Delusional depressions: natural history and response to treatment

Rating scales measuring the severity of psychotic depression

OBJECTIVE

Unipolar psychotic depression (PD) is a severe and debilitating syndrome, which requires intensive monitoring. The objective of this study was to provide an overview of the rating scales used to assess illness severity in PD.

METHOD

Selective review of publications reporting results on non-self-rated, symptom-based rating scales utilized to measure symptom severity in PD. The clinical and psychometric validity of the identified rating scales was reviewed.

RESULTS

A total of 14 rating scales meeting the predefined criteria were included in the review. These scales grouped into the following categories: (i) rating scales predominantly covering depressive symptoms, (ii) rating scales predominantly covering psychotic symptoms, (iii) rating scales covering delusions, and (iv) rating scales covering PD. For the vast majority of the scales, the clinical and psychometric validity had not been tested empirically. The only exception from this general tendency was the 11-item Psychotic Depression Assessment Scale (PDAS), which was developed specifically to assess the severity of PD.

CONCLUSION

In PD, the PDAS represents the only empirically derived rating scale for the measurement of overall severity of illness. The PDAS should be considered in future studies of PD and in clinical practice.

Efficacy and safety of mifepristone for the treatment of psychotic depression

Open-label studies and randomized clinical trials have suggested that mifepristone may be effective for the treatment of major depression with psychotic features (psychotic depression). A recent study reported a correlation between mifepristone plasma concentration and clinical response. The current study aimed to evaluate the safety and efficacy of mifepristone and, secondarily, to test whether response was significantly greater among patients with mifepristone plasma concentrations above an a priori hypothesized threshold. A total of 433 patients who met criteria for psychotic depression were randomly assigned to receive 7 days of either mifepristone (300, 600, or 1200 mg) or placebo. Response was defined as a 50% reduction in psychotic symptoms on both days 7 and 56. Cochran-Mantel-Haenszel tests compared (1) the proportion of responders among patients assigned mifepristone versus placebo and (2) the proportion of responders among the subset of patients with plasma concentrations greater than 1660 ng/mL versus placebo. Mifepristone was well tolerated at all 3 doses. The proportion of responders randomized to mifepristone did not statistically differ from placebo. Patients with trough mifepristone plasma concentrations greater than 1660 ng/mL were significantly more likely to have a rapid and sustained reduction in psychotic symptoms than those who received placebo. The study failed to demonstrate efficacy on its primary end point. However, the replication of a statistically significant linear association between mifepristone plasma concentration and clinical response indicates that mifepristone at sufficient plasma levels may potentially be effective in rapidly and durably reducing the psychotic symptoms of patients with psychotic depression.

Putative psychotic symptoms in the Mexican American population: prevalence and co-occurrence with psychiatric disorders

It is reported that Latin Americans describe culturally normative experiences or express putative psychotic symptoms in medical and mental health treatment settings that complicate the diagnostic process. Previous research reported that Latinos were more likely than European Americans and African Americans to have their diagnoses changed from schizophrenia to other disorders. This study describes the prevalence and likelihood of putative psychotic symptoms being expressed independent of any psychiatric disorder or co-occurring with common disorders such as depression or anxiety within a Mexican American population sample. Epidemiologic data of the Mexican American Prevalence and Services Survey (N = 3012) were used to contrast rates and patterns of putatively psychotic features among adults by demographic variables and diagnostic status using DSM-III-R criteria and receipt of treatment. Putative psychotic symptoms were reported by 17% of US-born and 7% of immigrants without disorders, and by 38% of US-born and 28% of immigrants with lifetime disorders, totaling 18% lifetime prevalence for the entire study population of Mexican Americans. First-rank Schneiderian symptoms were higher in those with a disorder compared with those without a disorder for both sexes. The results of this study indicate that putative psychotic symptoms are common among Mexican Americans, and their presence is a strong precautionary signal for evaluating clinicians to correctly distinguish whether putative psychotic symptoms are indicators of nonorganic psychoses or other psychiatric disorders, or are simply cultural expressions. Research is needed to identify the determinants of misdiagnosis in clinical practice, and guidelines are needed to assist clinicians.

Psychotic Major Depression

Numerous studies in the past three decades have characterised 'psychotic major depression', a subtype of major depression which is accompanied by delusions or other psychotic features. Evidence from phenomenological and neurobiological investigations indicates that this is a unique disorder with clinical and biological characteristics that are distinct from those of nonpsychotic depression and from other psychotic disorders. Treatment studies have provided evidence of small placebo effects and good responses to electroconvulsive therapy or combination treatment with an antidepressant plus an antipsychotic agent. However, until recently, there were only a few small, prospective, double-blind, controlled trials investigating the efficacy of antidepressant-antipsychotic combination pharmacotherapy, yet this constitutes the currently accepted and most universally applied 'standard of care' for psychotic depression. Treatment guidelines have been based largely on uncontrolled investigations of electroconvulsive therapy and studies using tricyclic antidepressants and first-generation antipsychotic drugs, which are not frequently chosen as first-line agents today because of concerns regarding tolerability and risks. However, recent open-label studies and large controlled trials of newer antidepressants and antipsychotics have yielded very divergent results thus far, so that the best treatment approach remains elusive. This review discusses the phenomenology and treatment of psychotic depression with a focus on the benefits and risks of various treatment approaches. Problems with this literature are highlighted, and strategies for future research are suggested.

Antidepressant treatment of psychotic major depression: potential role of the sigma receptor

Psychotic major depression is a severe condition that frequently proves difficult-to-treat. The most effective traditional treatments (electroconvulsive therapy and combinations of antipsychotics with tricyclic antidepressants) are associated with significant side effects, and the use of tricyclic antidepressants alone is largely ineffective. Recent evidence has indicated that the selective serotonin reuptake inhibitors, either alone or in combination with antipsychotics, may provide a desirable alternative to traditional treatments. Among selective serotonin reuptake inhibitors, fluvoxamine has been the best studied and, somewhat surprisingly, has proven effective in several studies as a monotherapy without the need to combine with an antipsychotic. It is proposed that the apparent efficacy of fluvoxamine in psychotic major depression may be related to its unique property of high affinity for the sigma 1 receptor, which is thought to play a role in psychosis and in the action of some antipsychotic drugs.

Challenges in the treatment of depression with psychotic features

Major depression with psychotic features (MDpsy), a disorder with considerable morbidity and mortality, is more common than is generally realized and is a most difficult form of depression to treat. Patients with MDpsy exhibit more frequent relapses and recurrences and have increased use of services, greater disability, and a poorer clinical course when compared with nonpsychotically depressed patients. Patients with MDpsy demonstrate distinct biological abnormalities in studies of the hypothalamic-pituitary-adrenal (HPA) axis, dopaminergic activity, enzyme studies, brain imaging, electroencephalogram sleep profiles, and measures of serotonergic function when compared with nonpsychotic depression. The social and occupational impairment in MDpsy has been hypothesized to be secondary to subtle cognitive deficits caused by the higher cortisol levels frequently observed in MDpsy patients. Several studies support a relationship between bipolar disorder and MDpsy, particularly in young-onset MDpsy. The most efficacious treatments for MDpsy include the combination of an antidepressant and an antipsychotic, amoxapine, or electroconvulsive therapy. Atypical antipsychotic medications may have particular relevance for the treatment of MDpsy because of the potential for reduced risk of extrapyramidal side effects and tardive dyskinesia, as well as antipsychotic and possibly antidepressant qualities. Based on the observations that MDpsy patients exhibit marked dysregulation of the HPA axis and elevated cortisol levels, several antiglucocorticoid strategies have been employed to treat MDpsy patients. Many questions regarding the acute and long-term treatment of MDpsy remain for future studies to address.

An open label trial of C-1073 (mifepristone) for psychotic major depression

BACKGROUND

The rationale for treating patients with psychotic major depression (PMD) with glucocorticosteroid receptor (GR) antagonists is explained.

METHODS

Thirty patients with PMD, with Hamilton Rating Scale for Depression (HAMD-21) scores of 18 or greater, were assigned in an open label trial to receive 50 mg, 600 mg, or 1200 mg of mifepristone for 7 days.

RESULTS

All the subjects completed the protocol; there were no dropouts. Side effects were mild and sporadic. Of 19 subjects in the combined 600- and 1200-mg group, 13 had a 30% or greater decline in their Brief Psychiatric Rating Scale (BPRS) scores, compared with 4 of 11 in the 50-mg group. In the 600- and 1200-mg group, 12 of 19 subjects showed a 50% decline in the BPRS positive symptom subscale, a more sensitive index for the symptoms seen in PMD, compared with 3 of 11 in the 50-mg group; 8 of 19 subjects in the 600- and 1200-mg group had a 50% decline in the HAMD-21, compared with 2 of 11 in the 50-mg group.

CONCLUSIONS

These results suggest that short term use of GR antagonists may be effective in the treatment of psychotic major depression and that further blinded studies are warranted.

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE

OBJECTIVE

To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression.

METHODS

The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score <or=10 on the 24-item Hamilton Rating Scale for Depression (HRSD) after 2 consecutive treatments, and a decrease of at least 60% from baseline.

RESULTS

The overall remission rate was 87% for study completers. Among these, patients with psychotic depression had a remission rate of 95% and those with nonpsychotic depression, 83%. Improvement in symptomatology, measured by the HRSD, was more robust and appeared sooner in the psychotic patients compared with the nonpsychotic patients.

CONCLUSION

Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Rapid reversal of psychotic depression using mifepristone

The rationale for treating psychotic major depression with glucocorticoid receptor (GR) antagonists is reviewed. Five patients with psychotic major depression were given 600 mg of mifepristone in a 4-day, double-blind, placebo-controlled crossover study. All the patients completed the protocol and adverse effects were not observed or reported. All of the five patients showed substantial improvements in their Hamilton Rating Scale for Depression scores while they were receiving mifepristone, and four of the five patients showed substantial improvement in their Brief Psychiatric Rating Scale scores. Little, if any, improvement was seen with placebo. These preliminary results suggest that short-term use of GR antagonists may be effective in the treatment of psychotic major depression and that additional study, perhaps using higher doses or more treatment days, seems warranted.

Factors affecting fluvoxamine antidepressant activity: influence of pindolol and 5-HTTLPR in delusional and nondelusional depression

BACKGROUND

It has been recently reported that the short variant of the serotonin transporter (5-HTT) gene-linked functional polymorphic region (5-HTTLPR) influences the antidepressant response to certain selective serotonin reuptake inhibitors. The aim of the present study was to test this finding in a sample of major and bipolar depressives, with or without psychotic features.

METHODS

One hundred fifty-five inpatients were treated with fluvoxamine 300 mg and either placebo or pindolol in a double-blind design for 6 weeks. The severity of depressive symptoms was weekly assessed with the Hamilton Rating Scale for Depression. Allelic variation of 5-HTTLPR in each subject was determined using a polymerase chain reaction-based technique.

RESULTS

5-HTTLPR short variant was associated with a poor response to fluvoxamine treatment, independently from the recorded clinical variables. More specifically, the diagnosis, the presence of psychotic features, and the severity of depressive symptomatology did not influence this association. Conversely, pindolol augmentation may ameliorate the rate of response in 5-HTTLPR short variant subjects, thus reducing the difference in the response rate among the genotype variants.

CONCLUSIONS

If confirmed, these results may improve patient care by helping the clinician to individualize treatment according to the patient's genetic 5-HTTLPR pattern.

Convulsive therapy: a review of the first 55 years

Convulsive therapy was introduced to psychiatric practice in 1934. It was widely hailed as an effective treatment for schizophrenia and quickly recognized as equally effective for the affective disorders. Like other somatic treatments, it was replaced by psychotropic drugs introduced in the 1950s and 1960s. But two decades later, ECT was recalled to treat pharmacotherapy-resistant cases. Avid searches to optimize seizure induction and treatment courses, to reduce risks and fears, to broaden the indications for its use, and to understand its mechanism of action followed. Unlike other medical treatments, however, these searches were severely impeded by a vigorous antipsychiatry movement among the public and within the profession. ECT is effective in the treatment of patients with major depression, delusional depression, bipolar disorder, schizophrenia, catatonia, neuroleptic malignant syndrome, and parkinsonism, and this breadth of action is both remarkable and unique. ECT is a safe treatment. No age or systemic condition bars its use. Its major limitations are the high relapse rates and the occasional profound effects on memory and recall that mar its success. Experiments to sustain its benefits with medications and with continuation ECT are underway. Its mode of action remains a mystery and this puzzle is an unappreciated challenge. The full impact of this intervention is yet to be felt.

ECT has much to offer our patients: it should not be ignored

ECT is an effective treatment for severe mental disorders, including major depression, delusional depression, bipolar disorder, manic delirium, schizophrenia, malignant catatonia, and neuroleptic malignant syndrome. It reduces suicidality, melancholia, catatonia, aggression, and excitement. Age is no barrier, with ECT successful in children, adolescents, and the old-old. It is effective when other treatments have failed. It is a safe treatment. The mortality rate is less than that associated with normal pregnancies. The fractures, panic, and amnesia that marked early treatments have now been modified. Even amnesia, which is often described as the main objection of patients, and the relapse rates are now comparable to the effects of medicines. It is an efficient treatment, costing less for a course of treatment than conventional new medicines and hospitalization. National and international psychiatric societies ignore ECT in their educational programmes. I believe that the leaders have a duty to our patients to provide a forum and educational opportunities for their members for all interventions that may relieve mental disorders. To ignore ECT, an effective treatment, is to do a disservice to our patients, and to abrogate the Hippocratic Oath to which many practitioners subscribe.

Patterns of symptom improvement during antidepressant treatment of delusional depression

We assessed the pattern of changes in depressive symptoms in delusional depressed inpatients treated openly with 300 mg/day of fluvoxamine for 6 weeks. We studied 59 inpatients affected by bipolar (n=23) and major depressive (n=36) disorders with psychotic features (DSM-IV) who showed complete responses to fluvoxamine treatment. Responses were evaluated using the Hamilton Rating Scale for Depression (HAMD-21, divided into: Core, Activity, Psychic anxiety, Somatic anxiety and Delusion clusters) administered at baseline and weekly until the 6th week. Random Regression Model (RRM) analysis was used to investigate the longitudinal time course of HAMD clusters. HAMD depressive symptom clusters decreased in a parallel manner from baseline to the end of the 6-week trial. The RRM analysis revealed no significant difference between HAMD clusters and the time course of the total HAMD score during treatment. Our data indicate that there is a simultaneous decrease in depressive symptoms during antidepressant treatment of delusional depressives.

Clinical and demographic features of psychotic and nonpsychotic depression

The present study evaluated clinical and demographic features of subjects with delusional versus nondelusional major depressive disorder. Two hundred eighty-eight subjects with mood disorder (bipolar disorder, n = 94; major depressive disorder, n = 194) were included in the study. No differences were observed for gender, polarity of mood disorder, age of onset, duration of index episode, number of episodes, number of previous hospital admissions, frequency of illness episodes, and number of suicide attempts. On the other hand, delusional subjects showed a higher rate of cluster A personality disorder and a lower level of education. We also detected a larger number of cluster B personality disorders among nondelusionals. Our data suggest that subjects with delusional mood disorder do not differ substantially from nondelusionals in terms of the clinical and demographic variables considered in this study except for personality disorders.

The differentiation of DSM-III-R psychotic depression in later life from nonpsychotic depression: comparisons of brain changes measured by multispectral analysis of magnetic resonance brain images, neuropsychological findings, and clinical features

BACKGROUND

Psychotic depression has been proposed as a distinct subtype of major depression. There is considerable evidence for this in younger patients, although the neuroimaging has been rudimentary. Volumetric imaging studies are required of consecutive cohorts of patients with depression.

METHODS

Ninety-nine consecutive elderly patients were diagnosed with DSM-III-R major depression. Eighteen were psychotic, and 81 were not. Sixty-six patients were given a neuropsychological test battery, and 44 had a magnetic resonance imaging brain scan. A model integrating clinical, psychological, and neuroimaging findings for the explanation of delusion formation during depression is proposed.

RESULTS

Psychotic depression was characterized by worse physical health, more family history of depression, a poorer response to antidepressant drugs, and more severe lowering of mood; however, the strongest predictors of the presence of delusions were diencephalic atrophy, reticular activating system lesions, brain stem atrophy, and left-sided frontotemporal atrophy. The psychotic patients had poorer performance on tests of frontal lobe function and mental processing speed.

CONCLUSIONS

In the elderly, psychotic depression is etiologically, clinically, and neuroradiologically distinct, and has different treatment requirements, from nonpsychotic major depression.

Predictors of response to amine-specific antidepressants

Discriminant function analysis of data from a double-blind comparative trial of lofepramine (a noradrenaline-specific reuptake inhibitor) and fluoxetine (a serotonin-specific reuptake inhibitor), involving 183 patients was used to identify predictors of response. Psychic anxiety significantly predicted a positive response to antidepressant medication, whereas psychomotor retardation, observed sadness, subjective lassitude and somatic complaints were significant predictors of nonresponse. Age, gender, endogenicity, duration of illness and number of previous episodes were not predictive of response. Significant differences were found between predictors of response to fluoxetine and lofepramine (P < 0.001 all groups). Predictors of response to lofepramine were similar to overall predictors, i.e., psychic anxiety predicted responders whilst observed sadness, psychomotor retardation, lassitude, inability to feel and somatic complaints predicted nonresponders. In contrast, baseline weight loss predicted response to fluoxetine, whereas anxiety, reduced insight and a tendency to blame others significantly predicted nonresponse. Such findings have practical implications for the management of depressive illness.

Old data, new interpretation: a re-analysis of Sir Aubrey Lewis' M.D. thesis

Sir Aubrey Lewis studied 61 depressives in considerable detail, principally cross-sectionally but also by reviewing progress. He concluded that he could find no qualitative distinctions between the depressed patients and thus established himself as a strong and influential advocate of the unitary view of depression (i.e. that depression varies dimensionally, not categorically). Subsequently, Kiloh & Garside (proponents of the binary view of two depressive 'types') coded the Lewis data and undertook a principal components analysis. They claimed success in distinguishing 'endogenous' and 'neurotic' depressive types within Lewis' sample. In this paper we re-analyse the data set using both a latent class categorical approach and mixture analyses. We suggest that any demonstration of sub-types was limited by relative homogeneity of the sample (in that up to 80% had probable or possible psychotic conditions), and by Lewis rating a number of important features (e.g. delusions) dimensionally rather than categorically. Nevertheless, we identify one categorical class (essentially an agitated psychotic depressive condition) and a residual (presumably heterogeneous) class. The presence of those two classes was supported by demonstrating bimodality in composite scores derived from the fourteen differentiating clinical features (and not evident when all clinical features were considered), and formally confirmed by mixture analyses. Membership of the categorical class was determined principally by psychotic features (delusions and hallucinations) and by objectively-judged psychomotor disturbance, and we consider the nature of that 'class'. Lewis' data set is unusual (in having self-report and observationally rated data), and historically important in demonstrating that conclusions may depend on the choice of variables examined and analytical approaches.

Patterns of course in patients with a cross-sectional diagnosis of schizoaffective disorder

The authors conducted a longitudinal study on two samples of patients, fulfilling Research Diagnostic Criteria for schizoaffective disorder and for major affective disorder, respectively. The long-term course in patients defined cross-sectionally as schizoaffective was very heterogeneous. Ten different patterns of course were identified. In schizoaffectives showing a bipolar course with the occurrence of pure affective episodes, the outcome was not different from that in patients with a cross-sectional diagnosis of major affective disorder, whereas in schizoaffectives whose course was characterized by the occurrence of schizodepressive episodes only, or of schizodepressive and schizophrenic episodes, the outcome was significantly poorer than in patients diagnosed as affective.

Specificity of plasma HVA response to dexamethasone in psychotic depression

Earlier reports have suggested that dexamethasone significantly increases levels of plasma homovanillic acid (HVA) in normal subjects, but that this effect may be altered in some depressed patients. To investigate the specificity of such alterations, we administered dexamethasone (1 mg p.o. at 11 p.m.) to 33 normal subjects, 27 depressed patients (8 with psychotic features), and 16 schizophrenic patients. Plasma for assay of cortisol and HVA was obtained at 4 p.m. before and on the day following dexamethasone administration. Dexamethasone induced significant increases in plasma HVA in the normal subjects and in the schizophrenic patients, but not in the depressed patients. Indeed, psychotically depressed patients tended to show a dexamethasone-associated decrease in plasma levels of HVA. In contrast to cortisol "suppression" or "nonsuppression," dexamethasone-induced changes in plasma levels of HVA (i.e., increases or decreases) sensitively and specifically discriminated between patients with affective and nonaffective psychoses.

Proposed delusional depression subtypes: preliminary evidence from a retrospective study of phenomenology and treatment course

An analysis of the phenomenology and treatment course of 52 subjects with delusional depression suggests that there may be various subtypes: bipolar, early-onset unipolar and possibly a late-onset unipolar. The bipolar subgroup tended to relapse in different but always psychotic directions, and was resistant to lithium carbonate treatment alone. Treatment refractoriness, delusional depressive recurrences, and a dementia-like presentation were associated with a small late-onset subgroup. A high rate of delusionally depressive relapses also characterized the early-onset unipolar group, however, patients with single episodes were found only in this subgroup.

Delusional and non-delusional depression in late life. Evidence for distinct subtypes

The study tests the hypothesis that delusional and non-delusional depressive illnesses are distinct entities in late life. Two groups of 24 patients with late-onset depression, one with and one without delusions, were compared retrospectively. At the index admission, deluded patients were significantly more depressed, were in hospital for longer, responded poorly to antidepressants alone and required more physical treatments, especially ECT and major tranquillisers. Although illness severity was a major factor accounting for these differences, the finding that only the deluded group experienced delusional relapses suggests an underlying intrinsic susceptibility. The discharge status was similar for both groups, as were relapse rates over 48 months and the clinical course of depressive symptoms over 42-104 months. The findings are consistent with studies of younger patients which point to a distinction between these two types of depression, but not with recent work suggesting a very poor prognosis for delusional depression in late life.

Placebo response rates in psychotic and nonpsychotic depression

The authors reanalyzed data from two earlier studies that used double-blind placebo-controlled formats to study the efficacy of amitriptyline. Using a 14-day drug-free 'wash-out' period, they found that the placebo response rates were 0% for psychotic depressives and 13.3% for nonpsychotic depressives. Amitriptyline was significantly superior to placebo for both psychotic (P less than or equal to 0.05) and nonpsychotic (P less than or equal to 0.05) depressed patients.

Clinical course and outcome of delusional psychosis

The purpose of the study was to examine first-admitted patients with delusional psychosis meaning functional psychosis with paranoid symptoms with respect to clinical course and outcome. The index population comprised 88 patients. At discharge from first admission the patients were classified according to ICD-8 and DSM-III. According to both diagnostic classifications the majority of the patients did not belong to either of the two major psychotic groups, schizophrenia or affective psychosis. During the 2-year observation period half of the patients took psychotropic drugs continuously, and almost half of the patients experienced one or more relapses. One third of the patients were readmitted, and in average the patients stayed in the hospital for 4 months during the observation period including the time of index admission. At follow-up half of the patients revealed positive psychotic symptoms, while two thirds were moderately or severely impaired because of psychotic illness or personality dysfunction. It is concluded that the present aftercare treatment is insufficient to prevent relapse and psychotic symptoms. In consequence of this the existence of delusions at first admission to hospital because of functional psychosis seems for many to predict an unfavourable course and outcome. Further study will search for clinical and social predictors of course and outcome in patients with delusional psychosis.

Evaluation and treatment of paranoid syndromes in the elderly: a review

Paranoid symptoms in the elderly patient may be a manifestation of medical, neurologic, psychiatric, or medication-induced illness. Because of the potential for multiple interacting factors between underlying organicity and psychiatric illness precise assessment of the etiology of the patient's psychotic behavior may be difficult. This article reviews the medical and neurologic illnesses often associated with paranoia in the elderly as well as the psychiatric differential diagnosis. Psychotic depression, late-onset schizophrenia, and delusional/paranoid disorders are examined, as are their treatments. Revisions in the nosology of late-onset psychosis as they are affected by revisions in DSM-III-R are also discussed.

The prognosis of depression in old age

The initial features and progress of depressive symptomatology over 42 to 104 months are presented for 100 elderly patients admitted with severe, non-neurotic depressive states; none had experienced a previous hypomanic episode. Sixty per cent either remained well throughout or had further episodes followed by full recovery; only 7% suffered continuous depressive symptoms. Of potential prognostic factors, only male sex and poor physical health, both at presentation and developing subsequently, were associated with poorer outcomes. The view is supported that treatment with well established methods achieves worthwhile and sustained improvement for most patients.

Platelet 5-HT uptake in delusional and nondelusional depressions

Platelet 5-hydroxytryptamine (5-HT) uptake was measured in a group of 28 endogenously depressed patients, at three points during the day, before, during and after treatment. It was also measured in 20 controls at the same three times. Uptake rates varied in control subjects in a manner consistent with the presence of a circadian rhythm in uptake. This variation was absent in depressed subjects. Deluded and nondeluded depressives showed a similar absence of variation but differed in the absolute values for their uptake rates. In particular deluded depressives did not show the lowering of platelet uptake rates, which has been widely reported for endogenous depression. This difference between the two groups was maintained after treatment was started but was not present after clinical recovery, suggesting a state-rather than trait-dependent marker. These differences between deluded and nondeluded depressives have implications for the investigation of platelet 5-HT uptake in other psychiatric illnesses.

Hallucinations in patients with major depression. Interactions between CSF monoaminergic and endorphinergic indices

CSF levels of radioreceptorassayed endorphins Fraction I (EndFI, n = 92) and homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) (n = 118) were measured in patients with major depressive disorders according to Research Diagnostic Criteria (18% were psychotic; 11% hallucinated during the peak of the depressive episode). CSF measures (both "raw" variables and ranks) were uni- and multivariately correlated with both dichotomized and scored measures of hallucinations of any type. Hallucinations were statistically strongly associated with higher HVA levels, irrespective of prior medication with neuroleptics, and with the interactive product HVA X EndFI and the interactive ratio HVA/5-HIAA. Results suggest interactions between dopaminergic, serotonergic and endorphinergic neurotransmission being involved in the biochemical substrate of depressive hallucinatory episodes.

Empirical study on an inpatient psychogeriatric unit: biological treatment in patients with depressive illness

A study of 112 psychogeriatric admissions identified seventy patients sufficiently depressed to require biologic treatment. Twenty-four patients completed a primary treatment trial with TCA's and seventeen with ECT. ECT proved to be more effective, (81.4% versus 62.5%), even though overtly psychotic and medically unstable patients preferentially received this treatment. The ECT response rate is comparable to other reports of its efficacy in the treatment of delusional depression. A higher morbidity rate of 27 percent in the TCA-treated group was observed. The authors conclude that ECT is a highly beneficial treatment modality for the carefully selected elderly patient with major depressive illness. They found that a higher number of ECT treatments than expected were required in their psychogeriatric patients, but did not find a higher morbidity other than increased confusion with more treatments. Careful repeated assessment of response to treatment combined with readiness for assertiveness, in spite of the advanced age of the patient, seem to be indicated. Conversely, excessive hesitance when caring for the elderly patient may lead to a premature termination of treatment, causing the patient to remain in a chronic mentally compromised state.

A corticosteroid/dopamine hypothesis for psychotic depression and related states

In recent years, considerable data have emerged that psychotic (delusional) depression is characterized by pronounced increases in hypothalamic-pituitary-adrenal (HPA) axis activity and positive responses to combined treatment with tricyclic antidepressants and antipsychotic (dopamine-blocking) agents. Recently, a number of observations in several species, including man, point to glucocorticoids' increasing dopamine activity in a variety of tissues and this effect is particularly marked in rat brain mesolimbic dopamine systems. We propose that glucocorticoids' enhancement of dopaminergic activity may explain the development of psychosis/delusions in the context of the depressive episode. Data in support of the hypothesis are presented and the identification of possible enzymatic risk factors are discussed. These interactions also have implications for understanding the biology of corticosteroid-induced psychoses in medical patients and some of the psychiatric complications of Cushing's Disease.

The dexamethasone suppression test in psychotic versus non-psychotic endogenous depression

The authors investigated the dexamethasone suppression test (DST) in 93 female patients with primary (endogenous) major depression; in 20 female paranoid schizophrenics, and in 17 healthy females. Depressed patients had a significantly higher rate of abnormal DST response and significantly higher post-dexamethasone serum cortisol levels than schizophrenics and normal controls. The unipolar and bipolar depressives showed a similar profile of DST abnormalities. Depressed patients with psychotic features had a significantly higher rate of positive DST results than non-psychotic patients.

Paranoid schizophrenia: an unorthodox view

Most paranoid patients have traditionally been diagnosed as schizophrenic, although considerable evidence points to the dissimilarities between paranoid and nonparanoid schizophrenic patients and to commonalities between paranoid and affective disorder groups. Based on a review of research, it is suggested that paranoid schizophrenia, at least in some of its varieties, may more fruitfully be conceptualized as a phenotypic expression of an underlying depressive mode than as a schizophrenic form. This formulation is presented within the framework of a broad examination of diagnostic issues.

Delusional depressive in-patients, 1892 to 1982

Three groups of 114 depressed patients admitted to hospital in Edinburgh, one in the year 1892, one in 1942-3 and one in 1981-2, were studied. The occurrence and content of depressive delusions were recorded. A significantly higher proportion of depressives had delusions in 1892 than in 1942-3, but there was no significant decline between 1942-3 and 1981-2. It is concluded that this decline in the proportion of depressive having delusions since 1892 probably does not reflect a genuine decline in the prevalence of depressive illness with delusions. The content of delusions differs between the years and between the sexes, and these differences are discussed.

Persistent discrepancy in international diagnostic practice since 1970

National admission statistics by diagnosis since 1970, were available from seven WHO member countries. All had officially introduced the ICD 8, but only two countries strictly adhered to the ICD categories in practice. The new 3-digit category 298 (Other psychosis) has met with no success, nor did the new subgroups of schizophrenia with a favourable outcome (295.4, 295.5 and 295.7) gain much acceptance. The discrepancy in diagnostic distribution is virtually unchanged from that before 1970 with a persistent wide concept of schizophrenia in U.S.A. and of depressive illness in England. A new feature is the striking increase in non-psychotic admissions at a time when there is a marked decline in the hospital population. This is taken to indicate that the social stigma attached to the term psychosis persists, and is met with evasion. A preference for unspecified terms (fourth digit 9) is evident, as is the use of terms which leave open whether the patient is psychotic or not (311 in ICD 9). Evidently, instruction in the use of the WHO glossary is called for. In the U.S.A. the replacement of the ICD by the local classification DSM-III is likely to accelerate the reluctance to accept international standards. Moreover, the development of local diagnostic systems for research purposes in England and U.S.A. is not without problems, as there is a disturbing lack of consensus in diagnosis between these two national systems. Obviously, we need the ICD with its clear concepts, and above all the ICD is valuable for securing continuity in diagnostic classification.

Recurrent psychotic depression. Evidence of diagnostic stability

A review of the research comparing psychotic and nonpsychotic depression gives considerable evidence to support the view that these groups are distinct diagnostic subtypes. A representative sample of the research favoring this view is presented. Particular note is made of Charney and Nelson's data on stability of diagnosis. Our finding of 92.3% of psychotic depressives experiencing previous and/or subsequent psychotic episodes is consistent with Charney and Nelson's findings. Additional support for stability of diagnosis is the rare occurrence of nonpsychotic depression found after the index psychotic admission. Clinical and research implications are discussed.

Response to dexamethasone in psychotic depression

The utility of the dexamethasone suppression test (DST) in the diagnosis of psychotic depression was examined by comparing the responses of 11 psychotic and 18 nonpsychotic depressed inpatients. Nine of 11 psychotic patients (81.8%) and 10 of 18 nonpsychotic patients (55.6%) showed nonsuppression (nonsignificant). Using the 0800h cortisol level alone, we found that significantly more psychotic patients (7 of 11; 63.6%) than nonpsychotic patients (3 of 18; 16.7%) showed nonsuppression. Nonsuppression at 0800h postdexamethasone may be a useful biologic marker for patients with psychotic depression. Implications of these data for the nosologic status of psychotic depression are discussed.

Lithium induces rapid relief of depression in tricyclic antidepressant drug non-responders

Eight patients suffering from a major unipolar depression and having field to respond to treatment for three weeks or more with tricyclic antidepressants were given lithium. All eight patients experienced a remarkable relief of their depression within 48 hours. This rapid antidepressant effect of lithium in "treatment-resistant' patients might be due to the enhancement of the efficacy of the central serotoninergic system, unveiling the tricyclic antidepressant-induced sensitization of the serotoninergic postsynaptic receptors.

Elderly depressives: treatment and follow-up

Seventy-four depressed inpatients, 65 years of age or more, were consecutively treated in the Geriatric Unit of St. Thomas Psychiatric Hospital, during the years 1972 to 1978. Four died while inpatients and sixty-nine left hospital after an average stay of 3 1/2 months. Ten patients had been readmitted during follow-up and within a period of between six months and two years after discharge. Five outpatients have died, two by suicide. Elderly depressives respond well to modern treatment provided medication and aftercare are maintained.

Depressed patients with schizophrenic or paranoid symptoms

Family history, response to treatment and outcome are reported in a series of 76 patients presenting with both depression and schizophrenic or paranoid symptoms. About 10% of psychotic admissions to the Maudsley and Bethlem Royal Hospitals met a study definition of "schizodepressive" illness. The patients were highly heterogeneous in history, clinical picture and outcome. Many followed a typical schizophrenic course, and others a typical course for effective disorders, but only 4 were given a final diagnosis of manic depressive disease. The best predictors of poor outcome were a mode of onset as an exacerbation of previous psychotic symptoms and the presence of schizophrenic symptoms at some time without depression. The best predictors of good outcome were Stephens' criteria of good prognosis schizophrenia and Kasanin's concept of "acute schizo-affective psychosis". These findings are not easily reconciled with Kraepelin's two entities principle but suggest a continuum of outcome between schizophrenia and unipolar depressive psychosis.

Three cases of unipolar delusional depression responsive to L-dopa

We reported three cases of unipolar delusional depression which took a characteristic two-stage clinical course. Anxiety and agitation with persecutory delusions predominated the picture at first, but they were soon replaced by severe psychomotor retardation or stupor associated with delusions of poverty and guilt. The administration of L-Dopa in the latter stage brought about a rapid improvement both in mood and psychomotor activity. We considered these cases in the light of the recent biochemical studies on affective psychosis.

Male delusional depressed patients: response to treatment

In view of the previous finding that female deluded depressed patients do not respond to tricyclic antidepressants, a retrospective review of charts of thirteen male patients with primary depression accompanied by delusions were undertaken. None improved on tricyclics alone, whereas all those treated initially with neuroleptics improved. Twelve out of thirteen patients showed no improvement until neuroleptics were added to the treatment regimen. Implications for classification and treatment are discussed.

Trials of lithium, chlorpromazine and amitriptyline in schizoaffective patients

Two drug trials in schizoaffective patients are reported. Nineteen "schizomanic" patients were treated for one month, on a double blind basis, with chlorpromazine or lithium and 41 "schizodepressive" patients with amitriptyline, chlorpromazine or both. In the schizodepressive patients there was a trend to a better response to chlorpromazine, but drug response generally was poor, only 20 per cent of patients recovering within the month. In the schizomanic patients lithium seemed as effective as chlorpromazine, which supports the view that these patients were suffering from a variant of mania.