Biomedical subjects
W A Scheftner
Publications and source records attributed to W A Scheftner.
Case report of withdrawal syndrome after olanzapine discontinuation.
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Lithium discontinuation and subsequent effectiveness.
OBJECTIVE: Several reports have raised concern that the discontinuation of lithium may result in treatment resistance following recurrence of affective disorder. This report explores this possibility. METHOD: The data derive from a large, naturalistic follow-up of patients with major depressive disorder or mania. Twenty-eight of the patients in the study were free of lithium and experiencing an episode of mania or schizoaffective mania diagnosed according to Research Diagnostic Criteria when they entered the study, recovered while taking lithium, later experienced a recurrence while not taking lithium, and then resumed lithium treatment. Survival analyses of time to recovery and, subsequently, time to recurrence, used continued lithium treatment as an additional censoring variable. RESULTS: Patients given lithium recovered no more quickly from their index episode than they did from their first prospectively observed episode. Moreover, lithium prophylaxis appeared no less effective after the first prospectively observed episode than after the index episode. CONCLUSIONS: These findings provide no evidence that lithium discontinuation results in treatment resistance when lithium is resumed.
Interactions of risk factors in predicting suicide.
The authors examined interactions among risk factors for suicide, a strategy not typically followed in suicide research. Their results suggest an explanation for gender differences in suicide rates and qualifications in the relationship between hopelessness and suicide based on history of drug and alcohol abuse.
Association between major depressive disorder and physical illness.
The association between major depressive disorder (MDD) and self-reported histories of specific physical illnesses was investigated in 320 controls and 1968 first-degree relatives and 254 spouses of probands in the NIMH Collaborative Depression study. The Schedule for Affective Disorders and Schizophrenia-Lifetime Version was used to assign Research Diagnostic Criteria (RDC) diagnoses and a structured self-report instrument was used to assess lifetime medical history. Lifetime MDD was diagnosed in 914 subjects, 402 of whom had been hospitalized or received somatic treatment ('treated' MDD). Strong associations were observed between MDD (either treated or untreated) and both frequent/severe headaches and migraine headaches. There was a marked gender effect such that the relative odds for a woman with treated MDD to report migraine were over 5:1. Other associations were found between MDD and skin infections, respiratory illness, ulcer, hypotension, and diabetes. This is the largest non-patient sample using standardized assessment of mental disorders by direct interview in which associations between specific physical illnesses and MDD have been demonstrated. Implications for clinical practice and neurobiological research in depression are discussed.
The assessment and management of the suicidal patient.
This chapter will be oriented toward the problem faced by the clinician in attempting to prevent suicide in patients under treatment. It will focus on the clinician's difficult task of assessing suicide potential and initiating interventions to prevent suicide in patients at high risk. Specifically, the state of the art in identifying the suicidal patient will be reviewed, and various interventions available to the clinician will be discussed.
Relationship of electroconvulsive therapy to course in affective illness: a collaborative study.
Bipolars treated with electroconvulsive therapy (ECT) during the index episode were matched on the variables of age, sex, previous admissions and previous hospitalizations with 23 bipolars who did not receive ECT. A similar match was made for 42 unipolars who were under the age of 40 at time of admission. All patients were followed for 5 years. Those patients treated with ECT, both bipolars and unipolars, had the same numbers of episodes in follow-up as their matched groups. However, in both bipolar and unipolar ECT-treated patients, there were more follow-up rehospitalizations. The reason for this is not known but three possibilities exist. Successful treatment with ECT may make the family and patient more prone to consider rehospitalization. Secondly, the originally treated ECT patients may have had more aggressive doctors who were more likely to rehospitalize. Finally, ECT may change the course of an individual's illness in such a way that more severe episodes occur and rehospitalizations are necessary. The findings suggest the need for long-term studies following ECT on clinical and biological variables.
Sex differences in the lifetime prevalence of depression: does varying the diagnostic criteria reduce the female/male ratio?
Most studies report the lifetime prevalence of major depressive disorder to be higher among women than men. One possible explanation is that this finding is the result of the diagnostic criteria used, in particular the inclusion of criterion symptoms associated with depressed mood. The number of criterion symptoms required for a diagnosis were varied and applied to 2163 first-degree relatives of affectively disordered probands of the NIMH Collaborative Study of the Psychobiology of Depression. Results indicated that differences between men and women in number of symptoms reported could not account for the difference in rates of depression. Women had a greater number of associated symptoms only at higher symptom levels, suggesting an excess of women only above a diagnostic threshold. Thus, findings supported a true difference in rates of major depressive disorder rather than a general trend for women to remember or report more criterion symptoms.
Concordance of symptoms in recurrent depressive episodes.
The presence or absence of 12 depressive symptoms was examined in 93 bipolar and 108 unipolar patients who had two discrete episodes of major depression over a 5-year period. For each symptom the concordance of its presence or absence across episodes was low. The agreement observed was largely that to be expected by chance. A substantial amount of concordance was obtained if differences in episode intensity (propensity to have symptoms) were taken into account. This suggests that although there may be factors related to depression which remain stable across episodes, symptom presentation is moderated by other factors, such as intensity, which vary from episode to episode.
Gender differences in the clinical features of unipolar major depressive disorder.
Gender differences in the presence or absence and the severity of forty-seven clinician-rated features of depression were examined, controlling for the sex of the rater. Subjects consisted of 498 moderately to severely depressed patients coming for treatment and diagnosed as suffering from nonpsychotic, unipolar major depressive disorder. Significant differences were found only for increased appetite and weight. No differences were observed in endogenous symptoms, global severity of depression, or impairment in functioning. The results indicate that, although the rate of major depressive disorder is greater in women, its symptomatology is relatively homogeneous with regard to gender.
Time-related predictors of suicide in major affective disorder.
The authors studied 954 psychiatric patients with major affective disorders and found that nine clinical features were associated with suicide. Six of these--panic attacks, severe psychic anxiety, diminished concentration, global insomnia, moderate alcohol abuse, and severe loss of interest or pleasure (anhedonia)--were associated with suicide within 1 year, and three others--severe hopelessness, suicidal ideation, and history of previous suicide attempts--were associated with suicide occurring after 1 year. These findings draw attention to the importance of 1) standardized prospective data for studies of suicide, 2) assessment of short-term suicide risk factors, and 3) anxiety symptoms as modifiable suicide risk factors within a clinically relevant period.
What is the mechanism by which suicide attempts predispose to later suicide attempts? A mathematical model.
A state dependence model of serial behavior suggests that each occurrence increases the subsequent likelihood of that behavior being repeated. A heterogeneity model, by contrast, suggests that the likelihood of a behavior occurring is predetermined, and uninfluenced by intervening occurrences. We have applied the random-effects probit model of Gibbons and Bock (1987) to examine the fit of the state dependence and heterogeneity models to longitudinal data on suicide attempts by 928 patients with affective disorder. Heterogeneity but not state dependence was required to model these data. The findings suggest that when considering patients with moderate to severe major affective disorder, the clinician should not interpret the absence of any recent suicide attempts to mean that the patient is at relatively low risk for attempting suicide in the future. An implication of the heterogeneity model is that suicide attempts made many years ago may have equal value to recent attempts when estimating an individual's "predisposition" to nonlethal attempts in the future.
Manic syndrome associated with zidovudine treatment.
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Depression and panic attacks: the significance of overlap as reflected in follow-up and family study data.
Ninety-one patients with panic attacks limited historically to depressive episodes had more severe depressive symptoms and were less likely to recover during a 2-year follow-up than 417 depressed patients who did not have panic attacks. Family study data clearly distinguished another 15 patients with panic disorder and secondary depression; interviewed relatives of panic disorder patients were significantly less likely to have primary depression and significantly more likely to have various anxiety disorders. These data support the hierarchical system by which many of the contemporary diagnostic systems separate panic disorder and major depression.
Family history and five-year suicide risk.
Family history was examined to determine whether suicide in index patients is associated with suicidal behaviour or mental disorder in their first-degree relatives. Twenty-seven suicides occurred within 5 1/2 years among 955 affectively disordered probands. Among 5042 proband relatives aged 18 years and older, 44 had committed suicide prior to proband entry to the study; however, only one was the relative of a proband suicide. Only two of the relatives who committed suicide were themselves related. As to attempted suicide of relatives, neither the number of attempts nor the severity of attempt was predictive of suicide in probands. Comparison of diagnosis between groups of relatives showed more drug abuse among relatives of proband suicides; this appears to be related to drug abuse among the proband suicides themselves. In contrast to the clustering of suicides within biological families found in other research, these data do not support the use of family history as a clinically useful indicator of suicidal potential in affectively disordered probands.
A field test of Motto's risk estimator for suicide.
The authors undertook a field test of Motto and colleagues' Risk Estimator for Suicide by selecting a subset (N = 593) of psychiatric patients with major or chronic affective disorder that corresponded to Motto's sample. They rated each subject on Motto's scale, using standardized data collected at hospital admission. Fourteen patients (2.4%) in their sample and 136 (4.9%) in Motto's sample died by suicide within 2 years. The authors tested the null hypothesis of a uniform suicide risk across all 10 deciles of risk scores by comparing observed and expected frequencies of suicide using the variance test for homogeneity of the binomial distribution. Their findings raise questions about Motto's risk scale but do not definitively invalidate it.
The endogenous sub-type of depression: a study of its internal construct validity.
The internal construct validity of the endogenous sub-type of major depression was investigated by statistically modelling the RDC endogenous and DSM-III melancholia diagnostic criteria. Data consisted of symptom ratings on 788 patients with major depression from NIMH Collaborative Depression Study. Results indicated that the symptoms in the criteria do not specify a dichotomous classification, melancholic-non-melancholic or endogenous-nonendogenous. Results did support the existence of two sub-typings, one related to anhedonia, and one related to vegetative symptoms. The vegetative sub-type rarely occurred in non-anhedonic patients. Previous studies may have found support for a simple endogenous sub-type because of this hierarchical relationship and as a result of methodological differences.