Responses to Corticotropin-Releasing Hormone in the Hypercortisolism of Depression and Cushing's Disease

Primary depression can be associated with substantial hypercortisolism, thus prompting some researchers to suggest that depression shares pathophysiologic features with Cushing's disease. Clinically, depression can be difficult or impossible to distinguish from mild or early Cushing's disease that is associated with depressive features. The purpose of this study was to evaluate whether the pituitary-adrenal responses to ovine corticotropin-releasing hormone could help to clarify the mechanism of hypercortisolism in depression and in Cushing's disease and to assist in the differential diagnosis of these disorders. As compared with controls (n = 34), depressed patients (n = 30) had basal hypercortisolism (P<0.001) that was associated with attenuated plasma ACTH responses to ovine corticotropin-releasing hormone (P<0.001). This indicates that in patients with depression, the corticotroph cell in the pituitary responds appropriately to the negative feedback of high cortisol levels. In contrast, patients with Cushing's disease (n = 29) had plasma ACTH hyperresponsiveness to ovine corticotropin-releasing hormone (P<0.001), despite basal hypercortisolism (P<0.001), which indicates a gross impairment of the mechanism by which cortisol exerts negative feedback on the pituitary. Less than 25 percent of the patients with depression or Cushing's disease had peak ACTH responses that overlapped. We conclude that the pathophysiologic features of hypercortisolism in depression and Cushing's disease are distinct in each of the disorders and that the ovine corticotropin-releasing hormone stimulation test can be helpful in their differential diagnosis. (N Engl J Med 1986; 314: 1329–35.), THE depressed phase of primary affective disorder is frequently associated with sustained hypercortisolism^1,2 (which is sometimes of sufficient magnitude to be termed a pseudo-Cushing's state), and patients with Cushing's disease often have signs of clinical depression.^{3 4 5 6} Although there has been controversy for many years about the cause of the hypercortisolism in patients with affective illness and Cushing's disease,^{4,7 8 9 10 11 12 13} the overlap in the clinical and biochemical manifestations of these illnesses has prompted some researchers to suggest that they share pathophysiologic features.^4,5,10 Clinically, patients with primary depression who are hirsute or obese and who have high plasma and urinary levels of free…