self-esteem, social support, attributional style and clinical characteristics, such as age at illness onset, number of previous episodes or of previous hospitalizations and presence of affective disorder in first-degree relatives, were not found to be risk factors for further recurrence. This study stresses the importance of social adjustment in evaluating the outcome of affectively ill patients maintained on medication prophylaxis.

Sleep in detoxified alcoholics: impairment of most standard sleep parameters and increased risk for sleep apnea, but not for myoclonias--a controlled study

OBJECTIVE

To assess recently alcohol-abstinent chronic alcoholic patients for selected parameters indicative of sleep quality.

METHOD

Patients (n = 24, 14 male), abstinent 3-6 weeks, and healthy controls (n = 20) were admitted to a clinical sleep unit. Measurements included sleep respiratory events and periodic limb movements, using strict methodology.

RESULTS

Clear signs of sleep deterioration and a high prevalence of apneic/hypopneic episodes were observed. Apneas were found at the same frequency for men and women; this has not been described before. No periodic limb movement was found.

CONCLUSIONS

Considering the high degree of morbidity and mortality observed in sleep apneic syndrome, systematic screening for sleep apneas is recommended for alcoholics seeking help.

Life events and primary affective disorders. A one year prospective study

BACKGROUND

Unipolar and bipolar patients with a chronic illness pattern were investigated to determine whether they experienced a higher number of life events prior to the onset of recurrent affective episodes.

METHOD

The study participants consisted of 27 recovered bipolar patients, 24 recovered unipolar patients and 26 healthy control subjects. Life events and psychiatric status were assessed by bimonthly interviews over the period of one year using the Inventory for Recent Life Events and the Research Diagnostic Criteria.

RESULTS

In both unipolar and bipolar patients, analyses revealed no significant differences in the number of life events experienced, irrespective of whether the patients had presented with a depressive episode of at least minor intensity during the study (all P > 0.1). Specifically, an increase in marital problems was observed in bipolar patients prior to the onset of recurrent hypomanic and manic episodes (P = 0.06).

CONCLUSION

The causal association between life events and the onset of depression, shown to be relevant in non-chronically depressed subjects, does not apply in chronic affective disorders. In addition, our results suggest that marital events have an impact on the onset of recurrent hypomanic and manic episodes.

Neuroendocrine and sleep variables in major depressed inpatients: role of severity

To evaluate the reliability of the endogenous concept of depressive illness according to the Newcastle Endogenous Depression Diagnostic Index (NEDDI), 155 major depressive inpatients with NEDDI scores > or = 6 (endogenous) were matched for gender and age (+/- 5 years) to 155 major depressive inpatients with NEDDI scores < 6 (nonendogenous). When sleep polygraphic variables, neuroendocrine parameters (dexamethasone suppression and thyrotropin-releasing hormone tests), and various clinical variables (unipolar/bipolar status, psychotic/nonpsychotic subtype, and severity of the depressive episode) were examined, statistically significant differences between endogenous and nonendogenous patients emerged for three variables: the thyroid-stimulating hormone response to the thyrotropin-releasing hormone test, the dexamethasone suppression test response at 16:00 h, and the percentage of time awake during the night. However, when the effects of age and severity of depression were controlled, those differences disappeared.

Psychosocial predictors of major affective recurrences in bipolar disorder: a 4-year longitudinal study of patients on prophylactic treatment

A total of 21 recovered bipolar patients on prophylactic treatment were prospectively followed up for a period of 1 year. Data for major recurrences were retrospectively collected for an additional 3-year period. During the entire 4-year period, over half of the patients (52%) had no major affective recurrences. Eight patients experienced a major depressive episode, while only two experienced a manic one. Psychosocial and clinical variables were assessed at entry to the study. The effect of these variables on the subsequent 4-year illness course was analysed using survivorship curves. The results show that the following psychosocial variables significantly predicted the occurrence of a major affective episode: low level of social support, maladjustment in social and leisure activities, and poor quality of relationships with extended family. In contrast, clinical variables which characterize illness history were not significantly associated with major recurrences.

Acute, subchronic and withdrawal sleep EEG changes during treatment with paroxetine and amitriptyline: a double-blind randomized trial in major depression

Paroxetine (30 mg), a selective serotonin (5-HT) reuptake inhibitor, was compared in a double-blind trial to amitriptyline (150 mg) in a sample of 40 inpatients aged 18-65 years who fulfilled Research Diagnostic Criteria for major depression. Patients were studied after a placebo drug washout period of 10 days and after an active 4-week treatment period. Sleep EEG recordings were performed before and at the end of the study as well as during acute treatment (first 2 days) and following withdrawal of active medication. Paroxetine shows an antidepressant effect similar to amitriptyline with a different side-effect profile typical of 5-HT reuptake inhibition. Paroxetine and amitriptyline decreased the amount of REM sleep, a well-known effect of classical antidepressants. Paroxetine also shared with other 5-HT reuptake inhibitors an alerting effect on sleep that was not shown to be detrimental on subjective sleep quality.

Relationship between the Newcastle scale and sleep polysomnographic variables in major depression: a controlled study

In order to investigate the reliability of the endogenous concept of depressive illness with some sleep EEG parameters, we studied 39 male inpatients suffering from a nonbipolar major depressive episode (15 endogenous (MDDE) and 24 nonendogenous (MDDNE)) and 20 age and sex matched normal controls (C). All patients were diagnosed according to the Research Diagnostic Criteria (RDC) and the endogenous character of the episode was assessed with the Newcastle Endogenous Depression Diagnostic Index. We found significant differences for the following variables between the three groups (MDDE, MDDNE and C): sleep period time (SPT), REM latency, stage II, slow wave sleep (SWS), REM latency expressed as a continuous variable and REM latency expressed as a dichotomizing variable with a threshold of 50 min. These variables were used to compare the endogenous and the nonendogenous depressed patients and also the major depressed patients and the normal controls. Significant differences were observed between all depressed patients and control subjects for amount of SWS and REM latency which were both reduced in endogenous and nonendogenous depressed patients. No significant difference was observed between endogenous and nonendogenous depressed patients, except for the REM latency expressed with a threshold of 50 min (more frequently observed in endogenous depressed patients). Our data support the observation that SWS and REM latency are decreased in major depressive patients. However, in this age and sex controlled study, subtyping nonbipolar major depressive disorder for an endogenous character by the Newcastle Endogenous Depression Diagnostic Index (NEDDI) did not reveal further significant differences for sleep EEG variables, except for the shortening of the REM latency expressed as a dichotomizing variable.

[Cerebral blood flow and post-TIA depression]

OBJECT

This study tries to evaluate the hypothesis of an association between severity of post-stroke depression and reduced cerebral blood flow (SPECT Xenon-133).

METHOD

37 patients in the fourth week of post-stroke evolution with RDS criteria of major depression (N = 20) and non-depressed patients (N = 17) were compared in regard to following parameters: values of cerebral blood flow (SPECT Xenon-133), localization of brain lesion (CT Scanner) and quantitative measurement of mood (HDRS, MARDS, BDI), functional ability (Barthel, Karnofsky), cognitive function (MMSE, WPT) and neurological function (Orgogozo's Scale).

RESULTS

Post-stroke major depression is more frequent (NS) in left and anterior lesions. We also demonstrated a significant association between total brain hypoperfusion and 1) severity of post-stroke depression, 2) severity of neurologic and functional impairments.

CONCLUSION

these results suggest a relationship between mood and cerebral perfusion following stroke.

Linkage analysis of bipolar illness with X-chromosome DNA markers: a susceptibility gene in Xq27-q28 cannot be excluded

Transmission studies have supported the presence of a susceptibility gene for bipolar (BP) illness on the X-chromosome. Initial linkage studies with color blindness (CB), glucose-6-phosphate dehydrogenase (G6PD) deficiency, and the blood coagulation factor IX (F9) have suggested that a gene for BP illness is located in the Xq27-q28 region. We tested linkage with several DNA markers located in Xq27-q28 in 2 families, MAD3 and MAD4, that previously were linked to F9 and 7 newly ascertained families of BP probands. Linkage was also examined with the gene encoding the alpha 3 subunit of the gamma-amino butyric acid receptor (GABRA3), a candidate gene for BP illness located in this region. The genetic data were analyzed with the LOD score method using age-dependent penetrance of an autosomal dominant disease gene and narrow and broad clinical models. In MAD3 and MAD4 the multipoint LOD score data suggested a localization of a BPI gene again near F9. In the 7 new families the overall linkage data excluded the Xq27-q28 region. However, if the families were grouped according to their proband's phenotype BPI or BPII, a susceptibility gene for BPI disorder at the DXS52-F8 cluster could not be excluded.

TSH response to TRH and EEG sleep in non-bipolar major depression: a multivariate approach

The TSH response to TRH and selected sleep EEG variables were studied in a homogeneous sample of 280 non-bipolar major depressed inpatients (95 males and 185 females). The TSH response to TRH was blunted in 28% of the sample. delta max TSH was correlated negatively with age, Hamilton rating scale, Newcastle scale, percentage of wake, and positively with basal TSH, percentage of stage II, slow wave sleep, REM sleep and REM latency. delta max TSH was also lower in male patients and in patients suffering from an endogenous or a psychotic subtype of major depression. Basal TSH was only correlated negatively with the Newcastle score. In view of intercorrelations between all these variables, and because of the confounding effect of age, gender and severity on both the TSH response to TRH and sleep EEG variables, a multiple regression analysis was performed and demonstrated that basal TSH and gender were the two variables with the highest contribution to the delta max TSH variance, followed by age and the presence of psychotic symptoms. When controlling strictly for these significant effects, correlation with the severity or with the endogenous character of depression, and with sleep EEG parameters disappeared.

Biological markers as classifiers for depression: a multivariate study

1. Delta TSH, REM latency, 4 pm and 11 pm post-dexamethasone cortisol values were determined after a wash-out period in a group of 74 non-selected depressed patients who were diagnosed (according to RDC with the SADS) as follows: 46 definite and 10 probable MD, 4 minor and 14 intermittent depression. 2. These biological variables, as well as gender, age and basal TSH were introduced in a principal component analysis. The four first PC scores explaining up to 77% of the data set were further calculated for each patients and used in a cluster analysis. A three clusters solution was retained. 3. DST escape and increased TSH response to TRH each identified subgroups of depressed patients. Conversely, blunted TSH response or REM latency were inefficient to classify patients. 4. Thus, HPA hyperactivity characterized CL-I patients (n = 29). These were more severely depressed, displayed more endogenous features and were reported as being more anxious. 5. Increased TSH response to TRH identified CL-III, exclusively composed of female patients (n = 10) that displayed more apparent sadness and tended to be older. 6. In CL-II, the usual sex-ratio for depressive illness was reversed and patients (n = 35) exhibited the least HPA axis disturbances and the same rate of blunted TSH response than in CL-I. They were also less severely depressed, displayed less endogenous characteristics and were rated as more mood reactive. 7. These results suggest heterogeneity in biological disturbances in depression and further stress the importance for controlling age, gender and severity of illness in studies investigating biological markers in depression.

[Quantitative psychopathology of depression: application of the Newcastle Scale]

Hypothalamo-pituitary axis disturbances, such as plasma cortisol escape after dexamethasone (DXM) administration or blunted TSH response to TRH, and sleep architecture abnormalities such as shortened REM latency are frequently encountered in depressive disorders. These anomalies only occur in a subgroup of depressed patients and could thus identify a biological or endogenous component to depressive illness. Several definitions of this endogenous depression have been proposed. In this regard, using biological criteria, the Newcastle scale remains the strongest validated clinical definition. In this study, 93 patients (58 women and 35 men) aged 15-79 years (mean: 42) who complained about a depressed mood were admitted for biological investigations (DXM and TRH tests, sleep EEG recording) after a drug wash-out period of at least 10 days. Patients were assessed with the Newcastle scale and diagnosed with RDC using the SADS. After the effects of age, gender and severity of illness were controlled for, multiple regression analyses showed that depressive pychomotor activity and weight loss were the 2 items of the Newcastle scale most contributing to explain the variances of the neuroendocrine tests results. Moreover, when the sample was dichotomized according to the presence of these 2 items, the 2 groups had significantly different post DXM cortisol values, TSH levels after TRH and REM latency values. The 2 groups (biological and non-biological) were then characterized using 16 depressive symptoms more frequently cited in 15 operational definitions of endogenous depression. A logistic regression analysis showed that weight loss, anhedonia, early awakening, and morning worsening of mood were the 4 symptoms that best distinguished biological from non-biological patients group. These symptoms could reflect biological abnormalities in depression and form the core of the endogenous depression.

Nonlinkage of bipolar illness to tyrosine hydroxylase, tyrosinase, and D2 and D4 dopamine receptor genes on chromosome 11

OBJECTIVE

Previous linkage and allelic association studies using DNA polymorphisms, cosegregation of cytogenetic abnormalities with psychiatric illness, and assignment of genes involved in neutotransmitter metabolism suggested that chromosome 11 may harbor a gene predisposing to bipolar illness. The authors examined linkage in the families of 14 probands with bipolar illness, with the candidate genes tyrosine hydroxylase (TH), D4 dopamine receptor (DRD4) at 11p15, tyrosinase (TYR) at 11q14-q21, and D2 dopamine receptor (DRD2) at 11q22-q23, as well as with the c-Harvey-ras oncogene (HRAS) and insulin gene (INS), both located at 11p15, a region that previously showed linkage to bipolar illness.

METHOD

The genetic data were analyzed with both lod score analysis (parametric) and affected-sib-pair analysis (nonparametric); both narrow and broad definitions of the clinical phenotype were used. Further influences of diagnostic uncertainties were accounted for by using diagnostic probability classes weighing the stability of each phenotype.

RESULTS

Two-point linkage results excluded close linkage of bipolar illness to each candidate gene; negative results were also obtained when the narrow definition of the clinical phenotype was used. Moreover, multipoint linkage analysis of HRAS and INS excluded the 11p15 region encompassing both DRD4 and TH. In agreement with the negative linkage results, affected-sib-pair analysis did not show preferential sharing of marker alleles at any of the candidate genes.

CONCLUSIONS

The negative results obtained under different genetic models exclude a frequent role for DRD4, TH, TYR, and DRD2 in the pathogenesis of bipolar illness.

Biological and clinical features of recurrent brief depression: a comparison with major depressed and healthy subjects

Recurrent brief depression (RBD) has recently been proposed as a new subtype of affective disorder characterized by episodes of major depression which last less than two weeks. The aim of this study was to further evaluate the validity of this putative subtype by means of clinical and biological data. DST, TSH response to TRH and sleep EEG variables were compared in 25 RBD patients sex- and age-matched to 25 major depressed (MD) and 25 healthy subjects. Family history, age at onset, and psychiatric comorbidity did not discriminate RBD from MD. Recurrent unipolar depression was found to be more prevalent in MD. Although less severely depressed during the biological tests, patients with RBD did not significantly differ from those with MDD on basis of DST non-suppression, blunted TSH response and shortening of REM latency. Compared to controls, a greater sleep onset latency was observed both in RBD and MD and a lower total sleep time in MD patients only. These results suggest that RBD could be viewed as a subtype of affective disorder sharing many characteristics with MDD.

5-HT2 receptor antagonism and slow-wave sleep in major depression

Specific sleep disturbances such as reduced slow-wave sleep (SWS) and decreased serotonergic (5-HT) activity have been observed in depressive disorders. Ritanserin, a specific 5-HT2 receptor antagonist, has been shown to increase SWS in healthy subjects. This study explored the effects of a single dose or ritanserin (5 mg) on sleep electroencephalography in 18 major depressed patients and in 10 control subjects. Ritanserin affected SWS differently in the two groups. Although stage 3 increased significantly in the groups, in contrast to controls, there was no significant effect of ritanserin on stage 4 in depressed patients. In the depressed group, irritability and DSM-III-R melancholic type predicted 40% or the variance of stage 4 increment after ritanserin, as assessed by stepwise multiple regression. These results are in agreement with a potential 5-HT disturbance, particularly at the 5-HT2 receptor level, in some clinical forms of depression.

Biological correlates of the Newcastle Scale in depressive illness: a multivariate approach

Rapid eye movement latency (RL), delta max thyroid-stimulating hormone (dmTSH) and 1600 (DST16) and 2300 (DST23) post-dexamethasone cortisol values were determined in a group of 93 depressed patients who were assessed with the Newcastle Endogenous Depression Diagnostic Index (NEDDI). After the effects of age, gender and severity of illness were controlled for, stepwise multiple regression showed that depressive psychomotor activity and weight loss were the 2 NEDDI items most contributing to explain DST23 variance, as was depressive psychomotor activity for dmTSH variance. When the depressive sample was dichotomized according to the presence of these 2 items, the 2 groups had significantly different DST16, DST23, dmTSH and RL values. This suggests that weight loss, agitation and retardation could represent a core feature of a biologically mediated depressive subtype.

[The practice of electroconvulsive therapy: current contribution. II.--administration and evaluation of treatment]

In this second of a two-part review about electroconvulsive therapy (ECT) practice, the author highlights recent advances in ECT course management with a special emphasis on pre-ECT evaluation, treatment procedures, evaluation of outcome and post-ECT course. Pre-ECT assessment should include an evaluation of medical risk factors and concomitant use of psychotropic or medical agents have to be reconsidered. Practical and technical aspects of stimulus administration and their relationships with post-ECT cognitive disabilities are then presented. Monitoring of treatment response and cognitive changes during ECT course is also discussed as well as post-ECT pharmacotherapy maintenance or continuation ECT.

Lack of association between HLA-DR antigens and sleep-onset REM periods in major depression

Narcolepsy is the disease disclosing the strongest association with the HLA system. Almost 100% of cases are associated with HLA-DR2 antigen. Moreover, narcolepsy is often characterized by the occurrence of sleep-onset REM (SOREM) periods. SOREM has also been demonstrated in major depression. To further investigate the relationship between SOREM and HLA-DR2, HLA-DR and HLA-DQ antigens were assessed in 50 research diagnostic criteria (RDC) major depressed patients. Depressed patients were elected for HLA typing on the basis of the presence of at least one SOREM period (n = 29) or three REM latencies above 50 min (n = 21) during three consecutives EEG nights recording. No significant differences were observed in the frequency of HLA-DR or HLA-DQ antigens between patients and controls. These results demonstrate a lack of association between SOREM and HLA-DR2 in major depression, and also do not confirm the presence of an association between antigens encoded by the HLA region of the chromosome 6 and major depressive illness.