Characterological depressions. Clinical and sleep EEG findings separating 'subaffective dysthymias' from 'character spectrum disorders'.

Early-onset characterological depressions are distinguished from late-onset chronic depressions that complicate the long-term course of unipolar and nonaffective illnesses. In turn, characterological depressions are divisible into at least two subtypes: (1) "Subaffective dysthymias" have even sex distribution, are often complicated by superimposed depressive episodes, rapid eye movement latency is shortened, and they tend to respond to tricyclics of lithium carbonate. In brief, they share many features of primary affective illness. (2) "Character spectrum disorders," by contrast, represent a heterogeneous mixture of personality disorders with inconstant depressive features, are more common in women, are often complicated by alcohol and drug abuse, and outcome tends to be unfavorable.

The long-term outcome of dysthymia in private practice: clinical features, temperament, and the art of management.

BACKGROUND: With the clinical availability of fluoxetine in the United States, we were interested in documenting improvements in the clinical care of dysthymic patients beyond what was reported from our clinic 2 decades earlier during the "tricyclic (TCA) era." METHOD: In open treatment of 42 consecutive DSM-III-R primary dysthymic patients who were personally followed up in our mood clinic since 1988, response was defined as sustained remission, i.e., no longer meeting criteria for dysthymia and achieving DSM-III-R Axis V Global Assessment of Functioning (GAF) score > 70 throughout much of the mean follow-up of 5 years. RESULTS: Compared to patients with nondysthymic episodic major depressive disorder (N = 42), dysthymic patients had a significantly earlier mean age at onset (12.6 vs. 34 years), were more likely to have never been married, had a greater frequency of superimposed major depressive episodes (except for the 14% [N = 6] with "pure" dysthymia), and had more psychiatric and fewer medical comorbidities; furthermore, patients with dysthymia had significantly greater familial loading of both unipolar and bipolar disorders. Continued treatment with TCA-type antidepressants or fluoxetine (including various augmenting strategies) led to an overall robust and sustained response rate of 76% (N = 32) among dysthymic patients; in tandem, major depressive episodes and suicidality were prevented in all responders. Females treated with fluoxetine had the highest response rate (85% [N = 17]); some were able to walk out of dependent abusive relationships for the first time in their lives. However, dramatic responses with "hyperthymic" switches in temperament occurred in only 12% of dysthymic patients; nearly all were males with bipolar family history. The more prototypic positive change among dysthymic responders consisted of coping with daily hassles without being overwhelmed. Qualitatively, the highest level of adaptive functioning was observed among fluoxetine-treated dysthymics (50% of responders [N = 12] achieved DSM-III-R GAF score of 81-90). Of TCA-treated patients, 39% had intolerable side effects, necessitating switch-over to fluoxetine. Agitation occurred in 11% of fluoxetine-treated patients (N = 4) and was associated with nonresponse and/or dropout; otherwise, this selective serotonin reuptake inhibitor was well tolerated, thereby contributing to long-term compliance. More provocatively, patients with dysthymia who had required extensive psychotherapeutic attention prior to state-of-the-art pharmacotherapy no longer required such therapy. CONCLUSION: These data extend and enrich what has been learned from controlled trials among dysthymic patients. With sustained pharmacotherapy and specialized clinical care in a private mood clinic, 3 of 4 patients immersed in gloom for much of their lives achieved for the first time good to superior levels of functioning that were maintained for an average of 5 years. Although the art of clinical management of dysthymia should be fully grounded in understanding the interpersonal context of depression, we submit that SSRIs such as fluoxetine appear broadly efficacious in areas previously deemed to be the domain of formal psychotherapy.

Bupropion as a promising approach to rapid cycling bipolar II patients.

Bupropion was added to lithium and/or levothyroxine in four female and two male bipolar II patients who had established baselines of at least 2 years of rapid cycling that had not responded to several of the most commonly used anticycling interventions. Although all six patients improved significantly, the response was dramatic in four (three female, one male) and is still sustained after an average of 2 years of continued treatment. Furthermore, unlike what happened in their prior course with more conventional antidepressants, none developed hypomania nor was rapid cycling observed during the course of continued pharmacotherapy. These findings, based on open but systematic clinical observation, suggest that bupropion may have special merit for rapid cycling, predominantly depressed bipolar patients and that, under close clinical vigilance, combining bupropion with appropriate doses of lithium is both efficacious and safe.

The role of bipolarity in depression in the family practice setting.

The literature suggests that bipolar spectrum disorders are more prevalent than previously thought but still poorly recognized. In the primary care setting, this poor recognition is largely the result of an insensitive, cross-sectional approach and clinicians' lack of familiarity with the phenomenology of bipolar II. Failure to recognize the role of bipolarity in depressive illness is more often a cause of the poor outcome of this illness in this setting than under dosing with antidepressants. Hypomania is easily missed in clinical evaluations and, as currently defined by DSM-IV, may not represent the most diagnostic marker for all variants of bipolar illness: Mood lability and energetic activity, temperamental traits embodied in the construct of cyclothymia, have emerged as more specific. Given emerging data that as much as one third of depressions in both psychiatric and primary care settings belong to the soft bipolar spectrum, practitioner education on the necessity to consider course, temperament, and family history in the approach to depression may improve the identification of bipolar spectrum disorders and limit unproductive or potentially harmful antidepressants use unprotected with mood stabilizers.

Saying 'no' to electroshock.

KIE: A 60-year-old man suffering from delusions and depression improved after an initial course of electroconvulsive therapy but then refused to continue the treatment. Doctors told him he could be committed and they eventually gained consent. Sherlock and Haykal believe the patient was treated in a morally justifiable manner. They argue that discharging the patient without treatment would have shown disrespect for his welfare, limiting rather than fostering autonomy. In contrast, Dresser contends that the physicians violated the law in administering ECT to a voluntary patient without his consent. Two legal mechanisms could have been considered: a competency hearing or a commitment proceeding.^ieng

Patterns of symptomatic change in depressed patients in a private inpatient mood disorders program.

This naturalistic study of 352 depressed patients admitted to a mood disorders program in a private psychiatric hospital demonstrated that, for the majority of patients, combining cognitive group therapy with ongoing supportive individual, psychoeducational, milieu, and pharmacological interventions resulted in rapid overall improvement and discharge within a few weeks. Improvement was manifested across cognitive and vegetative factor scores of the Beck Depression Inventory. However, patterns of symptom remission differed for subgroups defined by different lengths of stay. For example, patients hospitalized for 4 weeks showed good initial response, followed by a plateau in improvement, and, finally, continued response. These patients eventually reached the same level of functioning at discharge as did more rapidly responding patients with briefer stays. In contrast, a subset of patients (10% of the sample) hospitalized 5 weeks or more showed less overall improvement (especially in vegetative symptoms), plateauing at a moderately symptomatic level. These data suggest that in a minority of depressed individuals, continuing physiological disturbances may underlie dysthymia or residual depression. However, in contrast to the high rates (20-30%) of chronicity reported from tertiary care settings, these data indicate the relatively good initial treatment response of depressed patients admitted to a private psychiatric hospital.

Management of psychotropic-induced hyperprolactinemia.

The effects of individual psychotropic medications on serum prolactin concentrations are described, and recommendations for dealing with adverse effects are provided. Hyperprolactinemia can result in galactorrhea, amenorrhea, irregular menses, and anovulation; in men, impotence and azoospermia, with or without lactation and gynecomastia, can occur. Antipsychotics may block dopamine receptors in the pituitary prolactin-secreting cells and prevent dopamine-induced reduction of prolactin release. The magnitude of the increase in prolactin concentration correlates with the amount of antipsychotic drug given. The treatment of choice is reduction of the antipsychotic dosage or discontinuation of therapy. If adjustments to the antipsychotic dosage fail to resolve symptoms, the dopamine agonists bromocriptine and amantadine may be tried. Antidepressants may produce elevated serum prolactin concentrations, especially with long-term administration. However, the frequency of antidepressant-induced hyperprolactinemia is much lower than that seen with antipsychotics, and serious adverse clinical effects are uncommon. Other psychotropic drugs such as lithium, valproic acid, buspirone, carbamazepine, and benzodiazepines either are only rarely associated with symptomatic hyperprolactinemia or do not produce clinically important changes in prolactin concentrations. Antipsychotic drugs are the psychotropic agents most likely to cause symptomatic hyperprolactinemia. Bromocriptine or amantadine may provide symptomatic relief if withdrawal or adjustment of the antipsychotic dosage does not eliminate the symptoms.

On the nature of depressive and anxious states in a family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally.

Much of the scientific literature on affective states in primary care settings is derived from instrument-based diagnoses, typically without the benefit of clinical in-depth examination. In a naturalistic family practice setting, we prospectively evaluated 108 consecutive anxious and/or depressed patients. All diagnoses derived from semistructured interviews conducted by a family physician with enhanced training in mood disorders. Nonbipolar depressions were found in 60 of 108 patients (55.6%), nearly half of whom were in the depression not otherwise specified (DNOS) category; yet on careful history, all but two of 28 DNOS cases had major depressive episodes in the past. Twenty-eight patients (25.9%) were diagnosed with bipolar I, II, or III disorder or cyclothymia. Panic disorder was found in 9%, and obsessive-compulsive disorder and active chemical dependency were each diagnosed in 3%. Bipolar spectrum disorders were common (one in three within the depressive group) and at times were not recognized until several weeks or months into the treatment phase of the depressed or anxious state. Although the largest percentage of patients had DNOS at the index episode, bipolar illness (usually bipolar II) was also common. Our findings contrast with the nearly total unipolarity reported in the instrument-based (nonclinician) literature. If generalizable, our observations have significant implications for physician education and practice, since bipolar depressions require different interventions. Further investigation to explore interview approaches and/or instruments sensitive for hypomania and other "soft" bipolar features seems warranted.