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This report examines clinical features of 'pure' dysthymic disorder (DD, without superimposed major depressive disorder, MDD) in a sample of children and adolescents. Profiles of symptomatology and comorbidity as a function of age and gender are described. The sample consisted of 48 subjects (22 males, 26 females, age range 7-18 years, mean age 12.1 years) screened from consecutively referred children and adolescents. All subjects were comprehensively diagnosed with structured diagnostic interviews (Schedule for Affective Disorders and Schizophrenia for School Age, Diagnostic Interview for Children and Adolescents-Revised), according to DSM-IV criteria. Depressed mood, irritability, loss of energy and fatigue, guilt and low self-esteem were present in more than 70% of the subjects. Differences in symptomatic profile between males and females were not significant. Children showed less symptoms than adolescents, but the symptomatic profile was comparable (only anhedonia was significantly more frequent in adolescents). Anxiety disorders were more commonly comorbid with DD, especially separation anxiety disorder in children (33%) and generalised anxiety disorder in adolescents (67%). Externalising disorders were less frequently represented in our sample (14%). An early diagnosis of 'pure' DD before the first episode of MDD is crucial for a timely intervention.
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PMID:Depressive symptoms in children and adolescents with dysthymic disorder. 1115 Sep 28

Assessing psychiatric illness in geriatric patients can be difficult for a variety of reasons. First, medical comorbidity may obscure the diagnosis. For example, the patient with multiple chronic illnesses will often have many "vegetative" symptoms of either dementia or depression (e.g., fatigue, loss of energy, poor appetite) attributed to the primary medical condition rather than to an underlying psychiatric illness. Second, the phenomenology of psychiatric illness in the elderly is often different. For example, depression in the elderly is often characterized by prominent anhedonia--loss of interest in virtually everything--and physical complaints leading to an unnecessary medical workup. Third, physicians are often reluctant to diagnose new-onset mental illness in their elderly patients. The fear of stigmatizing the patient or physician discomfort with "psychologic language" often results in underdetection of straightforward psychiatric syndromes. This article will focus primarily on detection of 3 of the most common psychiatric syndromes: dementia, depression, and delirium. The field of geriatric psychiatry has done a good job of characterizing the prevalence (Table I) and clinical features of these syndromes. The problem--briefly addressed here--is how to incorporate some of these findings into a busy clinical practice where there is very little time for the assessment of psychiatric symptoms.
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PMID:Assessing psychiatric illness in geriatric patients. 1135 84

Lisa Capaldini, a physician who treats HIV-positive patients in San Francisco, discusses the multiple causes of fatigue. HIV-related fatigue is easy to overlook because it is attributed to be a normal part of HIV disease and begins slowly, worsening over time. It is important for HIV-positive patients and their doctors to maintain a fatigue inventory every few months to chronicle and compare energy levels to previous periods. For most patients, the cause of fatigue can be identified and treated. Fatigue can be categorized into several types, including: physical, psychological, morning, depression, and hypogonadism. Physical fatigue, usually evident after performing a specific activity, may be caused by anemia, chronic diarrhea or pain, or malaise from HIV treatments. Psychological fatigue can be divided into two categories: motivational, no will to do anything because the activities no longer are pleasurable (termed anhedonia), and mental, classified as diminished attention span, inability to concentrate, or difficulty calculating. Morning fatigue is evidenced by waking up tired and remaining tired, signaling a possible symptom of depression. Hypogonadism, caused by low levels of androgens and/or other sex hormones, produces a listless, depressed mood, and trouble concentrating. Treatment for hypogonadism differs for men and women, but consists of measuring androgens and restoring them to an adequate level with testosterone replacement. Testosterone replacement is available in an intramuscular shot, Testoderm and Androderm patches, or gels. Testosterone therapy for women requires the interaction of a primary physician who is familiar with hormone replacement therapy. Capaldini recommends CBCs, testosterone levels, DHEA levels, chemistry panels, and echocardiograms to diagnose fatigue.
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PMID:Fatigue and HIV: interview with Lisa Capaldini, M.D. Interview by John S. James. 1136 45

Diagnosing depression in cancer patients has been challenging because the diagnostic criteria include somatic symptoms frequently attributed to the cancer itself or its treatment. However, few studies have explored how to appropriately deal with individual somatic symptoms. The authors used data from 220 cancer patients with major depression to examine the intercorrelations among the DSM-IV somatic and nonsomatic symptom criteria as well as whether the presence of an individual somatic symptom could discriminate the severity of major depression. Appetite changes and a diminished ability to think were positively associated with anhedonia. Sleep disturbance and fatigue were not significantly associated with nonsomatic symptoms. These associations were consistent after adjusting for physical functioning and pain. Only patients with appetite changes showed a higher severity of depression. These results suggest that individual somatic symptoms differ in nature and that appetite-related symptoms and a diminished ability to think may be useful for diagnosing depression in cancer patients, whereas sleep disturbances and fatigue may not be as useful.
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PMID:Somatic symptoms for diagnosing major depression in cancer patients. 1272 6

In this paper, an extraordinary mother-son relationship involving 46 year-old, married, male patient with three children is discussed. He had never had any psychiatric complaint until his mother's death. However, he developed severe depressive and somatic symptoms following his 80 year-old mother's death. He showed no significant improvement after previous outpatient treatments and was admitted to the Psychiatric Department of Ege University School of Medicine with complaints of tension, insomnia, fatigue, anhedonia, hopelessness and pain all over his body. It was discovered that this man, who was loved and respected by both his family and his peers, used to suck his mother's breast twice daily. This act was no secret and was not considered a reason for seeking psychiatric help, a symptom of a disorder, or a source of distress for the son, mother, or any other family member. A phenomenon like this has never been reported in the literature before. We discuss this phenomenon through the dynamic formulation of the case using data from his psychiatric and developmental history as well as direct observation and psychological tests.
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PMID:[Forty-six year old baby]. 1456 74

Based on previous factor analyses of child and adolescent depression inventories, the following eight basic dimensions were identified, i.e., Pessimism, Weak Concentration, Sleep Problems, Anhedonia, Fatigue, Loneliness, Low Self-esteem, and Somatic Complaints. Each dimension was assessed by five items, so the Multidimensional Child and Adolescent Depression Scale has 40 brief statements answered on a 3-point intensity scale, i.e., None, Some, and A lot. The eight dimensions have good factorial validity and acceptable to good alpha and test-retest reliability, and good criterion-related validity using three self-report depression scales. The total scale score has from good to high coefficients of reliability and validity. The highest mean scores were on Fatigue and Anhedonia for Kuwaiti boys and girls, respectively, while the Loneliness subscale has the lowest mean score for both sexes. Girls attained significantly higher mean scores than boys for the total score as well as on all dimensions, with the exception of weak concentration. The scale has two compatible Arabic and English versions. It was designed to be useful in defining the profile of children's and adolescents' depression.
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PMID:The Multidimensional Child and Adolescent Depression Scale: psychometric properties. 1465 Jun 90

Although depression is frequent among patients with advanced cancer, very few studies have been conducted on its treatment. The objective of this study was to evaluate the efficacy of cognitive therapy for depression in women with metastatic cancer, using a multiple baseline experimental design. Six participants were enrolled in the study and were asked to complete daily and weekly mood assessments. Intervention time-series analyses conducted on daily mood data showed statistically significant improvement of depression symptoms, more importantly anhedonia, and associated features (i.e., anxiety, fatigue) for each participant. These improvements were also found to be clinically significant at post-treatment.
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PMID:Efficacy of cognitive therapy for depression among women with metastatic cancer: a single-case experimental study. 1553 Aug 44

The role of dopamine (DA) pathways in the pathophysiology of depressive disorder is poorly understood. However, because DA plays a key role in motivational behavior, it is important to study in a disorder characterized by anhedonia, lack of energy and psychomotor retardation. A recently developed dietary manipulation ('tyrosine (TYR) depletion') offers a novel method to assess the role of DA in major depression. We studied 15 euthymic women with a past history of recurrent depression, who received a 74 g amino-acid drink lacking TYR and phenylalanine (PHE) (TYR-free) and a balanced (BAL) amino acid drink on two separate occasions in a double-blind, random-order, crossover design. Plasma prolactin levels rose following the TYR-free drink relative to the balanced mixture, while performance on a spatial recognition memory task was impaired. However, relative to the BAL drink, the TYR-free drink did not lower objective or subjective measures of mood. We conclude that as in healthy volunteers, TYR depletion in euthymic subjects, with a past history of major depression, attenuated DA function, as reflected in increased plasma prolactin levels and decreased spatial memory performance. However ratings of depression were unaffected, suggesting that disruption of dopaminergic function by this manipulation does not induce a lowering of mood in individuals vulnerable to depression.
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PMID:Lack of effect of tyrosine depletion on mood in recovered depressed women. 1570 40

Cytokines whose primary function is that of acting as signaling molecules of the immune system, have been implicated in the provocation or exacerbation of mood disorders such as depression. This position has been supported by several lines of evidence; (1) proinflammatory cytokines (interleukin-1beta, interleukin-6, tumor necrosis factor-alpha) and bacterial endotoxins elicit sickness behaviors (e.g., fatigue, soporific effects) and symptoms of anxiety/depression that may be attenuated by chronic antidepressant treatment. Interleukin-2 (IL-2) induces less profound sickness, but elicits anhedonia, a key symptom of depression; (2) neuroendocrine and central neurotransmitter changes, reminiscent of those implicated in depression, may be elicited by some of these cytokines, and these effects are exacerbated by stressors; (3) severe depressive illness is accompanied by elevations of cytokine production or levels, although these effects are not necessarily attenuated with antidepressant medication; and (4) immunotherapy, using IL-2 or IFN-alpha, promote depressive symptoms that are attenuated by antidepressant treatment. It is proposed that chronic cytokine elevations engender neuroendocrine and brain neurotransmitter changes that are interpreted by the brain as being stressors, and contribute to the development of depression. Further, the effects of the cytokine treatments may act synergistically with stressors, and cytokines may provoke a sensitization effect so that the effects of later stressor experiences are exacerbated.
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PMID:Cytokines as a precipitant of depressive illness: animal and human studies. 1577 47

Treatment-resistant depression, i.e. partial or non response to antidepressants in spite of various treatment attempts with optimized doses and combinations, is rather common. With residual symptoms such as tiredness, anhedonia and concentration disturbances, the treatment strategy has often been to use monoamino-oxidase inhibitors (MAOIs). Their use, however, is limited due to interaction problems. Modafinil is recently developed wake-promoting drug with only minor side-effects. Pilot studies indicate that it appears to have an augmentation effect in treatment-resistant depression. This open-label study performed in the private psychiatric practice setting is the first to make a comprehensive evaluation of the target patient profile based on patient-reported symptoms. Modafinil in doses of 100-400 mg was administered as augmentation to ongoing antidepressant therapy in patients with partial response and suffering from hypersomnia. The total number of patients was 21 and 43% of these were responders (i.e. had a score reduction of >50% on the Major Depression Inventory (MDI) as well as remitters, i.e. the remission rate was 43%. At endpoint, the responders had psychological distress scores on the Symptom Checklist (SCL-92) on the level of the general Danish population. Baseline characteristics for responders were lower scores on depression, hostility, anxiety, somatization, obsession and psychoticism. Modafinil thus appears to be an appropriate augmentation to antidepressant treatment, leading to a remission rate of 43%. However, the results from this open-label study need ot be confirmed in a placebo-controlled trial.
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PMID:Modafinil augmentation in depressed patients with partial response to antidepressants: a pilot study on self-reported symptoms covered by the Major Depression Inventory (MDI) and the Symptom Checklist (SCL-92). 1620 39


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