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The dexamethasone suppression test in delusional depression
147
JAD 00289
The Dexamethasone
Suppression
Test in Delusional
Depression
Further Findings Jose L. Ayuso-Gutierrez ‘, Maria Isabel Almoguera?, Eduardo Garcia-Camba’, Jesus de1 Olmo Frias ’ and Josh Antonio Cabranes ’ I Depuriment
of Pgrhrcrtq~ und ’ Semcr
of Nuc~leur Medrci~w. Compluteme
Unrr~ersir,~, flospitul
Clirzrco. Mdml-
3 (Spurn)
(Received 21 May. 1984) (Revised. received 19 July. 1984) (Accepted 23 July, 1984)
Summary
The results of the overnight 1 mg Dexamethasone Suppression Test (DST) administered to 26 unipolar delusional depressed patients and 47 unipolar non-delusional depressed controls are reported. There were no significant differences between the rates of abnormal responses in the two groups. However, there was a higher percentage of normal responses in the delusional depressive sample with mood incongruency. While 55% of the mood-congruent depressive patients were non-suppressors, only 12% of the depressed patients with mood-incongruent psychotic features had abnormal DST responses.
Key words:
Dexumethasone
Suppression
Test ~ Unipolur delusional depression
Introduction
A number of studies (Carroll et al. 1980; Hwu et al. 1981; Rudofer et al. 1982) have demonstrated that depressed patients with delusions are more likely to show non-suppression of plasma cortisol after administration of dexamethasone than non-psychotic patients. However, other authors (Extein et al. 1982; Sweeney et al. 1982; Caroff et al. 1983) have not reported any significant differences in the rate of non-suppression between delusional and non-delusional depressed patients. On the other hand, in another study (Ayuso-Gutierrez et al. 1982) it was found that dexamethasone non-suppression was more fre0165-0327/85/$03.30
i” 1985 Elsevier Science Publishers
quently observed in non-delusional than delusional patients. Because of the conflicting data between the results obtained by our group and the findings from other investigators. we have carried out another DST evaluation in a larger sample of delusional depressed patients in order to clarify this issue. Methods
One hundred and two depressive patients admitted to the Hospital Clinic0 in Madrid between July 1982 and March 1984 were studied. All cases fitted the DSM-III (American Psychiatric Associa-
B.V. (Biomedical
Division)
14x
tion 1980) classification of major affective disorders. Cases with schizoaffective disorder were not included in the study. All patients were free of somatic diseases and also alcohol and drug abuse. Twenty-six of the unipolar depressive patients exhibited delusional thinking, and 47 did not. The remaining 29 were bipolar patients; therefore they were not included in the study itself. Exaggerated ideas of hopelessness and worthlessness were not considered sufficient for inclusion with the delusional group. The breakdown of delusions at index admission demonstrated that the most common delusions were reference and persecution (61%) delusions of guilt (61%) and of poverty (31%). Nihilistic delusions (19%) and somatic ones (15%) were less frequently reported. Sixty-five percent of the sample had multiple delusions and 35 percent had only one type of delusion. While the contents of delusions were considered to be completely consistent with mood in 18 cases according to DSM-III specifications, mood incongruency was found in 8 patients. Neuroendocrine evaluation was carried out within a few days of admission to hospital. The subjects were either drug-free or were treated with drugs known not to interfere with DST results (Carroll et al. 1981). The psychotropics used prior to DST evaluation included tricyclics. low-dose neuroleptics, or benzodiazepines (not more than 25 mg/day of diazepan or an equivalent). There was no significant difference in the treatment regimens of delusional and non-delusional patients before DST assessment. In order to calculate the basal cortisol values, blood was drawn 3 times; the patient was kept in bed so as to avoid any situations which might produce nervousness. An indwelling catheter was inserted into the vein and after the first extraction at 8.00 h, a saline solution was connected to maintain the vein patent and in this way, to avoid the possible stress produced by the puncture in the following samples. Subsequent blood samples were drawn at 8.30 h and 9.00 h. The basal cortisol level was calculated by the mean value of the last two samples. Dexamethasone was administered orally (1 mg) to each patient at 23.00 h. The second day blood samples were obtained at 8.30 and 9.00 h; and 16.30. 17.00. 23.30 and 24.00 h. Cortisol was assayed by radioimmunoassay using a commercial
kit (Sorin Biomedica). The results were expressed in mean values of both extractions corresponding to the three periods; morning. afternoon and evening. The data were not given to the clinicians until the diagnostic evaluations were completed. An abnormal DST result was recorded when any of the three mean serum cortisol concentrations was greater than 50 ng/ml. In our laboratory, the intra-assay variation coefficient, the interassay variation coefficient and the sensitivity are: 4.5%. 9.6%, and 4.5 ng/ml, respectively. The statistical tests applied included the Student (two-tailed) t-test for comparing group means. All serum cortisol samples were compared after log-transformation of the original values. The chisquare test was applied for categorical data using a Yates’ correction for those data with 1 degree of freedom. The Fisher’s exact probability test was used for 2 x 2 contingency tables in which at least one of the expected values was 5 or less. Results
Comparison of the demographic and clinical characteristics between delusional and non-delusional samples (Table 1) revealed no differences between groups in sex distribution. age at onset of illness, number of patients with prior affective episodes and duration of the current episode before admission. The mean age at current episode of the 26 delusional patients was significantly higher than the corresponding figure for the nonpsychotic group. The delusional sample had a significantly higher Hamilton Rating Scale (HRS) total score but this significant difference did not persist when items that might tap psychosis were deleted. Neither baseline and postdexamethasone serum cortisol levels differed significantly between delusional and non-delusional groups at any sample time (Table 2). The results of the DST did not show significant difference between the groups: 42.3% of non-suppressors among delusional depressives vs 44.6% on non-psychotic patients. We also compared the distribution of the DST abnormal responses in both groups in the three blood samples (Table 3). The results indicated the same pattern in the two depressive populations. Only 22.2’% of all abnormal results in the delu-
149
TABLE
TABLE
1
DESCRIPTIVE
CHARACTERISTICS
Delusional depression (n = 26)
Non-delusional depression (n = 47)
20:6
41 16
59.8 * 10.1
51.7* 13.5
Age at onset of illness (yr) (mean f SD)
47.5 f 12.2
40.7 + 15.1
Patlents with previous affective epixodes
1X (69.2%)
33 (70.2)
Characteristics
Sex ratio (F/M) Age at index admisslon (mean i SD)
(yr) *
Number
X.30-9.00 h 16.30~17.00 h 23.30-24.00 h
7 f 8.6
6.3 * 7.4
HRSD total score ** (mean * SD)
35.9 i 5.7
29.X + 6.3
Modified
29.6 + 4.6 _
27.6 i_ 5.5
HRSD total score ’
(meaniSD) “ Excluding the folkwing items: personalization and paranoia. * P i 0.01. ** P < 0.001.
SERUM
AND
of ahnormal
responses
Delusional depression (n = 26)
Non-delusional depression (n = 47)
4 (22.2%) 6 (33.3%) X (44.4%)
8 (21.69,) 12 (32.4%) 17 (45.9%)
guilt, hypochondriasis,
de-
2 CORISOL
Baseline cortisol X.30-9.00 h
OF
sional group and 21.6% in the non-delusional population were detected in the 8.3OG9.00 h sample. These data do not confirm the results of Caroff et al. (1983) who found a significantly higher rate of early onset of ‘escape’ (8.00 h) in the delusional depressed probands. Finally, we studied the response to the DST in the delusional group according to the mood congruency of delusional thinking (Table 4). The findings showed a higher rate of non-suppression in
VALUES
(ng/ml)
AND DST RESPONSE Delusional (n = 26)
*
Arith. mean SD Geo. mean SD range a
196.4 67.8 184.7 124.7-253.5
depression
Non-delusional (n = 47) 172.6 79.1 154.6 92.4-250
Post-dexamethasone X.30-9.00 h
cortisol
*
Arith. mean SD Gee. mean SD range ’
34.x 50.6 19.X 7.2-54.3
41.1 54.6 21.3 6.4-65.2
Post-dexamethasone 16.30~17.00 h
cortisol
*
Arith. mean SD Geo. mean SD range a
39.6 42.6 24.6 X.5-71.1
37.6 40.9 17.5 4.6-66.5
Post-dexamethasone 23.30-24.00 h
cortisol
*
Arith. mean SD Geo. mean SD range ’
37.3 35.x 22.2 7.2-69.0
45.3 35.X 23.3 6.44X5.1
11 (42.3%‘)
21 (44.6%)
Abnormal
FREQUENCY
x2 = 0.001: N.S
Duration of current episode before admission (month) (mean i SD)
TABLE
3
TIME OF BLOOD SAMPLING DST ABNORMAL RESPONSES
OF THE SAMPLES
DST * response
a Antilog of mean log + SD log. * Not significant at P < 0.05.
depression
150 TABLE
4
St:RUM CORTISOL VALUES DELUSIONAL DEPRESSION
(ng/ml)
AND
DST
RESPONSE
~
MOOD-CONGRUENT
Mood-congruent (n = IX) Baaeiinc cortisol X.30-9.00 h
Post-dexamethasone X.30~9.00 h
Post-dexamethasone 23.30-24.00 h
Abnormal
Arith. mean SD Gee. mean SD range ‘I cortisol
*
cortisol
DST response
Mood-incongruent (n = 8) 193.5 70.4 1X0.5 121.5-26X.1
202.x 65.‘) 194 141.X~265.6
Arith. mean SD Gee. mu11 SD range “
43.4 51.7 24.2 x-73
13.X 6.1 12.7 x.1 19.9
Arith. mean SD Gee. mean SD range ”
47.2 47.x 30.7 11.6~XO.7
21.6 14.4 15.2 5.1-45.7
Arith. mean SD Geo. mean SD range I’
41.4 3X.1 24.5 7.4-80.X
24.‘) 24.7 17.4 7.1-42.X
**
“ Antilog of mean log* SD log. * Significant 31 P < 0.05. ** Fisher’s exact test (two-tailed):
VS MOOD-INC‘ONGRUF.NT
10 (55.5%)
1(12.5?)
P c 0.00X.
the mood-congruent subgroup. While 55% of the mood-congruent depressive patients were non-suppressors, only 12% of the depressed patients with mood-incongruent features had abnormal DST responses, the difference being statistically significant. However. the analysis of post-dexamethasone cortisols as a continuous variable in moodcongruent vs mood-incongruent groups only showed significant differences in the morning extraction (8.3OC9.00 h). Our results might explain the contradictory findings reported in our previous study where a higher rate of non-suppression in non-delusional depression was found. However, since mood-incongruent delusional patients were overrepresented in that study (8 mood-incongruent vs 2 mood-congruent patients) the increased proportion of suppressors in depressed patients with delusional thinking compared to controls could be the effect of a larger percentage of mood-incongruent probands in the protocol.
References Diagnostic and Statistical American Psychiatric Association. Manual of Mental Disorders. 3rd edItIon, Washington. DC. 19x0. Ayuso-Gutierrer, J.L.. Garcia-Camba. J.E.. Olmo. J., Cabraner. J.A. and Almoguera. M.I.. Dexamrthaaone suppression test in patients with delusional and non-drlusional endogenous depression. In: Abstracts of the Collegium Internationale Neuro-Psychopharmacologicurn. 13th Congress. Jerusalem. Israel, 19X2. p. 31. Caroff. S., Winokur. A.. Rieger. W., Schweirer. E. and Amsterdam. J., Response to dexamethaaone in psychotic depression. Psychiat. Res., 8 (19X3) 59-64. Carroll. B.J., Greden. F.J., Feinberg. M.. James. N.M., Hackett, R.F.. Steiner, M. and Tarika. J.. Neuroendocrme dysfunction in genetlc subtypes of primary unipolar depression, Psychlat. Res.. 2 (1980) 251-25X. C‘arroll. B.J., Feinberg, M.. Greden. J.F.. Tarika. J.. Albala, A.A.. Haskett, R.F., Mel. James, N.. Kronfol. Z.. Lohr. N.. Steiner, M.. De Vigne. J.P. and Young. E., A specific laboratory test for the diagnosis of melancholia. Arch. Gen. Paychiat., 3X (1981) 15-22. Extrtn. I.. Gold. M.S.. Pot&h. A.L.C. and Sternbach. H.. The T.R.H. and dexamethasone suppression tests in the diagno-
151 sia of major unipolar depression. In: Abstracts of the CO\legium Internationale Neuro-Psychopharmacologicum, 13th Congress. Jerusalem. Israel. 1982, p. 204. Hwu. H.G.. Rudorfer. M.V. and Clayton, P.J.. Dexamethasone suppression test and subtypes of depression (Letter to Editar). Arch. Gen. Psychiat.. 38 (1981) 363. Rudorfer. M.V., Hwu, H.G. and Clayton. P.J., Dexamethasone
suppression test in primary depression - Significance of family history and psychosis, Biol. Psychiat.. 17 (1982) 41-48. Sweeney, D.R.. Extein. I.L., Pottash, A.L.C.. Gold, M. and Sternbach, H.. Neuroendocrine responses in delusional depression. In: Abstracts of the American Psychiatric Association. 135th Annual Meeting, Toronto, 1982, pp. 263-264.
JAD 00289
The Dexamethasone
Suppression
Test in Delusional
Depression
Further Findings Jose L. Ayuso-Gutierrez ‘, Maria Isabel Almoguera?, Eduardo Garcia-Camba’, Jesus de1 Olmo Frias ’ and Josh Antonio Cabranes ’ I Depuriment
of Pgrhrcrtq~ und ’ Semcr
of Nuc~leur Medrci~w. Compluteme
Unrr~ersir,~, flospitul
Clirzrco. Mdml-
3 (Spurn)
(Received 21 May. 1984) (Revised. received 19 July. 1984) (Accepted 23 July, 1984)
Summary
The results of the overnight 1 mg Dexamethasone Suppression Test (DST) administered to 26 unipolar delusional depressed patients and 47 unipolar non-delusional depressed controls are reported. There were no significant differences between the rates of abnormal responses in the two groups. However, there was a higher percentage of normal responses in the delusional depressive sample with mood incongruency. While 55% of the mood-congruent depressive patients were non-suppressors, only 12% of the depressed patients with mood-incongruent psychotic features had abnormal DST responses.
Key words:
Dexumethasone
Suppression
Test ~ Unipolur delusional depression
Introduction
A number of studies (Carroll et al. 1980; Hwu et al. 1981; Rudofer et al. 1982) have demonstrated that depressed patients with delusions are more likely to show non-suppression of plasma cortisol after administration of dexamethasone than non-psychotic patients. However, other authors (Extein et al. 1982; Sweeney et al. 1982; Caroff et al. 1983) have not reported any significant differences in the rate of non-suppression between delusional and non-delusional depressed patients. On the other hand, in another study (Ayuso-Gutierrez et al. 1982) it was found that dexamethasone non-suppression was more fre0165-0327/85/$03.30
i” 1985 Elsevier Science Publishers
quently observed in non-delusional than delusional patients. Because of the conflicting data between the results obtained by our group and the findings from other investigators. we have carried out another DST evaluation in a larger sample of delusional depressed patients in order to clarify this issue. Methods
One hundred and two depressive patients admitted to the Hospital Clinic0 in Madrid between July 1982 and March 1984 were studied. All cases fitted the DSM-III (American Psychiatric Associa-
B.V. (Biomedical
Division)
14x
tion 1980) classification of major affective disorders. Cases with schizoaffective disorder were not included in the study. All patients were free of somatic diseases and also alcohol and drug abuse. Twenty-six of the unipolar depressive patients exhibited delusional thinking, and 47 did not. The remaining 29 were bipolar patients; therefore they were not included in the study itself. Exaggerated ideas of hopelessness and worthlessness were not considered sufficient for inclusion with the delusional group. The breakdown of delusions at index admission demonstrated that the most common delusions were reference and persecution (61%) delusions of guilt (61%) and of poverty (31%). Nihilistic delusions (19%) and somatic ones (15%) were less frequently reported. Sixty-five percent of the sample had multiple delusions and 35 percent had only one type of delusion. While the contents of delusions were considered to be completely consistent with mood in 18 cases according to DSM-III specifications, mood incongruency was found in 8 patients. Neuroendocrine evaluation was carried out within a few days of admission to hospital. The subjects were either drug-free or were treated with drugs known not to interfere with DST results (Carroll et al. 1981). The psychotropics used prior to DST evaluation included tricyclics. low-dose neuroleptics, or benzodiazepines (not more than 25 mg/day of diazepan or an equivalent). There was no significant difference in the treatment regimens of delusional and non-delusional patients before DST assessment. In order to calculate the basal cortisol values, blood was drawn 3 times; the patient was kept in bed so as to avoid any situations which might produce nervousness. An indwelling catheter was inserted into the vein and after the first extraction at 8.00 h, a saline solution was connected to maintain the vein patent and in this way, to avoid the possible stress produced by the puncture in the following samples. Subsequent blood samples were drawn at 8.30 h and 9.00 h. The basal cortisol level was calculated by the mean value of the last two samples. Dexamethasone was administered orally (1 mg) to each patient at 23.00 h. The second day blood samples were obtained at 8.30 and 9.00 h; and 16.30. 17.00. 23.30 and 24.00 h. Cortisol was assayed by radioimmunoassay using a commercial
kit (Sorin Biomedica). The results were expressed in mean values of both extractions corresponding to the three periods; morning. afternoon and evening. The data were not given to the clinicians until the diagnostic evaluations were completed. An abnormal DST result was recorded when any of the three mean serum cortisol concentrations was greater than 50 ng/ml. In our laboratory, the intra-assay variation coefficient, the interassay variation coefficient and the sensitivity are: 4.5%. 9.6%, and 4.5 ng/ml, respectively. The statistical tests applied included the Student (two-tailed) t-test for comparing group means. All serum cortisol samples were compared after log-transformation of the original values. The chisquare test was applied for categorical data using a Yates’ correction for those data with 1 degree of freedom. The Fisher’s exact probability test was used for 2 x 2 contingency tables in which at least one of the expected values was 5 or less. Results
Comparison of the demographic and clinical characteristics between delusional and non-delusional samples (Table 1) revealed no differences between groups in sex distribution. age at onset of illness, number of patients with prior affective episodes and duration of the current episode before admission. The mean age at current episode of the 26 delusional patients was significantly higher than the corresponding figure for the nonpsychotic group. The delusional sample had a significantly higher Hamilton Rating Scale (HRS) total score but this significant difference did not persist when items that might tap psychosis were deleted. Neither baseline and postdexamethasone serum cortisol levels differed significantly between delusional and non-delusional groups at any sample time (Table 2). The results of the DST did not show significant difference between the groups: 42.3% of non-suppressors among delusional depressives vs 44.6% on non-psychotic patients. We also compared the distribution of the DST abnormal responses in both groups in the three blood samples (Table 3). The results indicated the same pattern in the two depressive populations. Only 22.2’% of all abnormal results in the delu-
149
TABLE
TABLE
1
DESCRIPTIVE
CHARACTERISTICS
Delusional depression (n = 26)
Non-delusional depression (n = 47)
20:6
41 16
59.8 * 10.1
51.7* 13.5
Age at onset of illness (yr) (mean f SD)
47.5 f 12.2
40.7 + 15.1
Patlents with previous affective epixodes
1X (69.2%)
33 (70.2)
Characteristics
Sex ratio (F/M) Age at index admisslon (mean i SD)
(yr) *
Number
X.30-9.00 h 16.30~17.00 h 23.30-24.00 h
7 f 8.6
6.3 * 7.4
HRSD total score ** (mean * SD)
35.9 i 5.7
29.X + 6.3
Modified
29.6 + 4.6 _
27.6 i_ 5.5
HRSD total score ’
(meaniSD) “ Excluding the folkwing items: personalization and paranoia. * P i 0.01. ** P < 0.001.
SERUM
AND
of ahnormal
responses
Delusional depression (n = 26)
Non-delusional depression (n = 47)
4 (22.2%) 6 (33.3%) X (44.4%)
8 (21.69,) 12 (32.4%) 17 (45.9%)
guilt, hypochondriasis,
de-
2 CORISOL
Baseline cortisol X.30-9.00 h
OF
sional group and 21.6% in the non-delusional population were detected in the 8.3OG9.00 h sample. These data do not confirm the results of Caroff et al. (1983) who found a significantly higher rate of early onset of ‘escape’ (8.00 h) in the delusional depressed probands. Finally, we studied the response to the DST in the delusional group according to the mood congruency of delusional thinking (Table 4). The findings showed a higher rate of non-suppression in
VALUES
(ng/ml)
AND DST RESPONSE Delusional (n = 26)
*
Arith. mean SD Geo. mean SD range a
196.4 67.8 184.7 124.7-253.5
depression
Non-delusional (n = 47) 172.6 79.1 154.6 92.4-250
Post-dexamethasone X.30-9.00 h
cortisol
*
Arith. mean SD Gee. mean SD range ’
34.x 50.6 19.X 7.2-54.3
41.1 54.6 21.3 6.4-65.2
Post-dexamethasone 16.30~17.00 h
cortisol
*
Arith. mean SD Geo. mean SD range a
39.6 42.6 24.6 X.5-71.1
37.6 40.9 17.5 4.6-66.5
Post-dexamethasone 23.30-24.00 h
cortisol
*
Arith. mean SD Geo. mean SD range ’
37.3 35.x 22.2 7.2-69.0
45.3 35.X 23.3 6.44X5.1
11 (42.3%‘)
21 (44.6%)
Abnormal
FREQUENCY
x2 = 0.001: N.S
Duration of current episode before admission (month) (mean i SD)
TABLE
3
TIME OF BLOOD SAMPLING DST ABNORMAL RESPONSES
OF THE SAMPLES
DST * response
a Antilog of mean log + SD log. * Not significant at P < 0.05.
depression
150 TABLE
4
St:RUM CORTISOL VALUES DELUSIONAL DEPRESSION
(ng/ml)
AND
DST
RESPONSE
~
MOOD-CONGRUENT
Mood-congruent (n = IX) Baaeiinc cortisol X.30-9.00 h
Post-dexamethasone X.30~9.00 h
Post-dexamethasone 23.30-24.00 h
Abnormal
Arith. mean SD Gee. mean SD range ‘I cortisol
*
cortisol
DST response
Mood-incongruent (n = 8) 193.5 70.4 1X0.5 121.5-26X.1
202.x 65.‘) 194 141.X~265.6
Arith. mean SD Gee. mu11 SD range “
43.4 51.7 24.2 x-73
13.X 6.1 12.7 x.1 19.9
Arith. mean SD Gee. mean SD range ”
47.2 47.x 30.7 11.6~XO.7
21.6 14.4 15.2 5.1-45.7
Arith. mean SD Geo. mean SD range I’
41.4 3X.1 24.5 7.4-80.X
24.‘) 24.7 17.4 7.1-42.X
**
“ Antilog of mean log* SD log. * Significant 31 P < 0.05. ** Fisher’s exact test (two-tailed):
VS MOOD-INC‘ONGRUF.NT
10 (55.5%)
1(12.5?)
P c 0.00X.
the mood-congruent subgroup. While 55% of the mood-congruent depressive patients were non-suppressors, only 12% of the depressed patients with mood-incongruent features had abnormal DST responses, the difference being statistically significant. However. the analysis of post-dexamethasone cortisols as a continuous variable in moodcongruent vs mood-incongruent groups only showed significant differences in the morning extraction (8.3OC9.00 h). Our results might explain the contradictory findings reported in our previous study where a higher rate of non-suppression in non-delusional depression was found. However, since mood-incongruent delusional patients were overrepresented in that study (8 mood-incongruent vs 2 mood-congruent patients) the increased proportion of suppressors in depressed patients with delusional thinking compared to controls could be the effect of a larger percentage of mood-incongruent probands in the protocol.
References Diagnostic and Statistical American Psychiatric Association. Manual of Mental Disorders. 3rd edItIon, Washington. DC. 19x0. Ayuso-Gutierrer, J.L.. Garcia-Camba. J.E.. Olmo. J., Cabraner. J.A. and Almoguera. M.I.. Dexamrthaaone suppression test in patients with delusional and non-drlusional endogenous depression. In: Abstracts of the Collegium Internationale Neuro-Psychopharmacologicurn. 13th Congress. Jerusalem. Israel, 19X2. p. 31. Caroff. S., Winokur. A.. Rieger. W., Schweirer. E. and Amsterdam. J., Response to dexamethaaone in psychotic depression. Psychiat. Res., 8 (19X3) 59-64. Carroll. B.J., Greden. F.J., Feinberg. M.. James. N.M., Hackett, R.F.. Steiner, M. and Tarika. J.. Neuroendocrme dysfunction in genetlc subtypes of primary unipolar depression, Psychlat. Res.. 2 (1980) 251-25X. C‘arroll. B.J., Feinberg, M.. Greden. J.F.. Tarika. J.. Albala, A.A.. Haskett, R.F., Mel. James, N.. Kronfol. Z.. Lohr. N.. Steiner, M.. De Vigne. J.P. and Young. E., A specific laboratory test for the diagnosis of melancholia. Arch. Gen. Paychiat., 3X (1981) 15-22. Extrtn. I.. Gold. M.S.. Pot&h. A.L.C. and Sternbach. H.. The T.R.H. and dexamethasone suppression tests in the diagno-
151 sia of major unipolar depression. In: Abstracts of the CO\legium Internationale Neuro-Psychopharmacologicum, 13th Congress. Jerusalem. Israel. 1982, p. 204. Hwu. H.G.. Rudorfer. M.V. and Clayton, P.J.. Dexamethasone suppression test and subtypes of depression (Letter to Editar). Arch. Gen. Psychiat.. 38 (1981) 363. Rudorfer. M.V., Hwu, H.G. and Clayton. P.J., Dexamethasone
suppression test in primary depression - Significance of family history and psychosis, Biol. Psychiat.. 17 (1982) 41-48. Sweeney, D.R.. Extein. I.L., Pottash, A.L.C.. Gold, M. and Sternbach, H.. Neuroendocrine responses in delusional depression. In: Abstracts of the American Psychiatric Association. 135th Annual Meeting, Toronto, 1982, pp. 263-264.