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Five patients with depressive illness who were DST nonsuppressors and who did not respond to unilateral nondominant brief-pulse ECT are described. When given a subsequent course of bilateral sinusoidal ECT, all five demonstrated marked clinical improvement associated with normalization of their DSTs.

The relationship of primary degenerative dementia (PDD) to major depressive disorder (MDD) is important clinically and theoretically. Neuroendocrine challenge strategies in PDD have focused primarily on the hypothalamic-pituitary-adrenal axis, have had varied results, and have not been coupled with assessment of response to antidepressant therapy. We studied the Thyrotropin-Releasing Hormone (TRH) test, the Dexamethasone Suppression Test (DST), and response to desipramine in 12 patients with PDD and 10 patients with MDD. The PDD patients had a high percentage of abnormal TRH tests and DSTs. This was not associated with improvement on desipramine.

Six patients who failed to respond to what would ordinarily be considered therapeutically effective courses of sequential unilateral nondominant (mean number 10) and bilateral brief-pulse electroconvulsive therapy (ECT) (mean number 10) with electroencephalographic (EEG) monitoring of seizure duration (all seizures >30 s) subsequently received courses of bilateral sinusoidal ECT (mean number 6) and responded well. Some theoretical implications and clinical considerations raised by these cases are discussed.

Of 37 endogenously depressed patients given a course of unilateral nondominant brief-pulse ECT, 20 responded well and received no further treatment; 17 showed minimal clinical improvement but improved significantly after a subsequent course of bilateral sinusoidal ECT. These findings suggest that there may be subgroups of depressed patients who respond differentially to unilateral and bilateral ECT, to high- and low-energy stimuli, or to combinations thereof. Seizure duration did not appear to be a crucial variable in the efficacy of ECT; among the unilateral nonresponders, seizures of equal duration induced by unilateral stimulation were not as therapeutically effective as those induced by bilateral ECT. Response to the first three ECTs appeared to be the only predictor of unilateral responsiveness.

Carbamazepine was given to five patients with mixed frontal lobe disease and a variety of primary psychiatric disorders. All five patients benefited significantly. A decrease in affective lability was the most consistent result. Carbamazepine may be an alternative to chronic high-dose neuroleptic therapy in these patients.

1. Brown adipocytes were isolated from the interscapular depot of male rats maintained at approx. 21 degrees C. In some experiments parallel studies were made with white adipocytes from the epididymal depot. 2. Insulin increased and noradrenaline decreased [U-14C]glucose incorporation into fatty acids by brown adipocytes. Brown adipocytes differed from white adipocytes in that exogenous fatty acid (palmitate) substantially decreased fatty acid synthesis from glucose. Both noradrenaline and insulin increased lactate + pyruvate formation by brown adipocytes. Brown adipocytes converted a greater proportion of metabolized glucose into lactate + pyruvate and a smaller proportion into fatty acids than did white adipocytes. 3. In brown adipocytes, when fatty acid synthesis from [U-14C]glucose was decreased by noradrenaline or palmitate, incorporation of 3H2O into fatty acids was also decreased to an extent which would not support proposals for extensive recycling into fatty acid synthesis of acetyl-CoA derived from fatty acid oxidation. 4. In the absence of glucose, [U-14C]lactate was a poor substrate for lipogenesis in brown adipocytes, but its use was facilitated by glucose. When brown adipocytes were incubated with 1 mM-lactate + 5 mM-glucose, lactate-derived carbon generally provided at least 50% of the precursor for fatty acid synthesis. 5. Both insulin and noradrenaline increased [U-14C]glucose conversion into CO2 by brown adipocytes (incubated in the presence of lactate) and, in combination, stimulation of glucose oxidation by these two agents showed synergism. Rates of 14CO2 formation from glucose by brown adipocytes were relatively small compared with maximum rates of oxygen consumption by these cells, suggesting that glucose is unlikely to be a major substrate for thermogenesis. 6. Brown adipocytes from 6-week-old rats had considerably lower maximum rates of fatty acid synthesis, relative to cell DNA content, than white adipocytes. By contrast, rates of fatty acid synthesis from 3H2O in vivo were similar in the interscapular and epididymal fat depots. Expressed relative to activities of fatty acid synthase or ATP citrate lyase, however, brown adipocytes synthesized fatty acids as effectively as did white adipocytes. It is suggested that the cells most active in fatty acid synthesis in the brown adipose tissue are not recovered fully in the adipocyte fraction during cell isolation. Differences in rates of fatty acid synthesis between brown and white adipocytes were less apparent at 10 weeks of age.

The most common features of cognitive impairment due to pseudodementia are a relatively acute onset, symptoms of six to 12 months duration; past psychiatric history, particularly depressive illness; age over 50; frequent "don't know" as opposed to "near miss" answers; normal electroencephalogram and computed tomographic scan of the brain, and absence of nocturnal worsening. With this profile, or three or four of these clinical features, a carefully monitored, aggressive trial of an antidepressant regimen is justified.

Of 31 depressed patients, 12 failed to respond to five unilateral brief-pulse ECTs. Eight of the 12 responded fully to bilateral sinusoidal ECT. In some patients, therapeutic outcome may be a function of the type of stimulus used.