Dosage effects of psychodynamic and schema therapy in people with comorbid depression and personality disorder: four-arm pragmatic randomised controlled trial.

BACKGROUND: Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder. AIMS: To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941. METHOD: We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder. RESULTS: Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010). CONCLUSIONS: Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

Exploring differences in quality of life in clinical populations of depressed outpatients with and without personality disorders.

BACKGROUND: Although depression and personality disorders (PDs) often co-occur, less is known about the impact of PDs on health-related quality of life (HRQOL) in patients with depression. This study explores the differences in HRQOL of depressed patients with and without PD. METHODS: Baseline data of 397 patients with depression from two randomised controlled trials were used for this analysis. HRQOL was measured with the EuroQol-5D (EQ-5D). Differences were examined between three groups: patients with 1) depression-only, 2) depression and comorbid PD and 3) PD and comorbid depression. The EQ-5D scores of the groups were compared with linear regression. RESULTS: HRQOL scores were lower in the depression-only group than the depression + PD group, even though depression severity was higher in patients with PD. HRQOL in the PD ± depression group did not differ from the other groups. In addition, no associations were found between the type or severity of PD and HRQOL. DISCUSSION: These findings could indicate that patients with PD are less affected by the impact of depression on HRQOL. In addition, the EQ-5D might not adequately capture the impact of PD on quality of life. Further research is needed to compare the EQ-5D with quality of life instruments that include more life domains. LIMITATIONS: Two study samples are combined, and therefore not designed to compare the three groups directly. Generalisation of the results should be done with caution. CONCLUSION: Depressed patients with PD report higher HRQOL than depression-only patients. Although higher HRQOL, patients with PD report more severe depressions than depressed-only patients.

Integrated treatment for patients with comorbid depression and personality disorders.

PURPOSE OF REVIEW: To provide an update on the epidemiology and the clinical consequences of depression complicated by comorbid personality disorders, and to discuss optimal treatment options. RECENT FINDINGS: Studies have confirmed the frequent co-occurrence of depression and personality disorders. These comorbid states are consistently associated with unfavourable clinical indicators such as duration of episode, symptom severity and recurrence of depression, as well as a negative effect on treatment outcome. Nevertheless, this is a neglected theme and there are hardly any well designed treatment studies available. SUMMARY: We advocate considering depression and personality as being more closely related and argue in favour of the development of integrated treatment options tailored to understanding symptoms as being interwoven with a variety of long-standing disturbing personality patterns. Both clinically and conceptually, psychodynamic and schema-focused approaches provide good opportunities to adjust available therapies and they could optimize outcomes in this complex patient group. Given the risk of treatment resistance and chronicity, a combination of psychotherapy and medication should always be considered.

The effect of comorbid personality disorder on depression outcome after short-term psychotherapy in a randomised clinical trial.

BACKGROUND: Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce. AIMS: To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive-behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression. METHOD: This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com). RESULTS: Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77-1.31 and d = 1.36, 95% CI 0.97-1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87-1.43 and d = 2.12, 95% CI 1.65-2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality. CONCLUSIONS: CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but - given remaining levels of depression in patients with personality disorder - they are probably inadequate for large numbers of patients with this comorbidity. DECLARATION OF INTEREST: None.

Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy.

BACKGROUND: Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change. METHODS: In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9-12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective. DISCUSSION: This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom. TRIAL REGISTRATION: This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR5941 ).