A double-blind comparison of citalopram (Lu 10-171) and amitriptyline in depressed patients.

In a controlled, clinical, multicentre trial comprising a total of 43 patients (17 men and 26 women) citalopram was compared double-blindly with amitriptyline. Nineteen patients of each group were classified as endogeneously depressed, whereas four patients of the citalopram group and one of the amitriptyline group were classified as non-endogenously depressed. The patients were seriously ill with a high frequency of previous depressive episodes and of mental disorders among their closest relatives. Thirteen of the patients in either group had received antidepressants without satisfactory effect before entry into the trial. Each patient was treated for a period of at least 3 weeks with daily citalopram doses of 30-60 mg or daily amitriptyline doses of 75-225 mg. A statistically significant reduction of MADRS scores (total scores as well as each of the 10 individual items) was recorded in both groups. The only difference between the groups was a trend towards a better effect on sleep disturbances in the amitriptyline group. Side-effects were recorded more frequently in the amitriptyline group than in the citalopram group, global assessment of side effects being significantly different in favour of citalopram. It is concluded that citalopram is an effective and safe drug in the treatment of endogenous depression - probably as efficacious as amitriptyline, but with fewer side effects.

Persecutory affective psychoses: a follow-up.

A series of 66 cases with persecutory affective psychoses was followed up between 5 and 44 years. These psychoses can be considered as a subgroup of catamnestically verified paranoid reactive psychoses. They comprise cases with and without clouded consciousness. The long-term prognosis is best for cases with clouded consciousness at the initial stage of the psychosis. The characteristics of premorbid personality, psychological precipitating factors and psychotic symptomatology are illustrated by several tables.

Higher nervous activity in psychiatric patients.

A review is presented of studies of higher nervous activity in psychiatric patients. In neuroses and reactive psychoses the basic pathology appears to be centered around the psychogenic complex structures. In addition, neuroses as well as reactive psychoses reveal general disturbances of higher nervous activity. In the schizophrenic and manic depressive psychoses there are indications of disturbances in deep-lying brain structures. Both types of psychoses are heterogeneous groups of clinical conditions. An important task for future experimental studies is to establish the types of disturbances of higher nervous activity in well-defined clinically homogenous groups. The final section deals with prophylactic psychiatry, with special emphasis on Gantt's suggestions for an international project.

Pseudoneurotic and pseudopsychopathic schizophrenia: a follow-up.

A series of 67 pseudoneurotic and pseudopsychopathic schizophrenics were followed up. The prognosis was good insofar as these psychoses do not develop schizophrenic deterioration. Complete recoveries are rare, as borderline characteristics tend to persist. We only considered 5 cases as completely recovered. The hospital diagnosis was predominantly reactive psychoses, and the largest group of close relatives also had reactive psychoses. The distinction between pseudoneurotic and pseudopsychopathic schizophrenia is fairly reliable. By independent coding of 64 cases, the authors agreed on about 58 cases and disagreed on about 6 cases.

Querulent paranoia: a follow-up.

This study deals with all querulent paranoias admitted to Gaustad Hospital during 1938-1972. As querulent paranoia is a rare clinical condition, a plea is made for a multicenter study. We had only 22 cases, but most of them have a follow-up over several years, so that we are able to know fairly well the long-term course of illness. The family background has very little to do with schizophrenia and manic-depressive psychoses. It seems that querulent paranoia is a psychogenic disorder, based on deviant personality structures and unlucky personal experiences. Somatic treatments with ECT and drugs have no effects.

Paranoiac psychoses: a follow-up.

74 patients with paranoiac psychoses were followed up. Paranoiac psychoses are characterized by affect-laden delusions, resemble the paranoias of Kraepelin, but have a better prognosis. 18 cases appeared to show a chronic course of illness, but only 1 case needed prolonged hospitalization in a mental hospital. Paranoiac psychoses are considered benign insofar as they have a nonschizophrenic long-term outcome. They resemble schizophrenic psychoses because the familial loading of psychoses is predominantly schizophrenic. To a great extent, the clinical picture revealed typical schizophrenic symptoms at the onset of the illness, so that at discharge from hospital there were often doubts as to whether psychoses should be classified as schizophrenias.

Prophylactic psychiatry.

The great contributions of Gantt to the problems of prophylactic psychiatry are pointed out. The author reviews his experiences with a 30-year follow-up of a population of 1800 persons. Over the 30 years, there appeared to be a 50% increase of neuroses, which raises great problems for mental health services. The Berlevåg population was offered optimal psychiatric services. Behavior therapy of neuroses and drug treatment of depression may possibly have lowered the prevalence of mental disorders. Psychophysiologic tests were used in the project. It is hoped that such tests may be utilized for early detection and treatment of mental disorders.

A comparison of nine systems to diagnose schizophrenia.

The files of 283 hospitalized patients discharged with a diagnosis of schizophrenia, schizoaffective schizophrenia, or paranoid state were examined without knowledge of the patient's subsequent history. These patients, most of whom had originally been diagnosed by DSM-I criteria, were retrospectively diagnosed by New York Research Diagnostic Criteria (RDC), the New Have Schizophrenia Index (NHSI), the St. Louis criteria, Taylor-Abrams 1978 criteria, Schneider's first-rank symptoms (FRS), the Washington IPSS 12-Point Flexible System, Astrup's process/nonprocess distinction, and DSM-III. Kappa values measuring pairwise diagnostic agreement amont the nine systems were typically low except among RDC, DSM-III, and St. Louis criteria. Long-term followup status was not significantly predicted by the FRS, NHSI, or Taylor-Abrams criteria. Diagnosis by means of the other systems, especially the Astrup process/nonprocess distinction, was significantly correlated with followup. However, Astrup's "process" schizophrenia is not operationally defined and could not be expected to be used with the degree of interrater reliability desired by researchers. On the other hand, of the operationally defined systems, DSM-III schizophrenia has the highest correlation with followup and is thus suggested for use by researchers desiring a highly homogeneous, although narrowly defined, population. Investigators wishing to cast a wider net could use a less restrictive system such as the RDC, with or without schizoaffectives included.

Reactive depression: a follow-up.

93 cases of reactive depression have been followed up in order to investigate the long-term course of illness. By independent classification of reactive and endogenous depressions the authors agreed on diagnosis for 94%. Ten subgroups of reactive depressions are illustrated by case histories. It is of practical importance to establish the clinical diagnosis of reactive depression because these states are different from endogenous depressions with regard to pathogenesis, prognosis and treatment.

Differential effects of person in the dog and in the human.

People have marked effects on dog's heart rate, with great individual variations for different persons. Apparently people to which the dog is attached have the greatest effect upon heart rate. Replications of the animal experiments using the psychotherapist and two other people revealed no effects upon the heart rate of a schizophrenic human. In the human the effects of people are probably best demonstrated in connection with verbal communication.

Physiological mechanisms of flooding (implosion) therapy.

Desensitization of psychological and physiological complex structures may be the most important element of flooding treatment. The implosive sessions are assumed to represent a supramaximal stimulation of pathologically excited and inert complex structures resulting in protective inhibition, irradiation of excitation, reduction of the excitation and inertness, and a decrease of the overshooting autonomic reactivity of the complex structures, leading to reduction of anxiety, aggression, and other pathologically increased feelings. Advantages such as stronger and improved flooding can be achieved by a flooding in hypnosis. The therapeutic indications go beyond the usual treatment of phobic states. In order to establish the psychological and physiological mechanisms in implosion there is a need for psychophysiological investigations. However, much is unknown about mechanisms. Controlled comparisons with other treatments give limited answers. Perhaps an international case history bank might establish which clinical conditions might benefit by technical modifications of flooding.

Psychophysiological studies of a geographically defined population.

In the Berlevag project attemps have been made at using psycho-physiological and cognitive measures as indexes of psychiatric morbidity.--With skin conductance response, psychotics and neurotics showed signs of autonomic inhibition compared with conduct disorders and normal controls. All groups except psychotics showed cognitive effects in conditioning. No differences between the groups could be established for stereotype indexes, but the Berlevag sample appeared to have unusual high stereotypy indexes. With word associations the patient groups were markedly different from controls, with most deviations in psychotics and least deviations in conduct disorders.--A comparison of word associations in samples of the Oslo and the Berlevag populations suggested that the associative network was very similar in the two populations. There are differences with regard to verbal fluency, response types and reaction times.--It is unresolved whether these differences measure psychiatric morbidity or reflect a culture-dependent character of the word association test.

Studies of higher nervous activity in functional phychoses.

Psychiatric illnesses can be conceived of as experiments of nature, providing a variety of pathopsychological mechanisms which may elucidate normal psychological processes. Clinically the reactive psychoses are predominantly psychogenic reaction types. They present disturbances of higher nervous activity, similar to those of the neuroses. The unconditional reflex activity is practically as in normal controls, and the most outstanding finding was the large effect of psychodynamic complex structures. This is a physiological parallel to the clinical manifestations with great concern over experienced mental trauma. In the manic-depressive psychoses the most characteristic feature is a marked disturbance of unconditional reflex activity. This factor may be an important physiological mechanism underlying the more biological than psychodynamic reaction type and partly explain the changes of mood and associated interferences with sleep, body weight, sexual activity, aggression and other instinctual and vegetative functions. Schizophrenic psychoses also present changes of unconditional reflex activity, predominantly in the direction of inhibition of response. In addition there are severe dissociations within and between the three levels of unconditional reflexes and the two signaling systems. It is suggested that schizophrenia represents a functional maladaptation, which can be explained from the principles of autokinesis and schizokinesis established by Gantt in animal experiments. Prognostic models based on experimentally established impairment of performances were shown to predict long-term risks of schizophrenic defects just as well as models based on constellations of clinical symptoms. I would predict that psychophysiology and experimental psychology will become increasingly more important for establishing diagnosis and prognosis in the functional psychoses. The data of this article point toward a basis for a prophylactic psychiatry.