Relationships between brain CT scan findings and cortisol in psychotic and nonpsychotic depressed patients

Potential biomarkers of emotional stress induced neurodegeneration

Mental health is a matter of great significance and interest both socially and scientifically. The present review aims to provide an informative platform about the classical biomarkers available to identify and diagnose the neurodegeneration induced by emotional stress and depression. Present article provides an expert comprehensive overview of the universally accepted markers and their mechanism of action involved in emotional stress assessment and its management. This envisioned piece of work emphasize on the incorporation of clinical markers in classical psychiatry experiments will make the information more significant, reliable and universally accepted. The information summaries in the article will facilitates the researchers of clinical psychiatry, neuropharmacology and neuropsychiatry in management of depressive disorders along with the identification of possible neurodegenerative association.

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Health is an overall outcome of emotional, physiological, endocrinological and neurological factors.

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Emotional stress and depression are silent causes of neurodegeneration.

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Clinical markers play a vital role in the management of neurological health.

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Endocrine secretions play a vital role in mediation of various neurotransmission, nerves excitability and neurodegeneration.

Structural brain networks in remitted psychotic depression

Major depressive disorder with psychotic features (psychotic depression) is a severe disorder. Compared with other psychotic disorders such as schizophrenia, relatively few studies on the neurobiology of psychotic depression have been pursued. Neuroimaging studies investigating psychotic depression have provided evidence for distributed structural brain abnormalities implicating the insular cortex and limbic system. We examined structural brain networks in participants (N = 245) using magnetic resonance imaging. This sample included healthy controls (n = 159) and the largest cross-sectional sample of patients with remitted psychotic depression (n = 86) collected to date. All patients participated in the Study of Pharmacotherapy of Psychotic Depression II randomized controlled trial. We used a novel, whole-brain, data-driven parcellation technique-non-negative matrix factorization-and applied it to cortical thickness data to derive structural covariance networks. We compared patients with remitted psychotic depression to healthy controls and found that patients had significantly thinner cortex in five structural covariance networks (insular-limbic, occipito-temporal, temporal, parahippocampal-limbic, and inferior fronto-temporal), confirming our hypothesis that affected brain networks would incorporate cortico-limbic regions. We also found that cross-sectional depression and severity scores at the time of scanning were associated with the insular-limbic network. Furthermore, the insular-limbic network predicted future severity scores that were collected at the time of recurrence of psychotic depression or sustained remission. Overall, decreased cortical thickness was found in five structural brain networks in patients with remitted psychotic depression and brain-behavior relationships were observed, particularly between the insular-limbic network and illness severity.

Validity of the Chinese Version of the Allen Cognitive Level Screen Assessment for Individuals with Schizophrenia

The purpose of this study was to examine the concurrent, construct validity (using the known groups method) and ecological validity of the Chinese version of the Allen Cognitive Level Screen Assessment (CACLS). Sixty-one individuals with schizophrenia and 61 control subjects were recruited to undergo the CACLS and the Chinese versions of the Mini-Mental State Examination (CMMSE) and Functional Needs Assessment (CFNA), respectively. The results suggested that the concurrent validity had initially been established because the CACLS score correlated moderately with the CMMSE scores (γ = 0.61; p < .01) and was highly correlated with the CFNA scores (γ = 0.71; p < .01). Based on the results of the Mann—Whitney U test ( Z = −8.679; p < .001) and the analysis of covariance ( F = 40.7; p < .001) to control possible confounding variables, the construct validity of the CACLS had initially been demonstrated. Suggestions for future studies of the CACLS are also made.

Anna-Monika Award Lecture, DGPPN Kongress, 2013: the role of the hypothalamic-pituitary-adrenal (HPA) axis in the pathogenesis of psychotic major depression

OBJECTIVES

This Anna Monika Award Lecture updates the role of the hypothalamic-pituitary-adrenal (HPA) axis in the pathogenesis and treatment of psychotic major depression (PMD).

METHODS

Published reports from our group and others on the clinical phenomenology (including cognition), HPA axis activity, and genetics of PMD are reviewed as are published trials of the GR antagonist, mifepristone.

RESULTS

Current prevalence of PMD is 0.4%. PMD patients demonstrate significant elevations in HPA activity (e.g., particularly high rates of dexamethasone non-suppression, high post-dexamethasone cortisol, etc.) as well as significant impairment in cognition (attention, executive function/response inhibition and verbal and visual memory). High cortisol levels correlate with a number of cognitive deficits (e.g., verbal memory). Allelic variants of the glucocorticoid receptor (GR) gene contribute significantly to both cortisol levels and to measures of psychosis; corticotropin-releasing hormone receptor 1 variants contribute to measures of depression and psychosis. GR antagonists have produced rapid improvement in psychotic symptoms, although failed trials indicate a therapeutic blood level that may require a dose of 1,200 mg/day that is much higher than the commonly tested 600 mg/day.

CONCLUSIONS

HPA axis over-activity appears to play a major role in the pathogenesis of PMD and is a target of drug development.

Hippocampal and left subcallosal anterior cingulate atrophy in psychotic depression

BACKGROUND

Psychotic depression is arguably the most diagnostically stable subtype of major depressive disorder, and an attractive target of study in a famously heterogeneous mental illness. Previous imaging studies have identified abnormal volumes of the hippocampus, amygdala, and subcallosal region of the anterior cingulate cortex (scACC) in psychotic depression, though studies have not yet examined the role of family history of depression in these relationships.

METHODS

20 participants with psychotic depression preparing to undergo electroconvulsive therapy and 20 healthy comparison participants (13 women and 7 men in each group) underwent structural brain imaging in a 1.5 T MRI scanner. 15 of the psychotic depression group had a first-degree relative with diagnosed affective disorders, while the healthy control group had no first-degree relatives with affective disorders. Depression severity was assessed with the Hamilton Depression Rating Scale and duration of illness was assessed in all patients. Automated neural nets were used to isolate the hippocampi and amygdalae in each scan, and an established manual method was used to parcellate the anterior cingulate cortex into dorsal, rostral, subcallosal, and subgenual regions. The volumes of these regions were compared between groups. Effects of laterality and family history of affective disorders were examined as well.

RESULTS

Patients with psychotic depression had significantly smaller left scACC and bilateral hippocampal volumes, while no group differences in other anterior cingulate cortex subregions or amygdala volumes were present. Hippocampal atrophy was found in all patients with psychotic depression, but reduced left scACC volume was found only in the patients with a family history of depression.

CONCLUSIONS

Patients with psychotic depression showed significant reduction in hippocampal volume bilaterally, perhaps due to high cortisol states associated with this illness. Reduced left scACC volume may be a vulnerability factor related to family history of depression.

Distinctive Clinical Correlates of Psychotic Major Depression: The CRESCEND Study

OBJECTIVE

The purpose of this investigation was to identify distinctive clinical correlates of psychotic major depression (PMD) as compared with non-psychotic major depression (NPMD) in a large cohort of Korean patients with major depressive disorder (MDD).

METHODS

We recruited 966 MDD patients of age over 18 years from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Diagnoses of PMD (n=24) and NPMD (n=942) were made with the DSM-IV definitions and confirmed with SCID. Psychometric scales were used to assess overall psychiatric symptoms (BPRS), depression (HAMD), anxiety (HAMA), global severity (CGI-S), suicidal ideation (SSI-Beck), functioning (SOFAS), and quality of life (WHOQOL-BREF). Using independent t-tests and χ(2) tests, we compared clinical characteristics of patients with PMD and NPMD. A binary logistic regression model was constructed to identify factors independently associated with increased likelihood of PMD.

RESULTS

PMD subjects were characterized by a higher rate of inpatient enrollment, and higher scores on many items on BPRS (somatic concern, anxiety, emotional withdrawal, guilt feelings, tension, depression, suspiciousness, hallucination, motor retardation, blunted affect and excitement) global severity (CGI-s), and suicidal ideation (SSI-Beck). The explanatory factor model revealed that high levels of tension, excitement, and suicidal ideation were associated with increased likelihood of PMD.

CONCLUSION

Our findings partly support the view that PMD has its own distinctive clinical manifestation and course, and may be considered a diagnostic entity separate from NPMD.

Obstructive sleep apnea and neurocognitive performance: the role of cortisol

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent disorder with multiple consequences including negative effects on neurocognitive function. Several domains of cognitive function are impaired in OSA patients, but the mechanisms through which this sleep disorder results in impairment are not clear. Given the well-known effects of cortisol on cognitive function, in particular memory, the dysregulating effects of OSA on cortisol levels are hypothesized as a potential pathway leading to cognitive impairment.

METHODS

Fifty-five participants with OSA (mean apnea-hypopnea index [AHI], 30.3) were assessed over 2 days. Over a 24-h period, blood samples were collected every 2h to examine cortisol levels. The following night, sleep was monitored with polysomnography (PSG). Participants were given a battery of neurocognitive tests, which assessed seven cognitive domains.

RESULTS

OSA severity assessed by oxygen desaturation index (ODI) was associated with 24-h cortisol levels. AHI, ODI, and nighttime cortisol levels were associated with global deficit scores (GDS) in cognitive functioning, particularly in domains of learning, memory, and working memory (P<.05 for all). Hierarchical linear regression analysis revealed that nighttime cortisol accounted for 9-16% of variance in learning (P=.018), memory (P=.003), and working memory (P=.016) domains, though apnea severity did not significantly predict any additional variance.

CONCLUSIONS

In our sample of patients with OSA, nocturnal cortisol levels were associated with neuropsychologic functioning above and beyond the influence of covariates and apnea severity. These findings suggest that OSA-related alterations in cortisol activity may partially explain the pathophysiology of neuropsychologic impairments in sleep apnea.

Stress and neurodevelopmental processes in the emergence of psychosis

The notion that stress plays a role in the etiology of psychotic disorders, especially schizophrenia, is longstanding. However, it is only in recent years that the potential neural mechanisms mediating this effect have come into sharper focus. The introduction of more sophisticated models of the interplay between psychosocial factors and brain function has expanded our opportunities for conceptualizing more detailed psychobiological models of stress in psychosis. Further, scientific advances in our understanding of adolescent brain development have shed light on a pivotal question that has challenged researchers; namely, why the first episode of psychosis typically occurs in late adolescence/young adulthood. In this paper, we begin by reviewing the evidence supporting associations between psychosocial stress and psychosis in diagnosed patients as well as individuals at clinical high risk for psychosis. We then discuss biological stress systems and examine changes that precede and follow psychosis onset. Next, research findings on structural and functional brain characteristics associated with psychosis are presented; these findings suggest that normal adolescent neuromaturational processes may go awry, thereby setting the stage for the emergence of psychotic syndromes. Finally, a model of neural mechanisms underlying the pathogenesis of psychosis is presented and directions for future research strategies are explored.

Structural and functional neuroimaging studies in major depressive disorder with psychotic features: a critical review

The relationship between major depressive disorder with psychotic (MDDP) features and schizophrenia has long been recognized, and the neurobiological boundaries between these disorders can nowadays be investigated using neuroimaging techniques. This article provides a critical review of such studies, addressing how they support a dimensional approach to the nosology and pathophysiology of psychotic disorders. A proportion of neuroimaging studies carried out to date indicate that MDDP subjects display structural and functional abnormalities in some brain regions specifically implicated in the pathophysiology of mood disorders, such as the subgenual cingulate cortex. This reinforces the validity of the classification of MDDP in proximity to major depression without psychosis. There is some neuroimaging evidence that MDDP may be associated with additional brain abnormalities relative to nonpsychotic major depression although less prominently in comparison with findings from the neuroimaging literature on schizophrenia. Brain regions seen as critical both to emotional processing and to models of psychotic symptoms, such as the hippocampus, insula, and lateral prefrontal cortex, have been implicated in separate neuroimaging investigations of either schizophrenia or major depression, as well as in some studies that directly compared depressed patients with and without psychotic features. These brain regions are key targets for future studies designed to validate imaging phenotypes more firmly associated with MDDP, as well as to investigate the relationship between these phenotypes and possible etiological influences for MDDP.

Altered brain function underlying verbal memory encoding and retrieval in psychotic major depression

Psychotic major depression (PMD) is associated with deficits in verbal memory as well as other cognitive impairments. This study investigated brain function in individuals with PMD during a verbal declarative memory task. Participants included 16 subjects with PMD, 15 subjects with non-psychotic major depression (NPMD) and 16 healthy controls (HC). Functional magnetic resonance imaging (fMRI) data were acquired while subjects performed verbal memory encoding and retrieval tasks. During the explicit encoding task, subjects semantically categorized words as either "man-made" or "not man-made." For the retrieval task, subjects identified whether words had been presented during the encoding task. Functional MRI data were processed using SPM5 and a group by condition ANOVA. Clusters of activation showing either a significant main effect of group or an interaction of group by condition were further examined using t-tests to identify group differences. During the encoding task, the PMD group showed lower hippocampus, insula, and prefrontal activation compared to HC. During the retrieval task, the PMD group showed lower recognition accuracy and higher prefrontal and parietal cortex activation compared to both HC and NPMD groups. Verbal retrieval deficits in PMD may be associated with deficient hippocampus function during encoding. Increased brain activation during retrieval may reflect an attempt to compensate for encoding deficits.

The validity of the severity-psychosis hypothesis in depression

BACKGROUND

Psychotic depression (PD) is classified as a subtype of severe depression in the current diagnostic manuals. Accordingly, it is a common conception among psychiatrists that psychotic features in depression arise as a consequence of depressive severity. The aim of this study was to determine whether the severity of depressive and psychotic symptoms correlate in accordance with this "severity-psychosis" hypothesis and to detect potential differences in the clinical features of PD and non-psychotic depression (non-PD).

METHODS

Quantitative analysis of Health of the Nation Outcome Scales (HoNOS) scores from all patients admitted to a Danish general psychiatric hospital due to a severe depressive episode in the period between 2000 and 2010 was performed.

RESULTS

A total of 357 patients with severe depression, of which 125 (35%) were of the psychotic subtype, formed the study sample. Mean HoNOS scores at admission differed significantly between patients with non-PD and PD on the items hallucinations and delusions (non-PD=0.33 vs. PD=1.37, p<0.001), aggression (non-PD=0.20 vs. PD=0.36, p=0.044) and on the total score (non-PD=10.55 vs. PD=11.87, p=0.024). The HoNOS scores on the two items "depression" and "hallucinations and delusions" were very weakly correlated.

LIMITATIONS

Diagnoses were based on normal clinical practice and not formalized research criteria.

CONCLUSIONS

The symptomatology of PD and non-PD differs beyond the mere psychosis. Furthermore, severity ratings of depressive and psychotic symptoms are very weakly correlated. These findings offer further support to the hypothesis stating that the psychotic- and non-psychotic subtypes of depression may in fact be distinct clinical syndromes.

Salubrious effects of oxytocin on social stress-induced deficits

Social relationships are a fundamental aspect of life, affecting social, psychological, physiological, and behavioral functions. While positive social interactions can attenuate stress and promote health, the social environment can also be a major source of stress when it includes social disruption, confrontation, isolation, or neglect. Social stress can impair the basal function and stress-induced activation of the hypothalamic-pituitary-adrenal (HPA) axis, impairing function of multiple biological systems and posing a risk to mental and physical health. In contrast, social support can ameliorate stress-induced physiological and immunological deficits, reducing the risk of subsequent psychological distress and improving an individual's overall well-being. For better clinical treatment of these physiological and mental pathologies, it is necessary to understand the regulatory mechanisms of stress-induced pathologies as well as determine the underlying biological mechanisms that regulate social buffering of the stress system. A number of ethologically relevant animal models of social stress and species that form strong adult social bonds have been utilized to study the etiology, treatment, and prevention of stress-related disorders. While undoubtedly a number of biological pathways contribute to the social buffering of the stress response, the convergence of evidence denotes the regulatory effects of oxytocin in facilitating social bond-promoting behaviors and their effect on the stress response. Thus, oxytocin may be perceived as a common regulatory element of the social environment, stress response, and stress-induced risks on mental and physical health. This article is part of a Special Issue entitled Oxytocin, Vasopressin, and Social Behavior.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on psychotic depression

This new version of the psychotic depression algorithm has been developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The most effective treatment modality for inpatients with severe psychotic depression is electroconvulsive therapy. The first-line psychopharmacological treatment is a combination of an antidepressant (either a tricyclic or a selective serotonin reuptake inhibitor) and an antipsychotic. If one of these combinations has failed, consider switching to the other. If both combinations have failed, the next psychopharmacological option would be to augment the combination with lithium. Another option, though with limited evidence, is monotherapy with clozapine. If there is a good reason to avoid combination therapy with an antipsychotic, then a trial of monotherapy with a TCA or an SSRI can be supported. If that fails, adding an antipsychotic or ECT should be considered.

The treatment of psychotic major depression: is there a role for adjunctive psychotherapy?

BACKGROUND

Psychotic depression is a relatively prevalent mood disorder associated with greater symptom severity, a poorer course of illness and higher levels of functional impairment compared with nonpsychotic depression. Separate lines of investigation suggest that various forms of cognitive-behavioral therapy are efficacious for treating severe forms of nonpsychotic depression as well as primary psychotic disorders. However, there currently are no empirically supported psychotherapies specifically designed for treating psychotic depression.

METHOD

We review the efficacy of current somatic treatments for the disorder and discuss the limited data to date on potentially useful psychotherapeutic approaches. In particular, we describe the clinical improvement observed in a subgroup of hospitalized patients with psychotic depression treated with Acceptance and Commitment Therapy as part of a larger clinical trial.

RESULTS

Pilot results demonstrated that Acceptance and Commitment Therapy was associated with clinically significant reductions in acute symptom severity and impairment compared with treatment as usual.

CONCLUSION

The findings suggest that patients with psychotic depression can benefit from psychotherapy. Clinical and research recommendations in this area are presented.

Effects of antidepressant treatment on neural correlates of emotional and neutral declarative verbal memory in depression

BACKGROUND

Multiple studies have documented deficits in verbal declarative memory function in depression that improve with resolution of symptoms; imaging studies show deficits in anterior cingulate function in depression, a brain area that mediates memory. No studies to date have examined neural correlates of emotionally valenced declarative memory using affectively negative (sad) verbal material that is clinically relevant to understanding depression. Also no studies have examined the effects of treatment on neural correlates of verbal declarative memory. The purpose of this study was to examine the effects of treatment with antidepressants on verbal declarative memory in patients with depression.

METHODS

Subjects with (N=18) and without (N=9) mid-life major depression underwent positron emission tomography (PET) imaging during verbal declarative memory tasks with both neutral paragraph encoding compared to a control condition, and emotional (sad) word pair retrieval compared to a control condition. Imaging was repeated in 13 subjects with depression after treatment with antidepressants.

RESULTS

Patients with untreated depression had a failure of anterior cingulate activation relative to controls during retrieval of emotional word pairs. Antidepressant treatment resulted in increased anterior cingulate function compared to the untreated baseline for both neutral and emotional declarative memory.

LIMITATIONS

Limitations include a small sample size and variety of antidepressants used.

CONCLUSIONS

These results are consistent with alterations in anterior cingulate function that are reversible with treatment in patients with depression. These findings may have implications for understanding the mechanism of action of antidepressants in the treatment of depression.

Current issues in the classification of psychotic major depression

Depression is one of the most common mental disorders worldwide. There are a number of depression subtypes, and there has been much debate about how to most accurately capture and organize the features and subtypes of major depression. We review the current state of categorizing unipolar major depression with psychotic features (psychotic major depression, PMD), including clinical, biological, and treatment aspects of the disorder. We then propose some improvements to the current unipolar major depression categorization system. Finally, we identify important issues in need of further research to help elucidate the subtype of unipolar PMD.

The neuropsychological profile of psychotic major depression and its relation to cortisol

BACKGROUND

Our study described the neuropsychological profile of psychotic major depression (PMD) compared to nonpsychotic major depression (NPMD) patients and psychiatrically healthy controls (HC). We predicted that higher cortisol levels would be associated with greater cognitive deficits.

METHODS

Twenty-nine PMDs, 24 NPMDs, and 26 HCs were recruited at Stanford University Medical Center. Psychiatric ratings, cortisol levels from 1800-0900 hours, and neuropsychological test data were obtained.

RESULTS

PMDs had more severe cognitive impairments compared with NPMDs and HCs with the exception of simple verbal attention. PMDs had elevated mean cortisol levels from 1800 to 0100 hours which were significantly correlated with poorer verbal memory and psychomotor speed performance. Cortisol slopes from 1800 to 0100 hours were also significantly correlated with verbal memory and working memory.

CONCLUSIONS

While PMDs' ability to attend passively to information appears intact, they have more difficulty processing, manipulating, and encoding new information. Elevated cortisol levels, as seen in PMD patients, are associated with poorer cognitive performance especially related to verbal memory for lists of words and working memory.

Detecting psychotic major depression using psychiatric rating scales

OBJECTIVE

The aim of this study was to assess whether individual or clusters of psychiatric symptoms can differentiate patients with psychotic major depression (PMD) from those with nonpsychotic depression (NPMD).

METHOD

Data were pooled from two studies investigating patients with moderate depression. A total of 129 subjects were studied. Patients in Sample 1 were unmedicated, while the majority of the patients in Sample 2 were taking psychotropic medications. Baseline rating scales were obtained for all subjects, including the Hamilton depression rating scale and the brief psychiatric rating scale (BPRS). We used discriminant function analyses, logistic regression, and ROC analyses to determine the patterns in symptoms that differentiated the groups.

RESULTS

Psychotic patients were adequately differentiated by the unusual thought content (UTC) item of the BPRS. Even mild UTC endorsement was an indicator of PMD. Furthermore, results suggest that the positive symptom subscale of the BPRS was even better at differentiating PMD from NMPD patients. Sensitivity and specificity for this scale were 84% and 99%, respectively.

CONCLUSION

Psychotic major depression is often undiagnosed and poorly treated. One reason for this trend is the failure of physicians to inquire in a more detailed manner about positive symptoms in patients with primary mood symptoms. Although physicians are not likely to have the time to conduct an entire BPRS during an evaluation, our results suggest that a few key symptoms, if assessed directly, may aid the psychiatrist to more effectively diagnose and subsequently treat their depressed patients.

The impact of medical illness on executive function

Executive function can be defined as one's ability to plan, initiate, sequence, monitor, and inhibit complex goal-directed behaviors. Although executive impairment is generally associated with dementia, recent studies have suggested that patients with chronic diseases, such as hypertension, chronic obstructive pulmonary disease, and diabetes, may also have executive deficits independent of psychiatric comorbidities. Because executive function is associated with functional outcomes, medication compliance, and the capacity to give informed consent, it is important that it be assessed. However, it is the authors' impression that executive function is not adequately assessed in medical settings, despite the availability of reliable measures. This article reviews the impact of medical illness on executive function and discusses practical diagnostic instruments and treatment strategies. The changes in functional status associated with executive impairment as well as pathophysiology and treatment strategies are also discussed.

Urinary cortisol excretion as a predictor of incident cognitive impairment

Elevated glucocorticoid levels have been associated with cognitive impairment, including dementia. However, few longitudinal studies have examined the association between resting cortisol levels and the incidence of cognitive impairment. We measured overnight urinary excretion of cortisol in 538 high-functioning men and women, 70-79 years of age, in 1988, and assessed their cognitive functioning in 1988, 1991, and 1995 using the short portable mental status questionnaire (SPMSQ). Compared to participants in the bottom quartile of urinary cortisol at baseline, those in the top three quartiles had higher risk of incident cognitive impairment over the 7-year follow up (i.e., decline in SPMSQ score to below six out of nine). This association was not affected by adjustment for age, gender, education level, ethnicity, smoking, prevalent cardiovascular disease, and blood pressure (adjusted odds ratio for the highest quartile 2.34, 95% confidence interval, 1.07-5.14). There was no effect modification by gender; the association was equally strong in men and women. We conclude that urinary excretion of cortisol predicts incident cognitive impairment in older men and women.

Cognitive function and cerebral assessment in patients who have Cushing's syndrome

Cushing's syndrome (CS) is a relevant model to better understand the effects of glucocorticoid (GC) excess on the human brain. The importance of GC excess on the central nervous system is highlighted by the high prevalence of neuropsychiatric disorders such as depression and cognitive impairment in patients who have CS. In addition, there is a high incidence of apparent diffuse loss of brain volume in patients who have CS. Recent studies indicate at least partial reversibility of these abnormalities following correction of hypercortisolism.

Relationship among Dexamethasone Suppression Test, personality disorders and stressful life events in clinical subtypes of major depression: An exploratory study

Background

The present study aimed to investigate the relationship between dexamethasone suppression test, personality disorder, stressful life events and depression.

Material

Fifty patients (15 males and 35 females) aged 41.0 ± 11.4 years, suffering from Major Depression according to DSM-IV criteria entered the study.

Method

Diagnosis was obtained with the aid of the SCAN v 2.0 and the IPDE. Psychometric assessment included the HDRS, HAS, the Newcastle Scale (version 1965 and 1971), the Diagnostic Melancholia Scale, the Personality Deviance Scale and the GAF scale. The 1 mg DST was used.

Statistical Analysis

Included MANOVA, ANOVA with LSD post hoc test and chi-square test.

Results

Sixteen (32%) patients were non-suppressors. Eight patients without Personality Disorder (PD) (23.5%), and 5 of those with PD of cluster B (50%) were non-suppressors. Atypical patients were the subtype with the highest rate of non-suppression (42.85%). No difference between suppressors and non-suppressors was detected in any of the scales.

Discussion

The results of the current study suggest that pathological DST is not a core feature of major depression. They also suggest that there are more than one subtypes of depression, concerning the response to stress. It seems that the majority of depressed patients (50%) does not experience high levels of stress either in terms of self reported experience or neuroendocrine function. The rest of patients however, either experience high levels of stress, or manifest its somatic analogue (DST non-suppression) or have a very low threshold of stress tolerance, which makes them to behave in a hostile way.

The regional cerebral blood flow changes in major depressive disorder with and without psychotic features

Depressive patients with psychotic features demonstrate distinct biological abnormalities in the hypothalamic-pituitary-adrenal axis (HPA), dopaminergic activity, electroencephalogram sleep profiles and measures of serotonergic function when compared to nonpsychotic depressive patients. However, very few functional neuroimaging studies were specifically designed for studying the effects of psychotic features on neuroimaging findings in depressed patients. The objective of the present study was to compare brain Single Photon Emission Tomography (SPECT) images in a group of unmedicated depressive patients with and without psychotic features. Twenty-eight patients who fully met DSM-IV criteria for major depressive disorder (MDD, 12 had psychotic features) were included in the study. They were compared with 16 control subjects matched for age, gender and education. Both psychotic and nonpsychotic depressed patients showed significantly lower regional cerebral blood flow (rCBF) values in the left and right superior frontal cortex, and left anterior cingulate cortex compared to those of controls. In comparison with depressive patients without psychotic features (DwoPF), depressive patients with psychotic features (DwPF) showed significantly lower rCBF perfusion ratios in left parietal cortex, left cerebellum but had higher rCBF perfusion ratio in the left inferior frontal cortex and caudate nucleus. The present study showed that DwPF have a different rCBF pattern compared to patients without psychotic features. Abnormalities involving inferior frontal cortex, striatum and cerebellum may play an important role in the generation of psychotic symptoms in depression.

Effects of glucocorticoids on declarative memory function in major depression

BACKGROUND

Major depression has been associated with hypercortisolemia in a subset of patients with depression. Administration of exogenous cortisol and other glucocorticoids to healthy human subjects has been observed to result in a transient impairment in verbal declarative memory function. The purpose of this study was to assess the effects of the glucocorticoid, dexamethasone, on verbal declarative memory function in patients with untreated unipolar major depressive disorder (MDD).

METHODS

Fifty two men and women with (n = 28) and without (n = 24) MDD received placebo or dexamethasone (1 mg and 2 mg on 2 successive days) in a double-blind, randomized fashion. Declarative memory was assessed with paragraph recall at baseline (day 1) and day 3.

RESULTS

There was a significant interaction between diagnosis and drug (dexamethasone vs. placebo) on paragraph recall. In the healthy subjects, memory improved from baseline to day 3 with placebo and was unchanged with dexamethasone, whereas in MDD patients memory function showed a pattern of decreasing with placebo and improving with dexamethasone from baseline to day 3.

CONCLUSIONS

These findings are consistent with an altered sensitivity of declarative memory function in MDD to regulation by glucocorticoids. Possible explanations of the findings include alterations in glucocorticoid receptors in the hippocampus or other brain regions mediating declarative memory, or differential sensitivity to dexamethasone-induced reductions in cortisol, in patients with MDD.

Neuropsychological correlates of psychotic features in major depressive disorders: a review and meta-analysis

Neuropsychological functioning has been a focus of study in psychotic disorders for many decades. These studies have focused primarily on schizophrenia, and less so on the affective psychoses, including psychotic major depression PMD. Several studies have provided evidence of cognitive dysfunction in PMD. However, these studies have utilized different assessment methods and instruments. Consequently, a clear picture of the nature and severity of cognitive impairment in PMD has yet to emerge in the literature. The current review seeks to provide a summary of the literature by composing a quantitative and qualitative review of the research to date on the cognitive impairment in psychotic major depression, specifically as it contrasts to those deficits observed in nonpsychotic depression. This review also provides a summary model of the pathophysiology of PMD to provide the necessary context to understanding the biological mechanisms of these impairments.

Neuroimaging studies of mood disorder effects on the brain

Studies of early-onset recurrent depression, late life depression associated with neurologic disorders, and bipolar illness have revealed structural brain changes within a neuroanatomical circuit. This circuit, originally described by, has been termed the limbic-cortical-striatal-pallidal-thalamic tract and is comprised of structures which are extensively interconnected. In three-dimensional magnetic resonance imaging studies of affective illness, many of the structures that comprise this tract have been found to have volume loss or structural abnormalities. Mechanisms proposed to explain volume loss in depression include glucocorticoid neurotoxicity, decreased brain-derived growth factor, decreased neurogenesis, and loss of plasticity.

Challenges in the treatment of depression with psychotic features

Major depression with psychotic features (MDpsy), a disorder with considerable morbidity and mortality, is more common than is generally realized and is a most difficult form of depression to treat. Patients with MDpsy exhibit more frequent relapses and recurrences and have increased use of services, greater disability, and a poorer clinical course when compared with nonpsychotically depressed patients. Patients with MDpsy demonstrate distinct biological abnormalities in studies of the hypothalamic-pituitary-adrenal (HPA) axis, dopaminergic activity, enzyme studies, brain imaging, electroencephalogram sleep profiles, and measures of serotonergic function when compared with nonpsychotic depression. The social and occupational impairment in MDpsy has been hypothesized to be secondary to subtle cognitive deficits caused by the higher cortisol levels frequently observed in MDpsy patients. Several studies support a relationship between bipolar disorder and MDpsy, particularly in young-onset MDpsy. The most efficacious treatments for MDpsy include the combination of an antidepressant and an antipsychotic, amoxapine, or electroconvulsive therapy. Atypical antipsychotic medications may have particular relevance for the treatment of MDpsy because of the potential for reduced risk of extrapyramidal side effects and tardive dyskinesia, as well as antipsychotic and possibly antidepressant qualities. Based on the observations that MDpsy patients exhibit marked dysregulation of the HPA axis and elevated cortisol levels, several antiglucocorticoid strategies have been employed to treat MDpsy patients. Many questions regarding the acute and long-term treatment of MDpsy remain for future studies to address.

The second-generation 'atypical' antipsychotics: similar improved efficacy but different neuroendocrine side effects

The neuroendocrine aspects of schizophrenia generally receive little attention. This is in marked contrast to depressive disorders, where neuroendocrine issues are central to discussions of pathophysiology and treatment. Although the nature of neuroendocrine dysfunction is less well characterized in schizophrenia than in major depression, a number of neuroendocrine abnormalities have been described. Hypercortisolemia has been extensively documented in patients with schizophrenia, particularly during acute exacerbations, with persistent hypercortisolemia being associated with ventricular enlargement and poor outcome. Similarly, abnormalities in thyroid function, the hypothalamo-pituitary-gonadal axis, growth hormone, prolactin, neurotensin, and other neuroendocrine parameters have also been described in schizophrenia. While the precise neuroendocrine profile of schizophrenia is incompletely characterized, the impact of antipsychotic medications employed in its treatment on various endocrine parameters is better understood. Different conventional and atypical antipsychotics variably contribute to hyperprolactinemia, insulin resistance, and other abnormalities. A critical overview of neuroendocrine abnormalities in schizophrenia is provided and the differential impact of different antipsychotics in contributing to neuroendocrine dysfunction is discussed.

The somatics of psyche: structural neuromorphometry of bipolar disorder

Many neuroimaging investigations report structural differences in subjects with bipolar disorder; however, conflicting results are common in the limited number of available investigations. Thus, the structural correlates of bipolar disorders remain poorly understood. The authors reviewed the early investigations using computed tomography and examined gross structural differences, such as cerebral atrophy, ventricular enlargement, or cerebellar atrophy. Many of these investigations report significant differences in these features compared with controls, whereas others found no such differences. More recent magnetic resonance imaging (MRI) investigations have employed increasingly sophisticated imaging and research methodologies, allowing for the quantitative examination of specific brain regions. Because neuropsychological and functional studies suggest abnormalities in frontal, temporal and subcortical regions, many investigators have focused their MRI neuromorphometric studies on these temporal limbic structures. However, the number of investigations examining each of these regions remains small, and conflicting results continue to be reported. It seems clear that for many brain regions, the structural changes from normal may be subtle, and that the differences in the reported studies may be due to differences in research methodologies between studies and across centers.

Persistent cognitive impairment following surgical treatment of Cushing's syndrome

Chronic exposure to elevated glucocorticoid (GC) levels in Cushing's syndrome (CS) is associated with deficits in cognitive function. It has already been shown that CS patients scored significantly lower than controls on several aspects of cognitive function (J. Int. Neuropsychol. Soc. 6 (2000) 20). In the present study, 13 subjects who presented with CS were investigated one year after surgical treatment to determine the extent to which the effects of hypercortisolism on cognitive function are reversible. Subjects were evaluated with a battery of tasks, similar to the original battery of a year earlier and including tests of attention, visuospatial processing, memory, reasoning and verbal fluency. Except for one task of visual organization, the results showed little change in performance, suggesting that prolonged exposure to high levels of GC can cause long-lasting deleterious effects on cognitive function. The data suggest that correction of hypercortisolism is not necessarily correlated with short-term improvement in cognitive function.

Structural changes in the brain in depression and relationship to symptom recurrence

Depression is an important public health problem affecting about 15% of the general population; however, little is known about possible changes in the brain that might underlie the disorder. Neuroimaging has been a powerful tool to map actual changes in the brain structure of depressed patients that might be directly related to their symptoms of depression. Some imaging studies of brain structure have shown smaller hippocampal volume with the chronicity of depression correlating to a reduction in volume. Although the meaning of these findings is unclear, other studies have shown increased amygdala volume. Studies have found reductions in volume of the frontal cortex, with some studies showing specific reductions in subregions of the frontal cortex, including the orbitofrontal cortex. Findings of an increase in white matter lesions in elderly patients with depression have been replicated and correlated with late-onset depression, as well as impairments in social and cognitive function. These findings point to alterations in a circuit of brain regions hypothesized to include the frontal cortex, hippocampus, amygdala, striatum, and thalamus, that underlie symptoms of depression.

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE

OBJECTIVE

To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression.

METHODS

The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score <or=10 on the 24-item Hamilton Rating Scale for Depression (HRSD) after 2 consecutive treatments, and a decrease of at least 60% from baseline.

RESULTS

The overall remission rate was 87% for study completers. Among these, patients with psychotic depression had a remission rate of 95% and those with nonpsychotic depression, 83%. Improvement in symptomatology, measured by the HRSD, was more robust and appeared sooner in the psychotic patients compared with the nonpsychotic patients.

CONCLUSION

Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Corticosteroids and cognition

The brain is a major target organ for corticosteroids. It has been observed that excessive circulatory levels of endogenous and exogenous corticosteroids are frequently associated with cognitive impairment in a wide variety of clinical disease states. Cognition and low levels of corticosteroids have been less well studied. In this paper we review the literature on glucocorticosteroid effects on cognition and delineate specific functions that appear to be causally affected. We draw a possible connection to specific areas of brain perturbation, including the hippocampus and frontal lobe regions. The possibility that cognitive dysfunction caused by glucocorticoids can be pharmacologically managed is introduced.

3D MRI studies of neuroanatomic changes in unipolar major depression: the role of stress and medical comorbidity

Increasing evidence has accumulated for structural brain changes associated with unipolar recurrent major depression. Studies of neuroanatomic structure in early-onset recurrent depression have only recently found evidence for depression-associated structural change. Studies using high-resolution three-dimensional magnetic resonance imaging (MRI) are now available to examine smaller brain structures with precision. Brain changes associated with early-onset major depression have been reported in the hippocampus, amygdala, caudate nucleus, putamen, and frontal cortex, structures that are extensively interconnected. They comprise a neuroanatomic circuit that has been termed the limbic-cortical-striatal-pallidal-thalamic tract. Of these structures, volume loss in the hippocampus is the only consistently observed change to persist past the resolution of the depression. Possible mechanisms for tissue loss include neuronal loss through exposure to repeated episodes of hypercortisolemia; glial cell loss, resulting in increased vulnerability to glutamate neurotoxicity; stress-induced reduction in neurotrophic factors; and stress-induced reduction in neurogenesis. Many depressed patients, particularly those with late-onset depression, have comorbid physical illnesses producing a high rate of hyperintensities in deep white matter and subcortical gray matter and brain damage to key structures involved in the modulation of emotion. Combining MRI studies with functional studies has the potential to localize abnormalities in blood flow, metabolism, and neurotransmitter receptors and provide a better integrated model of depression.

Psychotic symptoms in posttraumatic stress disorder

Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.

Biology and recent brain imaging studies in affective psychoses

Psychosis is a cardinal symptom of schizophrenia, but also occurs in other psychiatric conditions, including mood disorders. In many instances, brain abnormalities in psychotic and mood disorders appear to be on a spectrum, with the most marked changes in schizophrenia, followed by psychotic mood disorders, followed by nonpsychotic mood disorders. Such observations are consistent with the notion that mood disorders and schizophrenia represent a continuum of disease. However, in some instances, cerebral changes with psychosis may be qualitatively different, rather than merely more severe than those seen in mood disorders, more consistent with the theory that they are discrete entities. We review brain imaging studies that have advanced our knowledge of psychosis in mood disorders, with respect to the continuum versus discrete entity hypotheses.

Neuroanatomic substrates of late-life mental disorders

Advances in magnetic resonance imaging (MRI) techniques have made it possible to quantify anatomic brain abnormalities in neuropsychiatric disorders. This review focuses on controlled, quantitative MRI studies in depression, degenerative disorders, and psychosis in the elderly. Although many of the anatomic abnormalities detected are observed across disorders, the patterns of regional involvement may be more selective and disorder specific. We integrate MRI findings with relevant clinical and neurobiologic observations in an attempt to develop a cohesive model of late-life psychiatric illness. Although the model primarily alludes to the pathophysiology of late-life depression, it may have broader biologic implications for other mental disorders in the elderly.

Clinical and demographic features of psychotic and nonpsychotic depression

The present study evaluated clinical and demographic features of subjects with delusional versus nondelusional major depressive disorder. Two hundred eighty-eight subjects with mood disorder (bipolar disorder, n = 94; major depressive disorder, n = 194) were included in the study. No differences were observed for gender, polarity of mood disorder, age of onset, duration of index episode, number of episodes, number of previous hospital admissions, frequency of illness episodes, and number of suicide attempts. On the other hand, delusional subjects showed a higher rate of cluster A personality disorder and a lower level of education. We also detected a larger number of cluster B personality disorders among nondelusionals. Our data suggest that subjects with delusional mood disorder do not differ substantially from nondelusionals in terms of the clinical and demographic variables considered in this study except for personality disorders.

Candidate neuroanatomic substrates of psychosis in old-aged depression

1. The authors investigated the candidate neuroanatomic substrates underlying delusional thought disorder in old-aged depressed patients by using magnetic resonance imaging (MRI), and examined the relationship between volumes for individual brain structures and clinical correlates of particular relevance to depression: executive cognitive impairment and global severity of depression. 2. MR morphometry was performed on nineteen deluded depressed patients and 26 non-deluded depressed patients, all older than 55 years of age. Subjects were administered a neuropsychological test battery and measures of depression. 3. The absolute volume of prefrontal cortex (PFC) was smaller in the deluded depressed group than in non-deluded depressed group (131.79 +/- 37.26 ml vs. 152.65 +/- 26.13 ml, p = 0.03); a difference that was statistically significant even after adjusting for the effect of whole brain volume (p = 0.01). No group differences were observed in the volumes of the basal ganglia, the temporal lobes, the superior temporal gyri, the amygdala-hippocampal complex, the lateral ventricles, or whole brain. The relative volume of PFC correlated inversely and significantly with the index of Wisconsin Card Sorting Test (WCST) performance (r = -0.76, p < 0.01) in depressed patients. 4. PFC may be one of the candidate neuroanatomic substrates underlying delusional thought disorder in old-aged depression.

Clinical, demographic and social characteristics of psychotic depression

The goal of this study was to compare the clinical, demographic and social characteristics of psychotic and non-psychotic depression in the elderly and younger age groups. Depressed patients (n = 674) meeting DSM-III-R criteria for major depressive episode were classified into two groups, psychotic and non-psychotic, based on the presence of delusions or hallucinations. The patients with psychotic and non-psychotic depression were compared on clinical, demographic, and social characteristics. Bivariate analyses revealed that younger age, psychomotor retardation, guilt, feelings of worthlessness, history of delusions in the past, and increased suicidal ideation and intent were found more commonly in psychotic as compared to non-psychotic depression. A fully adjusted logistic regression model also confirmed younger age, history of past delusions, and increased feelings of worthlessness to be associated more with psychotic than with non-psychotic depression. Trends were observed for psychotic depression to be associated with poor subjective social support and with bipolar illness. Cerebrovascular risk factors and gender composition did not differ significantly in the psychotic vs. non-psychotic groups. The study confirms previously described findings such as increased guilt, increased psychomotor retardation and increased suicidality in psychotic depression in a large sample of depressed patients. The study also introduces the concept of age as an important variable influencing psychotic depression. The limitation of this finding is that it is applicable to tertiary care samples. Further studies are needed to confirm this finding in other subgroups.

Sleep-onset rapid eye movement periods in neuropsychiatric disorders: implications for the pathophysiology of psychosis

This paper reviews the literature describing the occurrence of sleep-onset rapid eye movement periods in narcolepsy, schizophrenia, psychotic depression, and delirium tremens; the association of narcolepsy with psychotic disorders; the neuropathology of the brainstem in narcolepsy and schizophrenia; and other behavioral disorders resulting from probable brainstem pathology. These findings suggest that some forms of psychosis are a manifestation of pathophysiological changes in the brainstem. Some implications of this hypothesis for the treatment of psychoses are discussed. Future research should investigate psychoses and the psychobiological correlates of such biological markers as sleep-onset rapid eye movement periods across diagnostic categories.

Clinical, magnetic resonance imaging and endocrinological differences between delusional and non-delusional depression in the elderly

OBJECTIVE

To investigate neuroradiological, endocrinological and clinical differences between delusional and non-delusional depression.

DESIGN

A cross-sectional study of depressed subjects.

SETTING

Melbourne, Australia.

PARTICIPANTS

Sixty-one subjects (inpatients) over the age of 55 meeting DSM-III-R criteria for major depression of whom 22 had delusional subtype of depression.

MEASURES

Clinical assessment, including documentation of vascular risk factors. Cognitive assessment by the Cambridge Cognitive Examination (CAMCOG). Magnetic resonance imaging (MRI) scans were performed on a 0.3 Tesla scanner with temporal lobe atrophy, periventricular lesions (PVL) and deep white matter lesions (DWML) rated visually on 4-point scales. A standard 1 mg dexamethasone suppression test (DST) was performed.

RESULTS

Subjects with delusional depression had significantly more vascular risk factors than those without delusions. There were no differences in measures of temporal lobe atrophy, PVL, DST results or cognitive test scores, though there was a non-significant trend for DWML to be more prevalent in those with delusions. Delusional depression was associated with a shorter duration of history and more frequent treatment with ECT.

CONCLUSIONS

The increase in vascular risk factors and trend towards greater DWML on MRI suggests an organic contribution to delusional depression in the elderly. In contrast to some previous reports, we found no differences in cortical MRI appearance or neuroendocrine measures between groups.

The anatomy of mood disorders--review of structural neuroimaging studies

The structural neuroimaging findings in mood disorders were reviewed, to evaluate evidence for a neuroanatomic model of pathophysiology, involving the prefrontal cortex, the basal ganglia, the amygdala-hippocampus complex, thalamus, and connections among these structures. Global atrophy is not consistently found. The best replicated finding is an increased rate of white matter and periventricular hyperintensities. A smaller frontal lobe, cerebellum, caudate, and putamen appear present in unipolar depression. A larger third ventricle, and smaller cerebellum and perhaps temporal lobe appear present in bipolar disorder. These localized structural changes involve regions that may be critical in the pathogenesis of mood disorders. Generalized and localized anatomic alterations may be related to age or vascular disease. The clinical and biological correlates of these changes need to be investigated to allow development of a more complete model of pathophysiology of mood disorders.

Hippocampal atrophy in recurrent major depression

Hippocampal volumes of subjects with a history of major depressive episodes but currently in remission and with no known medical comorbidity were compared to matched normal controls by using volumetric magnetic resonance images. Subjects with a history of major depression had significantly smaller left and right hippocampal volumes with no differences in total cerebral volumes. The degree of hippocampal volume reduction correlated with total duration of major depression. In addition, large (diameter > or = 4.5 mm)-hippocampal low signal foci (LSF) were found within the hippocampus, and their number also correlated with the total number of days depressed. These results suggest that depression is associated with hippocampal atrophy, perhaps due to a progressive process mediated by glucocorticoid neurotoxicity.

Cerebral atrophy and plasma cortisol levels in alcoholics after short or a long period of abstinence

Basal cortisol levels were significantly lower in 4 week abstinent alcoholics (n = 11; group A) than in normal controls (n = 9; group C), whereas no significant difference was found between alcoholics abstinent greater than 1 year (n = 9; group B) and controls. In all groups, dexamethasone induced a similar decrease in circulating cortisol concentrations. Computed tomographic examinations showed a significantly higher ventricular-brain ratio VBR) and wider 3rd ventricle width in group A than in group B; no significant differences were observed between groups B and C. In contrast, the number of cerebral sulci was similar in all groups. A negative relationship was found between neuroradiological findings and basal cortisol values in group A, but not in groups B and C. The neuropsychological tests showed worse scores in group A than in the other groups. These findings show subcortical damages and reduced cortisol levels in alcoholics after 4 weeks of abstinence. These alterations appear to be at least in part reversible after a long period of abstinence.

Hypothalamic-pituitary-adrenal axis activity and 1-year outcome in depression

The relationships of longitudinal biological measures to longer-term outcome in depressed patients have not been well explored. This study was designed to investigate whether in a sample of depressed patients: (a) symptomatic and functional outcome at 1 year was significantly different in psychotic major depressed (PMD) patients as compared with nonpsychotic major depressed (NPMD) patients and (b) high urinary or plasma cortisol levels at baseline or 1 year were associated with poorer outcomes at 1 year. Forty-two depressed patients (9 psychotic, 33 nonpsychotic) were evaluated at baseline and at 1 year using a battery of clinical ratings and measures of cortisol. A group of normal, healthy control subjects were similarly evaluated at baseline. At 1-year follow-up, PMD patients did not differ from NPMD patients in their Hamilton Depression Rating Scale (HDRS) and Brief Psychiatric Rating Scale scores (BPRS), but PMD patients demonstrated significantly poorer social and occupational functioning. Significant correlations were observed (n = 18) between higher levels of urinary and plasma cortisol at 1 year and poorer social and occupational functioning at 1 year, independent of the degree of residual depression. In contrast, baseline measures of urinary and plasma cortisol did not predict social and occupational functioning at 1 year.