J.-D. Guelfi

Comorbidity of personality disorders and unipolar major depression: A review

The association of major depressive disorders with personality disorders is relevant in terms of clinical, therapeutic and prognostic aspects. However, the prevalence of this association remains unclear. This may be due to methodological considerations. Nonetheless, it could be estimated from this review that 20% to 50% of inpatients and 50% to 85% of out-patients with a current major depressive disorder have an associated personality disorder. Cluster B personality disorders, in particular borderline (10-30%), histrionic (2-20%) and antisocial (0-10%), seem to be overrepresented, even if the narcissistic one is rare (less than 5%). The main characteristic of Cluster C personality disorders is the great variability of results across studies, except for the obsessive compulsive personality disorder, whose prevalence is consistent and rather high (0-20%). Cluster A personality disorders are an heterogeneous group, since the prevalence of schizotypal personality disorder is rather high (0-20%), the prevalence of paranoid personality disorder is low (less than 5%) and the prevalence of schizoid personality disorder is quite variable from one study to another. The prevalence of personality disorders among patients with a lifetime major depression has been insufficiently studied, although it may concern half of these patients. The prevalence of current of lifetime major depression among patients with a personality disorder has not been sufficiently studied and results are very scattered. Also, the coexistence of personality disorder and major depression is frequent, and this review emphasizes the heterogeneity of the personality styles associated with major depression. Finally, an optimization of methods and the adjunction of a dimensional point of view to the categorical approach may help to study the comorbidity of major depression and personality disorders and its consequences.

Impulsivity: a relevant dimension in depression regarding suicide attempts?

BACKGROUND This study focuses on clinical impulsivity in depressed patients, regarding suicide attempts. METHODS Fifty depressed in-patients were assessed for impulsivity with the Impulsivity Rating Scale and the Baratt Impulsivity Scale, at admission (W0) and after 4 weeks of treatment (W4), with special attention to suicide attempts. RESULTS In the whole sample, impulsivity scores decreased significantly between W0 and W4. The scale and the questionnaire correlated slightly with each other, suggesting some differences in impulsivity assessment between patients and clinicians. The two subgroups of patients, suicide attempters (SA) (n = 16) and non-suicide attempters (NSA) (n = 34), were different neither in terms of sample characteristics and antidepressant treatments nor in terms of depression and general psychopathology assessments. However, SA patients scored higher on the impulsivity scale and questionnaire than NSA patients, both at W0 and W4. These results suggest first that impulsivity may be both a trait and a state in depressed suicide attempters and second that it may be relevant in terms of suicide attempts in depression.

Severe anorexia nervosa in men: comparison with severe AN in women and analysis of mortality.

OBJECTIVE To compare clinical characteristics of men and women with severe AN and to analyze mortality in men. METHOD One thousand and nine patients including 23 anorectic males were hospitalized in St. Anne Hospital in Paris between 1988 and 2004. Data were collected during hospitalization. Fatal outcome was assessed in 2008. RESULTS Men presented significantly later age of onset, were more likely to have a history of premorbid overweight than women and less likely to have attempted suicide. Mortality in men was high (standardized mortality ratio: 8.08; 95% CI: 1.62-23.62). Several predictive factors for mortality in men were identified: lower admission body mass index (BMI), later age at admission, and AN-R subtype. All the three deceased patients had dropped out from the inpatient unit. The 10-year survival did not differ between men and women, but men died sooner after hospitalization. DISCUSSION Male inpatients should receive close follow-up after their discharge, especially if they have a restrictive form of AN, present low BMI, or are older at admission.

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.

Mortality and Its Predictors in Severe Bulimia Nervosa Patients

BACKGROUND The risk of mortality remains unclear for bulimia nervosa (BN) patients, especially the most severe. The aims of this study were to improve knowledge on BN and mortality. METHODS With initial evaluation at admission, 258 BN (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) consecutive inpatients were included (1988-2004). Vital status was established from the French national register. Standardized Mortality Ratio (SMR) calculation and bivariate Cox analysis were performed for the hypothesised predictors of mortality. RESULTS Mean follow-up duration was 10.5 years. Ten deaths were recorded, and the crude mortality ratio was 3.9%; SMR = 5.52 [CI95 (2.64-10.15)]. The majority of deaths were from suicide [6/10, SMR = 30.9 (5.7-68.7)]. The mean age at time of death was 29.6 years. Predictive factors were previous suicide attempt and low minimum BMI. CONCLUSIONS Severe BN patients are at higher risk of death (mainly suicide) especially if previous suicide attempt or previous low BMI. More studies are needed to confirm these results.

Efficacy of intravenous citalopram compared with oral citalopram for severe depression. Safety and efficacy data from a double-blind, double-dummy trial.

BACKGROUND Intravenous administration is often beneficial in the treatment of severely depressed patients. It is mainly the tri- and tetracyclic antidepressant drugs that can be administered intravenously. However, these drugs have a less favourable safety profile than newer antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs). Citalopram is the only SSRI that is available in a formulation for infusion. This double-blind, randomised, multicentre trial was designed to compare the efficacy and tolerability of citalopram infusion (40 mg per day) and citalopram tablet (40 mg per day). METHODS Patients were randomised to receive either placebo tablet plus citalopram infusion (the infusion group; n=135) or citalopram tablet plus placebo infusion (the tablet group; n=119). After receiving randomised treatment for eight days, all patients entered an open treatment phase, during which they received oral citalopram 40 mg per day for five weeks. RESULTS Although there was no difference in Montgomery-Asberg Depression Rating Scale (MADRS) scores at the end of the randomised treatment period, by the end of the open treatment phase the reduction in MADRS scores was significantly greater in the infusion group than in the tablet group (p=0.015). The infusion group also showed superior efficacy in Clinical Global Impressions assessments. Citalopram was equally well tolerated in both treatment groups. CONCLUSIONS This trial confirmed the efficacy of citalopram 40 mg per day, and clearly supports the use of citalopram infusion in the treatment of severely depressed, hospitalised patients.

L'intensité de la détresse péritraumatique prédit la survenue des symptômes post-traumatiques parmi des victimes d'agressions

Resume La detresse emotionnelle peritraumatique est une dimension recente dont nous avons cherche a verifier a quel point elle pouvait predire l’evolution des symptomes post-traumatiques. Les victimes ont ete recrutees consecutivement dans 5 centres de consultations specialisees en region parisienne aupres de victimes d’agressions individuelles et de hold-up. Parmi les 100 sujets inclus initialement, 63 ont ete suivis par deux evaluations a 6 mois d’intervalle, la premiere par un clinicien avec une hetero-evaluation associee a des questionnaires et la deuxieme uniquement par des questionnaires: le Peritraumatic Distress Inventory (PDI) pour la mesure de la detresse emotionnelle peritraumatique ; le Peritraumatic Dissociative Experience Questionnaire a ete utilise pour mesurer l’intensite de la dissociation ; l’Impact of Event Scale-Revised (IES-R) pour mesurer l’intensite des symptomes de l’etat de stress post-traumatique (ESPT) ; le Mini International Neuropsychiatric Interview (MINI) pour le diagnostic de depression et d’etat de stress post-traumatique (ESPT) pose par un evaluateur. Les scores de dissociation peritraumatique evalues a la premiere etape etaient correles aux scores d’IES-R initiaux et a 6 mois avec respectivement des coefficients de correlation de 0,50 et 0,63 entre les scores de PDEQ et PDI initial et le score d’IES-R a 6 mois. Alors que les analyses statistiques descriptives indiquent des «tendances» de lien, c’est par une regression lineaire multiple hierarchique en tenant compte du type d’evenement qu’il apparait que le score de detresse peritraumatique ameliore la variance de 14 % pour predire le score d’IES-R a 6 mois compare a la prediction du score d’IES-R initial. Cette etude est la premiere qui montre sur une enquete prospective la puissance du score de detresse emotionnelle peritraumatique pour predire l’evolution d’un trouble post-traumatique. Nos resultats confirment que le type de traumatisme predit fortement le pronostic a 6 mois dans cette population.

Night eating syndrome and winter seasonal affective disorder

Night eating syndrome (NES) and winter seasonal affective disorder (SAD) share some features such as snacking for high-carbohydrate/high-fat food with increased weight, emotional distress, circadian disturbances, good response to serotoninergic antidepressants (SSRIs) and bright-light therapy. This study assessed the prevalence and socio-demographical and clinical correlates of the NES in a sample of 62 consecutive depressed outpatients with winter seasonal features (DSM-IV criteria). Depression was assessed with the 29 item-HDRS and Sigh-SAD version and with the 7-item depression subscale of the Hospital Anxiety and Depression scale. The prevalence of NES was low (4.8%). Patients suffering from NES were significantly older with a greater duration of the illness. NES was not related to depression and to Body Mass Index. NES and winter SAD are not overlapping disorders.

Reports on defense styles in depression.

Introduction: ‘State effect’ of depression on personality makes its assessment during depression difficult. Many clinicians do not only refer to the patient, but use additional information sources, especially reports from close informants. Our hypothesis was that an informant could assess the defensive functioning of the depressed patient. The objective of this study was to investigate the validity of the informants’ assessment of defense styles in depressed patients. Methods: Sixty-three inpatients with DSM-IV major depression as primary diagnosis were included. They were administered the Defense Style Questionnaire (DSQ) at admission (D0) and 28 days after treatment (D28) according to their current state. At the same time, informants rated an adapted version of the DSQ (INF-DSQ), according to the patient’s current (D0 and D28) and premorbid defensive functioning (D0). Otherwise, severity of depression was assessed using the 17-item Hamilton Depression Rating Scale at D0 and D28. Results: Agreement between patient’s and informant’s DSQ scores was moderate, both at D0 and D28, even if comparison of mean defense scores does not show significant difference. Mature defense scores significantly increased between D0 and D28, whereas immature defense scores significantly decreased, with both the DSQ and INF-DSQ. During the episode, informants are able to discriminate premorbid from current D0 defenses, but not from current D28 defenses. Conclusion: Even if this study has strong limitations, our results argue for the interest of close informants to assess premorbid personality. Before it could be validated, the INF-DSQ should be further studied in other subgroups of patients, especially its ability to give accurate descriptions of patient’s premorbid defenses during an acute episode.

Prévalence de la dépression dans la sclérose en plaques. Revue et méta-analyse

Resume Introduction L’objectif de cette revue est d’evaluer la frequence de la depression au cours de la sclerose en plaques (SEP). Materiel et methode Nous avons realise une meta-analyse en utilisant deux methodes de combinaison basees sur les niveaux de signification (p). Resultats La frequence de la depression dans la SEP est significativement plus elevee que dans d’autres pathologies chroniques. Cette meta-analyse fournit un p combine significatif, indicateur d’un effet de la SEP par rapport a d’autres maladies chroniques sur la frequence de la depression. L’importance de cet effet peut etre qualifiee de moyen (effet standardise d de Cohen a 0,29, intervalle de confiance a 95 p. 100 : 0,09-0,49) et est donc probablement cliniquement pertinente. Conclusion Ce resultat plaide en faveur du caractere specifique de l’association SEP et depression qui ne serait donc ni fortuite ni seulement liee aux facteurs non specifiques de toute maladie chronique.