Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

BACKGROUND: Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs). METHOD: An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use. RESULTS: Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another. CONCLUSIONS: DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders.

BACKGROUND: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. METHOD: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. RESULTS: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. CONCLUSIONS: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

Interpersonal psychotherapy. Current status.

Interpersonal psychotherapy (IPT), a time-limited treatment for major depression, was developed, defined in a manual, and tested in randomized clinical trials by the late Gerald L. Klerman, MD, and collaborators. It has subsequently been modified for different age groups and types of mood and nonmood disorders and for use as a long-term treatment. Having begun as a research intervention, IPT has yet to be well disseminated among clinicians or in residency training programs. The publication of efficacy data, the recent appearance of two practice guidelines that include IPT among treatments for depression, and the interest in defined treatments for managed care have led to increasing requests for information and training.

Maintenance therapy for chronic depression. A controlled clinical trial of desipramine.

BACKGROUND: Previous studies have shown the efficacy of antidepressants in the treatment of chronic depression. We report the results of a long-term study comparing desipramine hydrochloride and placebo for maintenance therapy of remitted patients with chronic depression. METHODS: Outpatients who met DSM-III-R diagnostic criteria for "pure" dysthymia (n = 51), dysthymia with current major depression ("double depression") (n = 64), or chronic major depression (n = 14) were treated on an open basis with desipramine. Full and partial remitters after 10 weeks entered a continuation phase of open treatment with desipramine for 16 weeks. Remitted patients then were randomized to continue desipramine treatment or tapered to placebo treatment for a maintenance phase of up to 2 years. Relapse rates and time to relapse during maintenance therapy were compared between the two treatment groups. RESULTS: Acute-phase treatment results did not differ significantly according to chronic depression subtype. Remission persisted with a high degree of stability during the continuation phase. Relapse rates during the maintenance phase were 52% for the placebo group and 11% for the active desipramine group (chi 2 = 8.1, P = .004). Most placebo relapses occurred during the first 6 months of maintenance therapy. Active medication was significantly more effective than placebo in that subgroup entering the maintenance phase in full remission and in those patients who fulfilled criteria for a diagnosis of pure dysthymia or double depression on entry to the study. CONCLUSION: Long-term maintenance treatment with desipramine appeared to be effective in the prevention or postponement of relapse of depression in patients who responded to desipramine during the acute and continuation phases.

Treatment of depressive symptoms in human immunodeficiency virus-positive patients.

BACKGROUND: This randomized clinical trial compared 16-week interventions with interpersonal psychotherapy, cognitive behavioral therapy, supportive psychotherapy, and supportive psychotherapy with imipramine for human immunodeficiency virus (HIV)-positive patients with depressive symptoms. METHODS: Subjects (N = 101; 85 male, 16 female) with known HIV seropositivity for at least 6 months were randomized to 16 weeks of treatment. Inclusion criteria were 24-item Hamilton Depression Rating Scale score of 15 or higher, clinical judgment of depression, and physical health sufficient to attend outpatient sessions. Therapists were trained in manualized therapies specific for HIV-positive patients. Treatment adherence was monitored. RESULTS: Subjects randomized to interpersonal psychotherapy (n = 24) and supportive psychotherapy with imipramine (n = 26) had significantly greater improvement on depressive measures than those receiving supportive psychotherapy (n = 24) or cognitive behavioral therapy (n = 27). Similar results appeared in the completer subsample. CONCLUSIONS: Depressive symptoms appear treatable in HIV-positive patients. Interpersonal psychotherapy may have particular advantages as a psychotherapy for patients who have experienced the significant life events of HIV infection.

Psychotherapy of dysthymia.

OBJECTIVE: The author reviews empirical research on the psychotherapy of dysthymia. Dysthymia, a prevalent mood disorder, has been shown frequently to respond to antidepressant medication. The need for a treatment for dysthymic subjects unable or unwilling to take, or unresponsive to, medication still remains. METHODS: Studies were located by computerized search and the author's knowledge of the literature. All reports of studies on psychotherapy outcome for dysthymic patients, except studies of late-life chronic major depression, were included. RESULTS: Psychotherapy research on dysthymia has been confined to small, usually uncontrolled studies with varying methods and limited follow-up. Cognitive approaches have been most frequently studied; the results have not been dramatic but do suggest that some dysthymic patients respond to brief cognitive therapies. Preliminary results of an ongoing study of interpersonal psychotherapy are promising. CONCLUSIONS: Given the public health importance of dysthymia and the availability of treatments, the time is ripe for clinical trials of antidysthymic psychotherapy. The author proposes the following guidelines for such trials: time-limited, manual-based psychotherapy, interpersonal focus, serial design, continuation and maintenance treatment, combined treatments, and follow-up assessments.

A case report of mania and congenital deafness.

The authors report treatment of an initial manic episode in a congenitally deaf teenager. It appears that bipolar illness in the deaf is rare and that integrating handicapped patients into a general psychiatric setting may prevent regression.

Open trial of interpersonal psychotherapy for the treatment of social phobia.

OBJECTIVE: Interpersonal psychotherapy is a time-limited treatment initially developed to treat depression. It has not been studied for the treatment of anxiety disorders. METHOD: Interpersonal psychotherapy was modified and tested in a 14-week, open trial of nine patients with DSM-IV social phobia. RESULTS: At termination, seven (78%) were independently rated as much or very much improved on overall social phobia symptoms. Nearly all clinician ratings and self-ratings of social phobia symptoms significantly improved. Changes approximated those of established treatments for social phobia. CONCLUSIONS: Interpersonal psychotherapy may have efficacy for the treatment of social phobia. Further study in a comparison trial is warranted.

An empirical study of defense mechanisms in dysthymia.

OBJECTIVE: The psychodynamic approach to understanding dysthymia has rarely been empirically tested. In this pilot study the Defense Mechanism Rating Scales were used to examine psychodynamic data from patients with dysthymia and patients with panic disorder in order to test the hypotheses that 1) dysthymic patients would be similar to panic patients in endorsing primarily lower-maturity defense mechanisms, 2) dysthymic patients would use a distinct pattern of defense mechanisms, different from that of panic patients, and 3) dysthymic patients would endorse more frequently than panic patients four individual defenses that tend to handle anger and low self-esteem poorly: devaluation, passive aggression, projection, and hypochondriasis. METHOD: Twenty-two subjects meeting the DSM-III-R criteria for primary early-onset dysthymia and 22 subjects meeting the DSM-III-R criteria for primary panic disorder were interviewed on videotape and rated on the Defense Mechanism Rating Scales. RESULTS: The dysthymic subjects scored significantly higher on narcissistic, disavowal, and action defense levels and on the four individual defenses of devaluation, projection, passive aggression, and hypochondriasis, as predicted, as well as on two additional defenses, acting out and projective identification. Both groups tended to use lower-maturity defense mechanisms. CONCLUSIONS: The defense mechanism profile identified for dysthymia differs from that for panic disorder and supports particular psychodynamic hypotheses about chronic depression. It could be useful in devising treatment strategies and as a measure of treatment efficacy.

Cardiovascular morbidity in high-risk patients during ECT.

OBJECTIVE: Cardiovascular events are the principal cause of medical morbidity in patients receiving ECT. To assess the risks of ECT for individuals with preexisting cardiovascular disease, the authors examined medical complications in older patients treated with ECT during a 1-year period. METHOD: A case-control design was used in a review of the charts of 80 consecutive patients who received ECT from August 1990 to August 1991. On the basis of accepted clinical criteria, patients over 50 years of age were divided into two groups: one at increased risk for cardiac complications (N = 26) and one at standard cardiac risk (N = 27). Outcome was measured with a scale designed to assess clinically relevant medical complications. RESULTS: The risk group was older and had received more medical consultations before ECT than the nonrisk group. Although patients in the risk group were more likely to develop minor complications during ECT, they did not differ significantly from the comparison group in the rate of major complications. No patients died or sustained permanent cardiac morbidity during ECT. CONCLUSIONS: In contrast to a similar study at the same site 15 years earlier, the current study found ECT to be relatively safe in an unselected study group of elderly patients with preexisting cardiac risk factors. The findings underscore the advances in ECT technique over the past 15 years and the importance of identifying and carefully managing patients with cardiac risk factors before and during ECT.

Sexual functioning in chronically depressed patients treated with SSRI antidepressants: a pilot study.

OBJECTIVE: This prospective study assessed changes in depression and sexual functioning in chronically depressed men and women during treatment with selective serotonin reuptake inhibitors (SSRIs). METHOD: Twenty-five subjects (14 women, 11 men) with DSM-III-R dysthymia, chronic major depression, or double depression were administered the Arizona Sexual Experience Scale and the Hamilton Depression Rating Scale before and after 6 weeks of treatment with sertraline or paroxetine. RESULTS: As measured by scores on the Arizona Sexual Experience Scale, desire, psychological arousal, and overall sexual functioning significantly improved in women; orgasm delay, orgasm satisfaction, and overall sexual functioning significantly worsened in men. CONCLUSIONS: This study suggests that after SSRI treatment, difficulties with desire and psychological arousal in depressed women tend to remit, whereas in men orgasmic dysfunction appears to be a side effect to medication.

Individual psychotherapies for depressed HIV-positive patients.

OBJECTIVE: The authors present preliminary data from two treatment modalities of a randomized clinical trial in which they compared 16-week interventions of interpersonal psychotherapy to supportive psychotherapy. METHOD: HIV-positive patients who were not acutely medically ill and had scores of 15 or higher on the Hamilton Depression Rating Scale were randomly assigned to one of four treatment modalities. They were assessed by the Hamilton scale and Beck Depression Inventory at 8 and 16 weeks. Most subjects who underwent either interpersonal psychotherapy (N = 16) or supportive psychotherapy (N = 16) were male, gay or bisexual, white, and college educated. RESULTS: Results of last-observation-carried-forward and completer analyses showed that scores on the Hamilton scale and Beck Depression Inventory decreased significantly for both treatments. Differential improvement for interpersonal psychotherapy appeared by midtreatment (week 8) and persisted at termination. CONCLUSIONS: This is the first controlled study of individual psychotherapies for depressed HIV-positive patients. Results suggest that a specific antidepressant psychotherapy, interpersonal psychotherapy, has advantages over a supportive therapy.

The treatment of chronic depression, part 1: study design and rationale for evaluating the comparative efficacy of sertraline and imipramine as acute, crossover, continuation, and maintenance phase therapies.

BACKGROUND: Chronic depressions are common, disabling, and undertreated, and prior chronicity predicts future chronicity. However, few studies directly inform the acute or maintenance phase treatments of chronic depressions and even less is known about the effects of treatment on psychosocial functioning. METHOD: We describe the design and rationale for 2 parallel double-blind, randomized, multicenter acute and maintenance phase treatment trials. One focused on DSM-III-R major depression currently in a chronic (> or = 2 years) major depressive episode, the other on DSM-III-R major depression with concurrent DSM-III-R dysthymia ("double depression"). RESULTS: Considering the critical knowledge deficits, we designed a 12-week acute phase safety and efficacy trial of sertraline versus imipramine, followed by a 16-week continuation treatment phase for subjects with a satisfactory therapeutic response. Patients receiving sertraline who successfully completed the continuation phase entered a 76-week maintenance trial to compare sertraline with placebo; those taking imipramine continued without a placebo substitution. As part of the acute trial, subjects completing but failing to respond to the initial 12-week acute phase medication were crossed over (double-blind) to the alternative medication for a 12-week acute phase trial. We obtained naturalistic follow-up data (up to 18 months) for subjects exiting the protocol at any time. CONCLUSION: Multiphase protocols for chronic depression can test efficacy by randomized contrasts as well as shed light on key clinical issues such as the degree of response or attrition expected at particular times in a trial or the preferred medication sequence in a potential multistep treatment program.

The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine.

BACKGROUND: Chronic depression appears to be a common, frequently disabling illness that is often inadequately treated. Unlike episodic depressions with shorter illness duration, neither acute nor long-term treatment approaches for chronic depression have been well studied. METHOD: 635 outpatients at 12 sites who met DSM-III-R criteria for chronic major depression or double depression were randomly assigned to 12 weeks of double-blind treatment with either sertraline (in daily doses of 50-200 mg) or imipramine (in daily doses of 50-300 mg). Efficacy and safety were assessed either weekly or every 2 weeks during the 12 weeks of acute treatment. RESULTS: Despite high rates of chronicity (mean duration of major depression = 8.9+/-9.1 years; mean duration of dysthymia = 23+/-13 years) and high rates of comorbidity, 52% of patients achieved a satisfactory therapeutic response to sertraline or imipramine (by a conservative, intent-to-treat analysis). Approximately 21% of the patients who had achieved a therapeutic response at week 12 had not done so at week 8, confirming the longer time to response in depressions with high chronicity. Patients treated with sertraline reported significantly fewer adverse events and were significantly less likely to discontinue treatment due to side effects than imipramine-treated patients (6.3% vs. 12.0%). CONCLUSION: These results indicate that patients suffering from depression with high chronicity can achieve a good therapeutic response to acute treatment with either sertraline or imipramine, although sertraline is better tolerated.

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine.

BACKGROUND: Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported. METHOD: We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples. RESULTS: Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples. CONCLUSION: These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Cost effectiveness of screening for clinical trials by research assistants versus senior investigators.

This study evaluates the relationship between interviewer level of experience and the positive predictive value and cost of telephone screening of subjects for randomized clinical trials. This is a previously uninvestigated area. Respondents to advertisements for chronic depression treatment research received brief, semi-structured telephone interviews (N = 347) either by research assistants (RAs) or by a senior investigator (SI). Those who met criteria based on the phone interview were then interviewed in person using the SCID-P. The RAs did not significantly differ from the SI in the proportion of phone screen positives who were also SCID positive or the proportion of phone screen positives who were randomized. While the SI performed phone interviews significantly faster than the RAs, the SI's higher salary generated a phone screening cost per randomized subject 56% more than that of RAs. The results suggest that trained research assistants are more cost effective than senior investigators for initial screening of depressed patients for research protocols. Further studies are needed to determine whether the findings reported would generalize to other research settings or patient populations.

Psychotherapy for dysthymic disorder.

The psychotherapy of dysthymic disorder has received too little serious attention and funding. Impressive advances in the pharmacotherapy of dysthymic disorder should not obscure the need for psychosocial treatment for the high proportion of patients who do not respond to medication. Despite the dearth of psychotherapy outcome studies in this area, such data that do exist suggest that relatively brief, focal, antidepressant psychotherapies may successfully treat many patients with lifelong mood disorders. Maintenance therapy probably is indicated to ensure the persistence of treatment gains.

Acute response of social functioning in dysthymic patients with desipramine.

Despite some evidence that short-term antidepressant treatment improves social dysfunction in depressed patients, little is known about the response of specific social impairments in dysthymic patients to antidepressant medication. We examined the effect of acute (10 weeks), open-label desipramine (DMI) treatment on social functioning in subjects with DSM-III-R dysthymia. Social functioning was assessed with the social adjustment scale self-report (SAS-SR) at baseline and at week 10. Compared with DMI nonresponders DMI responders showed significantly greater improvement in overall social functioning (F2,45 = 5.46, P < 0.0001) and in enjoyment of leisure time (F2,45 = 14.38, P < 0.0001) on the SAS-SR. Dysthymic patients who respond to DMI improve significantly in social functioning. Diminished capacity to enjoy leisure time may be a state marker of depression in some chronically depressed patients.

Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients.

We investigated prevalence and comorbidity of DSM-III dysthymic disorder in a psychiatric outpatient clinic. Seventy-five consecutive outpatients received structured interviews. Prevalence of dysthymic disorder was 36% in the consecutive sample. Thirty-four dysthymic and 56 non-dysthymic patients were compared for comorbidity. Dysthymic subjects were more likely to meet criteria for major depression, social phobia, and avoidant, self-defeating, dependent, and borderline personality disorders. Dysthymic disorder was usually of early onset, predating comorbid disorders, and had often not received adequate antidepressant treatment. These results help define dysthymic disorder as prevalent, usually predating axis I comorbidity, and associated with particular axis II diagnoses.