Conor Duggan

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Abstract Objectives: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference. Design: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes. Setting: 31 general practices in Trent region. Participants: Patients aged 18–70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms. Main outcome measures: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria. Results: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval −2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrists overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse. Conclusions: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment. What is already known on this topic Antidepressants and specific psychological interventions are effective in major depression. Generic counselling has not previously been compared with antidepressants in primary care What this study adds 12 months after starting treatment, generic counselling is as effective as antidepressants Patients treated with antidepressants may recover more quickly Given a choice, more patients opt for counselling Patients who choose counselling may benefit more than those with no strong preference

Neuroticism: a vulnerability marker for depression evidence from a family study

INTRODUCTION We investigated the relationship between depressive illness and personality traits from the Eysenck Personality Inventory (EPI) using data from a family study. METHODS The first-degree relatives of a series of 89 probands with RDC major depression (MD) were subdivided by their lifetime RDC diagnosis into: (1) relatives recovered from MD (n = 34); (2) never-ill relatives (n = 45). The neuroticism (N) and extraversion (E) scores of these two groups were compared using a multilevel linear model, allowing for potential confounders. The relationship between age of onset and recurrence of MD and N scores in group 1 was also examined. RESULTS (1) Raised N scores were associated with a past history of major depression. (2) There was no such relationship for E scores. (3) Current depressive symptoms were also associated with an increased N score but this did not explain the relationship between previous major depression and N scores. (4) Recurrent episodes of major depression in the recovered MD relatives were significantly associated with increased N scores. CONCLUSION These data suggest that raised N may be a vulnerability marker for major depression.

The attitudes of 'tomorrow's doctors' towards mental illness and psychiatry : changes during the final undergraduate year

To compare the efficacy of two teaching styles, didactic teaching and problem based learning, in producing enduring change in final‐year medical students’ attitudes towards psychiatry and mental illness.

Childhood trauma, dissociation and self-harming behaviour: A pilot study

OBJECTIVE Childhood trauma is known to be an important antecedent in those who engage in deliberate self-harm (DSH). We aimed to explore the mediating mechanisms between childhood trauma and subsequent DSH in a sample of women detained in a high secure setting. METHOD From a previous incidence study into DSH, we subdivided a group of 50 women as follows: non-harmers (N = 13), infrequent harmers (N = 22) and frequent harmers (N = 15). These three groups were then compared on several measures believed to be associated with DSH. RESULTS The frequency of DSH was related to low self-esteem, increased dissociation, anger (both inwardly and outwardly directed), impulsivity, and a history of sexual and physical abuse. When these variables were entered into a path analytic model exploring the relationship between childhood trauma and subsequent DSH, two paths emerged: one major path which linked childhood sexual abuse to DSH via increased dissociation and another, more minor association, linking childhood sexual abuse via reduced self-esteem. CONCLUSION This study shows a strong association between high levels of dissociation and an increased frequency of self-harming behaviour. This association is theoretically plausible and has therapeutic implications.

Quality of parenting and vulnerability to depression: Results from a family study

BACKGROUND We examined a group of subjects at familial risk of depression and explored the relationship between the perceptions of parents and a history of depression. We also investigated: (a) whether any difference in perceived parenting found between those with and without a past history of depression was an artefact of the depression; and (b) whether the relationship between parenting and depression was explained by neuroticism. METHOD We took a sample of first-degree relatives selected from a family study in depression and subdivided them by their history of mental illness on the SADS-L, into those: (a) without a history of mental illness (N = 43); and (b) those who had fully recovered from an episode of RDC major depression (N = 34). We compared the perceptions of parenting, as measured by the Parental Bonding Instrument (PBI), in these two groups having adjusted for the effect of neuroticism and subsyndromal depressive symptoms. We also had informants report on parenting of their siblings, the latter being subdivided into those with and without a past history of depression. RESULTS Relatives with a past history of depression showed lower care scores for both mother and father combined compared with the never ill relatives. The presence of a history of depression was associated with a non-significant reduction in the self-report care scores compared to the siblings report. Vulnerable personality (as measured by high neuroticism) and low perceived care were both found to exert independent effects in discriminating between the scores of relatives with and without a history of depression and there was no interaction between them. CONCLUSION This study confirmed that low perceived parental care was associated with a past history of depression, that it was not entirely an artefact of having been depressed, and suggested that this association was partially independent of neuroticism.

THE TREATMENT OF DELIBERATE SELF-HARM IN BORDERLINE PERSONALITY DISORDER USING DIALECTICAL BEHAVIOUR THERAPY: A PILOT STUDY IN A HIGH SECURITY HOSPITAL

Deliberate self-harm (DSH) presents a significant health problem, especially as treatments have not been particularly successful in reducing repetition. Dialectical behaviour therapy (DBT; Linehan, 1993) is one approach that has reported some success in reducing self-harm rates in borderline personality disorder patients, who self-harm frequently, though it remains largely untested outside its original setting. The present study aimed to assess the effectiveness of DBT in self-harming women in an institutional setting in the United Kingdom where self-harm is common. Female patients at Rampton Hospital who were displaying self-harming behaviour and met criteria for borderline personality disorder ( N = 10) participated in the full one-year treatment package of DBT. Patients were assessed on self-harm rates and on a number of psychological variables, pre-, during- and post-therapy, including a 6-month follow-up. There was a significant reduction in DSH during therapy, which was maintained at 6-month follow-up. This was paralleled by a reduction in dissociative experiences and an increase in survival and coping beliefs, alongside improvements in depression, suicide ideation, and impulsiveness. The findings are preliminary but the results suggest that DBT might provide an effective treatment for severe self-harm in institutional settings, and also highlight some of the psychological mechanisms that might mediate these improvements in self-harming behaviour.

Does recurrent depression lead to a change in neuroticism

The hypothesis that recurrent or chronic depressive illness produces a long-term change in neuroticism was examined in a sample (N = 34) from a consecutive series of 89 depressed patients admitted to the Maudsley Hospital in 1965/6. The Eysenck Personality Inventory (EPI) was administered at the time of the index illness both when the patients were depressed and on recovery, and then again at follow-up 18 years later. The change in the neuroticism (N) score over the 18-year-period was compared in good and poor outcome groups defined variously by a global rating of outcome, frequency of episodes, extent of subsequent hospitalization and the presence or absence of subsequent chronicity. The mean N score for the sample as a whole did not change significantly over the 18 years, and no differential change in the N score was observed between any of the good and poor outcome groups. Thus, the hypothesis was not supported.

Can future suicidal behaviour in depressed patients be predicted

The determinants of suicidal behaviour over 18 years were examined in a series of 89 depressed in-patients, using index data on clinical features, personality, and history of past loss. Seven variables were selected from univariate analyses and their relationship with (1) the presence or absence, (2) frequency, (3) intent, and (4) medical threat of suicidal behaviour was then explored by generalised linear modelling. Severe dysphoria, past alcoholism and chronic physical illness were most predictive of suicidal attempting; however, different variables predicted the frequency, degree of intent and severity of medical threat of subsequent suicidal attempts. Thus, our results suggest that different aspects of long-term suicidal behaviour have different determinants.

The successes and failures of the DSPD experiment: the assessment and management of severe personality disorder

In the last 10 years a sum in excess of £200 million has been spent in developing a new programme of treatment for those deemed to have dangerous and severe personality disorder (DSPD) in England. This proto-diagnosis is a new concept in forensic psychiatric practice and, although its conception was bold, it carried considerable risks in implementation as so little was known about the effective management of this group of disorders. We review the successes and failures of this pioneering programme a decade after its introduction and conclude that although much has been gained from the experiment – particularly in developing services for those with personality disorder in general – it has been less effective in managing those whom it was primarily targeting and may not have been cost-effective.

An assessment of change in negative relating in two male forensic therapy samples using the Person’s Relating to Others Questionnaire (PROQ)

This study tests the hypothesis that the negative relating of men with a forensic history can be reduced by psychotherapeutic intervention. The Persons Relating to Others Questionnaire (PROQ), a measure of negative relating, was administered to two male forensic therapy samples, one in a medium secure unit and one in a prison therapeutic community. In the first it was given at assessment prior to admission, at three and nine months after admission, and at follow-up, one year after discharge. In the second it was given on admission, after nine months, and after 18 months. There were significant improvements in mean scores on a number of scales in both samples. Over a fifth of both samples demonstrated reliable improvement. In both samples the major improvement in mean scores occurred relatively early in the period of stay, and thereafter the improvement was sustained. In the first sample, it was still apparent at follow-up.