Nicholas G. Ward

The effectiveness of tricyclic antidepressants in the treatment of coexisting pain and depression

&NA; A group of moderately to severely depressed individuals with moderate anxiety were studied to determine the frequency and nature of pain complaints and their response to doxepin. It was discovered that 100% of these subjects had chronic pain complaints, most of which paralleled the course of depression. Headache was most commonly noted. Doxepins analgesic effects were intimately associated with its antidepressant effects. There was a highly significant relationship between improvement of depression and reduction of pain on doxepin (P < 0.005). Conversely, patients who obtained minimal antidepressant effect also obtained minimal analgesic effect. Psychophysiologic and biochemical hypotheses of this association of pain and depression are discussed.

The analgesic effects of caffeine in headache

&NA; Caffeine is frequently added to mild analgesic preparations but its effect when used alone on pain has never been studied in humans. Using a double‐blind placebo‐controlled multiple crossover design, 53 patients with non‐migrainous headaches were given placebo, acetaminophen, 2 doses of caffeine and 2 combinations of caffeine with acetaminophen. Caffeine appeared to have independent analgesic effects that were equivalent to acetaminophen and were still significant when statistical adjustments were made for prior caffeine consumption and caffeines effects on mood.

The Effect of Differences in Objective and Subjective Definitions of Childhood Physical Abuse on Estimates of Its Incidence and Relationship to Psychopathology.

The relationship between objective and subjective definitions of physical abuse and the lifetime prevalence of depression was examined in 280 women attending a family medicine clinic at a large medical center. Based on their responses to a detailed questionnaire regarding discipline and abuse in childhood, 28.2% of these women were objectively defined as abused. Only 11.4% subjectively defined themselves as abused. The proportion of women who experienced depression during their lifetime was highest among those who defined themselves as abused (83%), intermediate among those who met objective criteria for having been physically abused, but did not define themselves as such (56%), and lowest among those who did not meet objective criteria for a history of physical abuse (35%). Similar relationships were found for history of psychotherapy, receipt of psychoactive medication, history of hospitalization for depression, suicide attempts and self-injury.

Subtypes of psychiatric inpatient women who have been sexually abused

The sexual abuse histories of 171 women admitted to a psychiatric inpatient service revealed that 40.3% had a positive history of sexual abuse. The DSM-III diagnoses made on discharge were not related to presence of abuse, age of abuse onset, duration and frequency of abuse, or relationship of the victim to the perpetrator. However, the diagnosis of personality disorder was associated with greater invasiveness of sexual abuse. Cluster analysis of the MMPIs provided by these women revealed four clusters. Membership in the more disturbed cluster was associated with a history of sexual abuse, but not with invasiveness, age of onset, relationship to the perpetrator, or duration and frequency of abuse. The implications of these findings for the role of mitigating factors, such as coping style and adaptation to stress, are discussed.

Skin conductance: a potentially sensitive and specific marker for depression

Resting skin conductance levels (SCLs) were measured in 50 patients with unipolar depression, in 71 controls (control group 1), and in 334 “stressed” normal controls (control group 2) who were first parents of newborns. The depressed group had significantly (p<.00001) lower SCLs than did either control group, but the two control groups did not differ from each other. For women a criterion of SCL<3.0 /µmho/cm2 yielded a sensitivity of 95% (SE 4.4%) and a specificity of 91% (SE 5.0%) for Control Group 1. For males a criterion of SCL<4.8 yielded a sensitivity of 93% (SE 4.9%) and a specificity of 89% (SE 5.0%) for control group 1. There was no significant difference in SCL between drug-free and medicated patients. SCL was abnormally low in all depression subtypes.

Successful lithium treatment of transvestism associated with manic-depression.

A case of transvestism in a 24-year-old manic-depressive man is described. The behavior had been maintained for 2 years and disappeared soon after lithium treatment was begun. It has not returned during the first year on lithium. Dynamic and behavioral explanations for this unusual therapeutic response are considered. The dynamic explanation involves the assumption that the transvestism was perpetuated by mood-dependent motives that were eliminated by lithium. The behavioral explanation involves the assumption that the manic state itself became an intermittent reinforcer for the transvestism, and the lithium, by eliminating the mania, created a relatively permanent extinction period.

A comparison of the acute effects of dextroamphetamine and fenfluramine in depression

Fenfluramine (Fen) 40 mg, a selective releaser of serotonin, and dextroamphetamine (Dex) 15 mg were administered in a double-blind crossover design to 16 subjects with major affective disorder, depression. Three hours after administration both drugs significantly improved depression and improved vigor, fatigue, and confusion-bewilderment on the subscales of the Profile of Mood States. Dex was significantly better than Fen only on the vigor and fatigue subscales. Other data from this study suggest that when used acutely Fen can mimic long-term antidepressant effects, whereas the acute effects of Dex are similar to its stimulating effects in normals.

Urinary 3-Methoxy-4-Hydroxyphenethylene Glycol in the Prediction of Pain and Depression Relief with Doxepin: Preliminary Findings

A group of patients with both depression and chronic pain were treated with doxepin for 4 weeks. Elevated (above median) initial levels of urinary 3-methoxy-4-hydroxyphenethylene glycol (MHPG, a metabolite of central nervous system [CNS] norepinephrine metabolism) were found to be significantly related to final pain relief, but not to improvement in depression. Anxiety, as measured on the Zung Anxiety Scale, was an important covariable, as high anxiety levels were significantly associated with both higher MHPG levels and with pain relief. Possible biochemical and psychophysiological mechanisms associated with the modulation of pain are discussed.

Chronic pain, depression, and the dexamethasone suppression test

&NA; In most healthy individuals, dexamethasone suppresses adrenal cortisol production. However, in patients with major depression, non‐suppression frequently occurs and thus may be a marker for depression. The purpose of the present study was to examine the relationship of dexamethasone suppression test (DST) non‐suppression to clinical variables such as major depression, site and duration of pain, prior surgery, and medication use in 81 chronic pain patients beginning inpatient pain treatment (Inpt. Pain), and 33 medication‐restricted outpatients with chronic back pain and depression (Outpt. Back). In the Inpt. Pain group, the specificity of DST non‐suppression for depression was 82% and for sensitivity 24%. In the Outpt. Back group, its sensitivity was 18%. Within the diverse inpatient samples, there was 69% non‐suppression in patients with headache pain only, compared to 15% in patients with other sites of pain (P < 0.01), but there was no significant difference in depression rate between these two groups. In the Inpt. Pain group, non‐suppressors also had significantly less prior surgery. In the Outpt. Back group, opioid use was significantly higher in non‐suppressors (33%) than in suppressors (11%). In chronic pain populations, the DST appears not to be useful clinically for the detection of depression and may be significantly affected by clinical variables other than depression.

Change in auditory asymmetry with amobarbital: evidence of cerebral pharmacological asymmetry?

Eleven right-handed subjects were administered a dichotic listening test to assess cerebral hemispheric dominance, both under a drug-free condition and following systemic injection of the barbiturate, amobarbital. The finding of increased right ear advantage during the drug period reflects increased left cerebral dominance, and suggests that amobarbital may have an asymmetric, pharmacological effect on the two cerebral hemispheres.