Disordered personality style: higher rates in non-melancholic compared to melancholic depression

Sydney Melancholia Prototype Index (SMPI): translation and cross-cultural adaptation to Brazilian Portuguese

Introduction

Depression is possibly not a single syndrome but rather comprises several subtypes. DSM-5 proposes a melancholia specifier with phenotypic characteristics that could be associated with clinical progression, biological markers or therapeutic response. The Sydney Melancholia Prototype Index (SMPI) is a prototypic scale aimed to improve the diagnosis of melancholia. So far, there is only an English version of the instrument available. The aim of this study is to describe the translation and adaptation of the English version of the SMPI into Brazilian Portuguese.

Methods

Translation and cross-cultural adaptation of the self-report (SMPI-SR) and clinician-rated (SMPI-CR) versions into Brazilian Portuguese were done following recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). This guideline includes the following steps: preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, debriefing results review, proofreading and final report.

Results

The Brazilian Portuguese versions of the SMPI were well-accepted by respondents. Changes in about two-thirds of the items were considered necessary to obtain the final Brazilian Portuguese version of the SMPI.

Conclusions

Both versions of the SMPI are now available in Brazilian Portuguese. The instrument could become an important option to enhance studies on melancholia in Portuguese-speaking samples.

Melancholic features in inpatients with major depressive disorder associate with differential clinical characteristics and treatment outcomes

To determine whether the presence of melancholic features in hospitalized patients with major depressive disorder (MDD) was associated with specific clinical characteristics and treatment outcomes, supporting melancholic depression as a distinct subtype within MDD. 126 acutely ill inpatients with MDD were enrolled in an open, 6-week trial with fixed-dose fluoxetine 20mg daily. Symptom severity was assessed regularly, using the 17-item Hamilton Depression Rating Scale (HAMD-17) and Clinical Global Impression of Severity (CGI-S). Melancholic features were defined according to the DSM-IV criteria. Clinical variables were compared between patients with and without melancholic features. Generalized estimating equations method was used to explore the differences in HAMD-17 and CGI-S scores between the 2 groups over time. Clinical response was defined as having a 50% or greater reduction in HAMD-17 scores. 96 (76.2%) of the 126 patients with at least one post-baseline assessment met the criteria for melancholic depression. Melancholic depression differed from non-melancholic depression in clinical characteristics and predicted a better response to fluoxetine treatment. The differentiation between melancholic and non-melancholic depression within MDD hence is clinically significant and valid.

Clinical differences between melancholic and nonmelancholic depression as defined by the CORE system

BACKGROUND

The definition and delineation of melancholia have remained elusive for an extended period. A longstanding signal of psychomotor disturbance has been operationalized via the observer-rated CORE measure and with CORE-assigned melancholic and nonmelancholic compared in several Australian studies. Replication studies in other regions have not previously been reported. This study compares Brazilian patients with melancholic and nonmelancholic depression according to the CORE measure of psychomotor disturbance in terms of clinical characteristics, suicide ideation, stressful life events, quality of life, parental care, and personality styles.

METHODS

A total of 181 patients with unipolar major depression attending a tertiary care outpatient service in Brazil were evaluated in relation to melancholic status and study variables.

RESULTS

The CORE-assigned melancholic patients presented higher symptom severity, greater prevalence of suicide ideation, and Axis I comorbidities than nonmelancholics. Scores of dysfunctional personality styles and dysfunctional parental care measures were also higher among melancholics. Quality-of-life scores were low in both groups.

LIMITATIONS

The absence of a criterion standard for the diagnosis of melancholia and the use of medication can be potential limitations of the study.

CONCLUSION

Differences suggest that CORE-assigned melancholia defines a distinct group of patients and probably a disorder distinct from nonmelancholic depression not only in quantitative but also in qualitative aspects.

Personality differences between depressed melancholic and non-melancholic inpatients

OBJECTIVE

The aim of the present study was to confirm that non-melancholic depression corresponds to a higher degree of personality dysfunction compared to melancholia.

METHOD

A total of 188 inpatients, with a main DSM-IV diagnosis of major depressive disorder, were classified as melancholic and non-melancholic according to CORE system, DSM-IV, Research Diagnostic Criteria (RDC) Retarded Depression, and RDC Agitated Depression. Personality was assessed by means of the Temperament and Personality Questionnaire (T&P). Only patients at the nadir of their episode were included.

RESULTS

Compared to non-melancholic depressives, patients with CORE melancholia scored lower on social avoidance and higher on effectiveness and cooperativeness; patients with RDC Retarded Depression scored lower on Anxious-Worrying and Cooperativeness; patients with RDC Agitated Depression scored lower on Social Avoidance, Rejection Sensitivity and Anxious-Worrying, and higher on Effectiveness; while patients with DSM-IV melancholia scored higher on Irritability and lower on Cooperativeness. Both CORE and RDC Agitated Depression were associated with higher scores of Perfectionism.

CONCLUSIONS

The hypothesis of an association of melancholic depression with less marked personality dysfunction was confirmed for CORE melancholia and RDC Agitated Depression, and not supported for DSM-IV melancholia. Mixed evidence was obtained for RDC Retarded Depression. Personality of melancholic depressives seems to be characterized not only by less dysfunction but also by perfectionism, akin to the features of Tellenbach's typus melancholicus.

Neuropsychological impairment in major depression: its nature, origin and clinical significance

Neuropsychological impairment is well established as a feature of major depressive disorder (MDD) but studies have shown a variable pattern of impairment. This paper seeks first to clarify this by examining methodological and clinical factors that give rise to variability in study findings. Second, it examines theories of the origin of these neuropsychological abnormalities. Third, it reviews evidence regarding the clinical significance of different patterns of deficit. A selective review was undertaken of the literature with a particular emphasis on methodological factors, the influence of clinical subtypes and prevalent theories of neuropsychological abnormality. Methodological issues and the heterogeneity of MDD account for considerable variability in results. Specific investigation of the subtypes of psychotic MDD, melancholic MDD and bipolar depression reduces this heterogeneity and results are more consistent in the elderly. Hypothalamic-pituitary-adrenal axis dysfunction is associated with neuropsychological dysfunction in MDD although evidence of direct causation is not definitive at present. Impairment of executive and psychomotor function is a consistent finding, particularly in the elderly, and may reflect frontostriatal-limbic dysfunction. There is growing evidence that this may have clinical significance. It is suggested that future research take very careful account of the exact phenotype of MDD. Classification based on neuropsychological profile may, in fact, be useful. Further research should examine further the clinical importance of patterns of neuropsychological impairment.

A Taxometric Study of the Center for Epidemiological Studies Depression Scale

The authors assessed the latent structure of depressive symptoms as measured by the Center for Epidemiological Studies Depression Scale (CES-D; L. S. Radloff, 1977). By using taxometric procedures, the authors conducted analyses of CES-D data obtained from a large college student population. These procedures incorporated strategies for interpreting analyses of skewed indicators and small putative taxa. The authors hypothesized that CES-D total scores would be represented as a dimension, with a taxonic distribution of a factor incorporating somatic symptoms. Results indicated that all CES-D factors, including the factor composed of somatic complaints, were dimensional. Administration of the Diagnostic Interview Schedule-IV (L. N. Robins, L. Marcus, & W. Reich, 1996) to one quarter of the participants indicated that the CES-D was effective in identifying cases of current or recent clinical depression. Evidence of the dimensionality of CES-D indicators in a student population is consistent with a continuity view of depressive symptoms.

Duloxetine in the treatment of Major Depressive Disorder: a comparison of efficacy in patients with and without melancholic features

BACKGROUND

The most prominent feature of melancholic depression is a near-total loss of the capacity to derive pleasure from activities or other positive stimuli. Additional symptoms can include psychomotor disturbances, anorexia, excessive guilt, and early awakening from sleep. Melancholic patients may exhibit treatment responses and outcomes that differ from those of non-melancholic patients. Pooled data from double-blind, placebo-controlled studies were utilized to compare the efficacy of duloxetine in depressed patients with and without melancholic features.

METHODS

Efficacy data were pooled from 8 double-blind, placebo-controlled clinical trials of duloxetine. The presence of melancholic features (DSM-IV criteria) was determined using results from the Mini International Neuropsychiatric Interview (MINI). Patients (aged >or= 18 years) meeting DSM-IV criteria for major depressive disorder (MDD) received duloxetine (40-120 mg/d; melancholic, N = 759; non-melancholic, N = 379) or placebo (melancholic, N = 519; non-melancholic, N = 256) for up to 9 weeks. Efficacy measures included the 17-item Hamilton Rating Scale for Depression (HAMD17) total score, HAMD17 subscales (Maier, anxiety, retardation, sleep), the Clinical Global Impression of Severity (CGI-S) and Patient Global Impression of Improvement (PGI-I) scales, and Visual Analog Scales (VAS) for pain.

RESULTS

In data from all 8 studies, duloxetine's advantage over placebo did not differ significantly between melancholic and non-melancholic patients (treatment-by-melancholic status interactions were not statistically significant). Duloxetine demonstrated significantly greater improvement in depressive symptom severity, compared with placebo, within both melancholic and non-melancholic cohorts (p <or= .001 for HAMD17 total score, CGI-S and PGI-I). When analyzed by gender, the magnitude of improvement in efficacy outcomes did not differ significantly between duloxetine-treated male and female melancholic patients. In the two studies that assessed duloxetine 60 mg once-daily dosing, duloxetine-treated melancholic patients had significantly greater improvement compared with placebo on HAMD17 total score, CGI-S, PGI-I, 3 of 4 subscales of the HAMD17, and VAS overall pain severity (p < .01). Estimated probabilities of response and remission were significantly greater for melancholic patients receiving duloxetine 60 mg QD compared with placebo (response 74.7% vs. 42.2%, respectively, p < .001; remission 44.4% vs. 24.7%, respectively, p = .002.

CONCLUSIONS

In this analysis of pooled data, the efficacy of duloxetine in patients with melancholic features did not differ significantly from that observed in non-melancholic patients.

Epidemiology of personality disorders

Epidemiology is concerned with the occurrence of disease in populations. Epidemiologic studies measure the prevalence and distribution of disorders, investigate questions of case definition, determine risk factors, and evaluate the natural history and consequences of disorders. This paper reviews and discusses empiric advances made over the past 2 years in the epidemiologic study of personality disorders.

Predictors of 1-year outcome in depression

OBJECTIVE

We compared several different methods for assessing depression 'recovery' over a 1-year review interval, to determine the utility of the contrasting approaches. Second, we assessed baseline predictors of 1-year outcome and recovery status. Third, we examined the extent to which predictors showed consistency across the variable definitions of outcome and recovery.

METHODS

Twelve-month outcome was assessed in a sample of 182 subjects who at baseline assessment met DSM criteria for a major depressive episode. The contrasting methods involved a defined percentage reduction in Beck Depression Inventory self-rating scores, formalised change point definitions, no longer meeting DSM-IV major depression criteria, and clinical global improvement (CGI) ratings.

RESULTS

Sixty-one per cent reached formalised change point criteria for full remission or recovery when trajectories across the 12-month interval were examined. Other measures quantified recovery rates ranging from 43% to 70%. Those with a psychotic or melancholic depression were more likely to have achieved recovery status in some analyses. Non-recovery at 12 months was predicted most consistently by higher baseline levels of anxiety and depression; high trait anxiety and a lifetime anxiety disorder; disordered personality function; and having reported exposure to acute and enduring stressors at baseline assessment.

CONCLUSIONS

While the CGI was the superior system in terms of number of significant discriminating predictors of outcome, the change point definitional approach provides much greater information across the follow-up interval, arguing for their complementary utility. As several currently identified baseline predictors of outcome (i.e. anxiety, disordered personality function) also predicted onset of depression, their relevance as both depression-inducing and depression-propagating variables is suggested.

'Acting out' and 'acting in' behavioural stress responses: the relevance of anxiety and personality style

OBJECTIVE

To look for links between 'acting out' and 'acting in' behavioural stress responses with anxiety and disordered personality function.

METHOD

Depressed patients completed a self-report measure of behavioural responses to stress 1 year after baseline assessment of anxiety levels, personality functioning and other study variables.

RESULTS

Patients were assigned to four factorial groups on the basis of variable 'acting out' and 'acting in' scale scores, and effects of individual scale scores also examined. 'Acting in' styles were indicative of high trait anxiety, disordered personality functioning and, in particular, a Cluster C personality disorder style. 'Acting out' was linked most clearly with a Cluster B personality disorder style.

CONCLUSIONS

We demonstrate links between behavioural stress responses and anxiety levels and disordered personality functioning. Assessing behavioural stresses responses may shape the clinical expression of some depressive disorders and inform the clinician about the likely salience of anxiety and personality styles.