Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010

Borderline personality features in relationship to childhood trauma in unipolar depressive and bipolar disorders

BACKGROUND

Childhood trauma, including emotional neglect, emotional abuse, physical abuse, and sexual abuse, may contribute to borderline personality features like affective instability, identity problems, negative relationships, and self-harm. This study aims to explore how different types of childhood trauma affect these features in bipolar versus unipolar depressive disorders.

METHODS

We included 839 participants of the Netherlands Study of Depression and Anxiety (NESDA) with a lifetime diagnosis of major depressive disorder single episode (MDDS; N = 443), recurrent major depressive disorder (MDD-R; N = 331), or bipolar disorder (BD; N = 65). Multivariate regression was used to analyze data from the Childhood Trauma Interview and borderline features (from the self-report Personality Assessment Inventory).

RESULTS

On average, participants were 48.6 years old (SD: 12.6), with 69.2 % being women, and 50.3 % of participants assessed positive for childhood trauma. Adjusted analyses revealed that participants diagnosed with BD, followed by MDD-R, exhibited the highest number of borderline personality features. Additionally, within the entire group, a strong association was found between childhood trauma, especially emotional neglect, and the presence of borderline personality features.

CONCLUSION

Given the high prevalence of childhood trauma and borderline personality features, screening for these factors in individuals with mood disorders is crucial. Identifying these elements can inform and enhance the management of the often fluctuating and complex nature of these comorbid conditions, leading to more effective and tailored treatment strategies.

Treating depression in patients with borderline personality disorder: clinical clues on the use of antidepressants

Personality disorders (PD) are described as enduring patterns of markedly deviant and pervasive inner experiences and behaviors, with onset in adolescence, which lead to severe distress or impairment. Patients suffering from major depressive disorder (MDD) display higher rates of comorbidity with personality disorders, often complicating the treatment, and worsening the outcomes. Borderline personality disorder (BPD) is the most common of PD and is frequently associated with MDD, with which shares several features. The most part of research agrees on the fact that comorbid BPD in MDD patients quite doubles the poor response to treatments. Moreover, no treatment strategy stands out currently to emerge as more effective in these cases, thus urging the call for the need of new approaches. Herein, we revise the current literature on BPD, its neurobiology and comorbidity with MDD, as well as the more recent treatment strategies used. Then, based on its pharmacology, we propose a possible role of trazodone as a valuable tool to approach comorbid BPD-MDD.

Personality assessment in nursing home residents with mental and physical multimorbidity: two informant perspectives

OBJECTIVES

In older patients with mental and physical multimorbidity (MPM), personality assessment is highly complex. Our aim was to examine personality traits in this population using the Hetero-Anamnestic Personality questionnaire (HAP), and to compare the premorbid perspective of patients' relatives (HAP) with the present-time perspective of nursing staff (HAP-t).

DESIGN

Cross-sectional.

SETTING

Dutch gerontopsychiatric nursing home (GP-NH) units.

PARTICIPANTS

Totally, 142 GP-NH residents with MPM (excluding dementia).

MEASUREMENTS

NH norm data of the HAP were used to identify clinically relevant premorbid traits. Linear mixed models estimated the differences between HAP and HAP-t trait scores (0-10). Agreement was quantified by intraclass correlation coefficients (ICCs). All HAP-HAP-t analyses were corrected for response tendency (RT) scores (-10-10).

RESULTS

78.4% of the patients had at least one premorbid maladaptive trait, and 62.2% had two or more. Most prevalent were: "disorderly" (30.3%), "unpredictable/impulsive" (29.1%) and "vulnerable" (27.3%) behavior. The RT of relatives appeared significantly more positive than that of nursing staff (+1.8, 95% CI 0.6-2.9, p = 0.002). After RT correction, the traits "vulnerable", "perfectionist" and "unpredictable/impulsive" behavior scored higher on the HAP than HAP-t (respectively +1.2, 95% CI 0.6-1.7, p < 0.001; +2.1, 95% CI 1.3-2.8, p < 0.001; +0.6, 95% CI 0.1-1.1, p = 0.013), while "rigid" behavior scored lower (-0.7, 95% CI -1.3 to -0.03, p = 0.042). Adjusted ICCs ranged from 0.15 to 0.58.

CONCLUSIONS

Our study shows high percentages of premorbid maladaptive personality traits, which calls for attention on personality assessment in MPM NH residents. Results also indicate that the HAP and HAP-t questionnaires should not be used interchangeably for this patient group in clinical practice.

Dosage effects of psychodynamic and schema therapy in people with comorbid depression and personality disorder: four-arm pragmatic randomised controlled trial

BACKGROUND

Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder.

AIMS

To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941.

METHOD

We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder.

RESULTS

Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010).

CONCLUSIONS

Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

Clinical profiles of adolescent personality pathology: a latent structure examination of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) in a help-seeking sample

BACKGROUND

Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5, heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge.

METHODS

The final sample comprised 502 participants aged 11-18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure.

RESULTS

The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment.

CONCLUSIONS

A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.

Group schema therapy combined with psychomotor therapy for older adults with a personality disorder: an open-label, multicentre, randomised controlled trial

BACKGROUND

Although several types of psychotherapy effectively reduce psychological distress associated with personality disorders, randomised controlled trials (RCT) have systematically excluded older patients. We aimed to examine the effectiveness of group schema therapy combined with psychomotor therapy (GST + PMT) in later life compared with treatment as usual (TAU).

METHODS

We did an open-label, multicentre, RCT in eight outpatient clinics for geriatric psychiatry in the Netherlands. Adults aged 60 years or older with a full or subthreshold cluster B or C personality disorder according to DSM criteria were included and randomly assigned 1:1 to GST + PMT or TAU by an independent researcher applying a computer-generated sequence per study site when 8 to 16 patients had given informed consent; investigators and interviewers were kept blinded until end of follow-up. Included individuals received 20 weekly sessions of GST + PMT or TAU with 1 year of follow-up. The primary outcome was psychological distress, measured with the 53-item Brief Symptom Inventory. The trial was registered with International Clinical Trials Registry Platform, NTR6621.

FINDINGS

Of the 145 study participants recruited between Feb 21, 2018, and Jan 21, 2020, 102 patients (median age of 69 years [IQR 63-71], 62 [61%] female) who concluded therapy before the COVID-19 pandemic (cutoff March 20, 2020) were included in the intention-to-treat analysis (51 in each study group), because COVID-19 measures substantially disrupted delivery of group therapy. GST + PMT significantly improved psychological distress compared with TAU over the 6-month treatment period (Cohen's d 0·42, 95% CI 0·16 to 0·68; p=0·0016). The pre-post effect of GST + PMT remained stable during follow-up, whereas patients receiving TAU further improved, resulting in a non-significant difference between groups at 1 year (Cohen's d 0·21, 95% CI -0·07 to 0·48; p=0·14). No patients reported adverse events.

INTERPRETATION

Psychotherapy focused on personality disorders is effective in later life, resulting in a faster improvement in psychopathology than TAU. Future studies should focus on increasing effectiveness by intensifying or prolonging treatment.

FUNDING

Netherlands Organization for Health Research and Development.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Revisiting the concept of bipolar depression: comparison of diagnostic validators between melancholic and non-melancholic episodes

The current definition of bipolar disorder derives with minimal changes from one that emerged through expert consensus in the late 1970s, and the topic of its validity tended to be neglected in the literature. The aim of this exploratory study was to compare patients with bipolar disorder with a history of melancholic and non-melancholic depressive episodes in a series of external diagnostic validators. One hundred eight subjects were categorized as melancholic or non-melancholic in relation to their history of depressive episodes through the clinician-rated Sydney Melancholia Prototype Index (SMPI). The external validators used were clinical-demographic variables, family history of bipolar disorder, neurocognitive performance and functional outcome. There were 43.5% of the patients with a history of melancholia and 56.5% of non-melancholic depression. Non-melancholic depressions were overrepresented in females, while melancholic depressions had a female:male ratio closer to unity. Patients with melancholia had more history of BD in first-degree relatives and better functional outcome than those with non-melancholic depression. There were no differences between groups regarding neurocognitive performance. Results tended to be unchanged when controlled for confounders. Our preliminary results highlight the inherent heterogeneity in the current concept of bipolar depression, and suggest the need for further clinical research to elucidate its validity.

Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

Psychiatric risks for worsened mental health after psychedelic use

BACKGROUND

Resurgent psychedelic research has largely supported the safety and efficacy of psychedelic therapy for the treatment of various psychiatric disorders. As psychedelic use and therapy increase in prevalence, so does the importance of understanding associated risks. Cases of prolonged negative psychological responses to psychedelic therapy seem to be rare; however, studies are limited by biases and small sample sizes. The current analytical approach was motivated by the question of whether rare but significant adverse effects have been under-sampled in psychedelic research studies.

METHODS

A "bottom margin analysis" approach was taken to focus on negative responders to psychedelic use in a pool of naturalistic, observational prospective studies (N = 807). We define "negative response" by a clinically meaningful decline in a generic index of mental health, that is, one standard error from the mean decrease in psychological well-being 4 weeks post-psychedelic use (vs pre-use baseline). We then assessed whether a history of diagnosed mental illness can predict negative responses.

RESULTS

We find that 16% of the cohort falls into the "negative responder" subset. Parsing the sample by self-reported history of psychiatric diagnoses, results revealed a disproportionate prevalence of negative responses among those reporting a prior personality disorder diagnosis (31%). One multivariate regression model indicated a greater than four-fold elevated risk of adverse psychological responses to psychedelics in the personality disorder subsample (b = 1.425, p < 0.05).

CONCLUSION

We infer that the presence of a personality disorder may represent an elevated risk for psychedelic use and hypothesize that the importance of psychological support and good therapeutic alliance may be increased in this population.

Course and clinical correlates of obsessive-compulsive disorder with or without comorbid personality disorder

BACKGROUND

Personality disorders (PDs) are often comorbid with obsessive-compulsive disorder (OCD) which may influence symptom presentation and course. This investigation sought to examine the impact of comorbid PDs on clinical presentation and symptom chronicity in a large, prospective longitudinal OCD study.

METHODS

Participants (n = 263) were treatment-seeking adults with a primary diagnosis of OCD separated into two groups: individuals with and without a co-occurring PD. We conducted two-tailed t-tests to compare symptom severity, functioning, and quality of life between the OCD + PD group (n = 117) and the OCD w/o PD group (n = 146). Chronicity analyses were conducted to compare the amount of time in-episode for OCD and major depressive disorder (MDD) between the two groups.

RESULTS

The OCD + PD group reported greater OCD and depression severity, lower levels of psychosocial functioning and worse quality of life than the OCD w/o PD group. The OCD + PD group exhibited greater OCD and MDD symptom chronicity; over 5 years the OCD + PD group spent 16.2 % weeks longer at full criteria for OCD and three times as many weeks in episode for MDD than the OCD w/o PD group.

LIMITATIONS

Focusing on PDs as a group limited our ability to make observations about specific PDs. Further, the participants in our sample were predominantly White and all were treatment seeking which limits the generalizability of our findings.

CONCLUSIONS

Our results suggest that those with OCD and comorbid PDs present with greater overall impairment and may require additional considerations during treatment conceptualization and planning.

Psychometric properties of the Japanese version of the standardised assessment of personality abbreviated scale

This study was undertaken to translate the Standardised Assessment of Personality - Abbreviated Scale (SAPAS) into Japanese and to evaluate its validity and reliability. SAPAS is one of the most rapid tools for assessing personality disorder (PD) and has excellent sensitivity and good specificity, whereas other PD assessment tools require such a significant investment of time that they are infeasible for large surveys or routine clinical practice. Customary assessment in clinical practice ideally incorporates screening for PD, as it is associated with a substantial public health burden, including premature mortality and increased health service utilization. Furthermore, PD's status as a key prognostic variable of mental disorders also drives PD screening. While SAPAS has been translated into several languages, there has been no Japanese version. Therefore, we translated SAPAS into Japanese (SAPAS-J) and evaluated its reliability and validity. Study 1 recruited undergraduates to reveal its test-retest reliability. Although its internal consistency was not high, since the intent of the original SAPAS was to assess the broad character of personality disorder with the fewest possible items, minimal correlations between items were reasonable. We tested two factorial models, the single-factor model and the higher-order-single-factor model, and the latter offered better fitting. This higher-order model contained a three-factor structure corresponding to clusters described in DSM-5. It measures general PD traits as a common higher-order latent variable comprising those factors. Correlations of SAPAS-J with the much longer PD screening questionnaire in Study 1 and depressive and anxiety symptoms in Study 2 from the general population support its validity. Although validation for the clinical use of SAPAS-J is limited, our research with non-clinical populations demonstrated sufficient validity to justify its use in the context of psychopathological analog research. Since PD is understood as a continuum, the severity of which is distributed dimensionally, the analog study recruiting from the general population and attempting to reveal psychopathological mechanisms of PD is meaningful.

Predictors of short-term response and the role of heavy alcohol use in treatment of depression

BACKGROUND

Depression and alcohol use disorders frequently co-occur. However, research on psychosocial interventions for treating this dual pathology is limited. The Ostrobothnian Depression Study (ODS) aimed to increase the systematic use of evidence-based methods, particularly among patients with comorbid depression and substance use in a naturalistic setting. This is a secondary analysis of the ODS study. The aim of the present study was to explore the predictors of a response to treatment during the first six months of the ODS intervention with a specific focus on the role of comorbid heavy alcohol use.

METHODS

The study sample (n = 242) comprised psychiatric specialist care patients with depression (Beck Depression Inventory score ≥ 17) at baseline. Patients with a baseline Alcohol Use Disorders Identification Test (AUDIT) score > 10 (n = 99) were assigned to the AUD (Alcohol Use Disorder) group in this study. The ODS intervention comprised behavioral activation (BA) for all and additional motivational interviewing (MI) for those in AUD group. The predictors of response to treatment (minimum of 50% reduction in depressive symptoms) during the first six months were analyzed with logistic regression models.

RESULTS

In the total sample at six months (n = 150), predictors of response to treatment were more severe depression (OR 1.10, CI 1.02-1.18), larger amounts of alcohol consumed (OR = 1.16, CI 1.03-1.31) and antipsychotic medication "not in use" (OR = 0.17, CI 0.07-0.44). In the non-AUD group (n = 100), more severe depression (OR 1.12, CI 1.01-1.25) and antipsychotics "not in use" (OR 0.20, CI 0.06-0.67) also predicted a positive response. Among AUD group patients (n = 50), larger amounts of alcohol consumed (OR 1.54, CI 1.04-2.27) and antipsychotic medication "not in use" (OR 0.12, CI 0.02-0.60) predicted a response to the treatment intervention.

CONCLUSIONS

The severity of symptoms and comorbid disorders were found to predict better treatment response, suggesting that the intervention was more effective in patients with severe symptoms. Patients with depression should be treated effectively regardless of having concomitant AUD. The results of this study suggest that BA combined with MI should be one of the treatment options for this dual pathology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02520271 (11/08/2015).

The absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder

BACKGROUND

Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR.

AIMS

We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis.

METHODS

We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR.

RESULTS

We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria.

CONCLUSIONS

Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.

Early maladaptive schemas and addictive behaviours: A systematic review and meta-analysis

BACKGROUND

Recently, early maladaptive schemas have been increasingly focused as the underlying factor of several psychopathologies. The primary objective is to systematically review and meta-analytically analyse the evidence on the relationship between early maladaptive schemas and types of addictive behaviours. Additionally, the secondary objective was to examine potential moderators of the effect sizes.

METHODS

The systematic search was conducted on three databases including 'Scopus', 'Web of Science' and 'PubMed'. They were searched for quantitative studies investigating the relationship between early maladaptive schemas and addictive behaviours. The studies that were non-English and had insufficient information to calculate effect sizes were excluded. The random-effect model was utilized to estimate the pool effect sizes, and the meta-regression was used for moderation analysis.

RESULTS

Thirty-three studies with 12,577 participants were included for analyses. Most of included studies were conducted in the United States (k = 12, 36.36%). The mean ages of participants varied from 13.32 to 46.09 years. The findings indicated that all of early maladaptive schemas and schema domains positively correlated with addictive behaviours. The disconnection and rejection, impaired limits and impaired autonomy were the domains with the highest association with substance addictions (pool r = 0.338, 3.26 and 3.16, respectively). Furthermore, disconnection and rejection and impaired autonomy were the schema domains with the highest association with behavioural addictions (0.310 and 0.304, respectively). The moderation analysis demonstrated that study design was the factor affecting the effect sizes between schema domain and addictive behaviours.

LIMITATION

All included studies were from peer-reviewed journals in English. Moreover, the number of research examining the relationship between early maladaptive schemas and behavioural addictions was limited.

CONCLUSION

The findings provide evidence supporting the idea that substance addictions and behavioural addictions have shared risk factors, supporting the validity of the schema model, which can be applied for targeting and preventing addictive behaviours.

Associations Between the Suicidal Ideation and the Tolerance for Psychological Pain and Tolerance for Physical Pain in Patients Diagnosed with Major Depressive Disorder

Purpose

Patients with major depressive disorder (MDD) may experience more frequent and severe psychological and physical pain complaints compared to those without depression. As the tolerance to psychological pain decreases in patients with MDD, the severity of suicidal ideation tends to increase. Furthermore, the tolerance for physical pain (TPP) has been related with suicidal behavior. We aimed to demonstrate the impact of TPP on suicidal ideation in patients with MDD in the presence of psychological pain.

Patients and Methods

We included 123 patients with MDD and 114 healthy volunteers who had no previous psychiatric diagnosis. Sociodemographic data form, Psychache Scale (PS) and Tolerance for Mental Pain Scale (TMPS) were used to assess psychological pain. Beck Scale for Suicide Ideation (BSIS) and Beck Depression Inventory (BDI) were administered to participants. To assess the TPP, we used a device based on the principle of electronic dynamometry.

Results

The mean BDI, BSIS, PS, and TPP scores in the MDD group were higher, and the mean TMPS score was lower than those in the control group (p < 0.001 for each, p = 0.03 for TPP). We found statistically significant correlations between BDI, TMPS, BSIS, PS, and TPP scores (p < 0.05 for each). TPP was a partial mediator in the relationship between TMPS and BSIS scores (β = -1.814; p < 0.001).

Conclusion

We found that tolerance of psychological pain was a strong predictor of suicidal ideation, and TPP was mediating this relationship. These findings suggest that considering both tolerance to psychological pain and TPP may be beneficial when assessing the risk of suicide in individuals with MDD.

Patient characteristics, validity of clinical diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D): design, procedures and outcomes

BACKGROUND

Suicidality, ranging from passive suicidal thoughts to suicide attempt, is common in major depressive disorder (MDD). However, relatively little is known about patient, illness and treatment characteristics in those with co-occurring MDD and suicidality, including the timing of and factors associated with the offset, continuation or reemergence of suicidality. Here, we present the background, rationale, design and hypotheses of the Patient Characteristics, Validity of Clinical Diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D) study, an investigator-initiated, observational study, funded by Janssen-Cilag GmbH.

METHODS/RESULTS

OASIS-D is an eight-site, six-month, cohort study of patients aged 18-75 hospitalized with MDD. Divided into three sub-studies and patient populations (PPs), OASIS-D will (i) systematically characterize approximately 4500 consecutively hospitalized patients with any form of unipolar depressive episode (PP1), (ii) evaluate the validity of the clinical diagnosis of moderate or severe unipolar depressive episode with the Mini-International Neuropsychiatric Interview (M.I.N.I.) and present suicidality (at least passive suicidal thoughts) present ≥ 48 h after admission with the Sheehan-Suicide Tracking Scale (S-STS), assessing also predictors of the diagnostic concordance/discordance of MDD in around 500 inpatients (PP2), and (iii) characterize and prospectively follow for 6 months 315 inpatients with a research-verified moderate or severe unipolar depressive episode and at least passive suicidal thoughts ≥ 48 h after admission, evaluating treatment and illness/response patterns at baseline, hospital discharge, 3 and 6 months. Exploratory objectives will describe the association between the number of days with suicidality and utilization of outpatient and inpatient care services, and structured assessments of factors influencing the risk of self-injurious behavior without suicidal intent, and of continuous, intermittent or remitted suicidality during the 6-month observation period.

CONCLUSION

Despite their frequency and clinical relevance, relatively little is known about patient and treatment characteristics of individuals with MDD and suicidality, including factors moderating and mediating the outcome of both MDD and suicidality. Results of the OASIS-D study are hoped to improve the understanding of the frequency, correlates and 6-month naturalistic treatment and outcome trajectories of different levels of suicidality in hospitalized adults with MDD and suicidality.

TRIAL REGISTRATION

NCT04404309 [ClinicalTrials.gov].

The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence

Bipolar disorder is a complex and heterogeneous psychiatric condition that affects more than 2% of the population. The assessment and treatment of bipolar disorder can be a challenge for clinicians, given its clinical complexity and the rapidly changing treatment landscape with the growing range of treatment options that are becoming available for various phases of the illness. To help clinicians navigate the complexity involved in the assessment and management of bipolar disorder, the guidelines of the 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) synthesized the evidence on the efficacy, safety, and tolerability of treatments for bipolar disorder and translated it into first-, second-, and third-line treatment recommendations. The main objective of this contribution is to provide clinicians with a summary of the 2018 CANMAT/ISBD guideline recommendations with the addition of any new evidence for the treatment of bipolar disorder across the lifespan.

The impact of MDQ positivity on quality of life impairment: Does it support the hypothesis of "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS)?

Background

DSM-5 separates bipolar (BD) from depressive disorders, but some experts consider BD as part of a spectrum of mood disorders. The interpretation of numerous false positives of BD screened by the Mood Disorders Questionnaire (MDQ) is part of this debate. Recent study results suggest that the worsening of health-related quality of life (H-Qol) associated with MDQ positivity does not depend solely on mood disorders. This study aims to clarify whether the impairment may be due to other concomitant disorders, unrelated to mood disorders, leading to a worsening of H-Qol. Additionally, the study aims to explore if MDQ positivity itself observe clinical significance.

Design and methods

The study involved pairs of cases (MDQ+) and controls (MDQ-) matched for sex, age, and absence of DSM-IV psychiatric comorbidity. The impact of MDQ positivity on the quality of life in a sample of MDQ+ comorbid with MDD was measured and compared to impact of MDD in other chronic disorders.

Results

The H-Qol was significantly worse in MDQ+ than in controls (both groups without any psychiatric co-morbidity). The worsening was similar to severe chronic disorders The burden of worsening quality of life due to MDD was mild in another sample of MDQ positives with comorbid MDD.

Conclusion

The study hypothesizes that MDQ positivity may be related to hyperactivation and dysregulation of rhythms typical of stress disorders. In fact, MDQ+ was found strongly related to sleep disturbances. Future studies could verify if a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), causes worsening the H-Qol in MDQ+.

Parental personality disorder symptoms and children's social skills: a prospective community study

Acquiring age-appropriate social skills, arguably a major prerequisite for favorable psychosocial development in children, is targeted in a range of interventions. Hence, identifying factors that limit this acquisition may inform preventative and treatment efforts. Personality disorders are characterized by pervasive and enduring dysfunctional interpersonal functioning, including parenting, and could thus entail risk for offspring in not developing adaptive interpersonal skills. However, no study has tested this possibility. A representative sample drawn from two birth cohorts of Norwegian 4-year-olds (n = 956) and their parents was followed up at ages 6, 8, and 10 years. Parents' personality disorder symptoms were measured dimensionally with the DSM-IV and ICD-10 Personality Questionnaire, and children's social skills were evaluated by the Social Skills Rating System. A difference-in-difference approach was applied to adjust for all unmeasured time-invariant confounders, and parental symptoms of depression and anxiety were entered as covariates. Increased Cluster B symptoms in parents of children aged 4 to 6 years predicted decreased social skill development in offspring (B = -0.97, 95% CI -1.58, -0.37, p = 0.002). On a more granular level, increased symptoms of borderline (B = -0.39, CI -0.65, -0.12, p = 0.004), histrionic (B = -0.55, CI -0.99, -0.11, p = 0.018), and avoidant (B = -0.46, CI-0.79, -0.13, p = 0.006) personality disorders in parents predicted decreased social skill development in offspring. Subclinical levels of borderline, histrionic and avoidant personality disorders in parents may impair the development of social skills in offspring. Successfully treating these personality problems or considering them when providing services to children may facilitate children's acquisition of social skills.

Does Screening for Bipolar Disorders Identify a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS)? A Heuristic Working Hypothesis

The aim of this paper is to verify if people with a positive score on the Mood Disorder Questionnaire (MDQ) without comorbidity of mood disorders showed a worse level of Health-related Quality of life (HRQol) compared to a control-matched sample of MDQ negatives, identifying a specific syndrome. This is a case-control study based on a database from a community survey. Cases: MDQ-positive without mood disorders; Controls: MDQ negatives matched by sex, age, and psychiatric diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria. Tools: MDQ, the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS) semi-structured interview for psychiatric diagnosis, and the Health Survey Short Form (SF-12) for measuring HRQol. People scoring positive on the MDQ without a diagnosis of mood disorders showed significantly lower scores on the SF-12 compared to people of the same age and of the same sex with an equal diagnosis of psychiatric disorders not related to mood disorders (35.21 ± 6.30 vs. 41.48 ± 3.39, p < 0.0001). In the debate whether a positive score on the MDQ selects an area of "malaise" due to the presence of disorders differing from Bipolar Disorders, or if a positive score on the MDQ may be considered a "subthreshold" form of bipolar disorder in people who may later develop bipolar disorder, a third hypothesis can be advanced, i.e., that a positive score on the MDQ identifies a specific "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), characterized by a considerable amount of suffering and not attributable to other disorders, and which might represent a trigger for the previously mentioned disorders with which a positive score on the MDQ is associated, probably including, in severe conditions, bipolar disorder.

Investigation of the role of personality traits and emotion regulation on personality functioning in patients with depression/anxiety disorder

The relationship between the dimensional assessment of personality and difficulties in emotion regulation has yet to be made clear. The present study aimed to investigate the role of personality traits and emotion regulation on personality functioning. Difficulties in Emotion Regulation Scale (DERS), Beck Anxiety Inventory, Beck Depression Inventory, Personality Inventory for DSM-5 (PID-5) and Level of Personality Functioning Scale (LPFS) were rated for 220 patients with depression and/or anxiety disorder diagnosis and 100 healthy controls. Stepwise regression analyses (SRA) were used to find potential predictors of personality functioning, and generalized linear analyses (GLA) were used to find mediators between the traits and personality functioning. SRA results in the clinical group showed that higher depression, antagonism, difficulties in impulse control and difficulties in awareness predicted higher levels of dysfunction in personality. According to GLA results in the clinical group, the impulse subscale of DERS partially mediated the relationship between antagonism and level of impairment in personality functioning. Our results indicate that certain emotion regulation styles and personality traits play an important role in predicting personality functioning in the clinical sample of depression and anxiety patients. Future studies should focus on specific emotion dysregulation strategies and broaden the dimensional personality literature in different samples.

Technologically assisted intensive home treatment: feasibility study

Introduction

In recent year, many attempts have been made to provide patients with alternatives to psychiatric hospitalization during acute distress. Although several hospitalization alternatives have been offered, most of them still require patients to be distanced from their families, friends, and the social environment.

Methods

In this report we describe the implementation of a novel approach to psychiatric care termed "Technologically assisted Intensive Home Treatment", where patients arriving to emergency settings are directed to home care with technological aids that enable close monitoring and ongoing contact with their therapists.

Results

We describe the rationale and treatment principles of the treatment, and provide an elaborative description of the implementation process during the first year of implementation.

Discussion

Additional attention is given to factors associated with early dropout from the program, in order to inform readers of predictors to optimal care. Limitations and directions for future research and practice are discussed.Clinical Trial Registration: The study was registered in the database of clinical trials (registration number SHEBA-19-6555-MW-CTIL) and in the Ministry of Health (registration number MOH_2022-08-22_011992).

Screening, Genetic Variants, and Bipolar Disorders: Can Useful Hypotheses Arise from the Sum of Partial Failures?

Bipolar disorder (BD) is a relevant public health issue, therefore accurate screening tools could be useful. The objective of this study is to verify the accuracy of the Mood Disorder Questionnaire (MDQ) and genetic risk as screeners, and their comparison in terms of reliability. Older adults (N = 61, ≥60 years) received a clinical psychiatric evaluation, the MDQ, and were evaluated according to the presence of the genetic variant RS1006737 of CACNA1C. MDQ+ versus the diagnosis of BD as a gold standard shows a sensitivity of 0.286 (Cl 95% 0.14-0.39); a specificity of 0.925 (Cl 95% 0.85-0.08); a predictive positive value (PPV) of 0.667 (Cl 95% 0.33-0.91); and a predictive negative value (PNV) of 0.702 (Cl 95% 0.65-0.75). The positivity for the variant RS1006737 of the CACNA1C against the diagnosis of BD as a gold standard shows a sensitivity of 0.750 (Cl 95% 0.55-0.90); a specificity of 0.375 (Cl 95% 0.28-0.45); a PPV of 0.375 (Cl 95% 0.28-0.45); and a PNV of 0.750 (Cl 95% 0.55-0.90). The reliability between the MDQ+ and positivity for the variant RS1006737 of the CACNA1C was very low (K = -0.048, Cl 95% -0.20-0.09). The study found that both the genetic and the paper and pencil test were quite accurate, but were not reliable in case finding. In fact, despite some validity, albeit specular (in the case of a positive genetic test, the probability of having the disorder is very high, whereas in the case of a negative score on the paper and pencil test, the probability of not having the disorder is very high), the unreliability of the two tests (i.e., they certainly do not measure the same underlying dimension) opens the door to the need for an interpretation and the possibility of a synergistic use for screening. From a heuristic perspective, which obviously requires all of the necessary verifications, this study seems to suggest the hypothesis that a condition of hyperactivation common to disorders and stress conditions, and identified by a positive score on the MDQ (which is common to BD, post-traumatic stress disorder (PTSD), and anxiety disorders and whose genetic basis has not yet been clarified) can trigger BD in people with a predisposition to hyperactivity (i.e., in people with the condition identified by the analyzed genetic variant).

Evaluating the role of maladaptive personality traits in schema therapy and cognitive behavioural therapy for depression

BACKGROUND

Advancements in the treatment of depression are pivotal due to high levels of non-response and relapse. This study evaluated the role of personality pathology in the treatment of depression by testing whether maladaptive personality traits (1) predict changes in depression over treatment or vice versa, (2) change themselves over treatment, (3) change differentially depending on treatment with schema therapy (ST) or cognitive behavioural therapy (CBT), and (4) moderate the effectiveness of these treatments.

METHODS

We included 193 depressed inpatients (53.4% women, Mage = 42.9, SD = 13.4) participating in an assessor-blind randomized clinical trial and receiving a 7-week course of ST or CBT. The research questions were addressed using multiple indicator latent change score models as well as multigroup structural equation models implemented in EffectLiteR.

RESULTS

Maladaptive traits did not predict changes in depressive symptoms at post-treatment, or vice versa. However, maladaptive trait domains decreased over treatment (standardized Δμ range: -0.38 to -0.89), irrespective of treatment with ST or CBT. Maladaptive traits at baseline did not moderate the effectiveness of these treatments.

CONCLUSIONS

Self-reported maladaptive personality traits can change during treatment of depression, but may have limited prognostic or prescriptive value, at least in the context of ST or CBT. These results need to be replicated using follow-up data, larger and more diverse samples, and informant-rated measures of personality pathology.

A quantitative analysis of the relationship between affective state and personality ratings in inpatient depression (RAPID)

BACKGROUND

The relationship between major depressive disorder (MDD) and personality disorders is complex, with implications for diagnosis and treatment. We sought to explore the relationship between these disorders quantitatively in an inpatient setting.

METHODS

We conducted a structured observational study exploring symptoms of depression and selected neurocognitive functions over the span of an inpatient admission in those with depression and personality disorders. Sixty inpatients presenting with symptoms of depression completed ratings of mood and neurocognitive function. Diagnosis was confirmed by structured clinical interview (SCID-5-RV) at discharge and used to allocate patients to one of the two groups for analysis: those with MDD-only and those with a personality disorder (with or without MDD).

RESULTS

On admission, observer-based ratings of depression were significantly higher in the MDD-only group while subjective ratings were higher in the personality disorder group. Depression rating scores lessened in both groups during the admission, but at discharge, the personality disorder group continued to report higher subjective ratings. The personality disorder group also rated themselves as more cognitively impaired than the MDD-only group and unlike the MDD-only group, they did not report subjective improvements in cognitive function over the course of admission. Objective assessment of cognitive function demonstrated improvements in both groups.

CONCLUSIONS

In this study, the presence of a personality disorder was associated with greater subjective severity of depressive symptomatology and selected neurocognitive functioning, despite similar or lower objective severity in comparison with those with MDD. This finding has implications for understanding the patient journey through health care settings.

Correlates of Homelessness Among Adults with Personality Disorder

Although personality disorders (PDs) are more common among persons experiencing homelessness than the general population, few studies have investigated the risk of experiencing homelessness among persons with PDs. This study seeks to identify the demographic, socioeconomic, and behavioral health correlates of past-year homelessness among persons with antisocial, borderline, and schizotypal PDs. Nationally representative data of the civilian, noninstitutionalized population of the United States was used to identify correlates of homelessness. Descriptive statistics and bivariate associations between variables and homeless status were summarized prior to conducting several multivariate logistic regression models to identify correlates of homelessness. Main findings revealed positive associations between poverty, relationship dysfunction, and lifetime suicide attempt with homelessness. In the antisocial PD (ASPD) and borderline PD (BPD) models, comorbid BPD and ASPD, respectively, were associated with higher odds of past-year homelessness. Findings underscore the importance of poverty, interpersonal difficulties, and behavioral health comorbidities on homelessness among persons with ASPD, BPD, and schizotypal PD. Strategies to promote economic security, stable relationships, and interpersonal functioning may buffer against the effects of economic volatility and other systemic factors that could contribute to homelessness and persons with PD.

The maladaptive domains according to the alternative model of personality disorders (AMPD) criterion B in patients with affective disorders and temperamental triads related to these domains: two unique profiles

OBJECTIVES

The study aimed to (i) compare the maladaptive domains and facets according to the Alternative Model of Personality Disorders (AMPD) Criterion B in patients with a type II bipolar disorder (BD-II) or major depressive disorder (MDD) with healthy controls (HCs), and (ii) investigating the relationship between affective temperaments and these domains and facets in the total sample.

METHODS

Outpatients diagnosed with current BD-II (n = 37; female 62.2%) or MDD (n = 17; female 82.4%) based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and community HCs (n = 177; female 62.1%) in Kermanshah from July to October 2020 included this case-control study. All participants completed the Personality Inventory for DSM-5 (PID-5), the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and the second version of the Beck Depression Inventory (BDI-II). Data were analyzed using analysis of variance (ANOVA), Pearson correlation, and multiple regression.

RESULTS

The score of patients with BD-II in all five domains and those with MDD in three domains including negative affectivity, detachment, and disinhibition are significantly higher than the HCs (p < 0.05). Depressive temperament (related to negative affectivity, detachment, and disinhibition) and cyclothymic temperament (related to antagonism and psychoticism) were the most important correlates of the maladaptive domains.

CONCLUSIONS

Two unique profiles are proposed, including three domains of negative affectivity, detachment, and disinhibition associated with the depressive temperament for MDD, and two domains of antagonism and psychoticism related to cyclothymic temperament for BD-II.

Intuition and meaning in life in persons with varying level of depressive symptoms and impairments in personality functioning

OBJECTIVES

The current research explored the interplay between intuition, meaning in life, and psychopathology. Specifically, we investigated whether experiential and reflective components of meaning in life are associated with depressive symptoms and personality pathology, whether intuition is related to the experience of meaning, and whether psychopathology has disruptive effects on intuition as well as on the link between intuition and the experience of meaning.

METHODS

We tested our preregistered hypotheses in two independent studies. In Study 1, N = 448 participants completed self-report instruments assessing the experiential and the reflective dimensions of meaning in life, depressive symptoms, and impairments in personality functioning. Intuition was operationalized as the ability to intuitively detect semantic coherence in an experimental task. Additionally, self-reported confidence in intuition was assessed. In Study 2, we aimed to replicate our findings and hypotheses that emerged from Study 1 with a new sample of N = 1189 participants.

RESULTS

In both studies, participants with more depressive symptoms or higher levels of personality pathology experienced life as less meaningful but reflected significantly more about meaning in life. The intuitive ability to discriminate between coherence and incoherence in the experimental task was neither related to the experience of meaning in life nor to psychopathology, but more confidence in intuition was associated with experiencing life as more meaningful and with less psychopathological symptoms. It was tentatively supported that the association between meaning in life and intuition was moderated by psychopathology.

CONCLUSION

The findings are discussed in terms of their clinical implications and regarding the cognitive-affective processes potentially underlying people's experience of life being meaningful.

How can the DSM-5 alternative model of personality disorders advance understanding of depression?

BACKGROUND

The DSM-5 introduced an alternative model of personality disorder (AMPD) that includes personality dysfunction plus maladaptive-range traits. This study clarifies relations of depression diagnoses and symptoms with AMPD personality pathology.

METHOD

Two samples (Ns 402 and 601) of outpatients and community-dwelling adults completed four depression (criteria met for major depressive disorder and dysthymia; dysphoria and low well-being scales), ten trait (two scales for each of five domains-negative affectivity, detachment, disinhibition, antagonism, psychoticism), and eight dysfunction (four scales for each of two domains-self- and interpersonal pathology) measures. Diagnoses were made using a semi-structured interview; other measures were self-reports. We quantified cross-sectional relations between depression and personality pathology with correlation and multiple regression analyses.

RESULTS

Collectively (median R²; ps < 0.0001), the trait (0.46) and dysfunction (0.50) scales predicted the depression measures strongly, with most predictive power shared (0.41) between traits and dysfunction. However, trait and dysfunction scales altogether predicted depression (median R² = 0.54) more strongly than either domain alone, ps < 0.0001. Participants with depression diagnoses showed elevations on all nonadaptive trait and personality dysfunction measures, particularly negative temperament/affectivity and self-pathology measures.

LIMITATIONS

Generalization of findings to other populations (e.g., adolescents), settings (e.g., primary care), and measures (e.g., traditional personality disorder diagnoses) is uncertain. Cross-sectional analyses did not test changes over time or establish causality.

CONCLUSIONS

The AMPD is highly relevant to depression. Assessment of personality pathology, including both personality dysfunction and maladaptive-range traits, stands to advance understanding of depression in adults.

Exploring the effect of group schema therapy and comorbidity on the treatment course of personality disorders

PURPOSE OF REVIEW

To provide an update of outcome studies of schema group therapy for personality disorders and the effect of comorbidity in order to explore whether schema group therapy might be effective for this patient group and what dosage is required.

RECENT FINDINGS

Studies of short-term schema group therapy for personality disorders with or without comorbidity show moderately effective results but the majority of patients fail to achieve full remission from global psychological symptom distress. Preliminary findings revealed that those unremitted patients might benefit from 40 to 60 sessions. Patients with severe personality disorders (such as borderline personality disorders) seem to need longer and/or more intensive treatment dosage to recover.

SUMMARY

We advocate short-term schema therapy in groups as a valuable first step in a stepped-care programme for patients with moderate personality disorders and comorbidity.Treatment extension or treatment intensification may be indicated in patients who do not recover. Patients with severe personality disorders seem to require long-term outpatient group treatment, with a combination of group and individual treatment being preferable. High-quality randomized controlled trials are needed in order to determine which treatment dosage is necessary for whom.

Scoping Review on the Multimodal Classification of Depression and Experimental Study on Existing Multimodal Models

Depression is a prevalent comorbidity in patients with severe physical disorders, such as cancer, stroke, and coronary diseases. Although it can significantly impact the course of the primary disease, the signs of depression are often underestimated and overlooked. The aim of this paper was to review algorithms for the automatic, uniform, and multimodal classification of signs of depression from human conversations and to evaluate their accuracy. For the scoping review, the PRISMA guidelines for scoping reviews were followed. In the scoping review, the search yielded 1095 papers, out of which 20 papers (8.26%) included more than two modalities, and 3 of those papers provided codes. Within the scope of this review, supported vector machine (SVM), random forest (RF), and long short-term memory network (LSTM; with gated and non-gated recurrent units) models, as well as different combinations of features, were identified as the most widely researched techniques. We tested the models using the DAIC-WOZ dataset (original training dataset) and using the SymptomMedia dataset to further assess their reliability and dependency on the nature of the training datasets. The best performance was obtained by the LSTM with gated recurrent units (F1-score of 0.64 for the DAIC-WOZ dataset). However, with a drop to an F1-score of 0.56 for the SymptomMedia dataset, the method also appears to be the most data-dependent.

Prevalence and prediction of dropout during depression treatment in routine outpatient care: an observational study

Efficacious treatments are available for major depressive disorder (MDD), but treatment dropout is common and decreases their effectiveness. However, knowledge about prevalence of treatment dropout and its risk factors in routine care is limited. The objective of this study was to determine the prevalence of and risk factors for dropout in a large outpatient sample. In this retrospective cohort analysis, routinely collected data from 2235 outpatients with MDD who had a diagnostic work-up between 2014 and 2016 were examined. Dropout was defined as treatment termination without achieving remission before the fourth session within six months after its start. Total and item scores on the Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) at baseline, and demographic variables were analyzed for their association with dropout using logistic regression and elastic net analyses. Data of 987 subjects who started routine outpatient depression treatment were included in the analyses of which 143 (14.5%) dropped out. Higher DM-TRD-scores were predictive for lower dropout odds [OR = 0.78, 95% CI = (0.70-0.86), p < 0.001]. The elastic net analysis revealed several clinical variables predictive for dropout. Higher SES, higher depression severity, comorbid personality pathology and a comorbid anxiety disorder were significantly associated with less dropout in the sample. In this observational study, treatment dropout was relatively low. The DM-TRD, an easy-to-use clinical instrument, revealed several variables associated with less dropout. When applied in daily practice and combined with demographical information, this instrument may help to reduce dropout and increase treatment effectiveness.

An Exploratory Study of MMPI-2-RF Personality and Psychopathology Profiles of Adults with Autism Spectrum Disorder without Intellectual Disability

OBJECTIVE

More empirical research is needed to disentangle the phenotypes of autism spectrum disorder (ASD) and cluster C personality symptomatology (CCPD), as both show similarities in their clinical presentation. We explored personality and psychopathology dimensions as conceptualized in contemporary dimensional taxonomies (i.e., hierarchical taxonomy of psychopathology; HiTOP) in adults with ASD without intellectual disability operationalized by the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF).

METHOD

Applying secondary analytic processes using clinical data, we cross-examined the MMPI-2-RF profiles of adults with ASD (n = 28) compared to adults with Cluster C personality disorders (CCPD; n = 28) and a control group (n = 28) by conducting nonparametric tests and assessing effect sizes.

RESULTS

The profiles of the ASD and CCPD groups evidenced to be similar, and both average clinical profiles diverged from the average control group profiles by elevated levels of demoralization, internalizing, and somatization symptomatology. There were small differences between the average profiles of adults with ASD and adults with CCPD. Additional research using dimensional measures of psychopathology could elucidate the dimensional phenotypes of ASD and CCPD.

CONCLUSIONS

Based on the results in this study, the MMPI-2-RF may not meaningfully discriminate between the two clinical presentations, with the exception of various externalizing scales.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors

BACKGROUND

Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes.

METHODS

Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model.

RESULTS

The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change.

CONCLUSIONS

Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Impact of personality functioning and pathological traits on mental wellbeing of older patients with personality disorders

BACKGROUND

Although personality disorders are common and consequential, they are largely ignored in geriatric mental healthcare. We examined the relative contributions of different aspects of personality disorders and comorbid mental disorders to the impairment of mental wellbeing in older adults.

METHODS

Baseline data were used of 138 patients who participated in a randomized controlled trial on schema therapy for geriatric mental health outpatients with a full or subthreshold cluster B or C personality disorder. Personality was assessed according to both the categorical and dimensional model of DSM-5. Aspects of mental wellbeing assessed were; psychological distress, positive mental health, subjective health, and life satisfaction. The current study uses baseline data of the RCT to examine the associations between different aspects of personality pathology and mental wellbeing by multivariate regression analysis, controlling for age, sex, level of education, and number of chronic somatic illnesses.

RESULTS

The vast majority of patients (79.0%) had one or more mental disorders in addition to personality disorder. Personality pathology was responsible for the core of the mental health burden experienced by patients, and negated the influence of co-occurring mental disorders when entered subsequently in multivariate analysis. Personality dimensions proved to be highly predictive of mental wellbeing, and this contrasted with absence of influence of personality disorder diagnosis. Although the personality functioning dimensions - and in particular Identity integration (large effect size with partial eta-squared = 0.36) - were the primary predictors of mental wellbeing, personality trait dimensions added significant predictive value to that (Disinhibition 0.25 and Negative affect 0.24).

CONCLUSIONS

Personality disorders seriously affect the mental wellbeing of patients, and this overshadows the impact of comorbid mental disorders. In particular personality functioning and pathological traits of the Alternative Model of Personality Disorders (AMPD) of DSM-5 contribute to this impact on mental wellbeing. Alertness for and treatment of personality disorders in geriatric mental healthcare seems warranted.

Real-world clinical predictors of manic/hypomanic episodes among outpatients with bipolar disorder

Background

Bipolar disorder is a mental illness in which manic and depressive states are repeated, causing psychosocial dysfunction. Manic/hypomanic episodes cause problems with interpersonal, social and financial activities, but there is limited evidence regarding the predictors of manic/hypomanic episodes in real-world clinical practice.

Methods

The multicenter treatment survey on bipolar disorder (MUSUBI) in Japanese psychiatric clinics was administered in an observational study that was conducted to accumulate evidence regarding bipolar disorder in real-world clinical practice. Psychiatrists were asked to complete a questionnaire about patients with bipolar disorder who visited 176 member clinics of the Japanese Association of Neuro-Psychiatric Clinics by conducting a retrospective medical record survey. Our study extracted baseline patient characteristics from September to October 2016, including comorbidities, mental status, duration of treatment, Global Assessment of Functioning (GAF) score, and pharmacological treatment details. We investigated the presence or absence of manic/hypomanic episodes over the course of one year from baseline to September-October 2017.

Results

In total, 2231 participants were included in our study, 29.1% of whom had manic/hypomanic episodes over the course of one year from baseline. Binomial logistic regression analysis revealed that the presence of manic/hypomanic episodes was correlated with lower baseline GAF scores, rapid cycling, personality disorder, bipolar I disorder, and a mood state with manic or mixed features. Substance abuse was also a risk factor for manic episodes. There was no significant association between a baseline antidepressant prescription and manic/hypomanic episodes.

Conclusions

In Japan, 29.1% of outpatients with bipolar disorder had manic/hypomanic episodes over the course of one year. Our study suggested that a low GAF score, rapid cycling, personality disorder, bipolar I disorder, substance abuse, and baseline mood state could be predictors of manic/hypomanic episodes. Based on our findings, an antidepressant prescription is not a predictor of manic/hypomanic episodes.

Selbstmitgefühl mediiert den Zusammenhang zwischen dysfunktionalen Persönlichkeitsstilen und der mentalen Gesundheit depressiver Patient_innen

Zusammenfassung. Theoretischer Hintergrund: Ein selbstunsicherer und Borderline-Persönlichkeitsstil scheinen positiv mit Symptomschwere und negativ mit Lebenszufriedenheit bei depressiven Personen zusammenzuhängen. Selbstmitgefühl könnte hierbei eine vermittelnde Rolle spielen. Fragestellung: Die vorliegende Studie untersuchte, ob ein geringeres Selbstmitgefühl den Zusammenhang eines selbstunsicheren bzw. Borderline-Persönlichkeitsstils mit geringerer Lebenszufriedenheit und höherer Symptomschwere vermittelt. Methode: In einer Querschnitts-Erhebung beantworteten 78 ambulante Patient_innen mit Majorer Depression Fragebögen zu Selbstmitgefühl, Lebenszufriedenheit, depressiver Symptomschwere und Persönlichkeitsstilen. Anschließend wurden Mediationsanalysen berechnet. Ergebnisse: Die Ergebnisse implizieren, dass ein geringeres Selbstmitgefühl den Zusammenhang zwischen einem selbstunsicheren Stil und depressiver Symptomschwere vermittelt. Insbesondere eine ausgeprägtere Selbstverurteilung vermittelte den Zusammenhang zwischen einem selbstunsicheren bzw. Borderline-Stil und geringerer Lebenszufriedenheit. Schlussfolgerungen: Selbstmitgefühl zu stärken und insbesondere Selbstverurteilung zu reduzieren könnte bei depressiven Patient_innen mit selbstunsicherem oder Borderline-Stil ein Ansatzpunkt zur Verbesserung der mentalen Gesundheit sein, was in Interventionsstudien untersucht werden sollte. Limitationen der Studie sind das querschnittliche Design und die geringe interne Konsistenz einzelner Selbstmitgefühls-Facetten.

Failure to resolve loss and compromised mentalizing in female inpatients with major depressive disorder

Attachment and mentalizing are central concepts in research on the etiology, course, and treatment of depression. The goal of this cross-sectional study was to clarify the unique value of these constructs in characterizing the presence, severity, and chronicity of depression. We examined 50 female inpatients suffering from Major Depressive Disorder (MDD) in comparison to 47 matched healthy controls regarding their attachment states of mind, mentalizing capacities, and clinical variables indicating depression severity and chronicity (e.g. illness duration, number of hospitalizations). In the group of depressed patients, unresolved attachment with regard to loss was significantly overrepresented. Dimensionally, patients were more disorganized and more insecure, whereas there was no difference on the dismissing-preoccupied dimension between the two groups. Mentalizing was significantly lower in patients than in healthy controls. Logistic regression analysis revealed attachment insecurity, mentalizing deficits, and unresolved loss to be incrementally relevant to predict MDD. Correlations with clinical parameters in the group of depressed patients showed positive associations between mentalizing deficits, attachment insecurity, and variables indicating illness chronicity. Our findings highlight the relevance of the inability to resolve or reappraise loss experiences in depressive states.

Alliance rupture profiles by personality disorder pathology in psychotherapy for depression: Tendencies, development, and timing

OBJECTIVE

Clinical and theoretical considerations presume that patients with different personality disorder (PD) clusters will be associated with distinct alliance rupture profiles; however, there is scarce empirical literature examining this. The present study adopted a systematic framework for investigating profiles of alliance ruptures for individuals belonging to each of the three PD clusters.

METHOD

The sample consisted of 94 patients from a randomized controlled trial for treatment of depression. PD cluster features were assessed at intake and ruptures were assessed across treatment. Three sets of multilevel analyses were conducted to test differences between the PD clusters in the general tendency to show a rupture profile, rupture development throughout the treatment, and timing of predicting ruptures by PD within sessions.

RESULTS

The three clusters were associated with distinct profiles of alliance ruptures. Clusters A and B were characterized by a general tendency to show more withdrawal and confrontation ruptures. Cluster A had a greater decrease in confrontation ruptures over the course of treatment, while cluster B had a greater decrease in withdrawal ruptures. Cluster C was characterized by a general tendency to show fewer withdrawal and confrontation ruptures, with a greater increase in both ruptures over the course of treatment. For withdrawal ruptures, the differences between clusters were evident from the beginning of sessions, whereas for confrontation ruptures, there was less of a difference between beginning and end of sessions.

CONCLUSION

The distinct profiles of alliance ruptures for each PD cluster may contribute to progress towards tailoring treatment to individuals with PDs.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

From a Symptom-Based to a Person-Centered Approach in Treating Depressive Disorders in Adolescence: A Clinical Case Formulation Using the Psychodynamic Diagnostic Manual (PDM-2)'s Framework

BACKGROUND

Depressive disorders in adolescence are among the most challenging clinical syndromes to diagnostically identify and treat in psychotherapy. The Psychodynamic Diagnostic Manual, Second Edition (PDM-2) proposes an integration between nomothetic knowledge and an idiographic understanding of adolescent patients suffering from depression to promote a person-centered approach. This single-case study was aimed at describing and discussing the clinical value of an accurate diagnostic assessment within the PDM-2 framework.

METHOD

Albert, a 16-year-old adolescent with a DSM-5 diagnosis of major depressive disorder, was assessed using instruments from various perspectives: the Structured Clinical Interview for DSM-5; the Psychodynamic Chart-Adolescent of the PDM-2, and other clinician-report instruments; and the Shedler-Westen Assessment Procedure for Adolescents and Defense Mechanisms Rating Scale Q-sort, coded by external observers.

RESULTS

Albert's assessment revealed impairments in various mental capacities, especially in regulating self-esteem. He presented a borderline personality organization at a high level and an emerging narcissistic personality syndrome.

CONCLUSIONS

The case discussion showed the importance of providing clinically meaningful assessments to plan for effective treatments in youth populations. Especially, it is necessary to understand the adolescent's unique characteristics in terms of mental and personality functioning and consider the developmental trajectories and adaptation processes that characterize this specific developmental period.

Differences in Psychiatric Comorbidities and Gender Distribution among Three Clusters of Personality Disorders: A Nationwide Population-Based Study

Personality disorders (PDs) are grouped into clusters A, B, and C. However, whether the three clusters of PDs have differences in comorbid mental disorders or gender distribution is still lacking sufficient evidence. We aim to investigate the distribution pattern across the three clusters of PDs with a population-based cohort study. This study used the Taiwan national database between 1995 and 2013 to examine the data of patients with cluster A PDs, cluster B PDs, or cluster C PDs. We compared the differences of psychiatric comorbidities classified in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition across the three clusters of PDs. Moreover, we formed gender subgroups of the three PDs to observe the discrepancy between male and female. Among the 9845 patients, those with cluster A PDs had the highest proportion of neurodevelopmental disorders, schizophrenia and neurocognitive disorders, those with cluster B PDs demonstrated the largest percentage of bipolar disorders, trauma and stressor disorders, feeding and eating disorders, and substance and addictive disorders, and those with cluster C PDs had the greatest proportion of depressive disorders, anxiety disorders, obsessive–compulsive disorders, somatic symptom disorders, and sleep–wake disorders. The gender subgroups revealed significant male predominance in neurodevelopmental disorders and female predominance in sleep–wake disorders across all three clusters of PDs. Our findings support that some psychiatric comorbidities are more prevalent in specified cluster PDs and that gender differences exist across the three clusters of PDs. These results are an important reference for clinicians who are developing services that target real-world patients with PDs.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare

BACKGROUND

The majority of patients with major depressive disorder (MDD) have comorbid mental conditions.

OBJECTIVES

Since most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD).

METHODS

The Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort.

RESULTS

A total of 34,713 patients had MDD as a primary diagnosis over the period 2000-2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes.

CONCLUSIONS

Psychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.

How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations

Adherence to antidepressants is crucial for optimal treatment outcomes when treating depressive disorders. However, poor adherence is common among patients prescribed antidepressants. This targeted review summarizes the main factors associated with poor adherence, interventions that promote antidepressant adherence, pharmacological aspects related to antidepressant adherence, and formulates 10 clinical recommendations to optimize antidepressant adherence. Patient-related factors associated with antidepressant non-adherence include younger age, psychiatric and medical comorbidities, cognitive impairment, and substance use disorders. Prescriber behavior-related factors include neglecting medical and family histories, selecting poorly tolerated antidepressants, or complex antidepressant regimens. Multi-disciplinary interventions targeting both patient and prescriber, aimed at improving antidepressant adherence, include psychoeducation and providing the patient with clear behavioral interventions to prevent/minimize poor adherence. Regarding antidepressant choice, agents with individually tailored tolerability profile should be chosen. Ten clinical recommendations include four points focusing on the patient (therapeutic alliance, adequate history taking, measurement of depressive symptoms, and adverse effects improved access to clinical care), three focusing on prescribing practice (psychoeducation, individually tailored antidepressant choice, simplified regimen), two focusing on mental health services (improved access to mental health care, incentivized adherence promotion and monitoring), and one relating to adherence measurement (adherence measurement with scales and/or therapeutic drug monitoring).

Exploring differences in quality of life in clinical populations of depressed outpatients with and without personality disorders

BACKGROUND

Although depression and personality disorders (PDs) often co-occur, less is known about the impact of PDs on health-related quality of life (HRQOL) in patients with depression. This study explores the differences in HRQOL of depressed patients with and without PD.

METHODS

Baseline data of 397 patients with depression from two randomised controlled trials were used for this analysis. HRQOL was measured with the EuroQol-5D (EQ-5D). Differences were examined between three groups: patients with 1) depression-only, 2) depression and comorbid PD and 3) PD and comorbid depression. The EQ-5D scores of the groups were compared with linear regression.

RESULTS

HRQOL scores were lower in the depression-only group than the depression + PD group, even though depression severity was higher in patients with PD. HRQOL in the PD ± depression group did not differ from the other groups. In addition, no associations were found between the type or severity of PD and HRQOL.

DISCUSSION

These findings could indicate that patients with PD are less affected by the impact of depression on HRQOL. In addition, the EQ-5D might not adequately capture the impact of PD on quality of life. Further research is needed to compare the EQ-5D with quality of life instruments that include more life domains.

LIMITATIONS

Two study samples are combined, and therefore not designed to compare the three groups directly. Generalisation of the results should be done with caution.

CONCLUSION

Depressed patients with PD report higher HRQOL than depression-only patients. Although higher HRQOL, patients with PD report more severe depressions than depressed-only patients.

Antisocial Personality Disorder in Bipolar Disorder: A Systematic Review

Background and Objectives: Bipolar Disorder (BD) is a severe psychiatric disorder that worsens quality of life and functional impairment. Personality disorders (PDs), in particular Cluster B personality, have a high incidence among BD patients and is considered a poor prognostic factor. The study of this co-morbidity represents an important clinical and diagnostic challenge in psychiatry. Particularly, clinical overlap has been shown between antisocial personality disorder (ASPD) and BD that could worsen the course of both disorders. We aimed to detect the frequency of ASPD in bipolar patients with greater accuracy and the impact of ASPD on the clinical course of BD. Materials and Methods: A systematic literature search was conducted in PubMed, Embase, MEDLINE and the Cochrane Library through December 2020 without language or time restriction, according to PRISMA statement guidelines. Results: Initially, 3203 items were identified. After duplicates or irrelevant paper deletion, 17 studies met the inclusion criteria and were included in this review. ASPD was more frequent among BD patients, especially in BD type I. BD patients with ASPD as a comorbidity seemed to have early onset, higher number and more severe affective episodes, higher levels of aggressive and impulsive behaviors, suicidality and poor clinical outcome. ASPD symptoms in BD seem to be associated with a frequent comorbidity with addictive disorders (cocaine and alcohol) and criminal behaviors, probably due to a shared impulsivity core feature. Conclusions: Considering the shared symptoms such as impulsive and dangerous behaviors, in patients with only one disease, misdiagnosis is a common phenomenon due to the overlapping symptoms of ASPD and BD. It may be useful to recognize the co-occurrence of the disorders and better characterize the patient with ASPD and BD evaluating all dysfunctional aspects and their influence on core symptoms.