Tokumi Fujikawa

Incidence of silent cerebral infarction in patients with major depression.

Background and Purpose There have been few studies of the incidence of silent cerebral infarction detected by magnetic resonance imaging in patients with presenile or senile major depression. Methods We examined silent cerebral infarction in patients with presenile and senile major depression who were diagnosed at Hiroshima Prefectural Hospital. The diagnostic criteria of the American Psychiatric Association (DSM-III-R) were used. Patients with stroke or focal neurological symptoms were excluded. Results Silent cerebral infarction was observed in 51.4% of the patients with presenile-onset presenile depression, and the incidence was significantly higher than in patients with juvenile-onset presenile depression (P<.01). Among the patients with senile major depression, silent cerebral infarction was observed in 65.9% of those with presenile-onset depression and in 93.7% of those with senile-onset depression Conclusions Our findings suggest that half of presenile-onset major depression and the majority of senile-onset major depression might be organic depression related to silent cerebral infarction. Because major depression occurring for the first time during or after the presenile period may be related to silent cerebral infarction, it is important to keep this possibility in mind when treating such patients. (Stroke. 1993;24:1631-1634.)

Silent Cerebral Infarctions in Patients With Late-Onset Mania

BACKGROUND AND PURPOSE Previously we have studied the relationship between senile depression and silent cerebral infarctions (SCIs). The goal of this study was to clarify the relationship between late-onset mania and SCIs using MR imaging. METHODS Twenty manic patients who developed a bipolar disorder after 50 years of age (late-onset mania) were selected prospectively. These patients were compared with 20 age- and sex-matched patients who developed an affective disorder while younger than 50 years of age (early-onset affective disorder) and with 20 patients who developed major depression after 50 years of age (late-onset major depression). Patients with focal neurological symptoms were excluded from the study. All patients underwent MR imaging to assess the incidence of SCIs. Patients diagnosed with SCIs were subclassified according to whether the infarction type was perforating, cortical, or mixed. RESULTS The incidence of SCIs in patients with late-onset mania was 65.0%; this incidence was significantly higher than that of patients with early-onset affective disorders (P < .05). The incidence of the mixed type of SCI was 50.0% in patients with late-onset mania; this was significantly higher than that in patients with late-onset major depression (P < .05). CONCLUSIONS Our findings suggest that approximately half of the cases of late-onset mania might be secondary mania related to SCIs. Because the mixed type of SCI is more prevalent in the patients with late-onset mania than in those with late-onset major depression, mania may be associated with the larger areas of brain damage and hence may be a more serious form of affective illness than major depression.

Background factors and clinical symptoms of major depression with silent cerebral infarction.

Background and Purpose We previously reported that major depression developing during or after the presenile period is frequently combined with silent cerebral infarction and that these patients have a high risk of stroke. Therefore, we investigated whether the background factors and clinical symptoms of patients with major depression with silent cerebral infarction [SCI( + )] differed from those in patients with major depression without silent cerebral infarction [SCI(−)] before medical treatment. Methods Patients with major depression with onset after 50 years of age were classified based on magnetic resonance imaging findings into the SCI( + ) (n=37) or SCI(−) (n=20) group. The diagnostic criteria for major depression were those of the American Psychiatry Association (DSM‐III‐R). Patients with stroke or focal neurological symptoms were excluded. The SCI( + ) group was subclassified according to whether the infarction area was perforating, cortical, or mixed artery. Family history of affective disorder, risk factors for stroke, and Zungs Self‐rated Depression Scale (SDS) score before medical treatment of the group were compared. Results The SCI( + ) group had a significantly lower (P<.05) frequency of family history of affective disorder but a significantly higher (P<.01) frequency of hypertension than did the SCI(−) group. The mean SDS score in the SCI( + ) group was significantly higher than that in the SCI(−) group (P<.01). The mean SDS score of the mixed artery infarction group was higher than that of the perforating artery infarction group (P<.05). Conclusions Patients with major depression with silent cerebral infarction present more marked neurological factors and more severe depressive symptoms than do those without silent cerebral infarction. Because these features were more prominent in the patients with mixed artery infarction with broad obstructions, we consider that the area of brain damage caused by cerebral infarction is positively related to the severity of depressive symptoms. (Stroke. 1994;25:798‐801.)

Response of patients with major depression and silent cerebral infarction to antidepressant drug therapy, with emphasis on central nervous system adverse reactions.

BACKGROUND AND PURPOSE We previously found that silent cerebral infraction (SCI) is present in most patients older than 50 years with major depression. The present study was designed to clarify the response to antidepressant pharmacotherapy in patients with major depression associated with SCI. METHODS Using clinical charts, we retrospectively studied patients older than 50 years who were admitted for antidepressant drug therapy. Patients with bipolar affective disorder and those with focal neurological symptoms were excluded. All patients underwent magnetic resonance imaging and were classified as SCI-negative or SCI-positive. The SCI-positive group was subclassified into those with moderate SCI (either perforating area or cortical area) (n = 15) and those with severe SCI (both perforating and cortical areas) (n = 7). Duration of treatment in hospital and the incidence of central nervous system adverse reactions to the antidepressant drugs were compared between the two groups. RESULTS The duration of hospital treatment in patients with severe SCI was significantly longer than in those with moderate SCI (P < .01). The percentage of patients with adverse central nervous system reactions to antidepressant drugs was significantly higher in the SCI-positive group than in the SCI-negative group (P < .05). Patients with severe SCI had significantly more adverse reactions than those with moderate SCI (P < .05). CONCLUSIONS Depressed patients with severe SCI required longer hospital treatment and had more drug-related adverse reactions of the central nervous system. These findings suggest that the depression associated with severe SCI may be resistant to treatment.

The 3-year course and outcome of patients with major depression and silent cerebral infarction

We retrospectively investigated the relationship between major depression and silent cerebral infarction (SCI) over a 3-year period in 64 patients older than 50 years of age with unipolar depression. All patients underwent magnetic resonance imaging (MRI) at their first admission for depression and were classified into groups based on the presence or absence of SCI. The number of admissions due to depression was greater in the SCI (+) group (N = 32) than in the SCI (-) group (N = 32) (P < 0.05). The incidences of delirium and neurological disorders were significantly higher in the SCI (+) group than in the SCI (-) group. Our findings suggest that patients with depression and SCI had a higher rate of hospitalization and were more likely to develop psychiatric and neurological disorders than patients with depression without SCI.

Changes in auditory P300 in patients with major depression and silent cerebral infarction

We examined event-related potentials in patients with senile depression and silent cerebral infarction (SCI) to clarify the features of the P300 component. P300 event-related potentials were recorded in drug-free depressed patients (N = 16) and normal controls (N = 17). All patients underwent magnetic resonance imaging and were classified as SCI-positive (N = 7) or SCI-negative (N = 9). In depressed patients, the P300 was reexamined after antidepressant treatment. Prior to treatment, P300 amplitudes in depressed patients were significantly smaller than those in normal controls (P < 0.01). P300 amplitudes increased significantly in SCI-negative patients following recovery (P < 0.05), but did not change in SCI-positive patients. SCI may interrupt the treatment-related P300 amplitude increase in depressed patients.

Quetiapine Treatment for Behavioral and Psychological Symptoms in Patients with Senile Dementia of Alzheimer Type

The purpose of this study was to assess the effect of quetiapine in the treatment of behavioral and psychological symptoms of dementia (BPSD) in patients with senile dementia of Alzheimer type (SDAT). Sixteen SDAT patients with BPSD were recruited and quetiapine (25– 200 mg/day) was prescribed for 8 weeks. BPSD were evaluated with the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) and Cohen-Mansfield Agitation Inventory (CMAI) at week 0 (baseline) and week 8 (endpoint). The severity of the extrapyramidal symptoms was also assessed by the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) at baseline and endpoint. Significant improvements were seen in the CMAI total score and in the BEHAVE-AD subscales of delusions, activity disturbances, aggressiveness, diurnal rhythm disturbances and in the BEHAVE-AD overall severity. There was no significant difference between the baseline and endpoint in the DIEPSS score. These data indicate that quetiapine is effective in controlling BPSD with favorable adverse-event profiles.

Clinical features and treatment response of patients with major depression and silent cerebral infarction.

Previously, we reported a relationship between silent cerebral infarction (SCI), as detected by magnetic resonance imaging (MRI), and late onset major depression. In the present study, we clarify the clinical features of the depressive phase of patients with major depression and SCI, and their response to antidepressant pharmacotherapy. Using clinical charts, we retrospectively examined patients with depression, who were first admitted for antidepressant pharmacotherapy. All patients were classified according to the MRI findings and the age on admission (older or younger than 50 years) into either the young SCI(–) group (n = 23), the elderly SCI(–) group (n = 27) or the elderly SCI(+) group (n = 20).The characteristics of the clinical features were evaluated at the time of admission, after 2 weeks of treatment and at the time of discharge using the Hamilton rating scale for depression (HAMD). These data were compared between each patient group. No differences in the clinical features, as evaluated by HAMD, were observed between the three groups at the time of admission. However, the mean length of treatment was significantly longer and the treatment response, as evaluated by the total HAMD score, was significantly worse in the elderly SCI(+) group than in the other two groups, when examined after 2 weeks of treatment and at the time of discharge. The elderly SCI(+) group demonstrated higher scores in feelings of guilt, suicide, retardation and hypochondriasis than the young SCI(–) group and the elderly SCI(–) group after two weeks of treatment, and higher scores in early insomnia, late insomnia, somatic anxiety and hypochondriasis at the time of discharge. Our findings suggest that while the presence of SCI does not affect the clinical features observed at the time of admission, it does affect the treatment response to antidepressant pharmacotherapy.

Cognitive Dysfunction in Recovered Depressive Patients with Silent Cerebral Infarction

In this study, we characterized cognitive functioning in patients with major depression and silent cerebral infarction (SCI), as detected by magnetic resonance imaging (MRI), after they had recovered from depression. Thirty-five patients with unipolar depression who experienced the onset of depression after the age of 50 underwent MRI and were classified as SCI(+) (n = 17) or SCI(–) (n = 18). The Wechsler Adult Intelligence Scale-Revised (WAIS-R) and the Uchida-Kraepelin psychodiagnostic test were administered after the patients had recovered from depression. In addition, the intelligence quotient (IQ) and mental speed of the patients in the two groups were compared. The total, verbal and performance IQ scores, as determined by the WAIS-R, were significantly lower in the SCI(+) group than in the SCI(–) group. The mental speed of patients in the SCI(+) group, as assessed by the Uchida-Kraepelin psychodiagnostic test, was almost half that of the SCI(–) group. Our findings provide further evidence that a comprehensive impairment of cognitive functioning, especially a severe reduction in mental speed, remains after recovery from depression in patients with major depression and SCI.

Long-Term Prognosis of Patients with Major Depression and Silent Cerebral Infarction

Objective: Many studies have examined the effects of cerebrovascular changes on treatment response in geriatric depression. However, few such studies have examined the relationship between cerebrovascular changes and long-term prognosis. We examined the effects of cerebrovascular changes on the course of geriatric depressive symptoms, dementia rates, and mortality over a follow-up period of approximately 10 years. Method: Participants were 84 patients with major depression (age of onset over 50 years); patients suffering from strokes, neurological disorders, and other psychiatric disorders were excluded. Magnetic resonance imaging findings were used to classify all patients into silent cerebral infarction (SCI)-positive (n = 37) or SCI-negative groups (n = 47). Prognoses were ascertained using a review of clinical charts and mailed questionnaires. Results: Only 5% of patients with SCI were able to maintain remission whereas 36% of patients without SCI were able to do so. Total duration of depressive episodes was significantly longer in the SCI-positive group than in the SCI-negative group. SCI was also associated with a higher risk of dementia. Conclusion: The results of this long-term follow-up study demonstrate that the presence of SCI is associated with a relatively poor prognosis in geriatric depression.