Victoria J. Grochocinski

Reliability and validity of the Panic Disorder Severity scale: replication and extension

UNLABELLED The Panic Disorder Severity Scale (PDSS) is a recently developed seven-item instrument to rate overall severity of Panic Disorder. The scale has previously shown good psychometric properties in a sample of Panic Disorder patients with no more than mild agoraphobia. The purpose of this paper is to confirm reliability and validity, to provide an estimate of a cut-score discriminating the presence or absence of current DSM-IV Panic Disorder, and to determine the factor structure of the instrument. PROCEDURES 104 psychiatric outpatients, including 54 with current Panic Disorder, underwent structured diagnostic assessment and the PDSS interview. The PDSS was repeated within 3-17 days. RESULTS we confirmed reliability and validity of the instrument and found a one-factor solution fit the data. A cut-off score of eight identifies patients with current panic with a sensitivity of 83.3%, and a specificity of 64%. CONCLUSION the PDSS is a simple, reliable instrument for use in Panic Disorder studies. A cut-score of eight may be useful as a tool to screen patients in settings such as primary care, for diagnosis-level symptoms.

Full-Information Item Bifactor Analysis of Graded Response Data

A plausible factorial structure for many types of psychological and educational tests exhibits a general factor and one or more group or method factors. This structure can be represented by a bifactor model. The bifactor structure results from the constraint that each item has a nonzero loading on the primary dimension and, at most, one of the group factors. The authors develop estimation procedures for fitting the graded response model when the data follow the bifactor structure. Using maximum marginal likelihood estimation of item parameters, the bifactor restriction leads to a major simplification of the likelihood equations and (a) permits analysis of models with large numbers of group factors, (b) permits conditional dependence within identified subsets of items, and (c) provides more parsimonious factor solutions than an unrestricted full-information item factor analysis in some cases. Analysis of data obtained from 586 chronically mentally ill patients revealed a clear bifactor structure.

All-night spectral analysis of the sleep EEG in untreated depressives and normal controls

Sleep was recorded in nine drug-free depressive patients and nine age- and sex-matched normal control subjects. All-night spectral analysis of the sleep electroencephalogram (EEG) showed a significantly reduced power density in the 0.25-2.50 Hz band in the depressive group. Power density values integrated over the entire frequency range (0.25-25.0 Hz) exhibited for both groups a decreasing trend over the first three non-REM/REM sleep cycles. In each cycle depressives had lower values than controls. The results are consistent with hypothesis that the build-up of a sleep-dependent process is deficient in the sleep regulation of depressive patients.

The Role of Interpersonal and Social Rhythm Therapy in Improving Occupational Functioning in Patients With Bipolar I Disorder

OBJECTIVE Recent studies demonstrate the poor psychosocial outcomes associated with bipolar disorder. Occupational functioning, a key indicator of psychosocial disability, is often severely affected by the disorder. The authors describe the effect of acute treatment with interpersonal and social rhythm therapy on occupational functioning over a period of approximately 2.5 years. METHOD Patients with bipolar I disorder were randomly assigned to receive either acute and maintenance interpersonal and social rhythm therapy, acute and maintenance intensive clinical management, acute interpersonal and social rhythm therapy and maintenance intensive clinical management, or acute intensive clinical management and maintenance interpersonal and social rhythm therapy, all with appropriate pharmacotherapy. Occupational functioning was measured with the UCLA Social Attainment Scale at baseline, at the end of acute treatment, and after 1 and 2 years of maintenance treatment. RESULTS The main effect of treatment did not reach conventional levels of statistical significance; however, the authors observed a significant time by initial treatment interaction. Participants initially assigned to interpersonal and social rhythm therapy showed more rapid improvement in occupational functioning than those initially assigned to intensive clinical management, primarily accounted for by greater improvement in occupational functioning during the acute treatment phase. At the end of 2 years of maintenance treatment, there were no differences between the treatment groups. A gender effect was also observed, with women who initially received interpersonal and social rhythm therapy showing more marked and rapid improvement. There was no effect of maintenance treatment assignment on occupational functioning outcomes. CONCLUSIONS In this study, interpersonal and social rhythm therapy, with its emphasis on amelioration of interpersonal and role functioning, improved occupational functioning significantly more rapidly than did a psychoeducational and supportive approach with no such emphasis on functional capacities.

Comparison of full-dose versus half-dose pharmacotherapy in the maintenance treatment of recurrent depression

Recent evidence points to the prophylactic efficacy of maintaining recurrent unipolar patients on the same dose of antidepressant medication that was used to treat the acute episode (Frank et al., 1990; Kupfer et al., 1992). Therefore, the question of whether such patients should be tapered to a lower maintenance dose after successful resolution of an acute episode is clearly important. In this report we describe a small randomized clinical trial in which patients were assigned to either full-dose or half-dose maintenance treatment for a period of 3 years. Survival analysis suggests that superior prophylaxis can be achieved with a full-dose as compared to a half-dose maintenance treatment strategy (p < 0.07). Mean survival time for the full-dose subjects was 135.17 (SE 19.75) weeks as compared to 74.94 (SE 19.78) weeks (median of 43.1 weeks) for the half-dose subjects. We conclude that for patients who have suffered several recurrences, full-dose maintenance treatment is the more effective prophylactic strategy.

Application of automated REM and slow wave sleep analysis: II. Testing the assumptions of the two-process model of sleep regulation in normal and depressed subjects

Abnormalities in a two-process model of sleep regulation (a sleep-dependent process, termed Process S, and a sleep-independent circadian process, termed Process C) have been proposed to account for sleep abnormalities in depressive states. The major tenets of the two-process model of sleep regulation as applied to depression are: the level of process S, as reflected by the electroencephalographic (EEG) slow-wave activity, corresponds to the sleep-dependent facet of sleep propensity; the pathognomonic changes of sleep in depressives are a consequence of a deficiency in the build-up of process S. The application of automated rapid eye movement (REM) and delta wave analyses in normal subjects and younger depressed patients supports the model to some extent: The time spent asleep is positively correlated with total delta waves (normals and depressives) and average delta waves (depressives); delta sleep is lower in depressives than in normals; the average delta wave count is significantly reduced in younger depressives over the total night and in non-REM period 1. The model also postulates that measures of phasic REM activity are inversely related to process S, suggesting that process S can be regarded as exerting an inhibitory influence on phasic REM activity.

Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy.

BACKGROUND Although many studies suggest that, on average, depression-specific psychotherapy and antidepressant pharmacotherapy are efficacious, we know relatively little about which patients are more likely to respond to one versus the other. We sought to determine whether measures of spectrum psychopathology are useful in deciding which patients with unipolar depression should receive pharmacotherapy versus depression-specific psychotherapy. METHOD A total of 318 adult out-patients with major depression were randomly assigned to escitalopram pharmacotherapy or interpersonal psychotherapy (IPT) at academic medical centers at Pittsburgh, Pennsylvania and Pisa, Italy. Our main focus was on predictors and moderators of time to remission on monotherapy at 12 weeks. RESULTS Participants with higher scores on the need for medical reassurance factor of the Panic-Agoraphobic Spectrum Self-Report (PAS-SR) had more rapid remission with IPT and those with lower scores on the psychomotor activation factor of the Mood Spectrum Self-Report (MOODS-SR) experienced more rapid remission with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Non-specific predictors of longer time to remission with monotherapy included several panic spectrum and mood spectrum factors and the Social Phobia Spectrum (SHY) total score. Higher baseline scores on the 17- and 25-item Hamilton Depression Rating Scales (HAMD-17 and HAMD-25) and the Work and Social Adjustment Scale (WSAS) also predicted a longer time to remission, whereas being married predicted a shorter time to remission. CONCLUSIONS This exploratory study identified several non-specific predictors but few moderators of psychotherapy versus pharmacotherapy outcome. It offers useful indicators of the characteristics of patients that are generally difficult to treat, but only limited guidance as to who benefits from IPT versus SSRI pharmacotherapy.

Comparison of automated REM and slow-wave sleep analysis in young and middle-aged depressed subjects

A comparison of electroencephalographic sleep measures between young and middle-aged groups of depressed inpatients was conducted with specific interest in the application of automated measures of REM and delta wave sleep. Aside from the expected differences in sleep continuity, increased Stage 1 percent, decreased Stage 2 percent, and decreased REM latency in the middle-aged depressives as compared to the younger depressives, distinct findings from automated analyses were noted in the distribution of REM and delta sleep throughout the night. Although the younger depressed patients showed increased numbers of delta waves, the middle-aged depressives showed greater average REM count. Such changes were more pronounced in the first third of the night. Finally, in the middle-aged depressives, little statistical relationship between manual measures of slow-wave sleep and automated measures of delta sleep was found.

Application of automated REM and slow wave sleep analysis: I. Normal and depressed subjects.

Computerized analysis of rapid eye movement (REM) and delta electroencephalographic (EEG) sleep patterns in normal and depressed subjects offers opportunities to examine sleep more precisely than previously possible. In the present study, automated REM analyses demonstrated good reliability with traditional manual procedures in both normal and depressed subjects. However, automated delta analyses correlated well with traditional scoring in normal subjects, but not in depressed patients. These findings suggest the use of automated delta techniques similar to those employed in this report or spectral analytic techniques in the following types of studies: specificity of delta sleep in various psychiatric syndromes, changes in delta sleep produced by the administration of psychotropic agents, relationships between delta sleep and sleep-related neuro-endocrine patterns, and, finally, relationships between delta sleep patterns and other biological rhythms such as activity and temperature.

Comparison of effects of desipramine and amitriptyline on EEG sleep of depressed patients

Despite their widespread use, there are few data concerning the effects of tricyclic antidepressants on EEG sleep in depression. The present study documented the effects of desipramine (DMI, n=17) and amitriptyline (AT, n=16) upon EEG sleep in hospitalized depressed patients as part of a double-blind protocol involving 28 days of active treatment. Compared to placebo, patients receiving DMI showed somewhat worsened sleep continuity, particularly after 1 week of administration when the dose was 150 mg/day. On the other hand, sleep architecture and REM measures showed a rapid suppression of REM sleep, and then partial tolerance for this effect was observed with continued administration of DMI for 3 weeks. DMI was a more potent suppressor of REM sleep, while AT was more sedative. Based on these differences in effects upon EEG sleep, a discriminant function was derived and resulted in a correct classification of 87.5% of AT cases and 76.5% of DMI cases. These results are discussed in terms of the differences in pharmacological profiels for uptake blockade and anticholinergic potency for these two compounds.