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Kool M, Van H, Arntz A, Bartak A, Peen J, Dil L, de Boer K, Dekker J. Dosage effects of psychodynamic and schema therapy in people with comorbid depression and personality disorder: four-arm pragmatic randomised controlled trial. Br J Psychiatry 2024; 225:274-281. [PMID: 38602168 DOI: 10.1192/bjp.2024.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
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.
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Affiliation(s)
- Marit Kool
- NPI, Amsterdam, The Netherlands; Research Department, Arkin Mental Healthcare, Amsterdam, The Netherlands; and Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henricus Van
- NPI, Amsterdam, The Netherlands; and Research Department, Arkin Mental Healthcare, Amsterdam, The Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Anna Bartak
- private practice, Amsterdam, The Netherlands
| | - Jaap Peen
- Research Department, Arkin Mental Healthcare, Amsterdam, The Netherlands
| | | | | | - Jack Dekker
- Research Department, Arkin Mental Healthcare, Amsterdam, The Netherlands
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Baljé AE, Greeven A, Deen M, van Giezen AE, Arntz A, Spinhoven P. Group schema therapy versus group cognitive behavioral therapy for patients with social anxiety disorder and comorbid avoidant personality disorder: A randomized controlled trial. J Anxiety Disord 2024; 104:102860. [PMID: 38714138 DOI: 10.1016/j.janxdis.2024.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/15/2024] [Accepted: 03/31/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND Patients with social anxiety (SAD) and comorbid avoidant personality disorder (AVPD) are severely impaired. Group cognitive behavioral therapy (GCBT) is considered an effective treatment for SAD. More knowledge on treatment of SAD with comorbid AVPD is needed. Schema therapy, developed for personality and chronic mental disorders, may be a promising treatment. METHODS We conducted a randomized controlled trial in an outpatient population (n = 154) with both SAD and AVPD. Group Schema Therapy (GST) and GCBT were compared on SAD symptoms (Liebowitz Social Anxiety Scale) and manifestations of AVPD (Avoidant Personality Disorder Severity Index). RESULTS Intention-to-treat analysis showed no significant differences between treatments at 3 months post-treatment and one-year follow-up. Both modalities led to significant and substantial improvements. No significant between-differences were found in depressive symptoms (Inventory of Depressive Symptoms) and quality of life (World Health Organization Quality of Life-BREF). Per-protocol analysis showed similar outcomes and no significant differences in recovery from SAD and AVPD. Significantly more patients completed GST. CONCLUSION GST and GCBT are valuable treatments for SAD with comorbid AVPD. The higher treatment retention in ST indicates ST is more acceptable than GCBT. Future studies should focus on enhancing treatment effects and improving retention to GCBT.
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Affiliation(s)
- Astrid E Baljé
- Department of Anxiety Disorders/Psyq, The Hague, the Netherlands; Institute of Psychology/Leiden University, Leiden, the Netherlands.
| | - Anja Greeven
- Department of Anxiety Disorders/Psyq, The Hague, the Netherlands; Institute of Psychology/Leiden University, Leiden, the Netherlands.
| | - Mathijs Deen
- Institute of Psychology/Leiden University, Leiden, the Netherlands; Parnassia Group Academy/Parnassia Psychiatric Institute, The Hague, the Netherlands.
| | - Anne E van Giezen
- Department of Anxiety Disorders/Psyq, The Hague, the Netherlands; Institute of Psychology/Leiden University, Leiden, the Netherlands.
| | - Arnoud Arntz
- Department of Clinical Psychology/University of Amsterdam, Amsterdam, the Netherlands.
| | - Philip Spinhoven
- Department of Anxiety Disorders/Psyq, The Hague, the Netherlands; Institute of Psychology/Leiden University, Leiden, the Netherlands.
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Vittengl JR, Jarrett RB, Ro E, Clark LA. How can the DSM-5 alternative model of personality disorders advance understanding of depression? J Affect Disord 2023; 320:254-262. [PMID: 36191644 DOI: 10.1016/j.jad.2022.09.146] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | | | - Eunyoe Ro
- Southern Illinois University Edwardsville, USA
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Brown RJ, Burton AL, Abbott MJ. The relationship between distress tolerance and symptoms of depression: Validation of the Distress Tolerance Scale (DTS) and short-form (DTS-SF). J Clin Psychol 2022; 78:2609-2630. [PMID: 35510827 PMCID: PMC9790670 DOI: 10.1002/jclp.23370] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/13/2022] [Accepted: 04/20/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Distress tolerance (DT) has been found to be implicated in the development and maintenance of depressive symptomatology and various other significant psychological conditions. As such, it is critical to have measures of DT that are effective and easy to administer. This study aimed to examine the factor structure, psychometric properties, and clinical utility of the Distress Tolerance Scale (DTS) and the short-form version, the Distress Tolerance Scale Short-form (DTS-SF), in a large population of individuals with varying levels of self-reported depressive symptoms. METHOD A total of 959 participants completed an online battery of questionnaires which included an assessment of depressive symptoms as well as the DTS and related measures. Results: Confirmatory factor analyses validated the four-factor structure of the DTS and the one-factor structure of the DTS-SF. Good construct validity and good internal consistency were observed across both the DTS and DTS-SF. CONCLUSION Overall, this paper provides new evidence for the validity, reliability and discriminative ability of the DTS and the brief version of the questionnaire, the DTS-SF.
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Affiliation(s)
- Ruby J. Brown
- Clinical Psychology Unit, School of PsychologyThe University of SydneySydneyNew South WalesAustralia
| | - Amy L. Burton
- Clinical Psychology Unit, School of PsychologyThe University of SydneySydneyNew South WalesAustralia,Discipline of Clinical Psychology, Graduate School of HealthUniversity of Technology SydneySydneyAustralia
| | - Maree J. Abbott
- Clinical Psychology Unit, School of PsychologyThe University of SydneySydneyNew South WalesAustralia
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Marčinko D, Jakšić N, Šimunović Filipčić I, Mustač F. Contemporary psychological perspectives of personality disorders. Curr Opin Psychiatry 2021; 34:497-502. [PMID: 34292181 DOI: 10.1097/yco.0000000000000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the recent literature on contemporary psychological perspectives of personality disorders, including novel psychotherapeutic interventions aimed at these vulnerable individuals. RECENT FINDINGS Among the various psychological theories and models of personality disorders, still the most popular and researched are psychodynamic, cognitive and interpersonal perspectives. More specifically, object relations theory, cognitive schema conceptualization and interpersonal circumplex model have produced the most empirical investigations of personality disorders in recent years. Latest work has suggested that all three perspectives have contributed to and are compatible with the dimensional personality disorders framework in DSM-5-AMPD and ICD-11 (including level of personality functioning and personality traits). These models have yielded specific psychological treatments of personality disorders; although most psychotherapies have been constructed for patients with borderline personality disorder (BPD), there is an increasing number of treatment modalities aimed at individuals with other forms of personality disorder, such as those with narcissistic or antisocial traits/disorders. More research into their effectiveness and long-term benefits is necessary. SUMMARY Novel research keeps updating our knowledge on the cause, manifestations and psychological treatments of personality disorders, particularly from psychodynamic, cognitive and interpersonal perspectives.
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Affiliation(s)
- Darko Marčinko
- Department of Psychiatry and Psychological Medicine, University Hospital Center Zagreb
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nenad Jakšić
- Department of Psychiatry and Psychological Medicine, University Hospital Center Zagreb
| | | | - Filip Mustač
- Department of Psychiatry and Psychological Medicine, University Hospital Center Zagreb
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Kan K, Lokkerbol J, Jörg F, Visser E, Schoevers RA, Feenstra TL. Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare. PHARMACOECONOMICS 2021; 39:721-730. [PMID: 33723804 PMCID: PMC8166711 DOI: 10.1007/s40273-021-01012-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Kaying Kan
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research Center, Interdisciplinary Centre for Psychopathology and Emotion Regulation, PO Box 30001, Hospital zip code CC72, 9700 RB, Groningen, The Netherlands.
| | - Joran Lokkerbol
- Centre of Economic Evaluation and Machine Learning, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
| | - Frederike Jörg
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research Center, Interdisciplinary Centre for Psychopathology and Emotion Regulation, PO Box 30001, Hospital zip code CC72, 9700 RB, Groningen, The Netherlands
- GGZ Friesland, Research Department, Leeuwarden, The Netherlands
| | - Ellen Visser
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research Center, Groningen, The Netherlands
| | - Robert A Schoevers
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Interdisciplinary Centre for Psychopathology and Emotion Regulation, Groningen, The Netherlands
| | - Talitha L Feenstra
- University of Groningen, Department of Science and Engineering, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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