Janice M. McKenzie

Bulimia comorbidity in the general population and in the clinic

This study compares rates of comorbidity of lifetime psychiatric disorder in a clinical sample of women with bulimia, with general population base rates, and with rates of comorbidity among bulimic women in the general population. Eighty-four per cent of the clinical sample of bulimic women had a lifetime affective disorder, and 44% a lifetime alcohol or drug disorder. These rates of disorder were significantly higher than the base rates in the general population. Bulimic women in the general population also had more affective and substance-use disorders than the general population base rates, but the rates of these disorders were lower than found in the clinical sample. In the general population, quite similar rates of other disorders including generalized anxiety, panic, phobia and obsessive-compulsive disorder, are found among those with bulimia, substance-use disorder and depression. Furthermore, among those with depression and substance-use disorder in the general population, rates of eating disorder are comparable. Rather than suggesting a specific relationship between bulimia and either depression or substance-use disorder, the data from this study suggest that the presence of any disorder is associated with a non-specific increase in the likelihood of other psychiatric disorder.

Age-dependent antidepressant pharmacogenomics: polymorphisms of the serotonin transporter and G protein β3 subunit as predictors of response to fluoxetine and nortriptyline

In 169 depressed patients randomized to treatment with either fluoxetine or nortriptyline, we examined whether polymorphisms of the serotonin transporter and the G protein beta3 subunit influenced response to these antidepressants. For depressed patients under the age of 25 yr the T allele of the G protein beta3 subunit was associated with a markedly poorer response to nortriptyline, while serotonin transporter polymorphisms did not predict antidepressant response. However, in patients 25 yr or older, the G protein beta3 polymorphisms did not predict antidepressant response, while the s,s genotype of the serotonin transporter was associated with a poorer response to both fluoxetine and nortriptyline. These differential pharmacogenetic predictors of antidepressant response by age, may provide clues to understanding the discontinuities in pharmacological responsiveness of child/adolescent and adult depressive disorders.

The Long-Term Efficacy of Three Psychotherapies for Anorexia Nervosa: A Randomized, Controlled Trial

OBJECTIVE To evaluate the long-term efficacy of three psychotherapies for anorexia nervosa. METHOD Participants were women with broadly defined anorexia nervosa who had participated in a RCT comparing specialized psychotherapies (cognitive behavior therapy, CBT, and interpersonal psychotherapy, IPT) with a control condition (specialist supportive clinical management, SSCM), and attended long-term follow-up assessment (mean 6.7 years ± 1.2). RESULTS Forty three of the original sample of 56 women participated in long-term follow-up assessment (77%). No significant differences were found on any pre-selected primary, secondary or tertiary outcome measures among the three psychotherapies at long-term follow-up assessment. Significantly different patterns of recovery were identified for the psychotherapies across time on the primary global outcome measure. Although SSCM was associated with a more rapid response than IPT, by follow-up all three treatments were indistinguishable. DISCUSSION Potential implications for the timing of interventions to improve treatment response in anorexia nervosa are critically examined.

Interpersonal psychotherapy for anorexia nervosa.

OBJECTIVE This paper outlines the rationale for treating individuals with anorexia nervosa using interpersonal psychotherapy. METHOD We review theoretical, empirical, and psychotherapy literature relating to interpersonal functioning in anorexia nervosa. RESULTS Etiological theories emphasize interpersonal and family dysfunction in the development of anorexia nervosa. Research supports the notion that families of individuals with anorexia nervosa have dysfunctional patterns of communication. The history of treatment for anorexia nervosa emphasizes the need for resolution of interpersonal dysfunction, within the traditions of psychodynamic, family therapy, and multidimensional therapies. DISCUSSION Interpersonal psychotherapy is a time-limited psychotherapy based on the notion that regardless of etiology, interpersonal relationships are intertwined with symptomatology. The goals of the therapy are to improve interpersonal functioning and thereby decrease symptomatology. Factors identified as important in the development of anorexia nervosa are readily conceptualized within the interpersonal psychotherapy problem areas of grief, interpersonal disputes, interpersonal deficits, and role transitions.

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

A differential response to nortriptyline and fluoxetine in melancholic depression: the importance of age and gender.

Objective: To consider the impact of age and gender on the antidepressant response to nortriptyline and fluoxetine in melancholic depression.

Hospitalization for anorexia nervosa

In 1980 and 1981, 112 patients received a principal diagnosis of anorexia nervosa during their first admission to a psychiatric unit in New Zealand. Over the subsequent 5 years 48 (43%) were readmitted to hospital on one or more occasions, with those who were 16 years or less being more likely to be readmitted. These patients with anorexia nervosa spent longer in hospital for each admission that any other group of psychiatric patients with non-organic disorders, and over the 5-year follow-up the average cumulative length of stay was exceeded only by patients with schizophrenia and organic disorders. These findings suggest the need for further study into the best treatment setting for patients with anorexia nervosa, and to what extent chronicity in anorexia nervosa may be reduced

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.

Bipolar II disorder: personality and outcome in two clinical samples

OBJECTIVE To compare the personality traits and disorders of patients with bipolar II disorder and major depression and to examine the impact on treatment outcome of a bipolar II diagnosis. METHOD Patients from two clinical trials, a depressive sample (n = 195, 10% bipolar II) and a bulimic sample (n = 135, 16% bipolar II), were assessed for personality traits using DSM-IV criteria. Patients were randomised to treatments (fluoxetine or nortriptyline for depressive sample; cognitive behaviour therapy for bulimic sample) and followed for 3 years (depressive sample) or 5 years (bulimic sample) to assess the impact on outcome of a bipolar II diagnosis. RESULTS Bipolar II patients were assessed as having more borderline, histrionic and schizotypal personality traits than patients with major depression. A baseline bipolar II diagnosis did not impact negatively on treatment outcome, and less than 5% of bipolar II patients developed bipolar I disorder during follow up. CONCLUSIONS The low rate of conversion of bipolar II to bipolar I disorder and the lack of adverse impact of the diagnosis on outcome, questions the need for antimanic or mood stabiliser medication in most bipolar II patients.