Discriminating primary clinical states in bipolar disorder with a comprehensive symptom scale

OBJECTIVE

We assessed the spectrum and severity of bipolar symptoms that differentiated bipolar disorder (BD) clinical states, employing the Bipolar Inventory of Symptoms Scale (BISS) which provides a broader item range of traditional depression and mania rating scales. We addressed symptoms differentiating mixed states from depression or mania/hypomania.

METHOD

One hundred and sixteen subjects who met DSM-IV-TR criteria for BD and were currently in a depressed, manic/hypomanic, mixed episode, or recovered state were interviewed using the BISS.

RESULTS

A subset of manic items differed between mixed episodes and mania/hypomania or depression. Most anxiety items were more severe in mixed subjects. BISS Depression and Manic subscales differentiated episodes from recovered status. The majority of depression and manic symptoms differentiated mood states in the predicted direction. Mixed episodes had overall greater mood severity than manic/hypomanic episodes or depressed episodes.

CONCLUSION

These results indicate that a small subset of symptoms, several of which are absent in DSM-IV-TR criteria and traditional rating scales for bipolar studies, aid in distinguishing mixed episodes from depressive or manic/hypomanic episodes. The results also support the utility of a comprehensive BD symptom scale in distinguishing primary clinical states of BD.

Development of the bipolar inventory of symptoms scale

OBJECTIVE

Most rating scales for bipolar disorders (BDs) do not encompass the spectrum of symptomatology now established as characterizing the illness. We report the rationale, format, reliability and initial validity studies of the Bipolar Inventory of Symptoms Scale (BISS), a 44-item scale designed to encompass the spectrum of behavioral disturbances in BDs.

METHOD

Structured video interviews of 20 patients representing four bipolar syndromal subtypes were rated by nine raters.

RESULTS

Generally, high inter-rater reliability and internal consistency were established for the depression and mania subscales and the BISS total score. The BISS discriminated across subtypes of bipolar patients with depressed, manic/hypomanic, mixed manic or recovered status.

CONCLUSION

The BISS has adequate reliability, concurrent validity and is capable of discriminating between bipolar subtypes. It also provides a comprehensive scale to assess discrete behavioral components of BD.

Psychomotor performance and monoamine function in bipolar and unipolar affective disorders

BACKGROUND

Affective disorders are associated with prominent psychomotor abnormalities that may be related to changes in arousal or motivation due to altered catecholamine function.

METHODS

We investigated relationships between performance on psychomotor tests of motor speed (reaction time and tapping speed) and visual tracking (trail making and dot placement) and catecholamine system function including cerebrospinal fluid (CSF) or urinary concentrations of catecholamines or their metabolites. Subjects were medicine-free inpatients with unipolar depression or with manic, depressive, or mixed episodes of bipolar disorder, and healthy controls matched by gender and stratified by age.

RESULTS

Unipolar and bipolar depressed patients were impaired in motor speed, dexterity, and visual tracking, whereas manic and mixed patients did not differ from controls. Tapping speed correlated positively with CSF 3-methoxy-4-hydroxyphenylglycol in healthy controls and with CSF homovanillic acid in bipolar depressed subjects. Increased catecholamine function correlated with slowing in all other measures for patients with bipolar disorder. Relationships between catecholamines and psychomotor function were weaker in unipolar depressed subjects. Psychomotor function was related to severity of depression in bipolar, but not in unipolar, patients.

CONCLUSIONS

These data suggest that catecholamine systems are associated with increased arousal and psychomotor impairment in patients with bipolar disorder. Similar behavioral changes have different neurotransmitter relationships in unipolar disorder.

Need for a new paradigm for the clinical trials of antidepressants

The current clinical trials model for antidepressants (AD) was developed in the 1960s. It views major depression as a unitary disorder, and "antidepressants" as having illness-specific therapeutic actions. The established efficacy measures are the Hamilton symptom rating scale and the CGI, which provide summary measures of improvement. In contrast, the DSM IV defines depression as heterogeneous, with such broad classes as unipolar and bipolar showing different response to treatments. Research further indicates depression to be comprised of major affective and behavioral components which vary in intensity across patients, and the tricyclic ADs to have multiple actions that affect various components sequentially. "New" ADs, products of rapid advancements in the neurosciences, are more precise in their actions on brain monoamine systems, targeted to affect behaviors with greater specificity. A new trials model sensitive to the varied behavioral effects needs to be developed to adapt to these quicker acting, targeted antidepressants. A componential model is recommended that employs an array of behavioral methods, and subtype classification and statistical approaches to estimate onset and sequence of multiple drug actions. The NIMH can intervene to accelerate improvements by initiating funding programs to implement more effective clinical methods and models.

A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia. North American EGb Study Group

CONTEXT

EGb 761 is a particular extract of Ginkgo biloba used in Europe to alleviate symptoms associated with numerous cognitive disorders. Its use in dementias is based on positive results from only a few controlled clinical trials, most of which did not include standard assessments of cognition and behavior.

OBJECTIVE

To assess the efficacy and safety of EGb in Alzheimer disease and multi-infarct dementia.

DESIGN

A 52-week, randomized double-blind, placebo-controlled, parallel-group, multicenter study.

PATIENTS

Mildly to severely demented outpatients with Alzheimer disease or multi-infarct dementia, without other significant medical conditions.

INTERVENTION

Patients assigned randomly to treatment with EGb (120 mg/d) or placebo. Safety, compliance, and drug dispensation were monitored every 3 months with complete outcome evaluation at 12, 26, and 52 weeks.

PRIMARY OUTCOME MEASURES

Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog), Geriatric Evaluation by Relative's Rating Instrument (GERRI), and Clinical Global Impression of Change (CGIC).

RESULTS

From 309 patients included in an intent-to-treat analysis, 202 provided evaluable data for the 52-week end point analysis. In the intent-to-treat analysis, the EGbgroup had an ADAS-Cog score 1.4 points better than the placebo group (P=.04) and a GERRI score 0.14 points better than the placebo group (P=.004). The same patterns were observed with the evaluable data set in which 27% of patients treated with EGb achieved at least a 4-point improvement on the ADAS-Cog, compared with 14% taking placebo (P=.005); on the GERRI, 37% were considered improved with EGb, compared with 23% taking placebo (P=.003). No difference was seen in the CGIC. Regarding the safety profile of EGb, no significant differences compared with placebo were observed in the number of patients reporting adverse events or in the incidence and severity of these events.

CONCLUSIONS

EGb was safe and appears capable of stabilizing and, in a substantial number of cases, improving the cognitive performance and the social functioning of demented patients for 6 months to 1 year. Although modest, the changes induced by EGb were objectively measured by the ADAS-Cog and were of sufficient magnitude to be recognized by the caregivers in the GERRI.

Onset of antidepressant activity: reexamining the structure of depression and multiple actions of drugs

The question of when antidepressant drugs (AD) initiate significant clinical actions in depressed patients is still unsettled. Findings from early studies on whether there is a lag in the onset of therapeutic actions were in disagreement. More recent results with the selective serotonin reuptake inhibitors (SSRIs) and other new ADs indicate that clinical actions occur within the first 2 weeks. In this paper, evidence from efficacy studies with the ADs is reviewed and the methodologic and conceptual obstacles to achieving definitive results about the onset issue are analyzed. Depression, formerly viewed as a homogenous disorder, is now seen as heterogenous and multifaceted in structure. Such major structural components as anxiety and disturbed psychomotor functioning can be as significant to the core of the disorder as depressed mood itself. Further, the ADs have been shown to act initially on different facets of the clinical disorder which then result in multiple clinical actions, e.g., an initial reduction in anxiety followed by stimulation of motor activity. Data from the NIMH Collaborative Study of the Psychobiology of Depression are used to illustrate: (1) the componential structure of severe depressive disorder; (2) the sequence of change in the major behavioral components of the disorder associated with the tricyclic drugs; (3) the consequent "multiple" onsets of clinical actions; and (4) measurement of the clinical significance and visibility of the early behavioral changes. Recent results describing new behavioral and methodological approaches, the use of early clinical changes to predict outcome, and strategies for designing sound studies of onset are discussed.

Drug-induced actions on brain neurotransmitter systems and changes in the behaviors and emotions of depressed patients

Despite cumulative evidence that the tricyclic drugs result in significant changes in the functioning of brain serotonergic (5-HT) and nordrenergic (NE) systems, such changes have not been found to be associated with recovery from depression. Based upon evidence that the 5-HT and NE systems were associated with different emotions, it was hypothesized that changes in these systems were associated with different components of behavior in drug-responsive patients and not with changes in the "whole" disorder. Findings from this multihospital study of 104 unipolar and bipolar depressed patients showed early drug-associated reductions in anxiety and hostility in treatment responders to precede changes in motor retardation and depressed mood. Adopting this approach of looking for relationships between changes in components of major depression and changes in neurotransmitter system function, decreases in 5-HT and NE metabolite concentrations in cerebrospinal fluid (CSF) in patients treated with tricyclics, were found to be correlated with changes in specific behaviors. Results indicated the following: (1) drug-induced changes in the 5-HT system to be associated with mood aspects, notably anxiety, and depressed mood; changes in NE primarily with the psychomotor, secondarily with the mood components of the depressed state; (2) the pattern of relationships between changes in 5-HT and in mood in the unipolar was different than that in the bipolar subtype. The results indicate that in determining the relationships of biochemical changes to behavioral ones, that it is important to take into account the type of depression (bipolar or unipolar), as well as examining individually and over time those components that make up the disorder of depression. These results support evidence that tricyclics have multiple behavioral actions, that response is mediated through changes in specific behaviors and that this approach warrants further application in prospective studies of antidepressant drug mechanisms and their therapeutic actions.

Adrenomedullary function in depressed patients

In this paper from the Collaborative Depression Study (CDS)--Biological, a set of data analyses are presented which indicate that depressed states and perhaps depressed mood are associated with a greater activation of the adrenomedullary system than the sympathetic nervous system [as measured by norepinephrine (NE) and normetanephrine excretion]. For the most part this finding of predominant activation of the adrenomedullary system is seen in unipolar and not bipolar patients.

The pattern of physical symptom changes in major depressive disorder following treatment with amitriptyline or imipramine

The study describes a sequential analysis of depression-related physical symptoms and their relationship to imipramine and amitriptyline plasma levels over 4 weeks of treatment in 79 unipolar and bipolar patients hospitalized for major depressive disorder. Insomnia diminished in all patients after 2 weeks of drug administration. After 4 weeks, the sleep of patients whose depressive disorder has significantly improved was nearly normal, whereas patients who remained depressed showed continued sleep impairment. Reductions in loss of appetite, weight and sexual interest paralleled mood improvement. Tricyclic plasma levels significantly correlated with improved sleep. The findings suggest a close link between depressed mood and physical symptoms during recovery from major depressive disorder.

Expressive characteristics of anxiety in depressed men and women

This study was aimed at identifying the expressive, movement, and social behaviors associated with anxiety in the syndrome of major depression. The sample consisted of 97 hospitalized male and female depressed patients. Expressive and social behaviors were evaluated prior to treatment in a structured videotaped interview. Anxiety was measured using a multi-vantaged approach including doctor's rating, nurse's rating, patient self-report, and a separate video rating. Results indicate that anxiety was significantly associated with agitation, distressed facial expression, bodily discomfort, and poor social interaction in both sexes. Men and women differed in certain respects: anxiety was highly related to motor retardation in women only, and to hostility in men only. Differences in the pattern of expressive behavior between high and low anxious, depressed patients were clearly significant, and several were large enough to serve as clinical indicators. These findings help to characterize the expressive features of anxiety in the context of severe depression, and add to the growing literature on sex differences in depression.

Specificity of mixed affective states: clinical comparison of dysphoric mania and agitated depression

To investigate the clinical specificity of mixed affective states, we compared clinical characteristics of mixed (dysphoric) manics to those of agitated depressed patients. The subjects were inpatients studied in the NIMH Clinical Research Branch Collaborative Study on the Psychobiology of Depression, Biological Studies. Behavior and symptom ratings for depressive and manic symptoms were obtained during a 15-day placebo washout period. Patients with agitated depression were compared to those in acute manic episodes with and without prominent depressive symptoms. Mania ratings clearly distinguished agitated depressed from mixed manic patients. Concerning depression and general psychopathology, mixed manics had more severe agitation, hostility and cognitive impairment than did agitated depressed patients. Depressed mood and anxiety did not differ significantly between the two groups. Nurse ratings for depression and anxiety, based on ward behavior, were similar for mixed manics and agitated depressed patients, while physician-interview rated depression and anxiety were higher in agitated depressed patients. These data support the existence of superimposed depressive and manic syndromes in mixed manics.

Hypothalamic-pituitary-adrenocortical function in mixed and pure mania

There is little information about hypothalamic-pituitary-adrenocortical (HPA) axis function in mania, particularly in mixed states. We therefore investigated HPA function and its relationship to clinical state in 19 hospitalized manic patients meeting Schedule for Affective Disorders and Schizophrenia - Research Diagnostic Criteria for acute manic episodes, compared patients with and without a mixed presentation, and examined correlations between HPA activity and behavior. Data were available from 13-16 patients. Behavioral and biochemical analyses were conducted during a 15-d placebo period. Patients with mania had elevated cerebrospinal fluid (CSF) and urinary free cortisol excretion compared with healthy subjects, and did not differ from depressed patients in any cortisol measures. Mixed manics had significantly higher morning plasma cortisol, postdexamethasone plasma cortisol and CSF cortisol than pure manics. Five of 7 mixed manics and 3 of 9 pure manics were dexamethasone suppression test (DST) nonsuppressors. Afternoon plasma cortisol and CSF cortisol correlated significantly with depressed mood; urinary free cortisol correlated with anxiety. None of the cortisol measures correlated with mania or agitation scores. These data suggest that increased cortisol secretion is a characteristic of the depressed state in mixed manics, although pure manics may also have increased DST nonsuppression.

Identifying the specific clinical actions of amitriptyline: interrelationships of behaviour, affect and plasma levels in depression

Despite increasing knowledge of the neurochemical bases of the action of the tricyclic drugs, little is known about the sequence of psychological effects which precede recovery in drug-responsive patients. This research was aimed at identifying the specific behavioural effects associated with the therapeutic action of amitriptyline in depression. The design involved measurement (post-hoc) of weekly changes in a severely depressed placebo-resistant group who recovered with drug treatment, compared with a group of similar patients treated for the equivalent four weeks, who showed minimal to no clinical response. The research strategy, in accordance with a dose-response paradigm, was to determine which of the early changes in emotion and behaviour found in treatment responders were systematically associated with plasma concentrations of amitriptyline or its major metabolite. Amitriptyline was found to act within seven days on the components of anxiety and on hostility in the responders, and on sleep disorder in all patients. After 12 to 14 days of treatment these effects increased, with improvements in other significant components distinguishing the responders from the non-responders. At the 12th to 14th treatment days when a steady state concentration of drug in plasma was approached, reductions in anxiety and hostility and in certain somatic components correlated significantly with plasma concentrations of amitriptyline. Implications of the findings for clarifying the specificity of clinical actions of the tricyclic drugs, and for understanding the psychobiological dynamics underlying rapid drug-induced recovery in depression, were explored.

Mania: sympathoadrenal function and clinical state

We investigated sympathoadrenal and sympathetic nervous system activity, catecholamine disposition, and clinical state in 19 hospitalized manic patients. Severity of the core manic syndrome, anxiety, and hostility correlated with 24-hour urinary excretion of epinephrine relative to its metabolites, but only weakly with norepinephrine. Agitation, however, correlated most strongly and significantly with norepinephrine. Eight of the patients had mixed states: concurrent manic and depressive syndromes. There were no differences between mixed and pure manic patients with respect to catecholamine or metabolite excretion or precursor/product ratios, but mixed manic patients tended to have higher excretion of norepinephrine and had increased variance with respect to catecholamine measures. These data suggest that the function of the adrenal medulla, whether directly or indirectly, is important in the symptoms of both mixed and pure mania.

Response to treatment with antidepressants of patients with severe or moderate nonpsychotic depression and of patients with psychotic depression

Hospitalized patients were divided into nonpsychotic severely depressed (N = 53), nonpsychotic moderately depressed (N = 54), and psychotic depressed (N = 25) groups and treated with either imipramine or amitriptyline, up to 250 mg/day, for 4 weeks. Good response occurred in 39% of the 38 severely depressed, 67% of the 49 moderately depressed, and 32% of the 19 psychotic depressed patients who completed treatment. The response of the patients with nonpsychotic severe depression did not differ significantly from the response of those with psychotic depression, and both groups fared worse than the group with nonpsychotic moderate depression.

Problems with the differentiation of anxiety and depression

This paper discusses the problems of differentiating anxiety and depression. Assessment of these two clinical states is particularly difficult since they are typically intermingled. Theoretical analysis of the current use of the constructs and a sound psychometric approach can disentangle them. Unfortunately, the most widely used assessment methods do not measure anxiety and depression independently.

On the expression of psychosis in different cultures: schizophrenia in an Indian and in a Nigerian community

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and "self-centered" orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

Sociodemographic and prior clinical course characteristics associated with treatment response in depressed patients

A sociodemographic and clinical picture is presented of 82 depressed subjects who had an unequivocal response or lack of response to treatment with amitriptyline or imipramine. Patients with less severe depressive illness were found more likely to respond to treatment, while those with psychotic features were more likely to be treatment resistant. Sociodemographic and other prior and current clinical course variables were not predictive of treatment response in depressed patients.

Reflex sympathetic dystrophy affecting the knee

Thirty-six patients with reflex sympathetic dystrophy primarily affecting the knee were reviewed. Injuries or operation about the patellofemoral joint triggered its onset in 64% of patients. Co-existent mechanical derangement of the knee was present in 64% of patients. Those patients who underwent sympathetic blockade or sympathectomy within one year of onset of symptoms had significantly better pain and function scores than those in whom intervention was later. Early diagnosis remains the key to successful management. Surgery for co-existent mechanical derangement in the affected knee should not be performed until the syndrome is controlled.

The timing, specificity and clinical prediction of tricyclic drug effects in depression

This research was aimed at studying the rate of action of tricyclic drugs in depressive disorders, specifying the behavioural effects associated with recovery, and predicting clinical response. The research design involved comparison of a recovered group with a group treated for the equivalent four weeks, who showed minimal to no response. The findings indicated significant differences in baseline characteristics between responders and non-responders. Further, the drugs were found to act early in the responders, within the first week of treatment. Specific changes at one week which distinguished responder and non-responder groups occurred in the disturbed affects, and in cognitive functioning. Improvements also occurred in somatic symptoms, but these latter changes were general and not associated with later recovery. At 2 1/2 weeks, all facets of the depressed condition showed positive change in the responders. Implications of the results for assessing rate of tricyclic drug actions, their effects on the interaction of affect and neurochemistry, and the practical application of the results for the clinical situation, are discussed.

Lithium carbonate treatment of mania. Cerebrospinal fluid and urinary monoamine metabolites and treatment outcome

Treatment of manic patients with lithium carbonate was associated with significant decreases in cerebrospinal fluid (CSF) 3-methoxy-4-hydroxyphenylglycol (MHPG) and urinary norepinephrine excretion. These measures, before treatment, were higher in manic patients than in either depressed or normal subjects and correlated significantly with severity of mania. Levels in CSF of homovanillic acid and 5-hydroxyindoleacetic acid did not correlate with severity or with change during lithium carbonate treatment. Responders (about 70% of the patients) did not differ from nonresponders in pretreatment mania ratings or neurotransmitter measures. The CSF MHPG and urinary norepinephrine excretion were reduced during lithium carbonate treatment in both responders and nonresponders. Unlike the case before treatment, urinary MHPG excretion was higher during treatment in nonresponders than in responders and correlated with several indexes of symptom severity. These results support a relationship between mania and increased noradrenergic function. Treatment outcome, however, was not related exclusively to the reduction of noradrenergic indexes by lithium carbonate since reductions were similar in both responders and nonresponders. Reduced noradrenergic activity may therefore be necessary but not sufficient for successful outcome during lithium carbonate treatment.

Weight loss, cortisol levels, and dexamethasone suppression in major depressive disorder

Appetite and/or weight loss are integral, albeit not necessary, symptoms of depression. We explored the contribution of diminished appetite and/or weight loss ascertained by history to the hypothalamic-pituitary-adrenocortical (HPA) axis dysregulation in 120 patients with primary major depressive disorder. Significant positive relationship for both appetite and weight loss with cortisol levels in plasma and cerebrospinal fluid (CSF) were observed. Plasma cortisol levels were consistently higher in patients who noted both appetite and weight loss as opposed to patients without appetite or weight loss. Depressed patients with weight loss showed higher rates of dexamethasone-nonsuppression. Age and severity of depression influenced but did not eliminate the significance of the findings, suggesting that weight loss accounts in part for the HPA-axis function changes observed in depression.

Diagnosis and treatment of mixed mania

In a study of 19 manic patients, the authors found that eight suffered from mixed mania, a condition in which depressive symptoms are found in the context of classic manic features. The presence of a mixed manic state predicted at least a slower and possibly a poor response to lithium therapy. The authors suggest that the delineation of a subgroup of mixed manic patients might help to identify potential lithium-resistant patients.

The use of patch angioplasty to alter the incidence of carotid restenosis following thromboendarterectomy

Eighty-nine consecutive patients were followed for twelve to twenty-four months after carotid thromboendarterectomy. Forty-seven underwent operations using a standard carotid closure; a second group of forty-two patients had a saphenous vein patch graft applied in closure. The patients were evaluated with carotid duplex scans at regular intervals to evaluate the incidence of early restenosis. Patients with positive duplex scans underwent arterial angiography or digital subtraction angiography. Operative mortality was zero. Twelve late deaths occurred; eleven due to cardiac disease. In the unpatched group, 19.1% of the patients developed significant restenosis (a luminal narrowing of greater than 50%) with only a 2.4% incidence occurring in the patched group, a statistically significant difference (p less that 0.05). There was a higher incidence of symptomatic restenosis in the unpatched group, though the results were not considered significant. Venous patch rupture was seen in three patients who have not been included in the study group. All of these had venous patches harvested from a distal greater saphenous vein site at the ankle. The authors recommend venous patch closure with a thicker patch taken from the proximal saphenous vein at the groin to reduce the incidence of early restenosis and to avoid venous patch rupture. Regular non-invasive evaluation is recommended to detect restenosis with careful clinical follow-up to evaluate neurologic complications.

Structural behavior of the halo orthosis pin-bone interface: biomechanical evaluation of standard and newly designed stainless steel halo fixation pins

The structural response of the halo orthosis pin-bone interface to transverse loading was evaluated on an Instron testing machine using fresh cadaver calvarium sections. Commercially available stainless steel (control) pins and newly designed stainless steel experimental pins were evaluated. Cyclic loading tests and load-to-failure tests were performed. Of the many designs tested, one pin demonstrated an improvement in structural properties at the pin-bone interface compared with the control pin. Furthermore, the new pin design was more resistant to insertional torque reduction when subjected to cyclic loading after insertions at 4 and 6 in-lb. Both the control and experimental pins exhibited improved structural behavior at 8 in-lb of insertional torque compared to the currently recommended 6 in-lb.

Cerebrospinal fluid amine metabolites. Relationships with behavioral measurements in depressed, manic, and healthy control subjects

We studied 99 hospitalized depressed, 14 manic, and 61 healthy control subjects and evaluated relationships during a drug-free baseline period between behavioral measures (postulated to be associated with brain norepinephrine, dopamine, and serotonin function) and metabolites of these neurotransmitters sampled from lumbar cerebrospinal fluid (CSF): 3-methoxy-4-hydroxyphenylglycol (MHPG), homovanillic acid, and 5-hydroxyindoleacetic acid. Depressed subjects with increased anxiety, agitation, somatization, and sleep disturbance were found to have significantly elevated concentrations of CSF MHPG; this relationship was not found in the healthy controls. A correlation between CSF MHPG level and an anxiety/agitation dimension measured in all subjects was statistically significant but explained a modest portion of the total variance. No consistent relationships were found between CSF MHPG and depression/retardation, hostility/interpersonal sensitivity, and global severity, nor did any of these measures correlate significantly with the levels of the other monoamine metabolites, although some trends were found. Other factors did not account for the relationships between CSF MHPG and some behavioral measures, including diagnostic subgroup, motor movement, age, sex, and premenopausal or postmenopausal status in women. Suggested relationships among drug treatment modality, eventual treatment outcome, behavioral and mood state at baseline, and these metabolite levels will require further analyses.

Intervertebral disc nutrition. Diffusion versus convection

Nutrient diffusion across the vertebral endplate can occur by convection (bulk flow) or diffusion. Previous studies, using animal models, suggested diffusion as the primary mechanism of small-solute transport but did not adequately determine the contribution of bulk flow to total nutrient transport. This study was designed to reevaluate disc nutrition across the endplate. Ten microcuries of radioactive sulphate in aqueous solution were injected into L4 vertebral bodies of 13 rabbit spines following sacrifice. One hour of continuous passive flexion/extension in a physiologic range of motion was performed on five spines, while eight spines served as motionless controls. Autoradiographic techniques were used to analyze and compare the isotope uptake in the L4-L5 disc. There was no significant difference in disc uptake or the ratio of disc/bone uptake between the two groups. Motion does not significantly facilitate the transport of small solutes into the disc during short periods of time.

Biochemistry and suicidal behavior in depressed patients

The present study was undertaken in order to further explore the relationship between monoamine levels and hypothalamic-pituitary-adrenocortical (HYPAC) functioning and suicidal behavior in depressed patients. One hundred and thirty-two depressed inpatients participated in the NIMH Collaborative Study on the Psychobiology of Depression. Similar to previous reports, our suicide attempters were younger, more likely to be bipolar, had an earlier age at onset, and displayed more psychotic features. No correlation between cortisol hypersecretion or Dexamethasone Suppression Test (DST) nonsuppression and suicide attempts were found. Only the pre-DST evening plasma cortisol distinguished the groups, being lower in the attempter group. We were unable to confirm the previously reported correlation between cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HIAA) and suicide attempts. Of the monoamines examined, only urinary and plasma 3-methoxy-4-hydroxphenylglycol (MHPG) differed between suicide attempters and nonattempters, showing lower levels in the attempter group. There was a trend for CSF MHPG in the same direction. This latter reduction was restricted to the bipolar group.

Lithium treatment of mania: clinical characteristics, specificity of symptom change, and outcome

The effects of lithium treatment and prediction of response in 18 manic patients were studied as part of the National Institute of Mental Health Collaborative Study of the Psychobiology of Depression. Patients were rated using the Mania Diagnostic and Severity Scale (MADS) and an additional battery of behavioral constructs developed for measurement of state and drug response in depressed patients. About 67% of the patients had good treatment outcome after 26 days of lithium treatment. Responders did not differ from nonresponders before treatment with respect to delusions, hallucinations, or irritable-paranoid symptoms. Nonresponders were rated as more anxious than responders before treatment and had higher scores on the Hamilton Rating Scale for Depression. Improvement on the MADS, however, did not correlate with pretreatment behavioral ratings. Patients with relatively high ratings for aspects of behavior not specific to mania tended to improve in these regardless of change in MADS score. Manic patients who were also depressed (44%) had higher mania ratings than manic patients who were not depressed. Patients with concomitant depression and mania had significantly worse overall treatment outcome, although their depression ratings improved during lithium treatment.

Reflex sympathetic dystrophy as a cause of poor results after total knee arthroplasty

In a series of 662 primary total knee arthroplasties, reflex sympathetic dystrophy (RSD) was diagnosed in five patients (0.8%), four of whom demonstrated marked limitation of flexion requiring manipulation during the early postoperative period. Limitation of flexion, along with excessive pain and cutaneous hypersensitivity, should alert the surgeon to the possibility of RSD. Classic posttraumatic RSD findings of objective vasomotor changes and radiographic osteopenia may be difficult to interpret in patients after total knee arthroplasty. Sympathetic blockade is the key diagnostic and therapeutic measure in the management of RSD. RSD should be considered in a differential diagnosis of early poor results after total knee arthroplasty.

Depressive behavior and hyperactive adrenocortical function

This study examined relationships between depressive subtypes, clinical-behavioral characteristics, and hypothalamic-pituitary-adrenocortical (HPA) function in 132 hospitalized depressed patients. There were significant positive correlations between several pre- and postdexamethasone plasma cortisol measures and anxiety, psychomotor disturbance, distressed expression, and sleep disturbance. Few significant relationships were seen between illness severity and HPA function. Virtually no endocrine differences were seen between endogenous and nonendogenous subtypes or between psychotic and nonpsychotic subtypes. These results and the previous literature suggest a profile of depressed patients with HPA overactivation; they are likely to be anxious, to have sleep and psychomotor disturbances, to have lost weight in the current episode, and to be older.

Somatic symptoms in primary affective disorder. Presence and relationship to the classification of depression

The incidence and severity of somatic symptoms were determined in 132 patients with major depressive disorder and 80 normal controls. The role of somatic symptoms was analyzed in relation to the unipolar-bipolar division, Research Diagnostic Criteria (RDC) subtypes, hypersomnia, and appetite increase. The data suggest that the rate and level of somatic symptoms increased with the severity of depression and age, only appetite loss differentiated unipolar from bipolar patients, and the classic somatic symptoms of depression were present in most RDC subtypes and not exclusively associated with the "endogenous" subtype. Hypersomnia or increased appetite identified two overlapping depressive subgroups; patients in both groups were young and characterized by high interpersonal sensitivity. Hypersomniac depressed patients were less anxious and agitated; patients with increased appetite were more hostile and showed a greater decrease in libido than age-matched and sex-matched patients with neither symptom.

Lower-extremity sensibility testing in patients with herniated lumbar intervertebral discs

The significance of sensory changes determined by pinprick and light touch in individuals with a herniated lumbar disc has been questioned. Discrepancies may be related to the subjectiveness of the test, failure to use dermatome-specific testing sites, overlap of areas that are innervated by different nerve roots, anatomical variations, or lack of sensitivity of the testing technique. For this study, we assessed the results of sensory examinations of twenty-five patients with documented herniation of a lumbar disc. The examinations were done using Semmes-Weinstein monofilaments, vibrometry, pinprick, and light touch in the autonomous skin areas supplied by the fourth and fifth lumbar and first sacral-nerve roots. Right-left differences in Semmes-Weinstein pressure thresholds of more than fifteen milligrams per square millimeter enabled us to localize disc lesions to a specific root in 100 per cent of patients and differences in vibratory thresholds of more than 3.5 micrometers, to localize the correct level in 88 per cent. Lesser differences in thresholds did not help to identify the involved root. The mean sensory threshold on the side of the disc lesion was found to be significantly greater than that on the opposite side by both vibrometry and pressure aesthesiometry (p less than 0.005). These findings were not duplicated using light touch or pinprick testing. Even with the most sophisticated sensibility-testing techniques, correct identification of the nerve root that was compressed by a herniated lumbar disc was accurate in only 50 per cent of patients.

Mania. Diagnosis, state measurement and prediction of treatment response

The phenomenology of the manic state and its response to lithium drug treatment were intensively studied as part of a larger NIMH Clinical Research Branch Collaborative Program on the Psychobiology of Depression. In view of the weaknesses in current methods for measuring the components of the manic state, a new instrument was developed, the Manic Diagnostic and Severity Scale (MADS). Its sensitivity in diagnosis and in measuring change was compared to other scales already in use. Finally baseline clinical data is presented that suggests that the presence of a "mixed" manic state is a predictor of lack of clinical response to lithium treatment.

Hereditary tendo Achillis contractures

A study was performed on eight patients with tendo Achillis contractures. Family histories were obtained and a short regimen of casting was performed. Hereditary tendo Achillis contracture is an autosomal dominant condition with variable expression. It is a relatively benign condition that is both a cosmetic and functional problem for the patient. The disorder responds well to a short course of casting. Follow-up exercises are necessary to maintain normal ankle motion and heel strike during gait. Operative treatment was not necessary in these patients.

Pretreatment neurotransmitter metabolite levels and response to tricyclic antidepressant drugs

Relationships between pretreatment neurotransmitter metabolite levels and response to imipramine and amitriptyline were studied in 104 depressed patients. Normal values for urinary norepinephrine and low values for urinary MHPG were associated with greater incidence of drug response in bipolar, but not unipolar, patients. For unipolar, but not bipolar, patients low CSF 5-HIAA and high urinary metanephrine values were associated with a greater incidence of drug response. These data indicate that the pretreatment functional state of catecholamine and serotonin systems is associated with type of response to drug treatment. The authors present hypotheses about the association of alterations in serotonin and norepinephrine systems and definable subtypes of depression.

A multi-vantaged approach to measurement of behavioral and affect states for clinical and psychobiological research

The development of methods based on the “multivantaged” assessment of behavioral, affect, and cognitive constructs in patients with affective disorders, is reponed. The state and outcome constructs were derived for application in clinical and psychobiological studies, particularly those aimed at testing biobehavioral hypotheses and the evaluation of the effects of drugs. The development of the constructs is based on the combining of scales from established measures which assess the patient in the interview, on the ward, from his self-report, and from a new vantage, through video methodology. Psychometric analyses primarily from data from the NIMH Collaborative Study of the Psychobiology of Depression describe the assembling of the 11 state constructs, and the estimation of their reliabilities, their interrelationships, and their validities. The methods are shown to be capable of characterizing pathologic and “normal” affects, social and expressive behaviors, and impairments in the cognitive and somatic spheres. They differentiated such diverse groups as depressives, manics, and normals, and such behaviorally similar depressive types as the unipolar and bipolar. Preliminary evidence is reported which indicates differential sensitivity to the effects of tricyclic drugs

Behavioural measurement and drug response characteristics of unipolar and bipolar depression

This research is part of the NIMH--CRB Collaborative Study on the psychobiology of depression. The main objective of the research programme is to test hypotheses concerning the interaction of neurobiological mechanisms and behaviour in the depressive disorders. Part I of the report describes the rationale and the overall approach to measuring behavioural state and outcome in the research programme. Part II reports on the results of applying the behavioural methods to a comparison of the clinical phenomenology of unipolar and bipolar depression. The behavioural patterns expressed during the episode by the two groups are different. Further, the two types are shown to react differently to treatment with tricyclic drugs, reinforcing the thesis that they are qualitatively distinct forms of the depressive disorders.