Negative symptoms, depression and Alzheimer's disease

Apolipoprotein E and affective symptoms in mild cognitive impairment and Alzheimer's disease dementia: A systematic review and meta-analysis

OBJECTIVE

APOE status has been associated to affective symptoms in cognitively impaired subjects, with conflicting results.

METHODS

Databases CINAHL, Embase, PsychINFO and PubMed were searched for studies evaluating APOE genotype with affective symptoms in MCI and AD dementia. Symptoms were meta-analyzed separately and possible sources of heterogeneity were examined.

RESULTS

Fifty-three abstracts fulfilled the eligibility criteria. No association was found between the individual symptoms and APOE ε4 carriership or zygosity. For depression and anxiety, only pooled unadjusted estimates showed positive associations with between-study heterogeneity, which could be explained by variation in study design, setting and way of symptom assessment.

CONCLUSIONS

There is no evidence that APOE ε4 carriership or zygosity is associated with the presence of depression, anxiety, apathy, agitation, irritability or sleep disturbances in cognitively impaired subjects. Future research should shift its focus from this single polymorphism to a more integrated view of other biological factors.

Determinants of brain SPECT perfusion and connectivity in treatment-resistant depression

This study aims to characterize and compare functional brain single photon emission tomography (SPECT) perfusion and connectivity in treatment-resistant depression (TRD) according to distinct demographic or clinical profiles (male vs. female; old vs. young; unipolar vs. bipolar) and to study their relationship to the severity and the duration of episode/illness. We retrospectively included 127 consecutive patients who met DSM-IV criteria for a nonpsychotic major TRD episode. All patients were studied using (99m)Tc-ethyl cysteinate dimer SPECT. Whole-brain, voxel-based, between-groups analyses were performed according to demographic and clinical data and in comparison to 37 healthy subjects. Voxel-wise interregional correlation was also performed to compare functional SPECT connectivity. Finally, relationships were searched for regarding severity and duration of episode/illness. The whole group of patients exhibited significant hypoperfusion within bilateral fronto-temporal, insular, and anterior cingulate cortices, as well as within the left caudate. Functional connectivity between left frontal and left cerebellar regions was higher in patients than in healthy subjects. Gender, age, and type of mood disorder did not influence these SPECT patterns. A significant relationship was found between brain SPECT perfusion and either duration or global severity of illness in particular frontal areas. Our data support the hypothesis of a shared SPECT pattern, whatever the profile of TRD, involving fronto-temporal regions and the cerebellum.

Negative symptoms of schizophrenia: clinical features, relevance to real world functioning and specificity versus other CNS disorders

Negative symptoms have long been recognized as a central feature of the phenomenology of schizophrenia, dating back to the early descriptions by Kraepelin and Bleuler. Over the ensuing century, there have been important clarifications and reconceptualizations regarding the phenomenology of negative symptoms in schizophrenia. This review explores these developments, including the delineation of two underlying subdomains of negative symptoms - amotivation (i.e., avolition/apathy and asociality) and diminished expression (i.e., poverty of speech and affective flattening). Further, advances in our understanding of specific motivational and hedonic deficits seen in schizophrenia are explored. The findings that negative symptoms stand apart from depressive and cognitive symptoms in schizophrenia are also discussed. In terms of the predictors of functional outcomes in schizophrenia, we explore both the direct role of negative symptoms in this regard, as well as their indirect role through cognition. We then broaden our examination of negative symptoms to related disorders across the schizophrenia spectrum, as well as to other neuropsychiatric illnesses, where negative symptoms have been increasingly recognized. We explore the differential characteristics of negative symptoms across these illnesses, and their relevance to functional outcomes. This transdiagnostic presence and relevance of negative symptoms highlights the need for continued exploration of their phenomenology and neurobiology as we move to develop effective interventions to address these debilitating symptoms and improve functional outcomes.

Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes

BACKGROUND

Most elderly persons who attempt suicide suffer from depression. This study aimed to investigate one-year outcomes in suicide attempters aged 70+, and to identify predictors of these outcomes.

METHODS

101 persons (mean age 80) who were hospitalized after a suicide attempt were interviewed at baseline and followed for one year by record linkage. Face-to-face interviews were carried out with 71% of those who were alive after one year (60 out of 85). Outcome measures included major/minor depression, Montgomery-Asberg Depression Rating Scale (MADRS) score, repeat non-fatal/fatal suicidal behavior and all-cause mortality.

RESULTS

One half (52%) of all those who were interviewed scored <10 on the MADRS at follow-up. Among those with major depression at baseline, two thirds (26 out of 39) no longer fulfilled criteria for this disorder. Factors associated with non-remission of major depression (MADRS ≥ 10) included higher baseline depression and anxiety scores, higher suicide intent and lower Sense of Coherence. There were two suicides and six non-fatal repeat attempts. The relative risk of death (any cause) was 2.53 (95% CI = 1.45-4.10, p<0.001).

LIMITATIONS

This is a naturalistic study; participants received non-uniform treatment as usual. The proportion with repeat suicidal behavior was lower than anticipated and the study was thus underpowered with regard to this outcome.

CONCLUSIONS

Half of the surviving attempters were free from depressive symptoms at one-year follow-up and there were relatively few repeat attempts. However, all cause mortality remained high in this elderly cohort.

Prevalence and longitudinal stability of negative symptoms in healthy participants

OBJECTIVE

Although negative symptoms are prominent in older patients with schizophrenia, it is unknown whether this pattern is prevalent in healthy participants. The objective of this study was to evaluate whether negative symptoms are present in healthy populations and to determine whether they are linked to illness-related processes or normal aging.

METHODS

A systemic review of 26 studies that have administered negative symptom assessments to healthy participants was conducted. In addition, 213 (age > 40 years old) healthy participants completed PANSS and SANS ratings at both baseline and 1-year follow-up. One-hundred participants also completed ratings after 3 years.

RESULTS

Across all reviewed studies, negative symptoms were absent in the majority of participants. Comparable results were found in the current study's large longitudinal evaluation with middle-aged to older adults.

CONCLUSIONS

Taken together, the data suggest that healthy volunteers do not suffer from prominent negative symptoms. This finding is consistent with the hypothesis that the greater prevalence and severity of negative symptoms in older patients is not related to normal aging but to illness-related processes.

Omega-3 supplementation in mild to moderate Alzheimer's disease: effects on neuropsychiatric symptoms

BACKGROUND

Epidemiological and animal studies have suggested that dietary fish or fish oil rich in omega-3 fatty acids (omega3), docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), may have effects in psychiatric and behavioral symptoms in Alzheimer's disease (AD). An association with APOEomega4 carriers and neuropsychiatric symptoms in AD has also been suggested.

OBJECTIVE

To determine effects of dietary omega3 supplementation to AD patients with mild to moderate disease on psychiatric and behavioral symptoms, daily functions and a possible relation to APOEgenotype.

METHODS

Randomized, double-blind, placebo-controlled clinical trial where 204 AD patients (74+/-9 years) with acetylcholine esterase inhibitor treatment and a MMSE>15 points were randomized to daily intake of 1.7 g DHA and 0.6 g EPA (omega3 group) or placebo for 6 months. Then, all received the omega3 supplementation for 6 more months. Neuropsychiatric symptoms were measured with Neuropsychiatric Inventory (NPI) and Montgomery Asberg Depression Scale (MADRS). Caregivers burden and activities of daily living (Disability Assessment for Dementia, DAD) were also assessed.

RESULTS

One hundred and seventy-four patients fulfilled the trial. 72% were APOEomega4 carriers. No significant overall treatment effects on neuropsychiatric symptoms, on activities of daily living or on caregiver's burden were found. However, significant positive treatment effects on the scores in the NPI agitation domain in APOEomega4 carriers (p=0.006) and in MADRS scores in non-APOEomega4 carriers (p=0.005) were found.

CONCLUSIONS

Supplementation with omega3 in patients with mild to moderate AD did not result in marked effects on neuropsychiatric symptoms except for possible positive effects on depressive symptoms (assessed by MADRS) in non-APOEomega4 carriers and agitation symptoms (assessed by NPI) in APOEomega4 carriers. ClinicalTrials.gov identifier: NCT00211159

A review of studies of the Montgomery-Asberg Depression Rating Scale in controls: implications for the definition of remission in treatment studies of depression

The Montgomery-Asberg Depression Rating Scale (MADRS) is one of the most commonly used symptom severity scales to evaluate the efficacy of antidepressant treatment Various cut-offs have been employed in antidepressant efficacy trials to define remission, although little empirical work has been carried out to determine the validity of various thresholds. One approach towards deriving a valid cut-off score for defining remission is to determine whether a patient's level of symptoms falls within the normal range of values after treatment We therefore conducted a literature review of studies of the MADRS in healthy controls to determine the normal range of values. We identified 10 studies of 14 samples that included data on the MADRS for 569 controls. Across all studies, the mean (+/- SD) weighted MADRS score, adjusting for sample size, was 4.0 (5.8) (95% confidence interval 3.5-4.5). These results are consistent with the findings of our study of the validity of different cut-offs to define remission on the MADRS-based on a narrow definition of remission, which required a complete absence of clinically significant symptoms of depression, the optimal MADRS cut-off was < or = 4 whereas based on a broader definition, the optimal cut-off was < or = 9. The findings can be used for normative comparisons in which post-treatment group mean scores are compared to mean scores from normative samples. A limitation of the review is that none of the studies was based on a randomly selected sample from the general population. In addition, the rigor of the screening used to exclude individuals with psychopathology in most studies is unknown; thus, some of the controls may have had diagnosable depression, thereby elevating the mean scores in the presumptively healthy control group.

Selective hypoperfusion of anterior cingulate gyrus in depressed AD patients: a brain SPECT finding by statistical parametric mapping

This study tests the hypothesis that depression in patients with Alzheimer's disease (AD) is due to a specific pathogenesis rather than a reactive phenomenon. Forty-three AD patients received a psychiatrist's interview, neuropsychological assessments, and a 99mTc-hexamethyl propyleneamine oxime single photon emission computed tomography (HMPAO-SPECT). Analysis by statistical parametric mapping (SPM) showed that the depressed group had selective hypoperfusion in the bilateral anterior and posterior cingulate gyri and precuneus. Using the Hamilton Depression Rating Scale as a parameter, an inverse correlation was found between cerebral perfusion and the severity of depression. The right anterior cingulate gyrus demonstrated a most significant reduction in perfusion. These locations are akin to the imaging findings in patients with primary depression, indicating a specific pathogenesis for depression in AD.