• A modified dexamethasone suppression test (DST) has had unprecedented evaluation among biologic tests proposed for clinical use in psychiatry. It has not proved to reflect pathophysiologic changes at the level of the central nervous system or pituitary, and tissue availability of dexamethasone itself may contribute to test outcome. The sensitivity of the DST in major depression is limited (about 44% in over 5,000 cases) but is higher in psychotic affective disorders and mixed manic-depressive states (67% to 78%). The high specificity of the DST vs control subjects (over 90%) is not maintained vs other psychiatric disorders (77% specificity overall), and acute "distress" may contribute to nonsuppression of cortisol. The test may have power in differentiating severe melancholic depression, mania, or acute psychosis from chronic psychosis (87% specificity) or dysthymia (77% specificity). The DST status adds about 11% to the prediction of short-term antidepressant response. Suggestions that failure to maintain normal suppression of cortisol predicts poor outcome are not secure. Uncritical enthusiasm or excessive skepticism regarding the DST are unwarranted.

The Dexamethasone Suppression Test for Diagnosis and Prognosis in Psychiatry: Commentary and Review

something is wrong. Systems of health care articulate categories of somatic disease, based on abstract ethnophysiologic ideas, that give the healer a unique way of thinking and acting. Patient and healer, using different forms of discourse, must then negotiate a satisfactory exchange (Eisenberg, 1977). Sometimes this process of negotiation reveals conflicts between the basic perceptions and values of healer and sufferer.

Culture, Affect and Somatization: Part Ii

Objective The purpose of this article is to provide an overview of existing systems for the diagnosis of the endogenous (melancholic) subtype of major depression. Method The authors review the critical empirical research examining this subtype and discuss its implications for DSM-IV. They examine the relationship of endogenous/melancholic symptoms to other clinical features, treatment response, selected laboratory tests, consistency across episodes, family history, and particular courses of illness. Results Melancholic symptom features are predictive of a positive response to ECT and to tricyclic antidepressants in the severely ill. Key features include psychomotor retardation, unreactive mood, pervasive anhedonia, and distinct quality of mood. Melancholic features are associated with shorter REM latency and/or nonsuppression of cortisol during the dexamethasone suppression test. Depressive episodes that are not melancholic may take on melancholic features with repetition and passage of time in some individuals. Once melancholic features are present, it is unclear whether they repeat across subsequent episodes. Melancholic features are not uniquely associated with a positive family history of depression per se, but they may be especially associated with a family history of severe depression. Conclusions The available evidence suggests some clinical utility and some (albeit not entirely consistent) validity for the concept of melancholic features. Consequently, DSM-IV will retain the designation "with melancholic features," return to the shorter DSM-III feature listing, and broaden the designation by requiring either unreactive mood or pervasive anhedonia but not both. Further research on this subgroup is indicated.

Melancholic Symptom Features and DSM-IV

• Based on a survey of the classic literature and studies examining the correlates of a clinical diagnosis of endogenous or nonendogenous depression, we found 14 variables that should discriminate endogenous and nonendogenous depressives. We applied four definitions of endogenous depression (Feinberg and Carroll, DSM-III , Research Diagnostic Criteria, and Newcastle) to a consecutive series of 152 unipolar major depressive inpatients. We examined the concordance between the definitions and the relationship between each definition and clinical, demographic, family history, and psychosocial factors. The DSM-III and Newcastle definitions were less inclusive than the other two definitions. We found some support for the validity of each of the four definitions. The validity of the Newcastle scale was the most frequently supported, with the endogenous depressives having a lower rate of personality disorder, marital separations and divorces, familial alcoholism, life events, and nonserious suicide attempts.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/493761/archpsyc_43_3_005.pdf

The validity of four definitions of endogenous depression. II. Clinical, demographic, familial, and psychosocial correlates

The dexamethasone suppression test, the Hamilton Depression Rating Scale and the DSM-III depression categories

Using a pluridiagnostic approach, the dexamethasone suppression test (DST) was studied in 67 depressed inpatients in its relationship to diverse clinical variables. The International Classification of Diseases (ICD), the Research Diagnostic Criteria (RDC), the Newcastle Index, the Hamilton Depression Rating scale (HAM-D), and the Bf-s self rating questionnaire were applied. Fifty-two per cent of endogenous depressed (ICD), 51% of major depressive (RDC) and 53% of endogenous depressed (Newcastle) patients demonstrated dexamethasone nonsuppression (DSTN) with a value above 110 nm/l. Six per cent of neurotic depressed (ICD), 9% of minor depressive (RDC) and 23% of neurotic depressed (Newcastle) patients were dexamethasone nonsuppressors. Significantly higher values (after P-correction) for DSTN could be detected in severity ratings as measured with Newcastle (P less than 0.001) and HAM-D global score (P less than 0.001) and also for HAM-D factor 4 (somatic complaints, P = 0.001). All the other evaluated variables did not discriminate between patients with dexamethasone suppression and with nonsuppression.

S. Kasper

Papers

Dexamethasone suppression test in a pluri‐diagnostic approach: its relationship to psychopathological and clinical variables