Criteria For Major Depressive Episode Research Articles

A double-blind, randomized comparison of fluvoxamine with mianserin in depressive illness

The efficacy and CNS effects of the selective 5-HT re-uptake inhibitor fluvoxamine were compared with mianserin in depressed hospital out-patients in a double-blind randomized trial. Patients had to meet DSM-III criteria for Major Depressive Episode and achieve a score of at least 30 on the Montgomery-Asberg Depression Rating Scale (MADRS) after a 1-week placebo baseline period. Active treatment was for 6 weeks with an initial dose of either 100 mg fluvoxamine or 60 mg mianserin; after 1 week the dosage could be increased to 300 mg or 180 mg, respectively. Data from 63 patients (30 received fluvoxamine) were analyzed. The treatment groups were comparable with regard to age and history and severity of depression. Efficacy assessments showed similar improvements with each drug; MADRS scores improved by 65.6% with fluvoxamine and by 60.8% with mianserin. There were no significant differences between treatments at any assessment. Sedative effects were assessed using the Leeds Sleep Evaluation Questionnaire and the Digit Symbol Substitution Test. Mianserin caused a shift towards sedation in the first week in all visual analogue scales; getting to sleep and sleep quality were improved but waking was more difficult than with fluvoxamine. Similarly, the mianserin group performed less well on the Digit Symbol Substitution Test. The study confirmed that both drugs are effective treatments for depressive illness but that mianserin gives rise to sedation during the first week.

Depression and posttraumatic stress disorder in Southeast Asian refugees.

The authors report on 404 Southeast Asian refugees seen at a community clinic. Approximately three-quarters of these patients met DSM-III criteria for major depressive episode, and 14% had posttraumatic stress disorder. Complaints of pain and sleep disturbances were the predominant presenting symptoms. Most of the men were married, but more than 40% of the women were widowed. Between 15% and 30% of the patients reported specific traumatic experiences either in their homeland or during their escape. Widowhood and such traumatic experiences were positively correlated with more symptoms of depression and anxiety.

Anger and hostility in depression.

The present study examined the relationship between depression and various dimensions of anger using multiple measures of anger and hostility and comparing depressed subjects with both a normal sample and a clinical sample with predominant anger difficulties. Three groups of subjects were obtained: a normal sample of 120 parents of elementary school children, 36 psychiatric inpatients meeting Research Diagnostic Criteria for major depressive episode, and 54 hospitalized veterans meeting Diagnostic Interview Schedule criteria for posttraumatic stress disorder (PTSD). The three groups differed significantly on all measures of anger experience, hostility, anger suppression, and anger expression. The depressed group reported greater levels of hostility and anger experience than the normal group but less than the PTSD group. On measures of anger suppression and expression, the depressed group exhibited more suppression than either the normal or the PTSD group and generally reported levels of anger expression comparable with the normal group's. The PTSD group reported the highest levels of anger expression. Within the depressed group, severity of depression was positively associated with levels of hostility and anger experience but was not related to measures of anger expression and was only partially related to anger suppression. These results are discussed as they relate to the "anger turned in" hypothesis of psychodynamic theories of depression, and directions for future research are noted.

Fluoxetine treatment of depression

In an open study of depressed inpatients, the effects of the selective serotonin uptake blocker fluoxetine on 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), 4-hydroxy-3-methoxyphenyl glycol (HMPG) and N-terminally extended substance P (SP) in cerebrospinal fluid (CSF) were measured. Thirteen unmedicated patients who met the DSM-III criteria for major depressive episode were included, and 9 completed the study. During treatment the 5-HIAA concentration decreased by 46%. The HVA and HMPG concentrations also decreased significantly, but to a lesser degree. The mean level of N-terminally extended SP was unaffected by fluoxetine treatment, but the pretreatment level correlated significantly with the pretreatment level of HMPG. The pretreatment level of HVA was the only biochemically variable that appeared to predict therapeutic outcome. The plasma concentrations of both fluoxetine and its metabolite norfluoxetine increased significantly between 3 and 6 weeks. Plasma and CSF levels of both the parent drug and its active metabolite were correlated.

Adrenocorticotropin and cortisol response to lysine vasopressin in relation to the outcome of the dexamethasone suppression test in major depressive disorder.

The pathophysiology behind the abnormalities of the hypothalamic pituitary adrenal cortex axis found in patients with major depressive disorder was studied by the use of the vasopressin test. The response of plasma adrenocorticotropin (ACTH) and cortisol to the injection of 10 IU lysine-vasopressin (LVP) was investigated in 18 patients meeting the DSM-III criteria for major depressive episode. The response was correlated to the outcome of the dexamethasone suppression test (DST) with the use of two different cut-off points, 139 nmol/l and 200 nmol/l respectively. The results show that no significant difference was found in ACTH or cortisol response between patients having a normal or abnormal DST. The results do not seem to support the hypothesis that the abnormalities of the hypothalamic pituitary adrenal cortex axis involve a hypersecretion of corticotropin-releasing factor (CRF) and a subsequent desensitization of the corticotrophs to CRF-stimulated ACTH release.

A proposed new approach to the clinical subclassification of depressive illness.

This paper focuses on the classification of mood disorders. Data are reported from 227 outpatients who met DSM-III-R criteria for Major Depressive Episode. Each patient was evaluated by the Semistructured Interview for Depression (SID), which was developed and organized according to a decision tree model. The SID was used both to identify the sample with major depressive disorders and, then, to subclassify them into five subtypes. Three bipolar types (I, II, III) and two unipolar types (recurrent and single episode) were distinguished, and comparisons among the subtypes are presented. Therapeutic implications of the classification are discussed in relation to recent advances in targeting short and long-term treatments for specific subtypes.

The dexamethasone suppression test and prediction of outcome in patients receiving ECT.

Twenty-six in-patients satisfying DSM-III criteria for major depressive episode were assessed using the Newcastle Diagnostic and ECT Predictor Scales and the dexamethasone suppression test (DST), prior to commencing a course of electroconvulsive therapy (ECT). The Newcastle ECT Predictor Scale was successful in predicting both immediate outcome and outcome over the 6 months following ECT; the DST was unsuccessful in predicting either immediate or 6-month outcome.

Nonpsychiatric physicians' identification and treatment of depression in patients with diabetes

The recognition of depression by nonpsychiatric physicians was studied in a group of patients with diabetes mellitus. One hundred fourteen patients participating in a longitudinal study of diabetes control and complications also agreed to undergo psychiatric evaluation. Twenty-eight (24.6%) of these patients satisfied the Diagnostic and Statistical Manual of Mental Disorders (ed 3) (DSM-III) criteria for major depressive episode. Outpatient and inpatient medical records of these patients were examined and compared to those from a control group of 28 patients without psychiatric diagnosis (psychiatrically well). Physicians recorded the presence of abnormal psychological features (e.g., anxious or depressed mood) in 19 (68%) of the depressed patients and in 1 (3.4%) of the controls ( χ 2 = 22.5, P < .001). A clinical diagnosis of depression, however, was assigned to only 10 (35.7%) of the depressives and to none (0.0%) of the controls ( χ 2 = 14.4, P < .001). Fourteen (50%) of the patients with depression were prescribed one or more psychotropic medications (10 were given antidepressants); 3 (10.7%) of the controls were prescribed these drugs ( χ 2 = 8.4, P < .01). We conclude that diabetologists do correctly identify features of depression in patients with diabetes. However, in only approximately one third of cases is the diagnosis recorded and treatment initiated.

Depression following acute spinal cord injury.

Nine patients meeting the DSM-111 criteria for major depressive episode were identified among 84 consecutive admissions to the Spinal Injuries Unit of the Austin Hospital. All were successfully treated with antidepressants. The means of recognition of depression, the differentiation of a depressive illness from grief and the implications for rehabilitation are discussed.

Cerebrospinal Fluid Monoamine and Monoamine Metabolite Levels and the Dexamethasone Suppression Test in Depression

The cerebrospinal fluid levels of norepinephrine and six monoamine metabolites were measured in 23 patients meeting DSM-III criteria for major depressive episode, 15 of whom also met criteria for melancholia. Life events during the six-month period before the onset of depression were recorded using Paykel's method. There was no difference in Hamilton depression ratings between patients with life events and those without. However, depressed patients who did not have a life event in the six months before the onset of depression had significantly lower levels of the dopamine metabolite homovanillic acid and the serotonin metabolite 5-hydroxyindoleacetic acid than those with life events. The incidence of nonsuppression on the dexamethasone suppression test was also greater in patients with a major depressive episode who did not have an undesirable life event than in those who did. Thus, the presence or absence of life events led to a separation into biologically distinct groups.

Anxiety in Patients With Pheochromocytomas

Anxiety has been considered an important clinical feature of patients with pheochromocytomas. We studied 17 patients with active pheochromocytoma to determine whether they experienced anxiety that met criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, for either panic disorder or generalized anxiety disorder. Fifty-two patients with primary anxiety disorders were used as a comparison group. Six patients with pheochromocytomas had norepinephrine-secreting tumors and 11 had mixed-secretion tumors, with elevated levels of both epinephrine and norepinephrine. None of the 17 patients described the severe apprehension or fear characteristic of panic attacks and none described agoraphobia. One patient received a diagnosis of possible panic disorder, two met criteria for generalized anxiety disorder, and two met criteria for major depressive episode. Thus, the elevated levels of catecholamines secreted by pheochromocytomas are not sufficient to elicit an anxiety disorder.

The dexamethasone suppression test in demented outpatients with and without depression

The dexamethasone suppression test (DST) was given to 33 elderly, male outpatients, previously diagnosed by DSM-III criteria as having dementia. Fifteen of these patients also had signs and symptoms of depression and, except for the presence of organic mental syndrome, would have met DSM-III criteria for major depressive episode. Of these 15 depressed, demented patients, 40% had abnormal DST results. None of the 18 patients who had dementia alone had abnormal DSTs. Our data suggest that in elderly, demented outpatients, an abnormal DST may be associated with concomitant depression.

Desipramine plasma concentration and antidepressant response

• The relationship of desipramine hydrochloride plasma concentration and antidepressant response was determined in 30 depressed inpatients treated for three weeks with desipramine. All patients had a nondelusional unipolar depression, met DSM-III criteria for major depressive episode with melancholia, and had a Hamilton score of 18 or greater after one week of hospitalization without medication. Eightynine percent of the patients with plasma concentrations above 115 ng/mL responded, in contrast to 14% of those with concentrations below this level, a significant difference (Fisher's exact test, P

The NIMH diagnostic interview schedule modified to record current mental status

The National Institute of Mental Health Diagnostic Interview Schedule (DIS) was modified to record detailed information on current mental status in addition to the lifetime symptom history. Use of the modified DIS in a field survey indicates that information on current symptoms is required to distinguish persons who meet all DSM-III criteria for Major Depressive Episode at or around the time of interview from former cases who fail to meet all criteria at interview. Thus, the unmodified DIS may overestimate the 1-month period prevalence rates for Major Depressive Episode, by counting symptomatic former cases as having the disorder at or around the time of the interview. An analysis of symptom count data also suggests that the unmodified DIS count of lifetime depressive symptoms is not a good measure of current symptom status.

Desipramine plasma concentration and antidepressant response.

The relationship of desipramine hydrochloride plasma concentration and antidepressant response was determined in 30 depressed inpatients treated for three weeks with desipramine. All patients had a nondelusional unipolar depression, met DSM-III criteria for major depressive episode with melancholia, and had a Hamilton score of 18 or greater after one week of hospitalization without medication. Eighty-nine percent of the patients with plasma concentrations above 115 ng/mL responded, in contrast to 14% of those with concentrations below this level, a significant difference (Fisher's exact test, P less than .001). Ten initial nonresponders were converted to responders when dosage increase raised desipramine plasma concentration to 125 ng/mL or above. In clinical practice a plasma concentration of 125 ng/mL would be a useful guideline as a threshold above which desipramine is likely to be effective.

Depression in children and adolescents with malignancy.

This is a prospective and retrospective study of 35 children and adolescents with cancer treated at a pediatric Hematology-Oncology division. Using DSM-III diagnostic criteria for Major Depressive Episode, 17% of the sample were found to be depressed. This study also describes some of the distinguishing characteristics of adults and children with cancer. For example, of particularly note in this study was the apparent nonchalance of younger children diagnosed as having cancer. The children also, however, demonstrated anger more frequently, which is not a common finding in adult patients with cancer.

The dexamethasone suppression test as a predictor of sleep deprivation antidepressant effect

An abnormal dexamethasone suppression test (DST) result, a sensitive and specific marker for endogenous depression, was found to be associated with an antidepressant response to sleep deprivation in patients who met DSM-III criteria for Major Depressive Episode regardless of whether they met criteria for melancholia or psychotic subtypes of this disorder. These findings support previous reports of an association between an abnormal DST result and antidepressant effects of sleep deprivation in depressed patients. Our results extend the positive association between an abnormal DST result and the antidepressant response to sleep deprivation to include depressed patients who are clinically nonmelancholic during thair current episode but who have an abnormal DST result.

Major depressive episode and low dose dexamethasone suppression test.

The authors studied the validity of a low dose (0.5 mg) dexamethasone suppression test (DST) in identifying depression. Nine patients who met the criteria of major depressive episode (MDE) in the Diagnostic and Statistical Manual of Mental Disorders, another nine psychiatric patients and one normal subject underwent the DST. At least one of the two blood samples obtained either at 8 a.m. or at 2 p.m. from each of the nine patients with MDE showed a cortisol concentration of over 5.0 micrograms/dl, while the cortisol concentration in the other 10 subjects was uniformly suppressed under this level. All the patients with MDE could be identified by nonsuppression of the cortisol secretion at 8 a.m. or at 2 p.m. An "early escape" phenomenon in depressed patients reported by Carroll et al. (1976) was absent in a 0.5 mg DST, and the blood samples at 8 p.m. were less useful for identifying the depressive patient. The reason why the one point sampling method used by previous investigators was insufficient to identify the depressed patient was discussed.

Exacerbation of Psychosis by Tricyclic Antidepressants in Delusional Depression

The authors describe three patients with delusional unipolar depression whose delusional thinking worsened markedly following administration of tricyclic antidepressant drugs. The patients had met Research Diagnostic Criteria for major depressive episode and had no evidence of schizophrenia or mania. Since tricyclic antidepressants are known to exacerbate psychosis in schizophrenic patients, it is sometimes suggested that the exacerbation of psychotic thinking in depressed patients indicates schizophrenia. The authors suggest that such an exacerbation does not in itself indicate schizophrenia but may occur in patients with an affective disorder who are prone to depressive delusions. The authors discuss the use of antipsychotic medication in this patient group and present a neurochemical hypothesis to explain the interaction of the drug with the illness, which results in exacerbation of psychotic thinking.