Objective: To report a series of newly diagnosed thyrotoxic patients with concurrent acute psychosis, and to assess the association between the two disorders. Design: Retrospective study of thyrotoxic patients with associated psychosis ('thyrotoxic psychosis'; TP) requiring inpatient psychiatric care. New Zealand thyrotoxicosis annual incidence figures and first psychiatric admission rates for affective psychosis were utilised to statistically assess the co-occurrence of thyrotoxicosis and affective psychosis. Patients and Methods: During the 20-year study period, 18 inpatients (16 women and 2 men), mean age 54 years, with TP were identified. No patient had a past history of thyrotoxicosis, but four had required psychiatric inpatient care many years earlier. Thyrotoxicosis was documented by radioimmunoassay of thyroid hormone levels, and thyroid scintiscan. Psychiatric manifestations were classified using ICD9 criteria. Results: Thyroid hormone levels were markedly elevated in more than half of our TP patients. All younger patients had Graves' disease, and most older patients toxic nodular goitre. All patients were treated with antithyroid drugs, and all but one subsequently received 131 I therapy. Two patients were not mentally ill when thyrotoxicosis was diagnosed, but suffered major mood swings when thyroid hormone levels were falling. There was no specific psychiatric clinical picture but affective psychoses were commonest -seven depression, seven mania. The other diagnoses were two schizophreniform, one paranoid, and one delirium. Initially, neuroleptic medication was used in all but one patient, and during long-term follow-up (median 11 years) more than half our series had remained well with no further psychiatric problems. Statistical analysis was restricted to thyrotoxic patients with first psychiatric hospital admission for affective psychosis. During the 20-year period, there were nine thyrotoxic patients (95% confidence interval 4.5-17.1) with concurrent affective psychosis requiring first admission, and the calculated expected number was only 0.36. These findings indicate a clear association well above chance co-occurrence. Conclusion: TP is not a specific clinical picture, but affective psychoses are commonest. Statistical analysis of thyrotoxic patients with concurrent affective psychoses showed an incidence well above chance co-occurrence. It appears that thyrotoxicosis may be a precipitant of acute affective psychosis.

Background: Interpersonal psychotherapy and cognitive-behavioural therapy (CBT) are established as effective treatments for major depression. Controversy remains regarding their effectiveness for severe and melancholic depression. Aims:To compare the efficacy of interpersonal psychotherapy and CBT in people receiving out-patient treatment for depression and to explore response in severe depression (Montgomery-Åsberg Depression Rating Scale (MADRS) score above 30), and in melancholic depression. Method: Randomised clinical trial of 177 patients with a principal Axis I diagnosis of major depressive disorder receiving 16 weeks of therapy comprising 8 -19 sessions. Primary outcome was improvement in MADRS score from baseline to end of treatment. Results: There was no difference between the two psychotherapies in the sample as a whole, but CBT was more effective than interpersonal psychotherapy in severe depression, and the response was comparable with that for mild and moderate depression. Melancholia did not predict poor response to either psychotherapy. Conclusions: Both therapies are equally effective for depression but CBT may be preferred in severe depression. Declaration of interest: None.

Despite the two therapies having comparable efficacy in patients with depression, response to interpersonal psychotherapy (but not cognitive-behavioural therapy) is affected by personality traits. This could suggest the two therapies are indicated for different patients or that they work by different mechanisms.

Both therapies are equally effective for depression but CBT may be preferred in severe depression.

Age and gender appear to be critical variables in understanding differential antidepressant responses to tricyclic antidepressants and selective serotonin reuptake inhibitors in melancholic depression.