William W. K. Zung

Management of general medical patients with symptoms of depression

This article describes the management of depressive symptoms in a group of ambulatory patients in general medical care during a 1-year period. It also examines patient outcomes by types of management and aggressiveness of treatment. Subjects are 112 male patients longitudinally enrolled in a V.A. General Medical Clinic who screened positively on both the Zung Self-rating Depression Scale and the DSM-III criteria. Medical records were abstracted to obtain information on mental health management. During the follow-up year, 48% of the moderately depressed patients received some form of mental health management compared to 92% of the severely depressed patients. Of the treatment modes, only patients who had a mental health clinic visit and/or psychiatric consultation were significantly more improved than those not so treated--but only at 6 months (p = 0.09) and 9 months (p = 0.02). Actual treatment experience was then classified into three levels based on intensity, duration, and combinations of treatments. Of the three levels, only those patients in the moderately aggressively treated condition were significantly more improved at 3 months (p = 0.02) and at 6 months (p = 0.04) than those in the no-treatment condition.

Sleep and Dream Patterns in Twins: Markov Analysis of a Genetic Trait

As early as 1936, Davis and Davis [1] reported on the influence of heredity on electroencephalograms (EEGs) by the direct method of studying twins. The inheritance of monozygotic (MZ) twins would be similar while that of dizygotic (DZ) twins would have variable heredity the same as that of ordinary siblings. They found that the waking alpha rhythms from one MZ twin resembled those from the other as closely as the record of the same person on successive recordings. Raney [2] in studying lateral dominance of the EEG in MZ twins concluded that the EEGs of identical twins are more similar than those of unrelated children only when treated as a group. Lennox and Gibbs [3] studied EEGs of normal and epileptic twins and concluded that, although epilepsy per se was not hereditary, cerebral dysrhythmia was. They further suggested that the EEG could be used as evidence in decisions dealing with the zygosity of twins and in tracing the heredity of abnormal cerebral rhythms. Using the concept that characteristics which can be shown to appear regularly in MZ twins and irregularly in DZ twins as evidence of the hereditary nature of any given trait, Lennox, Gibbs, and Gibbs [4] studied the waking alpha tracings of MZ and DZ twins. The EEG records were judged identical in 85% of the cases in MZ twins and alike in only 5% of the DZ twin group. Vogel [5] analyzed various EEG traits in 208 pairs of twins and found good agreement in MZ twins. Tangheroni and Pardelli [6] reported complete identity of EEG tracings between MZ couples but rhythms of discordant frequency and morphology in DZ couples.

A Cross-Cultural Survey of Depressive Symptomatology in Normal Adults

Depression as a diagnostic entity consists of signs and symptoms which may be manifest in normal individuals. The purpose of this study was to determine how much depressive symptomatology as measured by the Self-rating Depression Scale is present in a normal adult population representing different countries and cultures. A total of 1981 normal subjects was tested in six countries. Rank ordering of the mean SDS indices showed Czechoslovakia to be highest, followed by Sweden, Germany, Spain, England, and the U. S. A. Statistical testing by using analysis of variance indicated that these differences were quantitatively significant. Factor analysis of items indicated qualitative similarities across the countries studied, as evidenced by the fact that loadings were larger on items reflecting the psychological features of depression in all countries studied. This is in contrast to factor analysis results of previous data from depressed patients, where the factor loadings contained physiological as well as psychological items. A similarity between rank ordering of self-rated depression scores and reported suicide death rates for the countries studied was noted.

A self-rating pain and distress scale

Abstract The author used the most commonly agreed-upon characteristics of pain and accompanying distress to construct a 20-item Pain and Distress (PAD) scale and administered it to 122 pain patients and 195 normal controls. The pain patients scored significantly higher on the overall index (indicating more pain) than did the controls, regardless of sex, race, and age. They also scored significantly higher than did controls on all 20 individual items. Based on results from statistical validation, use of the scale correctly classified 99.5% of normal controls and 84.4% of pain patients, who had been previously so identified clinically.

Depression scales: Self- or physician-rating? A validation of certain clinically observable phenomena

Abstract The question raised in the title of this article is of basic importance not only to the researcher but also to the clinician who uses rating scales as an adjunct in the diagnosis and treatment of his depressed patients. To be considered are the ease with which the measurements are made, their accuracy, and the time requisite for that measurement and accuracy. During the course of the evaluation of an experimental antidepressant, observations by one of the authors led to the hypothesis that he could differentiate, on a clinical basis, patients in whom he could expect an unreliable correlation between scores obtained on the Zung Self-Rating Depression Scale1 and the Hamilton Physician-Rating Scale.2 Although there are a number of factors that may influence scores obtained on rating scales, both self3 and physician,4 the knowledge of such factors has not been directly applied to the question of whether to use a self- or physician-rating scale. Our purpose is to show that patients who can be described clinically as either sensitizers or repressors tend to show an unreliable correlation between Zung and Hamilton scores. Sensitizers are defined as individuals who tend to be oversensitive, to overinterpret, and to ruminate about potential or real threats and conflicts. They have a negative self-concept and emphasize their own helplessness and weakness. Repressors are defined as individuals who tend to use avoidance, suppression, repression, and denial of potential threats and conflicts.5 This sensitization-repression dimension can be determined rather accurately by clinical interviews and seem, as we will attempt to demonstrate, to have some correlation with the degree of ego development.

Comparative efficacy and safety of bupropion and placebo in the treatment of depression.

This was a 4-week, three-center, double-blind, randomized, parallel, placebo-controlled evaluation of the efficacy and safety of bupropion in hospitalized depressed patients. Results from 27 placebo and 48 bupropion-treated patients were analyzed for efficacy and safety. Assessments of efficacy and safety were made at baseline and weekly during the study. Primary and secondary measures of efficacy included the Clinical Global Impressions for severity (CGI-S) and improvement (CGI-I) of illness, Hamilton Depression and Hamilton Anxiety Scales, and the Zung Self-Rating Scales for depression and anxiety. Assessments of safety included vital signs, electrocardiogram, clinical laboratory tests, and adverse experiences. Dosages of bupropion were 300–600 mg/day. Results showed that bupropion was significantly (P<0.01) more effective than placebo at termination of study on the CGI-S, CGI-I, Hamilton Depression and Hamilton Anxiety Scales. On the Zung Self-Rating Depression and Anxiety Scales, statistical trends favored bupropion at termination of study over placebo (P<0.10). Adverse events in the bupropion and placebo groups were minimal with notable absence of sedation and anticholinergic-and cardiovascular-related side effects. We conclude that bupropion was significantly more effective than placebo in treating depression and accompanying anxiety in depressed inpatients.

Computer Simulation of Sleep EEG Patterns with a Markov Chain Model

For the most part, recent investigations of sleep and dream states of human subjects have followed a procedure which calls for the analysis of continuous electroencephalographic (EEG) recordings made during an all-night sleep on the part of various populations of subjects [1–5]. Comparisons of sleep EEG data from different investigations of human subjects have been found to be exceedingly difficult to achieve, in part because of the very large number of EEG tracings recorded during a single night of continuous sleep. For example, the analysis of one night’s sleep EEG recording may involve the rather formidable task of reducing as much as one third of a mile of EEG tracings into a meaningful form. Furthermore, the complete lack of standardization of methods of data presentation in sleep research renders comparisons among the results of sleep studies published by different authors exceedingly difficult. Therefore, it is not surprising to find that existing methods of data reduction and reporting such as histograms, tables showing percentage of time spent in different stages of sleep, and all-night sleep graphs are all either completely inadequate or lead to gross oversimplifications of results and do not facilitate easy comparisons. In addition, none of the existing methods of analyzing all-night sleep EEG patterns lend themselves to the analysis of the observed phenomenon of continuous shifts in the stages of sleep.

Effect of Electroconvulsive Therapy on Memory in Depressive Disorders

Memory as a function of the central nervous system is said to be disturbed in patients with depression, in addition to which, patients who are treated with electroconvulsive therapy (ECT) for their depression are said to be more confused and have further memory loss. A simple model of this is as follows: assuming the presence of a base line with respect to memory functions in normal individuals [see Fig. 1 (A)], patients with depressive illnesses have shown a decrement of this function [Fig. 1 (B)], while patients with depression treated with ECT have shown further decrease of their memory function [see Fig. 1 (C)]. As the illness is ameliorated, either spontaneously or by treatment, there is a return of this function to the premorbid level [Fig. 1 (D)].

Suicide prevention by suicide detection

Abstract Suicide prevention is based on detection followed by intervention. Detection is accomplished by being aware of known high-risk factors when interviewing patients, and keeping these in mind as high indices for potential suicide. These high-risk factors include: history of previous treatment for emotional problems; present depressive disorder, anxiety, or alcoholism; decreased physical health with multiple ailments; presence of self-blame and guilt; loss of self-control; and lack of emotional support systems. Intervention includes the use of hospitalization, psychotropic drugs, and the doctor-patient relationship.