Diagnosis and neuroanatomical correlates of depression in brain-damaged patients. Implications for a neurology of depression.
01 Dec 1981-Archives of General Psychiatry (American Medical Association)-Vol. 38, Iss: 12, pp 1344-1354
TL;DR: Based on five case studies, several clinical guidelines for recognizing and diagnosing depression in brain-damaged patients are offered and initial hypotheses about the neuroanatomical basis of the depressive syndrome are generated.
Abstract: • Recognizing depression in brain-damaged patients poses considerable problems. The standard dignostic criteria often are not applicable since the neurological lesion may distort or even obliterate salient features of depression. Patients actually may deny being depressed or dysphoric, not have a depressive affect, or be totally unaware of abnormal vegetative behaviors. Furthermore, brain lesions themselves may produce striking behavioral alterations that can be mistakenly attributed to depression, or striking behavioral changes due to depression may be mistakenly attributed to the brain lesion. Based on five case studies, several clinical guidelines for recognizing and diagnosing depression in brain-damaged patients are offered. These cases also provide a data base to generate initial hypotheses about the neuroanatomical basis of the depressive syndrome. By observing how focal brain lesions modify the signs and symptoms of depression, inferences are made about brain areas crucial for modulating the various features of the depressive syndrome.
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TL;DR: A working model of depression implicating failure of the coordinated interactions of a distributed network of limbic-cortical pathways is proposed to facilitate continued integration of clinical imaging findings with complementary neuroanatomical, neurochemical, and electrophysiological studies in the investigation of the pathogenesis of affective disorders.
Abstract: A working model of depression implicating failure of the coordinated interactions of a distributed network of limbic-cortical pathways is proposed. Resting state patterns of regional glucose metabolism in idiopathic depressed patients, changes in metabolism with antidepressant treatment, and blood flow changes with induced sadness in healthy subjects were used to test and refine this hypothesis. Dorsal neocortical decreases and ventral paralimbic increases characterize both healthy sadness and depressive illness; concurrent inhibition of overactive paralimbic regions and normalization of hypofunctioning dorsal cortical sites characterize disease remission. Normal functioning of the rostral anterior cingulate, with its direct connections to these dorsal and ventral areas, is postulated to be additionally required for the observed reciprocal compensatory changes, since pretreatment metabolism in this region uniquely predicts antidepressant treatment response. This model is offered as an adaptable framework to facilitate continued integration of clinical imaging findings with complementary neuroanatomical, neurochemical, and electrophysiological studies in the investigation of the pathogenesis of affective disorders.
1,505 citations
TL;DR: In this paper, the authors examined 10 right-handed patients with focal lesions of the right hemisphere and disorders of affective language, including prosody, prosodic repetition and comprehension of emotional gesturing.
Abstract: It was recently proposed that the affective components of language, encompassing prosody and emotional gesturing, are a dominant function of the right hemisphere, and that their functional-anatomic organization in the right hemisphere mirrors that of propositional language in the left hemisphere. Ten right-handed patients with focal lesions of the right hemisphere and disorders of affective language are described. Observations were made about each patient's spontaneous prosody, prosodic repetition, prosodic comprehension, and comprehension of emotional gesturing. Using this particular examination strategy, which is derived from the usual bedside approach to aphasic disorders, the organization of affective language in the right hemisphere does mirror the organization of propositional language in the left hemisphere. Furthermore, the disorders of affective language seem to be classifiable in the same manner as the aphasias. Thus, the term "aprosodia," preceded by specific modifiers such as motor, global, transcortical sensory, etc, seems appropriate when classifying the various disorders of affective language that occur following-right-hemisphere damage. The relationships between affect, mood, pathologic laughing and crying, and depression are also discussed.
743 citations
TL;DR: Evidence is provided of a differentiation of factors likely to be implicated in the development of depression after stroke based on the period of time since the stroke event.
Abstract: BACKGROUND AND PURPOSE: This prospective study was designed to examine the contributions of neurobiological, functional, and psychosocial factors to major depression after stroke. In addition, the ...
681 citations
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...Nondepressed 9 (19) 38 (81) 8 (19) 34 (81) 1 (3) 31 (97)...
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TL;DR: The whole brain metabolic rates for patients with bipolar depression increased going from depression or a mixed state to a euthymic or manic state, and patients with unipolar depression showed a significantly lower ratio of the metabolic rate of the caudate nucleus, divided by that of the hemisphere as a whole.
Abstract: Cerebral metabolic rates for glucose were examined in patients with unipolar depression (N = 11), bipolar depression (N = 5), mania (N = 5), bipolar mixed states (N = 3), and in normal controls (N = 9) using positron emission tomography and fluorodeoxyglucose F 18. All subjects were studied supine under ambient room conditions with eyes open. Bipolar depressed and mixed patients had supratentorial whole brain glucose metabolic rates that were significantly lower than those of the other comparison groups. The whole brain metabolic rates for patients with bipolar depression increased going from depression or a mixed state to a euthymic or manic state. Patients with unipolar depression showed a significantly lower ratio of the metabolic rate of the caudate nucleus, divided by that of the hemisphere as a whole, when compared with normal controls and patients with bipolar depression.
575 citations
TL;DR: It is suggested that geriatric depression with reversible dementia is a clinical entity that includes a group of patients with early-stage dementing disorders and is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders.
Abstract: Objective: The goals ofthis longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement ofdepression and 2) to compare it with that ofdepressed, neverdemented patients. Method: The subjects were 57 elderly patients consecutively hospitalized f or major depression. At entry into the study, 23 subjects also met criteria for “reversible dementia, “ while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months. Results: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43 %) than in the group with depression alone (1 2%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented. � clusions: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group ofpatients with early-stage dementing disorders. Therefore, identification ofa reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders. (Am-”J Psychiatry 1993; 150:1693-1699)
460 citations
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TL;DR: The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type, used for quantifying the results of an interview, and its value depends entirely on the skill of the interviewer in eliciting the necessary information.
Abstract: Types of Rating Scale The value of this one, and its limitations, can best be considered against its background, so it is useful to consider the limitations of the various rating scales extant. They can be classified into four groups, the first of which has been devised for use on normal subjects. Patients suffering from mental disorders score very highly on some of the variables and these high scores serve as a measure of their illness. Such scales can be very useful, but have two defects: many symptoms are not found in normal persons; and less obviously, but more important, there is a qualitative difference between symptoms of mental illness and normal variations of behaviour. The difference between the two is not a philosophical problem but a biological one. There is always a loss of function in illness, with impaired efficiency. Self-rating scales are popular because they are easy to administer. Aside from the notorious unreliability of self-assessment, such scales are of little use for semiliterate patients and are no use for seriously ill patients who are unable to deal with them. Many rating scales for behaviour have been devised for assessing the social adjustment of patients and their behaviour in the hospital ward. They are very useful for their purpose but give little or no information about symptoms. Finally, a number of scales have been devised specifically for rating symptoms of mental illness. They cover the whole range of symptoms, but such all-inclusiveness has its disadvantages. In the first place, it is extremely difficult to differentiate some symptoms, e.g., apathy, retardation, stupor. These three look alike, but they are quite different and appear in different settings. Other symptoms are difficult to define, except in terms of their settings, e.g., mild agitation and derealization. A more serious difficulty lies in the fallacy of naming. For example, the term "delusions" covers schizophrenic, depressive, hypochrondriacal, and paranoid delusions. They are all quite different and should be clearly distinguished. Another difficulty may be summarized by saying that the weights given to symptoms should not be linear. Thus, in schizophrenia, the amount of anxiety is of no importance, whereas in anxiety states it is fundamental. Again, a schizophrenic patient who has delusions is not necessarily worse than one who has not, but a depressive patient who has, is much worse. Finally, although rating scales are not used for making a diagnosis, they should have some relation to it. Thus the schizophrenic patients should have a high score on schizophrenia and comparatively small scores on other syndromes. In practice, this does not occur. The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type. It is used for quantifying the results of an interview, and its value depends entirely on the skill of the interviewer in eliciting the necessary information. The interviewer may, and should, use all information available to help him with his interview and in making the final assessment. The scale has undergone a number of changes since it was first tried out, and although there is room for further improvement, it will be found efficient and simple in use. It has been found to be of great practical value in assessing results of treatment.
29,488 citations
TL;DR: The development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC), indicate high reliability for diagnostic judgments made using these criteria.
Abstract: • A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria.
6,238 citations
TL;DR: Diagnostic criteria for 14 psychiatric illnesses along with the validating evidence for these diagnostic categories comes from workers outside the authors' group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies.
Abstract: Diagnostic criteria for 14 psychiatric illnesses (and for secondary depression) along with the validating evidence for these diagnostic categories comes from workers outside our group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies. These criteria are the most efficient currently available; however, it is expected that the criteria be tested and not be considered a final, closed system. It is expected that the criteria will change as various illnesses are studied by different groups. Such criteria provide a framework for comparison of data gathered in different centers, and serve to promote communication between investigators.
5,308 citations
TL;DR: Abnormal DST results were found with similar frequency among outpatients and inpatients with melancholia; but they were not related to age, sex, recent use of psychotropic drugs, or severity of depressive symptoms.
Abstract: • Four hundred thirty-eight subjects underwent an overnight dexamethasone suppression test (DST) to standardize the test for the diagnosis of melancholia (endogenous depression). Abnormal plasma cortisol concentrations within 24 hours after dexamethasone administration occurred almost exclusively in melancholic patients. The best plasma cortisol criterion concentration, above which a DST result may be considered abnormal, was 5 ug/dL. The optimal dose of dexamethasone was 1 rather than 2 mg. Two blood samples obtained at 4 and 11 PM after dexamethasone administration detected 98% of the abnormal test results. This version of the DST identified melancholic patients with a sensitivity of 67% and a specificity of 96%. Baseline nocturnal plasma cortisol concentrations were not useful. Abnormal DST results were found with similar frequency among outpatients and inpatients with melancholia; but they were not related to age, sex, recent use of psychotropic drugs, or severity of depressive symptoms. Extensive evidence validates this practical test for the diagnosis of melancholia.
2,006 citations
TL;DR: Cognitive therapy resulted in significantly greater improvement than did pharmacotherapy on both a self-administered measure of depression (Beck Depression Inventory) and clinical ratings (Hamilton Rating Scale for Depression and Raskin Scale) and follow-up contacts indicate that treatment gains evident at termination were maintained over time.
Abstract: Forty-one unipolar depressed outpatients were randomly assigned to individual treatment with either cognitive therapy (N =19)or imipramine (N =22).As a group, the patients had been intermittently or chronically depressed with a mean period of 8.8 years since the onset of their first episode of depression, and 75%were suicidal. For the cognitive therapy patients, the treatment protocol specified a maximum of 20 interviews over a period of 12 weeks. The pharmacotherapy patients received up to 250 mg/day of imipramine for a maximum of 12 weeks. Patients who completed cognitive therapy averaged 10.90 weeks in treatment; those in pharmacotherapy averaged 10.86 weeks. Both treatment groups showed statistically significant decreases in depressive symptomatology. Cognitive therapy resulted in significantly greater improvement than did pharmacotherapy on both a self-administered measure of depression (Beck Depression Inventory)and clinical ratings (Hamilton Rating Scale for Depression and Raskin Scale).Moreover, 78.9%of the patients in cognitive therapy showed marked improvement or complete remission of symptoms as compared to 22.7%of the pharmacotherapy patients. In addition, both treatment groups showed substantial decrease in anxiety ratings. The dropout rate was significantly higher with pharmacotherapy (8 Ss)than with cognitive therapy (1 S).Even when these dropouts were excluded from data analysis, the cognitive therapy patients showed a significantly greater improvement than the pharmacotherapy patients. Follow-up contacts at three and six months indicate that treatment gains evident at termination were maintained over time. Moreover, while 68%of the pharmacotherapy group re-entered treatment for depression, only 16%of the psychotherapy patients did so.
789 citations