Diagnosis, personality and the long-term outcome of depression.

Patients diagnosed in the late 1960s as suffering from either endogenous or neurotic depression, or as presenting with depression but discharged with another neurotic diagnosis, were followed for 15 years. Diagnosis at index admission did not predict overall outcome, but patients with endogenous depression, an apparently stable diagnosis, had longer index admissions, were readmitted sooner, but spent less time ill than patients in either of the neurosis groups. Personality abnormality accounted for 20% of the variance in outcome in the neurotic groups and only 2% of the variance in the endogenous group. Thus there is evidence that endogenous and neurotic depression are two illnesses and that, in the neuroses particularly, prognosis will depend on the extent to which these personality abnormalities are modified by treatment.

The long-term outcome of depressive illness.

One hundred and forty-five patients with primary depressive illness admitted to a university hospital between 1966 and 1970 were followed up an average of 15 years later. Adequate data were obtained on 133 (92%) of the 145. During the follow-up period, 7% of the 133 had suicided, 12% had remained incapacitated by illness and only 20% had remained continuously well. Patients for whom the index admission was not their first were especially likely to be readmitted during the follow-up period. Patients with endogenous depression, none of whom developed schizophrenia during the follow-up period, were more likely to need readmission than patients with an index diagnosis of neurotic depression. In all other respects the prognosis for the two types of depression was the same, with considerable morbidity evident in both.

The epilepsy of Dostoevsky.

The evidence in favour of a diagnosis of limbic epilepsy in the case of Dostoevsky is reviewed. Independent records from numerous biographical sources support the widely held view that Dostoevsky had frequent convulsive episodes, that the episodes began in childhood and continued throughout his life and that Dostoevsky himself was able accurately to record the premonitory aura and sequelae of such episodes. In addition the increasing memory impairment he suffered both for recent and remote events from the age of 40 supports the presence of progressive brain damage. This information renders implausible the analytic interpretations of Freud and his followers, that Dostoevsky's epilepsy was hysterical in origin, where epileptiform somatization was presumed to dispose of excessive psychic excitation, and that this process had its roots in Dostoevsky's unconscious hatred of his father and latent homosexuality. Nevertheless, Dostoevsky's neuroticism is clearly supported by his life-long hypochondriasis, obsessionality, paranoid traits, tendency to reactive depressions, and experience of quasi-hallucinatory episodes which were probably not epileptic in origin. Neither his epilepsy nor his neuroticism can explain or detract from the profundity and wisdom of the literary monuments which clearly attest Dostoevsky's ample genius.

The trials of ECT.

Since its introduction in 1934, electroconvulsive therapy has been subjected to a large number of clinical trials of varying methodological sophistication. Although doubts continue to be expressed about the efficacy of ECT, there is a remarkable degree of unanimity in the findings of trials published over a period of 50 years: improvement rates in depression of 70-80 per cent, compared with 20-30 per cent in untreated controls. The principal caveat is that ECT is not a ubiquitous treatment, even in the field of depression, and only patients with endogenous illnesses, whether unipolar or bipolar, can be expected to respond. Even among these, ECT cannot be expected to prevent the relapses in an illness whose underlying course is episodic. The published studies leave little doubt that ECT is statistically more effective than any of the antidepressant drugs, although the relative difference in outcome between the 2 forms of therapy is small, and drugs are to be preferred in mild or moderate cases. However, ECT is an effective and rapidly acting treatment for severe depressive illness, and the rapidity of the response makes its early use desirable in patients at risk of suicide, and those showing marked retardation, agitation and weight loss.

An open trial of zimelidine in patients with endogenous depression.

13 patients with endogenous depression, who had failed to obtain a lasting response to other antidepressant drugs or to electroconvulsive therapy, were treated with zimelidine. 3 showed a marked, and 3 a mild improvement. Side effects were minimal.

The investigation of dementia: results in 200 consecutive admissions.

200 patients admitted consecutively to the Neuropsychiatric Institute, Sydney, with the provisional diagnosis of dementia were investigated. The diagnosis was confirmed in 164 patients, 16 patients had a chronic organic brain syndrome not characterised by intellectual deterioration, and 20 patients had pseudodementing functional illnesses. A potentially reversible cause of the dementia was found in 13 patients: these comprised 11.5% of the demented patients aged 45 to 64 years and 3.8% of the demented patients aged 64 years and older. It is recommended that all patients with a provisional diagnosis of dementia be investigated early in the course of their illnesses in anticipation of the finding of a reversible dementia or a treatable pseudodementing illness.

An endemic neurological disorder in tribal Australian aborigines.

Thirteen, and possibly sixteen cases of neurological disorder have been identified in a population of approximately 1100 tribal aborigines living in Groote Eylandt and the adjacent mainland. There were two relatively distinct clinical pictures: one coming on in childhood involved the motor system, the patients often having remarkably lax ligaments; and the other, generally of later onset, comprising cerebellar, upper motor neurone and sometimes supranuclear ophthalmoplegic features. There was some evidence that the two syndromes are varieties of a single condition. No causal factors were identified but there were indications that the disorder might be genetically determined. Attention is drawn to the similarities between this disorder and other ethnic-geographic isolates, particularly the ALS-Parkinsonism-dementia complex of Guam.

Six month evaluation of thiopropazate hydrochloride in tardive dyskinesia.

Using a blind evaluation of cinematographic films of patients suffering from tardive dyskinesia we found that thiopropazate hydrochloride in a dosage up to 30 mg daily was effective in reducing the severity of the dyskinesia in most patients. The overall improvement in the group of patients studied was not significant after one or three months of therapy but was significant after six months of treatment. The administration of thiopropazate hydrochloride over a six month period did not appear to aggravate the underlying pathophysiology so that the drug could be considered likely to be safe for long-term use. The anticholinergic antiparkinsonism agent benztropine mesylate aggravated the dyskinesia to a significant degree.

Asthenic personality, myth or reality.

One hundred and seventy five subjects admitted to hospital for neurotic conditions were assessed as to their personality types. Forty seven percent were judged as having personality traits consistent with the diagnosis of asthenic personality disorder. Thirteen of the 138 symptom, life history and psychological test items examined were found to be associated with the asthenic traits. Condensation of these thirteen items by factor analysis showed that two features--anxiety proneness and inability to cope with stress--together defined the disorder.

The neural basis of aggression and its treatment by psychosurgery.

The limbic system and its connections provide the neural basis for aggressive behaviour. Violent individuals may differ quantitively or qualitively from normal. Many of the latter suffer from epilepsy. In some the epileptiform discharges from the amygdala can only be recorded using depth electrodes. It can be taken that the control of abnormal degrees of violent behaviour is now possible. Should such operations be used? If so who should have them? What preacutions need to be taken that such operations are not abused? How can informed consent be obtained? The development of new surgical techniques make these questions pertinent if not urgent.

Depression: a multivariate study of Sir Aubrey Lewis's data on melancholia.

Principal component analyses were carried out on 51 items abstracted from Lewis's 1934 and 1936 papers. The first component was bipolar, differentiating between endogenous items and those that were mainly neurotic. The distributions of the first component scores by cluster indicated that there were two separate clusters of patients, one mainly endogenous, the other neurotic. It was concluded that Lewis's data indicate that there are at least two qualitatively different depressive illnesses. Further component analyses were carried out using the 25 endogenous items. The first component was a general one of endogenous depression. The distributions of its scores were bimodal, indicating that there were two groups of patients, those who suffered from endogenous depression and those who did not. These analyses indicated that endogenous depression is a categorical illness.

Depressed lymphocyte function after bereavement.

During 1975 twenty-six bereaved spouses took part in a detailed prospective investigation of the effects of severe stress on the immune system. T and B cell numbers and function, and hormone concentrations were studied approximately 2 weeks after bereavement and 6 weeks thereafter. The response to phytohaemagglutinin was significantly depressed in the bereaved group on the second occasion, as was the response to concanavalin A at 6 weeks. There was no difference in T and B cell numbers, protein concentrations, the presence of autoantibodies and delayed hypersensitivity, and in cortisol, prolactin, growth hormone, and thyroid hormone assays between the bereaved group and the controls. This is the first time severe psychological stress has been shown to produce a measurable abnormality in immune function which is not obviously caused by hormonal changes.