Inflammatory proteins and miRNA-144-5p in patients with depression, anxiety, or stress- and adjustment disorders after psychological treatment

Both inflammatory proteins and microRNAs (miRNA) have been reported to be associated with various psychiatric disorders. However, the association between inflammatory proteins and miRNAs remains largely unknown, especially for patients with depression, anxiety, or stress- and adjustment disorders. In this study, we analyzed plasma levels of 92 inflammatory proteins from 178 patients with depression, anxiety, or stress- and adjustment disorders at baseline and after 8-week psychological treatments which resulted in a significant decrease in the Montgomery Åsberg Depression Rating Scale (MADRS-S) score. We investigated the response of the proteins after treatment and the correlation with miR-144-5p. After Benjamini-Hochberg correction for multiple testing, a total of 36 inflammatory proteins changed significantly after 8-week psychological treatments. Among the 36 significantly changed proteins, 21 proteins showed a decrease, and 17/21 proteins were inversely associated with plasma miR-144-5p levels at baseline. In addition, decreases in these proteins were associated with increases in miR-144-5p after treatment. The findings were similar after stratification by use of medications. The associations between the proteins and depression at baseline, measured by MADRS-S, as well as the change in protein levels and treatment response were, however, less clear. These findings need to be examined in future studies.

The endogenous and reactive depression subtypes revisited: integrative animal and human studies implicate multiple distinct molecular mechanisms underlying major depressive disorder

BACKGROUND

Traditional diagnoses of major depressive disorder (MDD) suggested that the presence or absence of stress prior to onset results in either 'reactive' or 'endogenous' subtypes of the disorder, respectively. Several lines of research suggest that the biological underpinnings of 'reactive' or 'endogenous' subtypes may also differ, resulting in differential response to treatment. We investigated this hypothesis by comparing the gene-expression profiles of three animal models of 'reactive' and 'endogenous' depression. We then translated these findings to clinical samples using a human post-mortem mRNA study.

METHODS

Affymetrix mouse whole-genome oligonucleotide arrays were used to measure gene expression from hippocampal tissues of 144 mice from the Genome-based Therapeutic Drugs for Depression (GENDEP) project. The study used four inbred mouse strains and two depressogenic 'stress' protocols (maternal separation and Unpredictable Chronic Mild Stress) to model 'reactive' depression. Stress-related mRNA differences in mouse were compared with a parallel mRNA study using Flinders Sensitive and Resistant rat lines as a model of 'endogenous' depression. Convergent genes differentially expressed across the animal studies were used to inform candidate gene selection in a human mRNA post-mortem case control study from the Stanley Brain Consortium.

RESULTS

In the mouse 'reactive' model, the expression of 350 genes changed in response to early stresses and 370 in response to late stresses. A minimal genetic overlap (less than 8.8%) was detected in response to both stress protocols, but 30% of these genes (21) were also differentially regulated in the 'endogenous' rat study. This overlap is significantly greater than expected by chance. The VAMP-2 gene, differentially expressed across the rodent studies, was also significantly altered in the human study after correcting for multiple testing.

CONCLUSIONS

Our results suggest that 'endogenous' and 'reactive' subtypes of depression are associated with largely distinct changes in gene-expression. However, they also suggest that the molecular signature of 'reactive' depression caused by early stressors differs considerably from that of 'reactive' depression caused by late stressors. A small set of genes was consistently dysregulated across each paradigm and in post-mortem brain tissue of depressed patients suggesting a final common pathway to the disorder. These genes included the VAMP-2 gene, which has previously been associated with Axis-I disorders including MDD, bipolar depression, schizophrenia and with antidepressant treatment response. We also discuss the implications of our findings for disease classification, personalized medicine and case-control studies of MDD.

Should the diagnosis of major depression be made independent of or dependent upon the psychosocial context?

BACKGROUND

The diagnosis of certain psychiatric syndromes (e.g. panic attacks, post-traumatic stress disorder) is crucially dependent on the psychosocial context in which they arise. For other syndromes (e.g. schizophrenia), the context is generally irrelevant. Should the diagnosis of major depression (MD) be made dependent upon or independent of the psychosocial context in which it occurs?

METHOD

Twins were selected from a population-based registry who, on personal interview, reported developing a full depressive syndrome either 'out of the blue' or in response to stressful life events (SLEs) rated objectively as having mild, low moderate, high moderate or severe long-term contextual threat (LTCT).

RESULTS

In these depressed subjects, no relationship was found between the level of adversity associated with onset and most indices of liability to depression, including risk of MD in co-twin and parents, level of neuroticism, risk for future depressive episodes, co-morbidity with other internalizing disorders and history of sexual abuse. Compared to the remainder of this epidemiologic cohort, subjects developing depression in response to the severe threat events had substantially elevated levels of all the examined indices of liability to MD.

CONCLUSIONS

Individuals who develop a full depressive syndrome in response to high-threat events do not have an appreciably lower liability to MD than those developing depression after exposure to low adversity and have much higher liability to depression than observed in their population cohort. These results support the hypothesis that, in general, MD can be diagnosed independently of the psychosocial context in which it arises.

Steady-state plasma levels of nortriptyline and its hydroxylated metabolites in Japanese patients: impact of CYP2D6 genotype on the hydroxylation of nortriptyline

The authors investigated the impact of the CYP2D6 genotype on steady-state concentrations of nortriptyline (NT) and its metabolites, trans-10-hydroxynortriptyline (EHNT) and cis-10-hydroxynortriptyline in a Japanese population of psychiatric patients. Forty-one patients (20 men and 21 women) were orally administered nortriptyline hydrochloride. The allele frequencies of the CYP2D6*5 and CYP2D6*10 were 4.9% and 34.1%, respectively. Significant differences in NT concentrations corrected for dose and weight were observed between the subjects with no mutated alleles and those with one mutated allele (mean +/- SD for no mutated alleles vs. one mutated allele: 70.3 +/- 25.4 vs. 98.4 +/- 36.6 ng/mL x mg(-1) x kg(-1); t = 2.54, dcf = 33, p < 0.05) and between the subjects with no mutated alleles and two mutated alleles (no mutated alleles vs. two mutated alleles: 70.3 +/- 25.4 vs. 147 +/- 31.1 ng/mL x mg(-1) x kg(-1); t = 5.87, df = 19, p < 0.0001). Also, a significant difference in the NT/EHNT ratio, which is representative of the hydroxylation ratio of NT, was observed between the subjects with no mutated alleles and those with two mutated alleles (no mutated alleles vs. two mutated alleles: 0.82 +/- 0.30 vs. 2.71 +/- 0.84; t = 7.86, df = 19, p < 0.0001). Multiple regression analysis showed that the number of mutated alleles of CYP2D6, which was the only significant factor, accounted for 41% and 48% of the variability in log(NT corrected for dose and weight) and log(NT/EHNT), respectively.

Search for association between suicide attempt and serotonergic polymorphisms

Serotonergic neurotransmission has been implicated in suicidal behavior. Polymorphisms in the genes coding for tryptophan hydroxylase, serotonin receptor 2A and serotonin transporter were investigated in a sample of suicide attempters (n = 165) and healthy control subjects (n = 99). No significant differences were found for any of the investigated polymorphisms. Neither did any significant differences emerge in comparison with control subjects when the suicide attempters were grouped into different diagnostic categories: unipolar disorder (n = 45), adjustment disorder (n = 37), substance use disorder (n = 37) and personality disorder, cluster B (n = 36). The results suggest that alleles defined by the investigated polymorphisms do not represent a major determinant in suicide attempt. However, a highly significant (P = 0.001; odds ratio, 1.47; 99% confidence interval, 1.42-1.53) allelic association between tryptophan hydroxylase and suicide attempt is indicated after pooling our data with literature data. In light of previous data, a possible association between the tryptophan hydroxylase polymorphism and a phenotype that may become differently stratified within differently selected samples of suicide attempters is discussed.

Lack of association between suicide attempt and a polymorphism at the dopamine receptor D4 locus

Dopaminergic neurotransmission has been implicated in suicidal behaviour. The 48 bp-repeat polymorphism in the gene coding for dopamine receptor D4 was investigated in a sample of suicide attempters (n = 165) and healthy control subjects (n = 99). No association between suicide attempts and this polymorphism was observed. Neither did any significant differences emerge in comparison with control subjects when the suicide attempters were grouped into different diagnostic categories: unipolar (n = 45), anxiety (n = 23), adjustment (n = 37) and personality disorders, cluster B (n = 36). The results suggest that alleles defined by the investigated polymorphism do not have a major impact on suicidal behaviour.

Dimensions and disorders of adolescent adjustment: a quantitative genetic analysis of unselected samples and selected extremes

One of the fundamental questions for developmental psychopathology concerns the etiological links between the normal and abnormal. To what extent do disorders differ quantitatively or qualitatively from variation in the normal range? Genetic research on the normal and the abnormal differs in terms of concepts, methods, statistics, and target audiences. An approach, referred to as "DF" analysis, provides a framework for integrating these two worlds of genetic analysis. We applied traditional correlational analyses as well as DF (DeFries & Fulker, 1985) analyses to mother and father ratings of adjustment of adolescent siblings in a 3-year longitudinal twin and step-family study. At wave 1, the sample included 720 sibling pairs (average age of 12.9 years for the younger sibling and 14.5 years for the older siblings) and, in wave 2, 395 pairs still living at home. Both correlational analyses of the entire sample and DF analyses of selected extremes suggested moderate genetic influence and modest shared environmental influence for internalizing and externalizing behavior problems. Similar estimates were found for unselected individual differences and selected extreme groups. A framework is proposed that focuses on quantifying the etiologies of disorders (QED) as measured on continuous dimensions.

Outcome evaluation of a short-term mental health day treatment program

OBJECTIVES

To determine whether a structured, 6-week mental health day treatment program was meeting its objectives and to examine the program's effectiveness with specific patient groups.

METHOD

Self-report questionnaires focusing on psychiatric symptoms, assertiveness, stress management, and social functioning were completed by patients directly prior to admission (pretest), at discharge (posttest), and at 4-month follow-up. Clinician ratings, including the DSM-III-R Global Assessment of Functioning (GAF) scale, were collected. Ninety-one participants completed pre- and posttests, and 51 completed the 4-month follow-up.

RESULTS

The majority of the participants displayed affective disorders or adjustment disorders. There was significant reduction in psychiatric symptoms and improvement in assertiveness, social functioning, and stress management from pretest to posttest. These gains were maintained at follow-up. All diagnostic groups responded similarly, except the bipolar disorder group.

CONCLUSION

These data indicate that the program was meeting its objectives and offer strong support for the usefulness of short-term day treatment for wide range of patients. The bipolar group performed differently compared with the other subsamples. The reliability of the GAF scale and when it may be most useful are discussed.

Recurrently situational (reactive) depression: a study of course, phenomenology and familial psychopathology

Probands with non-bipolar major depressive disorder (MDD) were grouped according to the consistency across episodes with which depression appeared to arise from situational factors. Situational depression showed significant diagnostic stability across the second and third recurrences in a 10-year follow-up. The relatives of recurrently situational probands had higher neuroticism scores, higher lifetime rates of MDD and, when depressed, fewer endogenous symptoms than did the relatives of non-situational probands. This study joins two others in finding an association between stress-related depression and high familial loadings for MDD. It also illustrates the value of diagnostic consistency across episodes as a means of refining groups for the study of diagnostic subtypes.

Depression as a consequence of inadequate neurochemical adaptation in response to stressors

Stressors induce behavioural disturbances and neurochemical changes in animals, some of which are reminiscent of the symptoms and presumed neurochemical concomitants of depression in humans. Just as in humans, where considerable inter-individual variability is evident in the symptom profile of depression, there is marked inter-individual and inter-strain variability in the behavioural effects of stressors in animals. It is proposed that stressors induce adaptive neurochemical changes, failure of which may engender behavioural disturbances. Variability in the symptoms of depression and in the efficacy of its pharmacological treatment may reflect the biochemical heterogeneity of the illness. Inter-individual differences in vulnerability to stressor-provoked neurochemical changes may contribute to the behavioural profiles observed.

The genetics of neurotic-reactive depression: a reanalysis of Shapiro's (1970) twin study using diagnostic criteria

The present study explored the role of genetic factors in the development of neurotic depression. Case studies of 16 monozygotic (MZ) and 14 same-sex dizygotic (DZ) twins from Robert Shapiro's 1970 study of non-endogenous depression were rediagnosed by two raters blind to the zygosity and identity of each twin. Diagnoses were made using Research Diagnostic Criteria (RDC) and George Winokur's 1985 criteria for neurotic-reactive depression. When neurotic depression was operationally defined using Winokur's criteria plus RDC major or definite minor depression, the concordance rate for MZ twins was significantly greater than that for DZ twins. Our results contrast with Shapiro's negative findings, probably due to our use of formal diagnostic criteria and Shapiro's requirement that cotwins be hospitalized to be considered concordant. The present results suggest that genetic factors play a role in the etiology of at least some forms of neurotic depression.

A family study of generalized anxiety disorder

The frequency of generalized anxiety disorder was higher among first-degree relatives of probands with generalized anxiety (N = 20) than among the relatives of control subjects (N = 20), but it was not higher among relatives of probands with panic disorder (N = 40) or agoraphobia (N = 40). Also, the frequency of panic disorder was higher among relatives of probands with panic disorder than among control relatives but was not higher among relatives of generalized anxiety probands. Relatives of probands with generalized anxiety who had the same disorder had a mild, stress-related illness. The results confirm the separation between generalized anxiety disorder and panic disorder but challenge the distinction between generalized anxiety and adjustment disorders.

Psychiatric morbidity among relatives of different subgroups of neurotic depression

The morbidity risk for affective disorders was calculated among the relatives of subgroups of reactive-neurotic depressive patients. The patients were divided into reactive and neurotic depressives. The parents of the neurotic subgroup had a significantly lower morbidity risk of affective disorders in comparison with the parents of the reactive subgroup. The role of genetic and environmental factors in the etiology of reactive-neurotic depression was discussed.

The impact of diagnostic misclassification on the pattern of familial aggregation and coaggregation of psychiatric illness

Family studies in psychiatry have traditionally been interpreted as if psychiatric diagnoses were made without error. This is unlikely to be true. The first section of this paper presents a model, based on several simplifying assumptions, which examines the impact of diagnostic misclassification on patterns of familial aggregation and coaggregation of two disorders. In the second section, the model is illustrated by examining the effect of varying misclassification rates on the patterns of aggregation and coaggregation in four simulated family studies of psychotic illness. Misclassification is considered which is equal or unequal for the two disorders, which is the same in probands and relatives or greater in relatives and which occurs between disorders of similar or quite different population risk. Misclassification in the range which commonly occurs in psychiatry can produce substantial effects on the observed pattern of familial aggregation and coaggregation. Furthermore, the proportion of diagnosed cases which are misclassified varies widely depending upon whether an affected individual is from the general population or is a relative of an individual affected with the same or a different psychiatric disorder. The third section of the paper illustrates a method for examining the fit of the proposed model to observed data and "correcting" for the effects of misclassification in family studies. For example, the familial coaggregation between bipolar illness and schizophrenia in a recent large family study can be entirely explained by the observed rates of diagnostic misclassification between the two disorders. The results of the proposed model strongly suggest that diagnostic misclassification should be considered in the interpretation of family studies of psychiatric illness.

Hazard, heredity and depression. A family study

The relationship between proband characteristics and familial aggregation of depression was assessed in an interview study of 83 families ascertained via probands who had a recent onset of depression. Contrary to expectations and to previous reports in the literature there were no differences between the frequencies of depression in the first degree relatives of probands who had or had not experienced adversity prior to the onset of their illness. Depression was actually slightly more common among the first degree relatives of probands who had experienced a threatening life event compared with the relatives of those who had not. Early onset of depression (before 32 yr) and a neurotic pattern of symptoms in probands were associated with significantly higher rates of current illness in relatives. However, both these differences disappeared when lifetime prevalence or morbid risk to age 65 were considered. Indeed the morbid risk of severe depression in the relatives of endogenously depressed probands was nearly twice that in the relatives of neurotic probands.

Family (genetic) studies in neurotic depression

Neurotic depression may be defined as a depression that occurs in the context of a long standing history of personality difficulties or neurotic symptoms. Two types of conditions fit this definition: (1) depressions secondary to personality disorder, neuroses or substance abuse; and (2) primary depressions with a family history of alcoholism. Depressions so defined show familial relationships with secondary depression, anxiety disorders, alcoholism, and depressions with personality disorders. The data suggest that these cluster in the same family and are related to the definition of neurotic depression given above. Whether these familial relationships are genetic awaits further research.

Psychiatric disorders in the biological and adoptive families of adopted individuals with affective disorders

To investigate the contribution of genetic and environmental factors in the etiology of mood disorders, a study was initiated to examine the frequency of psychiatric disorders in the biological and adoptive relatives of adult adoptees with mood disorders and in matched normal adoptees. Psychiatric evaluations of the relatives were made on the basis of independent blind diagnoses based on mental hospital and other official records. Analysis of the data showed an eightfold increase in unipolar depression among the biological relatives of the index cases and a 15-fold increase in suicide among the biological relatives of the index cases. These data demonstrate a significant genetic contribution to unipolar depression and suicide. They fail to disclose a significant contribution of family-associated transmission in the genesis of the mood disorders.

Genetic factors in moderately severe and mild affective disorders

The aim of this study was to investigate the contribution of hereditary factors in the development of affective and depressive adjustment disorders. I interviewed 151 index twins with moderately severe and mild affective illness, as well as their co-twins. The analysis of concordance rates indicates that hereditary factors may be important in the development of bipolar disorder and in major depression, except in non-psychotic, hysterical individuals. Furthermore, hereditary factors may not play any role in dysthymic disorder and depressive adjustment disorder. These findings are tentative and should be viewed against the methodologic limitations of this study, which include small sample size of the subgroups and the use of the Present State Examination as the basis for the DSM-III diagnoses.

Parental loss by death in the early childhood of depressed patients and of their healthy siblings

The incidence of parental loss by death before the age of 15 was investigated in a series of 200 depressed patients, sub-divided into unipolars, bipolars and neurotic-reactive depressives, and in their healthy siblings at risk. The age of onset of illness of patients who had lost a parent before 15 was compared with that of depressed controls. No excess of parental loss at any age was found in any of the patient sub-groups, as compared with their healthy siblings, nor did parental loss affect the age of onset of later depression. The results do not support the assumption that the loss of either parent by death in early childhood is significantly associated with depression in adult life, though parental death may be an important variable for individual patients.

Morbidity risk for psychiatric disorders in families of probands with affective disorders divided according to levels of platelet MAO activity

In a series comprising 166 subjects with affective disorders, the lowest and highest quartiles in the male and female platelet monoamine oxidase (MAO) distribution, respectively, were included. The morbidity risk in the first-degree relatives (parents and siblings) of these low and high platelet MAO subjects was determined. First-degree relatives of low platelet MAO probands were found to have an increased morbidity risk for neurotic-reactive depressions and for alcoholism. The results seem to be in line with the biological high-risk paradigm, indicating that platelet MAO could be a biological marker for increased vulnerability. First-degree relatives of high platelet MAO probands were found to have an increased morbidity risk for bipolar affective disorders.

The genetics of depression. A family study of unipolar and neurotic-reactive depressed patients

Sixty unipolar (23 male and 37 female) patients and 67 patients (25 male and 42 female) suffering from a neurotic-reactive depressive disorder, consecutively admitted to the Department of Psychiatry of Umeå University have participated in a family study aimed at identifying morbidity risks for psychiatric illnesses among first degree relatives (n = 437). Besides the classification of affective disorders used in Umeå for research purposes the patients have been classified, according to the ICD-9, DSM-III, age at onset (below or above 40 years), and the Winokur's classification of primary affective disorders. However, only the findings regarding the Umeå classification and the Winokur's classification are given in the present article. Of the patients 90% fulfilled Kendell's criteria for depression at the time of the investigation whereas the others were in a phase of remission when studied. The diagnosis of secondary cases were made without knowledge of the diagnoses of the probands. Among relatives of unipolar probands only two secondary cases of bipolar affective disorder were found--one among parents, and one among siblings (MR% 1.1 and 0.6 respectively). The overall morbidity risk for affective disorders (MR% 22.8 among parents and 15.5 among siblings) proved to be higher than in previous studies. In the families of neurotic-reactive patients the morbidity risk for bipolar affective disorders was also very low (MR% 1.0 among parents and 0.7 among siblings), whereas the overall MR% for affective disorders proved to be surprisingly high (12.1 among parents and 6.7 among siblings). No increased risk for schizophrenia or alcoholism was found among the relatives of either group. When the relatives were divided according to their sex no clear-cut difference in morbidity risk emerged when fathers and brothers were compared with mothers and sisters but alcoholisms occurred more frequently in male relatives. Preliminary findings in second degree relatives suggest that secondary cases of affective disorders might occur among second degree relatives of patients classified as suffering from "sporadic depression" according to Winokur's classification.

Genetic identification of a subgroup of depressed patients

HLA antigens, blood groups and red cell enzyme polymorphisms were studied in patients with different types of affective disorders and in patients suffering from cycloid psychoses. Several statistically significant results were found. In particular, a subgroup of depressed patients characterized by a very extreme distribution of haptoglobin groups was identified. The implications of this last finding for the definition of a particular subgroup of depressed patients is discussed.

Differentiation of primary affective illness from situational, symptomatic, and secondary depressions

Analysis of family history and antidepressant drug response variables of 100 "neurotic" depressives followed up prospectively over three to four years disclosed that primary depressions (unipolar and bipolar) could be distinguished from nonprimary cases by (1) the early occurrence of "pharmacological-hypomania;" (2) family history of bipolar illness; (3) family history for affective disorder in two or three consecutive generations, especially when "loaded." Although each of these variables alone occurred in only one fifth to one third of the primary group, they individually displayed better than 95% specificity for it. Thus, the confidence with which the diagnosis of primary affective illness could be made in the presence of any of these variables ranged from 88% to 100%. These findings argue for considering such nonsymptomatological variables for their potential in strengthening the phenomenologic diagnostic criteria for depressive illness.

Hysteria: a case note study

In a matched retrospective study, 31 patients with hysterical neurosis were compared with 31 with depressive neurosis. There were no significant differences between the groups for siblings' position, medical work, brain disease, poor marriage, frigidity, or family history of psychiatric disorder. Significantly more of the hysterics had a preceding head injury and 29% had a past history of hysteria. By the time of the study 48% had been treated for depression.

Secondary depression: familial, clinical, and research perspectives

The authors evaluate the clinical and research significance of the diagnosis of secondary depression by comparing 48 cases of primary and 26 cases of secondary depression. The patients with secondary depression have a higher familial prevalence of alcoholism, affective disorder, and drug abuse. The groups differ somewhat on a few sociodemographic, behavioral, and attitudinal variables but are similar in symptomatology, sex ratio, onset and duration of symptoms, treatment received, and response to treatment. These results suggest that the distinction between primary and secondary depression should be retained in research that examines neurochemistry or genetics. Primary and secondary depression appear to be identical from the persepctive of clinical care. Management of these patients should emphasize the diagnosis of depression rather than antecedent diagnoses.

Suicide pact in a depressed elderly couple: case report

An elderly depressed couple with multiple physical problems decided that death was preferable to their present lifestyle, and made a suicide pact. At the last minute the wife felt unable to go through with it and the couple entered a psychiartic hosptial. During their 3-week stay they were treated appropriately with amitriptyline and psychotherapy. Since discharge they have been followed closely for two years. Some psycho- and socio-dynamic and therapeutic aspects are discussed.

Neurotic illness in the families of children with asthma and wheezy bronchitis: a general practice population study

In a controlled population study 111 families of children with asthma and wheezy bronchitis were screened. The mothers of asthmatics suffered more depressive illness than controls. This correlates with the severity of the child's asthma. There was no difference in immunological status between depressive and non-depressive mothers of asthmatics.

[Comparative investigations of psychoses in parents, children and siblings (author's transl)]

Psychoses in 441 hospital patients from 210 families have been investigated comparatively. In 106 families 109 parents and 117 children suffer as do 215 siblings in 104 families. It has been established that the sexual appurtenance does not have a decisive importance in the genetic transmission of the psychoses, while comparing the diagnoses, a high percentage (84.5%) of coincidence is founded. Similarities appear in the clinical features, in their course, and the therapeutical effect. The psychoses begin at an earlier age and are taking a heavier course in children, when compared to parents and in the younger brothers and sisters when compared to the elder. In couples with different diagnoses, a similarity is determined as far as the investigated indices are concerned. The clinical features are atypical and symptoms and syndromes, characteristic for the different families, are manifested.

Haloperidol and chlorpromazine: a double-blind cross-over trial and clinical study in children and adolescents

It is possible that the most powerful “drug” in childhood management is the emotionally warm, reality orientated and consistently predictable parent. Such a concept can be exitended to the doctor or any other professional worker who is perceived to have similar qualities by his patients (Balint 1961). Against this, when psychoactive drugs are prescribed for children, one has to evaluate their varying pharmacological effects. This includes placebo and side effects which themselves may have a dynamic interaction and facilitate or retard behavioural changes in the child and attitudes in the parent. Generally child psychiatrists are reluctant to exhibit drugs in the first instance as all too frequently by the time a child is referred there is a history of multiple drug failure. It is believed that for this reason drugs may be underor over-valued and that the indications for their use are not yet well established. Yet it is the clinical experience of most professional workers in this field that drugs exert both powerful and specific effects and should be included in the therpeutic armamentarium.

This study attempts to assess the symptoms, traits and behaviour of a sample of disturbed children over a specified period during which they were given a sequence of psychoactive drugs, a placebo and a no-drug period. An attempt was made at the same time to assess the observable dynamics of the parent-child interaction and the probable relationship this has to the effects of psychoactive drugs.