Differential response to chlorpromazine, imipramine, and placebo. A study of subgroups of hospitalized depressed patients.
01 Aug 1970-Archives of General Psychiatry (American Medical Association)-Vol. 23, Iss: 2, pp 164-173
TL;DR: Researchers found a tranquilizer, thioridazine, best for their anxious depressives and imipramine best for the withdrawn-retarded depressives, which may have some relevance for the endogenous-neurotic distinction.
Abstract: A MAJOR aim of the present study was to examine the differential effects of chlorpromazine and imipramine among various depression subgroups. Tests were made of differential drug effects among Overall et al's 1 three empirically derived depressive subtypes, ie, anxious, hostile, and withdrawn-retarded depressives. These investigators found a tranquilizer, thioridazine, best for their anxious depressives and imipramine best for the withdrawn-retarded depressives. An examination was also made of differential drug effects among psychotic depressives, neurotic depressives, and schizophrenics with depression. As there is a tendency in this country to equate psychotic depression with endogenous depression, study findings may have some relevance for the endogenous-neurotic distinction. Proponents of this distinction have reported that imipramine is especially efficacious for endogenous depression and of little value in neurotic depressions. 2-12 Finally, tests were made of differential drug effects among depressed patients categorized on the basis of sex and age (below 40 and 40 and
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TL;DR: The historical evolution, development, rationale and validation of the Hopkins Symptom Checklist is described, a self-report symptom inventory comprised of 58 items which are representative of the symptom configurations commonly observed among outpatients.
Abstract: This report describes the historical evolution, development, rationale and validation of the Hopkins Symptom Checklist (HSCL), a self-report symptom inventory. The HSCL is comprised of 58 items which are representative of the symptom configurations commonly observed among outpatients. It is scored on five underlying symptom dimensions—sommatization, obsessive-compulsive, interpersonal sensitivity, anxiety and depression—which have been identified in repeated factor analyses. A series of studies have established the factorial invariance of the primary symptom dimensions, and substantial evidence is given in support of their construct validity. Normative data in terms of both discrete symptoms and primary symptom dimensions are presented on 2,500 subjects—1,800 psychiatric outpatients and 700 normals. Indices of pathology reflect both intensity of distress and prevalence of symptoms in the normative samples. Standard indices of scale reliability are presented, and a broad range of criterion-related validity studies, in particular an important series reflecting sensitivity to treatment with psychotherapeutic drugs, are reviewed and discussed.
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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
TL;DR: Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode.
Abstract: This paper draws attention to an important adverse outcome in depression, the occurrence of residual symptoms after partial remission. Among patients with definite major depression followed every 3 months to remission and thereafter, residual symptoms reaching 8 or more on the Hamilton Depression Scale 17-item total were present in 32% (19) of the 60 who remitted below major depression by 15 months. The pattern was of mild but typical depressive symptoms. Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode. There were weak associations with personality that might have been consequences of symptom presence. Residual symptoms were very strong predictors of subsequent early relapse, which occurred in 76% (13/17) of those with residual symptoms and 25% (10/40) of those without.
779 citations
TL;DR: The findings indicate the importance of social stress in puerperal depression, and postpartum blues were only associated with depression in the absence of life events, suggesting a small hormonal sub-group.
Abstract: A 20 per cent prevalence of mild clinical depression was found in 120 women assessed at about six weeks postpartum. The strongest associated factor was occurrence of recent stressful life events. Previous history of psychiatric disorder, younger age, early postpartum blues, and a group of variables reflecting poor marital relationship and absence of social support were also notable. Poor marital support acted as a vulnerability factor, only producing an effect in presence of stressful life events. Previous psychiatric history produced a strong independent effect, both with and without life events. Postpartum blues were only associated with depression in the absence of life events, suggesting a small hormonal sub-group. Overall the findings indicate the importance of social stress in puerperal depression.
703 citations
TL;DR: The effects of long-term antidepressant treatment on biogenic amine metabolism and on various indexes of presynaptic and postsynaptic receptor function are evaluated to provide support for hypotheses of amine receptor abnormalities in depression and indicate the need for expanded studies ofAmine receptor function in patients.
Abstract: • Considerable evidence suggests that the acute effects of antidepressant treatments on brain norepinephrine (NE) and serotonin (5-HT) systems cannot account fully for their delayed therapeutic action. This review evaluates the effects of long-term antidepressant treatment on biogenic amine metabolism and on various indexes of presynaptic and postsynaptic receptor function. In contrast to variable effects on NE and 5-HT turnover and on presynaptic receptor sensitivity, almost all long-term antidepressant treatments produce consistent alterations in a number of measures of postsynaptic amine receptor sensitivity. Longterm treatment has been found to reduce β-adrenergic sensitivity while enhancing responses to serotonergic and α-adrenergic stimulation, suggesting that modulation of receptor sensitivity may be a mechanism of action common to tricyclic antidepressants, "atypical" antidepressants, monoamine oxidase inhibitors, and electroconvulsive therapy. These findings provide support for hypotheses of amine receptor abnormalities in depression and indicate the need for expanded studies of amine receptor function in patients.
642 citations
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TL;DR: The Brief Psychiatric Rating Scale (BRS) as mentioned in this paper was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change, and it is recommended for use where efficiency, speed, and economy are important considerations.
Abstract: The Brief Psychiatric Rating Scale was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change. Sixteen symptom constructs which have resulted from factor analyses of several larger sets of items, principally Lorr's Multidimensional Scale for Rating Psychiatric Patients (MSRPP) (1953) and Inpatient Multidimensional Psychiatric Scale (IMPS) (1960), have been included for rating on 7-point ordered category rating scales. The attempt has been to include a single scale to record degree of symptomacology in each of the relatively independent symptom areas which have been identified. Some of the preliminary work which has led to the identification of primary symptom constructs has been published (Gorham & Overall, 1960, 1961, Overall, Gorharn, & Shawver, 1961). While other reports are in preparation, applications of the Brief Scale in both pure and applied research suggest the importance of presenting the basic instrument to the wider scientific audience at this time, together with recommendations for its standard use. The primary purpose in developing the Brief Scale has been the development of a highly efficient, rapid evaluation procedure for use in assessing treatment change in psychiatric patients while at the same time yielding a rather comprehensive description of major symptom characteristics. It is recommended for use where efficiency, speed, and economy are important considerations, while more detailed evaluation procedures, such as those developed by Lorr (1953, 1961) should perhaps be wed in other cases. In order to achieve the maximum effectiveness in use of the Brief Scale, a standard interview procedure and more detailed description of rating concepts are included in this report. In addition, each symptom concept is defined briefly in the rating scale statements themselves. Raters using the scale should become thoroughly familiar with the scale definitions presented herein, after which the rating scale statements should be sufficient to provide recall of the nature and delineation of each symptom area. , To increase the reliability of ratings, it is recommended that patients be interviewed jointly by a team of two clinicians, with the two raters making independent ratings at the completion of the interview. An alternative procedure which has been recommended by some is to have raters discuss and arrive at a
10,457 citations
TL;DR: There is evidence to indicate that the uncertainty about the most clear and convenient lines of demarcation within this clinical territory makes a large contribution to the unreliability of psychiatric diagnosis.
Abstract: An investigation of 129 in-patient depressives treated with E.C.T. is presented. All were followed up to 3 months, and 108 to 6 months. Initially all were scored for the presence or absence of 35 features considered to discriminate between endogenous and neurotic depressions. Diagnoses were allocated before or early during treatment. Patients were rated at the termination of E.C.T. at 3 months and at 6 months, on a four-point scale. At 3 months, only 12 out of 63 neurotic depressives were found to have responded well to E.C.T., whereas out of 53 endogenous depressives had done so; the corresponding figures for 6 months were 8 out of 53 and 34 out of 44.
A factor analysis of the features produced three significant factors, a bipolar factor corresponding to the distinction between endogenous and neurotic depression, a general factor with high loadings for many features common to all the depressive cases studied and, probably, a paranoid psychotic factor. The bipolar factor closely resembles that extracted in a previous investigation (Kiloh and Garside, 1963) and supports the hypothesis that these are two distinct depressive populations. Among features with high positive loadings on the first factor, and thus corresponding to a diagnosis of endogenous depression, were adequate premorbid personality, absence of adequate psychogenic factors in relation to illness, a distinct quality to the depression, weight loss, pyknic body build, occurrence of previous depressive episode, early morning awakening, depressive psychomotor activity, nihilistic, somatic and paranoid delusions, and ideas of guilt. Among features with a negative loading corresponding to a diagnosis of neurotic depression were anxiety, aggravation of symptoms in the evening, self-pity, a tendency to blame others, and hysterical features.
By means of multiple regression analysis, three series of 18 weighted coefficients for the differential diagnosis between the two varieties of depression and for the prediction of E.C.T. response at 3 and 6 months were calculated. The multiple correlations between the summed features on the one hand and diagnosis and outcome at 3 and 6 months on the other were 0.91, 0.72 and 0.74 respectively. It was thought that E.C.T. response could be better predicted by the direct use of the weights for E.C.T. response than from the diagnostic weights alone. The weights based on the 18 features were complex, and therefore a further table was constructed giving simplified weights based on ten features of diagnosis and ten features for prediction of outcome of treatment with E.C.T. after 6 months.
878 citations
TL;DR: It was demonstrated that the compound has potent antidepressant action and best responses were obtained in cases of endogenous depression showing the typical symptoms of mental and motor retardation, fatigue, feeling of heaviness, hopelessness, guilt, and despair.
Abstract: Over a three-year period, more than 500 psychiatric patients of various diagnostic categories were treated with imipramine hydrochloride. It was demonstrated that the compound has potent antidepressant action. Best responses were obtained in cases of endogenous depression showing the typical symptoms of mental and motor retardation, fatigue, feeling of heaviness, hopelessness, guilt, and despair. The condition is furthermore characterized by the aggravation of symptoms in the morning with a tendency to improvement during the day. Treatment with imipramine hydrochloride resulted in full or social recovery in a high percentage of the patients. As a rule, the initial response was evident within 2 to 3 days, while in some cases 1 to 4 weeks of therapy were required. In view of the symptomatic nature of the action of imipramine hydrochloride, therapy must be maintained as long as the illness lasts. The side effects noted were relatively slight, and with the exception of one case of severe allergic exanthema ne...
488 citations
TL;DR: The viewpoint that improvement must be evaluated in terms of underlying personality changes are discussed and a simple measure of self-awareness is described which may be a possible indicator of certain such changes.
Abstract: Since improvement under psychotherapy is not a unitary phenomenon, progress in studying the effectiveness of psychotherapy depends on the use of carefully defined and generally agreed upon criteria of improvement. In the present state of knowledge such criteria must be based on value judgments by the patient, and by persons with whom he interacts. It is suggested that the criteria comfort and effectiveness represent these values. Means of measuring them are described and problems connected with the measures considered. Some implications of the viewpoint that improvement must be evaluated in terms of underlying personality changes are discussed. A simple measure of self-awareness is described which may be a possible indicator of certain such changes.
421 citations
TL;DR: The break-up of some of the larger, global factors from the first study into smaller and more narrowly defined factors in the second study was a distinct asset in later efforts to discern the differential effects of various antidepressant drugs.
Abstract: In a prior study, we identified factors of psychopathology in the interview, ward behavior and self-report ratings of 124 depressed patients from 9 hospitals. The present study attempts to replicate these findings in a sample of 648 depressed patients from 10 hospitals. The criteria for patient sele
382 citations