Sex difference in cerebrospinal fluid/blood albumin quotients in patients with schizophreniform and affective psychosis

BACKGROUND

The importance of cerebrospinal fluid (CSF) diagnostics for psychiatry is growing. The CSF/blood albumin quotient (QAlb) is considered to be a measure of the blood-CSF barrier function. Recently, systematically higher QAlb in males than in females was described in neurological patients. The aim of this study was to investigate whether a sex difference could also be detected in a well-characterized psychiatric cohort.

METHODS

The patient cohort comprised 989 patients, including 545 females and 444 males with schizophreniform and affective syndromes who underwent CSF diagnostics, including QAlb measurement. The basic CSF findings and antineuronal autoantibody data of this cohort have already been published. This re-analysis employed analysis of covariance with age correction for QAlb mean values and chi2-testing for the number of increased age-corrected QAlb levels to investigate sex differences in QAlb.

RESULTS

The QAlb levels were elevated above reference levels by 18% across all patients, and a comparison between male and female patients revealed a statistically significant sex difference, with increased values in 26% of male patients and a corresponding rate of only 10% in female patients (chi2 = 42.625, p < 0.001). The mean QAlb values were also significantly higher in males (6.52 ± 3.69 × 10-3) than in females (5.23 ± 2.56 × 10-3; F = 52.837, p < 0.001).

DISCUSSION

The main finding of this study was a significantly higher QAlb level in male compared to female patients with psychiatric disorders, complementing previously described sex differences in neurological patient cohorts. This result indicates bias from some general factors associated with sex and could be partly explained by sex differences in body height, which is associated with spine length and thus a longer distance for CSF flow within the subarachnoid space down the spine from the occipital area to the lumbar puncture site in males compared to females. Hormonal influences caused by different estrogen levels and other sex-specific factors could also play a relevant role. The significance of the study is limited by its retrospective design, absence of a healthy control group, and unavailability of exact measures of spine length.

A miRNome analysis of drug-free manic psychotic bipolar patients versus healthy controls

The lifetime presence of psychotic symptoms is associated with more clinical severity, poorer outcome and biological changes in patients affected by bipolar disorder (BD). Epigenetic mechanisms have been evoked to explain the onset of psychotic symptoms in BD as well as the associated biological changes. The main objective of the present study was to evaluate the expression profiles of circulating microRNAs (miRNAs) in drug-free manic psychotic bipolar patients versus healthy controls (HC), to identify possible non-invasive molecular markers of the disorder. 15 drug-free manic psychotic bipolar patients and 9 HC were enrolled and 800 miRNAs expression profile was measured by Nanostring nCounter technology on plasma samples and validated through qPCR. Overall, twelve miRNAs showed a significantly altered expression between the two groups (p < 0.05). Functional annotation of predicted miRNAs targets by MultiMIR R tool showed repression in bipolar patients of genes with a role in neurodevelopment and neurogenesis, and upregulation of genes involved in metabolism regulation. We identified a signature of circulating miRNA characteristic of manic psychotic bipolar patients, suggesting a possible role in neurodevelopment and metabolic processes regulation.

Peroxisome proliferator-activated receptor gamma co-activator-1 alpha in depression and the response to electroconvulsive therapy

BACKGROUND

The transcriptional coactivator peroxisome proliferator-activated receptor-γ coactivator (PGC-1α), termed the 'master regulator of mitochondrial biogenesis', has been implicated in stress and resilience to stress-induced depressive-like behaviours in animal models. However, there has been no study conducted to date to examine PGC-1α levels in patients with depression or in response to antidepressant treatment. Our aim was to assess PGC-1α mRNA levels in blood from healthy controls and patients with depression pre-/post-electroconvulsive therapy (ECT), and to examine the relationship between blood PGC-1α mRNA levels and clinical symptoms and outcomes with ECT.

METHODS

Whole blood PGC-1α mRNA levels were analysed in samples from 67 patients with a major depressive episode and 70 healthy controls, and in patient samples following a course of ECT using quantitative real-time polymerase chain reaction (qRT-PCR). Exploratory subgroup correlational analyses were carried out to determine the relationship between PGC-1α and mood scores.

RESULTS

PGC-1α levels were lower in patients with depression compared with healthy controls (p = 0.03). This lower level was predominantly accounted for by patients with psychotic unipolar depression (p = 0.004). ECT did not alter PGC-1α levels in the depressed group as a whole, though exploratory analyses revealed a significant increase in PGC-1α in patients with psychotic unipolar depression post-ECT (p = 0.045). We found no relationship between PGC-1α mRNA levels and depression severity or the clinical response to ECT.

CONCLUSIONS

PGC-1α may represent a novel therapeutic target for the treatment of depression, and be a common link between various pathophysiological processes implicated in depression.

Reduced levels of vasopressin and reduced behavioral modulation of oxytocin in psychotic disorders

Oxytocin (OT) and arginine vasopressin (AVP) exert robust influence on social affiliation and specific cognitive processes in healthy individuals. Abnormalities in these neuroendocrine systems have been observed in psychotic disorders, but their relation to impairments in behavioral domains that these endocrines modulate is not well understood. We compared abnormalities of OT and AVP serum concentrations in probands with schizophrenia (n = 57), schizoaffective disorder (n = 34), and psychotic bipolar disorder (n = 75); their first-degree relatives without a history of psychosis (n = 61, 43, 91, respectively); and healthy controls (n = 66) and examined their association with emotion processing and cognition. AVP levels were lower in schizophrenia (P = .002) and bipolar probands (P = .03) and in relatives of schizophrenia probands (P = .002) compared with controls. OT levels did not differ between groups. Familiality estimates were robust for OT (h(2) = 0.79, P = 3.97e-15) and AVP (h(2) = 0.78, P = 3.93e-11). Higher levels of OT were associated with better emotion recognition (β = 0.40, P < .001) and general neuropsychological function (β = 0.26, P = .04) in healthy controls as expected but not in any proband or relative group. In schizophrenia, higher OT levels were related to greater positive symptom severity. The dissociation of OT levels and behavioral function in all proband and relative groups suggests that risk and illness factors associated with psychotic disorders are not related to reduced OT levels but to a disruption in the ability of physiological levels of OT to modulate social cognition and neuropsychological function. Decreased AVP levels may be a marker of biological vulnerability in schizophrenia because alterations were seen in probands and relatives, and familiality was high.

Measures of glycemic variability and links with psychological functioning

The goal of this article is to review the recent literature on measures of glycemic variability, links between glycemic variability and psychological functioning, and methods for examining these links. A number of commonly used measures of glycemic variability are reviewed and compared, including recently proposed methods. Frequently used measures of glycemic variability are also discussed in the context of research that uses continuous glucose monitoring for the collection of blood glucose data. The results of previous studies that have examined the link between psychological functioning and glycemic variability within relatively short-term time frames are reviewed. Methods for examining glycemic variability and its link with psychological functioning are discussed so that important research questions can be addressed to aid in understanding the effect of changes in psychological functioning on glycemic variability and vice versa in future research.

Hyperprolactinaemia - a risperidone side-effect

A 47 year old patient has been treated for psychotic depression for the last 5 years. The illness began manifesting through the symptoms of depressive thoughts, intrapsychic tension, projectivity, derealisation phenomena and pre-psychotic fears. She was treated with a combination of antidepressives, anxiolitics and hypnotics in ambulatory conditions. The therapy applied did not obtain the effects expected due to which an atypical antipsychotic was administered subsequently - risperidone, a 2 mg dose in the evening. After commencing the antipsychotic treatment, the symptoms started to weaken and a steady remission was obtained. Two years after a regular risperidone administration (in combination with fluoxetine, alprazolam and flurazepam) the patient reported some "bleeding" in October 2006. Hormonal blood tests were performed and high prolactin values were registered (2567.0 mIJ/L),due to which a gradual risperidone retractement was indicated. Medicamentous hyperprolactinaemia is a well known side effect of risperidone. A gradual risperidone retractement lead to a lowered and normal prolactin level within a month.

Decreased plasma BDNF level in depressive patients

BACKGROUND

Recent reports have suggested a pathophysiological role for brain-derived neurotrophic factor (BDNF) in major depressive disorder (MDD). We evaluated plasma levels of BDNF in patients with MDD.

METHODS

Plasma BDNF levels were measured in 77 MDD patients and 95 normal controls. The severity of psychiatric symptoms was measured with the Hamilton Depression Rating Scale and the Brief Psychiatric Rating Scale.

RESULTS

Plasma BDNF levels were significantly lower in MDD patients than in normal control subjects (p<0.001). Plasma BDNF levels were significantly lower in MDD patients with recurrent episodes than in MDD patients with the first episode or normal controls (p<0.001). Plasma BDNF levels were significantly lower in non-psychotic MDD patients than in psychotic MDD patients or normal controls (p<0.001). Plasma BDNF in suicidal MDD patients were significantly lower than those in non-suicidal MDD patients (p<0.001).

LIMITATIONS

We measured only plasma levels of BDNF. However, the cellular sources of BDNF in human plasma are not yet clearly defined.

CONCLUSIONS

Our study suggests that there is a decrease in plasma BDNF levels in untreated MDD patients. However, relapsed or recurrent episodes, suicidal behavior, and psychotic features could also affect the plasma levels of BDNF. Further studies are required to understand the source and role of the circulating BDNF in depression.

Hyperlipidemia following treatment with antipsychotic medications

OBJECTIVE

This study attempted to estimate the relative risk of developing hyperlipidemia after treatment with antipsychotics in relation to no antipsychotic treatment.

METHOD

A matched case-control analysis was performed with pharmacy and claims data from California Medicaid (Medi-Cal). Patients were excluded if they were treated for medical disorders or prescribed medications known to increase their risk of hyperlipidemia. Cases were ages 18 to 64 years with schizophrenia, major depression, bipolar disorder, or other affective psychoses and incident hyperlipidemia. Cases were matched to up to six control subjects by age, sex, race, and psychiatric diagnosis. Both groups were prescribed either no antipsychotic medication or had two or more prescriptions for one and only one antipsychotic medication during the 60 days prior to the first indication of hyperlipidemia (cases) or matched index date (controls) in the billing record. Conditional logistic regressions were used to derive odds ratios and 95% confidence intervals (95% CIs) of each antipsychotic medication in relation to no antipsychotic medication.

RESULTS

A total of 13,133 incident cases of hyperlipidemia were matched to 72,140 control subjects. As compared with no antipsychotic medication, treatment with clozapine (odds ratio: 1.82, 95% CI: 1.61-2.05), risperidone (odds ratio: 1.53, 95% CI: 1.43-1.64), quetiapine (odds ratio: 1.52, 95% CI: 1.40-1.65), olanzapine (odds ratio: 1.56, 95% CI: 1.47-1.67), ziprasidone (odds ratio: 1.40, 95% CI: 1.19-1.65), and first-generation antipsychotics (odds ratio: 1.26, 95% CI: 1.14-1.39), but not aripiprazole (odds ratio: 1.19, 95% CI: 0.94-1.52) was associated with a significant increase in risk of incident hyperlipidemia.

CONCLUSIONS

These findings suggest that most commonly prescribed antipsychotic medications increase the risk of developing hyperlipidemia in patients with schizophrenia or mood disorders.

Cortisol hypersecretion in unipolar major depression with melancholic and psychotic features: dopaminergic, noradrenergic and thyroid correlates

Evidence supports that hyperactivity of the hypothalamic-pituitary-adrenal axis has a pivotal role in the psychobiology of severe depression. The present study aimed at assessing hypothalamic-pituitary dopaminergic, noradrenergic, and thyroid activity in unipolar depressed patients with melancholic and psychotic features and with concomitant hypercortisolemia. Hormonal responses to dexamethasone, apomorphine (a dopamine receptor agonist), clonidine (an alpha 2-adrenoreceptor agonist) and 0800 and 2300 h protirelin (TRH) were measured in 18 drug-free inpatients with a DSM-IV diagnosis of severe major depressive disorder with melancholic and psychotic features showing cortisol nonsuppression following dexamethasone and 23 matched hospitalized healthy controls. Compared with controls, patients showed (1) lower adrenocorticotropin and cortisol response to apomorphine (p<0.015 and <0.004, respectively), (2) lower growth hormone response to clonidine (p=0.001), and (3) lower responses to TRH: 2300 h maximum increment in serum thyrotropin (TSH) level (p=0.006) and the difference between 2300 and 0800 h maximum increment in serum TSH values (p=0.0001). Our findings, in a subgroup of unipolar depressed inpatients with psychotic and melancholic features, are compatible with the hypothesis that chronic elevation of cortisol may lead to dopaminergic, noradrenergic and thyroid dysfunction.

Venous thromboembolism and escitalopram

Selective serotonin reuptake inhibitors (SSRIs) are currently used as a first-line treatment for depression, as they have a favorable side-effect profile. Escitalopram, a new SSRI, is also well-tolerated and serious side effects are rarely associated with its use. There have been several reports that SSRIs might increase bleeding tendency in some patients by affecting platelet function. However, to our knowledge, there have been no reports about their relation to thrombosis. In this brief report, we present a case of venous thromboembolism associated with escitalopram in a patient with psychotic depression without any major risk factors for thrombosis. SSRIs might have a dual effect on platelet function. The immediate and early effect of SSRI use on platelets might be an increase be an in tendency for thrombosis, whereas the late effect after repeated dosing might be an increase in tendency to bleed, as suggested by previous literature.

Antioxidant enzyme activities and oxidative stress in affective disorders

Recent data from several reports indicate that free radicals are involved in the biochemical mechanisms underlying neuropsychiatric disorders in human. The results of several reports suggest that lower antioxidant defences against lipid peroxidation exist in patients with depression and that there is a therapeutic benefit from antioxidant supplementation in unstable manic-depressive patients. We investigated the antioxidant enzyme status and the indices of oxidative stress and lipid peroxidation end products in erythrocytes from patients with affective disorder. For this purpose, we measured superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) activities, as well as malondialdehyde (MDA) and nitric oxide (NO) levels in patients with affective disorders (n=30) in both pre- and post-treatment periods, and in a control group (n=21). CAT activities were significantly decreased in both pre-, and post-treatment periods in patients compared to the control group. GSH-Px activity in the pre-treatment period in the patients was significantly lower than both post-treatment patient and control groups. MDA levels were increased in both pre-, and post-treatment patient groups compared to the control group. NO level was lower in the pre-treatment patient group than in the control group. There were statistically significant correlations between SOD and MDA, and SOD and NO in the pre-treatment patient and control groups. Because the overall study sample was small, and the post-treatment patient group was even smaller, it can tentatively be suggested that the antioxidant system is impaired during a mood episode in patients with affective disorders, normalizing at the end of the episode.

Psychotic depression and mortality

OBJECTIVE

Major depressive disorder is associated with elevated mortality rates that increase with the severity of depression. The authors hypothesized that patients with psychotic depression would have higher mortality rates than patients with nonpsychotic depression.

METHOD

Survival analytic techniques were used to compare the vital status of 61 patients with psychotic major depression with that of 59 patients with nonpsychotic major depression up to 15 years after hospital admission. Medical status was assessed with the Cumulative Illness Rating Scale. Dexamethasone suppression test (DST) data were available for 101 patients.

RESULTS

The mortality rate for subjects with psychotic depression was significantly greater than that for those with nonpsychotic depression, with 41% versus 20%, respectively, dying within 15 years after hospital admission. A proportional hazards model with age and medical status entered as covariates confirmed a significantly higher mortality rate in patients with psychotic depression (hazards ratio=2.31). A positive DST result was associated with psychotic depression but was not related to vital status.

CONCLUSIONS

Patients with psychotic depression have a two-fold greater risk of death than do patients with severe, nonpsychotic major depression.

Estrogen administration does not reduce the rate of recurrence of affective psychosis after childbirth

BACKGROUND

High rates of postpartum relapse occur in women with histories of bipolar or schizoaffective disorder. These relapses may be triggered by the postdelivery fall in circulating estrogen through alteration of central neurotransmitter (especially dopaminergic) systems. This study tested the hypothesis that estrogen administration after childbirth would prevent postpartum relapse and would alter dopamine receptor sensitivity.

METHOD

Twenty-nine pregnant women with a Research Diagnostic Criteria diagnosis of hypomania (bipolar II), mania (bipolar I), or schizoaffective disorder participated in an open clinical trial. Three transdermal dose regimens of estrogen (17beta-estradiol) were tested. Starting doses were 200 (N = 13), 400 (N = 3), and 800 (N = 13) micro g/day, beginning within 48 hours after delivery and reduced by one half every 4 days for a total of 12 days. On the fourth day after starting estradiol therapy (before relapse occurred), subjects participated in a neuroendocrine challenge test that measured the sensitivity of the central nervous system (tubero-infundibular) dopaminergic system (plasma prolactin and growth hormone responses to apomorphine).

RESULTS

Estradiol at all dose regimens did not reduce the rate of relapse. However, of the 12 women who relapsed, those who had taken the highest dose of estradiol (800 micro g/day) needed less subsequent psychotropic medication (fewer chlorpromazine equivalents) and were discharged sooner than those who had taken either of the 2 lower doses. No differences in neuroendocrine responses to apomorphine were detected between women receiving the high-dose and the lower-dose regimens.

CONCLUSION

The results do not support the hypothesis that a fall in circulating concentrations of estrogens precipitates relapse in subjects at risk of postpartum affective psychosis. The use of prophylactic estrogen in such circumstances is therefore highly questionable.

Cortisol activity and cognitive changes in psychotic major depression

OBJECTIVE

The theory that psychotic major depression is a distinct syndrome is supported by reports of statistically significant differences between psychotic and nonpsychotic major depression in presenting features, biological measures, familial transmission, course and outcome, and response to treatment. This study examined differences in performance on a verbal memory test and in cortisol levels between patients with psychotic and nonpsychotic major depression and healthy volunteers.

METHOD

Ten patients with psychotic major depression, 17 patients with nonpsychotic major depression, and 10 healthy volunteers were administered the Wallach Memory Recognition Test and had blood drawn at half-hour intervals over the course of an afternoon to assay cortisol levels.

RESULTS

Subjects with psychotic major depression had a higher rate of errors of commission on the verbal memory test (incorrectly identified distracters as targets) than did subjects with nonpsychotic major depression or healthy volunteers; errors of omission were similar among the three groups. Subjects with psychotic major depression had higher cortisol levels throughout the afternoon than subjects with nonpsychotic major depression or healthy volunteers. This effect became even more pronounced later in the afternoon.

CONCLUSIONS

Psychotic major depression is endocrinologically different from nonpsychotic major depression and produces cognitive changes distinct from those seen in nonpsychotic major depression.

Antipsychotics in the treatment of mood disorders and risk of tardive dyskinesia

Psychosis occurs commonly in patients with mood disorders and has traditionally been treated with typical antipsychotics. Exposure to typical antipsychotics poses a risk for the emergence of tardive dyskinesia. Atypical antipsychotics may have advantages over typical agents in the treatment of patients with mood disorders complicated by psychotic features. The studies of typical and atypical antipsychotics in the treatment of mood disorders were reviewed. Similarly, studies regarding the risk of tardive dyskinesia from typical and atypical agents in patients with mood disorders were surveyed. Typical and atypical antipsychotics appear to be comparably effective in the treatment of acute mania. Limited data regarding these medications in psychotic depression are available. Advantages of atypical antipsychotics include, for most agents, minimal extrapyramidal and prolactin effects, inherent thymoleptic activity, and lower rates of tardive dyskinesia. Atypical antipsychotics appear to have a number of advantages over typical agents in the treatment of patients with psychotic mood disorders.

HLA-DR7 in association with chlorpromazine-induced lupus anticoagulant (LA)

The presence of anti-phospholipid antibodies (aPL) has been associated with the major histocompatibility complex (MHC) genes. These autoantibodies occur in individuals with infections such as that produced by the human immunodeficiency virus 1 (HIV-1) or with syphilis, but they can also occur in drug-induced lupus-like syndromes. In the present study, we analysed the presence of aPL (detected as lupus anti-coagulant) and its relationship with the MHC markers in 93 Caucasian psychiatric patients chronically treated with chlorpromazine. Forty-one out of 93 patients were positive for LA, and the HLA-DR7 antigen was significantly increased in LA-positive patients as compared to normal controls or LA-negative patients (PC = 0.024, RR = 2.12 and P = 0.05, RR = 1.57, respectively). Likewise, we noted a significantly increased frequency of HLA-B44 in LA-positive patients as compared to normal controls (PC = 0.024, RR = 2.12), but not when compared to aPL-negative patients. No significant differences were found among any other class I, II or III MHC antigens. Haplotype analysis showed that DR7 was mostly part of the HLA-B44-DR7-FC31 and B7-DR7-SC31 haplotypes. These results suggest that the HLA-DR7 antigen might be playing a role in the production of aPL in chlorpromazine-treated patients.

5-HT brain function in affective disorder: d,l-fenfluramine-induced hormone release and clinical outcome in long-term lithium/carbamazepine prophylaxis

Prolactin (PRL) and Cortisol (CORT) responses to d,l-fenfluramine (FEN) challenge (60 mg) were examined in patients with affective disorders on two occasions under euthymic conditions: drug-free before admission to prophylactic treatment and after about 9 months of medication with lithium or carbamazepine. Response to treatment was assessed by a complex algorithm using continuous ratings in outpatient clinic over a period of 2 years. In general, treatment resulted in a delayed and diminished CORT release (n.s.); subgroup analysis revealed an attenuated CORT response (P < 0.05) in responders, whereas nonresponders showed no change in CORT secretion pattern except an enhanced CORT baseline value (P < 0.05). Cross-sectional comparison of responders with nonresponders under medication yielded a trend for greater CORT stimulation in nonresponders. This result was not affected by FEN/NorFEN or lithium/carbamazepine serum levels, baseline CORT values, age, sex, diagnostic distribution, number of appointments to the outpatient clinic or duration of medication at the time of FEN test session. Before onset of prophylactic medication responders and nonresponders could not be discriminated significantly regarding stimulated hormone release, probably due to the small sample size (n = 17). CORT response to FEN was increased in drugfree unipolar patients compared to bipolar (P < 0.05) and to schizoaffective patients (P < 0.1). In accordance with its well-documented presynaptic 5-HT-agonistic action lithium medication resulted in a significantly greater increase in CORT release than carbamazepine (P < 0.05). Evaluation of PRL stimulation showed patterns of secretion quite similar to those of CORT, without reaching statistical significance in most cases. Perhaps due to methodological differences in assessing treatment response, these data do not confirm former results, which supposed an enhanced 5-HT net activity in long-term prophylactic lithium treatment. Because of high interindividual variances of hormone parameters, the FEN-test procedure is not a useful tool for the prediction of therapeutical outcome in terms of clinical routine use. Relations of stimulated hormone response as a marker of central serotoninergic activity and clinical outcome are discussed.

[A comparative clinico-pharmacokinetic study of the use of equivalent daily doses of lithium carbonate and Contemnol]

Comparative study of the influence of equivalent doses of lithium carbonate and contemnol was studied in patients with phasic development of endogenous psychoses. 33 patients (17 men, 16 women) of 20-58 years or age were treated. According to IDC-10 there were observed schizoaffective psychoses in 22 patients (F25), bipolar affective disorders in 5 patients (F31) and chronic mood disorders in 5 individuals (F34). 2-daily comparative pharmacokinetic profiles of lithium carbonate and contemnol were presented and on the base of standard statistic analysis were estimated: lithium presence in blood, amplitude of variations of lithium concentration, number of peak concentrations, areas under pharmacokinetic curves. The study showed that concentration of lithium in blood increased gradually and achieved the maximal level in 6-7 hours after contemnol administration and was not practically changed during following 24 hours as compared to lithium carbonate. The results of the study confirmed that contemnol occurred to be the prolong of lithium carbonate and hadn't to be used more frequently than once a day.

Serum levels of clozapine and norclozapine in patients treated with selective serotonin reuptake inhibitors

OBJECTIVE

The selective serotonin reuptake inhibitor (SSRI) fluoxetine can increase serum levels of clozapine and norclozapine, but effects of other SSRIs are unknown. Thus, the authors evaluated interactions of clozapine with fluoxetine, paroxetine, and sertraline.

METHOD

Serum clozapine and norclozapine concentrations were assayed in 80 psychiatric patients, matched for age and clozapine dose, given clozapine (mean dose = 279 mg/day) alone or with fluoxetine (mean dose = 39.3 mg/day), paroxetine (mean = 31.2 mg/day), or sertraline (mean = 92.5 mg/ day). Each patient's dose of clozapine was stable for at least a month before serum sampling.

RESULTS

Concentrations of clozapine plus norclozapine averaged 43% higher, and the risk of levels higher than 1000 ng/ml was 10-fold greater (25%), in the patients taking SSRIs, with minor differences between patients taking the individual SSRIs.

CONCLUSIONS

SSRIs can increase circulating concentrations of clozapine and norclozapine, sometimes to potentially toxic levels.

The lithium index in a one-year follow-up

1. In a one-year follow-up 191 patients on lithium therapy, besides their regular check-ups, were assessed on mood, side-effects and intracellular lithium. 2. The authors were not able to find a correlation between the so called lithium index (i.e. the quotient intracellular lithium/plasma lithium) and the mood score. 3. In the group of patients which used no co-medication at all during the year of the follow-up the authors also failed to find a correlation between the lithium index and some of the clinically most relevant side-effects. However, in that selected group of "only-lithium-using-patients"-only 29 in all-the authors found a remarkable stability in the index value. 4. So even if the authors, in fact, rejected the lithium index estimation as a tool in daily praxis, the authors would once again underline the interesting findings about the so-called lithium index.

Plasma concentrations of gamma-aminobutyric acid (GABA) and mood disorders: a blood test for manic depressive disease?

gamma-Aminobutyric acid (GABA), an inhibitory neurotransmitter that serves about one-third of brain neurons, is involved in the development of depression and in the treatment of depression and mania with pharmacological therapy. Brain activity of GABA may be conveniently measured in plasma, and changes in plasma concentrations of GABA reflect brain GABA activity. Plasma concentrations of GABA are significantly lower than control values in about one-third of patients with major depressive disorder; concentrations are also low in patients with mania and in bipolar patients who are depressed. These low concentrations of GABA appear to persist after recovery from depression and are not increased by treatments that improve depressive symptoms. Follow-up studies suggest that GABA concentrations remain relatively constant over at least 4 years. Additionally, preliminary data suggest that low plasma GABA is a familial marker of mood disorders in a subset of patients. Despite the difficulty of demonstrating that a particular biochemical measure is a true genetic trait marker for vulnerability for development of an illness, the accumulated data suggest that low plasma GABA may represent a biological marker of vulnerability for development of various mood disorders.

Hormone responses to fenfluramine and placebo challenge in endogenous depression

Plasma prolactin and cortisol levels after oral administration of d-l fenfluramine hydrochloride (60 mg) and placebo were examined in 24 endogenously depressed patients and 21 age- and sex-matched normal control subjects in a randomized, double-blind study. Prolactin levels were significantly increased by fenfluramine in both groups, but the response was significantly blunted in the depressed patients compared with the controls. This effect was partially dependent upon elevated baseline cortisol levels in the depressed group and was also influenced by a history of weight loss. Plasma cortisol levels were not increased by fenfluramine in either group. These findings confirm previous reports and suggest that patients with endogenous major depression are characterized by central serotonergic hyporesponsivity. The need to account for baseline effects on hormonal responses to putative serotonergic agents is supported by the findings; however, these effects appear to be less striking when endogenicity is a prominent clinical feature of the depressive syndrome. The apparently complex influence of weight loss on prolactin response to serotonergic challenge remains to be clarified as well as the role played by the bioavailability of the challenge drug and its metabolite.

A clinical and biological validation of the DSM-III melancholia diagnosis in men: results of pattern recognition methods

Pattern recognition methods were carried out on a sample of 80 depressed men, assessed by means of 14 items relevant to depressive symptomatology of the Structured Clinical Interview for DSM-III-R. 1985 edition (SCID). A cluster analysis generated two classes, which were described as a vital (n = 35) and a nonvital cluster (n = 45). Vital depressives were characterized by psychomotor disorders, loss of energy, cognitive disturbances, a distinct quality of mood, early morning awakening and nonreactivity (the "vital" symptoms). Our findings support the descriptive validity of the DSM-III melancholia diagnostic category, although the DSM-III criteria are too conservative and include nonrelevant symptoms (e.g., diurnal variation, anorexia-weight loss) whilst excluding some important items (e.g., loss of energy, cognitive disorders). Vital depressed men were significantly older, more severely depressed and they exhibited biological disturbances (abnormal dexamethasone suppression test, lower basal thyroid secreting hormone) as opposed to nonvital depressives. There are several arguments to support the possibility that both clusters constitute relevant stages in the overall severity of illness continuum, whilst showing qualitative differences with regard to the vital symptoms. In other words, both clusters are continuous categories within the overall severity of illness continuum and form discrete categories with regard to the vital symptoms. By merging the dimensional and categorical hypotheses, we were able to construct a new integrated threshold model: unipolar depression in men is probably a homogeneous disease with reference to overall severity of illness, but--as severity increases--vital symptoms emerge, grouping together into a distinct profile, i.e., vital depression.

[A comparative study of the serum levels of thyrotropin in depressed patients and normal subjects]

Serum TSH levels were measured by radioimmunoassay in 85 affective disorders and 41 healthy control persons. The results showed that the serum TSH levels of the patient group were significantly lower than the normal control's. TSH levels among different clinical episodes, however, have no significant difference. Furthermore, There were not a marked difference of TSH levels in age, sex and used antipsychotics, antidepressants, lithium or not. The results suggested that further investigations were needed to understand thyroid function state.

Pharmacological effects of methylphenidate on plasma homovanillic acid and growth hormone

The acute pharmacological actions of methylphenidate, a potent psychotogenic stimulant, were studied by measuring plasma homovanillic acid (HVA) and serum growth hormone (GH) as indices of presynaptic and postsynaptic functions, respectively. Twenty psychiatric inpatients participated in a double-blind, placebo-randomized study of methylphenidate infusion. Multiple samples of plasma HVA and GH were measured before and up to 24 hours after both methylphenidate and placebo infusions. There was a robust and significant GH response during the 2-hour postmethylphenidate period when compared to placebo. The peak response was significantly greater in male patients than in female patients. Although there were no changes in plasma HVA during the 2 hours following the infusion, there was a significant decrease in HVA 24 hours after methylphenidate as compared to preinfusion baseline values. Plasma HVA values also tended to be lower 24 hours after methylphenidate when compared to the corresponding postplacebo value. Schizophrenic patients did not differ significantly from nonschizophrenic patients in their physiological or biochemical responses.

Vitamin B12 and folate status in acute geropsychiatric inpatients: affective and cognitive characteristics of a vitamin nondeficient population

This chart review study examined the serum vitamin B12 and folate status of 102 geriatric patients newly admitted to a private psychiatric hospital. Only 3.7% were B12 deficient and 1.3% were folate deficient; 4% were anemic. Nevertheless, those with below-median values of both vitamins had significantly lower Mini-Mental State scores than patients higher in one or both vitamins. Patients with "organic psychosis" with a negative family history for psychiatric disorder had significantly lower B12 levels than those with a positive family history. In major depression, folate levels correlated negatively with age at onset of psychiatric illness and length of hospitalization. These data suggest that (1) biochemically interrelated vitamins such as B12 and folate may exert both a separate and a concomitant influence on affect and cognition; (2) poorer vitamin status may contribute to certain geropsychiatric disorders that begin at a later age and lack a familial predisposition.

Prolactin response to low-dose haloperidol challenge in schizophrenic, non-schizophrenic psychotic, and control subjects

Haloperidol was administered IV to 46 male psychotic inpatients and 28 male control subjects. A two-way analysis of covariance, with age as the covariate, revealed that DSM-III schizophrenics (n = 27) had a lower prolactin response to haloperidol than did the controls (n = 28). There were no significant differences between the prolactin responses in schizophrenics, patients with affective disorders (n = 7), and those with other psychoses (n = 12), which included patients with paranoia, schizophreniform, schizoaffective disorder, and atypical psychoses. These findings support the proposition that tuberoinfundibular dopaminergic dysfunction may occur in certain patients with DSM-III schizophrenia.

Acute neurohumoral response to electroconvulsive therapy during pregnancy. A case report

The neurohumoral changes induced by electroconvulsive therapy (ECT) in pregnancy have not been described previously. In the nonpregnant adult, ECT causes an acute rise in prolactin, adrenocorticotropic hormone (ACTH), cortisol, norepinephrine, epinephrine and beta-endorphin. Because pregnancy alters the production and release of these hormones, consideration should be given to how ECT may further alter the neuroendocrine response, with possible implications for the success of treatment and the fetal response. A 30-year-old woman with a major affective disorder underwent a course of ECT beginning at 23 weeks' gestation. Serial hormonal assays of peripheral venous samples from -30 to +240 minutes were obtained during her first treatment. The prolactin, ACTH, norepinephrine, epinephrine, beta-endorphin, dopamine and oxytocin levels rose acutely and returned to baseline during observation. The maternal vital signs were stable. No increase in uterine activity or fetal heart rate abnormalities were observed during any treatment. A healthy infant weighing 2,900 g was delivered at term, with Apgar scores of 9 and 9 and no problems. We conclude that there are acute neurohumoral changes in specific hormones with ECT in pregnancy, but none of these changes appeared to adversely affect the fetus in our case.

Specificity of plasma HVA response to dexamethasone in psychotic depression

Earlier reports have suggested that dexamethasone significantly increases levels of plasma homovanillic acid (HVA) in normal subjects, but that this effect may be altered in some depressed patients. To investigate the specificity of such alterations, we administered dexamethasone (1 mg p.o. at 11 p.m.) to 33 normal subjects, 27 depressed patients (8 with psychotic features), and 16 schizophrenic patients. Plasma for assay of cortisol and HVA was obtained at 4 p.m. before and on the day following dexamethasone administration. Dexamethasone induced significant increases in plasma HVA in the normal subjects and in the schizophrenic patients, but not in the depressed patients. Indeed, psychotically depressed patients tended to show a dexamethasone-associated decrease in plasma levels of HVA. In contrast to cortisol "suppression" or "nonsuppression," dexamethasone-induced changes in plasma levels of HVA (i.e., increases or decreases) sensitively and specifically discriminated between patients with affective and nonaffective psychoses.

[Neuroendocrine and psychopharmacologic aspects of the pineal function. Melatonin and psychiatric disorders]

The development of psychiatric thought has always been in close association with the pineal gland. The importance of a relationship between pineal, and mental functions was stressed by Descartes when he placed the seat of rational thought as well as the confluence of body and soul in this organ (Cf. Descartes, L'Homme, 1664). His writings exerted such a strong influence that, quite soon indeed, physicians started regarding this gland as being the source of many mental disorders. In an attempt to find and explain a possible link between mental abnormalities, and the discovery of calcified pineals in necroptic studies, many theories were put forward during the 18th, and the 19th century. Afterwards, the importance of the gland went almost unnoticed until 1920, when Becker treated psychotic patients with pineal extracts. An up-to-1950 review by Kitay and Altschule (1954) reported 17 cases where pineal extracts were successfully injected to psychotic patients. In the present review, the author tries and summarizes several reports dealing with the influence of the pineal function on affective disorders, schizophrenia, sleep cycle, Parkinson disease, etc., as a contribution to future research work in this field.

Thyroid function in psychosis following childbirth

Postpartum thyroiditis has been suggested as a cause of psychosis following pregnancy. However, 30 hospitalized psychotic postpartum women and 30 control subjects matched for age and time since delivery showed no significant differences in thyroid function or the presence of thyroid antibodies.

Serum pseudocholinesterase in psychiatric patients

Serum pseudocholinesterase activity was measured in 123 subjects: 16 agitated depressives, 12 retarded depressives, 7 acute schizophrenics, 14 residual schizophrenics, 16 healthy individuals, 45 surgical patients, and 13 first-degree relatives of 4 agitated depressive patients. The agitated depressive and acute schizophrenic patients had significantly higher pseudocholinesterase serum activity than their retarded inmates. As first-degree relatives of agitated depressive patients showed high levels similar to their ill relatives, a genetic component might play a crucial role. The level of pseudocholinesterase activity in serum of the surgical patients was significantly lower than that of all the psychiatric patients and the controls. The implications of this observation are still obscure.

Lithium level and inter-episode symptoms in affective disorder

Forty-two patients with a history of affective disorder on lithium prophylaxis alone participated in a prospective 1-year study of inter-episode symptoms. Despite expected significant differences in mean plasma lithium level in patients, those with mean levels above the median (0.82 +/- 0.10 mEq/l) did not differ in incidence of major symptoms per visit, in mood shift per visit, or in rate of subclinical symptoms on the General Behavior Inventory from those patients with mean level below the median (0.52 +/- 0.09 mEq/l).

Effects of electroconvulsive therapy (ECT) on thyroid function parameters

Serum concentrations of thyroxine, triiodothyronine, TSH and prolactin were measured in 10 patients with affective disorders receiving ECT. Samples were drawn at -15 min, 0, +30 min, +60 min and +3 hr after ECT. A significant increase in both prolactin and TSH was observed 30 min after ECT. A small but significant decrease in triiodothyronine but no change in thyroxine was found in all post-ECT samples. The increase in TSH may be caused by an anti-dopaminergic effect of ECT at either the pituitary or the hypothalamic level.

The effect of lithium on platelet count

The effect of lithium on platelet count was studied by examining 12 patients treated with lithium carbonate without any additional medication, 13 patients treated with lithium carbonate with additional psychotropic medication, 25 patients with major affective disorder prior to any treatment, 25 patients with panic disorder prior to any treatment and 25 healthy controls. The platelet counts were increased in the group of subjects treated with lithium carbonate without any additional psychotropic medication. The increase was not clinically significant.

Selenium concentrations in blood and serum from patients with mental diseases

Blood and serum concentrations of selenium have been determined in a group of psychiatric patients and in 35 healthy controls. The psychiatric group consisted of 14 schizophrenics, seven paranoid disorders, six affective psychosis (manic-depressive), four reactive psychosis, 11 dementia senilis, 17 with a diagnosis of neurosis and two with delirium tremens. Normal values were found in all groups except for delirium tremens where decreased blood and serum values were found.

[Prolactin stimulation test using TRH in affective disorders (72 cases)]

Authors report results of stimulation test of prolactin by T.R.H. in 72 inpatients with affective disorders. They find well known effects of physiological factors (age, sex), and treatments (neuroleptics, lithium, L-Dopa). They did statistical analysis on plasma levels before and after T.R.H. stimulation. This test has no value for differential diagnosis between types of depressions. But it shows particular relation between high levels of prolactin and bipolarity.

Symptom exacerbation in psychotically depressed adolescents due to high desipramine plasma concentrations

The pharmacological treatment of two female adolescent patients meeting DSM-III criteria for psychotic depression is described. A combined antipsychotic and tricyclic antidepressant regimen led to clinical remission. However, a recrudescence in both psychotic and depressive symptoms developed as plasma desipramine levels rose 4 times higher than anticipated from the oral doses prescribed. Clinical improvement occurred in both cases when plasma desipramine levels were reestablished below 200 ng/ml. Thus, we recommend prospective monitoring of desipramine plasma levels, especially when an antipsychotic agent that inhibits the metabolism of the tricyclic antidepressant is also used. We further suggest that deterioration with the reemergence of the presenting clinical syndrome, without signs of delirium, represents a distinct manifestation of antidepressant toxicity. Finally, these cases support the existence of a therapeutic upper limit for desipramine plasma concentrations, above which clinical deterioration occurs.

Increase in white blood cell count and serum sodium level following the addition of lithium to carbamazepine treatment among three chronically psychotic male patients with disturbed affective states

Three male chronically psychotic patients (mean age 33.0 +/- S.D. 7.2 years), two with schizoaffective disorder and one with organic affective disorder, received carbamazepine (CBZ) because of affective symptoms (and, in one case, partial complex seizures) refractory to management with antipsychotic drugs. Coincident with CBZ administration (and clinical improvement), hyponatremia developed thought to be due to the antidiuretic effect of this drug. Lithium was added to counteract the antidiuretic effect of CBZ. Further clinical improvement ensured, serum sodium levels became normal, and there was an increase in the white blood cell count in each patient. The clinical implications of our findings are discussed.

Growth hormone and prolactin response to apomorphine in schizophrenia and the major affective disorders. Relation to duration of illness and depressive symptoms

The responses of serum prolactin (PRL) and growth hormone (GH) to the dopamine agonist apomorphine hydrochloride (0.75 mg subcutaneously) were studied in a large group of unmedicated hospitalized patients with functional psychoses. There were no differences in the GH response in various diagnostic groups. The PRL response was greater in patients with affective disorders. The GH response was inversely related to total duration of illness in the entire sample of patients, but this correlation was independent of age effect only in the group of patients with major depression. In schizophrenics, the effect of the two factors, age and duration of the illness, could not be separated. The apomorphine-induced GH response was significantly correlated with psychosis ratings and negative symptom scale scores. The apomorphine-induced PRL suppression correlated significantly with various measures of depression across diagnostic groups.

Opioid plasma levels in primary affective disorders. Effect of desimipramine therapy

Mean plasma levels of beta-endorphin (beta EP), beta-lipotropin (beta LPH) and ACTH were significantly higher in 22 patients with primary affective disorders (PAD) and in 2 schizoaffective subjects off therapy since 10 days than in 22 age- and sex-matched healthy controls. Desimipramine therapy (50-100 mg/day per os for 3-5 weeks) induced in parallel psychological improvement and fall in beta LPH-beta EP in 6 of 8 PAD patients treated, and a normalization of beta EP-beta LPH levels with minimal mood improvement in the 2 schizoaffective subjects. These results indicate that the opioid levels are increased in PAD and schizoaffective patients and normalized by the desimipramine therapy in those patients in whom the affective disorders improved.

Blood cells as biological trait markers in affective disorders

Data are reviewed on platelet monoamine oxidase activity, red blood cell/plasma lithium ratio, and tritiated imipramine binding to platelet membranes as trait markers for affective disorders. The results of various studies are not in agreement. Differences in methodological procedure are probably central to such discrepancies. At the present time, no single biological abnormality of blood cells has proved to be a trait marker for affective disorders; thus their use to identify vulnerability to mood disorders or predict favourable response to pharmacological treatment appears to be premature.

Plasma vitamin C concentrations in patients in a psychiatric hospital

Plasma vitamin C was measured in 885 patients in a psychiatric hospital and in 110 healthy controls. The average value was lower in the patients (0.51 mg/100 ml) than in the controls (0.87 mg/100 ml). Length of stay in hospital had little effect on plasma vitamin C in the patients, but the values were marginally lower in males, females on iron therapy and in those with senile dementia. In the patients, many of whom had been offered a similar diet for several years, age was not associated with a change in plasma vitamin C and this suggests that changes in vitamin C with age that have been reported reflect differences in intake. Few patients had values as low as those found in clinical scurvy (less than 0.1 mg/100 ml), but many (32 per cent) had concentrations below the threshold (0.35 mg/100 ml) at which some detrimental effects on health have been reported.

The effects of lithium treatment on cation transport processes in erythrocytes of patients with affective illnesses

The effect of lithium administration on cation transport processes in erythrocytes was investigated in 26 patients with affective illnesses. The measures of ouabain-dependent sodium and potassium transport, Na+K+ATP-ase activity and lithium-sodium countertransport in erythrocytes were taken before and after 14 days of lithium therapy. In eleven patients an additional assay was made, following 3-12 months of continuous lithium administration. A significant increase in sodium and potassium transport as well as Na+K+ATP-ase activity was found after 14 days of lithium therapy, while the intensity of lithium-sodium countertransport markedly decreased. Maintenance treatment with lithium tended to stabilize these changes on the altered level. A role of cation transport in the mechanism of lithium action is discussed. It is suggested that an increment of erythrocyte active cation transport may accompany the normothymic effect of lithium.

The relationship between prolactin levels and clinical ratings in manic patients treated with oral and intravenous test doses of haloperidol

Twelve manic patients were treated for 2 weeks with oral haloperidol; in 6 patients treatment commenced with intravenous haloperidol, and intravenous 'test' doses were given after 1, 3-5 and 14 days of oral medication. From 24 hours to 14 days baseline serum prolactin levels rose towards a plateau, as did the improvement in clinical ratings. After the first intravenous test doses of haloperidol, prolactin levels peaked at 1 hour; however, they fell to a low point at 24 hours, and no response to further test doses was seen for 3-5 days. The response tended to return at 14 days. The mechanisms underlying the changes in prolactin levels, and in clinical state, are discussed.