Letters

Severe deep white matter lesions and outcome in major depressive disorder

BMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7185.737b (Published 13 March 1999) Cite this as: BMJ 1999;318:737

Might vasculitis be cause of these lesions in elderly depressive patients?

  1. Michael Schirmer, Rheumatologist (michael.schirmer{at}uibk.ac.at),
  2. Sandra Fels, Medical student
  1. Department of Internal Medicine, University Hospital, A-6020 Innsbruck, Austria
  2. Manchester Royal Infirmary, Manchester M13 9BX
  3. University of Manchester Medical School, Manchester M13 9PT
  4. Forston Clinic, Herison, Dorchester, Dorset DT2 9TB
  5. Academic Department of Old Age Psychiatry, Withington Hospital, Manchester M20 8LR

    EDITOR—The study by O‘Brien et al clearly shows that deep white matter lesions on magnetic resonance imaging are relevant to the outcome in elderly depressed patients.1 It is not only psychiatrists for whom this result is important. Although the authors excluded all patients who had a known history of other diseases, depression with such an organic correlate might be secondary to a distinct disease of the central nervous system.

    Neuropathological studies are difficult to perform. Interestingly, deep white matter lesions have also been described in vascular diseases such as systemic lupus erythematosus2 and Behçet's disease.3 Patients with these diseases may present with depressive symptoms, possibly as a correlate of vasculitis in the central nervous system.

    There is a good chance that the deep white matter lesions described by O‘Brien et al represent localised vasculitis in the central nervous system. As patients with these lesions had a poor outcome, with a median survival time of only four months, clinical trials of immunosuppressive treatment would be justified despite lack of a proved pathogenetic mechanism. In severe forms of vasculitis in the central nervous system, regimens of corticosteroids, chlorambucil, and cyclophosphamide are well established.4 Lower doses of immunosuppressants might help to prevent serious side effects in this group of geriatric patients.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.

    Further investigation of deep white matter lesions is necessary

    1. Robert C Baldwin, Consultant old age psychiatrist (Rbaldwin{at}fs1.cmht.nwest.nhs.uk),
    2. Scott Walker, Medical student,
    3. Alan Jackson, Professor of neuroradiology,
    4. Stephen W Simpson, Consultant psychiatrist,
    5. Alistair Burns, Professor of old age psychiatry
    1. Department of Internal Medicine, University Hospital, A-6020 Innsbruck, Austria
    2. Manchester Royal Infirmary, Manchester M13 9BX
    3. University of Manchester Medical School, Manchester M13 9PT
    4. Forston Clinic, Herison, Dorchester, Dorset DT2 9TB
    5. Academic Department of Old Age Psychiatry, Withington Hospital, Manchester M20 8LR

      EDITOR—O‘Brien et al have shown that, in elderly patients with depressive disorder, severe deep white matter lesions are associated with a poor outcome, as measured by the quality of recovery from depression and time to relapse or recurrence, or both.1 Our group too has completed a follow up study. Of 44 subjects who had undergone magnetic resonance imaging three years earlier,2 37 were evaluated for follow up with a structured review of case notes with or without personal interview, the same categories being assigned as in O‘Brien et al's study.

      Association of periventricular change with dementia during follow up in 37 patients

      View this table:

      Our findings broadly correspond with those of O‘Brien et al. The presence of deep white matter hyperintensities was associated with poor overall clinical outcome, the poorest mean survival time (31.58 months to death in those with large confluent deep white matter lesions v 33.11 months in those without), higher residual depression rating scores (14.7 v 8.7), and a higher average number of relapses (3.63 v 1.05; all P<0.05).

      There were two additional findings. Firstly, specific lesions were associated with incomplete recovery or chronicity of depression: those in the pontine reticular formation and more than five Virchow-Robin spaces in the basal ganglia. Secondly, grade 3 periventricular lesions (deep irregular lesions) were associated with an increased risk of developing a dementia syndrome (Diagnostic and Statistical Manual of Mental Disorders (DSMIV) criteria being used). Twelve patients had deep irregular hyperintensities and five developed a dementia syndrome (χ2 test for association of periventricular change to development of dementia during follow up=18.09, df=9, P=0.034; table).

      Whether depression in old age is associated with a higher rate than expected of developing dementia is unclear. Certain subgroups—notably those with cognitive impairment at the outset of their depression—have a much increased risk.3 Periventricular lesions and deep white matter lesions may have different clinical implications. Periventricular lesions may be more relevant in the prediction of dementia, whereas deep white matter lesions influence the outcome depression. Further investigation of deep white matter lesions should be undertaken to establish more precisely their relevance to prognosis and treatment strategies, but periventricular lesions should not be overlooked as a potential marker of later dementia.

      References

      1. 1.
      2. 2.
      3. 3.