The effect of comorbid personality disorder on depression outcome after short-term psychotherapy in a randomised clinical trial

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.

Is bouldering-psychotherapy a cost-effective way to treat depression when compared to group cognitive behavioral therapy - results from a randomized controlled trial

BACKGROUND

Bouldering-Psychotherapy (BPT) has proven to effectively reduce depressive symptoms, but evidence on its cost-effectiveness is lacking. Corresponding information is paramount to support health policy decision making on a potential implementation of BPT in routine care.

METHODS

Using data from the German KuS trial BPT was compared with group Cognitive Behavioral Therapy (CBT). Severity of depression symptoms at end of the intervention was operationalized via Montgomery-Asberg Depression Rating Scale (MADRS) and Patient Health Questionnaire (PHQ-9). Adopting a societal perspective, direct medical costs and productivity loss were calculated based on standardized unit costs. To determine incremental cost-effectiveness ratios (ICER) and cost-effectiveness-acceptance curves (CEAC), adjusted mean differences (AMD) in costs (gamma-distributed model) and both effect parameters (Gaussian-distributed model) were obtained from 1000 simultaneous bootstrap replications.

RESULTS

BPT was related to improved effects (AMDs: MADRS -2.58; PHQ-9: - 1.35) at higher costs (AMD: +€ 754). No AMD was significant. ICERs amounted to €288 per MADRS-point and €550 per PHQ-9-point. For both effect parameters about 20% of bootstrap replications indicated dominance of BPT, and about 75% larger effects at higher costs. At hypothetical willingness to pay (WTP) thresholds of €241 (MADRS) and €615 (PHQ-9) per unit of change BPT had a 50% probability of being cost-effective.

CONCLUSION

BPT is a promising alternate treatment strategy which - in absence of established WTP thresholds for improving symptoms of depression - cannot unambiguously be claimed cost-effective. Further studies defining subgroups that particularly benefit from BPT appear paramount to delineate recommendations for an efficient prospective roll-out to routine care.

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.