The value of assays in tricyclic antidepressant therapy.

Studies are reviewed showing that neurotoxicity can be associated with plasma tricyclic antidepressant (TCA) assays above 350 ng/ml. The objective of this study was to develop guidelines in the use of plasma TCA assays from analysis of data of the treatment of patients with endogenous depressions and panic disorders with TCA dosages of 100-300 mgm per day. A total of 38.5% of a small group of patients treated with TCAs and concomitant neuroleptic therapy had plasma assays above 350 ng/ml; 16.7% of a larger group of patients treated with TCAs alone had assays above that level. Guidelines discussed for the use of plasma TCA assays come from analysis of the data and case vignettes.

The 2-mg dexamethasone suppression test in differentiating major depression with psychosis from schizophrenia.

The 2-mg dexamethasone suppression test (DST), performed in a drug-free acute exacerbation phase of illness shortly after admission, differentiated between major depression with psychosis and stringently diagnosed chronic schizophrenia. This has practical significance because effective drug treatment in each diagnostic group is different. Nonsuppression was seen in all six newly admitted patients in a drug-free acute exacerbation phase of illness with major depression with psychosis. Suppression was seen in all 20 newly admitted chronic schizophrenic patients in a drug-free acute exacerbation phase of illness, with the exception of two very agitated patients with mildly elevated 11 p.m. cortisol samples. Studies are briefly reviewed and suggest that nonsuppression with 1-mg DST may occur in the absence of pituitary-adrenal disinhibition and in the acute exacerbation phase of some chronic schizophrenic patients.

Recurrent psychotic unipolar depression.

Evidence is presented to support the validity of recurrent psychotic (or delusional) unipolar depression as a distinct clinical subtype. A combination of antipsychotic and antidepressant medication was effective during hospitalization for 10 of 12 patients so diagnosed, and as prophylaxis in outpatient follow-up for 7 of the 12. Three patients who discontinued their medication decompensated and were rehospitalized. Patients with this disorder are often misdiagnosed as having a schizophrenic or schizoaffective disorder and therefore do not receive the most appropriate chemotherapy. The dexamethasone suppression test can help to confirm the diagnosis in many of these patients and provide a laboratory correlate for clinical improvement.