Mixed anxiety-depressive disorder and major depressive disorder: comparison of the severity of illness and biological variables

Mixed anxiety-depressive disorder (MADD) is a new diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. Patients do not meet the criteria for specific anxiety or depressive disorders. The emergence of the symptoms is independent of stressful life events. There are many issues presently under investigation about the validity of this clinical entity. In this study, a group of 29 patients with MADD was compared with a group of 31 patients with major depressive disorder (MDD) to assess the differences and similarities between these two disease categories in terms of severity measures and biological variables. The dexamethasone suppression test (DST) was employed, and thyroid hormones and thyrotropin (TSH) levels were measured for the evaluation of hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axes, respectively. The patients with MADD were found to be less depressive and more anxious compared to those with MDD. DST responses and thyroid functions were found to be similar in the two groups. When severity of depression was controlled, k(max) and 2300-h cortisol values were found to be significantly higher in the MADD group. Although the patients with MDD and MADD presented with relatively different clinical features, there is not enough biological evidence indicating that MADD represents a discrete diagnostic category. However, there may be relatively higher HPA activity in MADD patients.

The specificity of stress responses to different nocuous stimuli: neurosteroids and depression

The role that adrenal cortex and neurosteroid hormones may have in the etiology and/or maintenance of depressive diseases is discussed. Selye's concept of stress as the summation of unspecific body responses of the autonomic central nervous system (CNS) and hypothalamic pituitary adrenal axis (HPAA) as the main characteristic of it is contrasted with Mason's view of stress responses as being specific for different stimuli, i.e., the neuroendocrine system responds with the production of a hormonal profile individualized and characteristic for the various stimuli applied. The data reviewed provides support for Mason's interpretation of stress as fundamentally a behavioral response. In turn, the high relevance of emotional factors in the determination of stress responses led to a reconsideration of cognitive-affective interactions in nervous systems. Recent results revealed that improvement in depression treated with antidepressants (ADs) is associated with an increase in the neurosteroid 3alpha 5alpha tetrahydroprogesterone, both in the blood and cerebrospinal fluid of recovered patients. The increase occurs with both selective serotonin reuptake inhibitors and tricyclic ADs. An evaluation of the possible and putative roles for neurosteroids in the CNS is presented and suggestions for enhancing the type of supporting data from the laboratory diagnosis of depressions are advanced.

Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain

OBJECTIVE

Although numerous organic conditions may cause chronic pelvic pain (CPP), diagnostic laparoscopy reveals a normal pelvis in many patients with CPP. However, psychological studies yield a high frequency of psychopathology and increased prevalences of chronic stress and traumatic life events, ie, sexual and physical abuse, in women with CPP, suggesting a relationship between posttraumatic stress disorder (PTSD) and CPP. As chronic stress and PTSD have been associated with specific alterations of the hypothalamic-pituitary-adrenal (HPA) axis, we explored stress history, psychopathology and HPA axis alterations in women with CPP.

METHOD

We recruited 16 patients with CPP and 14 painfree, infertile controls from a general hospital where diagnostic laparoscopy was performed. Psychological assessment included standardized interviews on clinical symptoms, abuse experiences and major life events as well as psychometric testing for PTSD-like symptoms and depression. Endocrinological evaluation involved determinations of diurnal salivary cortisol levels and hormonal responses to a corticotropin-releasing factor (CRF) stimulation test (100 microg human CRF) and a low-dose dexamethasone suppression test (0.5 mg).

RESULTS

We observed increased prevalences of abuse experiences and PTSD in women with CPP as well as a higher total number of major life events, whereas the mean extent of depression was within the normal range. With respect to endocrine measures, women with CPP demonstrated normal to low diurnal salivary cortisol levels, normal plasma-adrenocorticotropin (ACTH), but reduced salivary cortisol levels in the CRF stimulation test, and an enhanced suppression of salivary cortisol by dexamethasone.

CONCLUSION

Women with CPP demonstrate HPA axis alterations, that partly parallel and partly contrast neuroendocrine correlates of PTSD, but show marked similarity to findings in patients with other stress-related bodily disorders. These findings suggest that a lack of protective properties of cortisol may be of relevance for the development of bodily disorders in chronically stressed or traumatized individuals.

Natural steroids counteracting some actions of putative depressogenic steroids on the central nervous system: potential therapeutic benefits

Psychological similarities in the symptomatology of Cushing's and depressive diseases led to repeated attempts of treatment of the affective disease by suppression of adrenocortical secretion. While successful in many patients, all drugs employed-metyrapone, ketoconazole and aminoglutethimide-carry the danger of inducing adrenal insufficiency. In addition, their undesirable side effects were also a main reason for treatment suspension. In our 1990 proposal for the treatment of depression through control of adrenal steroid levels, we set as one of the goals the identification of steroids which can antagonize each other on their effects on the central nervous system. Specifically, we looked first at steroids that could counter each other's effects on long-term potentiation, a putative memory mechanism in the central nervous system. One reason for this was the consensus that memory mechanisms are affected in both Cushing's and depressive patients. Another was the fact that cortisol-type hormones which underlie, at least in part, the depressogenic actions of adrenal steroids also have inhibitory effects on LTP. We conjectured, then, that a steroid with opposite effects, one that could enhance long-term potentiation and, further, that could counter the depressant effects of corticosterone on long-term potentiation, could be of use in the treatment of depression. Dehydroepiandrosterone sulfate increases long-term potentiation in a dose-related manner, and preliminary data suggest that it also counteracts the depressant effects of corticosterone on long-term potentiation when injected simultaneously on experimental animals. Potentially at least, rather than resort to total suppression of adrenocortical activity, it may be possible to treat depression just by counteracting some of the effects of cortisol-like hormone actions in the central nervous system. Further, both in clinical trials as well as in experimental animals, dehydroepiandro-sterone sulfate has been shown to enhance performance in memory-requiring tasks.

Clinical, magnetic resonance imaging and endocrinological differences between delusional and non-delusional depression in the elderly

OBJECTIVE

To investigate neuroradiological, endocrinological and clinical differences between delusional and non-delusional depression.

DESIGN

A cross-sectional study of depressed subjects.

SETTING

Melbourne, Australia.

PARTICIPANTS

Sixty-one subjects (inpatients) over the age of 55 meeting DSM-III-R criteria for major depression of whom 22 had delusional subtype of depression.

MEASURES

Clinical assessment, including documentation of vascular risk factors. Cognitive assessment by the Cambridge Cognitive Examination (CAMCOG). Magnetic resonance imaging (MRI) scans were performed on a 0.3 Tesla scanner with temporal lobe atrophy, periventricular lesions (PVL) and deep white matter lesions (DWML) rated visually on 4-point scales. A standard 1 mg dexamethasone suppression test (DST) was performed.

RESULTS

Subjects with delusional depression had significantly more vascular risk factors than those without delusions. There were no differences in measures of temporal lobe atrophy, PVL, DST results or cognitive test scores, though there was a non-significant trend for DWML to be more prevalent in those with delusions. Delusional depression was associated with a shorter duration of history and more frequent treatment with ECT.

CONCLUSIONS

The increase in vascular risk factors and trend towards greater DWML on MRI suggests an organic contribution to delusional depression in the elderly. In contrast to some previous reports, we found no differences in cortical MRI appearance or neuroendocrine measures between groups.