Imaging spectrum in disseminated histoplasmosis: Case report and brief review

The clinical manifestations of chronic disseminated histoplasmosis are non-specific and resemble those of other chronic infections and malignancies. We report the radiographic, sonographic and contrast-enhanced CT appearances of histoplasmosis in an adult male with non-insulin dependent diabetes mellitus, who was HIV negative and presented with weight loss and pyrexia. Imaging studies simulated tuberculosis with mediastinal lymphadenopathy, bilateral fibrotic lung lesions, hepatomegaly and bilateral hypoattenuating adrenal enlargement, without clinical or laboratory evidence of hypoadrenalism. Computed tomography-guided fine-needle aspiration biopsy of adrenal glands revealed Histoplasma capsulatum. We report our experience to increase awareness of the imaging spectrum of disseminated histoplasmosis and its similarity to tuberculosis as, with increasing incidence of AIDS, the chances of these infections are likely to increase. Moreover, awareness of this entity is important because it is known that untreated disseminated histoplasmosis is fatal.     

Outcome in RDC schizo-affective depression: the importance of diagnostic subtyping

A 2-year semiannual follow-up of 40 patients with RDC schizo-affective disorder, depressed type revealed poorer outcomes among those who were subtyped as chronic or mainly schizophrenic patients than among their counterparts with nonchronic or mainly affective schizo-affective depression. Outcomes for these latter groups, in turn, were no worse than those for patients with psychotic major depression. Among a variety of predictors entered into step-wise regression analyses, diagnosis was most important in predicting recovery overall and outcome at 6 months, while demographic variables, particularly sex, predicted outcome at 2 years.     

A 20-year longitudinal observational study of somatic antidepressant treatment effectiveness

OBJECTIVE: This observational study examined the effectiveness of somatic antidepressant treatments as administered in the community. METHOD: The study group consisted of 285 subjects with an intake diagnosis of major depressive disorder who had entered the National Institute of Mental Health Collaborative Depression Study as early as 1978, had at least one additional affective episode, and had been followed for up to 20 years, as recently as 1999. The characteristics that distinguished subjects receiving various levels of somatic antidepressant treatment were accounted for in what was called a propensity for treatment intensity model. The effectiveness of somatic antidepressant treatment during major affective episodes was then examined. RESULTS: Those who received higher levels of antidepressant treatment tended to have more prior episodes, more severe depressive symptoms, and more intensive somatic therapy during prior episodes and prior well intervals than those who received lower levels. Treatment effectiveness analyses that were stratified by propensity for treatment intensity demonstrated that those who received higher levels of antidepressant treatment were significantly more likely to recover from affective episodes. In contrast, those treated with lower levels were no more likely to recover than those who did not receive somatic treatment. CONCLUSIONS: Despite the indications of more severe depressive illness, those who received higher levels of somatic antidepressant treatment were more likely to recover from recurrent affective episodes. Results from this observational study extend the generalizability of reports from randomized clinical trials of antidepressants to a wider, more representative group of individuals who suffer from major depression.     

The prospectively observed course of illness among depressed patients who commit suicide

OBJECTIVE: These analyses were conducted to describe the course of illness among patients with major affective disorders who commit suicide. METHOD: Twenty-nine patients who entered a long-term, high-intensity follow-up study of major affective disorders and who later committed suicide within 1 year of their last follow-up interview were individually matched to other patients by age, sex, the presence or absence of lifetime drug or alcohol abuse, time to last interview and polarity. Those who suicided were compared with their controls by depressive and substance abuse morbidity during follow-up, treatment resistance, treatment compliance, suicidal behavior and psychosocial adjustment. RESULTS: Among the various measures used to characterize the course of illness during a mean follow-up of 4.3 years, only those pertaining to suicidal behavior robustly separated the suicide group from their controls. Suicidal behavior in the remote past seemed as predictively important as suicidal behavior during follow-up. CONCLUSION: Of the various features monitored over time in patients with major affective disorder, suicidal behavior itself was the clearest correlate of risk for completed suicide.     

Manic-depressive (bipolar) disorder: the course in light of a prospective ten-year follow-up of 131 patients

For a five-year period, 131 bipolar patients were followed every 6 months; for the next 5 years, they were followed yearly. Each patient was interviewed in a systematic way that gave information about episodes, hospitalizations, cycle lengths and the presence of alcoholism. Women and men were not significantly different in the number of follow-up manic or depressive episodes or hospitalizations. Chronicity from index episode to the end of the 10-year follow-up was uncommon (4%). Alcoholism, which was common in these patients, showed a great diminution at the end of 10 years. Contrary to expectation, cycle lengths showed no systematic decrease in length over the follow-up. In this naturalistic study, treatment intensity was not related to decreasing episodes or to changes in cycle length. The number of episodes in the first 5 years of follow-up was not correlated with the number of episodes in the last 5 years. Cycle lengths in the first 5 years of follow-up were similar in length to the last 5 years of follow-up. A family history of mania in these bipolar patients was associated with more episodes in follow-up than if such a family history were absent. The patients whose alcoholism predated the onset of their affective illness were less likely to have episodes in the follow-up than the patients in whom affective illness predated the onset of the alcoholism.     

Tachyphylaxis in unipolar major depressive disorder

BACKGROUND: Major depressive disorder is usually a recurring illness, and maintenance treatment is used to forestall or prevent recurrent episodes of depression. This study describes recurrence of major depression despite maintenance pharmacotherapy, termed tachyphylaxis. METHOD: The study sample consisted of 103 subjects who participated in the NIMH Collaborative Depression Study, a multicenter longitudinal observational study of the mood disorders. Subjects diagnosed with unipolar major depressive disorder according to Research Diagnostic Criteria were enrolled from 1978-1981 and prospectively followed for up to 20 years. As an observational study, treatment was recorded but not controlled by anyone connected with the study. Subjects were selected for the present study if at some point during follow-up they received antidepressant medication for treatment of an episode of major depressive disorder, recovered from this episode, and subsequently received maintenance pharmacotherapy. Some subjects were successfully treated for multiple episodes of major depressive disorder and then received maintenance medication after each of these episodes, resulting in multiple maintenance treatment intervals. Data were collected using the Longitudinal Interval Follow-Up Evaluation, and mixed-effects logistic regression was used to test the association of sociodemographic and clinical variables with tachyphylaxis. RESULTS: For the 103 subjects, there were 171 maintenance treatment intervals in which a subject received maintenance pharmacotherapy after having recovered from an episode of major depressive disorder. The median duration of maintenance treatment was 20 weeks. Tachyphylaxis occurred during 43 (25%) of these 171 maintenance treatment intervals. The subtype of melancholic (endogenous) major depressive disorder significantly elevated the risk of tachyphylaxis during the subsequent maintenance treatment interval. CONCLUSIONS: Despite the use of maintenance pharmacotherapy, major depression recurs in a considerable number of patients. Improved prophylaxis for these patients requires other treatment strategies based upon a greater understanding of recurrence.     

Schizo-affective disorders: bipolar-unipolar subtyping. Natural history variables: a discriminant analysis approach

In view of tackling the problem of heterogeneity among the schizo-affectives, methods of univariate and multivariate statistical analysis (canonical discriminant analysis) were applied to the sociodemographic and natural history variables of four groups of affective disorder patients from the NIMH Collaborative Study on the Psychobiology of Depression Clinical section: the schizo-bipolar (SBP, n = 45), the schizo-unipolar (SUP, n = 30), the bipolar I (BP, n = 159) and the primary unipolar depressed (UP, n = 387) defined by Research Diagnostic Criteria. Two dimensions were identified among the four groups of 'affective' patients: the 'bipolar' and the 'schizophrenic' dimensions. They provided highly significant discrimination among the means of the four groups but were not very accurate in predicting group membership. The 'bipolar' dimension separates the UP from the BP and SBP, the SUP taking some intermediate value. The 'schizophrenic' dimension separates the BP and UP from the SUP, the SBP being intermediate. The two groups with the most similarities were the SBP and BP. The group with the most heterogeneity was the SUP, sharing similarities with the UP and SBP mostly. These conclusions are supported by results of familial aggregation on the same group of patients.     

Familial alcoholism in primary unipolar major depressive disorder

OBJECTIVE: Some studies have suggested relationships between depression in probands and alcoholism in relatives. Other studies have not, but some of these have used inappropriate control groups or failed to divide probands by sex. METHOD: The present study controlled for sex of probands and used several comparison groups to further explore the familial relationship between depression and alcoholism. Diagnoses for 723 directly interviewed relatives of 326 probands with primary unipolar depression were compared to diagnoses in 469 control subjects chosen by an acquaintanceship method to demographically resemble the relatives of affective disorder probands. Diagnoses in the uninterviewed relatives of both control and depressed subjects were used for comparisons as well. RESULTS: Results indicated higher rates of alcoholism in the families of depressed women but not in the families of depressed men. CONCLUSIONS: This familial association between alcoholism and depression may be the result of either genetic or environmental factors or an interaction between the two.     

Seizures following the withdrawal of alprazolam

Seizures were observed following the withdrawal of alprazolam administered in therapeutic dose for 10 weeks. A review of available case reports suggests that seizures, like other withdrawal phenomena, are more apt to occur with short-acting benzodiazepines. To prevent their occurrence these drugs should be discontinued gradually and consideration given to substituting long-acting drugs during the withdrawal period. Physicians should remain alert to the fact that seizures may occur as early as 24 hours after the abrupt withdrawal of short-acting benzodiazepines.