Sue Luty

Plasma oxytocin levels in depression and their correlation with the temperament dimension of reward dependence

Evidence suggests that the neuropeptide oxytocin plays a role in social affiliation. This behaviour may be related more to personality dimensions than specific psychiatric diagnoses. This study investigated the relationship between plasma oxytocin levels and personality dimensions using the Temperament and Character Inventory (TCI) in 60 outpatients with major depression. The strongest correlation was between plasma oxytocin levels and the temperament dimension of Reward Dependence (0.425 Pearson correlation). This suggested that 17% of the variance in plasma oxytocin levels was explained by the Reward Dependence scores. There was a significant positive correlation between plasma oxytocin levels and the Reward Dependence personality dimension

Measures of temperament and character are differentially impacted on by depression severity.

BACKGROUND Cloningers Temperament and Character Inventory (TCI) is a widely used measure of personality. Two scales of the TCI, harm avoidance (HA) and self directedness (SD), have been shown to be influenced by depressed mood. We examined how the seven TCI scales and their subscales are correlated with depression severity before and after treatment. We also examined whether changes in personality measures could be attributed to changes in depression severity. METHODS Two clinical samples of depressed out-patients were recruited for trials to examine predictors of treatment response to antidepressants (N=195) and psychotherapies (N=177). Assessment included the Montgomery-Asberg depression rating scales (MADRS), Hopkins Symptom Checklist (SCL-90) and TCI at baseline and after treatment. RESULTS After treatment, in both samples, depression severity correlated significantly with HA and negatively with SD. Multiple regression analysis revealed that changes in SD and HA over treatment were related to improvement in depression. In the psychotherapy trial baseline MADRS scores correlated with low SD and high HA. LIMITATIONS The trial results are applicable to mild-moderately depressed out-patients. CONCLUSIONS Depression severity influences the total scales and most of the subscale measures of HA and SD. Some personality traits, as measured by the TCI, were not impacted upon by mood. Clinically mood should be taken into account when assessing personality measures of negative affect using the TCI.

Effects of comorbidity and early age of onset in young people with Bipolar Disorder on self harming behaviour and suicide attempts

BACKGROUND The age of the first episode of illness in Bipolar Disorder has been shown to be an important predictor of outcome with early onset, particularly onset before puberty, associated with greater comorbidity, a poorer quality of life and greatest impairment in functioning. METHODS Baseline data from a psychotherapy study was used to examine the prevalence of other comorbid psychiatric conditions and the impact of onset at an early age on both self harming behaviour and suicide attempts in young people with Bipolar Disorder. RESULTS This study of 100 adolescents and young adults (aged 15-36 years) with Bipolar Disorder showed that comorbid conditions were very common, even at the start of their bipolar illness. Comorbidity increased as the age of onset decreased with very early onset (<13 years) patients bearing the greatest burden of disease. Greater comorbidity also significantly increased the risk of having self harmed and attempted suicide with high lethal intent. Self harming behaviour was predicted by having a lifetime diagnoses of Borderline Personality Disorder and Panic Disorder along with an early age of onset of Bipolar Disorder. In contrast, previous suicide attempts were predicted by greater comorbidity and not by very early (<13 years) age of onset.

Thyroid indices and response to fluoxetine and nortriptyline in major depression.

We investigated: (i) the status of thyroid hormones and their clinical correlates in patients with major depression; (ii) changes in thyroid hormone status after treatment with fluoxetine versus nortriptyline; and (iii) whether blunted thyrotropin-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) challenge predicts improvement after 6 weeks of fluoxetine versus nortriptyline treatment. Patients with major depression entering a treatment trial were assessed with the Structured Clinical Interview for DSM-III-R and were rated on the Montgomery–Asberg Depression Rating Scale (MADRS). Blood samples were taken for TSH, thyroxine (T4) and free thyroxine (FT4) measurement, and the maximum TSH response (δmaxTSH) to a TRH challenge test was undertaken. Patients were then randomly assigned to receive fluoxetine or nortriptyline for six weeks. At 6 weeks, patients repeated the thyroid hormone assessment and completed the MADRS. Mean concentrations of TSH, T4, FT4 and δmaxTSH were within reference ranges. T4 and FT4 levels decreased significantly after treatment in responders, but not in nonresponders. After treatment,δmaxTSH concentrations decreased significantly in patients who responded to fluoxetine, and increased in patients who responded to nortriptyline. Patients with δmaxTSH blunting at pretreatment were more likely to be male, to have higher MADRS scores and have a history of alcohol and drug dependence. Patients with a pretreatmentδmaxTSH of < 3.0 µm/ml showed greater improvement on the MADRS when treated with fluoxetine than if treated with nortriptyline. We observed a decrease in T4 and FT4 in responders to treatment with fluoxetine or nortriptyline. Positive relationships between δmaxTSH blunting and alcohol and drug abuse and severity of depression were found. Patients with bluntedδmaxTSH responded better to fluoxetine than to nortriptyline. It is suggested that a blunted DmaxTSH may reflect a predominantly serotonergic disturbance in this group of patients with major depression.

''I Really Don't Know Whether it is Still There'': Ambivalent Acceptance of a Diagnosis of Bipolar Disorder

Questioning a diagnosis of bipolar disorder is not surprising given the chronic and fluctuating nature of the illness. Qualitative research using thematic analysis was used to derive an understanding of the process patients used to make sense of their diagnosis of bipolar disorder. The findings suggested that receiving a diagnosis was an active process. Factors such as fluctuating moods, changing diagnoses or misdiagnosis, difficulties patients have differentiating self from illness, mistrust in mental health services, and experiences of negative side effects of medication can contribute to ambivalence about the diagnosis and lead to relapse. These findings highlight the need for clinicians to focus on patients’ perceptions of bipolar disorder and work with the ambivalence in the process of facilitating greater acceptance. This has the potential for reducing relapses through increased adherence with treatment.

Elevated C-reactive protein in depression: a predictor of good long-term outcome with antidepressants and poor outcome with psychotherapy

Depression has been associated with elevated levels of C-reactive protein (CRP) (Kuo, et al., 2005; Liukkonen, et al., 2006; Whooley, et al., 2007; Danese, et al., 2008). CRP is synthesized in and released from the liver in response to proinflammatory cytokines, and the concentration of CRP is used as an index of inflammation. Strong links between inflammation and depression have been identified (Lanquillon, et al., 2000; Tuglu, et al., 2003; O’Brien, et al., 2006); however, to date no studies have investigated the influence of baseline inflammation, as measured via an elevated CRP, on the longterm outcomes of the treatment of depression. Using CRP levels, we compared the treatment outcomes of depressed patients who were defined as having inflammation (CRP ≥ 10 mg/L) with those who did not show evidence of acute inflammation (CRP < 10 mg/L). Treatment outcomes were examined in two consecutively recruited samples of depressed patients; one a randomised trial of nortriptyline and fluoxetine (Joyce, et al., 2002) and the other a randomised trial of interpersonal psychotherapy (IPT) and cognitive behavioural therapy (CBT) (Luty, et al., 2007). Patients from both studies were first assessed using a structured clinical interview for DSM-IV. In both studies, the patient’s level of depression was rated using the Montgomery-Asberg Rating Scale (MADRS). CRP concentrations were measured by Canterbury Health Laboratories as part of a serum electrophoresis screen for acute phase reactants using rate nephelometry and immunoelectrophoresis. CRP results were available for 178 of the 195 patients in the antidepressant study and 168 of the 177 patients in the psychotherapy trial. Outcome was examined by multiple regression, trial type (drug or psychotherapy) and CRP status, and their interactions were entered into the model. Further analyses were conducted with t-tests. At baseline, the 13 patients with high CRP levels in the antidepressant trial were more depressed than the 165 with levels below 10 mg/L (MADRS 34.6 vs 30.9, t = 2.01, P = 0.046). There was no difference in depression severity between the 21 patients with high and 147 patients with low CRP levels (MADRS 25.3 vs 23.6) in the psychotherapy study. Patients with CRP concentrations greater than 10 mg/L also had higher plasma levels of three other acute phase reactants; α-1-antitrypsin, haptoglobin and orosomucoid. This indicates a global, acute inflammatory response. The psychotherapy trial was structured to involve 8–19 sessions of either IPT or CBT over a 16-week period. We chose a comparable time, 20 weeks after initial randomisation to antidepressants, for the other trial. The primary outcome, percentage improvement on clinician rated MADRS scores by baseline CRP status and treatment received (Figure 1), were investigated at these time points. The multiple regression analysis demonstrated a significant interaction between CRP status and treatment received (F = 6.04, P = 0.015). Patients that were treated with antidepressants with baseline CRP levels above 10 mg/L showed significantly more improvement (90.7% vs 70.4%, t = 4.474, P < 0.001), whereas those patients with elevated CRP who were treated with psychotherapies had poorer improvements (36.3% vs 55.1%, t = 2.07, P = 0.04). Patients from the antidepressant trial were followed up at 26, 52 and 78 weeks and again those with elevated CRP at baseline had better outcomes, Letter to the Editors

Further evidence for slow binocular rivalry rate as a trait marker for bipolar disorder

Objective: Binocular rivalry refers to a situation where contradictory information is presented simultaneously to the same location of each eye. This leads to the alternation of images every few seconds. The rate of alternation between images has been shown to be slower in euthymic participants with bipolar disorder than in healthy controls. The alternation rate is not uniformly slowed in bipolar disorder patients and may be influenced by clinical variables. The present study examined whether bipolar disorder patients have slower alternation rates, examined the influence of depression and explored the role of clinical variables and cognitive functions on alternation rate. Method: Ninety-six patients with bipolar disorder and 24 control participants took part in the study. Current mood status and binocular rivalry performance were analysed with nonparametric tests. A slow and a normal alternation group were created by median split. We subsequently explored the distribution of several clinical variables across these groups. Further, we investigated associations between alternation rate and various cognitive functions, such as visual processing, memory, attention and general motor speed. Results: The median alternation rate was significantly slower for participants with bipolar disorder type I (0.39 Hz) and for participants with bipolar spectrum disorder (0.43 Hz) than for control participants (0.47 Hz). Depression had no effect on alternation rate. There were no differences between participants with bipolar disorder type I and type II and in regard to medication regime and predominance of one rivalry image. There were also no differences in regard to the clinical variables and no significant associations between alternation rate and the cognitive functions explored. Conclusion: We replicated a slowing in alternation rate in some bipolar disorder participants. The alternation rate was not affected by depressed mood or any of the other factors explored, which supports views of binocular rivalry rates as a trait marker in bipolar disorder.

Interpersonal psychotherapy: An effective psychotherapeutic intervention for mental health nursing practice

Interpersonal psychotherapy (IPT) is well-recognized for the treatment of depression with many efficacy trials supporting its use, however, there is little discussion of its use in mental health nursing practice. This paper explores how IPT can be a useful intervention for mental health nursing practice and demonstrates the process of IPT with reference to a case study. The case study illustrates how IPT facilitates a shift for one woman from a passive subject position to a more self-assertive one. This shift was facilitated by identifying how she was constructing herself in relation to others by utilizing tactics of passivity and avoidance of conflict. The development of more satisfying subject positions facilitated an improvement in mood and recovery from depression.

A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent

AIM This case study explains how a psychotherapy previously used with adults can be used with adolescents by focusing on the specific developmental issues associated with adolescence. BACKGROUND Bipolar disorder is a damaging disorder to experience during the developmental phase of adolescence. Interpersonal social rhythm psychotherapy has been developed as an adjunct to medication for managing bipolar disorder and shows some promising outcomes in adults. DESIGN This is a single case study design drawn from a larger randomised control trial of two psychotherapies for bipolar disorder. The case study addressed the question: How can Interpersonal social rhythm therapy be applied with adolescents who have bipolar disorder? METHOD This study used a purposeful sampling process by selecting the youngest adolescent participating in the randomised control trial. All the subjects sessions of Interpersonal social rhythm therapy were taped, transcribed and analysed. The analysis involved describing the process of psychotherapy as it occurred over time, mapping the process as a trajectory across the three phases of psychotherapy experience and focusing the analysis around the impact of bipolar disorder and IPSRT on adolescent developmental issues, specifically the issue of identity development. RESULTS Interpersonal social rhythm therapy allowed the therapist to address developmental issues within its framework. As a result of participation in the psychotherapy the adolescent was able to manage her mood symptoms and develop a sense of identity that was age-appropriate. CONCLUSION Interpersonal social rhythm therapy provided the adolescent in the case study the opportunity to consider what it meant to have bipolar disorder and to integrate this meaning into her sense of self. RELEVANCE TO CLINICAL PRACTICE Bipolar disorder is a chronic and recurring disorder that can have a serious impact on development and functioning. Interpersonal social rhythm therapy provides an approach to nursing care that enables adolescents to improve social functioning.

The process of change in Interpersonal Psychotherapy (IPT) for depression: A case study for the new IPT therapist

Abstract This case study involves a set of transcripts of Interpersonal Psychotherapy (IPT) sessions from the Christchurch Psychotherapy for Depression Study. The case study explores the techniques employed by the therapist for a depressed patient who has identified interpersonal disputes as the interpersonal area to focus on. The psychotherapeutic interventions utilized by the IPT therapist included: seeking information; exploring parallels in other relationships; exploring relationship patterns; exploring communication patterns; signalling what is significant; providing support, exploring affect; exploring options; problem—solving; drawing analogy; and challenging. The themes that emerged in the patients response to IPT were: struggling, deconstructing, connecting, practicing and reconstructing.