Metabolic/inflammatory/vascular comorbidity in psychiatric disorders; soluble epoxide hydrolase (sEH) as a possible new target

The common and severe psychiatric disorders, including major depressive disorder (MDD) and bipolar disorder (BD), are associated with inflammation, oxidative stress and changes in peripheral and brain lipid metabolism. Those pathways are implicated in the premature development of vascular and metabolic comorbidities, which account for considerable morbidity and mortality, including increased dementia risk. During endoplasmic reticulum stress, the soluble epoxide hydrolase (sEH) enzyme converts anti-inflammatory fatty acid epoxides generated by cytochrome p450 enzymes into their corresponding and generally less anti-inflammatory, or even pro-inflammatory, diols, slowing the resolution of inflammation. The sEH enzyme and its oxylipin products are elevated post-mortem in MDD, BD and schizophrenia. Preliminary clinical data suggest that oxylipins increase with symptoms in seasonal MDD and anorexia nervosa, requiring confirmation in larger studies and other cohorts. In rats, a soluble sEH inhibitor mitigated the development of depressive-like behaviors. We discuss sEH inhibitors under development for cardiovascular diseases, post-ischemic brain injury, neuropathic pain and diabetes, suggesting new possibilities to address the mood and cognitive symptoms of psychiatric disorders, and their most common comorbidities.

Impact of chronically street homeless tenants in congregate supportive housing

New initiatives to house chronically street homeless (CSH) adults have led to increasing proportions of this population living in congregate supportive housing, but little is known about the impact of this shift on supportive housing programs. The present multisite, mixed-methods study examined service utilization and lease compliance among 52 chronically street homeless and 46 long-term shelter stayer (LTSS) adults during their first 12 months in congregate supportive housing. Quantitative analysis of administrative data revealed that CSH tenants used significantly more service resources than LTSS tenants, including more advocacy, escorting, and psychiatric treatment and more assistance with financial, housing, and mental and physical health issues. The 2 groups did not differ significantly on measures of lease compliance. Qualitative focus groups with CSH tenants, service provider staff, and property management staff all indicated that existing supportive housing services are suitable for this population, although some adjustments, additional resources, or both, may be indicated.

Suicidal ideation in major depression: sex differences and impact of comorbid anxiety

BACKGROUND

Being female and having comorbid anxiety are both thought to increase suicidality in patients with major depression. Whether these effects are independent or related to severity of depression is not known.

METHOD

We conducted a retrospective review of 533 patients (190 men, 343 women) with major depression at the time of assessment.

RESULTS

Suicidal ideation was present in 57.8% of all patients, and 43.2% of all patients had a lifetime anxiety disorder. Significantly more women than men experienced suicidal ideation, and both men and women with a lifetime anxiety disorder were more likely to be suicidal. Age and severity of depression did not account for these results.

CONCLUSIONS

In patients with a current major depression, being female and having a lifetime anxiety disorder increase suicidality independently of one another and independently of severity of depression.

Estimated prevalence of the seasonal subtype of major depression in a Canadian community sample

OBJECTIVE

To examine estimates of lifetime prevalence of seasonal affective disorder (SAD) in Toronto, Ontario.

METHOD

Random telephone numbers were generated for the city of Toronto, and 781 respondents completed a telephone interview. Trained nonphysician interviewers conducted all interviews, which involved structured questions for diagnosing major depression. Patterns of symptom change across seasons were evaluated to establish a diagnosis of SAD according to DSM-III-R criteria.

RESULTS

Correcting for sex and age, the prevalence of SAD defined by DSM-III-R criteria was 2.9% (95% CI, 1.7% to 4.0%), and the overall lifetime prevalence of major depression in the sample was 26.4% (95% CI, 23.3% to 29.4%). Some subjects were contacted for a follow-up interview conducted in person; the positive predictive value for the diagnosis of major depression for the telephone interview was 100%, and the negative predictive value was 93%.

CONCLUSIONS

The seasonal subtype of depression represents 11% of all subjects with major depression, suggesting that SAD is a significant public health concern. The telephone interview demonstrated adequate reliability, indicating that it is appropriate for epidemiological surveys of this nature.

Impaired distractor inhibition on a selective attention task in unmedicated, depressed subjects

BACKGROUND

Impaired distractor inhibition may contribute to the selective attention deficits observed in depressed patients, but studies to date have not tested the distractor inhibition theory against the possibility that processes such as transient memory review processes may account for the observed deficits. A negative priming paradigm can dissociate inhibition from such a potentially confounding process called object review. The negative priming task also isolates features of the distractor such as colour and location for independent examination.

METHOD

A computerized negative priming task was used in which colour, identification and location features of a stimulus and distractor were systematically manipulated across successive prime and probe trials. Thirty-two unmedicated subjects with DSM-IV diagnoses of non-psychotic unipolar depression were compared with 32 age, sex and IQ matched controls.

RESULTS

Depressed subjects had reduced levels of negative priming for conditions where the colour feature of the stimulus was repeated across prime and probe trials but not when identity or location was the repeated feature. When both the colour and location feature were the repeated feature across trials, facilitation in response was apparent.

CONCLUSIONS

The pattern of results supports studies that found reduced distractor inhibition in depressed subjects, and suggests that object review is intact in these subjects. Greater impairment in negative priming for colour versus location suggests that subjects may have greater impairment in the visual stream associated with processing colour features.

Is self-criticism unique for depression? A comparison with social phobia

BACKGROUND

This study further examined the diagnostic specificity of the self-critical personality dimension, as measured by the Depressive Experiences Questionnaire (DEQ; Blatt et al., 1976. The Depressive Experiences Questionnaire. Yale University Press, New Haven).

METHODS

Patients with major depression (n=26) were compared to social phobia patients (n=32).

RESULTS

Depressed patients scored significantly higher on the DEQ Self-Criticism dimension. However, when current level of depressed mood was controlled for, self-criticism was not a significant predictor of diagnostic status. Further, the level of DEQ self-criticism reported by patients with social phobia was almost three times greater than the level reported in an earlier diagnostic specificity study with panic disorder patients [Bagby et al., 1992. Diagnostic specificity of the dependent and self-critical personality dimensions in major depression. J. Affect. Disord. 26, 59-64].

LIMITATIONS

Only one measure of self-criticism was used in this study, and the research design was cross-sectional rather than prospective.

CONCLUSIONS

Self-criticism is not unique to major depression, and this personality dimension may be implicated in other forms of psychopathology [Blatt, 1991. A cognitive morphology of psychopathology. J. Nerv. Ment. Dis. 179, 449-458]. Some cognitive features believed to play an important role in depression may also be salient in persons with social phobia.

Mexiletine in treatment-resistant bipolar disorder

BACKGROUND

The purpose of this study was to evaluate the efficacy and safety of mexiletine, a medication with antiarrhythmic, anticonvulsant and analgesic properties, in treatment-resistant bipolar disorder patients.

METHODS

Twenty subjects with rapid-cycling bipolar disorder who had failed to respond or were intolerant to lithium, valproic acid and carbamazepine were entered into the 6-week, open label study. Subjects were followed on a weekly basis for dosing of mexiletine, blood levels, and completion of the Hamilton Depression Rating Scale (HAM-D) and the Manic State Rating Scale (MSRS). "Burden of Mood Symptoms" (BMS) was calculated by combining scores for the HAM-D and MSRS.

RESULTS

Thirteen subjects (10 female, 3 male), mean age 41 years (S.D.=7.6), and mean duration of illness 20 years (S.D.=7.7) completed the study. The dose range of mexiletine was 200-1200 mg/day. Full response (>/=50% reduction in BMS) was seen in 46% of the subjects, and a partial response (25-49% reduction in BMS) in 15%. Of note, 5/5 subjects with a mixed or manic state demonstrated a full or partial response.

LIMITATIONS

This study has an open label design, and a small number of subjects.

CONCLUSIONS

Mexiletine may be effective and safe in patients with highly treatment-resistant, chronic bipolar disorder. Randomized, controlled trials are required to confirm the current results.

Rumination and distraction in major depression: assessing response to pharmacological treatment

BACKGROUND

Response style theory of depression (RST) predicts that individuals who ruminate in response to their depressed mood will suffer an amplification and prolongation of that mood, whereas individuals who engage in distraction responses will alleviate and attenuate their depressed mood. RST has been shown to predict prolonged depression in samples of non-clinical, untreated individuals with mild to moderate depression but has not been tested in samples of depressed patients undergoing treatment.

OBJECTIVE

In this preliminary investigation we examined: (1) whether RST predicts non-response to pharmacotherapy with outpatients suffering from major depression, and (2) whether distractive and ruminative responses are associated with clinical variables hypothesized to be associated with them.

METHODS

Eighty-nine depressed outpatients being treated with standard antidepressant pharmacotherapy were administered the Response Style Questionnaire, a scale designed to measure rumination and distraction, prior to treatment.

RESULTS

Distraction, but not rumination, predicted change in depression severity over the course of treatment and overall treatment outcome. Neither rumination nor distraction was associated with previous number of depressive episodes or duration of current depressive episode.

DISCUSSION

These results provide only partial support for RST as a predictor of treatment response. Future investigations are needed to determine if rumination and distraction are predictive of recurrent depressive episodes in recovered depressed patients.

LIMITATIONS

As the data in this study was retrieved from a clinical database, the conclusions of this report must be viewed tentatively. Replication with other clinical samples is needed.

Do depressed subjects who have failed both fluoxetine and a tricyclic antidepressant respond to the combination?

BACKGROUND

Recent evidence suggests that the combination of fluoxetine and desipramine may provide a rapid and effective treatment for depression.

METHOD

The current study evaluated 13 subjects with DSM-III-R nonpsychotic major depression who had previously failed either desipramine or imipramine and who were currently unsuccessfully treated with fluoxetine. Desipramine or imipramine was added to fluoxetine and Hamilton Rating Scale for Depression (HAM-D) scores, Beck Depression Inventory (BDI) scores, and plasma tricyclic levels were monitored for 3 weeks.

RESULTS

Of the 13 subjects, 7 (54%) had a greater than 40% decline in HAM-D scores and 4 of these (31%) had 50% or greater decline in HAM-D. At week 3, responders (767 +/- 282 nmol/L) had a significantly higher mean tricyclic level as compared with nonresponders (515 +/- 95 nmol/L, F = 25.1, p < .0001), and change in BDI scores was significantly correlated with tricyclic level (r = -0.60, p < .05).

CONCLUSION

These findings suggest that in some subjects the positive clinical effect of combining fluoxetine and a tricyclic antidepressant may be related to the plasma levels of the tricyclic compound.

Selective alteration of personality in response to noradrenergic and serotonergic antidepressant medication in depressed sample: evidence of non-specificity

Recent investigations suggest that serotonergic mechanisms modulate dimensions of personality, in particular decreases in Anger-Hostility and increases in Affiliation. None of these studies, however, demonstrated a specific serotonergic effect on personality, as other neurotransmitter systems have not been assessed for their impact on these personality dimensions. In this study, 76 depressed outpatients were treated with either the noradrenergic antidepressant desipramine (n = 38) or a selective serotonin re-uptake inhibitor (paroxetine or sertraline) (n = 38) over a period of 8-14 weeks. Personality scores were measured pre- and post-treatment using the revised NEO Personality Inventory, which measures five basic dimensions of personality, with subscales assessing Anger-Hostility and Affiliation (Gregariousness). There was a significant decrease in Neuroticism and Anger-Hostility, and a significant increase in Extraversion and Gregariousness following antidepressant treatment. Although changes in neuroticism and extraversion were significantly correlated with change in depression severity, Anger-Hostility and Gregariousness personality scores were not. Therefore, changes in these personality traits were not attributable to a non-specific effect of medication on changes in depression severity. There were no significant differences in personality change scores between the antidepressant treatment groups. Thus, while antidepressants may have a direct effect on neurochemical pathways relevant to personality, independent of changes in depression severity, these effects cannot be directly or specifically attributed to a serotonergic mechanism.

Relationship between antidepressant partial and nonresponse and subsequent response to antidepressant augmentation

OBJECTIVE

To evaluate the relationship between the degree of antidepressant nonresponse and subsequent response to lithium and triiodothyronine (T3) augmentation.

METHOD

This is a retrospective analysis of data combined from two previous controlled studies of lithium and triiodothyronine augmentation of tricyclic antidepressants.

RESULTS

There was no difference in the rate of augmentation response between partial and nonresponders to tricyclic antidepressant treatment.

CONCLUSIONS

Augmentation response does not appear to be related to the degree of nonresponse to the preceding antidepressant trial.

Impact of suppression of thyroxine on folate status during acute antidepressant therapy

Antidepressant response is associated with a rise in red cell folate (RCF) and a reduction in thyroxine (T4). Since T4 levels may directly influence folate status, it is possible that the increase in folate with recovery results from the decline in T4. To examine the possible role of thyroid hormones in the observed change in folate status during antidepressant therapy, T4, tri-iodothyronine (T3) or placebo was given in a double-blind fashion to 25 depressed subjects at the initiation of standard antidepressant treatment. Folate levels and mood [using the Hamilton Rating Scale for Depression (HAMD), Montgomery-Asberg Depression Rating Scale (MADRS) and Beck Depression Inventory (BDI)] were measured at baseline and following 4 weeks of therapy. Using MANOVA for repeated measures, there was a significant interaction between response status and time for vitamin and hormone levels. Univariate analysis confirmed that response was associated with a significant change in red cell folate, but not a significant change in T4 or T3. The mean change in RCF across the 4-week trial was significantly greater in the 14 responders than the 11 non-responders. Change in RCF, and not change in T4 or T3, was significantly correlated with change in HAMD and contributed significantly to the variance in change in HAMD. These results suggest that change in RCF is closely tied to response to antidepressant treatment, and this effect is not inhibited by exogenous administration of thyroid hormones or the changes in T4 that the exogenous hormones produce. These findings support the possible role of folate, independent of thyroid function, in the modulation of mood.

Hormonal and subjective responses to intravenous m-chlorophenylpiperazine in women with seasonal affective disorder

BACKGROUND

There is emerging evidence of serotonergic dysfunction in patients with seasonal affective disorder (SAD). We examined central serotonergic function in female patients with SAD (fall-winter pattern) by means of neuroendocrine and subjective responses to the postsynaptic serotonin receptor agonist m-chlorophenylpiperazine.

METHODS

Using a double-blind, randomized, placebo-controlled design, we assessed neuroendocrine and subjective responses to m-chlorophenylpiperazine (0.1 mg/kg intravenously) and placebo in 14 unmedicated female patients with SAD in the depressed state and 15 female normal controls. All testing was done in the fall-winter months and during the follicular phase of the menstrual cycle. Plasma prolactin and cortisol levels were used as neuroendocrine measures, while subjective responses were assessed by means of visual analog scales of 10 mood states.

RESULTS

On the basis of net responses to m-chlorophenylpiperazine (placebo effects subtracted from drug effects), patients with SAD exhibited blunted prolactin responses and less sadness than normal controls in response to the drug. When order of presentation of drug and placebo was taken into consideration, altered "calm" and "high" responses were also found in the patient group.

CONCLUSION

Evidence of dysfunction at or downstream to central serotonergic receptors in female patients with SAD confirms and extends findings from previous research.

Does the chronological relationship between the onset of dysthymia and major depression influence subsequent response to antidepressants?

OBJECTIVE

To determine whether the chronological relationship between the onset of dysthymia and the onset of the first major depression influences treatment outcome in patients with double depression (DD).

METHOD

Clinical and outcome measures previously collected in 77 consecutive outpatients who presented with major depression and who had pre-existing dysthymia (i.e. DD) were reviewed for the current retrospective analysis. Subjects had been administered the Schedule for Affective Disorders and Schizophrenia, Lifetime Version (SADS-LV), and the Hamilton Rating Scale for Depression (HAM-D) prior to open antidepressant treatment and after 5 and 12 weeks of therapy. Response was defined as a 50% decline in HAM-D to score +/-8. Subjects were divided into those with the onset of dysthymia before the first major depression (DysB; n = 47), onset of dysthymia after major depression (DysA; n = 12) and those with onset of both condition within 2 years of each other (INDIST; n = 18).

RESULTS

There were no significant differences between these three groups in baseline HAM-D. However, DysA subjects had significantly higher mean HAM-D scores than the DysB subjects at week 5 and the INDIST subjects at week 12. Response rates at week 12 were lower in subjects with DysA (33%) as compared with DysB (57%; Fisher's exact test, P = 0.06) and INDIST (78%; Fisher's Exact test P = 0.02).

CONCLUSIONS

These findings suggest that the onset of the first episode of dysthymia after the first major depressive episode (i.e. DysA) may adversely affect response to subsequent treatments in patients with DD.

Hormonal and subjective responses to intravenous meta-chlorophenylpiperazine in bulimia nervosa

BACKGROUND

Several lines of evidence point to serotonergic abnormalities in patients with bulimia nervosa (BN). Our goal was to further examine central serotonergic function in bulimic patients using neuroendocrine and subjective responses to the postsynaptic serotonin receptor agonist meta-chlorophenylpiperazine (mCPP).

METHOD

Using a double-blind, randomized, placebo-controlled design, we assessed neuroendocrine and subjective responses to intravenous mCPP (0.1 mg/kg) and placebo in 16 patients with BN, free of medication, and 14 normal control subjects. Plasma prolactin and cortisol levels were used as neuroendocrine measures, whereas subjective responses were measured using a visual analog scale of 10 different mood states.

RESULTS

Compared with controls, the BN group exhibited blunted prolactin and net cortisol responses following mCPP challenge. Subjective responses, while preliminary, also differed between groups on items related to anxiety, calmness, and altered self-awareness.

CONCLUSION

Evidence of dysfunction at or downstream of central serotonergic receptors in BN confirms and extends findings of prior research.

Thyroid hormone levels before unsuccessful antidepressant therapy are associated with later response to T3 augmentation

Thyroid function was measured in 24 patients before antidepressant treatment, and following failure of acute desipramine treatment but before triiodothyronine (T3) augmentation. While all measures of thyroid function were within the euthyroid range, eventual T3 augmentation responders were found to have, prior to any antidepressant treatment, lower levels of TSH and higher levels of thyroxine (T4) and free thyroxine index (FTI) than non-responders. This suggests that T3 augmentation may be of particular importance in subjects with comparatively elevated levels of serum FTI.

Bipolar disorder, unipolar depression and the Five-Factor Model of personality

We examined differences between personality characteristics of euthymic bipolar disorder patients (BD) (n = 34) and recovered unipolar depressed patients (UD) (n = 74) using the taxonomy of the Five-Factor Model of personality (FFM) as measured by composite scales derived from the NEO Personality Inventory (NEO PI) and the revised NEO PI (NEO PI-R). Euthymic BD patients scored significantly higher on the Openness (O) dimension and the Positive Emotions facet of the E dimension than did recovered UD patients. For O, euthymic BD patients scored higher on the Feelings facet. These results suggest not only that euthymic BD patients are more likely to experience positive affects than recovered UD patients, but also that euthymic BD patients are more receptive to their positive and negative feelings than are recovered UD patients.

Seasonal and non-seasonal depression and the five-factor model of personality

The purpose of this study was to compare the personality characteristics of patients with non-psychotic, major depression, seasonal subtype (SAD) to patients with non-psychotic, major depression, without seasonality (non-SAD). The patients were consecutive referrals to a university-affiliated mood disorders outpatient clinic. The personality characteristics were assessed using the five-factor model of personality (FFM) as measured by the revised NEO Personality Inventory (NEO PI-R). Patients were assessed during the acute depressive episode. Controlling for severity of depression, differences were found on only one of the five dimensions, with the SAD patients (n = 43) scoring significantly higher on the Openness dimension than non-SAD patients (n = 57). Based on these results we infer SAD patients may represent a psychologically distinct subgroup of depressed patients-more imaginative, more emotionally sensitive and likely to entertain unconventional ideas than non-SAD patients. This personality constellation may explain why individuals with SAD are more sensitive to and may amplify the mild dysphoria typically associated with winter months.

A controlled comparison of light box and head-mounted units in the treatment of seasonal depression

BACKGROUND

Patterns of response to the light box and head-mounted unit (HMUs) in seasonal affective disorder (SAD) appear to differ. The current study employed a "no light" condition to compare the response rates with the light box and HMU against a plausible placebo.

METHOD

Forty-three subjects with DSM-III-R nonpsychotic, unipolar major depression, seasonal subtype, were randomly assigned, in a double-blind manner, to receive 2 weeks of active treatment with a light box (N=9) or HMU (N=12) that emitted no visible light, or 2 weeks of placebo treatment with a light box (N=12) or HMU (N=10) that emitted no visible light. Response was defined as a 50% or greater reduction in both the 17-item "typical" score and 8-item "atypical" score on the Structured Interview Guide for the Hamilton Rating Scale for Depression-SAD version (SIGH-SAD).

RESULTS

Using ANOVA for repeated measures, with change in total SIGH-SAD score as the dependent measure, we found no significant main effect of light (F=0.20, p=N.S.) or unit (F=0.50, p=N.S.), and no interaction (F=0.21, p=N.S.). Using log-linear analysis, we found no significant difference in response rate between the four cells (likelihood ratio chi-square = 2.1, p=N.S.). Using chi-square analysis, we found no significant difference in response rates between patients who received light (48%) versus patients who received no light (41%; chi-square = 0.2, p=N.S.) or between patients who received the light box (38%) versus HMU (50%; chi-square = 0.62, p=N.S.).

CONCLUSION

The failure to detect any significant difference in efficacy between active and placebo treatments calls into question the specificity of light in light therapy for SAD. Methodological limitations, particularly small sample size, are discussed.

Response to an open trial of a second SSRI in major depression

BACKGROUND

We evaluated the efficacy of a second serotonin selective reuptake inhibitor (SSRI) in patients who had failed to respond to the first SSRI used.

METHOD

Fifty-five patients with major depression who had failed one of the SSRIs for their current depressive episode were included. After failing a trial of one SSRI, they received a second SSRI in an open clinical trial.

RESULTS

On the basis of the Clinical Global Impression-Improvement scale, 28 of 55 patients had a marked or complete antidepressant response.

CONCLUSION

These data provide preliminary clinical evidence that substituting a second SRI may be a useful clinical alternative in depressed patients who fail to respond to an adequate trial of an SSRI.

Augmentation strategies: focus on anxiolytics

Approximately 20% to 40% of patients will fail to respond to the first antidepressant used for their current major depressive episode. Furthermore, it has been suggested that a further 20% to 30% of patients will have only a partial response. There are four main options to consider in the treatment of these patients: optimization, substitution, augmentation, and combination therapy. Several combination antidepressant treatments have been used in treatment-refractory depression. Moreover, various augmentation strategies have also proved to be successful. Although the empirical data to support these treatment options are limited, augmentation treatment has several potential advantages over the other clinical options available, particularly substitution. These data are reviewed and clinical applications discussed. Particular attention is paid to the role of anxiolytics as augmentation agents in the treatment of major depression.

Serum Mg2+ and Ca2+/Mg2+ ratio in major depressive disorder

Serum Mg2+ has been implicated in the symptom severity and pathophysiology of mood disorders. Furthermore, the recent findings of blunted signalling through the G-protein-coupled adenylyl cyclase (AC) pathway in major depressive disorder (MDD) and the importance of Mg2+ in G-protein/AC function led us to reexamine in a large sample whether serum Mg2+ concentrations were decreased in MDD patients. In 145 drug-free MDD patients compared with 2 control groups: (a) patients with bipolar disorder (n = 33) and (b) non-mood-disordered patients (n = 47), there were no differences in Mg2+ levels or Ca2+/Mg2+ ratios. Neither of these measures differed when comparing responders and nonresponders to antidepressant treatment.

Multicenter, placebo-controlled study of fluoxetine in seasonal affective disorder

OBJECTIVE

The authors investigated the efficacy and safety of fluoxetine in the treatment of winter seasonal affective disorder.

METHOD

Sixty-eight outpatients who met the DSM-III-R criteria for recurrent major depressive episodes, seasonal (winter) pattern, were randomly assigned to 5 weeks of treatment with fluoxetine, 20 mg/day (N = 36), or placebo (N = 32). The outcome measures included the 29-item modified Hamilton Depression Rating Scale, administered by experienced clinicians, and the self-rated Beck Depression Inventory; adverse events and safety data were also recorded. Clinical response was defined as a greater than 50% reduction in depression score between baseline and study termination.

RESULTS

Both groups showed significant improvement. The fluoxetine group had lower depression scores at termination than the placebo group, but these differences did not achieve statistical significance. However, the rate of clinical response in the fluoxetine group (59%) was superior to that in the placebo group (34%). Post hoc analyses showed that the greatest fluoxetine responses were in the most markedly depressed patients and that overall response was greater for patients studied later in the season. Fluoxetine was well tolerated, and few subjects dropped out because of adverse events.

CONCLUSIONS

On the basis of clinical response rate, fluoxetine appears to be an effective, well-tolerated treatment for seasonal affective disorder. Because the differences between fluoxetine and placebo in the continuous outcome measures did not reach statistical significance, further studies with larger study groups and longer treatment periods are required to conclusively demonstrate efficacy of fluoxetine for seasonal affective disorder.

Treatment of seasonal affective disorder: a review

OBJECTIVE

To review the status of current treatment of seasonal affective disorder (SAD).

METHOD

Treatment studies of SAD published between January 1989 and March 1995 were identified using a computerized MEDLINE literature search. Additional citations were obtained from the reference sections of these articles. Studies included in this review were selected using operational methodologic criteria.

RESULTS

Many studies support the efficacy of bright light therapy using a fluorescent light box. The best studied protocol is > 2500 lux white light for 2 hours per day, but newer protocols using 10,000 lux for 30 minutes have comparable response rates. Studies of light visors and other head-mounted devices also report similar response rates, but have not yet shown superiority over putative control conditions. There are fewer medication studies in SAD, but controlled studies suggest that fluoxetine, d-fenfluramine and propranolol are effective. Other treatments such as dawn simulation require further study. No studies of psychological treatments for SAD were found. Many studies had methodologic limitations, including brief treatment periods, small sample sizes, and lack of replication, that limit the generalizability of findings.

CONCLUSION

There are several well-studied, effective treatments for SAD, including light therapy and medications. However, further research must be done to demonstrate sustained treatment response over time, to clarify the intensity-response relationship of light therapy, to clarify the role of light therapy and medications, and to assess combination treatments.

A comparison of Tridimensional Personality Questionnaire dimensions in bipolar disorder and unipolar depression

The harm avoidance (HA) personality dimension has been hypothesized to be a vulnerability factor for unipolar depression (UD) but not for bipolar disorder (BD). The reported difference on HA scores between these diagnostic groups may have been compromised by the assessment of BD patients who had not fully recovered. To test the diagnostic specificity of elevated HA scores and to elucidate whether assumptions about differences between patients with UD or BD might be attributed to the lingering effects of mood state, the Tridimensional Personality Questionnaire (TPQ) was administered to recovered patients with either BD or UD and a nonpatient comparison group. Both patient groups scored higher on the HA dimension than the nonpatient comparison group, but the patient groups did not differ from one another on this dimension. Moreover, novelty seeking (NS) scores were elevated in subjects with BD compared with both UD patients and nonpatient subjects. These results suggest that high HA scores may be associated with a mood disorder diagnosis, whereas high NS scores may be associated with the BD subtype.

Seasonal fluctuations in mood and eating behavior in bulimia nervosa

Thirty-five bulimia nervosa (BN) patients with high seasonality scores on a modified version of the Seasonal Pattern Assessment Questionnaire (SPAQ) were administered semistructured clinical interviews to further assess their seasonal symptom patterns. A diversity of patterns were identified, consistent with a multidimensional model of seasonality in the BN population. Overall, the results suggest that seasonality may be an important dimension to consider in patients with BN.

Change in folate status with antidepressant treatment

Ninety-nine consecutive unmedicated outpatients with a major depressive illness had blood drawn for measurement of serum folate (SF), red cell folate (RCF), and vitamin B12 within 24 hours of completion of ratings of severity of depression at the beginning and ending of a 5-week trial of desmethylimipramine (mean dose = 149.2 mg/day, range = 75-225 mg). As compared with nonresponders, responders had a significantly higher mean SF at baseline (nonresponders = 13.8 nmol/l; responders = 17.7 nmol/l) and RCF showed a significant inverse correlation with severity of depression and a significant positive correlation with age of onset of illness. At week 5, change in severity of depression was significantly correlated with change in RCF, and significantly more responders than nonresponders had an increase in RCF. The possible role of folate status in the regulation of mood and response to treatment is discussed.

Dim versus bright red (light-emitting diode) light in the treatment of seasonal affective disorder

Forty-three subjects with seasonal affective disorder were randomly assigned to receive 2 weeks of treatment with either bright- (mean 4106 lx) or dim-light (mean 96 lx) therapy, using red light-emitting diode light sources, in a head-mounted unit. Defining response as a 50% reduction in the 21-item Hamilton Depression Rating Scale score to a post-treatment score of less than 8, there was no significant difference in response rate between patients receiving bright light (67%) as compared with patients receiving dim light (68%). Possible explanations for the similar response rate to 2 very different illuminances of red light are discussed.

Is hypersomnolence a feature of seasonal affective disorder?

We examined hypersomnolence as experienced among individuals meeting standardized diagnostic criteria for Seasonal Affective Disorder (SAD). Data were available from 115 individuals attending a mood disorders clinic specializing in treatment of this disorder. Three modes of assessment were employed: retrospective self-reports (Seasonal Patterns Assessment Questionnaire), cross-sectional interviews (Standardized Interview Guide for the Hamilton Depression Scale, SAD Version), and prospective sleep diaries. Results indicated that self-reported total hours of sleep varied significantly across the seasons, with longest sleep occurring in winter and shortest sleep in summer. Seasonal sleep changes, as indicated by the SPAQ did not correlate significantly, however, with severity of depressive symptoms as indicated by the Hamilton scale. Multiple regression analyses indicated that only social activity levels (one of seven SPAQ items) was significantly and uniquely related to the severity of depression. When data obtained by the three instruments were compared, self-reported hours of sleep (whether measured by SPAQ or Hamilton interview) were significantly higher than indicated by prospective sleep diaries. We conclude that hypersomnolence may not be a central feature of SAD and that the validity of the SPAQ as an index of this disorder requires further investigation.

Predictors of response to lithium and triiodothyronine augmentation of antidepressants in tricyclic non-responders

Although both lithium and triiodothyronine (T3) augmentation strategies may be rapid, safe, and effective ways of treating patients who fail to respond to tricyclics, little is known about the clinical or biochemical correlates of response. We examined clinical and endocrine variables which distinguished T3 and lithium responders from each other and from non-responders in a post-hoc analysis of two studies involving 51 subjects who had received these augmentation strategies under double-blind conditions. Lithium non-responders were more severely depressed and had more insomnia and weight loss than responders. T3 responders could be distinguished from lithium responders by greater weight loss. There were no reliable clinical differences between T3 responders and non-responders. Thyroid function tests did not differ between any of the treatment or response groups. Our findings suggest that clinical but not endocrine variables may distinguish responders to these two augmentation strategies.

A comparison of personality characteristics of seasonal and nonseasonal major depression

During the acute depressive episode, seasonal affective disorder (SAD) patients (N = 24) differ significantly from non-SAD major depressives (N = 17) on five of 13 personality variables measured, although severity of depression appears to be similar. SAD patients score significantly lower on the self-criticism and dependency dimensions of the Depressive Experiences Questionnaire (DEQ) and significantly higher on three personality trait scales (including schizotypal, narcissistic, and avoidant) of the Millon Clinical Multiaxial Inventory (MCMI). Our data suggest that those with seasonal depression may represent a psychologically distinct subgroup of depressives.

Anxious and non-anxious bipolar disorder

Eighty-one outpatients with bipolar disorder (BD) were grouped by SADS anxiety symptom scores (high vs. low) or diagnosis of generalized anxiety disorder, and/or panic disorder. BD patients with high anxiety scores were more likely to have suicidal behaviour (44% vs. 19%), alcohol abuse (28% vs. 6%), cyclothymia (44% vs. 21%) and an anxiety disorder (56% vs. 25%) with a trend toward lithium non-responsiveness. Diagnosis of an anxiety disorder was related only to high anxiety and lower GAS scores. Thus, anxiety may have similar clinical relevance in BD as it does in unipolar patients.

The Tridimensional Personality Questionnaire in major depression

The authors examined Tridimensional Personality Questionnaire scores in 40 patients with unipolar nonpsychotic major depression before and after antidepressant treatment. They found that scores on the novelty seeking and reward dependence dimensions were not affected by depressed state or by treatment response status. However, scores on the harm avoidance dimension were significantly lower in antidepressant responders and were altered by depressed state.

A placebo-controlled comparison of lithium and triiodothyronine augmentation of tricyclic antidepressants in unipolar refractory depression

OBJECTIVE

To directly compare the efficacy of lithium carbonate and liothyronine sodium (triiodothyronine) in the augmentation of therapeutic response in antidepressant nonresponders.

DESIGN

A randomized, double-blind, placebo-controlled study of 2 weeks' duration.

SETTING

The Mood Disorders Program, Clarke Institute of Psychiatry and the University of Toronto, Ontario.

PATIENTS

Fifty outpatients, males and females, with unipolar, nonpsychotic major depression who had failed to respond to treatment with desipramine hydrochloride or imipramine hydrochloride.

RESULTS

Both liothyronine and lithium were more effective than placebo in reducing scores on the Hamilton Rating Scale for Depression. However, the antidepressant augmenting effect of these two compounds did not differ from each other. When response was defined as a 50% or more reduction in the Hamilton Rating Scale for Depression scores and a final score less than 10, we found that 10 of 17 subjects responded to liothyronine, nine of 17 responded to lithium and three of 16 responded to placebo.

CONCLUSIONS

Our study suggests that both lithium and liothyronine may be considered as alternatives in augmenting antidepressant response in patients who do not respond to treatment with a tricyclic antidepressant.

Anxiety disorders and anxiety symptoms in a clinic sample of seasonal and non-seasonal depressives

Thirty-eight patients with seasonal affective disorder (SAD) were compared with 33 non-seasonal recurrent major depressives (non-SAD) who presented during the winter months for differences in the prevalence of concurrent anxiety disorders and the impact of anxiety on treatment response. SAD patients received light therapy, whereas non-SAD patients received antidepressant medications. There was no differences in the prevalence of any anxiety disorder, or on scores of anxiety on the Hamilton Rating Scale for Depression between the SAD and non-SAD groups. The presence of any anxiety disorder was associated with a better response rate in SAD patients, and an inferior response rate in non-SAD patients. The findings refute previous suggestions that anxiety is more common in SAD than in non-SAD, but suggest that the presence of anxiety may be associated with differential treatment response rates.

Side effects of light therapy in seasonal affective disorder

The authors report the frequency of side effects of light therapy in 105 patients with seasonal affective disorder treated with three intensities of light. Common symptoms to emerge during treatment were headache (19%), eyestrain (17%), and feeling "wired" (14%). There was no relationship between side effects and intensity of light used.

Light visor treatment for seasonal affective disorder: a multicenter study

The effectiveness of light therapy in seasonal affective disorder (SAD) was evaluated in 105 subjects across five centers. Three intensities of light (60 lux, 600 lux, and 3500 lux) were used in a 2-week randomized, parallel design. There was no significant difference in antidepressant efficacy of the three intensities of light. All three intensities produced a similar frequency of antidepressant response to each other and to that reported in previous studies. There were site differences in the severity of depression during light treatment, but diagnosis and medication status did not affect antidepressant response. These findings suggest that light therapy has an antidepressant action by a nonspecific effect or that light is biologically active in the treatment of SAD across a wide range of intensities.

Clinical features of situational and nonsituational major depression

Clinical lore has long supported the subtype of situational or reactive depression. To date, however, there has been limited empirical research support for this subtype of major depression. We examined demographic, clinical and personality features of situational and nonsituational depression in 89 outpatients with unipolar nonpsychotic major depressive disorder. Situational depressives had a less recurrent course of illness and appeared to respond more completely to the antidepressant used for their current episode. Demographic and personality measures did not distinguish situational and nonsituational depression.

Folate, vitamin B12 and cognitive impairment in patients with Alzheimer's disease

This study examines the relationship between folate, vitamin B12 and severity of cognitive impairment in patients with Alzheimer's disease (AD) as compared with other disorders associated with cognitive impairment. The patients were 97 consecutive referrals to an AD clinic. Forty patients had either possible or probable AD, 31 had other dementias (OD) and 26 had mild cognitive impairment (cognitively impaired, not demented; CIND). Patients had blood drawn for serum, red cell folate and B12, as well as other biochemical indicators of nutrition, within 24 h of the Mini-Mental State Examination (MMSE). In the AD group, only B12 was significantly correlated with MMSE. Using regression analysis, B12 contributed significantly to variance in MMSE. There was no correlation between MMSE and serum, red cell folate or B12 in the OD or CIND group and no significant correlation between MMSE and other nutritional indices in any group. These findings suggest the possibility of a specific relationship between B12 levels and severity of cognitive impairment in patients with AD.

Diagnostic specificity of the dependent and self-critical personality dimensions in major depression

Validational studies of self-critical and dependent personality dimensions as vulnerability factors for depression have been tested primarily with depressed samples, employing research designs devised to address state vs. trait and trait-situational congruity issues. In this study we examined the diagnostic specificity to depression of these two personality dimensions, comparing Self-Criticism and Dependency scores as measured by the Depressive Experiences Questionnaire (DEQ) in two samples of outpatients: (1) panic disorder with agoraphobia; and (2) non-psychotic, unipolar major depression. As hypothesized, the two groups differed on Self-Criticism, with the depressed group scoring higher, but no differences were found for Dependency. These findings were similar even when depressed mood was partialed out. These results complement a growing body of research associating Self-Criticism, as specifically measured by the DEQ, with depression.

Major depression and subclinical (grade 2) hypothyroidism

Subclinical hypothyroidism (SCH) has been reported to occur in patients with a variety of affective syndromes. However, the clinical correlates of SCH in patients with major depression have received limited attention. We therefore examined demographic, clinical and treatment response variables in a cohort of patients with unipolar, nonpsychotic major depression with and without SCH. Of 139 subjects, 19 had SCH defined as an elevated basal TSH with normal circulating levels of T3 and T4. Major depression with SCH differed from that without SCH by the presence of a concurrent panic disorder and a poorer antidepressant response.

The thyroid and melancholia

Several studies that have examined heterogeneous groups of patients suggest that altered thyroid function may distinguish melancholic from nonmelancholic depression. We therefore measured basal thyroid hormone levels in 90 unipolar depressed patients who were divided into melancholic and nonmelancholic subgroups according to three definitions. Levels of thyroxine, triiodothyronine, and thyrotropin, obtained using an ultrasensitive assay, did not distinguish the subtypes of depression. However, severity of depression contributed significantly to the difference between these subtypes according to DSM-III and Research Diagnostic Criteria.

Coping styles, psychopathology and intellectual performance in patients with familial adenomatous polyposis

Thirty-eight patients with familial adenomatous polyposis (FAP) were compared with 19 patients with ulcerative colitis (UC) for differences in illness-related variables, coping styles, psychiatric symptomatology, and intellectual performance. Patients with FAP had significantly less education, longer time since recent surgery, less psychiatric illness, and evidence of less preoccupation with their illness, as compared with UC patients. FAP patients with a positive family history (N = 28) scored significantly lower on both verbal and performance intellectual tests, even when taking education into account, compared with FAP patients without a family history (N = 9). The relevance of these findings to the ongoing monitoring and surveillance of patients with FAP is discussed.