Janet D. Carter

Infants in a neonatal intensive care unit: parental response

Objective: To compare the psychosocial functioning of the parents (mother and father) of infants admitted to a neonatal intensive care unit (NICU) with the parents of infants born at term and not admitted to the NICU. Design: Random sample of NICU parents and term non-NICU parents were assessed across a variety of psychiatric and psychosocial measures shortly after the birth of their infant. Setting: Christchurch Women’s Hospital, New Zealand. Labour ward and level III NICU. Participants: A total of 447 parents (242 mothers; 205 fathers) with an infant admitted to a regional NICU during a 12 month period; 189 parents (100 mothers; 89 fathers) with infants born at term and not requiring NICU admission. Main outcome measures: Depression and anxiety symptoms, psychosocial functioning. Results: Overall, levels of anxiety and depression were low in both parent groups. Compared with control parents, a higher percentage of NICU parents had clinically relevant anxiety and were more likely to have had a previous NICU admission and be in a lower family income bracket. Infant prematurity was associated with higher levels of symptomatology in both NICU mothers and fathers. Conclusions: Specific interventions are not needed for most parents who have an infant admitted to the NICU as they appear to adapt relatively successfully. Infant prematurity impacts negatively on the father as well as the mother. Consequently these parents may benefit from increased clinical attention.

Screening and treatment for depression during pregnancy: a cautionary note

OBJECTIVE The aim of this study was to evaluate the recruitment and retention of depressed pregnant women, identified initially through screening, to a randomized controlled psychotherapy trial. METHOD Consecutive pregnant women presenting for routine ultrasound scan were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Women who scored greater than 12 on the EPDS and who agreed to contact were invited to attend an initial assessment to determine eligibility for the trial. Consenting, eligible women were randomized to either cognitive behaviour therapy (CBT) or routine clinical care (RCC). Follow-up assessments were conducted at mid (6 weeks following initial assessment), end (approximately 36 weeks gestation), and postpartum (approximately 4 months postdelivery) for all participants. RESULTS 400 women were offered the EPDS, and 93% completed the questionnaire (370/400). Thirteen percent (49/370) of these women scored greater than 12, although only a minority of these women agreed to be contacted (15/49). Of those who agreed to be contacted, less than half attended initial interview (7/15 attended; 3/15 ineligible; 5/15 declined). Upon interview, all women except for one, were eligible and consenting (6/7). Three women were randomized to CBT and three to RCC. Only one woman randomized to CBT chose to commence treatment, and only one woman randomized to RCC was offered treatment for her low mood by her lead maternity provider. CONCLUSIONS While the vast majority of pregnant women were willing to complete a depression screening questionnaire, most did not agree to additional contact or assessment, and either were not offered treatment or did not accept treatment. This was not an effective recruitment strategy for a randomized controlled psychotherapy trial.

Gender differences in the presentation of depressed outpatients: a comparison of descriptive variables

BACKGROUND Gender differences in the clinical manifestation of depression and related variables were examined in 170 depressed outpatients. METHOD Age of onset of depression, chronicity, recurrence, subtype of depression, self-harm history and prior treatment history were assessed with structured clinical interviews. Depression symptom profile, family psychiatric history and social, occupational and interpersonal functioning were assessed with self-report and clinician ratings. RESULTS Overall, males and females were remarkably similar. Significant findings were that depressed females reported significantly more appetite increase, weight gain and carbohydrate craving, and in general, expressed their depression in a more emotional manner, than depressed males. CONCLUSION Psychosocial and biological explanations for these results are explored. LIMITATIONS Descriptive study and multiple testing

I Actually Don't Know Who I Am : The Impact of Bipolar Disorder on the Development of Self

Abstract The majority of patients with bipolar disorder have onset prior to twenty years with early onset associated with increased impairment. Despite this, little attention has been given to the psychosocial developmental impact of this disorder. This qualitative study explored the impact of having bipolar disorder on the development of a sense of self and identity. Key findings from this qualitative study identified that for these participants, bipolar disorder had a significant impact in the area of self and identity development. Bipolar disorder created experiences of confusion, contradiction, and self doubt which made it difficult for these participants to establish continuity in their sense of self. Their lives were characterized by disruption and discontinuity and by external definitions of self based on their illness. Developing a more integrated self and identity was deemed possible through self-acceptance and incorporating different aspects of themselves. These findings would suggest that it is critical to view bipolar disorder within a psychosocial developmental framework and consider the impact on the development of self and identity. Afocus on the specific areas of impact and targeting interventions that facilitate acceptance and integration thus promoting self and identity development would be recommended.

A dopamine transporter polymorphism is a risk factor for borderline personality disorder in depressed patients

BACKGROUND Borderline personality disorder (BPD) is often co-morbid with major depression and may complicate its treatment. We were interested in differences in genetic and developmental risk factors between depressed patients with or without a co-morbid BPD. METHOD Out-patients with major depressive disorder were recruited for two treatment trials. Assessment of depressed patients included the assessment of personality disorders, developmental risk factors and DNA samples for genetic analyses. RESULTS In each study there was a significant association between the 9-repeat allele of the dopamine transporter (DAT1) and BPD, with odds ratios (OR) > 3 and p < or = 0.02. This association remained significant when developmental risk factors for BPD (childhood abuse and neglect and borderline temperament) were also included in the analyses. The OR was even larger in the depressed patients aged > or = 35 years (OR 9.31, p = 0.005). CONCLUSION This replicated association in depressed patients between the 9-repeat allele of DAT1 and BPD may provide clues to understanding the neurobiology of BPD. The finding that the association is larger in the older depressed patients, suggests that the 9-repeat allele may be associated with a poorer prognosis BPD, rather than a young adult limited variant of BPD.

Patient predictors of response to cognitive behaviour therapy and interpersonal psychotherapy in a randomised clinical trial for depression.

OBJECTIVES This study examined patient predictors of response to interpersonal psychotherapy (IPT) and cognitive behaviour therapy (CBT). METHOD Participants were 177 adults with a primary diagnosis of major depressive disorder randomised to 16 weekly sessions of either IPT or CBT. Pre and post treatment depressive symptomatology was assessed by an independent clinician with the Montgomery Asberg Depression Rating Scale. RESULTS General predictors of response were perceived logic of therapy, recurrent depression and childhood reasons for depression (r² =.21). Only one differential predictor of treatment response was identified. Increasing comorbid personality disorder symptoms was associated with decreases in response to IPT but not CBT. CONCLUSION The results indicate that attention to specific pretreatment patient factors may enhance response to psychotherapy.

Psychotherapy for depression: A randomized clinical trial comparing schema therapy and cognitive behavior therapy

BACKGROUND The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression. METHODS In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders. RESULTS ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders. LIMITATIONS This study needs replication. CONCLUSIONS This preliminary research indicates that ST may provide an effective alternative therapy for depression.

The relationship of demographic, clinical, cognitive and personality variables to the discrepancy between self and clinician rated depression

BACKGROUND The measurement of depression severity is an important aspect of both clinical and research practices. However, studies examining the self-report Beck Depression Inventory (BDI) and the clinician Hamilton Depression Rating Scale indicate only moderate correlations. The aim of this study was to examine the correlation between two self-report measures, the revised BDI, the Hopkins Symptom Checklist with the clinician rated, Montgomery-Asberg Depression Rating Scale. The secondary aim was to investigate patient factors which contribute to discordant ratings. METHODS Depression severity and demographic, clinical, personality, cognitive, and personality factors that may contribute to a self-report-clinician rated discrepancy were examined in 177 adult outpatients with a Major Depressive Episode (DSM-IV) participating in a randomised clinical trial comparing CBT and IPT for depression. All assessment was conducted prior to treatment randomisation. RESULTS Self-report and clinician rated depression were moderately correlated. Individuals with higher clinician rated depression severity, increased levels of rumination and females were more likely to have higher self-report rated depression (BDI-II and SCL-90) than clinician rated depression. In addition, younger patients and those with melancholic depression had higher BDI-II compared to MADRS scores. LIMITATIONS Results require replication. CONCLUSIONS Self-reported and observer rated depression were only moderately correlated. Researchers and clinicians interpreting the level of depression need to be cognizant of the patient factors that may contribute to either underreporting or overreporting self-report scores relative to observer ratings.

An association study of DRD2 and COMT polymorphisms with novelty seeking and harm avoidance scores, in two independent samples of depressed patients

BackgroundIt was recently reported that an interaction of the dopamine D2 receptor (DRD2) and catechol-O-methyltransferase (COMT) influences the behavioural approach system – as measured using Carver and Whites Behavioural Inhibition and Behavioural Approach System (BIS/BAS) scales – in a sample of healthy German subjects. The Temperament and Character Inventory (TCI), in particular the novelty seeking (NS) and harm avoidance (HA) scales, correlates moderately with the BIS/BAS measure. This study aimed to examine support for an association of DRD2 and COMT with behavioural activation, using the TCI within two independent samples of depressed outpatients (for both samples n = 146).MethodsTwo clinical samples of depressed patients were ascertained to assess the efficacy of two different pharmacotherapy and psychotherapy treatments. Analysis of variance (ANOVA) was used to analyse NS and HA scale and subscale scores with respect to gene loci within each clinical sample. Analysis of covariance were undertaken to examine the association of age and gender with NS and HA scores. An association of age group or gender with gene loci were explored using chi-squared tests, in each sample.ResultsNo significant effect of DRD2 or COMT, either independently or as an interaction, on NS or HA scores was observed, within either sample. Whilst age was significantly negatively associated with NS scores, including age in the two- and three-way interactions did not affect the significance of the association of personality with gene loci.ConclusionThis study suggests that the COMT-DRD2 Equilibrium Model of Positive Emotionality recently proposed by Reuter and his colleagues is not applicable amongst currently depressed individuals, whose behavioural approach and inhibition tendencies have been assessed using the TCI.

Childhood neglect and abuse as predictors of antidepressant response in adult depression

Background: Childhood neglect and abuse are recognized as risk factors for depression, but are not often studied as predictors of treatment response in depression. Methods: Clinically depressed outpatients (n=195) were asked about childhood experiences before beginning a randomized antidepressant trial with either fluoxetine or nortriptyline. Three treatment outcomes were measured: Adequate trial, six‐week response and two months sustained recovery. Results: Patients reporting low paternal care (paternal neglect), as measured by the Parental Bonding Instrument (PBI), were less likely to complete an adequate six‐week trial of medication. Patients who reported high maternal protection (maternal overprotection) on the PBI had poorer treatment response in the short‐term at six weeks, and longer term, for two months of sustained recovery. However, abuse, whether sexual, physical, or psychological in nature, did not predict treatment response. Conclusions: The experience of having a neglectful father or an overprotective mother was more predictive of response to treatment for depression than abuse, suggesting that the quality of ongoing intra‐familial relationships has a greater impact on treatment outcomes for depression than experiences of discrete abuse in childhood. Depression and Anxiety, 2009.