Ira M. Lesser

Frontal lobe degeneration Clinical, neuropsychological, and SPECT characteristics

The clinical, neuropsychological, and cerebral blood flow characteristics of eight patients with frontal lobe degeneration (FLD) were studied. Social withdrawal and behavioral disinhibition were the earliest and most common clinical presentations, and psychiatric symptoms typically preceded the onset of dementia by several years. Neuropsychological testing showed selective impairment of frontal and memory tasks with relative sparing of attention, language, and visuospatial skills. Single-photon emission computerized tomography demonstrated frontal and temporal hypoperfusion with relative sparing of parietal and occipital blood flow. Previous studies suggest that the neuropathologic findings in patients with FLD are varied; some demonstrate frontal gliosis, neuronal loss, and Pick bodies while others show only gliosis and neuronal loss.

Combining Medications to Enhance Depression Outcomes (CO-MED): Acute and Long-Term Outcomes of a Single-Blind Randomized Study

OBJECTIVE Two antidepressant medication combinations were compared with selective serotonin reuptake inhibitor monotherapy to determine whether either combination produced a higher remission rate in first-step acute-phase (12 weeks) and long-term (7 months) treatment. METHOD The single-blind, prospective, randomized trial enrolled 665 outpatients at six primary and nine psychiatric care sites. Participants had at least moderately severe nonpsychotic chronic and/or recurrent major depressive disorder. Escitalopram (up to 20 mg/day) plus placebo, sustained-release bupropion (up to 400 mg/day) plus escitalopram (up to 20 mg/day), or extended-release venlafaxine (up to 300 mg/day) plus mirtazapine (up to 45 mg/day) was delivered (1:1:1 ratio) by using measurement-based care. The primary outcome was remission, defined as ratings of less than 8 and less than 6 on the last two consecutive applications of the 16-item Quick Inventory of Depressive Symptomatology--Self-Report. Secondary outcomes included side effect burden, adverse events, quality of life, functioning, and attrition. RESULTS Remission and response rates and most secondary outcomes were not different among treatment groups at 12 weeks. The remission rates were 38.8% for escitalopram-placebo, 38.9% for bupropion-escitalopram, and 37.7% for venlafaxine-mirtazapine, and the response rates were 51.6%-52.4%. The mean number of worsening adverse events was higher for venlafaxine-mirtazapine (5.7) than for escitalopram-placebo (4.7). At 7 months, remission rates (41.8%-46.6%), response rates (57.4%-59.4%), and most secondary outcomes were not significantly different. CONCLUSIONS Neither medication combination outperformed monotherapy. The combination of extended-release venlafaxine plus mirtazapine may have a greater risk of adverse events.

Progressive Right Frontotemporal Degeneration: Clinical, Neuropsychological and SPECT Characteristics

The behavioral, neuropsychological and single photon emission computerized tomography characteristics of 5 patients with progressive degeneration of the right hemisphere are described. In all, the brain regions with greatest involvement were right-frontal and temporal. Psychosis, compulsions and behavioral disinhibition were the dominant, and often first, symptoms. Affect was flattened and the patients seemed distant and remote. Neuropsychological testing did not reveal a consistent pattern that helped localize the abnormality to the right frontotemporal region. These patients contrast dramatically to those with left frontotemporal degeneration in whom behavior and psychiatric status is often normal. This study suggests that the right hemisphere may be primary for the control of social conduct.

a Review of the Alexithymia Concept

&NA; Alexithymia is a term meaning “no words for mood.” It has been applied to patients who have marked difficulty in verbal expression of emotions and limited ability to use fantasy. These patients often have psychosomatic illnesses and tend to do poorly in traditional dynamic psychotherapy. The concept is discussed from an historical perspective and its current status in the understanding of psychosomatic illness is assessed. The alexithymia literature is critically reviewed with a focus on definition, measurement, etiological speculations, and the relevance of alexithymia to the psychotherapeutic process. The alexithymic concept has much to offer heuristically, but most of the literature to date has been anecdotal and theoretical, with few research investigations. Suggestions are made for future research that could serve to validate the concept and provide answers to questions regarding symptom formation and psychological problems.

Ethnic differences in clinical presentation of depression in adult women.

This study examined ethnic differences in self-report and interviewer-rated depressive symptoms and estimated the contributions of sociodemographic and psychosocial factors in predicting severity of depression. One hundred twenty-five clinically depressed African American (n = 46), Caucasian (n = 36), and Latina (n = 43) women were recruited. After controlling for differences in socioeconomic status, African American women reported more symptoms of distress and Latinas were rated as significantly more depressed than the other groups. However, these ethnic differences were not moderated by either education or employment. Finally, hierarchical regression analysis indicated that severity of depression was predicted by low education, being single, being Latina, high perceived stress, and feelings of hopelessness. Additional research is needed to validate these results and to investigate their clinical significance.

Performance on frontal lobe tests in healthy, older individuals

Changes with age in cognitive abilities subserved by the frontal lobes have not been well studied, and the existing research has been contradictory, possibly due to uncontrolled effects of medical and psychiatric illness. The purpose of this study was to compare performance of healthy middle‐aged and older individuals on four frontal lobe tests (Wisconsin Card Sorting Test, Stroop Test, Auditory Consonant Trigrams, and Verbal Fluency) to provide information regarding age differences in frontal lobe abilities. Data were obtained on 61 individuals screened for the absence of significant medical, neurologic, and psychiatric illness grouped by three age decades: 50–59, 60–69, and 70–79. Few statistically significant differences were found between groups, suggesting that in a medically and psychiatrically healthy population of older adults, minimal evidence of age differences in frontal lobe abilities can be documented.

Wisconsin card sorting test performance in healthy, older adults: Relationship to age, sex, education, and IQ

We obtained Wisconsin Card Sorting Test (WCST) scores on 91 (35 male and 56 female) healthy, well-educated individuals aged 45 to 83. Women scored better than men on six WCST scores (categories, errors, perseverative responses, % perseverative errors, % conceptual level responses, and trials to first category), while subjects with more than 16 years of education outscored those limited to high school education on four measures (perseverative responses, errors, % perseverative errors, % conceptual level responses). Individuals older than 70 years of age scored less well than younger subjects on only two indices (errors, % conceptual level responses). Full Scale IQ was not related to WCST scores. Our findings suggest that WCST scores should be interpreted within the context of patient gender, education, and age.

Rey-osterrieth complex figure performance in healthy, older adults: Relationship to age, education, sex, and IQ

Abstract Despite the widespread use of the Rey-Osterrieth Complex Figure Test (RO) in clinical practice and research protocols, minimal information is available regarding the influence of demographic factors and intellectual level on test performance, particularly in older individuals. The purpose of the present study was to provide data regarding the relationship of age, IQ, education, and sex to RO copy, 3-min recall, and percent retention in healthy middle-aged and older individuals. Data were obtained on 91 individuals screened for the absence of significant medical, neurologic, and psychiatric illness. RO performance was most closely associated with age and FSIQ; sex and education were not predictive of RO scores. Significantly poorer RO scores did not emerge until age 70 and older.

Neuroendocrine aspects of primary endogenous depression. V. Serum prolactin measures in patients and matched control subjects

To ascertain the extent of dysregulation of prolactin (PRL) secretion in endogenous depression, we determined nocturnal serum PRL concentrations and PRL responses to thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (LHRH), and dexamethasone administration in 40 Research Diagnostic Criteria (RDC) primary, definite endogenous depressives and 40 individually matched normal control subjects. Compared to their matched controls, the patients showed no difference in basal nocturnal PRL concentrations, a marginally significant 20%-25% increase in the PRL response to TRH, and no differences in post-LHRH or postdexamethasone PRL concentrations. In the patients, there was a weak, negative correlation between age and PRL (r = -0.30), but none of the other subject characteristics or specific dimensions of depressive symptomatology were significantly related to the PRL measures. The PRL measures also were unrelated to pre- and postdexamethasone cortisol concentrations and to the thyrotropin (TSH) responses to TRH in both groups of subjects. In contrast to the previously reported hypothalamo-pituitary-adrenal cortical and thyroid axis abnormalities in these patients, our findings suggest that PRL secretion was relatively normal.

Clinical and Neuroradiologic Features Associated With Chronicity in Late-Life Depression

The authors conducted a 6-year follow-up of 16 patients with late-life depression to evaluate the relationships between clinical and neuroradiologic variables and disease outcome. Patients had a comprehensive neuropsychiatric evaluation and magnetic resonance imaging (MRI) at baseline and follow-up. Eight of the 16 developed a chronic course of unremitting major depression sufficient to cause significant psychosocial impairment. Six patients with a chronic course and four patients with a non-chronic course of depression had white matter hyperintensities (WMH) on MRI at baseline. Four patients whose WMH increased in size over time developed a chronic unremitting course of depression. No patients with non-chronic depression had large areas of WMH at baseline or exhibited increased WMH size over time. Chronic depression was associated with severity of cerebrovascular risk factors, apathy, and poor quality of life. Treatment and prevention of cerebrovascular disease may improve the outcome of late-life depression.