Marie-Paule Austin

Subcortical hyperintensities on magnetic resonance imaging: clinical correlates and prognostic significance in patients with severe depression.

In 39 hospital inpatients with severe primary depressive disorders, we evaluated the relationships between subcortical hyperintensities on magnetic resonance imaging (MRI) and clinical features, neuropsychological impairment and response to standard therapies. Both white matter and gray nuclei lesions were associated with older age and the absence of a family history of affective disorder. White matter hyperintensities were also associated with onset of first affective episode after the age of 50 years and impaired psychomotor speed. Most importantly, the severity of white matter hyperintensities predicted a poorer response to treatment (r = -0.44, p < .01). Negative correlations of the same order were detected in those (n = 20) who received electroconvulsive therapy (r = -0.42, p = .06) and those (n = 19) who received pharmacotherapy alone (r = -.49, p < .05). This study provides preliminary evidence supporting the clinical and prognostic significance of extensive white matter hyperintensities in patients with severe depression.

Cognitive function in major depression.

Forty patients with a major depressive episode were divided into equal endogenous and neurotic sub-groups using the Newcastle scale. They were all rated on the 17-item Hamilton scale and with a variety of neuropsychological tests. They were compared with 20 age- and education-matched control subjects. Both endogenous and neurotic groups had impaired memory function on the auditory verbal learning test; recall and recognition were equally impaired suggesting that effort was not a major determinant of performance. The endogenous group was more impaired on digit symbol substitution and the Trail making test (A and B). Impairment was correlated with symptom scores on the Hamilton and Newcastle scales, even after allowing for the effect of age. It is concluded that the conventional distinction between organic and functional impairment breaks down in severe depressive illness. The implications of this for clinical neuropsychological testing and the anatomy of the brain dysfunction in depressive illness are discussed.

Antenatal screening for postnatal depression: a systematic review

Objective: To describe the screening properties of the antenatal tools which have been developed to predict depression after birth and to summarize the implications of the findings for antenatal screening.

The development of a refined measure of dysfunctional parenting and assessment of its relevance in patients with affective disorders

BACKGROUND The Parental Bonding Instrument (PBI) measures fundamental parenting dimensions (care and over-protection), but does not directly assess abusive parenting. METHODS We describe the development of the Measure of Parenting Style (the MOPS), comprising refined PBI scales assessing parental indifference and over-control, as well as a scale assessing parental abuse. RESULTS We examine psychometric properties of the MOPS, while several analyses build to the concurrent validity of the abuse scale as an experimental measure. We examine the extent to which both the PBI and the MOPS scales showed specificity of dysfunctional parenting to the non-melancholic depressive subtype, and across a range of anxiety disorders. Non-melancholic depressed patients returned anomalous parenting scale scores (compared to melancholic subjects), but only when such subtyping decisions were clinician-generated. Those receiving DSM-III-R lifetime anxiety diagnoses of panic disorder and of social phobia returned higher PBI protection and MOPS over-control scores than non-anxious subjects, while differences were not established for those with generalized anxiety disorder or obsessive compulsive disorder. CONCLUSIONS We consider the likely utility of the MOPS scale and note the module capacity of separate MOPS and PBI scales, which allow a set of options for assessing perceived parenting characteristics.

Single photon emission tomography with 99mTc-exametazime in major depression and the pattern of brain activity underlying the psychotic/neurotic continuum.

Forty patients with a major depressive episode were investigated at rest using Single Photon Emission Tomography (SPET or SPECT) with 99mTc-exametazime, an intravenous ligand taken into brain in proportion to regional cerebral blood flow, thereby providing an estimate of regional metabolism. All patients were unipolar and were rated on the Newcastle scale and with the 17-item Hamilton scale. They also completed a range of neuropsychological tests. They were compared with 20 control subjects matched for age, gender, premorbid intelligence and education. The uptake of 99mTc-exametazime was expressed for a range of anatomically defined regions of interest relative to calcarine/occipital cortex. The depressed group showed reduced uptake in the majority of cortical and sub-cortical regions examined, most significantly in temporal, inferior frontal and parietal areas. Unexpectedly, there was a strong positive association between uptake and scores on the Newcastle scale, especially in cingulate areas and frontal cortex. After removing the variance attributable to the Newcastle ratings, however, there emerged the expected negative association between Hamilton scores and anterior tracer uptake. The associations between neuropsychological impairment and regional brain uptake of tracer in part reflected the pattern seen with the Newcastle scale: for example, impairment of memory function correlated with higher uptake into posterior cingulate areas. We propose that depressive illness may be characterised by two processes. One leads to an overall reduction in anterior neocortical function, perhaps related to symptom severity. The other mechanism is manifest as relatively increased function, most notably within cingulate and frontal areas of the cerebral cortex in association with psychotic symptoms. The findings offer new understanding of the brain states underlying depressive illness and a potential focus to subsequent neuropharmacological analysis.

Early and late onset depression in old age: different aetiologies, same phenomenology

BACKGROUND Phenomenological differences between older patients with early onset (EO; onset of first major depressive episode before 60 years) and late onset (LO) depression have been inconsistent but, if real, may reflect differences in aetiology. We aimed to compare aetiological factors, phenomenology and cognitive function in older patients with depression by age of onset. METHODS Subjects were all patients > or =60 years old (n=73) from 407 consecutive attenders to a Mood Disorders Unit, diagnosed with DSM-III-R Major Depressive Episode, at or close to the nadir of their episode. Putative risk factors were assessed by structured interview. Psychological morbidity and depressive symptoms were assessed by the 21-item Hamilton Rating Scale for Depression, CORE rating of psychomotor disturbance, Newcastle Endogeneity Scale, Zung Depression Scale and General Health Questionnaire. Cognition was assessed by tests of memory, attention, executive function and motor speed. RESULTS Personality abnormalities, a family history of psychiatric illness and dysfunctional past maternal relationships were significantly more common in EO depression. The two age of onset groups were essentially similar in terms of depressive sub-type and severity, phenomenology, history of previous episode, and in neuropsychological performance. LIMITATIONS Use of self-report data, moderate sample size, sample not age-matched, tertiary referral patients. CONCLUSIONS EO and LO depression are similar phenotypically, but differ aetiologically. The pursuit of mechanisms which predispose depressive episodes may be heuristically more valuable than further investigation of individual depressive features in distinguishing early from late onset depression.

MATERNAL STRESS AND OBSTETRIC AND INFANT OUTCOMES: EPIDEMIOLOGICAL FINDINGS AND NEUROENDOCRINE MECHANISMS

This review examines the associations between antenatal maternal stress and obstetric and infant outcomes using preterm delivery as the key outcome indicator. This was done by means of a Medline search focusing predominantly on prospective, controlled studies which investigated both the associated epidemiological factors and putative neuroendocrine mechanisms.

Antenatal screening and early intervention for “perinatal” distress, depression and anxiety: where to from here?

SummaryRecent developments in the study of mental health issues surrounding childbirth, have brought about a shift from the narrow concept of “postnatal depression” (PND) to a consideration of the spectrum of depressive and anxiety disorders arising in the “perinatal” period – which in the mental health context is defined as encompassing pregnancy and the first year postpartum. This shift has been associated with a growing recognition of the potential for prevention and early intervention in the perinatal period.In this article, the difficulties of antenatal screening with the aim of predicting PND are highlighted and contrasted with the potential benefits of antenatal screening aimed at identifying psychological morbidity – whether pre-existing risk factors and/or current symptoms – which may have bearing across the entire perinatal period. The literature on randomized controlled trials of “targeted” antenatal interventions to reduce PND and “indicated” interventions in postnatally depressed women are also reviewed. Future clinical and research directions in the field of early intervention for perinatal mood and anxiety disorders are identified.

State changes in brain activity shown by the uptake of 99mTc-exametazime with single photon emission tomography in major depression before and after treatment

Twenty-eight patients with a major depressive episode previously investigated at rest using Single Photon Emission Tomography (SPET or SPECT) with 99mTc-exametazime, were followed up at an interval of 9-28 months with the same investigation after full recovery. All patients were unipolar and were rated on the Newcastle scale and with the 17-item Hamilton scale. The uptake of 99mTc-Exametazime was expressed relative to calcarine/occipital cortex. Sixteen patients were scanned when optimally matched for drug treatment (4) or on both occasions drug free (12). The other 12 patients were fully recovered but could not be matched for drug status; these patients showed significantly more retardation, diurnal mood variation and guilt at presentation. Significant bilateral increases in tracer uptake were confined to basal ganglia and inferior anterior cingulate cortex in the matched group, where there were additional increases in thalamus and posterior cingulate cortex on the right side. There were no statistically discernible changes in the neocortex in the matched sample. The unmatched sample yielded inconclusive evidence of increased tracer uptake in left temporal cortex. The findings give a potential focus to the neuropharmacological analysis of depressive illness because the topography of the state change in brain function implicates dopamine function.

Postnatal mental health of women giving birth in Australia 2002–2004: findings from the beyondblue National Postnatal Depression Program

Objectives: To describe the postnatal mental health status of women giving birth in Australia 2002–2004 at 6–8 weeks postpartum. Method: Women were recruited from 43 health services across Australia. Women completed a demographic questionnaire and an Edinburgh Postnatal Depression Scale (EPDS) in pregnancy; the latter was repeated at 6–8 weeks following childbirth. Results: A total of 12 361 postnatal women (53.8% of all postnatal women surveyed) completed questionnaires as part of a depression screening programme; 15.5% of women screened had a postnatal EPDS>9 and 7.5% of women had an EPDS>12 at 6–8 weeks following childbirth. There was significant variation between States in the percentage of women scoring as being potentially depressed. The highest percentage of women scoring EPDS>12 were in Queensland and South Australia (both 10.2%) while Western Australia had the lowest point prevalence (5.6%). Women recruited from private health services in Western Australia had a significantly lower prevalence of elevated EPDS scores than those women recruited from the public health service (EPDS >12: 3.6% vs 6.4%, p=0.026); differences in the prevalence of elevated EPDS scores were not significant between public and private in Australian Capital Territory (EPDS>12: 7.6% vs 5.8%, p=0.48), where income and education was significantly higher than other States for both groups. Conclusions: Postnatal depressive symptoms affect a significant number of women giving birth in Australia, and the point prevalence on the EPDS may be higher for women in the public sector, associated with lower incomes and educational levels. Maternity services – particularly those serving women with these risk factors – need to consider how they identify and manage the emotional health needs of women in their care. Specific State-related issues, such as availability of specialist perinatal mental health services and liaison between treating health professionals, also need to be considered.