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Biomedical subjects

D P Devanand

Publications and source records attributed to D P Devanand.

At least 19 recordsLinked to original sources
PubMed1999

Functional significance of mild cognitive impairment in elderly patients without a dementia diagnosis.

The authors investigated differences in functional ability among three groups of subjects who were not diagnosed with dementia: normal control (NC) subjects (n=35); Clinical Dementia Rating Scale (CDRS) score of 0 (minimal impairment; n=26); and CDRS 0. 5 (questionable dementia; n=42). CDRS 0 and 0. 5 patients reported significantly poorer functioning than NCs in household and other activities, but CDRS 0 and CDRS 0. 5 groups did not differ in self-reported functioning. It is likely that CDRS 0. 5 patients overestimated their functional abilities. Correlations between self- and informant reports of functional status were significantly lower in the CDRS 0. 5 group than in the CDRS 0 group, an important finding for clinical management because patients with questionable dementia may actually be more impaired than they admit. Informants' reports or standardized performance-based assessment should be considered in the clinical evaluation of such patients.

Activities of Daily Living↗
PubMed1998

Effects of electroconvulsive therapy on plasma vasopressin and oxytocin.

BACKGROUND: Animal studies suggest that vasopressin has cognitive-enhancing properties and oxytocin may have amnestic effects. A clinical report suggests that the acute increase in oxytocin-associated neurophysin predicts clinical response to electroconvulsive therapy (ECT) in depressed patients. METHODS: Medication-free patients with major depression were randomized to receive right unilateral or bilateral ECT administered with electrical stimulus intensity at either just above seizure threshold or at 150% above seizure threshold. The associations between plasma vasopressin, oxytocin, ECT treatment parameters, clinical outcome, and cognitive effects were assessed. RESULTS: The sample comprised 55 patients. At the second ECT, patients receiving ECT at 150% above initial seizure threshold had significantly greater increases in plasma vasopressin than patients receiving low-dose ECT (ps < .01-.04), with no effects of electrode placement. At the second and ninth ECT treatments, the vasopressin or oxytocin surges were not associated with clinical improvement, seizure duration, time to orientation, or memory test performance. There were inverse trend-level associations between the acute surge in oxytocin levels at the ninth ECT and clinical response, contradicting a report in the literature. CONCLUSIONS: Overall, these findings do not support the hypothesis that diencephalic seizure propagation is central to the mechanism of action of ECT.

Cognition↗
PubMed1998

Prolactin response to electroconvulsive therapy: effects of electrode placement and stimulus dosage.

BACKGROUND: It is unclear whether the serum prolactin (PRL) surge following electroconvulsive therapy (ECT) is a marker of optimal ECT administration. We investigated the relations among PRL surge, stimulus parameters, and outcome in major depressive disorder (MDD). METHODS: Seventy-nine patients with MDD were randomized in a double-blind trial to right unilateral (RUL) or bilateral (BL), and to low-dose (just above seizure threshold) or high-dose (2.5 x threshold) ECT. RESULTS: Change in PRL (delta PRL) varied among treatment groups, with significant effects of electrode placement (BL > RUL, p < .006), electrical dosage (high > low, p < .04), and gender (female > male, p < .005). There was no evidence that clinical improvement was associated with greater PRL surge. CONCLUSIONS: Although delta PRL varied with parameters impacting on response rates, these data indicate the PRL surge cannot serve as a useful index of clinically effective treatment. This finding does not support the view that diencephalic seizure propagation is necessary for ECT to exert therapeutic effects.

Adult↗
PubMed1998

A randomized, placebo-controlled dose-comparison trial of haloperidol for psychosis and disruptive behaviors in Alzheimer's disease.

OBJECTIVE: The goal of this study was to compare the efficacy and side effects of two doses of haloperidol and placebo in the treatment of psychosis and disruptive behaviors in patients with Alzheimer's disease. METHOD: In a 6-week random-assignment, double-blind, placebo-controlled trial (phase A), haloperidol, 2-3 mg/day (standard dose), and haloperidol, 0.50-0.75 mg/day (low dose), were compared in 71 outpatients with Alzheimer's disease. For the subsequent 6-week double-blind crossover phase (phase B), patients taking standard- or low-dose haloperidol were switched to placebo, and patients taking placebo were randomly assigned to standard- or low-dose haloperidol. RESULTS: For the 60 patients who completed phase A, standard-dose haloperidol was efficacious and superior to both low-dose haloperidol and placebo for scores on the Brief Psychiatric Rating Scale psychosis factor and on psychomotor agitation. Response rates according to three sets of criteria were greater with the standard dose (55%-60%) than the low dose (25%-35%) and placebo (25%-30%). The advantage of standard dose over low dose was replicated in phase B. In phase A, extrapyramidal signs tended to be greater with the standard dose than in the other two conditions, primarily because of a subgroup (20%) who developed moderate to severe signs. Low-dose haloperidol did not differ from placebo on any measure of efficacy or side effects. CONCLUSIONS: The results indicated a favorable therapeutic profile for haloperidol in doses of 2-3 mg/day, although a subgroup developed moderate to severe extrapyramidal signs. A starting dose of 1 mg/day with gradual, upward dose titration is recommended. The narrow therapeutic window observed with haloperidol may also apply to other neuroleptics used in Alzheimer's disease patients with psychosis and disruptive behaviors.

Aged↗
PubMed1998

Compliance with disposition to primary care physicians and psychiatrists in elderly homebound mentally ill patients.

In a naturalistic study, the authors evaluated homebound mentally ill elderly patients as part of a psychiatric outreach team in two rural/semi-urban regions. Of the 80 patients evaluated in the two counties, 15 patients were admitted to nursing homes and were excluded from the analyses of follow-up data. Of the remaining 65 patients, 36 were referred to a primary care physician and 29 to a psychiatrist. The follow-up rate with primary care physicians (75%) was significantly greater than with psychiatrists (41% [P < 0.006]). At 3- to 6-month follow-up by telephone, patients who were compliant showed significantly greater clinical improvement than those who were not compliant (P < 0.0001). Overall, the higher follow-up rate for primary care physicians, compared with psychiatrists, reinforces the importance of educating and training primary care physicians in the diagnosis and management of mental disorders in elderly patients.

Aged↗
PubMed1998

The relative efficiency of altering pulse frequency or train duration when determining seizure threshold.

In 12 depressed inpatients referred for bilateral electroconvulsive therapy (ECT), each patient was titrated at the first treatment session by using an ascending method-of-limits procedure with a step-wise increase in pulse frequency (frequency titration) or train duration (duration titration). At the second treatment session, seizure threshold was redetermined by using the method (frequency or duration titration) not used at the first treatment. Frequency or duration was maintained at the lowest level when the other parameter was titrated. Seizure threshold was significantly lower with duration titration (mean, 90 mC; SD, 27.3) than frequency titration (mean, 114 mC; SD, 35.6; p = 0.03). On average, patients in the duration-titration group required 1.2 (SD, 0.6) subconvulsive stimulations before a seizure was elicited, and patients in the frequency-titration group required 1.7 (SD, 0.9) subconvulsive stimulations before a seizure was elicited, a nonsignificant difference. These findings suggest that to elicit a seizure during ECT, increasing train duration may be slightly more efficient than increasing frequency. Basic and other clinical research findings indicate that increasing pulse width may be an inefficient way to elicit a seizure. Therefore the following sequence in the determination of seizure threshold is worth considering when using dose-titration or related techniques: the train duration should be increased first before increasing pulse frequency, and the decision to increase pulse width should be reserved for patients who do not seize at the maximal duration and frequency settings. Further empiric research is needed to establish the utility of this approach.

Adult↗
PubMed1998

Lithium and maintenance electroconvulsive therapy.

This clinical report describes the successful use of a combination of lithium carbonate and maintenance electroconvulsive therapy (ECT) in the treatment of severe bipolar depression. The patient was initially taken off the lithium and given a course of ECT with remarkable improvement in symptoms. He subsequently underwent maintenance ECT, during which lithium was restarted without any side effects. Rating scales were used to assess memory, depression, and mental status. This case suggests that the overlap of the two treatments may be especially beneficial when the plan is to taper maintenance ECT while continuing pharmacotherapy.

Bipolar Disorder↗
PubMed1997

The course of psychopathologic features in mild to moderate Alzheimer disease.

BACKGROUND: The onset and course of the psychopathologic features of Alzheimer disease have not been established in prospective, longitudinal studies. METHODS: Two hundred thirty-five patients with early, probable Alzheimer disease were recruited at 3 sites and observed naturalistically for up to 5 years. At 6-month intervals, the Columbia University Scale for Psychopathology in Alzheimer's Disease was administered. Markov analyses were used to predict the probability of a specific symptom developing or being maintained at the next visit. For each symptom category, the maximum frequency of occurrence at 4 consecutive points (duration, 2 years) was calculated. RESULTS: Misidentification, wandering or agitation, and physical aggression increased during follow-up. At any visit, the likelihood of a new symptom developing was greatest for behavioral disturbance, intermediate for paranoid delusions and hallucinations, and least for depressed mood with vegetative features. Wandering or agitation occurred at 3 or more of 4 consecutive visits (duration, 2 years) in the majority of patients, paranoid delusions and hallucinations were intermediate in their degree of persistence, and depressed mood with vegetative signs rarely persisted. CONCLUSIONS: Behavioral disturbance, particularly agitation, is common and persistent in patients with Alzheimer disease. Psychotic symptoms are less common and show moderate persistence over time. Depressed mood with vegetative signs is uncommon and rarely persists. These findings suggest leads about the optimal treatment duration for specific subtypes of psychopathologic features.

Aged↗
PubMed1997

Use of the Columbia University Scale to assess psychopathology in Alzheimer's disease.

The Columbia University Scale for Psychopathology in Alzheimer's disease (CUSPAD) was developed as a short, semistructured instrument that can be administered by a clinician or trained lay interviewer to the relatives or caregivers of patients with probable Alzheimer's disease (AD). The components of the scale focus on symptoms of psychosis, behavioral disturbance, and depression. A simple decision-tree approach is used to identify the presence of specific psychotic features and makes it possible for the instrument to be used by trained lay interviewers. Interrater reliability has been established. Use of this scale in a multicenter longitudinal study of patients with mild to moderate AD revealed that agitation was the most common and persistent symptom, depressed mood with vegetative signs was the least common and least persistent, and paranoid delusions and hallucinations showed moderate persistence over time. Besides its established psychometric properties, the strengths of the CUSPAD include its brevity, clarity in assessing psychotic symptoms, and ease of administration. These features make it useful for cross-sectional and longitudinal evaluation of the symptoms of psychopathology in AD. The main disadvantage is the lack of quantitative ratings of severity for many of the components, making it unsuitable for use in psychopharmacologic trials.

Aged↗
PubMed1997

Questionable dementia: clinical course and predictors of outcome.

OBJECTIVE: To evaluate the clinical course and predictors of outcome in outpatients with cognitive impairment who do not meet criteria for dementia at initial evaluation. DESIGN: Naturalistic longitudinal study. METHODS: Cognitively impaired patients in a memory disorders clinic who fell between the "normal" and "dementia" categories were defined broadly as "questionable dementia" (QD). Of 127 consecutive QD patients, 75 were followed for a minimum of 1 year (mean 2.5 years, SD 1.7). Baseline neuropsychological testing was conducted in 62 of these 75 QD patients. RESULTS: At the final follow-up time-point, 41.3% met diagnostic criteria for dementia (27 of 31 patients with dementia had possible or probable Alzheimer's Disease, AD), 44% were rated as not demented, and 14.7% remained as "uncertain" dementia. Increased age was associated with the final diagnosis of dementia, but duration of follow-up, Clinical Dementia Rating, and modified Mini Mental State (mMMS) scores were not predictive. Low scores on the mMMS delayed recall subtest, consistent long-term retrieval on the Selective Reminding Test, category naming for animals, and the WAIS-R digit symbol, picture arrangement, and block design subtests were predictive of the final diagnosis of dementia (all P < or = .01). mMMS delayed recall showed 66.7% sensitivity and 71.4% specificity, the other five neuropsychological subtests together showed 66.7% sensitivity and 66.7% specificity, and the six tests together showed 81% sensitivity and 76.9% specificity. Similar predictive accuracy was obtained for the final diagnosis of AD. CONCLUSIONS: In QD patients, poor performance on the mMMS delayed recall item may be a useful predictor of the diagnosis of dementia (and AD) on follow-up. Combining a screening instrument like the mMMS with specific neuropsychological tests may provide good predictive accuracy. In QD patients, the observed heterogeneity in diagnostic outcome, with most patients in the "dementia" and "no dementia" categories at follow-up, enhances the feasibility of evaluating early markers with predictive accuracy for dementia and AD.

Age Distribution↗
PubMed1997

Fluoxetine discontinuation in elderly dysthymic patients.

A group of 23 elderly outpatients with dysthymic disorder participated in a 13-week fluoxetine trial. Twelve responders received open continuation treatment and subsequently discontinued fluoxetine (mean: 32 weeks on medication). During the 24 weeks after discontinuation, 6 of the 12 patients relapsed. Clinical features, dose, and duration of fluoxetine treatment were not predictive of relapse. The 50% relapse rate in this small sample is lower than that reported in young adult dysthymic patients but is high enough to warrant clinical caution.

Adult↗
PubMed1997

Behavioral complications and their treatment in Alzheimer's disease.

Agitation, psychotic features, and depression are common behavioral complications seen in patients with Alzheimer's disease (AD). Agitation tends to be common and persistent in these patients, while psychotic features are less common and moderately persistent over time. Depressed mood with vegetative signs is uncommon and usually does not persist. The limited data available from controlled trials suggest that neuroleptics should be the first choice for the treatment of psychotic features and agitation. Anticonvulsants like valproate and benzodiazepines can be used to treat agitation in the absence of psychotic features. Trazodone and zolpidem are effective hypnotics, and buspirone may treat anxiety. Selective serotonin reuptake inhibitors should be the first choice for persistent depressed mood. Low doses of psychotropic medication are indicated, particularly for neuroleptics and benzodiazepines. Specific target symptoms and potential side effects should be identified and monitored during treatment. Drug interactions can be a problem, and the use of multiple psychotropic medications is discouraged because of the potential for neurologic toxicity. To avoid long-term side effects and unnecessary treatment for symptoms that may be transient, periodic attempts should be made to taper or discontinue the psychotropic medication.

Alzheimer Disease↗
PubMed1996

Subjective memory complaints prior to and following electroconvulsive therapy.

Using the Squire Subjective Memory Questionnaire (SSMQ), depressed patients rated their memory functioning prior to a course of brief pulse, electroconvulsive therapy (ECT) within the 1 week following the course and 2 months later. Normal controls made similar ratings at comparable intervals. Prior to ECT, patients reported poorer memory functioning than controls. There was marked improvements in the patients' self-reports shortly following ECT, and at 2-month follow-up SSMQ scores were generally comparable in patients and controls. At all time points, the severity of depressive symptoms was strongly associated with patients' reports of memory dysfunction. SSMQ subscales ("depression" and "ECT" items) were not differentially sensitive to effects of ECT or depression. Relations between ECT treatment parameters and changes in patients' self-evaluations only emerged after controlling for clinical state change. Shortly following ECT, there were no relations between SSMQ scores and objective measures of cognitive functioning. However, 2 months following ECT, there was a suggestion that greater retrograde amnesia for autobiographical memories was associated with self-rating of greater memory impairment.

Adult↗
PubMed1996

Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community.

BACKGROUND: It remains unclear whether depression increases the risk for dementia in the elderly. We evaluated the relationship between depressed mood at baseline and the incidence of dementia, particularly Alzheimer's disease, in the elderly living in the community. METHODS: A total of 1070 elderly individuals, aged 60 years or older, were identified as part of a registry for dementia in the Washington Heights community of North Manhattan, NY. In a prospective, longitudinal design with follow-up for 1 to 5 years, annual physician evaluation and neuropsychological testing were used to assess levels of cognitive impairment and to diagnose dementia. Depressive symptoms were evaluated with the 17-item Hamilton Rating Scale for Depression. Based on clinical considerations and a validity study, a positive score for the depressed mood item was used in statistical analyses. To confirm the results, the total Hamilton Rating Scale for Depression score was also evaluated as the "depression" variable. RESULTS: Of the 1070 subjects, 218 met criteria for dementia at baseline evaluation. In the 852 subjects without dementia, depressed mood was more common in individuals with greater cognitive impairment. In a follow-up study of 478 of these subjects without dementia (mean +/- SD, 2.54 +/- 1.12 years of follow-up), the effect of baseline depressed mood on the end-point diagnosis of dementia (93% had possible or probable Alzheimer's disease) was evaluated in a Cox proportional hazards model. Depressed mood at baseline was associated with an increased risk of incident dementia (relative risk, 2.94; 95% confidence interval, 1.76 to 4.91; P < .001). This effect remained after adjustment for age, gender, education, language of assessment, Blessed Memory Information and Concentration test scores, and Blessed Functional Activity Scale scores (relative risk, 2.05; 95% confidence interval, 1.16 to 3.62; P < .02). Similar results were obtained when the total Hamilton Rating Scale for Depression score was used as the depression variable, with the use of the same covariates (relative risk, 1.07 per point interval; 95% confidence interval, 1.02 to 1.11; P < .01). CONCLUSIONS: Depressed mood moderately increased the risk of developing dementia, primarily Alzheimer's disease. Whether depressed mood is a very early manifestation of Alzheimer's disease, or increases susceptibility through another mechanism, remains to be determined.

Age Factors↗
PubMed1996

The effects of electroconvulsive therapy on quantitative electroencephalograms. Relationship to clinical outcome.

BACKGROUND: The efficacy of electroconvulsive therapy (ECT) is determined by stimulus electrical intensity and electrode placement. Three theories offer different accounts for why increasing the stimulus dosage of right unilateral ECT enhances antidepressant effects. This study examined the effects of ECT on interictal quantitative electroencephalograms (EEGs), contrasting these theories in their predictions regarding global, lateralized, and topographic changes in ECT-induced slow-wave activity. The time course of EEG changes and associations with efficacy were also determined. METHODS: Sixty-two inpatients with major depressive disorder were randomized to ECT conditions that differed in stimulus intensity (low vs high dosage) and electrode placement (right unilateral vs bilateral). Resting, eyes closed, 19-lead EEG recordings were obtained at pretreatment, following a single treatment, following an average of 7 treatments, during the week following the ECT course, and after a 2-month follow-up period. RESULTS: Electroconvulsive therapy produced a marked short-term increase in delta and theta power. At a 2-month follow-up, there were no significant alterations in any frequency band. The ECT treatment conditions differed markedly in efficacy. Global and lateralized EEG effects did not distinguish effective and ineffective forms of treatment. Effective forms of ECT resulted in increased delta power in prefrontal regions, and this change was associated with the magnitude of symptomatic improvement. CONCLUSION: The induction of slow-wave activity in prefrontal cortex is linked to the efficacy of ECT.

Delta Rhythm↗
PubMed1996

Who responds to electroconvulsive therapy? A comparison of effective and ineffective forms of treatment.

BACKGROUND: It has been reported that real ECT is more effective than simulated treatment among depressed patients with delusions and/or retardation, and that ECT is not effective among depressed patients who lack these features. METHOD: In two randomised, double-blind studies, 143 patients with major depression were subtyped regarding psychosis, retardation and agitation. In both studies, low dosage, right unilateral ECT was ineffective compared with other forms of ECT. This report examined whether the depressive subtypes differed in clinical response to the ineffective and effective forms of ECT. RESULTS: The therapeutic advantage of effective forms of ECT was similar across the depression subtypes. Patients who lacked both psychosis and retardation showed this pattern. CONCLUSIONS: The findings cast doubt on the utility of these depression subtypes in predicting ECT response. ECT is a viable treatment option for patients with major depression regardless of the presence or absence of psychosis, retardation and/or agitation.

Adult↗
PubMed1996

A preliminary study of apolipoprotein E genotype and psychiatric manifestations of Alzheimer's disease.

We evaluated the frequency of depression and psychosis in 46 patients with AD and 135 control subjects with the apolipoprotein (APO) E3/3 or E3/4 genotype. Patients with AD and the APOE3/4 genotype had a more than threefold increase in the signs of depression and psychosis when compared with either patients with the APOE3/3 genotype or to control subjects. Our preliminary study suggests that the phenotype of AD associated with the epsilon 4 allele is more likely to include psychiatric manifestations.

Aged↗