The Modified Hamilton Rating Scale for Depression: reliability and validity

Course of illness in psychotic mania: is mood incongruence important?

Previous research is inconsistent regarding the significance of mood-incongruent psychotic symptoms in relation to the severity and course of bipolar disorder. In the present study, bipolar I patients were assessed at index hospitalization using standardized symptom measures and followed up to 28 months. We contrasted the symptomatic course in patients experiencing mood-congruent versus mood-incongruent psychotic symptoms. Results revealed that patients spent an average of 29% of the time during follow-up in a mood episode, but only 5% of the time with psychotic symptoms. Few differences were found at the index hospitalization and no differences were found on any longitudinal course variables between mood-congruence subtypes. Although experiencing high levels of psychosis at baseline, both subtypes improved considerably following hospitalization, and psychotic symptom levels remained relatively stable. Current results suggest that when provided efficacious treatment, mood-incongruent psychotic mania does not predict a worse symptomatic course of illness.

Change is not always linear: the study of nonlinear and discontinuous patterns of change in psychotherapy

The study of discontinuities and nonlinear change has been a fruitful endeavor across the sciences, as these shifts can provide a window into the organization of complex systems and the processes that are associated with transition. A common assumption in psychotherapy research has been that change is gradual and linear. The research designs and statistics used to study change often reflect this assumption, but some recent research reveals other patterns of change. We briefly review relevant literature on dynamical systems theory and on life transition and post-traumatic growth to highlight the significance of nonlinear and discontinuous change across areas of psychology. We describe recent applications of these ideas and methods to the study of change in psychotherapy and encourage their use to complement more traditional clinical trial designs.

Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) and major depressive disorder (MDD) appear highly comorbid. However, MDD in individuals with BDD has received little investigation.

METHODS

The prevalence and characteristics of comorbid MDD were assessed in 178 BDD subjects. BDD subjects with current comorbid MDD (n=68) were compared to BDD subjects without current comorbid MDD (n=96) on demographic and clinical characteristics. Predictors of current MDD were determined using logistic regression.

RESULTS

74.2% of subjects had lifetime MDD, and 38.2% had current MDD. The melancholic subtype was most common, and a majority of depressed subjects had recurrent episodes. Mean onset of BDD occurred at a younger age than MDD. Subjects with current comorbid MDD had many similarities to those without MDD, although those with comorbid MDD had more severe BDD. Subjects with comorbid MDD were also more likely to have an anxiety or personality disorder, as well as a family history of MDD. They also had greater social anxiety, suicidality, and poorer functioning and quality of life. Current MDD was independently predicted by a personality disorder and more severe BDD.

LIMITATIONS

It is unclear how generalizable the results are to the community or to subjects ascertained for MDD who have comorbid BDD. The study lacked a comparison group such as MDD subjects without BDD.

CONCLUSIONS

MDD is common in individuals with BDD. Individuals with current MDD had greater morbidity in some clinically important domains, including suicidality, functioning, and quality of life. A personality disorder and more severe BDD independently predicted the presence of current MDD.

Obsessive-compulsive disorder versus body dysmorphic disorder: a comparison study of two possibly related disorders

The relationship between obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD-spectrum disorder or even a type of OCD. However, few studies have directly compared these disorders' clinical features. We compared characteristics of subjects with OCD (n=210), BDD (n=45), and comorbid BDD/OCD (n=40). OCD and BDD did not significantly differ in terms of demographic features, age of OCD or BDD onset, illness duration, and many other variables. However, subjects with BDD had significantly poorer insight than those with OCD and were more likely to be delusional. Subjects with BDD were also significantly more likely than those with OCD to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. The comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity. In summary, OCD and BDD did not significantly differ on many variables but did have some clinically important differences. These findings have implications for clinicians and for the classification of these disorders.

Role of treatment alliance in the clinical management of bipolar disorder: stronger alliances prospectively predict fewer manic symptoms

The strength of the treatment alliance between patients and their clinicians may play a unique role in the management of bipolar disorder. However, few empirical studies have examined the alliance in bipolar disorder or its effects on patient outcomes. This study investigates variables associated with a strong treatment alliance in bipolar disorder, and the prospective effects of treatment alliance on patients' mood symptoms and treatment attitudes. Participants were 58 longitudinally followed individuals with Bipolar I disorder. We found that alliance ratings covaried with depressive symptoms, such that alliance strength increased as depressive symptoms decreased, and stronger alliances were associated with more social support. Tests of temporal association indicated that stronger alliances predicted fewer manic symptoms 6 months later. Stronger alliances also predicted less negative attitudes about medication and less of a sense of stigma about bipolar disorder. Thus, a strong treatment alliance may help to reduce manic symptoms over time. It may be that a strong treatment alliance encourages patients' greater acceptance of bipolar disorder and psychopharmacological interventions, and thus contributes to improved medication adherence and clinical outcomes. Considered in sum, these findings suggest that the treatment alliance is an integral component of the long-term management of bipolar disorder.

Development and reliability of the HAM-D/MADRS interview: an integrated depression symptom rating scale

The Hamilton Rating Scale for Depression (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS), two widely used depression scales, each have unique advantages and limitations for research. The HAM-D's limited sensitivity and multidimensionality have been criticized, despite the scale's popularity. The MADRS, designed to be sensitive to treatment changes, is briefer and more uniform. A limitation of the MADRS is the lack of a structured interview, which may affect reliability. The HAM-D and the MADRS are often used conjointly as endpoints in depression trials. We designed a hybrid questionnaire that allows administration of MADRS and 31 HAM-D items simultaneously. Seventy mood disorder patients (60 bipolar I, 10 major depressive disorder) were administered the HAM-D/MADRS Interview (HMI) as part of a larger study. Interrater reliability for 50 patients was excellent for the HAM-D and the MADRS (ICC=0.97-0.98). MADRS item reliabilities (ICC=0.86-0.97) were higher than obtained in studies that did not use a structured interview. Reliability coefficients for seven HAM-D(31) 'atypical' symptoms ranged from 0.77 to 0.95. HMI was highly correlated with the Global Clinical Impressions Scale. This is the first study we know of to investigate the reliability of a structured interview of either the MADRS or of the HAM-D(31). The HMI provides an easily administered, reliable method of rating depression severity which may improve consistency and validity of study findings.

Patients' expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder

Bipolar disorder is characterized by a chronic and fluctuating course of illness. Although nonadherence to pharmacotherapy is a frequent problem in the disorder, few studies have systematically explored psychosocial factors related to treatment discontinuation. Previous research with depressed patients receiving psychotherapy has suggested that expectancies for improvement are related to treatment outcomes and that the therapeutic alliance may partially mediate this relationship. The current study found evidence for a similar relationship between patients' initial expectancies for improvement, patient and doctor-rated alliance, and long-term outcomes in bipolar patients treated with pharmacotherapy for up to 28 months following an acute episode. The results highlight the need for the assessment of expectancies and alliance in bipolar treatment and suggest possible targets for psychosocial interventions.

Reactivity to a laboratory stressor among individuals with bipolar I disorder in full or partial remission

Strong links have been documented between life events and the course of bipolar disorder. Laboratory studies of stress provide an opportunity to understand the mechanisms involved in reactivity to stressors, but few such studies have been done in the bipolar field. In the current study, 28 people with bipolar I disorder in full or partial remission and 40 people with no history of a mood disorder were randomly assigned to 1 of 3 conditions involving different levels of failure feedback on a concept formation task. Confidence, affective reactions, and performance on a subsequent anagram task were assessed. Results provide tentative support for reactivity to the stressor among the bipolar group, although reactivity was limited to impaired anagram performance.

Escitalopram versus venlafaxine XR in the treatment of depression

This article reanalyses and reviews data from the two published randomized clinical trials comparing escitalopram and venlafaxine XR in the treatment of patients with major depressive disorder. The aim was to further compare the efficacy and tolerability of escitalopram and venlafaxine XR and to assess the impact of the two treatments on the patient's quality of life, as well as the benefit/risk of treatment. A total of 243 escitalopram-treated patients and 240 venlafaxine XR-treated patients were included in this analysis. Comparable treatment efficacy was achieved with respect to the prospectively defined primary efficacy endpoint (mean change from baseline in Montgomery Asberg Depression Rating Scale (MADRS) total score at week 8). An analysis of the outcome at the end of study by baseline severity showed that the treatment difference became greater the more severely depressed the patients were at baseline. At the highest permitted doses, in the subgroup of patients who were severely depressed (baseline MADRS > or =30), patients treated with escitalopram had a statistically significantly greater improvement (P<0.05) in mean MADRS total scores than patients treated with venlafaxine XR at endpoint. For these patients, treatment with 20 mg/day escitalopram resulted in a statistically significantly (P<0.05) higher remission rate at week 8 (47%) than treatment with venlafaxine XR (29%). This difference was confirmed by the analysis of the pooled data, which showed that patients in the escitalopram group had a significantly (P<0.05) higher mean number of depression-free days (30.4 days) than those in the venlafaxine XR group (26.2 days) over the 8-week period. The relative benefit of escitalopram versus venlafaxine XR was 1.46, indicating that a patient was more likely to benefit from treatment with escitalopram. The proportions of patients who withdrew owing to adverse events were 7.5% in the escitalopram group and 11.2% in the venlafaxine XR group. The mean number of discontinuation emergent signs and symptoms in the venlafaxine XR group (mean: 5.0) was significantly (P<0.001) higher than for the escitalopram group (mean: 2.4).

The prospective impact of sleep duration on depression and mania

OBJECTIVE

Many patients report sleeping less than 6 h per night during episodes of depression and mania. This type of sleep deficit may also be a risk factor for subsequent mood episodes; however, the long-term impact of sleep deficit remains unclear. The current study is among few longitudinal studies to assess the prospective effect of sleep deficit on depression and mania.

METHODS

A subsample of 54 individuals from a longitudinal study of bipolar I disorder was selected. Participants entered the study during a mood episode. Baseline symptom data were collected at month 4 to allow for recovery from the initial episode, sleep was assessed at month 6, and follow-up symptom data were obtained during months 7-12.

RESULTS

Sleep deficit predicted depressive symptoms across the 6-month follow-up but not mania.

CONCLUSIONS

It is likely that the impact of sleep deficit on mania was probably missed because assessments covered a full month. Monitoring sleep duration may help predict depression in bipolar disorder and provide an opportunity for targeting intervention.

An open-label study of escitalopram in body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common and impairing disorder. Selective serotonin reuptake inhibitors (SRIs) appear selectively efficacious for BDD, but pharmacotherapy research is limited, and escitalopram has not been studied. Fifteen subjects with BDD were treated with escitalopram and assessed with reliable and valid measures. BDD symptoms significantly improved (P<0.001), and 73.3% (n=11) of subjects were responders. Of the subjects, 46.7% were very much improved, and 33.3% were much improved. Depressive symptoms, delusionality, functioning and quality of life also significantly improved. Escitalopram was well tolerated. These preliminary data suggest that escitalopram is safe and efficacious for BDD.

The Brown Longitudinal Obsessive Compulsive Study: clinical features and symptoms of the sample at intake

OBJECTIVE

This article describes the method and intake findings of the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the naturalistic course of obsessive-compulsive disorder (OCD) in a large clinical sample using longitudinal research methodology.

METHOD

Intake data, collected between June 2001 and October 2004, are presented for 293 adult participants in a prospective, naturalistic study of OCD. Participants had a primary diagnosis of DSM-IV OCD and had sought treatment for the disorder.

RESULTS

Our findings indicate that OCD typically has a gradual onset and a continuous course regardless of age at onset. There is a substantial lag between the onset of the disorder and initiation of treatment. OCD, which almost always coexists with other psychiatric symptoms, leads to serious social and occupational impairment. Compared with participants with late-onset OCD, early-onset participants had higher rates of lifetime panic disorder, eating disorders, and obsessive-compulsive personality disorder. The groups also differed on the types of obsessive-compulsive symptoms that were first noticed, as well as on rates of current obsessions and compulsions.

CONCLUSION

The demographics, clinical characteristics, comorbidity rates, and symptom presentation of the sample are consistent with those reported for cross-sectional studies of OCD, including the DSM-IV Field Trial. The current sample has a number of advantages over previously collected prospective samples of OCD in that it is large, diagnostically well characterized, recruited from multiple settings, and treatment seeking. This unique data set will contribute to the identification of meaningful phenotypes in OCD based on stability of symptom dimensions, prospective course patterns, and treatment response.

Ten-year stability of personality disorders among outpatients with mood disorders

One of the core propositions in most clinical and descriptive models of personality disorders (PDs) is that these conditions are stable over time. However, the available empirical literature suggests that PDs are far less stable than these models imply. The present study examines the 10-year stability of PDs in a sample of depressed outpatients who were assessed for the full range of Axis II conditions across 5 assessments. Three primary issues are addressed: (a) the stability of categorical PD diagnoses, (b) the relative stability of dimensional PD traits, and (c) the absolute stability of PD traits. The stability of PD diagnoses was poor to fair, and the stability of dimensional PD traits was fair to moderate. Growth curve analyses revealed complex patterns of change in absolute scores for PD traits across the 10-year interval. Stability of PDs was generally comparable to that of anxiety disorder diagnoses and normal personality traits.

Gender similarities and differences in 200 individuals with body dysmorphic disorder

BACKGROUND

Gender is a critically important moderator of psychopathology. However, gender similarities and differences in body dysmorphic disorder (BDD) have received scant investigation. In this study, we examined gender similarities and differences in the broadest sample in which this topic has been examined.

METHODS

Two hundred subjects with BDD recruited from diverse sources were assessed with a variety of standard measures.

RESULTS

There were more similarities than differences between men and women, but many gender differences were found. The men were significantly older and more likely to be single and living alone. Men were more likely to obsess about their genitals, body build, and thinning hair/balding; excessively lift weights; and have a substance use disorder. In contrast, women were more likely to obsess about their skin, stomach, weight, breasts/chest, buttocks, thighs, legs, hips, toes, and excessive body/facial hair, and they were excessively concerned with more body areas. Women also performed more repetitive and safety behaviors, and were more likely to camouflage and use certain camouflaging techniques, check mirrors, change their clothes, pick their skin, and have an eating disorder. Women also had earlier onset of subclinical BDD symptoms and more severe BDD as assessed by the Body Dysmorphic Disorder Examination. However, men had more severe BDD as assessed by the Psychiatric Status Rating Scale for Body Dysmorphic Disorder, and they had poorer Global Assessment of Functioning Scale scores, were less likely to be working because of psychopathology, and were more likely to be receiving disability, including disability for BDD.

CONCLUSIONS

The clinical features of BDD in men and women have many similarities but also some interesting and important differences. These findings have implications for the detection and treatment of BDD.

Evaluation of the psychometric properties of the Beck Depression Inventory in a non-elderly adult sample of patients with generalized anxiety disorder

Although the Beck Depression Inventory (BDI) is commonly administered across a wide range of psychological disorders, its psychometric properties have not yet been examined in a non-elderly (aged 59 years or younger) adult sample of patients with generalized anxiety disorder (GAD). Completed BDIs were obtained from 48 patients with GAD (mean age=31.85 years) and 41 nonanxious control participants (mean age=30.49 years). The BDI exhibited good internal consistency in the clinical sample. Patients obtained more extreme scores on the BDI than did control participants, and patients with a comorbid mood disorder obtained more extreme scores on the BDI than did patients without a comorbid mood disorder. Patients' BDI scores correlated significantly more strongly with a clinician-administered measure of depression than with self-report measures of generalized anxiety, worry, social anxiety, or anxiety sensitivity, but not more strongly than with a clinician-administered measure of anxiety. BDI scores correlated positively with self-reported disability and negatively with life satisfaction. Overall, the BDI demonstrated good psychometric properties in this non-elderly adult sample of patients with GAD.

Social functioning in body dysmorphic disorder: assessment considerations

Individuals with body dysmorphic disorder (BDD) have markedly poor social functioning; however, previous reports may underestimate impairment. Scoring on certain functioning measures such as the Social Adjustment Scale-Self Report (SAS-SR) potentially excludes more severely ill individuals from some domains, thereby possibly underestimating functional impairment. To explore this issue, 73 individuals with BDD who reported having no primary relationship (and were therefore excluded from scoring on the SAS-SR Primary Relationship domain) were compared to 58 individuals with BDD who had a primary relationship. Subjects without a primary relationship had significantly poorer global social adjustment on several measures. They also had poorer scores on the Global Assessment of Functioning Scale and greater severity of BDD and depressive symptoms at a trend level. These findings suggest that the SAS-SR may underestimate social impairment. This underestimation may pertain to other domains of functioning, other disorders, and certain other functioning and quality of life measures.

Impact of obsessive-compulsive disorder on quality of life

BACKGROUND

Although obsessive-compulsive disorder (OCD) has been found to be the 10th leading cause of disability of all medical conditions in the industrialized world, comparatively little is known about psychosocial functioning and quality of life (QOL) in OCD, particularly with regard to their relationship with symptom severity.

METHOD

Quality of life and psychosocial function of 197 adults were assessed as part of a larger intake interview for a 5-year prospective study of OCD course. Two self-report measures (the Quality of Life Enjoyment and the Medical Outcomes Survey 36-Item Short-Form Health Survey) and 2 clinician-rated measures (the Range of Impaired Functioning Tool and the Social and Occupational Functioning Assessment Scale), each with established reliability and validity, were administered. Symptom severity was assessed with the Yale-Brown Obsessive-Compulsive Scale (YBOCS).

RESULTS

Quality of life was significantly impaired compared with published community norms with large effect sizes found for all domains assessed. The correlations (r) between all QOL measures and the YBOCS total score were significant, ranging from 0.40 to 0.77. Correlations between the YBOCS obsessions subscore and QOL measures were higher than those found between the YBOCS compulsions subscore and QOL. Insight as measured by the Brown Assessment of Beliefs Scale was significantly correlated with 5 of the 7 measures, although more modestly than the YBOCS correlations (r = 0.22 to 0.37). Subjects with a YBOCS score of 20 or higher had significant decline in QOL compared with those subjects with YBOCS scores lower than 20. Severity of obsessions and depressive symptoms, as well as marital status, were significant predictors of impairment in QOL.

CONCLUSIONS

These findings indicate that all aspects of QOL are markedly affected in individuals with OCD and are associated with OCD severity (particularly obsessional severity) and depression severity. Exploratory results suggest that QOL and psychosocial functioning begins to be more significantly affected at YBOCS scores higher than 20. This score might be considered as a threshold criterion for OCD for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Persistence of antidepressant treatment effects in a pharmacotherapy plus psychotherapy trial for active injection drug users

The objective of this study was to determine if combined psychotherapy and pharmacotherapy reduces reported depressive symptoms compared to an assessment only condition for active drug injectors over nine months. Using a randomized controlled trial at an outpatient academic research office, the researchers applied psychotherapy (eight sessions of cognitive behavioral therapy) plus pharmacotherapy (citalopram) to active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with symptoms persisting for at least three months, or major depression plus dysthymia, and a Modified Hamilton Rating Scale for Depression (MHRSD) score greater than 13. The MHRSD scale scores were then assessed at the completion of three, six, and nine months. Participants (n = 109) were 64% male and 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Study retention at nine months was 89%. At the completion of three months of acute treatment, 26% of combined treatment patients (n = 53), compared to 12% of control patients (n = 56), were in remission (p = .047). At both six and nine months, the between-group differences in remission rates and mean MHRSD scores were insignificant, although the overall mean MHRSD score decreased from baseline (p < .01). At all follow-up assessments, depression remission was significantly associated with lower heroin use. Among active drug injectors diagnosed with depression, symptoms decline over time. Combined treatment is superior to an assessment-only condition in depression remission rates at the end-of-treatment, but this difference does not persist.

Reductions in HIV risk behaviors among depressed drug injectors

OBJECTIVE

To determine if, by reducing depressive symptoms, combined psychotherapy and pharmacotherapy reduces HIV drug risk behavior compared to an assessment-only condition for active drug injectors over 9 months.

DESIGN

Randomized controlled trial.

SETTING

Outpatient academic research office.

PATIENTS

Active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with depressive features persisting for at least 3 months, or major depression plus dysthymia. In addition, participants had a Hamilton Rating Scale for Depression (MHRSD) score > 13.

INTERVENTION

Psychotherapy (8 sessions of cognitive behavioral therapy) plus antidepressant pharmacotherapy over 3 months.

MAIN OUTCOME MEASURES

HIV Risk Assessment Battery (RAB) drug scale scores measured at three, six and nine months, and depression remission (MHRSD score < or = 8).

RESULTS

Participants (n= 109) were 64% male, 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Overall, study retention at nine months was 89%. Reported HIV drug risk scores decreased sharply over the first 3 months and continued to decline throughout the follow-up period. Between group differences were not significant in the intention-to-treat analysis. However, highly adherent participants had significantly lower HIV drug risk scores at 3 months (p<05), but not 6 and 9 months. Depression remission was significantly associated with lower HIV drug risk scores at follow-ups.

CONCLUSIONS

Combined psychotherapy and pharmacotherapy did not produce a significant reduction in HIV drug risk beyond that seen in an assessment-only control group. The greatest declines in HIV drug risk were found in participants with high protocol adherence and those with depression remission.

Suicidality in bipolar I disorder

People with bipolar disorder are at high suicide risk. The literature suggests that suicidality is predicted by higher symptom severity and less use of pharmacological agents, but few studies have examined the joint contributions of these variables. The present study examines the conjoint contribution of symptom severity and pharmacological treatment to suicidal ideation and behavior among participants with bipolar disorder. The model was able to account for 53% of the variance in suicidality scores. Depression, mixed state, and hopelessness were significantly associated with suicidality. All other variables were nonsignificant once symptom severity had been controlled. Implications for future research are described.

Treatment matching in the posthospital care of depressed patients

OBJECTIVE

This study assessed the efficacy of 1) matching patients to treatments and 2) adding additional family therapy or cognitive therapy in a group of recently discharged patients with major depression.

METHOD

Patients with major depression were recruited during a psychiatric hospitalization. After discharge, they were randomly assigned to one of four treatment conditions that were either "matched" or "mismatched" to their pattern of cognitive distortion and family impairment. The four treatment conditions were 1) pharmacotherapy alone; 2) combined pharmacotherapy and cognitive therapy; 3) combined pharmacotherapy and family therapy; and 4) combined pharmacotherapy, cognitive therapy, and family therapy. Randomly assigned treatment continued for 24 weeks on an outpatient basis.

RESULTS

Among patients with at least moderate depressive symptoms at hospital discharge, low rates of remission (16%) and improvement (29%) were obtained. Matched treatment led to a significantly greater proportion of patients who improved and greater reductions over time in interviewer-rated depressive symptoms than mismatched treatment. However, matched treatment did not produce greater change in self-reported depression or interviewer-rated suicidal ideation. Treatment that included a family therapy component also led to a greater proportion of patients who improved and to significant reductions in interviewer-rated depression and suicidal ideation than treatment without family therapy.

CONCLUSIONS

These results suggest that 1) current treatments are not very efficacious in the aftercare of hospitalized depressed patients, 2) treatment matching moderately improves outcome for patients who are symptomatic at hospital discharge, and 3) inclusion of family therapy improves the outcome of posthospital care for depressed patients.

Anxiety disorder comobidity in Bipolar I Disorder: relationship to depression severity and treatment outcome

The present study investigated the greater symptom severity and poorer treatment response found in patients with bipolar illness and anxiety comorbidity, and examined depression as a potential mediator of this relationship. The sample consisted of 92 patients in an acute episode of Bipolar I Disorder with a current or past history of an anxiety disorder. Diagnoses were based on structured clinical interview, and participants were assessed at pre-treatment and then randomly assigned to pharmacotherapy alone or pharmacotherapy plus family intervention. Patients were assessed on a monthly basis by blind assessors over 28 months. Compared to patients without anxiety comorbidity, individuals with bipolar disorder and an anxiety disorder possessed greater current symptom severity, even after controlling for depression severity. Logistic regression analysis identified that being female and having higher current depression but not manic severity predicted comorbid anxiety. Comorbid anxiety was associated with poorer treatment response in the sample regardless of treatment type, particularly in subsequent depressive symptoms. Multiple regression analyses indicated that current depression but not manic severity partially mediated the relationship between comorbid anxiety and treatment outcome. Results from the current study investigating comorbid anxiety disorders are consistent with past research limited to anxiety symptoms. Depression only partially accounted for the link between comorbid anxiety and greater symptom severity and poorer treatment response, and examination of other factors is warranted. Because of the clinical relevance of comorbid anxiety in severe affective disorders, treatments designed to specifically address both concerns are needed.

Differential response to combined treatment in patients with psychotic versus nonpsychotic major depression

Research has demonstrated that depressed patients with psychotic features show poorer outcomes when treated with pharmacotherapy alone compared with those without psychotic features. However, research has not investigated whether this differential response also applies to combined treatment that includes pharmacotherapy and psychotherapy. In the current study, data were pooled from two clinical trials in which patients diagnosed with major depressive disorder with or without psychotic features were treated with combined treatment. Although similar in severity at pretreatment, results indicated that patients with psychotic depression showed a poorer response in terms of depression severity at postoutpatient treatment and at 6-month follow-up compared with those with nonpsychotic depression. Following treatment, patients with psychotic depression were over four times as likely to exhibit high levels of depression and suicidal ideation. Current state-of-the-art combined treatments have poorer efficacy in depressed patients with psychotic symptoms, and adapted treatment approaches are needed.

Subjective appraisal of Alzheimer's disease caregiving: the role of self-efficacy and depressive symptoms in the experience of burden

Most studies investigating correlates of Alzheimer's disease (AD) caregiver burden have focused on the role of objective factors as opposed to subjective factors. Although objective variables (e.g., caregiver age, patient dementia severity, functional status) have been shown to be significantly associated with burden, the correlations generally are modest and explain relatively little of the variability in caregiver outcomes. Moreover, many of these objective variables are not modifiable and are of limited use in the development of caregiver interventions. Thus, there continues to be a need to identify powerful and modifiable determinants of caregiver burden. This study examined the role of two subjective factors-self-efficacy and depressive symptoms-as predictors of AD caregiver burden. Based on a sample of 80 AD caregivers, hierarchical regression analyses revealed that self-efficacy and depressive symptoms each had a significant independent effect on the experience of burden even after accounting for objective factors. These findings suggest that caregiver interventions aimed to reduce burden may benefit from the incorporation of specific strategies to increase self-efficacy and decrease depressive symptoms.

Longitudinal comparison of depressive personality disorder and dysthymic disorder

BACKGROUND

Few studies have compared the related diagnostic constructs of depressive personality disorder (DPD) and dysthymic disorder (DD). The authors attempted to replicate findings of Klein and Shih in longitudinally followed patients with personality disorder or major depressive disorder (MDD) in the Collaborative Longitudinal Personality Disorders Study.

METHODS

Subjects (N = 665) were evaluated at baseline and over 2 years (n = 546) by reliably trained clinical interviewers using semistructured interviews and self-report personality questionnaires.

RESULTS

Only 44 subjects (24.6% of 179 DPD and 49.4% of 89 early-onset dysthymic subjects) met criteria for both disorders at baseline. Depressive personality disorder was associated with increased comorbidity of some axis I anxiety disorders and other axis II diagnoses, particularly avoidant (71.5%) and borderline (55.9%) personality disorders. Depressive personality disorder was associated with low positive and high negative affectivity on dimensional measures of temperament. Depressive personality disorder subjects had lower likelihood of remission of baseline MDD at 2-year follow-up, whereas DD subjects did not. The DPD diagnosis appeared unstable over 2 years of follow-up, as only 31% (n = 47) of 154 subjects who had DPD at baseline and also had follow-up assessment met criteria on blind retesting.

LIMITATIONS

Results from this sample may not generalize to other populations.

CONCLUSIONS

Depressive personality disorder and dysthymic disorder appear to be related but differ in diagnostic constructs. Its moderating effect on MDD and predicted relationship to measures of temperament support the validity of DPD, but its diagnostic instability raises questions about its course, utility, and measurement.

Mental health service use by patients with dysthymic disorder: treatment use and dropout in a 7 1/2-year naturalistic follow-up study

Little is known about long-term treatment use among patients with dysthymia. This paper describes patterns of treatment use by 85 outpatients with dysthymic disorder and a comparison group of 36 outpatients with nonchronic (episodic) major depression in a naturalistic follow-up. Patients with dysthymia had higher rates of treatment use across 7 1/2 years compared with patients with episodic major depression. Baseline variables that predicted which patients with dysthymia dropped out of treatment before recovering from dysthymic disorder included age, ethnicity, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axis II pathology as obtained from informant reports, higher self-reported autonomy, and receiving psychotherapy alone as compared to receiving a combination of psychotherapy and medication. Dysthymic disorder places a significant burden on the mental health services system, yet many outpatients with dysthymia may be receiving inadequate treatment. Younger patients, ethnic minority patients, and patients with personality disorders may be at increased risk of dropping out from treatment for depression. Combination treatments may increase treatment retention.

Avoidance and processing as predictors of symptom change and positive growth in an integrative therapy for depression

Depression is a leading cause of disability worldwide and can worsen the course of a variety of medical illnesses. There is a clear need to develop more potent treatments for this debilitating disorder and prevent its return. We are developing a promising psychotherapy that integrates components of current, empirically supported therapies for depression and also teaches healthy lifestyle and emotion regulation habits to promote psychological health. In the 1st open trial, growth curve analyses revealed a significant linear decrease in symptoms of depression in a sample of 29 clients who completed the therapy. Participants wrote essays about their depression each week, and the content was analyzed using a new coding system of change processes. Hierarchical linear modeling (HLM) revealed that peak levels of processing in the essays were associated with more improvement in depression and with the expression of more hope and of both negative and positive views of the self, presumably as clients explored their depressive views of self. Peak levels of avoidance were associated with less improvement in depression and with more hopelessness and negative views of the self. These preliminary results suggest possible targets of change that can facilitate symptom reduction and perhaps also promote psychological health.

Unlinking negative cognition and symptoms of depression: evidence of a specific treatment effect for cognitive therapy

In this study, the authors examined whether cognitive therapy alters the association between negative cognition and symptoms of depression. Participants were recruited during psychiatric hospitalization for depression. Following discharge, they were randomly assigned to 6 months of outpatient treatment. Treatment consisted of pharmacotherapy either alone or in combination with cognitive therapy and/or family therapy. Following this 6-month treatment period, negative cognition and symptoms of depression were assessed monthly for 1 year. Hierarchical linear modeling indicated that the association between negative cognition and depression during follow-up was weaker for patients randomized to cognitive therapy than for patients who did not receive cognitive therapy. Cognitive therapy appeared to unlink negative cognition and symptoms of depression to a greater extent than other forms of treatment.

Impact of comorbid anxiety and depression on quality of life and cellular immunity changes in patients with digestive tract cancers

AIM: A study was performed to investigate the impact of comorbid anxiety and depression (CAD) on quality of life (QOL) and cellular immunity changes in patients with digestive tract cancers.

METHODS: One hundred and fifty-six cases of both sexes with cancers of the digestive tract admitted between March 2001 and February 2004 in the Department of Medical Oncology, First Affiliated Hospital of Xi’an Jiaotong University were randomly enrolled in the study. Depressive and anxiety disorder diagnoses were assessed by using the Structured Clinical Interview for DSM-IV. All adult patients were evaluated with the Hamilton depressive scale (HAMD, the 24-item version), the Hamilton anxiety scale (HAMA, a modified 14-item version), quality of life questionnaire-core 30 (QLQ-C30), social support rating scale (SSRS), simple coping style questionnaire (SCSQ), and other questionnaires, respectively. In terms of HAMD ≥ 20 and HAMA ≥ 14, the patients were categorized, including CAD (n = 31) in group A, anxiety disorder (n = 23) in group B, depressive disorder (n = 37) in group C, and non-disorder (n = 65) in group D. Immunological parameters such as T-lymphocyte subsets and natural killer (NK) cell activities in peripheral blood were determined and compared among the four groups.

RESULTS: The incidence of CAD was 21.15% in patients with digestive tract cancers. The average scores of social support was 43.67±7.05 for 156 cases, active coping 20.34±7.33, and passive coping 9.55±5.51. Compared with group D, subjective support was enhanced slightly in group A, but social support, objective support, and utilization of support reduced, especially utilization of support with significance (6.16 vs 7.80, P<0.05); total scores of active coping decreased, while passive coping reversed; granulocytes proliferated, monocytes declined, and lymphocytes declined significantly (32.87 vs 34.00, P<0.05); moreover, the percentage of CD3, CD4, CD8 and CD56 in T lymphocyte subsets was in lower level, respectively, and CD56 showed a significant decline in group A (26.02 vs 32.20, P<0.05), however, CD4/CD8 ratio increased. Physical function, role function, fatigue, sleeplessness and constipation had significant changes among different groups by one-way ANOVA, and group A was in poor QOL. It revealed that global health-related quality of life (QL) were positively correlated with active coping and CD56; CAD was negatively correlated with QL, active coping and CD56. Furthermore, the step-wise regression analysis suggested that utilization of support, CD56, active coping, fatigue, sleeplessness and depression were significant factors contributing to QOL.

CONCLUSION: CAD, which can impair QOL and cellular immunity, occurs with a higher incidence in patients with digestive tract cancers. Hence, it is essential to improve mental health for them with specifically tailored interventions.

A growth curve analysis of the course of dysthymic disorder: the effects of chronic stress and moderation by adverse parent-child relationships and family history

Using mixed effects models, the authors examined the effects of chronic stress, adverse parent-child relationships, and family history on the 7.5-year course of dysthymic disorder. Participants included 97 outpatients with early-onset dysthymia who were assessed with semistructured interviews at baseline and 3 additional times at 30-month intervals for 7.5 years. Results indicated that higher levels of chronic stress 6 months prior to each follow-up predicted greater depression severity at follow-up, controlling for depression severity at the start of the chronic stress assessment. In addition, adverse parent-child relationships and family history of dysthymic disorder moderated this association. For patients with poorer parent-child relationships, chronic stress was associated with increased depression severity at follow-up, whereas patients with a higher familial loading for dysthymic disorder were less responsive to chronic stress over time.

Self-reported depressive symptom measures: sensitivity to detecting change in a randomized, controlled trial of chronically depressed, nonpsychotic outpatients

This study evaluated and compared the performance of three self-report measures: (1) 30-item Inventory of Depressive Symptomatology-Self-Report (IDS-SR30); (2) 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16); and (3) Patient Global Impression-Improvement (PGI-I) in assessing clinical outcomes in depressed patients during a 12-week, acute phase, randomized, controlled trial comparing nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), and the combination in the treatment of chronic depression. The IDS-SR30, QIDS-SR16, PGI-I, and the 24-item Hamilton Depression Rating Scale (HDRS24) ratings were collected at baseline and at weeks 1-4, 6, 8, 10, and 12. Response was defined a priori as a > or =50% reduction in baseline total score for the IDS-SR30 or for the QIDS-SR16 or as a PGI-I score of 1 or 2 at exit. Overall response rates (LOCF) to nefazodone were 41% (IDS-SR30), 45% (QIDS-SR16), 53% (PCI-I), and 47% (HDRS17). For CBASP, response rates were 41% (IDS-SR30), 45% (QIDS-SR16), 48% (PGI-I), and 46% (HDRS17). For the combination, response rates were 68% (IDS-SR30 and QIDS-SR16), 73% (PGI-I), and 76% (HDRS17). Similarly, remission rates were comparable for nefazodone (IDS-SR30=32%, QIDS-SR16=28%, PGI-I=22%, HDRS17=30%), for CBASP (IDS-SR30=32%, QIDS-SR16=30%, PGI-I=21%, HDRS17=32%), and for the combination (IDS-SR30=52%, QIDS-SR16=50%, PGI-I=25%, HDRS17=49%). Both the IDS-SR30 and QIDS-SR16 closely mirrored and confirmed findings based on the HDRS24. These findings raise the possibility that these two self-reports could provide cost- and time-efficient substitutes for clinician ratings in treatment trials of outpatients with nonpsychotic MDD without cognitive impairment. Global patient ratings such as the PGI-I, as opposed to specific item-based ratings, provide less valid findings.

Evidence-based assessment of depression in adults

From diverse perspectives, there is little doubt that depressive symptoms cohere to form a valid and distinct syndrome. Research indicates that an evidence-based assessment of depression would include (a) measures with adequate psychometric properties; (b) adequate coverage of symptoms; (c) adequate coverage of depressed mood, anhedonia, and suicidality; (d) an approach to suicidality that distinguishes between resolved plans and preparations and desire and ideation; (e) assessment of the atypical, seasonal, and melancholic subtypes; (f) parameters of course and chronicity; and (g) comorbidity and bipolarity. These complexities need to be accounted for when certain assessment approaches are preferred, and when ambiguity exists regarding the categorical versus dimensional nature of depression, and whether and when clinician ratings outperform self-report. The authors conclude that no one extant procedure is ideal and suggest that the combination of certain interviews and self-report scales represents the state of the art for evidence-based assessment of depression.

Longitudinal course of bipolar I disorder

The course of bipolar I disorder is characterized by frequently fluctuating levels of manic and depressive symptoms. In the current study, we sought to characterize the month-by- month course of this disorder in 61 patients who were originally enrolled in a clinical trial and were followed for a mean of 23.7 months (SD = 6.1). All patients in the trial received medication management; some received family psychosocial interventions as well. On a monthly basis, we assessed symptom severity using the Modified Hamilton Rating Scale for Depression (MHRSD) and the Bech-Rafaelson Mania Scale (BRMS). Each month, we categorized each participant as fully symptomatic, partially symptomatic, or asymptomatic in terms of both depressed and manic symptoms. We found that the median percent time fully symptomatic was 8%, the median percent time partially symptomatic was 22%, and the median percent time asymptomatic was 59%. Using DSM-IV-TR criteria for defining an acute mood episode, we found that the median length of episode was 1 month, and participants experienced, on average, one episode every 8 months. Estimates concerning percent time fully symptomatic and asymptomatic converge with those reported in other datasets.

Change in psychosocial functioning and quality of life of patients with body dysmorphic disorder treated with fluoxetine: a placebo-controlled study

In a 12-week placebo-controlled study of fluoxetine in the treatment of body dysmorphic disorder, the authors investigated change in psychosocial functioning and mental health-related quality of life in 60 subjects. The subjects were assessed with the LIFE-RIFT (a measure of impaired functioning), Social and Occupational Functioning Scale (SOFAS), and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) before and after receiving fluoxetine or placebo. At baseline, the patients had impaired psychosocial functioning and markedly poor mental health-related quality of life. Compared to placebo, fluoxetine was associated with significantly greater improvement in LIFE-RIFT and SOFAS scores and with improvement on the mental health subscale of the SF-36 that approached significance. Decrease in the severity of body dysmorphic disorder, as measured by the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder, was significantly correlated with improvement in functioning and quality of life.

Perfectionism, cognitive bias, and hopelessness as prospective predictors of suicidal ideation

Perfectionism, negative cognitive bias, and hopelessness were assessed among people hospitalized for depression (N = 121). Hopelessness and suicidal ideation were assessed 6 months after discharge. Path analyses indicated that higher perfectionism as an inpatient was directly associated with higher suicidal ideation 6 months later. Cognitive bias, in contrast, led to greater hopelessness 6 months later, which in turn led to higher concurrent suicidal ideation. Alternative models examined whether hopelessness partially or fully mediated the effect of perfectionism, whether hopelessness partially mediated the effect of cognitive bias, and whether inpatient depression and suicidal ideation severity explained the observed relationships. These alternative models were not supported. Perfectionism and negative cognitive bias both uniquely contributed to the prospective prediction of suicidal ideation.

Attachment patterns across multiple family relationships in adulthood: Associations with maternal depression

We explored attachment in a family context by applying family systems principles to the investigation of multiple attachment relationships within families. This study focused on maternal adult attachment with respect to family of origin experiences (assessed using the Adult Attachment Interview [AAI]) as well as maternal marital attachment (assessed using the Marital Attachment Interview [MAI]). We examined associations between maternal adult attachment (or marital attachment) and three levels of family functioning including individual maternal depression symptoms, dyadic marital satisfaction (reported by mothers), and family unit functioning. We also examined associations between combined attachment security (consistent secure, AAI secure/MAI insecure, AAI insecure/MAI secure, and consistent insecure) and family outcomes. Finally, we assessed the extent to which attachment representations operate differently in the context of family stress, namely maternal depression. We found that attachment security with respect to particular relationships was differentially associated with different levels of family functioning. Examination of the security of combined adult and marital attachment further supported the multilevel organization of the family system.

An Item Response analysis of the Hamilton Depression Rating Scale using shared data from two pharmaceutical companies

Although the Hamilton Depression Rating Scale (HAMD) remains the most widely used outcome measure in clinical trials of Major Depressive Disorder, the psychometric properties of the individual HAMD items have not been extensively studied. In the present paper, data from four separate clinical trials conducted independently by two pharmaceutical companies were analyzed to determine the relationship between scores on the individual HAMD items and overall depressive severity in an outpatient population. Option characteristic curves (the probability of scoring a particular option in relation to overall HAMD scores) were generated in order to illustrate the relationship between scoring patterns for each item and the range of total HAMD scores. Results showed that Items 1 (Depressed Mood) and 7 (Work and Activities), and to a lesser degree, Items 2 (Guilt), 10 (Anxiety/Psychic), 11 (Anxiety/Somatic), and 13 (Somatic/General) demonstrated a good relationship between item responses and overall depressive severity. However, other items (e.g. Insight, Hypochondriasis) appeared to be more problematic with regard to their ability to discriminate over the full range of depression severity. The present results illustrate that co-operative data sharing between pharmaceutical companies can be a useful tool for improving clinical methods.

Negative Cognitions Predict the Course of Bipolar Depression, Not Mania

Cognitive interventions for bipolar disorder have received increased attention, but very few prospective studies have focused on whether cognitive variables predict the course of bipolar disorder. Available studies have yielded conflicting results concerning the effects of negative cognitions on mania. In this study, 60 individuals with bipolar I disorder completed monthly symptom severity interviews. At a 6-month follow-up, they completed the Dysfunctional Attitudes Scale, the Negative Automatic Thoughts Questionnaire, and the Positive Automatic Thoughts Questionnaire. Participants then completed monthly symptom severity interviews for another 6 months. Cognitive scales were correlated with current depression and predicted increases in depression over time, but were not related to mania. Although results do not support negative cognitions as a predictor of mania, they do provide support for the increasingly common use of cognitive interventions to treat bipolar depression.

Adherence to treatment of depression in active injection drug users

The impact of depression on drug users is extensive, serving as a trigger for high-risk injection practices and continued drug use. Yet the ability to retain active drug users in mental health treatment has never been tested clinically. We recruited injection drug users (IDU) for a randomized study of combined psychotherapy and pharmacotherapy for the treatment of depression. Among the 53 SCID-diagnosed depressed subjects assigned to the combined treatment group, 43.4% were "fully adherent" to treatment (75% or greater attendance at cognitive-behavioral therapy (CBT) sessions or 75% or greater adherence to the pharmacotherapy regimen). The correlation of CBT attendance and pharmacotherapy use was high (r(s) =.74). Persons with double depression (major depression plus dysthymia) were most likely to be fully adherent (p =.01); frequency of heroin use was inversely associated with adherence. Developing public health treatment interventions to engage out-of-treatment, dually-diagnosed IDUs is possible.

The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression

The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbach's alpha =.86), the IDS-SR(30) (Cronbach's alpha =.92), and the HAM-D(24) (Cronbach's alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.

Cognitive predictors of symptom return following depression treatment

This study tested whether poor cognitive change during depression treatment predicted time to return of depressive symptoms. Depressed participants (N = 121) completed assessments of dysfunctional attitudes and extreme thinking (i.e., number of totally agree and totally disagree responses) during hospitalization and again after 6 months of outpatient treatment. Participants then completed monthly depression assessments for 1 year. Survival analyses for time to symptom recurrence during follow-up were conducted among participants who reported 50% improvement in their depressive symptoms and were at least partially asymptomatic at the end of treatment (n = 53). Poor change in dysfunctional attitudes and poor change in extreme thinking both predicted shorter time to return of depressive symptoms.

Switching to reboxetine: an efficacy and safety study in patients with major depressive disorder unresponsive to fluoxetine

The aim of the present study was to evaluate the efficacy and safety of an immediate switch to reboxetine, a selective noradrenaline reuptake inhibitor (selective NRI), in patients with depression unresponsive to the selective serotonin reuptake inhibitor (SSRI) fluoxetine. The study included 128 adult outpatients with DSM-IV major depressive disorder (MDD) who had not responded to at least 6 to 12 weeks of fluoxetine treatment, with at least 3 weeks of treatment on a minimum dose of 40 mg/d. Patients were switched, without a washout period, to reboxetine 4 mg twice daily, with the possibility of increasing the dose to 10 mg/d (given in divided doses) after 4 weeks of treatment. Efficacy was assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales. Safety was evaluated by recording spontaneously reported adverse events.A statistically significant (P < 0.001) improvement in the mean total HAM-D-17 score was seen from baseline by week 1 of treatment with reboxetine, and the improvement continue to week 8. CGI-I and CGI-S scores were similarly improved. The switch to reboxetine was well tolerated; the most common treatment-emergent adverse events were insomnia, headache, dry mouth, diaphoresis, and constipation, all of which were mild to moderate in severity and decreased in frequency as the study progressed.Immediate switching to reboxetine appears to be a safe and effective treatment for patients with depression who have failed to respond to an adequate dose of fluoxetine.

Family therapy and chronic depression

Individuals with chronic depression report significant problems in multiple areas of their family functioning, suggesting the importance of combining family therapy with psychotherapy and pharmacotherapy in the treatment of their depression. We describe a model of family functioning (the McMaster model) and therapy (the Problem-Centered Systems Therapy of the Family) and its application in the treatment of a young woman with chronic depression. The key elements of the family treatment are a comprehensive assessment of the family, a systematic progression through defined treatment stages, an open, collaborative stance with the family, and a focus on the family's responsibility for change. Family therapy can aid the amelioration of depressive symptoms and improve the ability of family members to deal more effectively with the depression as well as a wider range of problems.

Patients' versus informants' reports of personality disorders in predicting 7 1/2-year outcome in outpatients with depressive disorders

Concordance between patients' and informants' reports of personality disorders (PDs) is low, raising the questions of which source provides more valid data and whether both contribute unique information. This study compared patients' and informants' reports of PDs in predicting outcome in a 7 1/2-year follow-up of 85 depressed outpatients. Patients and informants were independently evaluated using structured interviews; outcome was assessed using structured interviews with patients. Both patients' and informants' reports of PD diagnoses and dimensional scores independently predicted depression symptoms and global functioning at follow-up. However, only informants' reports made a unique contribution to predicting social adjustment. This finding indicates that both patients and informants provide unique information on Axis II psychopathology and argues for the use of both sources in the assessment of PDs.