Treatment characteristics and outcome of depression among depressed adolescent outpatients with and without comorbid Axis II disorders

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.

Systematic Review and Meta-analysis: Outcomes of Routine Specialist Mental Health Care for Young People With Depression and/or Anxiety

OBJECTIVE

Depression and anxiety are the most prevalent mental health problems in youth, yet almost nothing is known about what outcomes are to be expected at the individual level following routine treatment. This paper sets out to address this gap by undertaking a systematic review of outcomes following treatment as usual (TAU) with a particular focus on individual-level outcomes.

METHOD

MEDLINE, Embase and PsycInfo were searched for articles published between 1980 and January 2019 that assessed TAU outcomes for youth depression and anxiety accessing specialist mental health care. Meta-analysis considered change at both group-level pre-post effect size (ES) and individual-level recovery, reliable change, and reliable recovery. Temporal analysis considered stability of primary and secondary outcomes over time. Subgroup analysis considered the moderating effect of informant; presenting problem; study design; study year; mean age of youth; use of medication; intervention dosage and type of treatment offered on outcomes. A protocol was preregistered on PROSPERO (CRD42017063914).

RESULTS

Initial screening of 6,350 publications resulted in 38 that met the inclusion criteria, and that were subsequently included in meta-analyses. This resulted in a final full pooled sample of 11,739 young people (61% of whom were female, mean age 13.8 years). The pre-post ES (Hedges' g) at first/final outcome (13/26 weeks) was -0.74/-0.87. The individual-level change on measures of self-report was 38% reliable improvement, 44% no reliable change, and 6% reliable deterioration. Outcomes varied according to moderators, informant, problem type and dosage.

CONCLUSION

Poor data quantity and quality are limitations, but this is the first study that indicates likely rates of reliable improvement for those accessing TAU. We propose the need for improved reporting of both individual-level metrics and details of TAU to enable greater understanding of likely current outcomes from routine care for youths with depression and anxiety in order to allow the potential for further improvement of impact.

Outcome of depressive mood disorder among adolescent outpatients in an eight-year follow-up

OBJECTIVES

This study investigated the eight-year course and outcomes of depressive mood disorders and the key outcome predictors among adolescent outpatients.

METHODS

Depressive adolescent outpatients (N = 148) in a naturalistic clinical setting were assessed at baseline, six months, 12 months and eight years using diagnostic and self-report instruments. Baseline predictors covered selected sociodemographic, clinical and treatment-related characteristics. The outcomes were time to recovery, recurrence, time spent being ill and longitudinal latent profiles of depressive symptoms.

RESULTS

The recovery rate from any depressive mood disorder was 73% at two years, 91% at five years and 94% by the end of the eight-year follow-up. Two thirds (67%) of the subjects presented at least one recurrence and 57% of them were depressed for 25% or more of the follow-up period. At the eight-year follow-up, 36% had a mood disorder, 48% suffered from anxiety and 26% had a personality disorder. Less severe depression at baseline predicted a shorter time to recovery, whereas recurrence was predicted by a younger age. A latent profile with initially moderate-level depressive symptoms but a poor distal outcome was associated with being female and borderline personality disorder.

LIMITATIONS

The female preponderance in the sample warrants caution when interpreting sex differences in the findings.

CONCLUSIONS

Although the depression outcome for some adolescents making the transition to young adulthood is promising, many of them experience long, even chronic episodes, and recurrences are common. Personality-disorder characteristics appeared to be significant outcome predictors in this adolescent population.

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

BACKGROUND

Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce.

AIMS

To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive-behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression.

METHOD

This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com).

RESULTS

Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77-1.31 and d = 1.36, 95% CI 0.97-1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87-1.43 and d = 2.12, 95% CI 1.65-2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality.

CONCLUSIONS

CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but - given remaining levels of depression in patients with personality disorder - they are probably inadequate for large numbers of patients with this comorbidity.

DECLARATION OF INTEREST

None.

The impact of borderline personality disorder and sub-threshold borderline personality disorder on the course of self-reported and clinician-rated depression in self-harming adolescents

BACKGROUND

Studies on adults suggest that the presence of comorbid depression and Borderline Personality Disorder (BPD) is associated with an elevated risk of self-harming behaviours and that self-harming behaviours, when present, will have higher severity. This comorbidity, furthermore, complicates clinical assessments, which may be an obstacle to early identification and proper intervention. Adolescents who self-harm frequently report high levels of depressive symptoms, but this is often not reflected in the clinicians' assessment. BPD is still a controversial diagnosis in young people, and less is known about the clinical significance of comorbid BPD in adolescent populations.The purpose of the present study was to examine the impact of BPD on the assessment and course of self-reported and clinician-rated depression in self-harming adolescents before and after a treatment period of 19 weeks. We hypothesized that, compared to adolescents without BPD, adolescents with BPD would self-report higher levels of depression at baseline, and that they would have less reduction in depressive symptoms.

METHODS

A total of 39 adolescents with depressive disorders and BPD-traits participating in a randomised controlled trial on treatment of self-harm with Dialectical Behaviour Therapy adapted for Adolescents or enhanced usual care were included. Adolescents with full-syndrome BPD (n = 10) were compared with adolescents with sub-threshold BPD (n = 29) with respect to their self-reported and clinician-rated depressive symptoms, suicidal ideation and global level of functioning at baseline, and after 19 weeks of treatment (end of trial period).

RESULTS

At baseline, adolescents with full-syndrome BPD self-reported significantly higher levels of depressive symptoms and suicidal ideation compared to adolescents with sub-threshold BPD, whereas the two groups were rated as equally depressed by the clinicians. At trial completion, all participants had a significant reduction in suicidal ideation, however, adolescents with BPD had a poorer treatment outcome in terms of significantly higher levels of clinician-rated and self-reported depressive symptoms and significantly lower levels of global functioning. At baseline as well as at trial completion, self-reported and clinician-rated levels of depressive symptoms were not significantly correlated in adolescents with BPD. In a multiple linear regression analysis, a diagnosis of BPD and a high baseline level of clinician-rated depressive symptoms predicted higher levels of depressive symptoms at trial completion, whereas receiving Dialectical Behaviour Therapy predicted lower levels of depressive symptoms.

CONCLUSION

Our findings suggest that a diagnosis of BPD may have a strong impact on the assessment and course of depressive symptoms in self-harming adolescents. Although rated as equally depressed, adolescents with BPD self-reported significantly higher levels of depressive symptoms and suicidal ideation at baseline, and showed a poorer outcome in terms of higher levels of depressive symptoms and lower levels of global functioning at trial completion compared to adolescents with sub-threshold BPD. Our findings suggest that receiving Dialectical Behaviour Therapy could lead to a greater reduction in depressive symptoms, although firm conclusions cannot be drawn given the limited sample size.Clinicians should be aware of the possibility of underestimating the severity of depression in the context of emotional and behavioral dysregulation. Providing BPD specific treatments seems to be important to achieve sufficient treatment response with regard to depressive symptoms in adolescents with BPD-traits.

TRIAL REGISTRATION

Treatment for Adolescents With Deliberate Self Harm; NCT00675129, registered May 2008.

Defense Mechanisms in Adolescence as Predictors of Adult Personality Disorders

Our study examines whether defense styles and separate defenses in depressed adolescent outpatients predict adult personality disorders (PDs). We obtained data from consecutive adolescent outpatients who participated in the Adolescent Depression Study at baseline and at the 8-year follow-up (N = 140). Defense styles were divided into mature, neurotic, image-distorting, and immature and a secondary set of analyses were made with separate defenses as predictors of a PD diagnosis. Neurotic, image-distorting, and immature defense styles in adolescence were associated with adulthood PDs. Neurotic defense style associated with cluster B diagnosis and image-distorting defense style associated with cluster A diagnosis. Separate defenses of displacement, isolation, and reaction formation were independent predictors of adult PD diagnosis even after adjusting for PD diagnosis in adolescence. Defense styles and separate defenses predict later PDs and could be used in the focusing of treatment interventions for adolescents.

The influence of comorbid personality disorders on recovery from depression

PURPOSE

The impact of personality disorders on the treatment of and recovery from depression is still a controversial topic. The aim of this paper is to provide more information on what has led to this disagreement.

MATERIALS AND METHODS

Clinician-rated Hamilton Depression Rating Scale (HAMD) scores were assessed among 82 depressed outpatients who were receiving a routine treatment combination of antidepressant medication and psychosocial intervention. The participants were followed up over five visits at 3-month intervals: at the baseline, at 3, 6, 9 and 12 months. Personality disorders were assessed after the last visit in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. These repeated measures were used to explore the impact of personality disorders on HAMD scores by using a linear mixed model.

RESULTS

Among the four personality clusters that were used (A, B, C, and mixed), only those in cluster B and in the mixed cluster were found to take significantly longer than those without personality disorders, for reduction in HAMD scores over the course of treatment.

CONCLUSION

In this study, the impact of personality disorders on treatment outcomes varied with the way that the personality disorder variables were described and used as independent predictors. This is because the outcomes were influenced by the impact weight of each personality disorder, even within the same cluster.