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Nighttime ACTH, cortisol, prolactin, and growth hormone secretion in prepubertal depression
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BXOLPSYCHIATRY 1995;37:593 683
4. NATURAL HISTORY AND COURSE OF ADULT ANXIETY DISORDERS
R. Noyes, Jr. University o f I o w a In general, the anxiety disorders appear to be chronic if left untreated in thc general population. Persons seeking treatment are likely to have more severe disorders and more comorbidity, but there is little data on this point. However, even treated persons appear to have chronic course; relatively few become free of symptoms, but a substantial proportion achieve a good outcome (little impairment) despite residual symptoms. A gradual amelioration may occur with the passage of years but, here again, there is little data. Individual disorders appear to differ in course and outcome, with social phobia and agoraphobia showing greater persistence and severity. Prognostic factors include severity, duration, and comorbidity (axis I and II). A variety of psychological therapies appear to affect course and outcome, although design problems limit interpretation of many studies. Prospective studies are needed that examine the outcome of subjects with all of the anxiety disorders obtained from the community. In addition to diagnostic stability, such studies can be expected to show important differences in outcome among individual disorders.
5. LONG-TERM TREATMENT OF ANXIETY DISORDERS M.R. Mavissakalian T h e O h i o State U n i v e r s i t y College o f Medicine, Columbus, OH 43210 The 1980s saw the development of specific and effective treatments for anxiety disorders. The long-term effects of these treatments, however, are not well known. Although follow-up studies suggest that improvement with behavioral treatments is lasting while relapse upon discontinuation of drug treatment is high, the prevailing notion that psychological treatments have enduring effects requires critical assessment, and only recently has research begun to elucidate maintenance/discontinuation issues involved in the pharmacological treatments of these disorders. In this critical review of the literature, an important methodological distinction will be made between the long-term outcome following an acute course of treatment and the effects of long-term treatment, including the specific role of maintenance treatment. The conclusion will underscore the need to have the longitudinal perspective in mind before embarking on a treatment course and will offer empirically based guidelines for the long-term treatment and management of patients suffering from panic disorder, particularly panic disorder with agoraphobia.
6. THE FREQUENCY OF REMISSION, RELAPSE AND RECURRENCE IN CHILDREN AND ADOLESCENTS WITH MDD G. Emslie, A.J. Rush, W.A. Weinberg, C. Hughes, & R. Kowatch T h e U n i v e r s i t y o f Texas Southwestern Medical Center at Dallas, Dallas, TX The course of major depressive disorder (MDD) in children/adolescents is characterized by continued depressive symptoms, ~)or functioning, and
THURSDAY,, MAY 18
increased suicidal risk; however, differences in definitions of terms describing outcome make comparisons across samples difficult. We have studied two samples of children/adolescents with MDD. In the initial sample, we reassessed 70 inpatients with MDD who had been evaluated extensively 1-6 years earlier. Fifty-nine (84%) were reinterviewed using the Kiddie-LIFE, and their intervening course was evaluated. From retrospective assessment, 98% had recovered within 1 year of initial evaluation, but 61% had at least one recurrence during the follow-up period. Of those with recurrence, 47% had thc recurrence within 1 year. The second sample is a prospective follow-up of 50 children/adolescent outpatients with major depressive disorder who were followed up prospectively for 1 year after completing a double-blind, randomized, placebo-controlled study of fluoxetine. Of the 50 subjects who completed 1 year of followup, eight (16%) had failed to recover in the 1 year follow-up period. Recovery was defined as at least 60 days with minimal symptoms. Of the remaining 42 subjects who met this recovery criterion, 23 had no recurrence following recovery and 19 had another episode of depression following recovery. The mean ages of those with a recurrence and those without a recurrence were 12.7 + 3.3 years and 11.8 +_ 2.5 years, respectively. Differences between those who did or did not have a recurrence were examined. There was a trend for those with comorbid anxiety disorders, dysthymic disorder, and melancholic depression to be more likely to have a recurrence.
7. NIGHTTIME ACTH, CORTISOL, PROLACTIN, AND GROWTH HORMONE SECRETION IN PREPUBERTAL DEPRESSION M.D. De Bellis, R.E. Dahl, J. Perel, B. Birmaher, M. AI-Shabbout, D.E. Williamson, B. Nelson, J. Puig-Antich, & N.D. Ryan D e p a r t m e n t o f P s y c h i a t r y , U n i v e r s i t y o f P i t t s b u r g h School of M e d i c i n e , Pittsburgh, P A 15213 Nighttime secretion of adrenocorticotropic hormone (ACTH), cortisol, prolactin, and growth hormone were examined in medication-free prepubertal children with major depression diagnosed by K-SADS-P (n - 38; 29 male; mean age + SD, 10.4 + 1.5 years) and normal control children (n 28; 13 male; 9.9 + 1.9 years). Previously, subjects underwent an "adaptation night," where an intravenous catheter and EEG electrodes were placed for blood sampling and standard all-night polysomnogram. During the next night, plasma samples were obtained at 20 min intervals after lights out. Hormonal concentrations, measured by radioimmunoassay, were aligned by EEG confirmed sleep onset. Areas under the curve were calculated for total secretion, log transformed, and compared using ANOVA. Unlike adult depressives, prepubertal depressed children had lower cortisol secretion during the first 4 hours after sleep onset (26.6 _+ 16.7 versus 39.4 _+ 23.3 mcg/dL; t = 2.6, df = 64, p = 0.01). ACTH, prolactin, and growth hormone secretion did not differ between these two groups. Basal ACTH concentration were lower when depressed inpatients were compared with depressed outpatients (444 + 80 versus 927 +_ 626 pg/ml; t = 2.87; df = 40, p < 0.01) and when depressed, sexually abused children were compared with nonabused, depressed children (431 + 172 versus 845 + 593 pg/ml; t = 2.1 ; df - 40, p < 0.05). There was a significant sex by diagnosis effect (F = 4.03, df = 1,62, p < 0.05) revealing lower growth hormone secretion in depressed females compared with depressed males (48.2 _+ 18.2 versus 95 _+57.9 ng/ml). These results stress the need for examination of clinical characteristics in biological studies of prepubertal depression.
BXOLPSYCHIATRY 1995;37:593 683
4. NATURAL HISTORY AND COURSE OF ADULT ANXIETY DISORDERS
R. Noyes, Jr. University o f I o w a In general, the anxiety disorders appear to be chronic if left untreated in thc general population. Persons seeking treatment are likely to have more severe disorders and more comorbidity, but there is little data on this point. However, even treated persons appear to have chronic course; relatively few become free of symptoms, but a substantial proportion achieve a good outcome (little impairment) despite residual symptoms. A gradual amelioration may occur with the passage of years but, here again, there is little data. Individual disorders appear to differ in course and outcome, with social phobia and agoraphobia showing greater persistence and severity. Prognostic factors include severity, duration, and comorbidity (axis I and II). A variety of psychological therapies appear to affect course and outcome, although design problems limit interpretation of many studies. Prospective studies are needed that examine the outcome of subjects with all of the anxiety disorders obtained from the community. In addition to diagnostic stability, such studies can be expected to show important differences in outcome among individual disorders.
5. LONG-TERM TREATMENT OF ANXIETY DISORDERS M.R. Mavissakalian T h e O h i o State U n i v e r s i t y College o f Medicine, Columbus, OH 43210 The 1980s saw the development of specific and effective treatments for anxiety disorders. The long-term effects of these treatments, however, are not well known. Although follow-up studies suggest that improvement with behavioral treatments is lasting while relapse upon discontinuation of drug treatment is high, the prevailing notion that psychological treatments have enduring effects requires critical assessment, and only recently has research begun to elucidate maintenance/discontinuation issues involved in the pharmacological treatments of these disorders. In this critical review of the literature, an important methodological distinction will be made between the long-term outcome following an acute course of treatment and the effects of long-term treatment, including the specific role of maintenance treatment. The conclusion will underscore the need to have the longitudinal perspective in mind before embarking on a treatment course and will offer empirically based guidelines for the long-term treatment and management of patients suffering from panic disorder, particularly panic disorder with agoraphobia.
6. THE FREQUENCY OF REMISSION, RELAPSE AND RECURRENCE IN CHILDREN AND ADOLESCENTS WITH MDD G. Emslie, A.J. Rush, W.A. Weinberg, C. Hughes, & R. Kowatch T h e U n i v e r s i t y o f Texas Southwestern Medical Center at Dallas, Dallas, TX The course of major depressive disorder (MDD) in children/adolescents is characterized by continued depressive symptoms, ~)or functioning, and
THURSDAY,, MAY 18
increased suicidal risk; however, differences in definitions of terms describing outcome make comparisons across samples difficult. We have studied two samples of children/adolescents with MDD. In the initial sample, we reassessed 70 inpatients with MDD who had been evaluated extensively 1-6 years earlier. Fifty-nine (84%) were reinterviewed using the Kiddie-LIFE, and their intervening course was evaluated. From retrospective assessment, 98% had recovered within 1 year of initial evaluation, but 61% had at least one recurrence during the follow-up period. Of those with recurrence, 47% had thc recurrence within 1 year. The second sample is a prospective follow-up of 50 children/adolescent outpatients with major depressive disorder who were followed up prospectively for 1 year after completing a double-blind, randomized, placebo-controlled study of fluoxetine. Of the 50 subjects who completed 1 year of followup, eight (16%) had failed to recover in the 1 year follow-up period. Recovery was defined as at least 60 days with minimal symptoms. Of the remaining 42 subjects who met this recovery criterion, 23 had no recurrence following recovery and 19 had another episode of depression following recovery. The mean ages of those with a recurrence and those without a recurrence were 12.7 + 3.3 years and 11.8 +_ 2.5 years, respectively. Differences between those who did or did not have a recurrence were examined. There was a trend for those with comorbid anxiety disorders, dysthymic disorder, and melancholic depression to be more likely to have a recurrence.
7. NIGHTTIME ACTH, CORTISOL, PROLACTIN, AND GROWTH HORMONE SECRETION IN PREPUBERTAL DEPRESSION M.D. De Bellis, R.E. Dahl, J. Perel, B. Birmaher, M. AI-Shabbout, D.E. Williamson, B. Nelson, J. Puig-Antich, & N.D. Ryan D e p a r t m e n t o f P s y c h i a t r y , U n i v e r s i t y o f P i t t s b u r g h School of M e d i c i n e , Pittsburgh, P A 15213 Nighttime secretion of adrenocorticotropic hormone (ACTH), cortisol, prolactin, and growth hormone were examined in medication-free prepubertal children with major depression diagnosed by K-SADS-P (n - 38; 29 male; mean age + SD, 10.4 + 1.5 years) and normal control children (n 28; 13 male; 9.9 + 1.9 years). Previously, subjects underwent an "adaptation night," where an intravenous catheter and EEG electrodes were placed for blood sampling and standard all-night polysomnogram. During the next night, plasma samples were obtained at 20 min intervals after lights out. Hormonal concentrations, measured by radioimmunoassay, were aligned by EEG confirmed sleep onset. Areas under the curve were calculated for total secretion, log transformed, and compared using ANOVA. Unlike adult depressives, prepubertal depressed children had lower cortisol secretion during the first 4 hours after sleep onset (26.6 _+ 16.7 versus 39.4 _+ 23.3 mcg/dL; t = 2.6, df = 64, p = 0.01). ACTH, prolactin, and growth hormone secretion did not differ between these two groups. Basal ACTH concentration were lower when depressed inpatients were compared with depressed outpatients (444 + 80 versus 927 +_ 626 pg/ml; t = 2.87; df = 40, p < 0.01) and when depressed, sexually abused children were compared with nonabused, depressed children (431 + 172 versus 845 + 593 pg/ml; t = 2.1 ; df - 40, p < 0.05). There was a significant sex by diagnosis effect (F = 4.03, df = 1,62, p < 0.05) revealing lower growth hormone secretion in depressed females compared with depressed males (48.2 _+ 18.2 versus 95 _+57.9 ng/ml). These results stress the need for examination of clinical characteristics in biological studies of prepubertal depression.