The association between major depression and levels of soluble intercellular adhesion molecule 1, interleukin-6, and C-reactive protein in patients with recent acute coronary syndromes

OBJECTIVE: This study was conducted to determine whether or not depression is associated with higher levels of inflammatory markers in patients recovering from acute coronary syndromes. METHOD: Plasma levels of soluble intercellular adhesion molecule 1 (sICAM-1) and interleukin-6 (IL-6) and the serum level of C-reactive protein were measured in 481 patients 2 months after hospitalization for acute coronary syndromes. Diagnosis of major depression was based on the Structured Clinical Interview for DSM-IV. RESULTS: Depressed patients showed significantly higher sICAM-1 levels, a difference that remained significant after adjustment for potential confounders (gender, smoking, presence of metabolic syndrome). Although there was no significant association between depression and IL-6, there was an interaction between depression and statin therapy for levels of C-reactive protein. Depressed patients not taking statins had markedly higher C-reactive protein levels than did nondepressed patients. There was no relationship with depression in those receiving statins. CONCLUSIONS: These results suggest chronic endothelial activation among depressed patients after acute coronary syndromes. Further research is needed to determine whether or not higher levels of sICAM-1 may identify a subgroup of depressed patients at particularly high risk for cardiac events among patients with established coronary artery disease or among those without previous coronary artery disease.     

Depression during the longitudinal course of schizophrenia

This prospective research investigated the occurrence and persistence of depression during the longitudinal course of schizophrenia. The research goals were to (1) compare depression in schizophrenia with that in schizoaffective and major depressive disorders, (2) assess whether some schizophrenia patients are vulnerable to depression, and (3) assess the relationship of depression to posthospital adjustment in schizophrenia. A total of 70 schizophrenia, 31 schizoaffective depressed, 17 psychotic unipolar major depressed, and 69 nonpsychotic unipolar major depressed patients were assessed during hospitalization and prospectively assessed for depression, psychosis, and posthospital functioning at 4.5- and 7.5-year followups. A large number (30% to 40%) of schizophrenia patients evidenced full depressive syndromes at each followup, including a subgroup of patients who evidenced repeated depression. Even when considering the influence of psychosis on outcome, depression in schizophrenia was associated with poor overall outcome, work impairment, lower activity, dissatisfaction, and suicidal tendencies. During the post-acute phase assessed, neither the rates nor the severity of depressive syndromes differentiated depression in schizophrenia from schizodepressive or major depressive disorders. However, the depressed schizophrenia patients showed poorer posthospital adjustment in terms of less employment, more rehospitalizations, and more psychosis than the patients with primary major depression. The high prevalence of depression in schizophrenia warrants its incorporation into theory about the disorder. A continuum of vulnerability to depression contributes to the heterogeneity of schizophrenia, with some schizophrenia patients being prone to depression even years after the acute phase. Depression in schizophrenia is one factor, in addition to psychosis, associated with poor outcome and requires specific attention to the treatment strategies by psychiatrists.     

Outcome at discharge and six months in major depression. The significance of psychotic features

Inpatients with nonbipolar psychotic major depression (N = 46) had significantly lower Hamilton Rating Scale scores at discharge and a significantly greater number of weeks back to their "normal selves" during a 6-month follow-up than did patients with nonpsychotic major depression (N = 159). While both baseline severity and the receipt of electroconvulsive therapy distinguished these groups, neither accounted for the outcome differences noted. Severity ratings at discharge were clearly more predictive of follow-up course in psychotic patients than they were in nonpsychotic patients. Moreover, patients with psychotic depression had clearer outcomes in that their average follow-up weeks were more likely to involve either full syndromes or a complete absence of depressive symptoms. This finding, if replicated, may account in part for the lack of consensus on the prognostic significance of psychotic depression.     

Impact of psychiatric hospitalization on behavioral complications of Alzheimer's disease.

OBJECTIVE: The authors conducted a prospective study of the clinical utility of the four DSM-III-R subtypes of primary degenerative dementia of the Alzheimer type (with delirium, with delusions, with depression, or uncomplicated) and acute psychiatric hospitalization for treatment of these subtypes. METHOD: The subjects were 120 consecutive inpatients with Alzheimer's disease, most of whom had behavioral abnormalities. Each subject received detailed physical, neurological, psychiatric, and mental status examinations. The presence or absence of specific behavioral problems was also documented. Patients were treated with medication, psychotherapy, and behavioral techniques. RESULTS: While all patients could be assigned to one of the four DSM-III-R behavioral subtypes, the uncomplicated subtype did not accurately reflect the burden of behavioral symptoms in the patients who did not have delirium, delusions, or depression. Each behavioral subtype responded in a characteristic way to inpatient treatment, as reflected by changes in scores on four psychometric scales used to assess cognitive impairment, psychiatric symptoms severity, and level of functioning at admission and at discharge, as well as by changes in residential setting following hospitalization. Half of all patients admitted from their homes and two-thirds of those with depression were able to go home following discharge. CONCLUSIONS: Behavioral syndromes in Alzheimer's disease should not be overlooked, because they have both clinical and prognostic significance. Short-term psychiatric hospitalization is effective and efficient for achieving the goal of returning patients to their homes and for safely implementing specific treatments in this frail population, and it may reduce the need for institutionalization.     

Tardive dyskinesia in elderly psychiatric patients: a 5-year study.

OBJECTIVE: The authors investigated the prevalence of tardive dyskinesia among elderly psychiatric patients who had never received neuroleptic medication before their first hospitalization. METHOD: The study was performed in the geriatric psychiatry unit of a university-affiliated hospital in Canada and involved all first-admission patients admitted from September 1984 through August 1989 who had never taken neuroleptic drugs. In September and October 1989, the patients who were available for follow-up were examined and given ratings on the Abnormal Involuntary Movement Scale to establish the presence or absence of tardive dyskinesia. The patients' records were reviewed for information on age, diagnosis, duration of hospitalization, neuroleptic treatment received after admission, anticholinergic drugs received, and drug-free periods. RESULTS: Of the 162 patients who were available and whose data were analyzed, a total of 99 had been treated with neuroleptics, and 35 (35.4%) of these were found to have tardive dyskinesia. Two of the 35 also had tardive dystonia. Significantly more patients with major depression than patients with primary degenerative dementia or delusional psychosis had tardive dyskinesia. CONCLUSIONS: This study confirms the higher vulnerability of elderly psychiatric patients treated with neuroleptics to the development of tardive dyskinesia. The authors stress that caution is especially necessary when neuroleptics are prescribed for older patients with major affective disorders.     

Antidepressants in the medically ill: prediction of benefits

Although depression secondary to medical illness occurs frequently, little is known about its response to conventional antidepressant therapy. In this retrospective study of 50 patients, the authors assessed the charted therapeutic effect of antidepressants and sought to define pretreatment features associated with good outcome. Half (9/18) of the patients with a previous history of depression improved while only 22% (7/32) of the patients without a previous history of depression showed improvement in mood. Those patients meeting DSM-III criteria for major depressive disorder were no more likely to benefit from antidepressants than were patients meeting criteria for adjustment disorder with depressed mood. The authors conclude that previous history of depression should be considered when assessing risks and benefits for antidepressants for medically ill patients with depressive syndromes.     

Psychodynamic psychotherapy and clomipramine in the treatment of major depression

OBJECTIVE: The authors compared a combination of clomipramine and psychodynamic psychotherapy with clomipramine alone in a randomized controlled trial among patients with major depression. METHODS: Seventy-four patients between the ages of 20 and 65 years who were assigned to ten weeks of acute outpatient treatment for major depression were studied. Bipolar disorder, psychotic symptoms, severe substance dependence, organic disorder, past intolerance to clomipramine, and mental retardation were exclusion criteria. RESULTS: Marked improvement was noted in both treatment groups. Combined treatment was associated with less treatment failure and better work adjustment at ten weeks and with better global functioning and lower hospitalization rates at discharge. A cost savings of 2,311 dollars per patient in the combined treatment group, associated with lower rates of hospitalization and fewer lost work days, exceeded the expenditures related to providing psychotherapy. CONCLUSIONS: Provision of supplemental psychodynamic psychotherapy to patients with major depression who are receiving antidepressant medication is cost-effective.     

Hierarchical diagnosis in chronic schizophrenia: a clinical study of co-occurring syndromes

Co-occurring or associated psychiatric syndromes (APS) such as depression, obsessive-compulsive disorder (OCD), and panic disorder have largely been hidden from view by exclusion rules that prohibit their being diagnosed in the presence of schizophrenia. This article presents data from a clinical study of APS in chronic schizophrenia and reviews the relevant literature. Thirty-seven chronic schizophrenia patients consecutively admitted to a day program were administered the Structured Clinical Interview for Diagnosis for DSM-IV and the Yale-Brown Obsessive Compulsive Scale symptom checklist. Exclusion rules prohibiting the diagnosis of APS were bypassed. Eighteen patients (48.6%) had one or more APS. Ten patients (27%) had major depression. Eleven (29.7%) met criteria for OCD. Four patients (10.8%) met criteria for panic disorder. These findings suggest that APS may be common in chronic schizophrenia and that there is a need to study these syndromes' clinical validity, including their treatability. A research plan to study the validity of these syndromes further is discussed.     

Cerebrovascular risk factors and depression in older primary care patients: testing a vascular brain disease model of depression.

The authors examined whether cerebrovascular risk factors (CVRFs) are associated with depressive diagnoses and symptoms in 303 primary-care patients age >/=60 years, as would be consistent with a small-vessel brain disease model of later-life depression. CVRFs were not significantly independently associated with major, minor, or subsyndromal depression, late-onset major depression, or overall depressive symptom severity. These data did not support the notion that a small-vessel brain disease model of depression might apply to the majority of older persons with depressive symptoms and syndromes in primary-care settings. Future work should include longitudinal study with larger sample sizes.     

Use of psychostimulants for the elderly

As the number of people over age 65 continues to grow, a clear understanding of the usefulness and limitations of psychostimulants in treating elderly persons becomes more important. The authors review the limited literature and discuss the use of psychostimulants for treating "senility," including their effects on cognition, amotivational syndromes, and depression. They conclude that early studies of "senile" patients suffered from a lack of clear diagnostic standards and did not address the issue of whether measurements of the target symptoms being assessed were reliable or valid. The authors suggest that future studies more clearly define age groups, diagnostic criteria, and scales to measure the effects of psychostimulants.     

Potentiation of antidepressant medications by phase advance of the sleep-wake cycle

Four patients with major depression who were unresponsive to antidepressant medications rapidly improved and remained euthymic after an advance of the sleep-wake cycle. Phase advance of the sleep-wake cycle and antidepressant treatment may have complementary effects on the circadian system. The authors suggest that the combination may be useful in treating drug nonresponders and in hastening response to antidepressant drugs.     

Psychiatric syndromes linked to reproductive function in women: a review of current knowledge

Four psychiatric syndromes related to reproductive function in women have been identified: postpartum depression, premenstrual syndrome (PMS), post-hysterectomy depression, and involutional melancholia. The authors review what is known about these syndromes and conclude, first, that postpartum depression comprises three separate syndromes, the most severe of which is most likely a variant of primary affective disorder. Second, research into the syndromal nature, biology, and treatment of PMS is still in its infancy due to a variety of methodological difficulties. Third, the rate of depression among women during the involutional period or following hysterectomy for benign pathology is not higher than it is at other times.     

The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up

The impact of clinically diagnosed depression on recovery in activities of daily living over a 2-year follow-up was examined in a prospective study of 63 stroke patients. Although impairment in activities of daily living, neurologic diagnoses and findings, lesion location and volume as measured on computed tomographic scan, demographic variables, cognitive impairment, and social functioning were comparable between depressed (n = 25) and nondepressed (n = 38) patients during their acute hospitalization, the two groups had different patterns of recovery in activities of daily living. At 2 years after suffering a stroke, patients with an in-hospital diagnosis of depression (either major or minor depression) were significantly more impaired in both physical activities and language functioning than were non-depressed patients. Among patients with major depression, this disparity in the recovery profile was present even after the depression had remitted. This study emphasizes the need for early recognition and treatment of poststroke depression.     

Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: a prospective study

OBJECTIVE: Suicide attempts predict repeat attempts and suicide completion. Major depression requiring hospitalization is a risk factor for suicidal acts, particularly in the 2 years following discharge. The authors prospectively studied the adequacy of antidepressant treatment and its impact on suicidal acts in the 2 years after hospitalization for major depression. METHOD: Patients (N=136) with major depression were interviewed at 3 months, 1 year, and 2 years after admission. At each interview, the presence of major depression and suicidal acts and the adequacy of antidepressant treatment were assessed. Cox's proportional hazards analysis with time-varying covariates was used to model the risk of a suicide attempt during the follow-up period. RESULTS: Major depression in the follow-up period increased the risk of a suicide attempt sevenfold. For each suicide attempt in a subject's history, the risk for an attempt in the follow-up period increased by 30%. Antidepressant treatment during the follow-up period was mostly inadequate. Consequently, a relationship between adequacy of antidepressant treatment during follow-up and the risk of a suicide attempt could not be found. Furthermore, subjects with a history of a suicide attempt at baseline were not treated more vigorously than nonattempters. CONCLUSIONS: Antidepressant treatment of depressed patients is strikingly inadequate, even in suicide attempters, known to be at higher risk for suicidal acts. This deficiency undermines the ability to measure the antisuicidal effects of antidepressants in naturalistic studies. Controlled studies of antidepressants are needed to evaluate effects on suicidal acts.     

Effects of alcohol consumption on the treatment of depression among elderly patients.

The authors examined the effects of alcohol use on the short-term and 3-4-month treatment outcomes of patients with late-life depression. Patients (N=2,666) were assessed for symptoms of depression, alcohol use, and disability during an initial inpatient hospitalization and then 3-4 months postdischarge. Contrary to our hypothesis that alcohol consumption imparted a significant additive detriment to treatment outcome in patients already suffering from major depression, the results suggest that treatment was effective even in those with concomitant use of alcohol. Moreover, there appeared to be an added benefit when even modest alcohol consumption was decreased among elderly patients suffering from depression.     

PANSS syndromes and quality of life in schizophrenia

BACKGROUND: Results from factor analysis studies have suggested that a five-dimensional structure appears to be a better representation of the psychopathological data of the PANSS. The purpose of this study was the detailed investigation of the association of schizophrenia syndromes and single symptoms with quality of life (QOL) in acute and remitted patients. The leading hypotheses were: (1) affective symptoms, especially depression and anxiety, are mostly associated with QOL longitudinally and (2) in the acute phase, QOL is also associated with positive schizophrenia symptoms. METHODS: For the present study, schizophrenia and schizophreniform patients were studied on admission, at the end of the acute phase and 6 months after hospitalization. Psychopathology was measured using the PANSS syndromes, QOL was assessed using disease-specific (SWN) and generic (MLDL, EDLQ) scales. RESULTS: Eighty-four patients entered the study and were assessed during the acute phase taking into account their history and actual treatment. Results revealed anxiety as the most important symptom and depression as the most important syndrome associated with different areas of QOL during and after hospitalization. Also cognitive and negative symptoms were associated with different QOL domains, but both positive symptom clusters showed no substantial association with QOL. CONCLUSIONS: Results of this longitudinal study investigating psychopathology and QOL in schizophrenia provide further support for the need to consider the psychopathological state and treatment setting when measuring QOL in schizophrenia and the need for a differential analysis of schizophrenia symptoms and QOL in the acute, mid-term and long-term phase. Anxiety reduction should be a critical goal of treatment in order to prevent further QOL impairment.     

Are there two depressive syndromes after stroke?

The objective of this study was to describe the clinical characteristics of minor depression after stroke and to compare this disorder with poststroke major depression and the nondepressed state. Ninety-four stroke inpatients were examined 8 weeks after stroke and reexamined 15 months later. Twenty-one (22%) of the 94 patients suffered from minor depression, 14 (15%) suffered from major depression, and 59 (63%) were not depressed. Minor depressed patients were twice as symptomatic as nondepressed patients but were only half as symptomatic as major depressed patients. Minor depressed patients were more likely than nondepressed patients to have a previous history of stroke and were more physically disabled. They were less likely than major depressed patients to have a family history of affective disorder. Depression symptom severity was associated with greater physical disability among minor but not major depressed patients. Fewer minor than major depressed patients were depressed at 15 months. These findings suggest that poststroke major and minor depression may be different depressive syndromes. Some cases of minor depression may be construed as an adjustment reaction to stroke disability.     

The relationship of life adversity, social support, and coping to hospitalization with major depression.

We evaluated the relationship between life events, social support, coping, and depression in 27 male inpatients meeting the requirements for Research Diagnostic Criteria major depressive disorder and in 35 age- and sex-matched nonpatients. Overall, the hospitalized depressed patients reported significantly more events and difficulties than did the controls, but this difference in statistical significance disappeared after excluding from analysis "non-independent" happenings which could have been brought on by depression. More hospitalized depressed patients (23 of 27, or 85%) than controls (8 of 35, or 22.9%) experienced markedly threatening events and difficulties ("marked adversities") in the 6 months before their interview. The depressed group also reported having significantly fewer social supports, being less satisfied with the emotional component of this support, and using more emotion-focused coping than the controls. A discriminant analysis predicted depressive status from a combination of marked adversities, reduced number of social supports, and greater use of emotion-focused coping. The results indicate that the relationship of life events to depression is complex. The excess number of events might be partly a product of dysfunctional behavior that "produces" depression-related events which might, in turn, exacerbate depression; simultaneously, patients are more likely to experience highly adverse events which might precipitate the depression in the first place. Reduced social supports and the use of emotion-focused coping appear to also be associated with hospitalization for major depression.     

Outcome of schizoaffective disorder at two long-term follow-ups: comparisons with outcome of schizophrenia and affective disorders

OBJECTIVE: This research assessed whether the outcome of schizoaffective disorder is more similar to that of schizophrenia or that of affective disorders. METHOD: The authors conducted a prospective follow-up study of 101 schizoaffective, schizophrenic, bipolar manic, and depressed patients assessed at three times: during hospitalization and 2 and 4-5 years later. The follow-up test battery involved detailed assessment of social functioning, work performance, symptoms, posthospital treatment, and rehospitalization. RESULTS: Outcome for schizoaffective patients 4-5 years after hospitalization differed significantly from that for patients with unipolar depression. However, the differences between schizoaffective and bipolar manic patients were more equivocal. Unlike the patients with bipolar disorder, only a limited number of patients with schizoaffective disorder showed complete recovery in all areas throughout the year preceding the 2-year follow-up and the year preceding the 4- to 5-year follow-up. The differences in outcome between schizoaffective and schizophrenic patients were also mixed. These two groups showed some similarities in outcome, but there were fewer schizoaffective than schizophrenic patients with uniformly poor outcome in all areas. CONCLUSIONS: Overall, schizoaffective patients showed some similarities to both schizophrenic and bipolar manic patients. Schizoaffective patients had somewhat better overall posthospital functioning than patients with schizophrenia, somewhat poorer functioning than bipolar manic patients, and significantly poorer functioning than patients with unipolar depression. The data suggest that when mood-incongruent, schizophrenic-like psychotic symptoms are present in the acute phase, they predict considerable difficulty in outcome, even when affective syndromes are also present, as in schizoaffective disorder. It is likely that schizoaffective disorder is not just a simple variety of affective disorder.     

Depression, hopelessness, and the desire for life-saving treatments among elderly medically ill veterans.

During a serious medical illness, several factors, including perceived quality of life, social support, functional disability, severity of illness, and presence of depressive symptoms, influence desire for life-saving treatments such as cardiopulmonary resuscitation (CPR), mechanical ventilation, tube feeding, and intravenous fluids. The authors examined the influence of depression and hopelessness on preferences for life- saving treatment in older, medically ill male patients in the medical service of a Veterans Administration Medical Center. Subjects with high levels of hopelessness desired less life-saving treatment during their current illness; they were at least five times more likely to refuse CPR if required during the current hospitalization. This effect remained statistically significant after removing confounds of race, education, and religiosity. The diagnosis of major depression did not significantly influence the desire for life-saving treatment. Our findings suggest that psychiatrists should assess patients for severity of hopelessness when evaluating decision-making capacity in the context of intervention refusal.