Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: effects on personality

A randomized controlled trial of desvenlafaxine-induced structural brain changes in the treatment of persistent depressive disorder

The anatomical changes that antidepressant medications induce in the brain and through which they exert their therapeutic effects remain largely unknown. We randomized 61 patients with Persistent Depressive Disorder (PDD) to receive either desvenlafaxine or placebo in a 12-week trial and acquired anatomical MRI scans in 42 of those patients at baseline before randomization and immediately at the end of the trial. We also acquired MRIs once in 39 age- and sex-matched healthy controls. We assessed whether the serotonin-norepinephrine reuptake inhibitor, desvenlafaxine, differentially changed cortical thickness during the trial compared with placebo. Patients relative to controls at baseline had thinner cortices across the brain. Although baseline thickness was not associated with symptom severity, thicker baseline cortices predicted greater reduction in symptom severity in those treated with desvenlafaxine but not placebo. We did not detect significant treatment-by-time effects on cortical thickness. These findings suggest that baseline thickness may serve as predictive biomarkers for treatment response to desvenlafaxine. The absence of treatment-by-time effects may be attributable either to use of insufficient desvenlafaxine dosing, a lack of desvenlafaxine efficacy in treating PDD, or the short trial duration.

Pharmacological strategies for the management of the antisocial personality disorder

INTRODUCTION

Antisocial personality disorder (AsPD) is a pervasive pattern of violation of others' rights, related to the concept of psychopathy. AsPD is stable over time from adolescence, with evidence of conduct disorder (CD) before 15 years. DSM-5 included a specifier 'with limited prosocial emotions' (LPE), which characterizes adolescents with higher developmental vulnerability to develop AsPD. Despite being relatively frequent with considerable societal impact, AsPD is a difficult-to-treat condition with high comorbidity rates and poor evidence for effective pharmacological interventions.

AREAS COVERED

We conducted a narrative review and searched PubMed up to September 2022. We included RCTs and naturalistic studies evaluating pharmacological interventions on AsPD in adults, including those with comorbid substance use disorder or psychopathic traits. Evidence in youths with CD, callous-unemotional (CU) traits and aggression were also reviewed, exploring the role of CU traits as moderators of response.

EXPERT OPINION

Psychosocial interventions are the first option, with possible improvement of CU traits, beyond behavioral and affective symptoms, particularly if implemented early during development. Limited information, based on low-quality studies, supports the pharmacological options. Second-generation antipsychotics, lithium, anti-epileptic drugs, and stimulants are first-line medications, according to different target symptoms. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Serotonin-norepinephrine reuptake inhibitor antidepressant effects on regional connectivity of the thalamus in persistent depressive disorder: evidence from two randomized, double-blind, placebo-controlled clinical trials

Previous neuroimaging studies have shown that serotonin-norepinephrine reuptake inhibitor antidepressants alter functional activity in large expanses of brain regions. However, it is not clear how these regions are systemically organized on a connectome level with specific topological properties, which may be crucial to revealing neural mechanisms underlying serotonin-norepinephrine reuptake inhibitor treatment of persistent depressive disorder. To investigate the effect of serotonin-norepinephrine reuptake inhibitor antidepressants on brain functional connectome reconfiguration in persistent depressive disorder and whether this reconfiguration promotes the improvement of clinical symptoms, we combined resting-state functional magnetic resonance imaging (fMRI) scans acquired in two randomized, double-blind, placebo-controlled trial studies of serotonin-norepinephrine reuptake inhibitor antidepressant treatment of patients with persistent depressive disorder. One was a randomized, double-blind, placebo-controlled trial of 10-week duloxetine medication treatment, which included 17 patients in duloxetine group and 17 patients in placebo group (ClinicalTrials.gov Identifier: NCT00360724); the other one was a randomized, double-blind, placebo-controlled trial of 12-week desvenlafaxine medication treatment, which included 16 patients in desvenlafaxine group and 15 patients in placebo group (ClinicalTrials.gov Identifier: NCT01537068). The 24-item Hamilton Depression Rating Scale was used to measure clinical symptoms, and graph theory was employed to examine serotonin-norepinephrine reuptake inhibitor antidepressant treatment effects on the topological properties of whole-brain functional connectome of patients with persistent depressive disorder. We adopted a hierarchical strategy to examine the topological property changes caused by serotonin-norepinephrine reuptake inhibitor antidepressant treatment, calculated their small-worldness, global integration, local segregation and nodal clustering coefficient in turn. Linear regression analysis was used to test associations of treatment, graph properties changes and clinical symptom response. Symptom scores were more significantly reduced after antidepressant than placebo administration (η 2 = 0.18). There was a treatment-by-time effect that optimized the functional connectome in a small-world manner, with increased global integration and increased nodal clustering coefficient in the bilateral thalamus (left thalamus η 2 = 0.21; right thalamus η 2 = 0.23). The nodal clustering coefficient increment of the right thalamus (ratio = 29.86; 95% confidence interval, -4.007 to -0.207) partially mediated the relationship between treatment and symptom improvement, and symptom improvement partially mediated (ratio = 21.21; 95% confidence interval, 0.0243-0.444) the relationship between treatment and nodal clustering coefficient increments of the right thalamus. Our study may indicate a putative mutually reinforcing association between nodal clustering coefficient increment of the right thalamus and symptom improvement from serotonin-norepinephrine reuptake inhibitor antidepressant treatments with duloxetine or desvenlafaxine.

Pharmacological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with rule-breaking, criminality, substance use, unemployment, relationship difficulties, and premature death. Certain types of medication (drugs) may help people with AsPD. This review updates a previous Cochrane review, published in 2010.

OBJECTIVES

To assess the benefits and adverse effects of pharmacological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also checked reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials in which adults (age 18 years and over) with a diagnosis of AsPD or dissocial personality disorder were allocated to a pharmacological intervention or placebo control condition.

DATA COLLECTION AND ANALYSIS

Four authors independently selected studies and extracted data. We assessed risk of bias and created 'Summary of findings tables' and assessed the certainty of the evidence using the GRADE framework. The primary outcomes were: aggression; reconviction; global state/global functioning; social functioning; and adverse events.

MAIN RESULTS

We included 11 studies (three new to this update), involving 416 participants with AsPD. Most studies (10/11) were conducted in North America. Seven studies were conducted exclusively in an outpatient setting, one in an inpatient setting, and one in prison; two studies used multiple settings. The average age of participants ranged from 28.6 years to 45.1 years (overall mean age 39.6 years). Participants were predominantly (90%) male. Study duration ranged from 6 to 24 weeks, with no follow-up period. Data were available from only four studies involving 274 participants with AsPD. All the available data came from unreplicated, single reports, and did not allow independent statistical analysis to be conducted. Many review findings were limited to descriptive summaries based on analyses carried out and reported by the trial investigators. No study set out to recruit participants on the basis of having AsPD; many participants presented primarily with substance abuse problems. The studies reported on four primary outcomes and six secondary outcomes. Primary outcomes were aggression (six studies) global/state functioning (three studies), social functioning (one study), and adverse events (seven studies). Secondary outcomes were leaving the study early (eight studies), substance misuse (five studies), employment status (one study), impulsivity (one study), anger (three studies), and mental state (three studies). No study reported data on the primary outcome of reconviction or the secondary outcomes of quality of life, engagement with services, satisfaction with treatment, housing/accommodation status, economic outcomes or prison/service outcomes.   Eleven different drugs were compared with placebo, but data for AsPD participants were only available for five comparisons. Three classes of drug were represented: antiepileptic; antidepressant; and dopamine agonist (anti-Parkinsonian) drugs. We considered selection bias to be unclear in 8/11 studies, attrition bias to be high in 7/11 studies, and performance bias to be low in 7/11 studies. Using GRADE, we rated the certainty of evidence for each outcome in this review as very low, meaning that we have very little confidence in the effect estimates reported. Phenytoin (antiepileptic) versus placebo One study (60 participants) reported very low-certainty evidence that phenytoin (300 mg/day), compared to placebo, may reduce the mean frequency of aggressive acts per week (phenytoin mean = 0.33, no standard deviation (SD) reported; placebo mean = 0.51, no SD reported) in male prisoners with aggression (skewed data) at endpoint (six weeks). The same study (60 participants) reported no evidence of difference between phenytoin and placebo in the number of participants reporting the adverse event of nausea during week one (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.06 to 16.76; very low-certainty evidence). The study authors also reported that no important side effects were detectable via blood cell counts or liver enzyme tests (very low-certainty evidence). The study did not measure reconviction, global/state functioning or social functioning. Desipramine (antidepressant) versus placebo One study (29 participants) reported no evidence of a difference between desipramine (250 to 300 mg/day) and placebo on mean social functioning scores (desipramine = 0.19; placebo = 0.21), assessed with the family-social domain of the Addiction Severity Index (scores range from zero to one, with higher values indicating worse social functioning), at endpoint (12 weeks) (very low-certainty evidence). Neither of the studies included in this comparison measured the other primary outcomes: aggression; reconviction; global/state functioning; or adverse events. Nortriptyline (antidepressant) versus placebo One study (20 participants) reported no evidence of a difference between nortriptyline (25 to 75 mg/day) and placebo on mean global state/functioning scores (nortriptyline = 0.3; placebo = 0.7), assessed with the Symptom Check List-90 (SCL-90) Global Severity Index (GSI; mean of subscale scores, ranging from zero to four, with higher scores indicating greater severity of symptoms), at endpoint (six months) in men with alcohol dependency (very low-certainty evidence). The study measured side effects but did not report data on adverse events for the AsPD subgroup. The study did not measure aggression, reconviction or social functioning. Bromocriptine (dopamine agonist) versus placebo One study (18 participants) reported no evidence of difference between bromocriptine (15 mg/day) and placebo on mean global state/functioning scores (bromocriptine = 0.4; placebo = 0.7), measured with the GSI of the SCL-90 at endpoint (six months) (very low-certainty evidence). The study did not provide data on adverse effects, but reported that 12 patients randomised to the bromocriptine group experienced severe side effects, five of whom dropped out of the study in the first two days due to nausea and severe flu-like symptoms (very low-certainty evidence). The study did not measure aggression, reconviction and social functioning. Amantadine (dopamine agonist) versus placebo The study in this comparison did not measure any of the primary outcomes.

AUTHORS' CONCLUSIONS

The evidence summarised in this review is insufficient to draw any conclusion about the use of pharmacological interventions in the treatment of antisocial personality disorder. The evidence comes from single, unreplicated studies of mostly older medications. The studies also have methodological issues that severely limit the confidence we can draw from their results. Future studies should recruit participants on the basis of having AsPD, and use relevant outcome measures, including reconviction.

Reinforcement sensitivity, depression and anxiety: A meta-analysis and meta-analytic structural equation model

Reinforcement Sensitivity Theory (RST) posits that individual differences in reward and punishment processing predict differences in cognition, behavior, and psychopathology. We performed a quantitative review of the relationships between reinforcement sensitivity, depression and anxiety, in two separate sets of analyses. First, we reviewed 204 studies that reported either correlations between reinforcement sensitivity and self-reported symptom severity or differences in reinforcement sensitivity between diagnosed and healthy participants, yielding 483 effect sizes. Both depression (Hedges' g = .99) and anxiety (g = 1.21) were found to be high on punishment sensitivity. Reward sensitivity negatively predicted only depressive disorders (g = -.21). More severe clinical states (e.g., acute vs remission) predicted larger effect sizes for depression but not anxiety. Next, we reviewed an additional 39 studies that reported correlations between reinforcement sensitivity and both depression and anxiety, yielding 156 effect sizes. We then performed meta-analytic structural equation modeling to simultaneously estimate all covariances and control for comorbidity. Again we found punishment sensitivity to predict depression (β = .37) and anxiety (β = .35), with reward sensitivity only predicting depression (β = -.07). The transdiagnostic role of punishment sensitivity and the discriminatory role of reward sensitivity support a hierarchical approach to RST and psychopathology.

Desvenlafaxine vs. placebo in the treatment of persistent depressive disorder

INTRODUCTION

Pharmacotherapy of non-major persistent depressive disorder (PDD) is little studied. We report a study of the serotonin-norepinephrine reuptake inhibitor (SNRI) desvenlafaxine (DVLX) for PDD.

METHOD

Non-psychotic, non-bipolar outpatients aged 20-65 having PDD without concurrent major depression (MDD) were randomized double-blind to desvenlafaxine or placebo for 12 weeks. All had Hamilton Depression Rating Scale (HDRS-24) score ≥ 12. Open-label DVLX was offered for 12 weeks following the acute trial.

RESULTS

Seventy-one subjects having mean baseline HDRS-24 20.27 ± 4.77 were eligible, of whom post-RZ data was available for all 59 randomized. The primary 12 week analysis did not differentiate DVLX-treated subjects' mean HDRS scores from those on placebo (6.53 ± 3.98 vs. 8.24 ± 4.96, F = 3.33, df = 1, p = .07). Several secondary analyses yielded statistically significant results, including Responder, CGI and QIDS.

DISCUSSION

As the primary analysis did not reach statistical significance, this is a negative study which does not support the use of DVLX for non-major PDD. Nevertheless, statistically significant secondary analyses suggest the overall negative result could be due to sample size or sampling, suggesting further studies of this medication might be appropriate in this population.

Temperament and character in patients with acute abdominal pain

BACKGROUND

Several conditions presenting with abdominal pain are associated with specific personality factors although it is unclear if this is true also in emergency clinic settings.

OBJECTIVE

To study personality factors among patients with acute abdominal pain in an emergency ward.

METHODS

Consecutive patients (N = 165) with abdominal symptoms at an emergency clinic were administrated the Temperament and Character Inventory (TCI). Three main groups were identified; specific abdominal diagnoses, (N = 77), non-specific abdominal pain, (N = 67) and organic dyspepsia (N = 21). TCI results were compared between clinical groups and a control group (N = 122).

RESULTS

As compared to individuals with specific abdominal diagnoses and controls, those with organic dyspepsia were significantly more anxious (harm avoidance), (p = 0.003), and had lower ability to cooperate (cooperativeness) (p = 0.048 and p = 0.004 respectively). They were also significantly more unpretentious (self-transcendence) compared to individuals with specific abdominal diagnoses (p = 0.048), non-specific abdominal pain (p = 0.012) and controls (p = 0.004) and evidenced less mature character (sum of self-directedness and cooperativeness) compared to those with specific abdominal diagnoses and controls (p = 0.003).

CONCLUSION

Individuals seeking care at an emergency clinic with organic dyspepsia showed a distinguishable pattern of personality features that distinguished them from the other comparison groups. Therefore an evaluation of personality factors may add a new dimension to the diagnostic investigation in the emergency care of abdominal pain and contribute to the optimization of the treatment of organic dyspepsia.

Do social functioning and symptoms improve with continuation antidepressant treatment of persistent depressive disorder? An observational study

OBJECTIVE

To determine efficacy of continued treatment with the serotonin norepinephrine reuptake inhibitor duloxetine on symptom reduction and functional improvement in outpatients with dysthymia.

METHOD

Fifty outpatients with DSM-IV-TR diagnosed dysthymia who had participated in a 10 week double-blind, placebo-controlled study of duloxetine received open treatment for three months. Nineteen duloxetine responders continued duloxetine, 24 patients initially treated with placebo started open duloxetine treatment, and 7 duloxetine non-responders were treated with desvenlafaxine or bupropion, selected by clinician choice.

RESULTS

Patients continuing duloxetine maintained symptom improvement, 84% meeting response and 63% remission criteria at week 22. Patients initially treated with placebo showed similarly high levels of response (83%) and remission (62%) at week 22, and most duloxetine non-responders subsequently responded to other antidepressants. Duloxetine-continuation patients improved modestly between weeks 10 and 22 on measures of social and cognitive functioning and temperament. Despite this improvement concurrently across several functional domains, 66.7% of patients continuing duloxetine remained in the impaired range of functioning according to the Social Adjustment Scale (SAS).

CONCLUSIONS

Continued duloxetine treatment appears to be effective in maintaining symptom response in dysthymic disorder, and has positive effects on social functioning. However, the majority of patients do not show normalization of functioning, even when controlling for remission status. Additional treatments should be considered to target residual impairments in social functioning in mood remitted patients with persistent depressive disorder.

Personality, Psychopathology, and Psychotherapy: A Pre-specified Analysis Protocol for Confirmatory Research on Personality-Psychopathology Associations in Psychotherapy Outpatients

The role of personality trait variation in psychopathology and its influence on the outcome of psychotherapy is a burgeoning field. However, thus far most findings were based on controlled clinical trials that may only poorly represent real-world clinical settings due to highly selective samples mostly restricted to patients with major depression undergoing antidepressive medication. Focusing on personality and psychopathology in a representative naturalistic sample of psychotherapy patients is therefore worthwhile. Moreover, up to date hardly any confirmatory research has been conducted in this field. Strictly confirmatory research implies two major requirements: firstly, specific hypotheses, including expected effect sizes and statistical approaches to data analysis, must be detailed prior to inspection of the data, and secondly, corresponding protocols have to be published online and freely available. Here, we introduce a longitudinal naturalistic study aimed at examining, firstly, the prospective impact of baseline personality traits on the outcome of psychotherapy over a 6-month observation period; secondly, the stability and change in personality traits over time; thirdly, the association between longitudinal change in psychopathology and personality; fourthly, the agreement between self-reports and informant rating of personality; and fifthly, the predictive validity of personality self-reports compared to corresponding informant ratings. For it, we comprehensively state a priori hypotheses, predict the expected effect sizes and detail the statistical analyses that we intend to conduct to test these predictions. Such a stringent confirmatory design increases the transparency and objectivity of psychopathological research, which is necessary to reduce the rate of false-positive findings and to increase the yield of scientific research.

Psychotropic drugs and personality changes: A case of lithium

BACKGROUND

The effect of psychopharmacological treatment on personality has been mostly studied with antidepressant drugs. Previously, we demonstrated an association between long-term lithium response and affective temperaments measured by the Temperament Scale of Memphis, Pisa, Paris and San Diego-Autoquestionnaire (TEMPS-A), and schizotypic traits, measured by the Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE). Therefore, we were interested whether long-term lithium treatment per se may influence personality traits measured by these scales.

METHODS

The study was performed on 40 patients with bipolar mood disorder (16 male, 24 female) with a mean age of 46 ± 10 years, either hospitalized or attending the outpatient clinic, Department of Adult Psychiatry, Poznan University of Medical Sciences. Among them, twenty patients (8 male, 12 female) have received lithium for 10-33 years, and twenty (8 male, 12 female) have never been exposed to lithium and have been given other mood-stabilizing drugs. Each patient, had the assessment made by the TEMPS-A and O-LIFE, during euthymic state.

RESULTS

Patients on long-term lithium treatment were significantly older and had longer duration of bipolar illness compared with non-lithium patients. Lithium-treated patients obtained significantly lower scores of cyclothymic and irritable temperaments on the TEMPS-A, and of unusual experiences, cognitive disorganization and impulsive nonconformity on the O-LIFE.

CONCLUSIONS

It is hypothesized that the differences in personality, revealed by the TEMPS-A and O-LIFE scales, are related to the long-term treatment with lithium. The decrease in cyclothymic temperament and in cognitive disorganization trait were previously shown to be associated with the therapeutic effect of lithium.

WITHDRAWN: Drugs versus placebo for dysthymia

This review has been withdrawn due to non‐compliance with Cochrane's Commercial Sponsorship Policy.

The editorial group responsible for this previously published document have withdrawn it from publication.

Behavioral activation therapy for return to work in medication-responsive chronic depression with persistent psychosocial dysfunction

OBJECTIVE

Chronic depression is associated with significant impairment in work functioning, relationships, and health. Such impairment often persists following medication-induced remission of depressive symptoms. We adapted and tested Behavioral Activation therapy with a goal of return to work (BA-W) in subjects with chronic depression who had responded to medication treatment but remained unemployed.

METHOD

Sixteen adults aged 18-65 with DSM-IV diagnosed Dysthymic Disorder or chronic Major Depression were recruited from clinical trials taking place at the New York State Psychiatric Institute between 4/2009 and 12/2012 and enrolled in 12 weeks of individual manual-driven BA-W. Functioning was measured at intake, post-treatment and at 24 week follow-up.

RESULTS

Eighty-seven percent (n=14) of subjects completed the full 12 weeks of BA-W. Hours of work related activity (p<.005, d=0.83), hours of paid work (p<.0003, d=0.54), and work productivity (p<.0004, d=-0.48) increased significantly over the study period. Earned income increased post-treatment (p=.068) with significant changes by 24 week follow-up (p=.011). Secondary outcomes including behavioral avoidance (p<.004, d=-0.56), and global functioning (p<.0003, d=1.42) were also significantly improved post-treatment. Effect sizes, including for outcomes with non-significant changes, were generally in the range of 0.5-0.8.

CONCLUSIONS

This pilot study provides preliminary evidence of the efficacy of a work-targeted psychotherapy to remediate vocational impairment in subjects with chronic depression. Data suggests that further testing of BA-W using a randomized controlled trial is warranted and may represent a significant advance in treatment for the residual disability present after successful pharmacotherapy.

Borderline personality disorder and chronic pain: a practical approach to evaluation and treatment

Patients with chronic pain present a spectrum of complexity that can be overwhelming for the individual practitioner. These patients require thoughtful care and a comprehensive treatment plan. This complexity should be acknowledged, not avoided, and the patient should be engaged, not shunned. A practical approach will assist in developing expertise and proceeding empathically. The presence of a superimposed personality disorder significantly increases the difficulty of caring for these patients. Studies investigating the prevalence of borderline personality disorder in patients with chronic pain averaged 30 %, highlighting the importance of being able to effectively treat this patient population. Appropriate management of these patients should focus on a collaboration to practice productive behaviors despite intense emotional distress. Longitudinal research provides a foundation for an optimistic prognosis that can be enhanced with this rehabilitative approach.

Two-year stability and change of neuroticism and extraversion in treated and untreated persons with depression: findings from the Netherlands Study of Depression and Anxiety (NESDA)

BACKGROUND

The personality dimensions neuroticism and extraversion likely represent part of the vulnerability to depression. The stability over longer time periods of these personality dimensions in depressed patients treated with psychological treatment or medication and in untreated persons with depression in the general population remains unclear. Stability of neuroticism and extraversion in treated and untreated depressed persons would suggest that part of the vulnerability to depression remains stable over time. The current study addressed the question whether treatment in depressed patients is related to changes in neuroticism and extraversion.

METHODS

Data are from 709 patients with major depressive disorder participating in a cohort study (Netherlands Study of Depression and Anxiety; NESDA). We determined the 2-year stability of extraversion and neuroticism in treated and untreated persons and related change in depression severity to change in personality over time.

RESULTS

Neuroticism decreased from baseline to 2-year follow-up (d=0.73) in both treated and untreated persons. Extraversion did not change significantly after controlling for neuroticism and depression severity at baseline and follow-up. Decreased depressive symptoms over time were related to decreased neuroticism (d=1.91) whereas increased depressive symptoms over time were unrelated to neuroticism (d=0.06).

LIMITATIONS

Patients were not randomized to treatment conditions and the groups are therefore not directly comparable.

CONCLUSIONS

Treated patients with depression in the general population improve just as much on depression severity and neuroticism as untreated persons with depression. This suggests that changes in neuroticism in the context of treatment likely represent mood-state effects rather than direct effects of treatment.

Trait anxiety levels before and after antidepressant treatment: a 3-wave cohort study

The aim of this study was to examine change in "trait anxiety" levels assessed repeatedly before and after antidepressant treatment in a large cohort of men and women. A total of 18,732 participants of the Finnish Public Sector Study with no initial record of depression or self-reported doctor diagnosis of depression completed the short form of the Spielberger Trait-Anxiety Inventory in 2000-2002 (T1), 2004-2005 (T2), and 2008-2009 (T3). We used prescription data from the nationwide Drug Prescription Register to identify antidepressant treatment between T1 and T2 (n = 710). Both men (β = 0.435, P < 0.001) and women (β = 0.300, P < 0.001) who received antidepressant treatment had higher trait anxiety levels at T1. Mixed models analyses of repeated measures showed a small but statistically significant decrease in trait anxiety scores for the overall sample of men (β = 0.023, P = 0.033) and women (β = 0.011, P = 0.031) between T1 and T3. The interaction term between time and antidepressant treatment status suggested a greater decrease in trait anxiety levels among men receiving antidepressant treatment, with an adjusted excess decrease in mean trait anxiety scores of 0.163 (P = 0.012) between T1 and T3. We found some evidence suggesting that this is also the case in women, although the evidence in our data was less consistent for women. This large-scale study provides evidence suggesting that antidepressant treatment is associated with a reduction in trait anxiety levels, particularly in men.

Antidepressants normalize the default mode network in patients with dysthymia

IMPORTANCE

The default mode network (DMN) is a collection of brain regions that reliably deactivate during goal-directed behaviors and is more active during a baseline, or so-called resting, condition. Coherence of neural activity, or functional connectivity, within the brain's DMN is increased in major depressive disorder relative to healthy control (HC) subjects; however, whether similar abnormalities are present in persons with dysthymic disorder (DD) is unknown. Moreover, the effect of antidepressant medications on DMN connectivity in patients with DD is also unknown.

OBJECTIVE

To use resting-state functional-connectivity magnetic resonance imaging (MRI) to study (1) the functional connectivity of the DMN in subjects with DD vs HC participants and (2) the effects of antidepressant therapy on DMN connectivity.

DESIGN

After collecting baseline MRI scans from subjects with DD and HC participants, we enrolled the participants with DD into a 10-week prospective, double-blind, placebo-controlled trial of duloxetine and collected MRI scans again at the conclusion of the study. Enrollment occurred between 2007 and 2011.

SETTING

University research institute.

PARTICIPANTS

Volunteer sample of 41 subjects with DD and 25 HC participants aged 18 to 53 years. Control subjects were group matched to patients with DD by age and sex.

MAIN OUTCOME MEASURES

We used resting-state functional-connectivity MRI to measure the functional connectivity of the brain's DMN in persons with DD compared with HC subjects, and we examined the effects of treatment with duloxetine vs placebo on DMN connectivity.

RESULTS

Of the 41 subjects with DD, 32 completed the clinical trial and MRI scans, along with the 25 HC participants. At baseline, we found that the coherence of neural activity within the brain's DMN was greater in persons with DD compared with HC subjects. Following a 10-week clinical trial, we found that treatment with duloxetine, but not placebo, normalized DMN connectivity.

CONCLUSIONS AND RELEVANCE

The baseline imaging findings are consistent with those found in patients with major depressive disorder and suggest that increased connectivity within the DMN may be important in the pathophysiology of both acute and chronic manifestations of depressive illness. The normalization of DMN connectivity following antidepressant treatment suggests an important causal pathway through which antidepressants may reduce depression.

Personality and depression: evidence of a possible mediating role for anger trait in the relationship between cooperativeness and depression

BACKGROUND

An increasingly growing area of empirical research has found consistent links between anger, depression, and temperament and character domains of personality, separately. However, precise nature of these relationships remains still unclear, and little is known about its underlying processes.

OBJECTIVES

The aim of our explorative research was to conduct a more detailed investigation into the relationships among depression, anger trait, and personality characteristics based on Cloninger's 7-factor personality theory in healthy individuals.

METHOD

In this preliminary study, 230 Italian undergraduates were investigated by using the Temperament and Character Inventory-Revised, the State-Trait Anger Expression Inventory-2, and the Beck Depression Inventory-II. Depression and cooperativeness were expected to have a negative and significant relationship and separate relationships with the trait-anger. Theoretically, a new hypothesis was that the trait-anger would mediate the relationship between depression and cooperativeness.

RESULTS

Zero-order and partial correlations and a path analysis based on Baron and Kenny's method (J Pers Soc Psychol.1986;51:1173-1182) for calculating multiple regression analyses were calculated. Consistent with the hypotheses, cooperativeness and depression were strongly associated; the trait-anger was significantly associated with both cooperativeness and depression, and the mediation model fit the data.

CONCLUSIONS

Behaviors related to the trait-anger could help to explain how depression and reduced cooperativeness are related each other.

Do antidepressants change personality?--a five-year observational study

BACKGROUND

Whether antidepressants influence personality is a major clinical and societal issue due to their widespread use. In an observational study, we investigated whether depressive patients' neuroticism and extraversion scores covary with antidepressant pharmacotherapy, and if so, whether this remains significant after accounting for depressive or anxiety symptoms.

METHODS

Major depressive disorder patients (N=237) were interviewed at up to four time-points in a five-year prospective longitudinal study. Changes in neuroticism plus extraversion scores were compared with changes in antidepressant pharmacotherapies and depressive plus anxiety symptoms to uncover any covariation between them. Autoregressive path models were used to examine this covariation at the sample level. Within-subject change was estimated using a random-effects latent change model.

RESULTS

Significant covariation is present in the change trajectories between personality scores and depressive symptoms; declining depression scores were associated with rising extraversion and declining neuroticism. Although the personality scores of many patients changed significantly over the five-year study, none of these changes were associated with changes in antidepressant pharmacotherapy.

LIMITATIONS

The study covered only two dimensions of personality. Single drug-specific analysis could not be done. Antidepressant blood levels were not measured.

CONCLUSION

No evidence emerged for significant covariation of antidepressant pharmacotherapy with neuroticism or extraversion scores. By contrast, changes in both personality dimensions were associated with changes in depressive symptoms, those in neuroticism also in anxiety symptoms. If antidepressants influence these personality dimensions, the effect size is likely markedly smaller than that of the disorders for which they are prescribed.

Pharmacological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with a wide range of disturbance including persistent rule-breaking, criminality, substance misuse, unemployment, homelessness and relationship difficulties.

OBJECTIVES

To evaluate the potential beneficial and adverse effects of pharmacological interventions for people with AsPD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to September 2009), EMBASE (1980 to 2009, week 37), CINAHL (1982 to September 2009), PsycINFO (1872 to September 2009) , ASSIA (1987 to September 2009) , BIOSIS (1985 to September 2009), COPAC (September 2009), National Criminal Justice Reference Service Abstracts (1970 to July 2008), Sociological Abstracts (1963 to September 2009), ISI-Proceedings (1981 to September 2009), Science Citation Index (1981 to September 2009), Social Science Citation Index (1981 to September 2009), SIGLE (1980 to April 2006), Dissertation Abstracts (September 2009), ZETOC (September 2009) and the metaRegister of Controlled Trials (September 2009).

SELECTION CRITERIA

Controlled trials in which participants with AsPD were randomly allocated to a pharmacological intervention and a placebo control condition. Two trials comparing one drug against another without a placebo control are reported separately.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies. Two review authors independently extracted data. We calculated mean differences, with odds ratios for dichotomous data.

MAIN RESULTS

Eight studies met the inclusion criteria involving 394 participants with AsPD. Data were available from four studies involving 274 participants with AsPD. No study set out to recruit participants solely on the basis of having AsPD, and in only one study was the sample entirely of AsPD participants. Eight different drugs were examined in eight studies. Study quality was relatively poor. Inadequate reporting meant the data available were generally insufficient to allow any independent statistical analysis. The findings are limited to descriptive summaries based on analyses carried out and reported by the trial investigators. All the available data were derived from unreplicated single reports. Only three drugs (nortriptyline, bromocriptine, phenytoin) were effective compared to placebo in terms of improvement in at least one outcome. Nortriptyline was reported in one study as superior for men with alcohol dependency on mean number of drinking days and on alcohol dependence, but not for severity of alcohol misuse or on the patient's or clinician's rating of drinking. In the same study, both nortriptyline and bromocriptine were reported as superior to placebo on anxiety on one scale but not on another. In one study, phenytoin was reported as superior to placebo on the frequency and intensity of aggressive acts in male prisoners with impulsive (but not premeditated) aggression. In the remaining two studies, both amantadine and desipramine were not superior to placebo for adults with opioid and cocaine dependence, and desipramine was not superior to placebo for men with cocaine dependence.

AUTHORS' CONCLUSIONS

The body of evidence summarised in this review is insufficient to allow any conclusion to be drawn about the use of pharmacological interventions in the treatment of antisocial personality disorder.

Personality change during depression treatment: a placebo-controlled trial

CONTEXT

High neuroticism is a personality risk factor that reflects much of the genetic vulnerability to major depressive disorder (MDD), and low extraversion may increase risk as well. Both have been linked to the serotonin system.

OBJECTIVES

To test whether patients with MDD taking selective serotonin reuptake inhibitors (SSRIs) report greater changes in neuroticism and extraversion than patients receiving inert placebo, and to examine the state effect hypothesis that self-reported personality change during SSRI treatment is merely a change of depression-related measurement bias.

DESIGN

A placebo-controlled trial.

SETTING

Research clinics. Patients Adult patients with moderate to severe MDD randomized to receive paroxetine (n = 120), placebo (n = 60), or cognitive therapy (n = 60).

OUTCOME MEASURES

NEO Five-Factor Inventory and Hamilton Rating Scale for Depression.

RESULTS

Patients who took paroxetine reported greater personality change than placebo patients, even after controlling for depression improvement (neuroticism, P < .001; extraversion, P = .002). The advantage of paroxetine over placebo in antidepressant efficacy was no longer significant after controlling for change in neuroticism (P = .46) or extraversion (P = .14). Patients taking paroxetine reported 6.8 times as much change on neuroticism and 3.5 times as much change on extraversion as placebo patients matched for depression improvement. Although placebo patients exhibited substantial depression improvement (Hamilton Rating Scale for Depression score, -1.2 SD, P < .001), they reported little change on neuroticism (-0.18 SD, P = .08) or extraversion (0.08 SD, P = .50). Cognitive therapy produced greater personality change than placebo (P </= .01); but its advantage on neuroticism was no longer significant after controlling for depression (P = .14). Neuroticism reduction during treatment predicted lower relapse rates among paroxetine responders (P = .003) but not among cognitive therapy responders (P = .86).

CONCLUSIONS

Paroxetine appears to have a specific pharmacological effect on personality that is distinct from its effect on depression. If replicated, this pattern would disconfirm the state effect hypothesis and instead support the notion that SSRIs' effects on personality go beyond and perhaps contribute to their antidepressant effects.

The influence of temperament on symptoms and functional outcome in people with psychosis in the Northern Finland 1966 Birth Cohort

OBJECTIVE

To describe symptom expression and functional outcome in psychotic disorders in relation with temperament traits assessed with the Temperament and Character Inventory (TCI) in a population-based sample.

METHOD

As part of the 31-year follow-up survey of the Northern Finland 1966 Birth Cohort, TCI temperament items were filled in by 4349 members of the cohort. In individuals with psychotic disorders, also positive and negative symptoms and outcome variables were assessed in a 35-year follow-up. Information of TCI and outcomes were available for altogether 41 individuals with psychosis.

RESULT

Reward dependence (RD) (rho=-0.45) and Persistence (P) (rho=-0.52) were significantly correlated with Positive and Negative Syndrome Scale (PANSS) negative symptoms. Higher P scores predicted higher social and occupational functioning (as measured by Social and Occupational Functioning Assessment Scale [SOFAS]), and higher Harm avoidance (HA) predicted a higher likelihood of being on a disability pension.

CONCLUSION

Results indicate that understanding of personality dimensions support better understanding of outcome and symptom expressions in psychotic disorders.

Cloninger's temperament and character dimensions of personality in patients with major depressive disorder

In this present study, we examined the relationship between the Cloninger's dimensional psychobiologic model of personality and depression in an outpatient population with major depressive disorder. Eighty-one depressed outpatients (67 women, 14 men) and 51 healthy controls (35 women, 16 men) filled out the Turkish version of the Temperament and Character Inventory (TCI). Depression severity was evaluated by using the 17-item Hamilton Depression Rating Scale and the 21-item Beck Depression Inventory. Depressed patients exhibited statistically significant higher scores for harm avoidance and lower scores for self-directedness compared to healthy controls. Sentimentality (RD1) and dependence (RD4) subscale scores of reward dependence and spiritual acceptance (ST3) subscale of self-transcendence were significantly higher; attachment (RD3) subscale of reward dependence, responsibility (SD1), purposefulness (SD2), resourcefulness (SD3), and congruent second nature (SD5) subscales of self-directedness were significantly lower in the depressed group. In the depressed patient group, main effects of sex were significant for reward dependence and cooperativeness; the scores of both dimensions were higher for women. The Beck Inventory was positively correlated with harm avoidance and negatively correlated with novelty seeking and self-directedness dimensions (P < .05). The duration of depression (16.33 +/- 20.18 months) or the mean onset age of depression (28.68 +/- 8.11 years) did not show significant correlations with TCI scales. This study confirms the relationship between harm avoidance and depression and suggests a relationship between self-directedness and depression.

Chronic pain and the measurement of personality: do states influence traits?

STUDY DESIGN

This is a structured evidence-based review of all available studies on the effect of pain, (a state phenomenon) on the measurement of personality characteristics (a trait phenomenon).

OBJECTIVES

To determine whether pain treatment changes trait scores.

SUMMARY OF BACKGROUND DATA

Recent evidence from the psychiatric literature indicates that the measurement of personality characteristics (traits) can be affected or changed by the presence of state psychiatric disorders, for example, depression. At issue then is whether the measurement of chronic pain patients' (CPPs') trait characteristics is affected by the presence of pain, a state problem.

METHODS

Computer and manual literature searches for pain studies that reported a prepain treatment and postpain treatment (test-retest) personality test or inventory score produced 35 such reports. These references were reviewed in detail and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized as to the type of study it represented according to the guidelines developed by the Agency of Health Care Policy and Research (AHCPR). In addition, a list of 15 quality criteria was utilized to measure the quality of each study. Each study was independently categorized for each criterion as positive (criterion filled), negative (criterion not filled), or not applicable, by two of the authors. Only studies having a quality score of 65% or greater were utilized to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results.

RESULTS

Of the 35 reports, 32 had quality scores of 65% or greater. According to the AHCPR guidelines, there was a consistent finding that the Minnesota Multiphasic Personality Inventory (MMPI) scores changed (improved) with treatment. In reference to the Millon Behavioral Health Inventory, Locus of Control, the Symptom Checklist-90-Revised (SCL-90-R), trait anxiety, and personality disorders, there were not enough studies to draw conclusions about consistency. In reference to coping/self-efficacy inventories, somatization/illness behavior inventories, and personality questionnaire studies, there was a generally consistent finding that these tests changed (improved) with pain treatment. Overall, of the 32 reports, 92.3% demonstrated a change in trait scores (improvement) with pain treatment. This evidence was categorized as consistent. Finally, 100% of a subgroup of reports (N = 12) that had controlled for pain indicated that there was a relationship between a change in pain scores and a change in trait scores.

CONCLUSIONS

Based on the above results, it was concluded that some trait tests and inventories may not be pain state independent. Therefore, caution is warranted in interpreting postpain development personality profiles as being indicative of the true prepain personality structure, if measured by these tests. Why trait scores may change with treatment, confounding test-retest issues, and whether trait tests actually measure what they allegedly measure are discussed.

Sensory-processing sensitivity in social anxiety disorder: relationship to harm avoidance and diagnostic subtypes

Sensory-processing sensitivity is assumed to be a heritable vulnerability factor for shyness. The present study is the first to examine sensory-processing sensitivity among individuals with social anxiety disorder. The results showed that the construct is separate from social anxiety, but it is highly correlated with harm avoidance and agoraphobic avoidance. Individuals with a generalized subtype of social anxiety disorder reported higher levels of sensory-processing sensitivity than individuals with a non-generalized subtype. These preliminary findings suggest that sensory-processing sensitivity is uniquely associated with the generalized subtype of social anxiety disorder. Recommendations for future research are discussed.

Assessing and interpreting personality change and continuity in patients treated for major depression

Structural, mean- and individual-level, differential, and ipsative personality continuity were examined in 599 patients treated for major depression assigned to 1 of 6 forms of a 6-month pharmaco-psychotherapy program. Covariation among traits from the Five Factor model remained invariant across treatment, and patients described themselves as slightly more extraverted, open to experience, agreeable and conscientious, and substantially more emotional stable after treatment. Trait changes were only to a small extent explained by changes in depression severity. There was evidence for differential, individual-level, and ipsative stability, with stable personality profiles in terms of shape and to a lesser extent in terms of scatter and elevation. Traits remain relatively stable, except for emotional stability, despite the depressive state and the psychopharmacological interventions.

A double-blind, randomised, controlled clinical trial of acetyl-L-carnitine vs. amisulpride in the treatment of dysthymia

AIM

Evaluation of the effect of acetyl-L-carnitine (ALCAR) vs. amisulpride measured by total Hamilton Depression Rating Scale score (HAM-D(21)) in patients with pure dysthymia (DSM IV). Two hundred and four patients were randomised and treated with ALCAR 500 mg b.i.d. or amisulpride 50 mg u.i.d. in a double-blind study, for 12 weeks.

RESULTS

A solid improvement of HAM-D(21) was observed in both treatment groups throughout the study. The results did not disclose statistically significant differences between treatments, although the confidence interval for the non-inferiority of the primary end-point exceeded the pre-established limit of 2 by 0.46 points. According to a non-inferiority margin of 3 (considered acceptable by recent published data) the primary end-point could have been fully satisfied. CDRS, MADRS and CGI, employed to further measure the clinical outcome, reported similar results in both treatment groups. The greater tolerability of ALCAR is of clinical relevance considering the chronicity of dysthymia, which often requires prolonged treatment.

The Tridimensional Personality Questionnaire: changes during psychological treatment of social phobia

Thirty-nine individuals completed 12 weekly group sessions of psychological therapy for social phobia (social anxiety disorder). Before and after treatment, participants filled out the Tridimensional Personality Questionnnaire (TPQ, [Cloninger C.R., 1987a. A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry, 44, 573-58]) and measures of social anxiety and depression. Treatment led to a significant reduction in social anxiety, depression, harm avoidance, and reward dependence. However, only pre-post changes in harm avoidance and depression were significantly correlated with pre-post changes in social anxiety. These results suggest that harm avoidance shows state-dependent changes during the course of treatment for social phobia. The implications of these findings for the trait/state distinction of the TPQ scales are discussed.

Temperament characteristics, as assessed by the tridimensional personality questionnaire, moderate the response to sertraline in depressed opiate-dependent methadone patients

During a randomized, double-blind, placebo controlled study of the effects of sertraline in depressed methadone-maintained patients, 82 completed the tridimensional personality questionnaire (TPQ) to assess whether temperament dimensions can affect treatment-related changes in mood and drug use. Mood outcome significantly differed according to scores on the reward dependence scale (RD). Low RD participants displayed a significantly better mood response to sertraline than high RD participants. Participants with high harm avoidance (HA) scores were more likely to be abstinent at the end of the 12 week trial of sertraline than low HA participants. High persistence (P) participants were less likely to be abstinent at the end of the 12-week trial. These results suggest that temperament dimensions may be important for identifying substance dependent patients more likely to benefit from pharmacological interventions for comorbid depressive disorders.

Exploring the boundary between temperament and generalized anxiety disorder: a receiver operating characteristic analysis

Studies of individuals with an increased tendency to experience negative emotions such as fear, sadness, and anger have documented links between this temperamental trait and anxiety disorders. There exists debate, however, concerning the degree to which high levels of a temperamental trait are a necessary and/or sufficient component of a DSM diagnosis. In this study, receiver operating characteristic (ROC) analyses assessed the relations between levels of harm avoidance (HA) and generalized anxiety disorder (GAD) diagnoses in 334 children and their parents. Analyses revealed HA scores to be highly predictive of GAD diagnoses in children (AUC=.791, P<.001) and adults (AUC=.818, P<.001). However, there were many individuals with high HA scores who did not qualify for a GAD diagnosis. These findings suggest that while there are strong associations between HA and GAD, high levels of HA are neither necessary nor sufficient in the formation of clinically significant anxiety symptoms.

Personality self-reports are concurrently reliable and valid during acute depressive episodes

BACKGROUND

It is alleged that depression distorts the assessment of general personality traits. To test that hypothesis, we examined scores on the Revised NEO Personality Inventory (NEO-PI-R) administered to acutely depressed patients at baseline and 14 to 26 weeks after treatment with antidepressant medication.

METHOD

Two hundred and fifty patients completed the NEO-PI-R at baseline, 109 patients after 14 to 26 weeks of antidepressant pharmacotherapy. 48 patients (49.5%) were identified as responders while 49 (50.5%) were identified as non-responders. The remaining 12 patients were excluded because they met HRSD response criteria but not the SCID-I MDD criteria at treatment completion.

RESULTS

At baseline, NEO-PI-R scales showed high internal consistency and replicated the normative factor structure, suggesting that psychometric properties were preserved. Among non-responders, retest correlations were uniformly high (rs=.50 to .88) and mean levels showed little change, providing evidence for the consistency of personality self-reports during an acute depressive episode. NEO-PI-R scales showed construct validity in the concurrent prediction of a number of clinical criteria. Effective treatment had significant effects on the mean levels of neuroticism, which decreased, and extraversion, openness, and conscientiousness, which increased.

LIMITATIONS

The participants were from a clinical database and were not randomly assigned for the treatment.

CONCLUSIONS

The results suggest that the effect of acute depression is to amplify somewhat the personality profile of people prone to depression. Rather than regard these depression-caused changes in assessed personality trait levels as a distortion, we interpret them as accurate reflections of the current condition of the individual. Personality traits have biological bases, and when they are changed (by disease or therapeutic interventions) trait levels change.

Tridimensional personality questionnaire factors in major depressive disorder: relationship to anxiety disorder comorbidity and age of onset

OBJECTIVE

We used the Tridimensional Personality Questionnaire (TPQ) to study the relationship between temperamental traits and comorbid anxiety disorders as well as age of onset of major depressive disorder (MDD) in 263 patients with MDD.

METHODS

Patients recruited for a large clinical study on MDD underwent a Structured Clinical Interview for DSM-III-R assessment and were administered the self-rated TPQ [mean age = 39.5 +/- 10.5 years, women = 138 (53%), initial 17-item Hamilton Rating Scale for Depression (HAM-D-17) score = 19.6 +/- 3.4]. The TPQ was scored for three previously identified factors -- harm avoidance (HA), novelty seeking (NS), and reward dependence (RD). Multiple linear regression methods were used to evaluate the relationship between TPQ factors and each comorbid anxiety disorder as well as between early-- vs. late-onset MDD, after controlling for age, gender and initial HAM-D-17 score (when these were related to the dependent variable in simple regressions).

RESULTS

Social anxiety disorder in MDD was strongly associated with higher scores on HA and lower scores on NS and RD (t = 5.4, p < 0.0001; t = 2.6, p = 0.009; t = 2.2, p = 0.028, respectively). A diagnosis of generalized anxiety disorder in MDD was significantly related to higher HA scores (t = 2.8, p = 0.006). The presence of comorbid obsessive-compulsive disorder was associated with lower NS scores (t = 2.3, p = 0.023) as was that of comorbid panic disorder (t = 2.0, p = 0.051). Finally, the presence of simple phobias was associated with lower scores on RD (t = 2.4, p = 0.016). HA scores were higher in patients with early onset of MDD (adjusted p = 0.05). Early versus late onset of MDD was not significantly related to NS or RD scores.

LIMITATIONS

Since our sample consisted of moderately depressed outpatients, our ability to generalize our findings to other populations is limited.

CONCLUSIONS

Features of temperament are related to patterns of anxiety disorder comorbidity and age of onset among patients with MDD. Higher levels of HA and lower levels of RD and NS were associated with an increased risk of anxiety disorder comorbidity in our sample. HA may also be related to early onset of depression.

Personality as a mediator of demographic risk factors for suicide attempts in a community sample

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.

Familiality of temperament in bipolar disorder: support for a genetic spectrum

BACKGROUND

The array of different diagnoses and clinical presentations seen in the family members of bipolar probands suggests a quantitative or spectrum phenotype. Consistent with this idea, it has been proposed that an underlying quantitative variation in temperament may be the primary phenotype that is genetically transmitted and that it in turn predisposes to bipolar disorder (BP). Choosing the appropriate phenotypic model for BP is crucial for success in genetic mapping studies. To test this theory, various measures of temperament were examined in the family members of bipolar probands. We predicted that a gradient of scores would be observed from those with BP to those with major depression to unaffected relatives to controls.

METHODS

Members of 85 bipolar families and 63 control subjects were administered clinical interviews for diagnosis (SCID) and two temperament assessments, the TEMPS-A and TCI-125. Subjects with BP, major depressive disorder, unaffected relatives, and controls were compared on each temperament scale and on eight factors extracted from a joint factor analysis of the TEMPS-A and TCI-125.

RESULTS

The four groups were found to be significantly different and with the expected order of average group scores for four of the TEMPS-A scales, three of the TCI-125 scales, and one of the extracted factors. On the fifth TEMPS-A scale, hyperthymic, controls scored higher than the other three subject groups contrary to expectations. Significant differences were seen between unaffected relatives and controls on the hyperthymic scale and on the first extracted factor, anxious/reactive.

LIMITATIONS

Controls were mainly recruited through advertisements, which may have introduced an ascertainment bias. It is also possible that mood state at the time of completing the questionnaire influenced subject's rating of their temperament. Additionally, bipolar I and bipolar II subjects were placed in the same group even though they had some differing clinical features.

CONCLUSIONS

Our data support the theory that some dimensions of temperament are transmitted in families as quantitative traits that are part of a broader bipolar spectrum. In particular, the hyperthymic scale of the TEMPS-A and the anxious/reactive extracted factor distinguished unaffected relatives from controls. The hyperthymic scale yielded results opposite to expectation with controls higher than any family group. This may be an artifact of the self-rated form of the questionnaire, a consequence of our grouping bipolar I and II subjects together, or the result of a "protective" factor and bears further study. Nevertheless, both of these scales may be useful quantitative traits for genetic mapping studies.

Trait and state aspects of harm avoidance and its implication for treatment in major depressive disorder, dysthymic disorder, and depressive personality disorder

The authors evaluated the trait/state issues of harm avoidance in depressive-spectrum disorders and its predictive potential for antidepressant response. Subjects with Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) major depressive disorder (n = 39), dysthymic disorder (n = 37), depressive personality disorder (n = 39), and healthy control subjects (n = 40) were evaluated with the Temperament and Character Inventory and the 17-item Hamilton Depression Rating Scale (HDRS-17) at baseline and after a 12 week antidepressant treatment period. Higher harm avoidance scores predicted lesser improvement in subjects with dysthymic disorder and major depressive disorder, as determined by lesser decrease in HDRS-17 scores. Mean harm avoidance scores in depressed subjects were consistently greater than those in healthy controls, controlling for age, gender and diagnosis. Mean harm avoidance scores decreased significantly in all depressive-spectrum disorders after treatment, but still remained higher than harm avoidance scores in control subjects. The present study reports that harm avoidance is a reliable predictor of antidepressant treatment in subjects with major depressive disorder and dysthymic disorder and that harm avoidance is both trait- and state-dependent in depressive-spectrum disorders.

Citalopram in the treatment of dysthymic disorder

This study aimed to provide preliminary data on the tolerability and effectiveness of citalopram for patients with dysthymic disorder. Twenty-one adult subjects meeting DSM-IV criteria for dysthymic disorder were enrolled in this 12-week open-label study, of whom 15 had pure dysthymia (e.g. no major depression in the past 2 years). Citalopram was initiated at 20 mg/day, and increased to a maximum of 60 mg/day. Response was defined as 50% or greater drop in score on the Hamilton Depression Rating Scale (HDRS) and a Clinical Global Impressions-I score of 1 ('very much improved') or 2 ('much improved'). Of these 15 pure dysthymic disorder subjects, all completed the trial, and 11 (73.3%) were treatment responders. All paired sample t-tests were highly significant, demonstrating significant average improvement on all measures of symptomatology and functioning. Scores on the 24-item HDRS decreased from 22.3+/-4.3 at baseline to 9.1+/-7.8 at week 12 [t(14)=6.1, P<0.001]. In addition, improvement was noted in self-reported measures of temperament and social functioning. The average final dose of citalopram was 39 mg/day. Side-effects were reported by nine of 15 subjects (60%), most frequently gastrointestinal symptoms (n=5), dry mouth (n=5) and sexual side-effects (n=3). These findings suggest the effectiveness and tolerability of citalopram in treating dysthymic disorder. Double-blind prospective studies are needed comparing citalopram both to placebo and to other medications, assessing both initial and sustained response to treatment.

Clinicians' predictions of patient response to psychotropic medications

Clinicians prescribe a medication when they assume that there is a reasonable probability of its success. There are many studies on the predictive value of social or clinical information, but these studies do not include the prognosis made by psychiatrists before treatment. These studies indicate that a small to moderate proportion of the total variance of outcome can be predicted from social or clinical information. It is peculiar that there are very few studies on the accuracy of psychiatrists’ “bets” about the effects of psychotropic drugs when they use the clinical characteristics of patients as predictors, considering the practical relevance of predicting the outcome of a psychiatric treatment. The absence of studies on the accuracy of clinicians’ bets or predictions in psychiatry is unfortunate.

Diagnosis and treatment of chronic depression in children and adolescents

Chronic unipolar depression is being increasingly recognized in general psychiatry as a particularly severe form of depressive illness that leads to significant symptomatology, prolonged suffering, and prolonged functional impairment in a variety of domains, including educational/vocational dysfunction as well as interpersonal impairment. Recent research on treatment interventions for adult patients with chronic depressions suggests that standard treatments for depressive illness may need modification to benefit patients with chronic illness. Little attention at this point has been given to the problem of chronic depression in children and adolescents. Many adults with chronic depressive disorders had onset of depression in their childhood or adolescence, making early identification of this form of illness a priority. The authors present a comprehensive review of emerging literature in the assessment, clinical course, and treatment of chronic forms of unipolar depression in youth. They then develop summary recommendations for the assessment and treatment of this type of mood disorder in youth, based on the currently available research and common sense clinical experience.

Dimensions of temperament and bright light response in seasonal affective disorder

Scale scores on the Tridimensional Personality Questionnaire (TPQ)-novelty seeking (NS), harm avoidance (HA), and reward dependence (RD)-can predict response to antidepressants. This study examined 89 patients with Bipolar Disorder (I, II) or Major Depressive Disorder, both with recurrent winter seasonal pattern. The TPQ was administered while the patients were depressed, following 10-14 days of bright light therapy (30 min, 10,000 lux) and after spontaneous springtime remission. The Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder Version (SIGH-SAD) assessed the severity of depression. At baseline, there were no significant differences between diagnostic subgroups or responders and non-responders on the TPQ or SIGH-SAD scales, though baseline RD scores were significantly higher in women than men. Furthermore, neither severity of depression nor magnitude of post-treatment clinical improvement was significantly correlated with baseline TPQ scores. Only HA scores decreased after treatment, with responders showing the greatest effect. HA scores also decreased from the baseline to springtime assessments for the group as a whole, with no difference between responders and non-responders. This is the first study to demonstrate that HA is state- rather than trait-dependent in seasonal affective disorder. The TPQ dimensions of temperament do not predict response to light therapy.

Comparison of the effects of fluoxetine, imipramine and placebo on personality in atypical depression

BACKGROUND

Atypical depression is associated with elevated rates of personality disorders. Studies have confirmed the efficacy of a several antidepressants in the treatment of atypical depression. Whether their pathological dimensions of personality diminish after benefitting from effective medication treatment is unclear.

AIMS

To determine the extent that pathological dimensions of character improved among patients who benefitted from treatment.

METHOD

One-hundred and fifty-four outpatients with DSM-IV Major Depression who met Columbia criteria for atypical depression were randomized to receive fluoxetine, imipramine or placebo for a 10-week double-blind clinical trial. The Temperament and Character Inventory (TCI) was administered at the initiation of treatment and 8 weeks later. Low scores on either of two Character dimensions (Self-Directiveness or Cooperativeness) indicate psychopathology.

RESULTS

Responders had a substantial reduction in Harm Avoidance, but post-treatment scores remained significantly higher than the normal control group (NCG). Fluoxetine and Imipramine did not produce different changes on personality, except for Self-Transcendence.

LIMITATIONS

High proportion of missing data, inadequate sample size, post-hoc analysis.

CONCLUSIONS

Among responders, Self-Directiveness improved and normalized; Harm Avoidance also improved but did not normalize. These data suggests that effective treatments reduce some pathological personality traits as well as improving mood.

The temperament and character inventory in major depression

Patients admitted for pharmacological treatment of a non-bipolar major depressive episode completed the Temperament and Character Inventory (TCI) prior to and after at least 6 weeks of treatment. Treatment with various antidepressants resulted in a 43% reduction of symptomatology. Scores on the harm avoidance dimension before and after treatment appeared to be significantly higher as compared to Dutch normative data. TCI scores did not predict response to treatment or show a change during treatment. It is concluded that, in this group of patients, the personality dimension harm avoidance is a trait factor without predictive value for antidepressant responsiveness.

Dysthymic disorder: treatment with citalopram

We studied 15 patients with dysthymic disorder with open-label citalopram. The purpose of this study was to determine the dose range and safety of citalopram necessary for treatment of patients with dysthymic disorder and to attempt to increase doses in order to enhance remission of patients with dysthymic disorder when treated. Citalopram was well tolerated. The mean dose used in this 10-week study was 37.3 mg and the majority of patients responded to treatment. Various criteria for response and remission were employed. These findings are intended to give guidelines for a subsequent treatment study of dysthymic patients with citalopram using a double-blind placebo-controlled strategy.

Serotonergic involvement in the psychosocial dimension of personality

Neurotransmitter systems have been associated with aspects of personality and changes in various dimensions have been shown after antidepressant treatment. A reduction in harm avoidance and an increase in self-directedness and cooperativeness, as measured by the Cloninger's Temperament and Character Inventory (TCI), have been reported in psychiatric patients receiving treatment with serotonergic antidepressants. However, some of these changes have been associated with clinical improvement. The present study therefore used a randomized, double-blind, placebo-controlled design to examine the role of the serotonergic system on these personality factors in the normal population. Twenty healthy male volunteers were randomly allocated to either placebo (n = 9) or citalopram treatment (n = 11) for 2 weeks. Baseline depression and anxiety scores were low and did not differ between groups. The TCI was administered pre- and post-treatment. There were no baseline differences on any TCI factor between groups. Citalopram induced a significant increase in self-directedness (p < 0.05) but not cooperativeness or harm avoidance ratings after treatment. Thus, citalopram has effects on personality aspects which appear to be separate from its antidepressant properties.

Dysthymic disorder: integrating research findings into clinical treatment

Dysthymic disorder, a form of chronic depression, has been studied over the past two decades. A variety of forms of research, from epidemiological research to psychopharmacology and psychotherapy outcome studies, has provided data that may help clinicians who treat patients with dysthymic disorder. This article reviews clinically relevant research studies and applies their findings to the clinical setting. Epidemiological research and prospective follow-up studies can define the risks of untreated and under-treated chronic depression. Studies on the phenomenology of dysthymic disorder can help the clinician assess target symptoms. Psychopharmacology and psychotherapy research can help guide treatment choices. The emerging literature on combining medication and psychotherapy can clarify goals for different phases of treatment. Thus the clinician has a significantly greater chance of helping patients with dysthymic disorder now than only 20 years ago.

Neurotransmitters, temperament and social functioning

Dimensional models can be usefully employed to describe both normal and disordered personality. Studies in molecular genetics, receptor binding, peripheral monoamines and pharmacological challenges have investigated the neurochemical basis of personality. Substantial evidence now exists to support a psychobiological model but the specificity of Cloninger's theory has not always been confirmed. Clinical studies have shown both temperament and character dimensions to improve with pharmacological treatment especially in treatment responders. Some personality changes are found to be independent of clinical effects and even to occur in normal subjects. Models of personality can help in predicting treatment outcome but individual dimensions may not be useful. It is hypothesised that social adaptation is related to the character dimensions and different sources of evidence link these to serotonergic actions. However, recent clinical studies have shown a specific effect of noradrenaline on self-perception and social motivation. Drugs with specific actions on different neurotransmitters may exert a distinctive pattern of effects on personality and social behaviour.