Giacomo d'Elia

COMPARISON OF ELECTROCONVULSIVE THERAPY WITH UNILATERAL AND BILATERAL STIMULATION

Studies of the electroencephalographic (EEG) pattern in electroconvulsive therapy (ECT) with traditional bitemporal stimulation have given fairly consistent information. During the seizure, when the recording requires total muscular relaxation, the EEG pattern is characterized by a bilaterally synchronous rhythm with decreasing frequency from 7 to 2 c/s and, during the tonic phase, superimposed spikes (Meyer-Mickeleit 1949, Piekenbrock, Taylor & Becka 1956, Piette 1958, Kirstein & Ottosson 1960). The activity stops simultaneously in all leads and is followed by an electrical silence. The first activity to appear after the seizure is bilaterally synchronous, episodic delta waves (0.5-3.5 c/s) often with frontal dominance. They later become continuous and are followed by more or less rhythmic delta mixed with theta (4-7.5 c/s) activity. By the time the patient regains consciousness an alpha rhythm (8-13 c/s) reappears. After the first treatment, an approximately normal state is resumed within about 30 minutes. After the following treatments the EEG changes become more persistent until the records remain abnormal between treatments. The persistence of the EEG changes is thus related to the number of treatments, but also to their frequency. The abnormalities are usually symmetrical (Meyer-Mickeleit 1949, Piekenbrock, Taylor & Becka 1956, Piette 1958, Kirstein & Ottosson 1960, Chatrian & Petersen 1960, Stein et al. 1968, see also Kalinowsky & Hippius 1969). The relationship between stimulus intensity, seizure and post-seizure activity was studied by Kirstein & Ottosson (1960) who found no quan-

X. Mortality, Suicide and Life‐cycles

This report covers part of an investigation (Perris: 1966) concerned with a possible differential diagnosis between bipolar (manic-depressive) and unipolar recurrent depressive psychoses according to the classification of Leonhard (1959) and deals with a study of mortality rate and the incidence of suicide. Some details will also be given concerning the lifecycles of patients who died during the period of investigation. Investigations into mortality in depressive psychotics have appeared in the litterature: Pollock (1931), Malzberg (1934), Essen-Moller [1935), Schultz (1 949), Stenstedt (1 952, 1959), Kinkelin (1 954), Astrup e t al. (1959). The mortality in the series combining both bipolar and unipolar depressive patients has been found to be higher than in the normal population. Pollock Cop. cit.) found that 65 per cent of his large series of ))manicdepressive)) patients died before the age of 50. Stenstedt (1952) reports that the remaining mean expectation of life in manic-depressive patients is about 15 per cent lower than in the normal population. Astrup e t al. (op. cit.) found that the mortality in a group of treated manic-depressive patients was higher in males. This finding is confirmed by Lewis (1964) who states that the crude death rate in men is nine times and in women six times the corresponding rate for persons aged 16 or more in the general population. As was pointed out elsewhere: Perris & d’Elia (1964) it is probable that under the diagnosis of involutional melancholia have also been collected, among others, depressive psychoses which were to be considered as ))unipolar)) in the sense of Leonhard (op. cit.). In his series of ))involutional melancholia)), Stenstedt (1959) found that the remaining mean expectation of life was 42 per cent in the males and 26 per cent in the females lower than in the general population. Stenstedt, however, makes some reservations on these results.

Electrodermal activity in antidepressant medicated and unmedicated depressive patients and in matched healthy subjects

A group of 59 depressive in‐ and outpatients displayed statistically significantly subnormal electrodermal activity (EDA) according to the skin conductance level, the skin conductance response magnitude, the skin conductance response rate, and the index of nonresponding during neutral tone stimulation, compared to 59 mentally and somatically healthy subjects, individually matched for age and sex. Comparisons between 20 antidepressant medicated and 20 unmedicated patients, matched for age, and comparisons between 21 drug‐free patients and 10 patients medicated exclusively with antidepressants yielded no statistically significant difference in any EDA variable. However, all the electrodermal central values were somewhat lower in the medicated patients, possibly an effect of greater severity of symptoms. The present and previous findings offer strong support to the hypothesis of a subnormal function of the electrodermal activity in groups of depressive patients.

IX. Therapy and prognosis

This report is part of a comprehensive study of bipolar (manic-depressive) and unipolar depressive psychoses (Perris: 1966, I-X) and gives an account of the prognosis and of the results of the therapy in these two groups of depressive psychotics treated at the Sidsjon Mental Hospital, with a follow-up of at least two years. In spite of numerous reports concerning the results of different therapies in depressive states, which have been published recently: Nystrom (1964), Carney et al. (1965), Mendels (1965), Hordern (1966), and of numerous meetings concerned with this problem, the opinions concerning therapeutic possibilities in depressive states and long-term results are still controversial. There are very few reports in the literature which might be compared with our investigation, the main obstacle being a difference in the classification of the cases. Our ))bipolar)) series, e.g. comprises only manic-depressive patients within the limits of Leonhard’s classification (1959), i.e. patients who experienced both manic as well as depressive phases. There is no comparison in the literature where less narrow criteria are generally used for the diagnosis of manic-depressive psychosis. Angst (1961) and Fazio & Giberti (1963) adopt Leonhard’s classification but their results are mainly concerned with imipramine therapy. Bruce et al. (1960), Catalano-Nobili & Cerquetelli (1960), Furst (1961), Nayrac et al. (1960), Degwitz (1961), Norris et al. (1961), Oltman & Friedman (1961, 1962), Kristiansen (1962), Flynn & Hirsch (1962), Wittenhorn et al. (1961), Alberti (1963), Hutchinson & Smedberg (1963), Raun (1964), Langsley & Siirdma (1965), Arnold & Kryspin-Exner (1965), among others, give in their reports a comparison between E. C. T. and antidepressants in the treatment of affective disorders. But the classification is often rather indefinite, the main stress laid upon a distinction of more or less severe ))endogenous)) depressions versus neurotic or ))exogenous)) depressive states.

Electrodermal activity in relation to diagnostic subgroups and symptoms of depressive patients

The electrodermal activity (EDA) in 59 depressive patients was investigated during stimulation with neutral tone stimuli. The patients were classified according to six dichotomies: 1) dysthymic disorder vs major depressive episode (DSM‐III); 2) melancholic vs nonmelancholic major depressive episode (DSM‐III); 3) endogenous vs nonendogenous (Newcastle scale); 4) high vs low inhibition; 5) psychomotor inhibition vs agitation; and, 6) indices of high vs low hypothalamic distrubance.

Changes in psychopathology in relation to EEG variables and visual averaged evoked responses (V. AER) in schizophrenic patients treated with penfluridol or thiothixene

In a study of 28 schizophrenic in‐patients treated with penfluridol or thiothixene, patients were followed with clinical ratings, EEG variables, the mean integrated amplitude (MIA) on both the left and right sides ‐ both with filters with frequency ranges from 7.5 to 13.5 and 0.5 to 25 Hz ‐ as well as its within‐patient variance (WPV) on both sides and with both filters, and also with visual averaged evoked responses (V. AER). Moreover, determinations of plasma levels of the drugs were conducted in a search for possible objective measurements of the effects of the treatment, but also to try to find measurements that would make it possible to predict the outcome of treatment. MIA left/right and WPV left/right were found to be the most promising variables to follow the effect of treatment, which were correlated to factors 1 and 2 of the Mårtens S‐scale. WPV left/right before treatment was correlated to changes in factor 4 of the S‐scale during the trial.

CAN SELF‐RATING REPLACE DOCTOR'S RATING IN EVALUATING ANTI‐DEPRESSIVE TREATMENT?

Sixteen depressive out‐patients with endogenous or mixed endogenous‐psychogenic depression were rated before and during antidepressive drug treatment using the Zung self‐rating scale, the Cronholm‐Ottosson depression scale and a global rating. The scores displayed a parallel course, but the correlations between them were only moderate, and between the score differences were still lower. When levels of significance of score differences and global ratings were used as measures of treatment effects, the self‐ratings were least sensitive. The study gives no support for a replacement of the doctors rating scale with self‐rating according to Zung.

PATHOPLASTIC SIGNIFICANCE OF THE PREMORBID SITUATION IN DEPRESSIVE PSYCHOSES

In this paper we give an account of a preliminary attempt at delimiting and defining the depressive psychoses. In a previous paper (D’ELIA & PERRIS, 1964) we discussed the theoretical points of view found in the literature concerning the nosography of affective disorders and recommended a classification mainly derived from the modern German nosographic doctrines (LEONHARD, 1959). Further, we have taken into consideration STENBACK’S notion of “middle age depressions”, which in our opinion is more correct than “involutional melancholy”, and have assumed that “middle age depressions’, according to STENBACK and “unipolar depressions” according to LEONHARD are merely different terms, which in reality cover the same nosographic entity. We presume that the characteristics of “unipolar depression”, which according to LEONHARD should be distinguished from the “bipolar” ones (manic-depressive), correspond on the whole to these considered as typical of the pure forms of the “involutional melancholy” in the sense of KRAEPELIN. That the agreement is not always absolute is chiefly due to the fact that the casuistics of involutional melancholy described in literature often cover mixed impure cases (late manicdepressive or other bipolar psychoses, brain atrophies, late schizophrenic psychoses with depressive onset, organic depressions, psychogenic and endoreactive psychoses) and also to the fact that no diagnosis is more difficult than the correct onc of a single episode of depression. A review of the literature on our subject gives theoretical support to our hypotheses particularly on the following points:

A DOUBLE BLIND COMPARISON BETWEEN DOXEPIN AND DIAZEPAM IN THE TREATMENT OF STATES OF ANXIETY

Doxepin in greater doses has shown both in open and blind studies antidepressive properties comparable to amitriptyline and imipramine: Pitts (1969), Belsasso et al. (1969), Castrogiovanni e t al. (1971). In smaller doses doxepin has anxiolytic properties therapeutically equal to those of the benzodiazepines; also according to both open and blind studies (Rickels et al. (1969), Kingstone et al. (1970), Sterlin e t al. (1970), B i a n c h i o Phillips (1972)).

Multifamily educational intervention in schizophrenia I. Does it have any effect

The aim of this study was to examine whether a multifamily educational program, consisting of six sessions, may increase the relatives amount of information about schizophrenia, change behavioural aspects related to criticism towards and emotional overinvolvement in the ill family member, and influence relatives perceived burden of the illness. At the end of the program the relatives showed a significant increase in their knowledge about schizophrenia. About 50% of the relatives who initially scored“high” in levels of criticism and emotional overinvolvement changed to“low” score levels. The educational program probably contributed to alleviate the relatives feelings of distress. However, the relatives were still highly concerned and worried about the possibility of suicide. The program did not result in decrease in objective burden and did not help relatives to cope with the consequences of the illness. The results of the study encourage the establishment of educational interventions, preferably in the...