Most trials of treatments for depression
focus on the hospital or the outpatient department. A
recent randomized controlled trial looked at standardized
treatments in primary care. Patients received
nortriptyline (91) or interpersonal psychotherapy (93) or
a physician's normal care (92). 70% of patients in the
pharmacotherapy or psychotherapy groups were judged
recovered at 8 months compared to only 20% of 'usual
care' patients. Twelve to sixteen sessions of IPT are
advocated.(Treating Major Depression in Primary Care
Practice - 8 month clinical outcomes by Schulberg H C et
al, 1996 - Arch Gen Psychiatry 53, 913-919).
Of interest to liaison psychiatrists is a study in the
Archives of General Psychiatry (Henk, H J et al 1996, 53,
899-904) entitled Medical Costs attributed to Depression
among patients with a history of high medical expenses in
a health maintenance organization. This looked at the
medical utilization costs of 50 000 patients enrolled in
the DeanCare (a health maintenance organization) for two
years. A depression screen was mailed to 786 high
utilizers. Depressed patients costs were significantly
higher (p<.001) The additional cost per patient was
$1498 per annum adjusted for age, sex, benefits package
and medical co-morbidity. Treatment costs accounted for
only a small percentage of total medical costs for
depressed high utilizers in the third year - suggesting a
direct cost-benefit to depression treatment.
Three research papers in a recent edition of Archives
of Psychiatry focus on brain imaging in obsessive
compulsive disorder(OCD). The first (Aylward et al, 1996;
53: 577-584) examined the brains of 24 patients with
adult-onset OCD and 21 controls. Measurements of the
basal ganglia did not demonstrate any differences.
Theories of OCD have included dysfunction of the basal
ganglia. This theoretical framework of caudate
dysfunction is not underpinned by consistent structural
or functional neuroimaging.
The second paper concerned functional MRI scanning during
periods of controlled symptoms and provoked symptoms in
each of ten patients (Breiter et al, 1996;53:595-606) and
simulation in five normal subjects .
Symptom provocation involved imaginary scenarios and in
vivo flooding. Excess brain activity was mapped in the
medial orbitofrontal, lateral frontal, anterior temporal,
anterior cingulate, and insular cortex together with
basal ganglia. Limbic activations were particularly
The third paper (Jenike et al, 1996;53:625-632)
quantified MRI scans of 10 female OCD patients and 10
controls. Patients with OCD had significantly less total
white matter, but significantly greater total cortex and
opercular volumes. Severity of OCD (measured by the
Yale-Brown Obsessive Compulsive Scale) correlated with
An important longitudinal study of 641 youths who were
assessed in childhood and then 10 years later was
published in the American Journal of Psychiatry
(Bernstein et al, 1996; 153: 907-913). Childhood conduct
problems were an independent predictor of all three
clusters of personality disorders (A, B and C) in
DSM-III-R. Depressive symptoms in boys were a predictor
of Cluster A personality disorders and immaturity was a
predictor of Cluster B personality disorders in girls.
Measures of childhood problems were derived by higher
order principal component analysis of childhood
behavioural ratings. Four measures of problems were used:
conduct problems, depressive symptoms, anxiety/fear and
immaturity. Personality disorders do therefore reflect
longstanding personality dysfunction.
An interesting hypothesis has been put forward by Oren
in The Neuroscientist (2, 4, 207-211, 1996). Oren
puts forward the hypothesis that haem moieties and bile
pigments in animals may mediate some light influences
upon neuroactive gases and biological rhythms ie the
concept of humoral phototransduction. Oren states
that like chlorophylls the haem tetrapyrrole structure
has a similar capacity to transduce photic energy. He
says that the biconcave erythrocyte has an ideal gas
exchange & light absorption area/volume ratio. Blood
flow through the retina and humoral phototransduction may
offer a model for the known effects of light upon
non-enucleated blind animals and people.
The model has interesting possibilities for the
direction of research into psychiatric disorders like
seasonal affective disorder.
BJPsych, 167, 683-688.
In a brave model of openness, the BJPsych published a
paper by McGuigan stating that at least 40% of papers in
the BJPsych have statistical errors; errors serious
enough in some cases to throw doubt on the conclusions of
researchers. The paper in the BJPsych calls this error
rate is 'unacceptably high'.
BJPsych, 167, 629-634.
Lucey et al report the results of a study looking at
30 outpatients from the Maudsley Hospital with DSM-III-R
criteria primary OCD. On SPET scanning, compared to 30
healthy controls, regional cerebral blood flow was
significantly reduced in OCD patients (and not related to
overall reduced perfusion). Reduced flow in the right
inferior frontal cortex appeared to correlate with
illness severity. The authors state that this reduced
perfusion was not associated with age, age of onset, sex,
handedness, depression or medication, (which is as well
since nearly a third of the patients' group were taking
either fluoxetine or clomipramine).
BJPsych, 167, 596-603.
Mason et al report a study of the outcome of 67
patients with ICD-9 schizophrenia 13 years later. 83% of
the sample were 'either (sic) dead, showed some degrees
of symptomatic or social disability, or continued in some
form of continued treatment'. 44% had a mild/recovered
treated outcome. The authors cite others' gloomy
interpretions of Kraepelin's 1919 prognosis and conclude
that Kraepelin's outcome is 'far too pessimistic'.
However the authors singularly fail to consider that this
comparison is spurious, since Kraepelin was documenting a
group of ill people (with dementia praecox) with no
effective treatments at all.
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