Emmanuelle Corruble

Understanding impulsivity in severe depression? A psychometrical contribution

BACKGROUND Depression, especially severe depression, is strongly associated with suicidality. Impulsivity is one of the main dimensions of suicidality. The objective of this study was to assess the structure of impulsivity in severe depression and its relationships to suicide attempts. METHODS 127 depressed in-patients were assessed at admission and after 4 weeks of treatment for depression and impulsivity with the Impulsivity Rating Scale (IRS) and the Impulse Control Scale (ICS) or the Baratt Impulsivity Scale (BIS). RESULTS Three dimensions of impulsivity were evidenced in these severely depressed patients, i.e., behavioral loss of control, nonplanning and cognitive. These three dimensions are state dependent. Recent suicide attempts in severe depression are related to loss of control and cognitive impulsivity but not to nonplanning. IRS ad ICS may assess primarily behavioral impulsivity, i.e., loss of control and nonplanning, whereas BIS may assess primarily cognitive impulsivity. CONCLUSIONS In the future, these three dimensions should be correlated to biological and genetic markers of impulsivity [serotonergic (5-HT) system] and prospective studies should assess the predictive value of the three dimensions of impulsivity in the occurrence of suicide attempts in depressed patients.

Concordance between self-report and clinician’s assessment of depression

In order to assess differences between self-assessment and clinicians assessment of depression, 64 depressed in-patients were assessed for depressive symptomatology at admission (D0), 10 days (D10) and 28 days (D28) after the beginning of antidepressant treatment, using the Inventory for Depressive Symptomatology Clinician Rated (IDS-C) and the Inventory for Depressive Symptomatology Self-Rated (IDS-SR). Associated symptoms (SCL-90R) were assessed at D0 and personality dimensions (TCI) at D28. Although agreement was high between IDS-C and IDS-SR total scores, D0, D0-D10 and D0-D28 total scores were significantly different between IDS-C and IDS-SR, showing a higher sensitivity to change for IDS-C as compared to IDS-SR. Differences between IDS-C and IDS-SR were due mostly to mood items and not to somatic items. Discrepancies between self-assessment and clinicians assessment of depressive symptomatology were linked neither to age, sex, familial status, single/recurrent and length of episode, nor to depression severity, but to associated symptoms and, to a lesser extent, personality dimensions: patients over-estimating their depressive symptomatology change relative to the psychiatrist tended to score high on phobic anxiety, Cooperativeness (especially Social Acceptance) and Self-Transcendence (especially Self-forgetfulness) and vice-versa.

Early and delayed personality changes associated with depression recovery? A one-year follow-up study.

Many studies have shown the state effect of depression on personality. However, the chronology of personality changes associated with depression recovery remains unstudied. The objective of this study is to assess early (first month) and delayed personality changes associated with depression recovery. Fifty-seven depressed inpatients were assessed with the Temperament and Character Inventory (TCI) at admission, 1 month, and 1 year post-treatment. Patients were divided into poor and favorable outcome. No significant personality change was observed in patients with poor depression outcome. Conversely, a favorable outcome of depression was associated with early and delayed personality changes. Early changes were: decrease in Harm avoidance (HA(1):Worry and pessimism), increase in Cooperativeness and Self-directedness (SD(1):Responsibility, SD(4):Self-acceptance, SD(2):Purposefulness and SD(3):Resourcefulness). Delayed changes were changes in character: increase in Self-Directedness (SD(1):Responsibility, SD(4):Self-acceptance, SD(5): Congruent second nature), decrease in Self-transcendence (ST(2):Transpersonal identification). This study shows the different status of personality changes associated with depression recovery, and it contributes to a better knowledge of the state effect and of subtle clinical changes in patients who are recovering from depression. It may also have implications for the prediction of depression outcome.

Depressive symptoms predict long-term mortality after liver transplantation☆☆☆

OBJECTIVE Depressive symptoms are common after liver transplantation (LT). We studied whether depressive symptoms affect long-term survival after LT. METHODS In a prospective cohort study, 134 liver transplant patients were assessed for depressive symptoms using the Beck Depression Inventory-short form (BDI), focusing on the 3 months post-LT score and on the score change from the waiting list period. They were followed up for long-term survival. The median duration of the follow-up period was 43 months post-LT. None of the 134 patients was lost to follow-up for survival. RESULTS A total of 33.6% of the LT patients had mild to moderate depressive symptoms 3 months post-LT. Eighteen (13.4%) patients died during the follow-up. Using Cox proportional hazards analysis, depressive symptoms were significantly associated with mortality (hazard ratio [HR] 1.22, 95% confidence interval (CI) 1.07-1.40, P<.003), one more point in the BDI score being associated with a 17% increase in mortality risk. Other predictive factors of mortality were older age and hepatitis C virus with recurrence 3 months post-LT. Similarly, an increase in depressive symptoms between the waiting list and 3 months post-LT periods predicted mortality (HR 1.18, 95% CI 1.01-1.38, P=.03), especially for patients without depressive symptoms on waiting list (HR 1.56, 95% CI 1.16-2.12, P=.004). CONCLUSION Depressive symptoms after LT and an increase in depressive symptoms between the waiting list and post-LT are associated with an increased risk of long-term mortality. Interventions that could reduce depressive symptoms could potentially decrease long-term mortality after LT.

THE BEREAVEMENT EXCLUSION AND DSM‐5

Pre‐DSM‐III (where DSM is Diagnostic and Statistical Manual), a series of studies demonstrated that major depressive syndromes were common after bereavement and that these syndromes often were transient, not requiring treatment. Largely on the basis of these studies, a decision was made to exclude the diagnosis of a major depressive episode (MDE) if symptoms could be “better accounted for by bereavement than by MDE” unless symptoms were severe and very impairing. Thus, since the publication of DSM‐III in 1980, the official position of American Psychiatry has been that recent bereavement may be an exclusion criterion for the diagnosis of an MDE. This review article attempts to answer the question, “Does the best available research favor continuing the ‘bereavement exclusion’ (BE) in DSM‐5?” We have previously discussed the proposal by the DSM‐5 Mood Disorders Work Group to remove the BE from DSM‐5.

Is DSM-IV bereavement exclusion for major depressive episode relevant to severity and pattern of symptoms? A case-control, cross-sectional study.

OBJECTIVE To assess the DSM-IV major depressive episode (MDE) bereavement exclusion criterion by comparing severity and pattern of symptoms in bereavement-excluded individuals satisfying all other DSM-IV MDE criteria to these same variables in MDE controls. METHOD A case-control, cross-sectional study of self-referred individuals seeking treatment for depressive symptoms was conducted. A total of 17,988 subjects met DSM-IV MDE symptom criteria. Of these, 1,521 individuals (8.5%) met all MDE criteria except the bereavement exclusion. They were matched by age, gender, marital status, and educational level with 1,521 MDE controls. Among the MDE controls, 292 had a recent bereavement and 1,229 did not. Severity of depression was measured by the number of MDE symptoms and the Montgomery-Asberg Depression Rating Scale (MADRS) score. Symptom cues of the bereavement-exclusion criterion were analyzed. The study was conducted between September 2003 and May 2004. RESULTS Bereavement-excluded subjects were more severely depressed than MDE controls without bereavement and similar to MDE controls with bereavement. Two symptom cues, suicidal ideation and worthlessness, and the majority of other depressive symptoms were more pronounced in bereavement-excluded individuals than in MDE controls. CONCLUSIONS Symptom cues of the DSM-IV MDE bereavement exclusion criterion should be modified since they could result in patients failing to be correctly diagnosed and treated.

Treatment response in major depression: Effects of personality dysfunction and prior depression

BACKGROUND The impact of personality dysfunction on the outcome of treatment for depression remains debated. AIMS To examine the relationship between the number of prior depressive episodes, personality dysfunction and treatment response for depression. METHOD In a large sample (n = 8229) of adult out-patients with a major depressive episode (DSM-IV), personality dysfunction was assessed using the Standardised Assessment of Personality - Abbreviated Scale (SAPAS). Potential predictors of treatment response at 6 weeks were examined via structural equation modelling. RESULTS The amount of personality dysfunction and number of prior episodes of depression were both associated with poor response to treatment. Once personality dysfunction was controlled for, the number of prior episodes of depression was not associated with treatment response. CONCLUSIONS Personality dysfunction is associated with impaired short-term response to antidepressant treatment in major depression. The apparent detrimental effect of prior depression on treatment response may be accounted for by pre-existing personality dysfunction.

Defense Styles, Impulsivity and Suicide Attempts in Major Depression

Background: The aim of our study was to identify if defense mechanisms are associated with impulsivity and lifetime suicide attempts in depressed patients. Sampling and Methods: The Defense Style Questionnaire, the Impulsivity Rating Scale and the Impulse Control Scale were used in 77 depressed inpatients. Results: Impulsivity was correlated positively with immature and neurotic styles and negatively with mature style. Some but not all defense mechanisms were relevant in this respect. The number of lifetime suicide attempts was positively correlated not only with impulsivity, but also with immature style and to a lesser extent with neurotic style. Several defense mechanisms were involved in these correlations: undoing, projection, passive aggression, acting out, splitting and somatization. Conclusions: Like impulsivity, defense styles may be relevant to discriminate recurrent suicide attempters in depression. Prospective assessment of defense styles and suicide attempts in depression is needed.

Defense styles in depressed suicide attempters

Abstract  Defense styles may discriminate between depressed patients with or without recent suicide attempts. The aim of the present study was to identify which defense mechanisms are associated with recent suicide attempts in depression. The Defense Style Questionnaire (DSQ) was rated at admission by 156 depressed inpatients with (n = 60) or without (n = 96) recent suicide attempt. Depression intensity was correlated negatively with mature style, humor and sublimation and positively with projection. Although it was not significantly different in terms of sociodemographic and depression variables, recent suicide attempters had higher scores on immature style, especially acting out, passive agression, autistic fantasy and projection. Prospective assessment of defense styles and suicide attempts should be carried out to determine whether these differences are a cause of imminent suicide attempts in depression. If so, the DSQ may be used in clinical practice to help discriminate depressed patients with high risk of imminent suicide attempt.

5-HTTLPR modulates antidepressant efficacy in depressed women.

Background As compared with the long variant (L), the short variant (S) of the functional polymorphic region of the serotonin transporter gene (5-HTTLPR) has been associated with a lower antidepressant efficacy in major depression, but some replication studies have evidenced contradictory results. Sex differences may explain these contradictory results. Methods One hundred and three inpatients (74 women and 29 men) with a major depressive episode were assessed prospectively for antidepressant efficacy after 4 weeks of treatment with selective serotonin reuptake inhibitors (SSRI) and non-SSRI drugs. Results As compared with LL/LS, the SS genotype of the 5-HTTLPR was associated with a lower antidepressant efficacy in depressed women (79 vs. 50% responders, P = 0.035). This result was shown with both SSRI and non-SSRI antidepressants. The logistic regression performed in women showed that response to treatment was related to genotype (odds ratio=0.15; 95% confidence interval=0.03–0.85; P = 0.03) and not to other variables. No effect of 5-HTTLPR was found in depressed men. Conclusion Despite a low power, this study suggests a significant effect of 5-HTTLPR genotype on antidepressant efficacy in depressed women but not in men, with both SSRI and non-SSRI drugs. Further research is needed to confirm this result and investigate its underlying mechanisms.