Stanley P. Kutcher

Nocturnal melatonin and 24-hour 6-sulphatoxymelatonin levels in various phases of bipolar affective disorder

Nine bipolar patients (2 men and 7 women) and 12 healthy control subjects completed overnight sampling for serum melatonin (MT) and urinary 6-sulphatoxymelatonin (aMT6s). The patients were investigated during manic, depressed, and/or euthymic states. Although serum MT levels did not differ significantly across the bipolar groups, in all cases serum MT levels were significantly lower than in control subjects. Differences in MT levels were also present between bipolar patients who were in a depressed phase and control subjects. There were no statistically significant differences in urinary aMT6s levels among the patients and control subjects, although in all cases nocturnal aMT6s levels were significantly higher than daytime levels. This study provides tentative evidence for decreased serum MT as a trait but not a state marker in bipolar affective disorder.

Thyroid function and bipolar affective disorder

Thyroid function tests and life course of illness were evaluated in 42 patients with bipolar affective disorder who had received at least 3 months of lithium carbonate treatment. Eight of 42 patients (19%) required thyroid replacement or had evidence of subclinical hypothyroidism associated with lithium treatment. Abnormalities of thyroid function were related to female sex and duration of lithium treatment but not to a rapid-cycling course of illness.

Lack of differential cognitive effects of lithium and carbamazepine in bipolar affective disorder

Cognitive functioning was assessed in medication-free as well as carbamazepine- and lithium-treated patients with manic-depressive illness. Across a range of tests measuring attention, concentration, visuomotor function, and memory, no significant differences were observed across the three patient groups as compared with control subjects without manic-depressive illness. The clinical and theoretical implications of these findings are discussed.

Psychological, topographic EEG, and CT scan correlates of frontal lobe function in schizophrenia

This study examined frontal lobe function in a group of 20 patients with schizophrenia, on and off medication, compared to 20 normals matched for age, sex, handedness, intelligence, and educational level. Schizophrenic patients generally did not perform as well as normals on the Wisconsin Card Sorting Test (WCST). Patients off medication performed less well on this test than those on medication. Those on medication did not perform as well as those off medication on the design and word fluency tests, which suggested that medications may affect various aspects of frontal lobe function differently. During the WCST, normal subjects demonstrated an increase in beta mean frequency of the electroencephalogram in frontal and centrotemporal regions which was not statistically significant in either schizophrenic group. This shift in beta mean frequency was found to correlate positively with performance on the WCST in normals, but not in patients. Patients with more negative symptoms tended to show a smaller increase in beta mean frequency during the WCST. Performance on the WCST was correlated negatively with ventricle-brain ratio in all subjects, suggesting that frontal lobe function might be related to computed tomographic measures in the normal population as well as in schizophrenic patients. There was no correlation with performance on the WCST and length of illness.

Personality dysfunction in depressed adolescents.

The personality characteristics of 35 consecutively assessed adolescents who met the DSM-III criteria for a current depressive disorder were assessed using independent structured interviews and paper and pencil measures. Sixty-five percent of the sample met the criteria for an Axis II personality disorder. The single most common diagnosis was borderline personality disorder (30%). Depressed adolescents with a concurrent personality disorder were less self-confident, displayed more neuroticism, and were emotionally reliant on others. They also demonstrated greater cognitive distortion. Teenagers who present with a depressive disorder warrant a comprehensive personality asessment. The combination of affective and personality disorder in such patients is associated with attitudes and interpersonal problems which should be therapeutically addressed in addition to symptomatic treatment of the depressed mood. Clinicians should be aware that depressed adolescents with personality disorder may be more likely to make a suicide attempt.

Temporal coherence in ultradian sleep EEG rhythms in a never-depressed, high-risk cohort of female adolescents.

BACKGROUND Previous work has indicated that low temporal coherence of ultradian sleep electroencephalographic rhythms is characteristic of depressed patients and of depressed women, in particular. It may also be evident in one quarter of those at high risk, based on a family history of depression. METHODS The present study evaluated temporal coherence of sleep electroencephalographic rhythms in 41 adolescent girls with a maternal history of depression (high risk) and 40 healthy controls (low risk). The entire sample was followed clinically every 6 months for 2 years. RESULTS Temporal coherence was significantly lower among the high-risk girls than in controls. Regression analyses predicted group from coherence values and correctly classified 70% of the high-risk group with a false-positive rate of 5% among controls. Moreover, 54% of the high-risk girls were identified with extreme low coherence. On clinical follow up, 14 girls showed depressive symptoms, 9 in the high-risk group (22.5%) and 5 controls (12.2%). Six met DSM-IV criteria for first-episode major depressive disorder, five high-risk and one control. Most importantly, 41% of those identified as having the most abnormal coherence values either showed symptoms of depression or met diagnostic criteria upon follow up. CONCLUSIONS Low temporal coherence is evident in adolescent girls at high risk for depression. The more abnormal the coherence, the greater the risk of a first episode of major depressive disorder within 2 years of sleep study, approximately 10 times greater than in controls.

Expert survey for the management of adolescent depression in primary care

OBJECTIVE. Primary care clinics have become the “de facto” mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS. Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS. Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, “active monitoring” was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS. Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Update and Recommendations for the Use of Antipsychotics in Early-Onset Psychoses

A review was undertaken of studies evaluating the efficacy and tolerability of antipsychotic medications for the management of psychosis in children and adolescents. All identified published and unpublished studies from 1996 onward were included for review. The search located one randomized control trial, seven open-label trials, six retrospective chart reviews, and nine case reports. The studies assessed the use of haloperidol, clozapine, risperidone, olanzapine, and quetiapine in the management of psychosis in children and adolescents. Most studies reported reasonable treatment response; however, extrapyramidal side effects, sedation, and weight gain are concerning. This points to the need for appropriate baseline assessments prior to initiating treatment with these agents. Particular attention should be given to assessment of the extrapyramidal system as well as to baseline weight, lipid profile, and blood glucose. Further study is needed to refine the use of antipsychotic medications in children and adolescents in order to minimize adverse effects while conferring an optimum therapeutic response. The importance of instituting effective early treatment in youth with psychoses is an important goal that may serve to lessen the long-term morbidity of the illness.

Live events and mania: A case-controlled study

Life events were evaluated in 14 patients with bipolar affective disorder in the year preceding a mania as well as in 14 patients with bipolar affective disorder without a mania matched for age, sex, and time of recall. There were a significantly greater number of uncontrolled and unanticipated life events in the patients with as compared to those without a mania. However, neither the total number of life events nor measures of distress and stress distinguished bipolar patients with as compared to those without mania.

Secondary mania with steroid withdrawal

A case of mania associated with steroid withdrawal is described, and a possible etiology suggested. Milder cases of mood disturbance secondary to steroid withdrawl may be more common than previously recognized.