Successful methylphenidate treatment of apathy after subcortical infarcts

Post-Stroke Neuropsychiatric Complications: Types, Pathogenesis, and Therapeutic Intervention

Almost all stroke survivors suffer physical disabilities and neuropsychiatric disturbances, which can be briefly divided into post-stroke neurological diseases and post-stroke psychiatric disorders. The former type mainly includes post-stroke pain, post-stroke epilepsy, and post-stroke dementia while the latter one includes post-stroke depression, post-stroke anxiety, post-stroke apathy and post-stroke fatigue. Multiple risk factors are related to these post-stroke neuropsychiatric complications, such as age, gender, lifestyle, stroke type, medication, lesion location, and comorbidities. Recent studies have revealed several critical mechanisms underlying these complications, namely inflammatory response, dysregulation of the hypothalamic pituitary adrenal axis, cholinergic dysfunction, reduced level of 5-hydroxytryptamine, glutamate-mediated excitotoxicity and mitochondrial dysfunction. Moreover, clinical efforts have successfully given birth to many practical pharmaceutic strategies, such as anti-inflammatory medications, acetylcholinesterase inhibitors, and selective serotonin reuptake inhibitors, as well as diverse rehabilitative modalities to help patients physically and mentally. However, the efficacy of these interventions is still under debate. Further investigations into these post-stroke neuropsychiatric complications, from both basic and clinical perspectives, are urgent for the development of effective treatment strategies.

Neuroanatomical Abnormalities in Older Depressed Adults With Apathy: A Systematic Review

OBJECTIVE

Apathy is a common phenomenon in late-life depression and is associated with poor outcomes. Apathy is often unrecognized in older depressed adults, and efficacious treatment options are lacking. This review provides a systematic review of the neuroanatomical abnormalities associated with apathy in late-life depression. In addition, the review summarizes the neuroimaging findings from studies of neurodegenerative and focal brain injury conditions that frequently present with apathy. The goal is to elucidate cerebral network abnormalities that give rise to apathy in older adults with mood disturbances and to inform future treatment targets.

METHOD

Systematic literature review.

RESULTS

The few studies that have directly examined the neuroanatomical abnormalities of apathy in late-life depression suggest disturbances in the anterior cingulate cortex, insula, orbital and dorsal prefrontal cortex, striatum, and limbic structures (ie, amygdala, thalamus, and hippocampus). Studies examining the neuroanatomical correlates of apathy in other aging populations are consistent with the pattern observed in late-life depression.

CONCLUSIONS

Apathy in late-life depression appears to be accompanied by neuroanatomical abnormalities in the salience and reward networks. These network findings are consistent with that observed in individuals presenting with apathy in other aging-related conditions. These findings may inform future treatments that target apathy.

On the pathophysiology and treatment of akinetic mutism

Akinetic mutism (AM) is a rare neurological disorder characterized by the presence of an intact level of consciousness and sensorimotor capacity, but with a simultaneous decrease in goal-directed behavior and emotions. Patients are in a wakeful state of profound apathy, seemingly indifferent to pain, thirst, or hunger. It represents the far end within the spectrum of disorders of diminished motivation. In recent years, more has become known about the functional roles of neurocircuits and neurotransmitters associated with human motivational behavior. More specific, there is an increasing body of behavioral evidence that links specific damage of functional frontal-subcortical organization to the occurrence of distinct neurological deficits. In this review, we combine evidence from lesion studies and neurophysiological evidence in animals, imaging studies in humans, and clinical investigations in patients with AM to form an integrative theory of its pathophysiology. Moreover, the specific pharmacological interventions that have been used to treat AM and their rationales are reviewed, providing a comprehensive overview for use in clinical practice.

Involvement of the reward network is associated with apathy in cerebral small vessel disease

INTRODUCTION

Apathy is a common yet under-recognised feature of cerebral small vessel disease (SVD), but its underlying neurobiological basis is not yet understood. We hypothesized that damage to the reward network is associated with an increase of apathy in patients with SVD.

METHODS

In 114 participants with symptomatic SVD, defined as a magnetic resonance imaging confirmed lacunar stroke and confluent white matter hyperintensities, we used diffusion tensor imaging tractography to derive structural brain networks and graph theory to determine network efficiency. We determined which parts of the network correlated with apathy symptoms. We tested whether apathy was selectively associated with involvement of the reward network, compared with two "control networks" (visual and motor).

RESULTS

Apathy symptoms negatively correlated with connectivity in network clusters encompassing numerous areas of the brain. Network efficiencies within the reward network correlated negatively with apathy scores; (r = - 0.344, p < 0.001), and remained significantly correlated after co-varying for the two control networks. Of the three networks tested, only variability in the reward network independently explained variance in apathetic symptoms, whereas this was not observed for the motor or visual networks.

LIMITATIONS

The analysis refers only to cerebrum and not cerebellum. The apathy measure is derivative of depression measure.

DISCUSSION

Our results suggest that reduced neural efficiency, particularly in the reward network, is associated with increased apathy in patients with SVD. Treatments which improve connectivity in this network may improve apathy in SVD, which in turn may improve psychiatric outcome after stroke.

Neural Correlates for Apathy: Frontal-Prefrontal and Parietal Cortical- Subcortical Circuits

Apathy is an uncertain nosographical entity, which includes reduced motivation, abulia, decreased empathy, and lack of emotional involvement; it is an important and heavy-burden clinical condition which strongly impacts in everyday life events, affects the common daily living abilities, reduced the inner goal directed behavior, and gives the heaviest burden on caregivers. Is a quite common comorbidity of many neurological disease, However, there is no definite consensus on the role of apathy in clinical practice, no definite data on anatomical circuits involved in its development, and no definite instrument to detect it at bedside. As a general observation, the occurrence of apathy is connected to damage of prefrontal cortex (PFC) and basal ganglia; “emotional affective” apathy may be related to the orbitomedial PFC and ventral striatum; “cognitive apathy” may be associated with dysfunction of lateral PFC and dorsal caudate nuclei; deficit of “autoactivation” may be due to bilateral lesions of the internal portion of globus pallidus, bilateral paramedian thalamic lesions, or the dorsomedial portion of PFC. On the other hand, apathy severity has been connected to neurofibrillary tangles density in the anterior cingulate gyrus and to gray matter atrophy in the anterior cingulate (ACC) and in the left medial frontal cortex, confirmed by functional imaging studies. These neural networks are linked to projects, judjing and planning, execution and selection common actions, and through the basolateral amygdala and nucleus accumbens projects to the frontostriatal and to the dorsolateral prefrontal cortex. Therefore, an alteration of these circuitry caused a lack of insight, a reduction of decision-making strategies, and a reduced speedness in action decision, major responsible for apathy. Emergent role concerns also the parietal cortex, with its direct action motivation control. We will discuss the importance of these circuits in different pathologies, degenerative or vascular, acute or chronic.

Prevention of poststroke apathy using escitalopram or problem-solving therapy

OBJECTIVE

Apathy occurs frequently following stroke and prior studies have demonstrated the negative effect of apathy on recovery from stroke. This study was a secondary analysis examining the efficacy of escitalopram, problem-solving therapy (PST), or placebo administered for 1 year to prevent the onset of apathy among patients with recent stroke.

METHODS

Patients within 3 months of an index stroke who did not meet DSM-IV diagnostic criteria for major or minor depression and who did not have a serious comorbid physical illness were enrolled. Patients were recruited from three sites: University of Iowa, University of Chicago, and Burke Rehabilitation Hospital. One hundred fifty-four patients without evidence of apathy at initial evaluation were included in the randomized controlled trial using escitalopram (10 mg patients ≤65 years; 5 mg patients >65 years) (N = 51) or placebo (N = 47) or non-blinded PST (12 total sessions) (N = 56) over 1 year. At 3, 6, 9, and 12 months, patients were assessed for diagnosis and severity of apathy using the Apathy Scale.

RESULTS

Using a Cox proportional hazards model of time to onset of apathy, participants given placebo were 3.47 times more likely to develop apathy than patients given escitalopram and 1.84 times more likely to develop apathy than patients given PST after controlling for age, sex, cognitive impairment, and diabetes mellitus status (adjusted hazard ratio: 3.47, 95% CI: 1.79-6.73 [escitalopram group]; adjusted hazard ratio: 1.84, 95% CI: 1.21-2.80 [PST group]).

CONCLUSION

Escitalopram or PST was significantly more effective in preventing new onset of apathy following stroke compared with placebo.

The human frontal lobes and frontal network systems: an evolutionary, clinical, and treatment perspective

Frontal lobe syndromes, better termed as frontal network systems, are relatively unique in that they may manifest from almost any brain region, due to their widespread connectivity. The understandings of the manifold expressions seen clinically are helped by considering evolutionary origins, the contribution of the state-dependent ascending monoaminergic neurotransmitter systems, and cerebral connectivity. Hence, the so-called networktopathies may be a better term for the syndromes encountered clinically. An increasing array of metric tests are becoming available that complement that long standing history of qualitative bedside assessments pioneered by Alexander Luria, for example. An understanding of the vast panoply of frontal systems' syndromes has been pivotal in understanding and diagnosing the most common dementia syndrome under the age of 60, for example, frontotemporal lobe degeneration. New treatment options are also progressively becoming available, with recent evidence of dopaminergic augmentation, for example, being helpful in traumatic brain injury. The latter include not only psychopharmacological options but also device-based therapies including mirror visual feedback therapy.

Apathy symptoms modulate motivational decision making on the Iowa gambling task

Background

The present study represents an initial attempt to assess the role of apathy in motivated decision making on the Iowa Gambling Task. Clinical descriptions of patients with apathy highlight deficits in the cognitive, emotional and behavioural aspects of goal directed activity, yet standard neurocognitive tests of these measures fail to demonstrate reliable sensitivity to the disorder. Available research suggests the Iowa Gambling Task is a robust test of complex emotional socio-executive processes involved in motivational decision making, which can analogue real-world goal-directed behaviour.

Methods

We ask whether performance on the Iowa Gambling Task can distinguish brain damaged patients with apathy symptoms from 1) brain damaged patients without apathy and 2) neurologically intact controls. Overall, 22 healthy adults and 29 brain damaged patients took part in this study.

Results

Brain damaged patients with apathy were distinctively impaired on the Iowa Gambling Task compared to both non-apathetic brain damaged patients and neurologically intact healthy controls. On the other hand, standard measures for the cognitive control of behaviour failed to show this sensitivity.

Conclusions

Our results demonstrated that the Iowa Gambling Task is sensitive to the presence of apathy symptoms. We discuss these findings in terms of neurocognition deficits in apathy and the related implications for rehabilitation and clinical intervention.

Attention-deficit/hyperactivity disorder in older adults: prevalence and possible connections to mild cognitive impairment

Attentional deficits are frequently seen in isolation as the presenting sign and symptom of neurodegenerative disease, manifest as mild cognitive impairment (MCI). Persistent ADHD in the geriatric population could well be misconstrued as MCI, leading to the incorrect assumption that such persons are succumbing to a neurodegenerative disease process. Alternatively, the molecular, neuroanatomic, or neurochemical abnormalities seen in ADHD may contribute to the development of de novo late life neurodegenerative disease. The present review examines the issue of causality vs confound regarding the association of ADHD with MCI, suggesting that both are tenable hypotheses.

Mood and motor trajectories in Parkinson's disease: multivariate latent growth curve modeling

OBJECTIVE

Apathy is a common feature of Parkinson's disease (PD) that can manifest independently of depression, but little is known about its natural progression in medically managed patients. The present study sought to characterize and compare trajectories of apathy, depression, and motor symptoms in PD over 18 months.

METHOD

Data from a sample of 186 PD patients (mean disease duration of 8.2 years) followed by the University of Florida Movement Disorders Center were obtained from a clinical research database. Scores on the Unified Parkinson's disease Rating Scale (motor portion), Apathy Scale, and Beck Depression Inventory at three time-points (baseline, 6 months, 18 months) were analyzed in a structural equation modeling framework.

RESULTS

A multivariate growth model controlling for age, sex, education, and disease duration identified linear worsening of both apathy (slope estimate = 0.73; p < .001) and motor symptoms (slope estimate = 1.51; p < .001), and quadratic changes in depression (slope estimate = 1.18; p = .07). All symptoms were positively correlated. Higher education was associated with lower apathy, depression, and motor severity. Advanced age was associated with greater motor and apathy severity. Female sex and longer disease duration were associated with attenuated motor worsening. Antidepressant use was associated only with depression scores.

CONCLUSIONS

These longitudinal results support the differentiation of apathy and depression in PD. Like motor progression, apathy progression may be linked at least partially to dopaminergic neurodegeneration. Empirically supported treatments for apathy in PD are needed.

Apathy following stroke

OBJECTIVE

We will review the available evidence on the frequency, clinical correlates, mechanism, and treatment of apathy following stroke.

METHODS

We have explored relevant databases (that is, PubMed, MEDLINE, and PsycINFO) using the following key words and their combinations: apathy, motivation, abulia, stroke, cerebrovascular disease, basal ganglia, prefrontal cortex, anterior cerebral infarction, and thalamus.

RESULTS

The frequency of apathy following stroke has been consistently estimated between 20% and 25%. It appears to be associated with the presence of cognitive impairment, a chronic course characterized by progressive functional decline, and with disruption of neural networks connecting the anterior cingulate gyrus, the dorsomedial frontal cortex, and the frontal pole with the ventral aspects of the caudate nucleus, the anterior and ventral globus pallidus, and the dorsomedian and intralaminar thalamic nuclei. Published treatment studies have been mostly limited to anecdotal case reports, generally using dopamine agonists or stimulant medications. Cholinesterase inhibitors and nefiracetam may significantly reduce apathetic symptoms. However, their efficacy was examined in relatively small clinical trials that require replication.

CONCLUSION

Apathy is a frequent neuropsychiatric complication of stroke that, although often associated with depression and cognitive impairment, may occur independently of both. Its presence has been consistently associated with greater functional decline. However, there is no conclusive evidence about which is the best treatment for this condition.

Neurobiology of apathy in Alzheimer's disease

Apathy is considered the most frequent neuropsychiatric disturbance in dementia and its outcome is generally deleterious. Apathy can be related to a dysfunction of the anatomical-system that supports the generation of voluntary actions, namely the prefrontal cortex and/or the prefrontal-subcortical circuits. In Alzheimer's disease, pathological and neuroimaging data indicate that apathy is likely due to a dysfunction of the medial prefrontal cortex. Accordingly, in this review article, we propose a pathophysiological model to explain apathetic behavior in Alzheimer's disease, combining data from neuroimaging, neuropathology and experimental research on the role of orbito-frontal cortex, anterior cingulate cortex, basal ganglia and dopamine in decision-making neurobiology.

Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults

BACKGROUND

Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive evidence to support its use.

OBJECTIVE

The aim of this paper was to review the efficacy and tolerability of methylphenidate in the treatment of depressive symptoms, fatigue, and apathy in medically ill older adults and adults receiving palliative care.

METHODS

English-language articles presenting systematic reviews, clinical trials, or case series describing the use of methylphenidate for the treatment of depressive symptoms, fatigue, or apathy in medically ill older adults or adults receiving palliative care were identified. The key words methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, fatigue, or apathy in (1) older adults (generally, age > or =65 years), particularly those with comorbid medical illness; (2) adults receiving palliative care; and (3) adults with other chronic illnesses. I excluded articles regarding treatment of depression in healthy young adults; bipolar disorder and attention-deficit/hyperactivity disorder; and narcolepsy, chronic fatigue syndrome, and related disorders.

RESULTS

A total of 19 controlled trials of methylphenidate in medically ill older adults or patients in palliative care were identified. Unfortunately, their conflicting results, small sample sizes, and poor methodologic quality limited the ability to draw inferences regarding the efficacy of methylphenidate, although evidence of tolerability was stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, and apathy in various medically ill populations.

CONCLUSION

In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.

Depression, disability and intermediate pathways: a review of longitudinal studies in elders

Cross-sectional studies demonstrate depression is associated with disability in elders. These studies also report that disability in depressed elders is associated with greater medical illness burden, cognitive impairment, and behavioral changes. Only longitudinal studies, however, can determine the impact of depression and its comorbidities on functional decline. This review summarizes the findings of 20 longitudinal studies examining the relationship between baseline or incident depression and functional decline. However, the mediational effects of potential risk factors identified by cross-sectional studies cannot be derived from the current literature. We propose a mediational effects model for future longitudinal studies, incorporating measures sensitive to both mood symptoms and the medical, cognitive, and behavioral comorbidities of depression to better understand the impact of each on functional decline and to focus future clinical interventions.

Methylphenidate for the treatment of apathy in Alzheimer disease: prediction of response using dextroamphetamine challenge

Apathy is a common behavioral symptom of Alzheimer's disease (AD), being present in up to 70% of patients. Apathy in AD and non-AD populations has been associated with dysfunction in the dopaminergic brain reward system, suggesting that pharmacotherapeutic targeting of this system may be an effective treatment for apathy in AD. We therefore performed a randomized, double-blind, placebo-controlled crossover trial of methylphenidate in a sample of 13 apathetic AD patients (6 men, 7 women; age mean 77.9 years [SD, 7.8 years]; Mini Mental Status Examination score, 19.9 [SD, 4.7]). Patients were treated with methylphenidate (10 mg PO twice a day) or an identical placebo in two 2-week phases separated by a 1-week placebo washout. All patients participated in a dextroamphetamine challenge test (one 10-mg oral dose) before treatment with methylphenidate to gauge the functional integrity of the dopamine brain reward system. Overall, patients demonstrated greater improvement with methylphenidate compared with placebo according to Apathy Evaluation Scale total change scores (end of treatment - baseline: Wilcoxon Z = -2.00; P = 0.047). However, a significantly greater proportion of patients experienced at least 1 adverse event with methylphenidate compared with placebo (3 vs 1; chi = 4.33, P = 0.038). Two patients experienced serious adverse events with methylphenidate, consisting of delusions, agitation, anger, irritability, and insomnia, which resolved upon discontinuation of the medication. Response to methylphenidate was associated with increases in inattention on a continuous performance task after dextroamphetamine challenge. Psychostimulants may be effective in treating features of apathy in AD, and dopaminergic changes may predict response.

Frontal-subcortical circuitry and behavior

The neuropsychiatric manifestations of neurodegenerative diseases are closely linked to neurocircuitry defects. Frontal-subcortical circuits, in particular, are effector mechanisms that allow the organism to act on its environment In this paper, we present the three main frontal-subcortical circuits: the dorsolateral prefrontal circuit allows the organization of information to facilitate a response; the anterior cingulate circuit is required for motivated behavior; and the orbitofrontal circuit allows the integration of limbic and emotional information into behavioral responses. Impaired executive functions, apathy, and impulsivity are hallmarks of frontal-subcortical circuit dysfunction. A variety of other neuropsychiatrie disorders, such as Tourette's syndrome, Huntington's disease, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, schizophrenia, and mood disorders may result from disturbances that have a direct or indirect impact on the integrity or functioning of these loops.

Neuroimaging of white matter in aging and dementia

Clinical neuroscientists have focused increasing attention on white matter connections in the brain and on the effects of aging and disease on these connections. Recent advances in magnetic resonance imaging (MRI) analysis have given researchers new tools for quantifying and visualizing white matter to better relate white matter structure and function. The goals of this article are (a) to acquaint the reader with both established and newer methods for imaging and quantifying white matter anatomy and pathology; and (b) to review recent findings on white matter pathology in aging and dementia. Computer-assisted quantification appears to offer better statistical power than visual rating scales for detecting these relationships. New MR modalities such as diffusion imaging can detect white matter abnormalities not shown with conventional acquisition sequences. These newer techniques hold promise for early detection of disease and for delineating functional connections between brain areas.

Epidemiology and Management of Apathy in Patients with Alzheimer??s Disease

Although apathy is a diagnostic term used with increasing frequency in both neurology and psychiatry, confusion still exists as to its proper definition and assessment, and whether apathy should be considered a symptom of major psychiatric diseases or an independent syndrome in its own right. Moreover, critical questions regarding the phenomenology and clinical correlates of apathy and the syndromic validity of this construct still exist. Despite these nosological concerns, there is strong evidence that apathy is a common finding in Alzheimer's disease (AD). However, the treatment of apathy is still elusive. Current data are obtained from randomised controlled trials that did not investigate apathy per se, but rather a number of other behavioural and psychological variables. In this context, acetylcholinesterase inhibitors and psychosocial interventions are the only available modalities for treating apathy in AD with some efficacy.

Treatment of psychiatric syndromes due to cerebrovascular disease

Neuropsychiatric syndromes are common in the setting of cerebrovascular disease. The most frequent psychiatric syndrome after stroke is depression. Emotionalism and apathy after stroke are also frequent and under-detected symptoms. Treatment principles are broadly similar to those currently used to treat non-organically ill patients. The evidence for pharmacological and psychological treatment for depression after stroke is scant, and of variable quality. Currently there is evidence of efficacy for both tricyclic antidepressants and SSRIs in the management of depression but the latter are better tolerated. Randomized controlled trials of antidepressants for post-stroke emotionalism are positive and this is encouraging. The current evidence base for psychological interventions either as first line or augmentative strategies is too limited and inconclusive to permit definite recommendations. Future studies might include multi-modal interventions using the principles of active case management and pharmacological studies which target both specific neuropsychiatric symptoms and underlying cerebrovascular disorder.

Chemotherapy and Cognition: Effects, Potential Mechanisms, and Management

The development of novel chemotherapeutic agents and advances in treatment technique have improved survival for patients diagnosed with some forms of cancer, but treatments are not always site specific and may place normal tissues at risk. The central nervous system (CNS) is susceptible to treatment effects and complaints of memory loss and generalized cognitive decline are common among cancer patients. Despite the frequency of subjective patient complaints, studies evaluating the cognitive abilities of patients have inconsistently reported chemotherapy-related declines. On careful review of the literature, discrepant findings across studies (some documenting chemotherapy-related cognitive declines and others failing to detect such changes) may be attributed to differences in methodology. Most studies have been retrospective in design, omit pretreatment assessment of function, use small or heterogeneous samples, use inappropriate measures to assess cognition, and fail to incorporate control subjects. Though rare to date, prospective, randomized, longitudinal studies that incorporate pretreatment comprehensive neuropsychological assessment are necessary to define the severity and pattern of treatment-related change. Building on a foundation of solid science, future studies may identify subgroups of patients susceptible to significant chemotherapy-related cognitive decline. Once these groups are identified and the mechanisms underlying the decline are elucidated, attention may be turned to the development of treatments that may optimize cognitive function and improve patient quality of life.

Methylphenidate may treat apathy independent of depression

OBJECTIVE

To report a case of apathy treated with methylphenidate in which improvement in apathy was independent of improvement of depression.

CASE SUMMARY

A 47-year-old woman with a 20-year history of recurrent major depression was diagnosed as having significant apathy with lack of initiative and motivation. Over the course of a 4-week treatment regimen with methylphenidate, her apathy, as measured by the Apathy Evaluation Scale, improved, with her score decreasing from 57 to 31. During this period, her depression, as assessed by the 21-item Hamilton Rating Scale for Depression, remained unchanged.

DISCUSSION

Our report of improvement of apathy with methylphenidate is consistent with other reports in the literature, although previous studies have not specifically used the rating scales to assess apathy. Even though this patient had experienced apathy for a long time, it had not been detected due to lack of direct questioning. In this case, as noted, the improvement of apathy was independent of improvement in depression.

CONCLUSIONS

A high degree of suspicion and specific inquiry is required for identification of apathy. Once detected, methylphenidate may be beneficial in its treatment, a strategy that may work independently of augmentation of antidepressants.

Selegiline in the management of apathy following traumatic brain injury

PRIMARY OBJECTIVE

To provide a brief review of apathy following traumatic brain injury (TBI) and describe the use of selegiline in a group of patients with this symptom.

MAIN OUTCOME

Four patients are described who showed improvement in Apathy Evaluation Scale scores and functional improvement, following the use of selegiline. In each case, selegiline was well tolerated whereas methylphenidate was not.

CONCLUSIONS

Selegiline shows potential for the management of apathy following TBI. This provides further evidence that impaired dopaminergic processes are prominent in the genesis of these symptoms. However, these findings require confirmation in controlled studies.

Apathy in schizophrenia: clinical correlates and association with functional outcome

Apathy is considered one of the negative symptoms of schizophrenia, but its natural history and relationship to other clinical characteristics have not been systematically studied. The purpose of this cross-sectional study was to measure the level of apathy in schizophrenia and its relation to other symptoms and functional outcome. Twenty-eight patients with schizophrenia, and receiving antipsychotic treatment, were assessed with the Apathy Evaluation Scale (AES). The mean level of apathy of patients with schizophrenia, as rated by the AES, was significantly higher than that of matched healthy control subjects. In the patients, apathy was not significantly correlated with positive symptoms or depressive symptoms. It was significantly correlated with the item "emotional withdrawal" on the negative subscale of the Positive and Negative Syndrome Scale (PANSS), but was not correlated with the overall negative subscale score. Apathy was more highly associated with functional outcome than were other symptom measures, and it was independently associated with functional outcome above and beyond other negative symptoms. It was not associated with observed interest in playing a video game or performance on a simulated clerical task.

Apathy and cognitive performance in older adults with depression

OBJECTIVES

Recent studies have linked apathy to frontal lobe dysfunction in persons with dementia, but few studies have explored this relationship in older, depressed persons without dementia. We examined the association between apathy and cognitive function in a group of older persons with major depression using standardized neuropsychological tests. We hypothesized that presence of apathy in depression is associated with poorer frontal executive performance.

METHODS

We analyzed data from 89 older adults with major depression. We defined apathy using four items from the Hamilton Psychiatric Rating Scale for Depression which reflect the clinical state of apathy, including 'diminished work/interest,' 'psychomotor retardation,' 'anergy' and 'lack of insight.'

RESULTS

Apathy most strongly correlated with two verbal executive measures (Stroop C and FAS), a nonverbal executive measure (Wisconsin Card Sorting Test-Other Responses), and a measure of information processing speed (Stroop B). Apathy was not associated with age, sex, education, medical illness burden, Mini-Mental State Examination score and Full Scale IQ score. Stepwise regression analyses of significant cognitive tests showed that apathy alone or apathy plus depression severity, age, or education accounted for a significant amount of the variance.

CONCLUSIONS

The results of this study provide support for an apathy syndrome associated with poorer executive function in older adults with major depression.

Electrodermal Responsiveness and Negative Symptoms in Brain Injured Patients

Abstract Electrodermal non-responsiveness has been associated with negative symptoms, especially among schizophrenic patients. The aim of this study was to examine how electrodermal non-response, defined as failure to elicit a skin conductance orienting response to a neutral auditory stimulus, was related to negative symptoms in patients with acquired brain injury. Sixty-four brain injured patients were assessed for apathy, lack of initiative, and emotional indifference. We found that EDA non-responders displayed significantly higher scores on rating scales used to assess apathy and related negative symptoms compared to EDA responders. No such differences were found regarding depressed mood/emotional distress or vegetative symptoms of depression. This difference could not be attributed to neurological etiology nor to localization of lesion. These findings, resembling psychophysiological findings in schizophrenia, indicate that EDA non-response is associated with apathy and related negative symptoms also in brain injured patients. This may also enable a better differentiation between negative symptoms of organic origin and emotional changes related to psychogenic factors after acquired brain damage.