Amelia Paterson

Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style

BACKGROUND Bipolar II disorder (BP II) and Borderline Personality Disorder (BPD) share common features and can be difficult to differentiate, contributing to misdiagnosis and inappropriate treatment. Research contrasting phenomenological features of both conditions is limited. The current study sought to identify differences in emotion regulation strategies in BP II and BPD in addition to examining relationships with perceived parental style. METHOD Participants were recruited from a variety of outpatient and community settings. Eligible participants required a clinical diagnosis of BP II or BPD, subsequently confirmed via structured diagnostic interviews assessing DSM-IV criteria. Participants completed a series of self-reported questionnaires assessing emotion regulation strategies and perceived parental style. RESULTS The sample comprised 48 (n=24 BP II and n=24 BPD) age and gender-matched participants. Those with BPD were significantly more likely to use maladaptive emotion regulation strategies, less likely to use adaptive emotion regulation strategies, and scored significantly higher on the majority of (perceived) dysfunctional parenting sub-scales than participants with BP II. Dysfunctional parenting experiences were related to maladaptive emotion regulation strategies in participants with BP II and BPD, however differential associations were observed across groups. LIMITATIONS Relatively small sample sizes; lack of a healthy control comparator group; lack of statistical control for differing sociodemographic and clinical characteristics, medication and psychological treatments; no assessment of state or trait anxiety; over-representation of females in both groups limiting generalisability of results; and reliance on self-report measures. CONCLUSIONS Differences in emotion regulation strategies and perceived parental style provide some support for the validity of distinguishing BP II and BPD. Development of intervention strategies targeting the differing forms of emotion regulatory pathology in these groups may be warranted.

Gender differences in depression severity and symptoms across depressive sub-types

BACKGROUND Lifetime rates of depression are distinctly higher in women reflecting both real and artefactual influences. Most prevalence studies quantifying a female preponderance have examined severity-based diagnostic groups such as major depression or dysthymia. We examined gender differences across three depressive sub-type conditions using four differing measures to determine whether any gender differences emerge more from severity or symptom prevalence, reflect nuances of the particular measure, or whether depressive sub-type is influential. METHODS A large clinical sample was recruited. Patients completed two severity-weighted depression measures: the Depression in the Medically Ill 10 (DMI-10) and Quick Inventory of Depressive Symptoms-Self-Report (QIDS-SR) and two measures weighting symptoms and illness correlates of melancholic and non-melancholic depressive disorders - the Severity of Depressive Symptoms (SDS) and Sydney Melancholia Prototype Index (SMPI). Analyses were undertaken of three diagnostic groups comprising those with unipolar melancholic, unipolar non-melancholic and bipolar depressive conditions. RESULTS Women in the two unipolar groups scored only marginally (and non-significantly) higher than men on the depression severity measures. Women in the bipolar depression group, did however, score significantly higher than men on depression severity. On measures weighted to assessing melancholic and non-melancholic symptoms, there were relatively few gender differences identified in the melancholic and non-melancholic sub-sets, while more gender differences were quantified in the bipolar sub-set. The symptoms most commonly and consistently differentiating by gender were those assessing appetite/weight change and psychomotor disturbance. CONCLUSION Our analyses of several measures and the minimal differentiation of depressive symptoms and symptom severity argues against any female preponderance in unipolar depression being contributed to distinctly by these depression rating measures. Our analyses indicated that gender had minimal if any impact on depression severity estimates. Gender differences in depressive symptoms and severity were more distinctive in bipolar patients, a finding seemingly not previously identified or reported. LIMITATIONS The study had considerable power reflecting large sample sizes and thus risks assigning significant differences where none truly exist, although we repeated analyses after controlling for the type I error rate.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study

To pursue the previously long‐standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone.

Anhedonia in melancholic and non-melancholic depressive disorders

BACKGROUND Anhedonia represents a core symptom of major depression and may be a potential marker for melancholia. However, current understanding of this construct in depressive sub-types is limited. METHOD Participants were recruited from the Black Dog Institute (Sydney) and Massachusetts General Hospital (Boston). Diagnostic groups were derived on the basis of agreement between clinician and DSM-IV diagnosis from structured interviews. Currently depressed unipolar melancholic, non-melancholic and healthy control participants were administered a probabilistic reward task (PRT) to assess a behavioural correlate of anhedonia-blunted reward-based learning. Self-reported measures of anhedonia, approach and avoidance motivation were completed by the Sydney sample. RESULTS Relative to healthy controls and non-melancholic participants, melancholic depressed participants had reduced response bias, highlighting blunted reward learning. Moreover, although non-melancholic participants were characterized by a delayed response bias, melancholic depressed participants failed to develop a bias throughout blocks. Response bias showed no associations with self-report measures of hedonic tone in depressed participants. Positive associations were observed between response bias, approach and avoidance motivation in non-melancholic participants only. LIMITATIONS Possible medication, fatigue and anxiety effects were not controlled; small sample sizes; inclusion criteria may have excluded those with severe melancholia and led to underestimation of group differences. CONCLUSIONS Melancholia is characterised by a reduced ability to modulate behaviour as a function of reward, and the motivational salience of rewarding stimuli may differ across depressive sub-types. Results support the view that melancholia is a distinct sub-type. Further exploration of reward system functioning in depressive sub-types is warranted.

Is essential fatty acid status in late pregnancy predictive of post-natal depression?

We tested the hypothesis that abnormal levels of omega‐3 and omega‐6 polyunsaturated fatty acids (PUFAs) during late pregnancy are associated with antenatal and post‐natal depression.

Melancholia: definition and management.

Purpose of review A 2004 review of ‘atypical depression’ in Current Opinion in Psychiatry could be read as more reifying the Columbian and DSM-IV concept rather than considering an alternative model that has been supported by independent studies undertaken in Australia and North America. Additional analyses of the Australian data set are reported to examine inter-study agreement further and to consider the implications. Recent findings Both studies recruited patients meeting criteria for a major depressive episode, and then contrasted patients meeting or not meeting DSM-IV criteria for definite atypical depression. In both studies, those with atypical depression were comparable in terms of female preponderance, age, age at first episode and depression severity, but developed earlier and more persistent episodes, showed a slight female preponderance, and were more likely to meet criteria for panic disorder, social phobia and hypochondriasis, and of avoidant and dependent personality styles. In both, there was a lack of evidence suggesting that atypical depression differs in severity, in being clearly less likely to have certain ‘endogeneity’ symptoms, or in being more likely to be associated with bipolar disorder, while neither the centrality of mood reactivity nor interdependence of symptoms could be demonstrated. Summary Findings from both studies challenge the view that atypical depression is an entity and the current model of its constituent features. Both found support for primacy of personality style (rather than mood reactivity) and for certain expressions of anxiety. Both effectively argue for and assist shaping of a revisionist model for conceptualizing atypical depression as a syndrome or spectrum disorder. Abbreviations AD: atypical depression; RS: residual subject.Purpose of review To overview historical ascriptions and the current nosological status of melancholia, before reporting diagnostic strategy, biological marker and treatment studies. Recent findings As melancholia has never been satisfactorily differentiated by reliance on symptoms, strategies that adopt a more prototypic approach and incorporate illness correlates in conjunction with symptoms appear to provide greater precision in differentiating melancholic and nonmelancholic depression. An early indicative biological marker – hyperactive Hypothalamic-Pituitary-Adrenal axis functioning – remains supported, whereas a number of other recently proposed candidate markers require clarification. Implications for treatment from recent clinical trials are also discussed. Summary We note that the Diagnostic and Statistical Manual 5 (DSM-5) definition of melancholia [as for Diagnostic and Statistical Manual IV (DSM-IV)] may be limited in its differentiating capacity and so compromise research into melancholias causes and treatments. Clarifying melancholias status, primary causes and differential treatment responsiveness awaits more precise definition of this depressive condition.

Cleaving depressive diseases from depressive disorders and non-clinical states

We sought to determine whether putative depressive diseases could be differentiated categorically from clinical depressive disorders and non‐clinical mood states.

Predictors of post-natal depression are shaped distinctly by the measure of 'depression'.

BACKGROUND Many variables have been proposed as predictive of post-natal depression (PND). AIMS To investigate and refine PND risk variables. METHOD We recruited a large sample and employed two measures of PND (the dimensional Edinburgh Postnatal Depression Scale or EPDS, and DSM-defined major depression). RESULTS High levels of stress in the post-natal period, previous depression and higher depression scores during pregnancy were the only consistent predictors across measures. Those exceeding the EPDS cut-off had additional psychosocial risk factors while those meeting criteria for major depression were strongly predicted by a past history of depression as well as higher pre-natal state depression scores. LIMITATIONS The EPDS has been used with variable cut off scores across multiple studies. We used only nine of the 10 EPDS items, electing to exclude the self-harm related question, but preserving the recommended EPDS cut-off score, and which might have impacted on predictions. CONCLUSIONS Study results generated a refined set of predictors of PND but, more importantly, identified that predictors of PND status are distinctly influenced by the measure of PND. Such inconsistencies are intrinsically noteworthy and of potential key importance in shaping intervention strategies.

Differentiating 'clinical' and 'non-clinical' depression.

There has been increasing concern about extensions to the definition of ‘clinical’ depression, but little evident investigation as to how clinical and non‐clinical depressive states might best be differentiated. This review considers the potential of many candidate symptom and non‐symptom parameters.

Is cognitive behaviour therapy of benefit for melancholic depression

OBJECTIVE This paper seeks to determine the relevance and likely salience of cognitive behaviour therapy (CBT) as a treatment for melancholic depression. METHODS The findings of a randomised trial comparing 12-week outcome of 18 patients with melancholic depression receiving antidepressant medication and 11 receiving CBT were evaluated, and qualitative explanations for the outcomes were provided principally by the treating CBT practitioners. RESULTS In the trial, CBT showed no improvement in depression severity in the first four weeks and then some level of improvement over the subsequent eight weeks. Outcome was superior for those receiving antidepressant medication at 12 weeks and was first demonstrated at four weeks. The benefits of CBT appeared to be in settling anxiety, dealing with cognitive processing of having a melancholic depression and addressing any personality vulnerabilities. CONCLUSION While a pilot study, our qualitative reports indicate that CBT may provide a useful role in managing melancholia as an adjunct to antidepressant medication. Future studies examining such a combination treatment model should seek to determine if indicative data provided here argue for a sequencing model of CBT being introduced after medication has addressed core biological underpinnings.