Biomedical subjects
Publications and source records attributed to W Coryell.
Melancholic depressed subjects scored significantly higher than did nonmelancholic subjects both on the depressive symptoms used and those not used for melancholic subtyping. The results suggest that DSM-III's melancholic criteria do not identify a qualitatively distinct subgroup, but instead reflect illness severity.
An earlier follow-up of inpatients with panic disorder attributed excess mortality among men to death from unnatural causes and from cardiovascular disease. The present study sought to determine the stability of this finding with a 12-year follow-up of 155 outpatients with anxiety neurosis. As in the first study, men were twice as likely to die as expected, and this excess in deaths was attributable to cardiovascular disease and suicide. Given the small numbers in both studies, however, the link between panic disorder and excess cardiovascular mortality remains tentative.
The authors examined the effect of state anxiety on the personality test scores of 56 patients receiving treatment for panic disorder and agoraphobia. The tests were administered before treatment and again 6 weeks later. For the 40 patients who improved by 5 or more points on the Hamilton Anxiety Rating Scale, significant changes in personality measures were observed at week 6, including increased emotional strength and extraversion and decreased interpersonal dependency. The authors conclude that state anxiety, like depression, is a possible confounding factor in personality measurement, and adjustment for it should be made in future studies.
Twenty-five inpatients with DSM-III major depressive disorder received ECT and were interviewed with the Structured Interview for DSM-III Personality Disorders. Patients with and patients without a personality disorder had similar short-term responses to ECT. The results of a 6-month prospective follow-up showed that depressed patients with a personality disorder were significantly more symptomatic and eight times more likely to be rehospitalized.
The Newcastle diagnostic index was completed on 159 depressed in-patients, who received the dexamethasone suppression test during their first week in hospital. Patients suffering from endogenous depression had a significantly higher rate of DST non-suppression, were older, were more frequently psychotic, and more frequently lost weight; even after controlling for these variables, DST non-suppression was significantly more frequent in the endogenous group. The relationship between Newcastle scores and the frequency of DST non-suppression was non-linear.
A sample of 184 hospitalized primary unipolar depressives was used to examine the relationship between the dexamethasone suppression test (DST) and Winokur's familial typology as a function of the broadness of the criteria used to diagnose the patients' first-degree relatives. When a high threshold was used (ie, alcoholic relatives were treated, antisocial relatives had legal problems, and depressed relatives were hospitalized), the DST-familial subtype relationship was much stronger than when a low threshold was used (ie, relatives were diagnosed according to the Family History Research Diagnostic Criteria). The differences in diagnosing family members may be responsible for the inconsistent results reported by investigators examining the relationship between Winokur's typology and the DST.
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Depressed inpatients with psychotic features were compared to those without them in terms of demographic features, depressive symptoms at intake and family history. These variables were then used to compare patients with mood-congruent psychotic features to those with mood-incongruent psychotic features. Patterns of familial psychopathology were similar for psychotic and non-psychotic patients. In accord with other studies, the families of mood-incongruent patients had slightly more schizophrenia and significantly less depression than did the families of mood-congruent patients. Depressive symptoms, particularly those used to define major depression and melancholia, were more severe in psychotic patients. Moreover, these particular depressive symptoms were more likely to distinguish mood-congruent from mood-incongruent patients than were other depressive symptoms. Thus mood-congruent psychotic features accompanied a more typical depressive syndrome than did mood-incongruent psychotic features.
Among inpatients treated without ECT, those with primary unipolar depression had significantly better outcomes at discharge than did those with secondary depression. This difference grew more striking during a 6-month follow-up; patients with secondary depression were clearly less likely to recover from the index depressive episode and had substantially higher symptom levels at the time of follow-up. In contrast, patients with DSM-III melancholia resembled depressed patients without melancholia on all outcome measures.
A consecutive series of 42 outpatients with major depression were classified as having endogenous or nonendogenous depression according to RDC, primary or secondary depression according to the criteria of Feighner et al. (1972) and suppression or nonsuppression according to a dexamethasone suppression test. These groups were then compared according to outcome after an initial placebo phase and after 6 weeks of treatment with desipramine. Patients with secondary depression were somewhat more likely to respond to placebo and were significantly less likely to complete the entire course of treatment. The primary/secondary distinction but not the endogenous/nonendogenous distinction predicted clinical status after desipramine therapy. In accord with earlier reports, nonsuppressors faired better than suppressors though this difference did not reach statistical significance. Moreover, nonsuppressors tended to have outcomes which were more discrete as reflected in a bimodal distribution for final scores, in contrast, final scores for suppressors assumed a more unimodal distribution.
We calculated a Research Diagnostic Criteria (RDC) endogenous score for 257 depressed inpatients based on the number of endogenous criteria present. The distribution of RDC endogenous scores was unimodal. There was no association between endogenous scores and results of the Dexamethasone Suppression Test, or morbid risk for depression in the patients' first-degree relatives. The morbid risk for a family history of alcoholism tended to decrease with increasing endogenous scores, although a consistent steady decline was not observed. The results suggest that the RDC criteria do not fit either the categorical or dimensional model of endogenous classification. Potential sources of difficulty with the RDC endogenous criteria are discussed.
Most studies examining the validity of the Research Diagnostic Criteria (RDC) for endogenous depression have been negative. RDC endogenous subtyping is not associated with short- or long-term treatment outcome, family history of affective disorder, or premorbid personality disorder. Studies examining its relationship to the dexamethasone suppression test (DST) are mixed; half report a significant association, and half do not. The RDC endogenous diagnosis may lack validity either because the criteria do not represent, or are not specific to, the endogenous subtype, or the diagnostic algorithm is inappropriate. In the present study, we conduct a discriminant function analysis on the 10 criteria for the endogenous subtype using DST results as the independent variable. We constructed a new diagnostic algorithm and cross-validated it on a second patient sample. In both samples the discriminant function classification was significantly associated with DST results, whereas the RDC algorithm was not.
Controversy exists regarding the relationship between anxiety states and major depression. We studied the binding of tritiated imipramine to platelet membranes in order to determine if patients with agoraphobia and panic attacks differed from depressed subjects or healthy volunteers on this biological parameter. Mean (+/- SD) Bmax and Kd values were significantly lower in patients with agoraphobia and panic attacks (787 +/- 276 fmole/mg protein and 0.35 +/- 0.14 nM, respectively) than in healthy volunteers (1237 +/- 201 fmole/mg protein and 0.71 +/- 0.37 nM, respectively). In addition, patients with agoraphobia and panic attacks had binding parameters that were similar to those of patients with bipolar or familial pure depressive disorder, but significantly lower than those of patients with depressive spectrum or sporadic depressive disorder. These findings have implications for both the nosology and pathophysiology of anxiety disorders.
Because melancholic subtyping is associated with pretreatment symptom severity, the type of data-analytic technique used in examining treatment validity may affect one's conclusions. We examined the relationship between the presence or absence of melancholia and the response to electroconvulsive therapy (ECT) in 87 depressed inpatients. Depending on the definition of improvement used, melancholic subtyping was either not associated with ECT response, or non-melancholics had a better outcome than melancholics. We suggest that standard methods of outcome evaluation be required in therapy outcome studies.
We examined the risk of psychiatric illness in the first-degree relatives of the 257 depressed inpatients upon whom we constructed the Iowa Discriminant Index (IDI) for endogenous depression. Nonendogenous depressives had a higher rate of alcoholism and antisocial personality in their families. IDI endogenous subtyping was not associated with a family history of depression. These results provide additional support for the validity of the empirically derived IDI.
Patients who met DSM-III criteria for agoraphobia with panic attacks underwent dexamethasone suppression tests (DSTs) before, during, and after treatment with alprazolam or placebo. Similarly, outpatients with major depression were given multiple DSTs as they participated in a study of desmethylimipramine efficacy. The likelihood of an abnormal escape from dexamethasone was similar in the two diagnostic groups; nonsuppression was somewhat more likely among patients with primary depression, but comparisons with agoraphobic groups remained statistically insignificant. These results apparently did not reflect misclassification of primary depression patients as agoraphobics since a history of major depression was not related to the likelihood of nonsuppression within that group. Moreover, change in DST results during treatment reflected clinical change among agoraphobics. After a review of relevant followup and family studies, we conclude that panic disorder and primary depression are separate illnesses and that hypothalamic-pituitary-adrenal axis hyperactivity is an epiphenomenon of both.
One hundred thirty depressed inpatients were rated on DSM-III axis IV on the basis of information collected from a comprehensive life events interview. Axis IV scores were more highly correlated with undesirable than desirable events, with exits than entrances, and with time-limited than chronic events. Higher axis IV scores were associated with a lower rate of abnormal dexamethasone suppression test results, a higher morbid risk for alcoholism, a greater frequency of personality disorders, and a greater likelihood of attempted suicide during the index episode.
Using cross-sectional evaluations 40 years after index admissions, the authors compared depressed patients with mood-congruent and those with mood-incongruent psychotic features. These patients were then compared with patients with nonpsychotic major depression, schizophreniform disorder, or schizophrenia. Outcome in the mood-congruent group resembled that in the nonpsychotic group and was significantly better than that in the mood-incongruent group. Patients in this latter group, however, had significantly better follow-up scores than did schizophrenic patients. These findings are consistent with a short-term outcome and family history study and suggest that patients with major depression and mood-incongruent psychotic features constitute a more diagnostically heterogeneous group than do those with mood-congruent psychotic features.