Jonathan M. Himmelhoch

Treatment of mixed mania

Mixed mania (i.e., a manic syndrome accompanied by depressive symptoms) and its response to long-term preventive drug treatment was studied as part of a larger NIMH collaborative study. Following recovery from a manic episode, patients received either lithium, imipramine, or the combination of lithium and imipramine for a 2-year period. It was found that patients who had recovered from a mixed manic state were at significantly higher risk for recurrences than patients who had recovered from a pure (non-mixed) manic state. Lithium and the combination of lithium and imipramine were highly effective preventive treatments for the pure manic group and poor treatments for the mixed group. Imipramine was ineffective for both the pure and mixed groups. The need for identifying mixed mania in therapeutic trials and in evaluating alternative treatments for lithium with this subgroup is discussed.

Effects of social skill training, amitriptyline, and psychotherapy in unipolar depressed women

The effects of four treatments for 120 female unipolar (nonpsychotic) outpatients were contrasted: (1) social skill plus placebo, (2) social skill plus amitriptyline, (3) amitriptyline, and (4) psychotherapy plus placebo. Highly experienced therapists conducted 12 weeks of initial treatment and then 6 months of maintenance treatment at reduced frequency. Patients in each treatment condition evinced marked improvements in depressive symptoms and overall neurotic symptomatology, but there was no differential effectiveness among the four approaches. Future research needs in this area are addressed.

Treatment of previously intractable depressions with tranylcypromine and lithium.

Twenty-one depressed patients with so-called “bipolar characteristics” and treated with tranylcypromine are reported. Twenty of these were already on lithium carbonate and 20 had failed to respond to these tricyclic antidepressants in the past. Eighteen patients were hypersomnic and 3 experienced no change in sleep pattern when depressed. Sixteen out of 21 had a good to excellent response to tranylcypromine. Four out of 5 failures demonstrated an “irritable-paranoid” tableau and were diagnosed “schizoaffective” in the past. Questions about the mechanism of action of monoamine oxidase inhibitors and of lithium are raised. The possible existence of subtypes of depression in addition to “unipolar” and “bipolar” is also discussed.

Developing an efficient clinical information system for a comprehensive psychiatric institute: II. Initial evaluation form

This paper describes the objectives, design, organization, content, evaluation, and implementation of the initial evaluation form, first component of a comprehensive psychiatric institute’s clinical information system. Major features of this effort are the involvement of a large number of clinicians in the form’s development, the use of complementary narrative and standardized components, the use of an expanded DSM-III multiaxial diagnostic format, pilot testing with over 1,000 patients, the evaluation of the form’s usefulness and interrater reliability, the form’s computerization, facilitating data retrieval and coordination with other institutional data bases, and the form’s monitoring.

A double-blind study of tranylcypromine treatment of major anergic depression.

Fifty-nine anergically depressed patients were randomly assigned to 6 weeks of double-blind treatment with either tranylcypromine or placebo. Anergic major depression most typically occurs in primary bipolar and in pseudounipolar affective illnesses. We hypothesized that tranylcypromine would be a highly effective and rapid treatment for depressions of this type. Results of repeated measures analyses of variance showed superiority of active drug over placebo by the end of the first week, and this improvement increased in significance at each successive visit. Improvement on tranylcypromine after week 1 was greater than that on placebo after week 6. Analysis of covariance of week 6 scores (corrected for week 0 scores) showed significantly greater improvement for tranylcypromine patients on all measures of depressive symptomatology. Tranylcypromine is a rapid, relatively safe, and dramatically effective treatment for anergic depression. Since 24 of 29 of the bipolar subjects had previously failed to respond to tricyclics and since bipolar depression is usually anergic, tranylcypromine should be compared to imipramine to determine the antidepressant of choice for manic-depressive illness.

Social anxiety, hypomania and the bipolar spectrum: data, theory and clinical issues

Reports in the literature indicate a subtle but consistent relationship between panic and bipolar II disorder. The possible connection between social phobia and bipolarity is less investigated. When we studied the treatment outcome of 32 social phobic patients administered either the reversible monoamine oxidase inhibitor (RIMA) meclobomide or the irreversible inhibitor MAOI phenelzine, we found that eighteen had remission > 50% of their socially anxious symptoms. Moreover, 14/18 of those improved became hypomanic, according to the Raskin Mania Scale (RMS) and the Young Mania Scale (YMS) coupled with expert clinical diagnosis. These findings possibly allude to a relationship of social phobia to bipolarity. Treatment with RIMA or MAOI exposed these subjects as having an atypical bipolar syndrome which is part of the bipolar spectrum. We then compared this special subset of subjects to the 18 socially phobic patients who failed to respond to RIMAs or MAOIs and to 26 patients with generalized anxiety disorder (GAD). Eleven of the 14 hypomanic responders gave histories of serious developmental deprivation (anaclisis); only 5/18 social phobics and 3/26 GADs without hypomanic responses had anaclitic histories. The author raises the possibility that anaclisis may have interacted with the impediment of volition of uncomplicated bipolar depression to produce social inhibition and anxiety. Finally, the author upholds the central role of depressive inhibition in bipolar disorder, which during antidepressant therapy often overshoots in a hypomanic direction; even in the absence of prior spontaneous hypomania, such disinhibition should classify this special subset of social phobic patients within the bipolar spectrum.

A comparison of social-skills training, pharmacotherapy and psychotherapy for depression

Abstract This study compared four treatments for unipolar (non-psychotic) depression: Amitriptyline, Social-Skills Training (SST) + Amitriptyline, SST + Placebo and Psychotherapy + Placebo. In addition, 25 normal women were assessed on the behavioral measures in order to evaluate the ecological validity of the dependent measures and the changes produced by treatment. The four treatments, conducted by experienced clinicians, all produced statistically-significant and clinically-meaningful changes in symptomatology. However, there were several notable differences. The SST groups had greater improvement on measures of social skill, and were more similar to the normal women after treatment. In addition the SST + Placebo group had the lowest level of attrition and had the highest proportion of patients who were significantly improved. Significance of the results for future research on SST and role-play measures of social skill was discussed.

When a Schizoaffective Diagnosis Has Meaning

Recently, there has been a flurry of studies showing that schizoaffective patients, diagnosed using acute symptom complexes, usually turn out to have affective disorders if they are rediagnosed applying more reliable longitudinal parameters. However, Occams razor cuts both ways. This investigation shows that if schizoaffective illness is diagnosed using the nonacute parameter “presence of interepisodic thought disorder,” it looks more like schizophrenia. Schizoaffectives diagnosed this way have earlier onset of illness, tend to remain unmarried, usually do not abuse alcohol or sedatives, have a worse response to psychopharmacological treatments, relapse more frequently, and tend to deteriorate.

Indications for carbamazepine in mental illness: Atypical psychiatric disorder or temporal lobe syndrome? ☆

Abstract A wide range of atypical, labile-pleomorphic psychiatric disorders respond specifically to carbamazepine. The disorders are characterized by evidence of some CNS impairment or a family history of epilepsy, and by mental changes typical for the interictal phase of temporal lobe epilepsy (TLE). Subtle seizures may be present and allow the diagnosis of TLE; in the absence of any seizures, the disorders are identified as temporal lobe syndrome (TLS). The conclusions are supported by the findings in a series of 28 consecutive psychiatric patients who were exemplary carbamazepine responders.

Adjustment of lithium dose during lithiumchlorothiazide therapy

There has been a long‐held belief that lithium salts cannot be used in the presence of thiazide diuretics. Recently, however, thiazldes have been demonstrated to be not only safe, but actually indicated in two situations in which lithium salts are used. The first is in the treatment of lithium‐induced nephrogenic diabetes insipidus and the second is in severe manic depressive illness in whicli high doses of lithium do not produce therapeutic serum or intraerythrocytic lithium concentrations . This new information now makes it possible for some manic depressive patients with serious medical illnesses (such as hypertension or congestive heart failure), in whom thiazide diuretics are routinely used, to be treated cautiously with lithium carbonate. This paper analyzes data from 13 patients taking lithium carbonate and varying doses of chlorothiazide in order to indicate the approximate magnitude of down ward adjustment of daily lithium dose which the clinician must make to safely give 500, 750, and 1,000 mg/day of chlorothiaride.