Fluoxetine treatment of dysthymia in the elderly

BACKGROUND

Despite their prevalence, little is known about the treatment of mild depressive syndromes in older patients. The purpose of this study was to evaluate the efficacy of fluoxetine in dysthymic disorder in the elderly.

METHOD

Twenty-three elderly outpatients with dysthymic disorder (DSM-III-R criteria) entered a 13-week study of fluoxetine (2-week placebo run-in period and 11 weeks of fluoxetine treatment with a dose range of 20-60 mg/day). Ratings to assess clinical response included the Hamilton Rating Scale for Depression (HAM-D), the Clinic Global Impression (CGI), and the Cornell Dysthymia Rating Scale (CDRS).

RESULTS

Nine patients (39%) had never received psychiatric treatment during the index episode, despite a long duration of illness (mean +/- SD = 18.5 +/- 17.1 years). Twenty of the 23 patients completed the entire study. The mean +/- SD HAM-D (24-item) score decreased from 14.6 +/- 3.7 to 7.9 +/- 5.0 during the trial, and the CDRS score decreased from 28.1 +/- 9.1 to 15.7 +/- 10.0. When response criteria of a 50% reduction from baseline in the HAM-D score, final HAM-D score < or = 8, and a CGI score of 1 or 2 (very much or much improved) were used, 12 (60%) of the completers were responders. Side effects were uncommon, and the fluoxetine was generally well tolerated.

CONCLUSION

These preliminary findings suggest that fluoxetine is an effective treatment in elderly patients with dysthymic disorder. Double-blind, placebo-controlled studies are warranted.

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.

Convulsive therapy in schizophrenia?

Schizophrenia is a clinical syndrome of extraordinary importance and complexity. Its early identification is difficult, and our concepts of its main characteristics have undergone many changes in the past century. Electroconvulsive therapy (ECT) was introduced as a treatment for dementia praecox. The initial reports were salutary, and the treatment was widely applied until it was replaced by psychoactive drugs. ECT was reintroduced in the 1970s in the treatment of therapy-resistant disorders. The initial reviews argued that ECT was not applicable in patients with schizophrenia, a conclusion based mainly on experience with chronic forms of the disorder. This article assesses the role of ECT in schizophrenia today. We find it to be an effective treatment for psychosis. ECT is particularly applicable in patients with first-break episodes, especially those marked by excitement, overactivity, delusions, or delirium; in young patients, to avoid debilitating effects of chronic illness; and in patients with syndromes characterized by catatonia, positive symptoms of psychosis, or schizoaffective features.

Cortical blood flow and negative symptoms in schizophrenia

An association between negative symptoms and frontal cortex abnormalities has been suggested in schizophrenic patients. We tested whether this association can be found when patients' task performance is good and while controlling for possible cortical atrophy. We investigated regional cerebral blood flow with the xenon-133 inhalation method in 9 unmedicated schizophrenic patients at rest and during performance of the Continuous Performance Test. Negative symptoms were quantified with the Scale for Assessment of Negative Symptoms. All patients could attend to the test and performed it successfully with mean accuracy of 91 +/- 8%. Changes of the left hemisphere hyperfrontality ratio were significantly correlated with severity of negative symptoms, especially for the subscales of attention (r = -0.83) and anhedonia (r = -0.70). These results lend further support to the putative association between negative symptoms and physiological abnormalities of the frontal cortex in schizophrenic patients.

Subjective side effects during electroconvulsive therapy

In 92 depressed patients who were randomized to unilateral or bilateral electroconvulsive therapy (ECT) at either low dosage (just above seizure threshold) or high dosage (2.5 times the seizure threshold), subjective side effects were assessed with the Columbia ECT Subjective Side Effects Schedule. A research nurse administered the instrument 4 h after each treatment during the ECT course. In 41 patients, the instrument was also administered before the ECT course. Headache, disorientation, and memory complaints were the most common subjective side effects during the ECT course. Somatic side effects did not change from early to late in the ECT course, and were not influenced by ECT electrode placement or dosage. Most individual somatic side effects, including nausea, tiredness, and muscle aches/pains did not change from pre-ECT to during the ECT course, and may have been a function of the persistent somatic symptoms of depression. Cognitive complaints increased from pre-ECT to during the ECT course, but there was no overall change from pre-ECT to immediately after the ECT course. Cognitive complaints were greater with bilateral compared with unilateral ECT, with no significant effect of electrical dosage. During the ECT course, subjective mood improved and psychomotor agitation decreased, particularly in clinical responders. These findings suggest that most putative somatic side effects are related to the depressive state rather than being induced by ECT. The observed changes reinforce the need to evaluate both subjective and objective side effects during ECT.

Predictors of retrograde amnesia following ECT

OBJECTIVE

Substantial progress has been made in identifying how the treatment parameters used in ECT impact on cognitive side effects. However, there is limited information regarding individual differences in vulnerability to these side effects. The authors examined patients' pretreatment global cognitive status and postictal orientation recovery time as potential predictors of the magnitude of retrograde amnesia for autobiographical memories after ECT.

METHOD

Seventy-one inpatients with major depressive disorder were randomly assigned to four ECT conditions that varied in electrode placement (right unilateral versus bilateral) and stimulus dosage (low versus high intensity). Orientation recovery time was assessed at virtually every session during the course of ECT. Global cognitive status was assessed with the modified Mini-Mental State examination before treatment, during the week after termination of treatment, and 2 months after treatment ended. Retrograde amnesia was assessed at these same time points with the Autobiographical Memory Interview.

RESULTS

Pre-ECT global cognitive status and the duration of postictal disorientation were strong predictors of the magnitude of retrograde amnesia in the week after the course of ECT and at 2-month follow-up. In general, these relationships were maintained regardless of technical parameters in the administration of the ECT.

CONCLUSIONS

Patients who manifest global cognitive impairment before treatment and patients who experience prolonged disorientation in the acute postictal period may be the most vulnerable to persistent retrograde amnesia for autobiographical information.

Regional cerebral blood flow in mood disorders: IV. Comparison of mania and depression

Cortical regional cerebral blood flow (rCBF) was assessed in minimally medicated, relatively young adults in episodes of either acute mania (n = 11) or major depression (n = 11) and in matched normal control subjects (n = 11), using the 133xenon inhalation method, under eyes-closed, resting conditions. The three groups were equivalent in global CBF. Both patient groups showed significant reductions of rCBF in anterior cortical areas and reduction of the normal anteroposterior gradient. In addition, there was evidence of abnormal, albeit similar, patterns of flow lateralization on a regional basis in both clinical groups compared with normal subjects. An exploratory analysis revealed preliminary evidence of rCBF differences between the clinical groups, localized to the inferior frontal cortex. Otherwise, the evidence in this study suggests that young adult manic and depressed patients are predominantly similar in cortical rCBF parameters.

Effects of electroconvulsive therapy on plasma GABA

There are no published data on the effects of seizures on indices of gamma-aminobutyric acid (GABA) function in human subjects. In study 1, the effects of electroconvulsive therapy (ECT) on free plasma GABA were studied in 39 inpatients with major depressive disorder. Acutely after ECT, free plasma GABA was significantly reduced for up to 1 h after seizure termination, and this finding replicated strongly in a subgroup of six patients who received a second course of ECT. In a second study at a different site that compared sham ECT and real ECT in seven patients, some doubt was raised about the replicability of the acute effect of ECT on GABA levels. Nonetheless, the strength of the findings in the larger study 1 sample suggests that, unlike virtually all other biochemical indices, free plasma GABA may be reduced acutely after ECT. This acute decrease could reflect decreased levels of GABA in brain extracellular space or decreased brain turnover. In study 1, compared with ECT nonresponders, ECT responders had higher GABA levels at both baseline and after a course of ECT. Because plasma GABA levels are known to be low in a subset of patients with major depression, the higher GABA levels observed in clinical responders before and after the ECT course indirectly suggest that patients least abnormal in GABA levels may show superior clinical response. This also suggests that low plasma GABA is not a state marker for depression.

Dichotic-listening measures of brain laterality in mania

Dichotic syllable and complex tone tests were used to compare performance asymmetries in manic patients (n = 35) with normal controls (n = 26) and to determine whether there were changes in laterality with remission of the manic state. Relationships of performance asymmetries to treatment outcome and symptom features were also examined. Compared with normal controls, manic patients showed overall poorer accuracy, particularly for complex tones presented to the left ear, and they failed to show the normal left-ear (right-hemisphere) advantage for complex tones. Abnormal laterality for complex tones was present in patients who later responded to treatment but not in nonresponders. In the euthymic state, patients showed improved left-ear accuracy for complex tones and more normal perceptual asymmetry. These findings suggest that mania is associated with a decrement in right-hemisphere processing of complex tonal information.

Visual fixation and smooth pursuit eye movement abnormalities in patients with schizophrenia and their relatives

Increasing evidence suggests that smooth pursuit eye movement (SPEM) dysfunction may serve as an endophenotype or genetic marker of schizophrenia. The authors tested SPEM and visual fixation (VF) in 31 patients with schizophrenia, 33 of their first-degree relatives, and 24 patients with major depressive disorder. A high rate of abnormal VF was found in schizophrenic patients and their first-degree relatives, but not in affective disorder patients with or without psychotic features. Rate of VF abnormality distinguished schizophrenic patients from acutely depressed mood disorder patients; SPEM did not. VF and SPEM performance correlated only moderately, suggesting that the pathophysiologies of these two eye movement abnormalities may be partially independent. Implications for identifying a schizophrenia endophenotype are discussed.

Cortical perfusion and gray matter weight in frontal lobe dementia

To evaluate the pathophysiology of frontal lobe dementia (FLD), the authors compared regional cerebral blood flow (rCBF) in matched groups of FLD, probable Alzheimer's disease (AD), and major depression patients and normal control subjects (n = 7 each). The planar xenon-133 technique allowed full quantification of cortical perfusion and estimates of the relative weight of gray matter (wg). FLD patients showed lower blood flow and wg in the frontal cortex than the other groups. Mean cortical perfusion was correlated with cortical wg in the FLD group only. These findings 1) suggest that matched reductions of frontal gray matter weight and perfusion occur in FLD and 2) support the use of rCBF in distinguishing FLD from AD and severe depression.

Hearing loss and asymmetry in major depression

To assess patterns of hearing loss and asymmetry in major depressive disorder (MDD), pure-tone and brief-click audiometric thresholds were measured in 59 inpatients with MDD and 40 normal control subjects. For both tasks, patients had higher bilateral thresholds, with marked hearing loss for the highest pure-tone frequency. At lower frequencies, patients displayed significant asymmetry, with poorer hearing in the left ear. After ECT, patients maintained the bilateral hearing losses; however, the baseline asymmetry resolved. These findings suggest that bilateral hearing loss may be a stable characteristic in severe depression. Poorer left ear pure-tone hearing may be present during the depressed state. The baseline asymmetry in audiometric deficits suggests right-hemisphere dysfunction in severe MDD.

The significance of clinical EEG abnormalities in depressed patients treated with ECT

Standard pretreatment clinical electroencephalograms (EEGs) were abnormal in 18.6% of 140 consecutive patients with Research Diagnostic Criteria (RDC) endogenous major depression. The patients were randomized to unilateral or bilateral and low- and high-dosage electroconvulsive therapy (ECT) conditions. Clinical features, short-term treatment response, and the rate and timing of relapse were contrasted in patients with normal and abnormal clinical EEG examinations. Psychotic depression was more common among abnormal EEG (61.5%) than normal EEG (38.9%) patients. Otherwise, the two groups were equivalent in a variety of demographic, clinical, and pharmacological variables. Patients with abnormal EEG findings tended to show a poorer rate of response to unilateral ECT, but a strong rate of response to bilateral ECT. Rates and timing of relapse were equivalent in the two groups. Other than the suggestion that bilateral ECT may be preferable in patients with clinical EEG abnormalities, little evidence was found that such abnormalities characterize discrete subgroups or have preductive utility with respect to ECT outcome.

Regional cerebral blood flow in mood disorders, III. Treatment and clinical response

BACKGROUND

Global and regional deficits in cerebral blood flow and glucose metabolism have been reported in major depression, but there is limited information on the effects of somatic treatment and clinical recovery on these abnormalities.

METHODS

We assessed cortical blood flow with the xenon 133 technique in depressed patients prior to a course of electroconvulsive therapy (ECT), 30 minutes before and 50 minutes after a single treatment, and during the week following ECT. Acute (preictal and postictal) effects of a single treatment also were studied in manic patients.

RESULTS

In the depressed and manic groups, larger blood flow reductions in the acute period, both globally and in particular patterns of brain regions, were associated with a superior clinical outcome following the treatment course. In depressed patients, similar patterns were observed for the blood flow changes over a full treatment course. Blood flow reductions in anterior cortical regions were strongly associated with a positive clinical response in both depression and mania.

CONCLUSIONS

The findings indicated that cerebral blood flow abnormalities in major depression were not reversed by successful treatment with ECT. Rather, particularly in responders, ECT resulted in additional perfusion reductions. The therapeutic properties of ECT are related to reduced functional brain activity in specific neural regions.

Dichotic-listening measures of brain laterality in mania

Dichotic syllable and complex tone tests were used to compare performance asymmetries in manic patients (n = 35) with normal controls (n = 26) and to determine whether there were changes in laterality with remission of the manic state. Relationships of performance asymmetries to treatment outcome and symptom features were also examined. Compared with normal controls, manic patients showed overall poorer accuracy, particularly for complex tones presented to the left ear, and they failed to show the normal left-ear (right-hemisphere) advantage for complex tones. Abnormal laterality for complex tones was present in patients who later responded to treatment but not in nonresponders. In the euthymic state, patients showed improved left-ear accuracy for complex tones and more normal perceptual asymmetry. These findings suggest that mania is associated with a decrement in right-hemisphere processing of complex tonal information.

Is dysthymia a different disorder in the elderly?

OBJECTIVE

This study evaluated elderly dysthymic patients in a late life depression clinic and compared their clinical features to previous findings in young adult dysthymic patients.

METHOD

Of 224 consecutive elderly outpatients, 40 (17.9%) met criteria for dysthymic disorder. A semistructured interview was used to obtain history, the Structured Clinical Interview for DSM-III-R--Patient Version and the Structured Clinical Interview for DSM-III-R Personality Disorders were used to make DSM-III-R diagnoses, and standard rating instruments for depression were administered.

RESULTS

The gender distribution was equal and major stressors were common. The mean age at onset of dysthymia was 55.2 years (SD = 15.4), with an average illness duration of 12.5 years (SD = 14.2). Early onset (before 21 years of age) and secondary dysthymia were rare. A history of major depression earlier during the course of dysthymic illness, comorbid anxiety disorders, and personality disorders were relatively uncommon. Cross-sectionally, cognitive and functional symptoms were more prominent than vegetative symptoms.

CONCLUSIONS

Dysthymia is not uncommon among depressed elderly outpatients who present for treatment. Elderly dysthymic patients differ from young adult dysthymic patients, who are mostly female with an early onset and who frequently have comorbid axis I and axis II disorders. Most elderly dysthymic patients do not appear to be young dysthymic patients who simply grew older, and the DSM-III-R subtyping of dysthymia into early/late onset and primary/secondary may not apply to the elderly. Further clinical studies of "pure" dysthymic disorder appear feasible in the elderly, and these are clearly needed.

Effects of pharmacologic catecholamine manipulation on smooth pursuit eye movements in normals

The pathophysiology of schizophrenia may be related directly or indirectly to abnormal dopaminergic activity. Both subcortical excess and frontal cortical deficiency of dopamine have been suggested, and primary or downstream failures of dopamine activation to the prefrontal cortex has been posited to explain some of the cognitive deficiencies in schizophrenia patients. Although the prefrontal cortex may also be a site for the disruption of smooth pursuit eye movements (SPEM), the most substantially described psychophysiological marker for schizophrenia vulnerability, no relationship of SPEM to dopaminergic activity has been demonstrated. In this study we explored the effect of altered dopamine function on SPEM quality through pharmacological manipulation of catecholamine tone in 11 healthy subjects. The subjects had SPEM measured at baseline, and under challenge conditions including amphetamine (0.3 mg/kg), haloperidol (2 mg), placebo, and combined amphetamine with haloperidol. Changes in the profile of mood scale (POMS) confirmed the expected subjective central nervous system effects the agents. Placebo and amphetamine had no effect on qualitative ratings of SPEM, but haloperidol, alone and in combination with amphetamine, disrupted eye tracking, producing a pattern of small saccadic intrusions characteristic of patients with schizophrenia. These findings link dopaminergic blockade with SPEM disruption in normal subjects.

Does ECT alter brain structure?

OBJECTIVE

The purpose of this study was to evaluate whether ECT causes structural brain damage.

METHOD

The literature review covered the following areas: cognitive side effects, structural brain imaging, autopsies of patients who had received ECT, post-mortem studies of epileptic subjects, animal studies of electroconvulsive shock (ECS) and epilepsy, and the neuropathological effects of the passage of electricity, heat generation, and blood-brain barrier disruption.

RESULTS

ECT-induced cognitive deficits are transient, although spotty memory loss may persist for events immediately surrounding the ECT course. Prospective computerized tomography and magnetic resonance imaging studies show no evidence of ECT-induced structural changes. Some early human autopsy case reports from the unmodified ECT era reported cerebrovascular lesions that were due to agonal changes or undiagnosed disease. In animal ECS studies that used a stimulus intensity and frequency comparable to human ECT, no neuronal loss was seen when appropriate control animals, blind ratings, and perfusion fixation techniques were employed. Controlled studies using quantitative cell counts have failed to show neuronal loss even after prolonged courses of ECS. Several well-controlled studies have demonstrated that neuronal loss occurs only after 1.5 to 2 hours of continuous seizure activity in primates, and adequate muscle paralysis and oxygenation further delay these changes. These conditions are not approached during ECT. Other findings indicate that the passage of electricity, thermal effects, and the transient disruption of the blood-brain barrier during ECS do not result in structural brain damage.

CONCLUSIONS

There is no credible evidence that ECT causes structural brain damage.

Physical properties and quantification of the ECT stimulus: I. Basic principles

The physical properties of the electroconvulsive therapy (ECT) stimulus markedly affect both efficacy and side effects. We review basic principles in characterizing these physical properties and in quantifying the ECT stimulus. The topics discussed include the application of Ohm's law, alternative composite units of ECT dosage (energy and charge), the use of constant-current, constant-voltage, and constant-energy principles in ECT devices, the nature of current shunting in ECT and the determinants of impedance, the relations between impedance and seizure threshold, the seizure-eliciting efficiency of alternative stimulus waveforms and of stimulus parameter configurations, and the role of reactive components (capacitance and inductance) in the ECT circuit. New findings are also presented regarding several of these issues.

Acute cognitive effects of subconvulsive electrical stimulation

Empirical titration procedures increasingly are being used to estimate initial seizure threshold. These procedures involve the administration of subconvulsive electrical stimulation. There has yet to be evaluation of the impact of such stimulation on the acute cognitive consequences of electroconvulsive therapy. In two studies we randomized depressed patients to right unilateral or bilateral ECT, with stimulus intensity maintained just above seizure threshold throughout the treatment course. These low dosage treatment groups received one or more subconvulsive stimuli in approximately 40% of treatment sessions, with a grand mal seizure also elicited at each session. Extensive neuropsychological evaluation was conducted at each session. We contrasted treatment sessions in which generalized seizures were preceded by subconvulsive stimulation with treatment sessions in which a single convulsive stimulation was applied. Across a variety of neuropsychological measures, there were no adverse cognitive consequences of subconvulsive stimulation.

Electroconvulsive therapy of acute manic episodes: a review of 50 years' experience

OBJECTIVE

The most common indication for electroconvulsive therapy (ECT) is major depression. It is less recognized that ECT is effective also in the treatment of acute mania. This article aims to provide a comprehensive and critical review of the literature on the use of ECT for manic patients.

METHOD

All published papers in the English language on the use of ECT in acute mania that could be found were reviewed with regard to efficacy, frequency and number of treatments, bilateral versus unilateral electrode placement, predictors of antimanic response, stability of therapeutic response, cognitive consequences, and other relevant issues.

RESULTS

The evidence indicates that ECT is associated with remission or marked clinical improvement in 80% of manic patients and that it is an effective treatment for patients whose manic episodes have responded poorly to pharmacotherapy. Manic patients do not require a high frequency or prolonged course of treatments to respond to ECT. The seizure threshold appears to be lower in manic patients than in depressed patients. The issues of relapse following response to ECT, cognitive consequences of ECT, and the relative merits of unilateral versus bilateral ECT in manic patients require further study.

CONCLUSIONS

ECT is an effective and safe treatment for acute mania. Remission of mania following ECT reflects a primary therapeutic effect rather than a secondary consequence of an ECT-induced organic brain syndrome.

Smooth pursuit eye movement abnormality in severe major depression: effects of ECT and clinical recovery

Smooth pursuit eye movement (SPEM) dysfunction is a putative genetic marker for schizophrenia, but it has also been described in major depression. The authors longitudinally evaluated effects of clinical state on SPEM quality in patients with depression. Prior to ECT, SPEM abnormality characterized 42% of 24 severely depressed patients, 60% of 30 schizophrenia patients, and 5% of 20 control subjects. SPEM was significantly correlated to Hamilton Rating Scale for Depression scores (r = 0.49, P = 0.02) in the depressed patients. Although SPEM was transiently disrupted by an acute ECT treatment, it improved during the treatment course. This improvement of SPEM quality with clinical recovery suggests that SPEM abnormality may be a state marker in severe major depression, in contrast to its invariable trait nature in schizophrenia.

EEG manifestations during ECT: effects of electrode placement and stimulus intensity

This study examined the ictal electroencephalographic (EEG) characteristics of four forms of electroconvulsive therapy (ECT) known to differ in efficacy. Previously, we demonstrated that titrated, low-dose right unilateral ECT reliably produces generalized seizures of adequate duration, but is remarkably weak in antidepressant effects. Using a new rating scale, we found that specific features of the ictal and immediate postictal EEG varied significantly with ECT stimulus intensity and electrode placement. The low-dose right unilateral condition differed from more effective forms of ECT in having the longest polyspike phase duration, averaging twice that of the other conditions; it was also the condition least likely to manifest bioelectric suppression immediately following seizure termination. In contrast, high-dose bilateral ECT--a treatment with particularly rapid antidepressant effects--resulted in the greatest peak slow-wave amplitude in both hemispheres. Total seizure duration did not differ among the four treatment conditions. These findings indicate that seizure duration is not a useful marker of therapeutic efficacy, and instead provide preliminary evidence that other features of the EEG may be more useful markers of treatment adequacy.