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Am J Psychiatry 1987; 144:1253-1262
Copyright © 1987 by American Psychiatric Association
The dexamethasone suppression test: an overview of its current status in psychiatry. The APA Task Force on Laboratory Tests in Psychiatry
The dexamethasone suppression test (DST) has had unprecedented evaluation
among biological tests proposed for clinical use in psychiatry. It is
hypothesized to reflect pathophysiologic changes at the CNS level. The
sensitivity of the DST (rate of a positive outcome, or nonsuppression of
cortisol) in major depression is modest (about 40%- 50%) but is higher
(about 60%-70%) in very severe, especially psychotic, affective disorders,
including major depression with psychotic as well as melancholic features,
mania, and schizoaffective disorder. The specificity (true negative
outcome) of the DST in normal control subjects is above 90%, but it varies
from less than 70% to more than 90% in psychiatric conditions that often
need to be separated from major affective disorders. In dementia the
specificity is even lower. In addition, a number of medical conditions,
including severe weight loss and use of alcohol and certain other drugs
(barbiturates, anticonvulsants, and others), can produce false positive
results. Positive initial DST status in major depression does not add
significantly to the likelihood of antidepressant response, and a negative
test is not an indication for withholding antidepressant treatment. Some
recent data suggest that DST-positive depressions (cortisol nonsuppression)
are less likely than DST-negative cases (cortisol suppression) to respond
to a placebo. If this is confirmed, it would increase the real magnitude of
the difference in treatment response between DST-positive and DST-negative
depressed patients. Failure to convert to normal suppression of cortisol
with apparent recovery from depression suggests an increased risk for
relapse into depression or suicidal behavior. Although the clinical utility
of the DST as currently understood is limited, in certain specific
situations its thoughtful use may aid clinical decision making. The
association of an abnormal test result with major affective disorders
encourages continued research on the DST.
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