Residual symptoms in older patients treated for major depression

OBJECTIVE: The purpose of this study was to identify residual symptoms in a sample of older adults treated for major depression and compare individual symptoms present at baseline with those at three months by remission status. METHODS: The sample was comprised of 229 patients with DSM-IV major depression who were participants in the NIMH Mental Health Clinical Research Center at Duke University. Symptoms were measured using the Montgomery-Asberg Depression Rating Scale (MADRS). RESULTS: At three months, 86 patients (37.6%) had remitted, or had a MADRS score less than or equal to 9. In the remitted group, the most frequently reported symptoms at three months were inner tension and lassitude. Among nonremitters, the most frequently reported symptoms were reported and apparent sadness, as well as lassitude and inner tension. In the sample as a whole, the symptoms most likely to be present at baseline but not three months were pessimistic and suicidal thoughts, while the most frequently reported emergent symptoms were reduced appetite and inner tension. Patients were much more likely to no longer have a particular symptom than to acquire a new symptom. Overall, the symptoms present at three months were not severe in either group. CONCLUSIONS: In older adults treated for major depression, residual symptoms at three months may include emergent symptoms as well as persistent symptoms, and are likely to include symptoms of anxiety as well as sadness. These findings have clinical implications for the treatment of late-life depression.     

精神分裂症伴发抑郁症状及其临床特征

目的 了解急性期住院精神分裂症患者伴发抑郁症状的发生率、临床特征及其相关因素。方法 对符合CCMD-3诊断标准的精神分裂症患者75例，分别于入院3天内评定PA．NSS、HAMD、TESS量表。结果 急性期抑郁发生率为30．7％，抑郁组与非抑郁组性别、婚姻、文化、年龄无显著性差异，抑郁组平均住院次数、偏执型精神分裂症所占比例多于非抑郁组。治疗前汉密顿抑郁量表总分与阴性量表、思维障碍症状群、反应缺乏症状群负相关，与一般精神病理量表、抑郁症状群正相关。结论 精神分裂症抑郁症状急性期较常见、较严重，偏执型精神分裂症更易出现抑郁症状。     

Dimensions of schizophrenic positive symptoms: an exploratory factor analysis investigation

Current psychopathology classifies schizophrenic positive symptoms into four groups: delusions, hallucinations, formal thought disorder, and catatonic symptoms. The present study explores the factor structure of different positive symptoms to refine this classification. The 35 positive symptoms of 429 psychiatric patients, consecutively admitted to any of 95 mental hospitals, with diagnosis of the ICD-10 F20 schizophrenia, were studied. After excluding those items with a base rate of 10% or less, factor analysis yielded six factors. The first factor was loaded by most of Schneider’s first-rank symptoms and two specific auditory hallucinations; the second by all the catatonic symptoms and incoherence; the third by bodily delusions/hallucinations; the fourth by delusions of persecution and reference; the fifth by grandiose and religious delusions; and the sixth by visual and miscellaneous hallucinations. The finding that schizophrenic positive symptoms may have more than four dimensions suggests the need for reclassification of schizophrenic symptoms and for reconsideration of evidence-based diagnostic criteria for the disorder. Received: 26 January 1996 / Accepted: 12 December 1998     

Serum cholesterol, suicidal tendencies, impulsivity, aggression, and depression in adolescent psychiatric inpatients.

BACKGROUND: This study was undertaken to examine the relationship between serum cholesterol levels and suicidal behaviors in adolescent psychiatric inpatients. Any association between serum cholesterol and measures of suicidal behavior, impulsivity, aggression, anxiety, and depression was also examined. METHODS: Consecutive admissions (n = 152) to an adolescent psychiatric inpatient unit were assessed using measures of suicidal behavior, violence, impulsivity, and depression. Serum cholesterol was compared between those admitted for reasons of suicidal tendencies and those for other reasons. Correlation between serum cholesterol and measures of suicidal behavior, violence, impulsivity, and depression were examined. RESULTS: Serum cholesterol levels were significantly higher in adolescent patients who were currently suicidal than in nonsuicidal adolescents. Within the suicidal group, but not in the total inpatient group, serum cholesterol correlated negatively with the degree of suicidal behavior. No correlation between serum cholesterol levels and depression, violence, and impulsivity were detected. No significant differences were found in serum cholesterol levels between diagnoses or between suicidal and nonsuicidal patients within each diagnostic group. CONCLUSIONS: The association between cholesterol and suicidal tendencies remains complex and may depend on several variables within the population studied. Its usefulness as a biologic risk factor in clinical samples remains to be determined.     

Dysphoric and depressive symptoms in chronic schizophrenia

This study suggests that depressive symptoms are less common in severe, chronic, schizophrenic inpatients than would be predicted if these symptoms were manifestations of negative symptoms or drug-induced parkinsonism. The findings further suggest that depressive symptoms in such patients are independent phenomena which conform to a depressive syndrome. This depression does not represent a misidentification of the negative symptoms affective flattening and alogia, as measured by the SANS, or parkinsonism or akathisia. The study findings fail to support the view that long-term depot antipsychotic medication plays an important role in the genesis of depression and dysphoria in chronic schizophrenic patients. Depressive symptoms were found to occur as frequently, and dysphoria more frequently, in schizophrenic patients in the year after drug withdrawal compared with patients continuing on maintenance drug treatment for the same period.     

Association of cholesterol and socio-demographic parameters with suicidality in the male patients with schizophrenia

Suicidal behavior is a major health risk in schizophrenia. The aim of this study was to evaluate serum cholesterol concentrations and some socio-demographic parameters in suicidal and non-suicidal men suffering from schizophrenia. Results of this study show that there were no differences in socio-demographic parameters between suicidal and non-suicidal schizophrenic patients but there was a difference in the level of cholesterol (lower in suicidal patients). Duration of untreated psychosis was higher in suicidal patients, which could means that suicidality is a process determined by many different factors including time of treatment. Suicidal patients in our study have been more seriously ill than non-suicidal (had higher scores on PANNS and HDRS-17) and we explained these findings by the fact of damage associated to higher time of non-treatment. Our results show that cholesterol has an important role in distinguishing suicidal from non-suicidal patients, which, if confirmed on a higher number of patients and in more studies, may be of considerable clinical significance. Clinical management of suicidal states is based on integrative approach and includes ensuring immediate safety, the use of psychosocial techniques to address depression and psychosocial stressors, and targeted pharmacotherapy for psychotic and depressive symptoms.     

Psychosocial correlates of suicidal intent among patients with schizophrenia

Suicidal intent is common among patients with schizophrenia, resulting in extreme personal distress, increased hospitalizations and healthcare expenditures, and early mortality. However, the psychosocial correlates of current suicidality among schizophrenic patients are not fully understood. This study attempted to identify psychosocial correlates of current suicidal intent in a sample of 267 patients with schizophrenia. Multiple regression analyses were used to assess the relationship between suicidality and current symptomatology, psychosocial problems, global functioning, and demographic characteristics. Results showed that depressive symptomatology as a single variable accounted for approximately 50% of the variance in ratings of suicidal intent. In addition, female gender, younger age, recent traumatic stress, and less severe psychotic symptoms each significantly predicted current suicidality independent of depressive symptoms. The combination of depression among younger female schizophrenic patients whose psychotic symptoms have abated and who are experiencing current traumatic stress may indicate extreme suicidal intent.     

Psychosocial predictors of depression in patients with acute coronary syndrome

OBJECTIVE: To describe the prevalence of depression according to ICD-10 criteria using a self-completed questionnaire and to identify psychosocial predictors of depression at discharge in patients with acute coronary syndrome. METHOD: A total of 899 patients with acute coronary syndrome completed the Major Depression Inventory at discharge and a questionnaire regarding previous depression and family history of depression. Information concerning civil status was obtained from the Civil Person Registry. RESULTS: Ninety patients (10%) were depressed according to ICD-10 criteria at discharge with 7.2% having a moderate to severe depression at discharge. Women were significantly more frequently and severely depressed than men. Patients with and without depression reported primarily somatic symptoms of depression. Cardiovascular risk factors or treatment did not differ between patients with and without depression. Previous depression (OR 2.9, 95% CI 1.4-6.0 adjusted) and female gender (OR 2.5, 95% CI 1.5-4.3 adjusted) predicted depression at discharge in a logistic regression model. CONCLUSION: Somatic symptoms of depression are prevalent in patients with acute coronary syndrome. The use of self-completed non-diagnostic questionnaires assessing symptoms of depression therefore is cautioned as patients may wrongly be identified as depressed. In patients with acute coronary syndrome depression is predicted by well-known psychosocial risk factors.     

Multivantaged assessment of depression in schizophrenia.

While it is recognized that depression frequently can occur together with fundamental symptoms of schizophrenia, estimates of the prevalence of schizophrenia-related depression have been very variable. This variability may be due in part to the difficulty in clearly separating depressive symptoms from negative symptoms. A more valid method of assessing depression might combine evaluations from multiple vantage points. This study, which involved 26 hospitalized schizophrenic patients, tested the proposition that complete assessment of depression requires three separate sources of input: self-rating (subjective mood state), clinician rating (affective state), and observer rating (behavioral manifestations). In the present study, patients were evaluated on self-rating instruments for mood states, clinician-rated scales including the Hamilton Rating Scale for Depression, and observer-rated scales. These vantage points, though overlapping in some respects, were found to provide independent information on the experience of depression in schizophrenia. Clinician-rated and observer-rated assessments tended to correlate significantly, while self-rated subjective reports were discordant, thus complementing the assessments from the other two vantage points.     

Suicidal behaviour in early psychosis

OBJECTIVE: This was to determine the prevalence of suicidal behaviours prior to and during the first year of treatment in a comprehensive early psychosis program (EPP) and to identify predictors of suicidal behaviour. METHOD: In a cohort study of 238 subjects, patients were assessed at initial presentation to an EPP and 1 year later. Measures included a range of demographic variables, suicide attempts, depression, positive and negative symptoms, social functioning and substance misuse. RESULTS: Although 15.1% attempted suicide prior to program entry, only 2.9% made an attempt in the year after program entry and 0.4% completed suicide. No further attempts were seen in those with previous parasuicide. These rates are lower than other published rates for first-episode patients. CONCLUSION: It is possible that specifically designed first-episode programs can reduce the suicidal behaviour in this high-risk population. The low prevalence of attempted suicide makes modeling predictors difficult.     

A comparison of the manifest content in dreams of suicidal, depressed and violent patients

The manifest dream content of psychiatric in-patients who had been admitted because of suicidal attempts was compared with three in-patient control groups, patients who had been admitted for: a) depression and suicidal ideation without attempt; b) depression with no suicidal ideation and; c) commission of a violent act without suicidality. Standardized tests of dream content were used as well as the Beck scale for depression and certain subscales of the MMPI. The results confirmed that both suicidal and violent patients have more death content and destructive violence in their dreams, but that this was a function of the severity of depression and certain character traits such as impulsivity rather than being specific to the behaviour itself. The dream content is continuous with, and probably reflects, the waking state in the case of the depressives. On the other hand some of the findings require a more complex dynamic explanation lending some support to the idea that the dream may have an adaptive function.     

Severity of depression and suicidal ideations among elderly people in Singapore

INTRODUCTION: Studies in the West have concluded that the severity of depression is the strongest predictor of the course of suicidal ideations among the elderly. However, Asian culture tends to be more reserved and this may impact on the reporting of suicidal ideations. This study aims to determine the prevalence of suicidal ideation among depressed elderly people in Singapore and attempts to investigate the relationship between severity of depression and suicidality.METHOD: Eighty consecutive depressed patients were recruited and severity of depressive symptoms rated with Beck's Depression Inventory (BDI). Suicidality was assessed using the Beck's Hopelessness Scale (BHS) and Beck's Suicide Intent Scale (BSS). Suicidal ideation was defined as any thought of wanting to kill oneself over the past seven days and not just a passive wish to die.RESULTS: 53.8% verbalized thoughts of wanting to kill themselves. Males were three times more likely to report suicidal thoughts. Severity of depression did not significantly influence the presence of suicidal thinking. The association of depression severity and suicidal ideations is not strongly supported.CONCLUSIONS: Elderly males were more likely to report suicidal ideations when depressed. Elderly patients who reported suicidal ideations were likely to be more severely depressed. However, in a depressed elderly person, the absence of suicidal ideations would not infer that the episode of depression was less severe.     

The status of fluvoxamine among the antidepressive agents]

Fluvoxamine was administered in an open trial of 50 hospitalized patients with major depression of the melancholic type (DSM-III-R) for an average period of 24.56 days in mean minimal and maximal daily doses of 100-311 mg orally after a wash-out interval of 1-14 days. Treatment achieved complete improvement in 54% and partial improvement in 16% of the patients, significantly more frequently in women than in men. The antidepressant effect of fluvoxamine was confirmed also by a statistically significant reduction of the global HAMD and FKD score, starting on the 7th day of the trial. The therapeutic effect was clinically apparent during the second week of treatment. The best therapeutic effect was achieved in anxiety depressions (65%), to a lesser degree inhibitory depressions (50%) and atypical ones (46%), as apparent from the value of Náhunek's antidepressive index 0.88 which suggests a significant anxiolytic effectiveness of fluvoxamine. Fluvoxamine had a positive effect on the majority of HAMD and FKD items, incl. a depressive mood, anxiety, feelings of guilt, anhedonia, reduced interest and ability, obsession, depressive thoughts and suicidal tendencies. Reduced motor activity, loss of appetite, insight, somatic symptoms, paranoidity and hypochondria were less influenced. At the onset of treatment the preparation did not reduced insomnia and thus in 72% patients hypnotics were added. In the course of fluvoxamine therapy no suicidal attempts were observed although 34 (68%) of the patients initially admitted had suicidal thoughts. Fluvoxamine is well tolerated by patients; as to side-effects gastrointestinal complaints were most frequent (in 28% of the patients).     

慢性精神分裂症患者的抑郁症状研究

目的:了解慢性精神分裂症患者的抑郁症状及其相关的影响因素。方法:对180名住院慢性精神分裂症患者测试卡尔加里精神分裂症抑郁量表(CDSS)、阳性症状量表(SAPS)、阴性症状量表(SANS)、治疗中出现的症状量表(TESS)及自编的相关因素调查表。结果:慢性精神分裂症患者的抑郁症状发生率为40.6%;有无抑郁发生的两组比较,在总病程、住院次数、文化程度、家庭经济水平、社会支持、自知力恢复及药物种类、剂量、时间及不良反应、阳性阴性症状和合并躯体疾病等方面差异有显著性。Logistic回归分析显示,精神分裂症患者出现抑郁症状的相关影响因素依次为:阴性症状、合并躯体疾病、抗精神病药的种类、社会支持、自知力及药物不良反应。结论:慢性精神分裂症患者抑郁症状发生率高、影响因素多,需从多方面对精神分裂症患者的抑郁进行预防和治疗。     

The treatment of negative symptoms and deficit states of chronic schizophrenia: olanzapine compared to amisulpride and placebo in a 6-month double-blind controlled clinical trial

OBJECTIVE: The aim of the study was to evaluate the efficacy of olanzapine (5 and 20 mg/day) over a 6-month period in chronic schizophrenic patients experiencing predominantly negative symptoms. METHOD: Two hundred and forty-four patients participated in a 6-month multicenter double-blind trial of placebo (n = 34), olanzapine 5 mg/day (n = 70), olanzapine 20 mg/day (n = 70), or amisulpride 150 mg/day (n = 70). Primary measure was the scale for the assessment of negative symptoms. RESULTS: Olanzapine 5 mg/day showed significantly greater improvement than placebo in negative symptoms and in the Positive and Negative Syndrome Scale total score. Baseline positive symptoms were low at baseline and changed minimally. The neurological tolerance of olanzapine, amisulpride and placebo were comparable. CONCLUSION: Olanzapine 5 mg/day was effective in treating negative symptoms in a group of schizophrenic with predominantly negative symptoms during the stabilization phase. Improvement in positive symptoms or extrapyramidal symptoms (EPS) was unlikely to explain this result while improvement in depression may have partially contributed.     

Features of Schizophrenic Patients and Patients with Depression as Observed by Family Members—Symptoms,Social Activities and Social Performance†

Abstract: We carried out a comparative study of a group of schizophrenic patients and a group of patients with depression, looking at 1) symptoms and social behaviors, 2) the performance level of socially expected activities and free-time activities, and 3) the level of expectations of family members with respect to patients' activities according to the results of a KAS evaluation by the family members of the two groups. The evaluation of symptoms and social behaviors by the family members clearly reflected the clinical features of schizophrenia and depression. In respect to the performance level of socially expected activities, depressive patients were evaluated significantly higher than schizophrenic patients. As for free-time activities, there were no differences between the two groups in the evaluation of levels of performance, but the family members of the depressive group expected a significantly higher level of free-time activities than was achieved, while such a significant discrepancy between expectation and performance was not observed for the schizophrenic group.     

Are there subtypes of suicidal schizophrenia? A prospective study

BACKGROUND: Tragically, suicide is not uncommon in schizophrenia. The principal objective of this study was to examine possible subtypes of suicidal schizophrenic patients and identify their clinical and psychopathological profiles at long-term follow-up. METHOD: The study involved 62 patients diagnosed with schizophrenia according to ICD-10 criteria, who were consecutively admitted following a suicide attempt. Of these subjects, 47 (75.8%) could be re-evaluated after 1 year. Sociodemographic, general clinical, and psychopathological variables were evaluated. RESULTS: Two predominant subgroups were identified according to suicidal motivation: psychotic motivation and depressive motivation. At re-evaluation after 1 year, the depressive motivation subgroup showed higher depression and hopelessness scores. This subgroup also had greater educational level, age, and duration of illness, and more frequent existence of previous suicide attempts compared to the psychotic motivation subgroup. Of note in the psychotic motivation subgroup was the presence of hopelessness. The variables of educational level, duration of illness, and previous suicide attempts were the ones that best distinguished these subgroups. CONCLUSION: These findings reinforce the notion that meaningful subgroups occur among suicidal schizophrenic patients. The different psychopathological profiles of the two prominent subgroups suggest the need for a different management approach in each case. The identification of these profiles in both subtypes at long-term follow-up may facilitate their detection by clinicians and, therefore, foster the adoption of appropriate preventive measures against subsequent suicidal behavior.     

Clinically significant non-major depression in a community-dwelling elderly population: epidemiological findings

OBJECTIVE: The aim of this study was to investigate the 1-month prevalence, symptom profiles and demographic correlates in late-life clinically significant non-major depression (CSNMD) among a community-dwelling elderly population. METHODS: One thousand five hundred subjects aged 65 years and older, who were randomly selected from three communities in Taiwan, received comprehensive psychiatric assessment by trained psychiatrists. Two categorical diagnoses of depressive disorder, including major depression and CSNMD, were made. The 1-month prevalence was calculated. Frequencies of depressive symptoms across CSNMD and major depression were compared. The risks of CSNMD based on demographic characteristics were estimated using multinominal logistic regression. RESULTS: The 1-month prevalence of CSNMD among the community-dwelling elderly was 8.8%. Symptoms of diminished interest, appetite changes, sleep disturbance, worthlessness or inappropriate guilt, trouble in concentrating or indecisiveness, and suicidal thoughts or acts were less frequent in CSNMD than in major depression, but symptoms of depressed mood, psychomotor changes, and fatigue or loss of energy were as frequent in both categories of illness. CSNMD shares similar demographic risks, such as living in an urban area, female gender and low educational status, with major depression. CONCLUSIONS: CSNMD is common among community-dwelling elders in Taiwan, and with its identical demographic characteristics, but qualitatively different presentation, we suggest CSNMD may be considered part of a spectrum of severe late life depressions with a distinct manifestation. Major depression and CSNMD may share common demographic characteristics with different manifestation. We conclude that late-life depression is a dimensional disease.     

Holocaust experience and suicidal ideation in high-risk older adults.

OBJECTIVE: Depression is an identified risk factor for suicidal ideation, a precursor for more serious suicidal behaviors. This risk might be further compounded in individuals who experience negative life events, including traumatic experiences, and those who might have comorbid illnesses. The authors examined the impact of past exposure to the Nazi Holocaust on the development of suicidal ideation in a sample of depressed older adults. METHODS: Authors conducted a retrospective cross-sectional study. The study sample comprised data on 530 consecutive eligible first admissions of Jewish patients who were referred and admitted to a geriatric psychiatry day hospital program between September 1986 and December 2000. RESULTS: Multiple logistic-regression analyses, controlling for social support, history of suicide attempts, and other negative life events, showed that severity of depression and exposure to the Holocaust were independently associated with suicidal ideation. Those not showing suicidal ideation were slightly more likely to have reported having a confidant. CONCLUSIONS: This is the first empirical study to demonstrate an increased likelihood for suicidal ideation in survivors of the Nazi Holocaust. The chronic stress produced by these traumatic events may have predisposed survivors to cope ineffectively as they age, thus resulting in suicidal ideation. Authors highlight the importance of a multifaceted approach when assessing suicidal behaviors in high-risk groups.     

Depressive symptoms induce paranoid symptoms in narcissistic personalities (but not narcissistic symptoms in paranoid personalities)

Based on clinical experience, anecdotal reports, and past empirical and conceptual work, we predicted that when people with narcissistic tendencies experience depressive symptoms, they are prone to develop paranoid attitudes. Moreover, we expected that this process was unidirectional, and that the combination of paranoid tendencies and depressive symptoms would not be associated with an increase in narcissistic symptoms. In both cases, results from our 6-month longitudinal study of 71 previously suicidal adults conformed to our expectations.