Examining the utility of a temperament model for modelling non-melancholic depression

The Spielberger trait anxiety inventory measures more than anxiety

Objective

Researchers tried to explain the overlap between anxiety and depression by suggesting that some items of self-administered questionnaires were badly selected and that both constructs should rather be considered as multidimensional. Thus, we hypothesise that the Spielberger trait anxiety inventory (TAI) includes items related to depression.

Method

A non-clinical sample of 193 subjects filled out the TAI and the Hospitalised Anxiety–Depression Scale. Factors were postulated on the basis of item content and submitted to confirmatory factor analysis (CFA).

Results

We found five factors: a 10-item anxiety factor containing three factors, a four-item unsuccessfulness factor correlated with the HADS anhedonia factor, and a six-item happiness factor.

Conclusion

The TAI scale encompasses measures of anxiety, depression and well-being. Consequently, the overlap with other measures of depression may result from item selection. This work awaits replication in independent normal and pathological samples.

How to choose an antidepressant medication

OBJECTIVE

We consider how to choose an antidepressant (AD) medication for the treatment of clinical depression.

METHOD

A narrative review was undertaken addressing antidepressant 'choice' considering a range of parameters either weighted by patients and clinicians or suggested in the scientific literature. Findings were synthesised and incorporated with clinical experience into a model to assist AD choice.

RESULTS

Efficacy studies comparing ADs offer indicative guidance, while precision psychiatry prediction based on genetics, developmental trauma, neuroimaging, behavioural and cognitive biomarkers, currently has limited clinical utility. Our model offers guidance for AD choice by assessing first for the presence of a depressive subtype or symptom cluster and matching choice of AD class accordingly. Failing this, an AD can be chosen based on depression severity. Within-class choice can be determined by reference to personality style, patient preference, medical or psychiatric comorbidities and side-effect profile.

CONCLUSION

Clarification of AD choice would occur if medications are trialled in specific depressive subtypes rather than using the generic diagnosis of major depressive disorder (MDD). Such 'top-down' methods could be enhanced by 'bottom-up' studies to classify individuals according to symptom clusters and biomarkers with AD efficacy tested in these categories. Both methods could be utilised for personalised AD choice.

Temperament, personality, and treatment outcome in major depression: a 6-month preliminary prospective study

BACKGROUND

Despite available treatments, major depression is a highly heterogeneous disorder, which leads to problems in classification and treatment specificity. Previous studies have reported that personality traits predict and influence the course and treatment response of depression. The Temperament and Personality Questionnaire (T&P) assesses eight major constructs of personality traits observed in those who develop depression. The aim of this study was to investigate the influence of T&P's eight constructs on the treatment outcome of depressed patients.

PATIENTS AND METHODS

A preliminary 6-month prospective study was conducted with a sample of 51 adult patients with a diagnosis of major depressive disorder (MDD) without remarkable psychomotor disturbance using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. All patients received comprehensive assessment including the T&P at baseline. We compared each T&P construct score between patients who achieved remission and those who did not achieve remission after 6 months of treatment for depression using both subjective and objective measures. All 51 (100%) patients received the 6-month follow-up assessment.

RESULTS

This study demonstrated that higher scores on T&P personal reserve predicted poorer treatment outcome in patients with MDD. Higher levels of personal reserve, rejection sensitivity, and self-criticism correlated with higher levels of depression. Higher levels of rejection sensitivity and self-criticism were associated with non-remitters; however, when we controlled for baseline depression severity, this relationship did not show significance.

CONCLUSION

Although the results are preliminary, this study suggests that high scores on T&P personal reserve predict poorer treatment outcome and T&P rejection sensitivity and self-criticism correlate with the severity of depression. Longer follow-up studies with large sample sizes are required to improve the understanding of these relationships.

The reliability and validity of the Japanese version of the Temperament and Personality Questionnaire for patients with non-melancholic depression

BACKGROUND

Parker et al. (2006) proposed a new approach to classify specific sub-types of non-melancholic depression caused by various stress factors and premorbid personality styles: the Temperament and Personality Questionnaire (T&P). The current study aim was to develop the Japanese version of the T&P and evaluate its reliability and validity.

METHODS

We studied 114 patients with non-melancholic depression. Reliability was assessed using the test-retest method. Convergent validity of the T&P was compared with the clinician ratings of each patient for the eight personality traits. We also assessed the impact of depressive state on the T&P.

RESULTS

The test-retest intraclass correlation coefficients among eight constructs of the T&P ranged from 0.77 to 0.89, indicating good-to-excellent reliability. Anxious Worrying (rho=0.29), Perfectionism (rho=0.17), Personal Reserve (rho=0.18), Irritability (rho=0.38), and Social Avoidance (rho=0.32) showed adequate levels of convergent validity; Rejection Sensitivity (rho=0.16), Self-criticism (rho=-0.02), and Self-focus (rho=0.07) showed relatively weak convergent validity. Perfectionism (rho=-0.06), Social Avoidance (rho=0.17), Anxious Worrying (rho=0.40), Personal Reserve (rho=0.30), Irritability (rho=0.28), Rejection Sensitivity (rho=0.35), Self-criticism (rho=0.49), and Self-focus (rho=0.24) showed minimal sensitivity to mood state effects.

LIMITATIONS

Only one site was used. While a Likert scale was used, the clinician-rated personality trait measure had not been validated.

CONCLUSIONS

The J-T&P is a reliable and valid measure for assessing temperament and personality in Japanese patients with non-melancholic depression.

Translation and cross-cultural adaptation of the Temperament & Personality Questionnaire into Brazilian Portuguese

Introduction: The Temperament & Personality Questionnaire (T&P) is a self-report instrument designed to evaluate personality styles overrepresented in patients with depression. This report briefly describes the translation and adaptation of the T&P into Brazilian Portuguese.Methods: The procedures, which included 10 steps, followed guidelines for the adaptation of self-report instruments defined by the International Society For Pharmacoeconomics and Outcomes Research (ISPOR) Task Force for Translation and Cultural Adaptation.Results: The author of the original T&P questionnaire authorized and participated in the translation conducted by the authors and independent native speakers. Evaluation of the translated questionnaire indicated that only minor adjustments were required in the Portuguese version.Conclusions: The Brazilian version of T&P, translated and adapted following a rigid standardized process, is available for use free of charge and may be especially useful in pursuing links between personality styles and depressive conditions.

The utility of the DSM nosology of mood disorders

Mood disorders have proven to be a fertile ground for nosological debate. Numerous attempts to classify them phenomenologically have been undertaken, but it is doubtful whether there will ever be widespread agreement until more definitive biological markers emerge. Although some individual classifications may have limited utility, the DSM nosology appears to incorporate most, if not all, of the mood disorders encountered in clinical practice. Indeed, with minor modifications, the DSM and ICD systems could be amalgamated to ensure universal agreement in our conceptualization of mood disorders.

Identifying "paradigm failures" contributing to treatment-resistant depression

BACKGROUND

"Treatment resistant depression" is likely to emerge from a number of factors, including application of the wrong diagnostic and treatment models.

METHOD

Current paradigms for managing both depression and treatment resistant depression are considered. We then examine the prevalence of a set of paradigm failures that appeared to contribute to treatment resistant depression in outpatients of a tertiary referral Mood Disorders Unit.

RESULTS

Six illustrative paradigm failures are described and their frequencies within the clinical sample reported. Identified paradigm failures were diagnosing and/or managing a non-melancholic condition as if it were melancholic depression, failure to diagnose and manage bipolar disorder, psychotic depression or melancholic depression, misdiagnosing secondary depression and failure to identify organic determinants.

CONCLUSION

We suggest that the identification of such "paradigm failures"--and of others that can be assumed to operate--has the potential to enrich the assessment and management of depressed patients, and reduce the prevalence of treatment resistance.

Progressing a spectrum model for defining non-melancholic depression

OBJECTIVE

To further develop a 'spectrum model' for non-melancholic disorders that encompasses underlying personality styles and clinical patterning.

METHOD

In a sample of patients with non-melancholic depression, we studied four personality constructs influencing risk to depression, assessing associational strength and specificity between personality scores and symptom and coping response patterns.

RESULTS

Analyses refined four personality dimensions (anxious worrying, irritability, social inhibition, and self-centredness) for testing the model. For all dimensions, personality style was specifically linked with a mirroring 'coping' response. Quantification of specific links allowed development of a spectrum model for the non-melancholic depressive disorders in which underpinning personality style showed some specific links with the clinical 'pattern' of symptoms and coping repertoires.

CONCLUSION

The model has the capacity to assist clinical assessment, identify aetiological personality influences and allow specific treatment effects for the heterogeneous non-melancholic depressive disorders to be determined.

Modern diagnostic concepts of the affective disorders

OBJECTIVE

To review critically alternative models of depression.

METHOD

Contrasting historical models are noted and some results of a study overviewing a temperament-based model for the non-melancholic disorders are presented.

RESULTS

Limitations to all models are considered.

CONCLUSION

As depression can present as a mood state, a syndrome, a disorder and as a disease, it is unwise to assume that a single model will suffice. A pure temperament diathesis model of non-melancholic depression is unlikely to be sufficient and would benefit from testing of additional personality constructs.

Properties of the temperament and character inventory in a Chinese sample

OBJECTIVE

To determine the influence of language and culture on the temperament and character (TCI) measure in a Chinese sample.

METHOD

We translated the TCI into Mandarin and had a non-psychiatric sample of Malaysian Chinese subjects complete the TCI at baseline and at a 1-month retest, with subsets completing English or Mandarin versions alternatively or on both occasions. Analyses examine the TCI factor structure and any impact of language and culture on TCI scoring.

RESULTS

We identified age, gender, occupation and language effects on TCI scale scores. Test-retest reliability was high and not compromised by language. Scale internal consistency was also high. Factor analyses of separate sets of TCI scales corresponded strongly to the structure identified in the TCI development studies.

CONCLUSION

The results indicate that TCI is likely to have applicability to Chinese subjects, and argue against properties being constrained by the English language or by western culture.

Influence of symptom attribution on reporting depression and recourse to treatment

OBJECTIVE

A Bristol general practice study demonstrated the extent to which patients' attribution style influences psychological diagnostic case rates. We pursue this issue and several implications in this Australian study.

METHOD

A survey was undertaken of six general practices in Sydney, and involving more than 900 routine general practice patients. Subjects completed questionnaires assessing personality styles observed in those with clinical depression, attributional response (i.e. 'psychological', 'somatic' and 'normalizing') to three somatic cues, state depression, lifetime depression, use of antidepressant medication, and recourse to professional help.

RESULTS

Responders attributing psychological explanations to the somatic cues had the highest state and lifetime depression rates, viewed their depression as more likely to be a 'disorder' and were more likely to have received treatment for depression. Those with a personality style of 'anxious worrying' reported increased morbidity across all depression variables, but personality did not make attributional style redundant in multivariate analyses.

CONCLUSIONS

Interpreting somatic cues in a psychological way is associated with higher rates of reported depression and increased recourse to depression treatment. Thus, a normalizing response style may make depression recognition and detection difficult. Study findings challenge the capacity of self-report measures to detect depression, especially in general practice settings.

Clinical and personality correlates of a new measure of depression: a general practice study

OBJECTIVE

There is a need for a brief, efficient depression screening measure for general practice settings, particularly for identifying those who are at high risk of depression. We therefore test the usefulness of a measure developed in a sample of medically ill hospitalized patients.

METHOD

More than 600 patients attending six Sydney general practices completed the Depression in the Medically Ill (DMI-10) measure, in conjunction with sociodemographic, depression history and personality profile measures. The impacts of sociodemographic, personality and lifetime depression variables on DMI-10 scores (and identified 'cases') were examined as a measure of its usefulness.

RESULTS

Gender did not influence depression scores, while there were slight associations between DMI-10 scores and age, marital and occupational status. Higher scores were returned by those with more severe, lengthier and perceived stressful medical illnesses. Using a predetermined cut-off score, 36% rated as putative 'cases', a prevalence almost identical to our general hospital study. 'Cases' were distinctly more likely to have had previous depressive episodes, to have sought help for such episodes and to have received antidepressant medication. They also scored higher on measures of anxious (anxious worrying and irritability) and self-critical ('depressive personality') personality styles.

CONCLUSIONS

The DMI-10 appears useful as a brief and acceptable screen for depression in a general practice setting, both identifying those who are likely to be currently depressed and those with a background of previous depression.