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REVIEW ARTICLE |
Department of Psychological Medicine, Division of Neuroscience and Psychological Medicine, Imperial College London, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
Department of Psychological Medicine, Division of Neuroscience and Psychological Medicine, Imperial College London, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
Department of Psychological Medicine, Division of Neuroscience and Psychological Medicine, Imperial College London, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
Correspondence: Professor Peter Tyrer, Department of Psychological Medicine, Division of Neuroscience and Mental Health, Imperial College London, St Dunstan's Road, London W6 8RP,UK. E-mail: p.tyrer{at}imperial.ac.uk
Declaration of interest P.T. and T.J. belong to a UK Medical Research Council Cooperative Group (Mencog) evaluating mental health interventions. P.T. is Editor of the British Journal of Psychiatry but had no part in the evaluation of this paper.
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ABSTRACT |
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Aims Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined.
Method Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies.
Results Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small.
Conclusions Combined depression and personality disorder is associated with a poorer outcome than depression alone.
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INTRODUCTION |
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METHOD |
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Inclusion criteria
Inclusion criteria were broad to ensure maximum accrual of information for
systematic review. Papers were selected if: (a) written in English; (b)
participants were assessed for both depression and personality disorder using
a scale published in a peer-reviewed journal; (c) the population studied was
aged at least 18 years; (d) assessment of outcome of depression was at least 3
weeks after initial assessment, this being considered the minimum time
necessary for treatment response. Both observational studies and randomised
trials were included and there were no restrictions with regard to type of
treatment or its duration.
Exclusion criteria
Studies that examined personality using a dimensional scale were excluded,
as these could not be compared directly with those in which a categorical
diagnosis of personality disorder was made.
Search method
Medline, Clinhal and Psychinfo were searched online from 1966, 1982 and
1882, respectively. The terms DEPRESSION, MENTAL ILLNESS and PERSONALITY
DISORDER were entered and combined. All abstracts were reviewed and those with
data suggesting satisfaction of the inclusion criteria read in full.
In addition, a hand search of the Journal of Affective Disorders was carried out by G.N.-H. This served as an audit of the online search and provided additional sources of information. All relevant review articles were also examined closely for eligible studies, especially those by McGlashan (1987), Reich & Green (1991), Reich & Vasile (1993), Shea et al (1992), Ilardi & Craighead (1995), Corruble et al (1996), Dreessen & Arntz (1998) and Mulder (2002). The grey literature was not examined as it was considered unlikely to provide further data.
Data extraction and checking
Two-by-two tables of the numbers of patients with or without personality
disorder cross-classified by response to treatment (and stratified by
treatment modality when possible) were drawn up for each paper, either by
direct extraction from published tables and text (including associated
papers), derived from summary percentages, or reconstructed from summary
statistics such as
2. The resultant 2 x 2 tables were
cross-checked against all information within each published paper (counts,
percentages, summary statistics, test statistics) to check for and resolve
(multiple) inconsistencies. For papers that did not report a dichotomous
outcome but presented outcome as a mean and standard deviation (s.d.) on a
rating scale such as the HRSD, the number of patients who responded was
defined as the percentage with outcome score < 6 and estimated using the
methods of Whitehead et al
(1999), assuming a normal
distribution of scores at outcome and allowing different variances in those
with and without personality disorders. In papers that reported means alone,
standard deviations were estimated by interpolation, from a regression of
ln(s.d.) on ln(mean) in the six studies that reported these for the HRSD. Only
the earliest outcome was allowed for each study; continuous outcomes were used
only when no dichotomous outcome was reported.
For some recent papers where the required data on personality status (or depression) seemed to be implied but could not be extracted or derived, authors were contacted with a request for relevant information in the form of a 2 x 2 table.
Every paper included in the meta-analysis was read and the data were extracted and cross-checked independently by two authors (G.N.-H. and T.J.); discrepancies were resolved by discussion.
Statistical analysis
Log (odds ratios, ORs) and their standard errors from each study were
entered into the RevMan 4.2. meta-analysis program (Cochrane Collaboration,
Oxford, UK; see
http://www.cc-ims.net/RevMan/current.htm)
using the generic inverse variance option. Results have been summarised using
conventional Forest plots and ORs, stratified by features of the studies
included. Summary ORs were estimated using a random effects model.
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RESULTS |
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Included studies
Characteristics of the 34 studies available for meta-analysis are
summarised in Table 1 in
chronological order of publication. There were 17 (50%) studies from North
America, 15 (44%) from Europe and 2 (6%) from the Far East. Four studies were
located in Iowa, USA (Pfohl et al,
1984,
1987; Zimmermann et
al, 1986; Black et al,
1988), and have been selectively included in the meta-analysis
since the first three clearly report different aspects of the same study. Four
studies located in Pittsburgh, USA
(Pilkonis & Frank, 1988;
Shea et al, 1990;
Stuart et al, 1992; Hirschfeld et al,
1998) have all been included since they report independent
data-sets (P. Pilkonis, personal communication, 2004). For the Nottingham
study of neurotic disorders (Tyrer et
al, 1990), only data for patients with dysthymia have been
abstracted, and from the study of Leibbrand et al
(1999), only data for patients
with comorbid major depressive disorder.
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Out of the 34 studies, 17 (50%) were prospective case series (cohort studies), 14 (41%) were randomised controlled trials (RCTs) and 3 (9%) were case series reviews; the majority (22 out of 34, 65%) focused on out-patients. The interval from the start of treatment to assessment of outcome varied from 3 weeks to just over a year (median=16 weeks, interquartile range 8-24); this parameter was not given in 3 studies. Response was based on rating scales for depression in 24 (71%), objective criteria for relapse in 1 (3%) and less objective criteria in 9 (26%). Out of the 24 studies using common depression scales as outcomes (HRSD, Beck Depression Inventory or Montgomery-Åsberg Depression Rating Scale), 5 (21%) reported only means (with or without s.d.), 3 (13%) reported percentages achieving at least 50% reduction from baseline, 12 (50%) reported percentages below a declared cut-off point and 4 (17%) used a complex combination. Table 1 also shows the numbers of patients with and without personality disorder with good or poor outcome, except for 6 studies that did not report a dichotomised response; overall 45% (746 out of 1663) of those with personality disorder had a good outcome compared with 57% (1054 out of 1860) of those without.
Table 2 summarises the results from studies reporting mean outcome scores on the HRSD, BDI and MADRS, together with estimates of ORs obtained from means (and s.d.) using the methods of Whitehead et al (1999). Also shown for comparison are ORs obtained from dichotomised outcomes reported by individual studies. Given the width of the 95% CI around the ORs, it is difficult to detect divergence between the two sets. However, it should be noted that the point estimates of the ORs estimated from means (and s.d.) are reasonably close to those reported for dichotomised outcomes, with the exception of Zimmerman et al (1986) (which occurs only when treatment is stratified by modality), Casey et al (1996) and Viinamaki et al (2002). On this basis we consider that the methods of Whitehead et al are sufficiently robust to allow inclusion of the six studies in Table 2 that do not report a dichotomised outcome. For the other ten studies in Table 2, the dichotomised outcome is used in the meta-analysis.
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Figure 1 shows a funnel plot of ORs (under a fixed-effects model) from the 34 studies in Table 1. In the absence of publication bias the points should be symmetrical about the vertical line at the pooled ORs. Although reasonably symmetrical, it does suggest the possible absence of small studies (large standard errors) with negative associations (ORs around 1 or less), which may be a natural consequence of the general tendency to publish positive studies.
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Figure 2 also shows, as expected, that the results from the studies that used miscellaneous criteria for response are more diverse than those that used Hamilton-type criteria, but none the less provide a consistent overview. There are fewer studies, six in total, that report continuous outcomes only, and only one of these excludes association with ORs greater than 2. There is no evidence of a trend with year of publication within any of the strata.
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In Fig. 4 the studies are stratified by their design and ordered within design type by interval from baseline to outcome assessment. The RCTs are less heterogeneous than the cohort studies and also suggest a smaller effect of personality disorder (OR=1.60 v. 2.73). Interval from baseline to outcome assessment does not appear to be related to the outcome of treatment. Table 2 shows that those with personality disorder had slightly higher mean Hamilton scores at baseline than those without (21.1 v. 19.9), and this could be associated with poorer response. However, they also had a smaller mean change (9.5 v. 11.0) and the duration of five of the seven studies exceeded 15 weeks.
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DISCUSSION |
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Overall, about 55% of patients with personality disorder had a poor outcome compared with about 45% of those without, demonstrating that many of those with depression and personality disorder remain unwell, a feature that is particularly noticeable in the long term (Kennedy et al, 2004; Tyrer et al, 2004). The total number of patients necessary to detect this difference (or larger) with 90% power, using a (two-sided) statistical test of the difference between two proportions at the 5% level of significance, exceeds 1000. None of the individual studies approached this target. The largest, by Hirschfield et al (1998), which included over 600 patients, achieved only 70% power to detect this effect. This partly explains the confusion in the literature and reinforces the need to combine evidence from separate studies to reach a sound conclusion.
Methodological strengths and weaknesses
Our research strategy was comprehensive and studies excluded because they
did not satisfy our inclusion criteria did not show important differences from
the included papers. Resources to include searches for papers not written in
English were unavailable.
A surprising finding was the relative dearth of studies exploring this issue either as a primary or secondary research aim. Depression is extremely common, the bread and butter of day-to-day psychiatry, and this is reflected in the research. Comorbidity with personality disorder is also common, but this is not as well reflected. Only a quarter of the studies identified as potentially useful provided the necessary data and only 14 were RCTs.
Our findings do not indicate whether the influence of personality disorder is independent of intervention. They suggest, however, that the treatment of depression with psychotherapy may be less effective in those with personality disorder. A recent study using interpersonal psychotherapy as maintenance treatment for women with depression found higher rates of recurrence and more rapid relapse in a subgroup with personality disorder (Cyranowski et al, 2004). It also found an increased need for pharmacotherapy, broadly supporting this conclusion. This somewhat counterintuitive finding needs cautious interpretation as the total numbers are not large and no effort has been made to substratify psychological treatment modalities. A specific type of psychological approach might have merit in this group, as has been shown for the specific treatment of borderline personality disorder (Linehan et al, 1991; Bateman & Fonagy, 1999; Verheul et al, 2003). The better result with drug treatment may also be a direct effect of treatment on personality pathology, as has been suggested in recent studies (Ekselius & von Knorring, 1998; Fava et al, 2002). There also might be important variation between the effects of different antidepressants in the presence of personality disorder (Mulder et al, 2003). The merits of combined drug and psychological treatment are also not yet known in the presence of personality disorder (Kool et al, 2003; de Jonghe et al, 2004).
Similarly the absence of a clear association with response to ECT requires cautious interpretation because of the comparatively small total numbers involved. Nevertheless there is some indication that ECT may be of benefit in those with severe depression and personality disorder. In many studies, initial depression scores were higher in the groups with personality disorder, potentially leading to a spurious conclusion of poor outcome when taking a fixed-scale score for recovery status. However, the difference was not large (an HRSD score difference of less than 1.5 between groups). The group with personality disorder also showed a smaller mean change with treatment regardless of the baseline measure, and there was no apparent relationship between the OR and the duration of study.
Finally by only analysing studies in which a categorical diagnosis was used, we excluded papers that provided dimensional ratings of personality only. This, however, allows for reproducible collation of the data in a fashion that is not only amenable to analysis but useful in day-to-day practice.
Implications for clinical practice
We conclude that if comorbid personality disorder is not treated patients
will respond less well to treatment for depression than do those with no
personality disorder; the same may apply even if no treatment is given. There
is no particular treatment that defies this association, although there is
some suggestion that the negative effect of personality disorder might be
attenuated by drug treatment. The results emphasise the importance of studying
the simultaneous treatment of depression and comorbid personality disorder,
since there is now better evidence that both drug and psychological
treatments, when specifically targeted at personality pathology, might be of
value (Leichsenring & Leibing,
2003; Newton-Howes &
Tyrer, 2003; Tyrer et
al, 2003). Some of the contrary findings in the literature
(Mulder, 2002) might reflect
the extent to which personality disorder has been treated, either explicitly
or covertly. Whatever the interpretation, a diagnosis of personality disorder
is not necessarily a poor prognostic indicator. These patients simply require
treatment of both the personality disorder and the depression. This offers a
challenge to clinicians. Despite our best endeavours patients with personality
disorder remain one of the most difficult groups in psychiatric practice.
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Clinical Implications and Limitations |
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LIMITATIONS
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STUDIES INCLUDED IN THE META-ANALYSIS |
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Ansseau, M., Troisfontaines, B., Papart, P., et al (1991) Compulsive personality as predictor of response to serotoninergic antidepressants. BMJ, 303, 760 -761.[Medline]
Black, D. W., Bell, S., Hulbert, J., et al (1988) The importance of axis II in patients with major depression: a controlled study. Journal of Affective Disorders, 14, 115 -122.[CrossRef][Medline]
Casey, P. & Butler, E. (1995) The effects of personality on response to ECT in major depression. Journal of Personality Disorders, 9, 134 -142.
Casey, P., Meagher, D. & Butler, E. (1996) Personality, functioning, and recovery from major depression. Journal of Nervous and Mental Disease, 184, 240 -245.[CrossRef][Medline]
Casey, P., Birbeck, G., McDonagh, C., et al (2004) Personality disorder, depression and functioning: results from the ODIN study. Journal of Affective Disorders, 82, 277 -283.[Medline]
Charney, D. S., Nelson, J. C. & Quinlan, D. M.
(1981) Personality traits and disorder in depression.
American Journal of Psychiatry,
138, 1601
-1604.
Davidson, J., Miller, R. & Strickland, R. (1985) Neuroticism and personality disorder in depression. Journal of Affective Disorders, 8, 177-182.[CrossRef][Medline]
Diguer, L., Barber, J. P. & Luborsky, L.
(1993) Three concomitants: personality disorders, psychiatric
severity, and outcome of dynamic psychotherapy of major depression.
American Journal of Psychiatry,
150, 1246
-1248.
Ekselius, L. & von Knorring, L. (1998) Personality disorder comorbidity with major depression and response to treatment with sertraline or citalopram. International Clinical Psychopharmacology, 13, 205 -211.[Medline]
Ezquiaga, E., Garcia, A., Bravo, F., et al (1998) Factors associated with outcome in major depression: a 6-month prospective study. Social Psychiatry and Psychiatric Epidemiology, 33, 552 -557.[CrossRef][Medline]
Fava, M., Bouffides, E., Pava, J. A., et al (1994) Personality disorder comorbidity with major depression and response to fluoxetine treatment. Psychotherapy and Psychosomatics, 62, 160 -167.[CrossRef][Medline]
Fava, M., Farabaugh, A. H., Sickinger, A. H., et al (2002) Personality disorders and depression. Psychological Medicine, 32, 1049 -1057.[Medline]
Goethe, J. W., Szarek, B. L. & Cook, W. L. (1988) A comparison of adequately vs. inadequately treated depressed patients. Journal of Nervous and Mental Disease, 176, 465 -470.[Medline]
Hardy, G. E., Barkham, M., Shapiro, D. A., et al (1995) Impact of cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression. Journal of Consulting and Clinical Psychology, 63, 997 -1004.[CrossRef][Medline]
Hirschfeld, R. M., Russell, J. M., Delgado, P. L., et al (1998) Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine. Journal of Clinical Psychiatry, 59, 669 -675.
Ilardi, S. S., Craighead, W. E. & Evans, D. (1997) Modelling relapse in unipolar depression: the effects of dysfunctional cognitions and personality disorders. Journal of Consulting and Clinical Psychology, 65, 381 -391.[CrossRef][Medline]
Joffe, R. T. & Regan, J. J. (1989) Personality and response to tricyclic antidepressants in depressed patients. Journal of Nervous and Mental Disease, 177, 745 -749.[Medline]
Keitner, G.I., Miller, I.W., Ryan, C.E., et al (1989) Compounded depression and family functioning during the acute episode and at 6-month follow up. Comprehensive Psychiatry, 30, 512 -521.[Medline]
Kool, S., Dekker, J., Duijsens, I. J., et al (2003) Efficacy of combined therapy and pharmacotherapy for depressed patients with or without personality disorders. Harvard Review of Psychiatry, 11, 133 -141.[CrossRef]
Leibbrand, R., Hiller, W. & Fichter, M. (1999) Effect of comorbid anxiety, depressive, and personality disorders on treatment outcome of somatoform disorders. Comprehensive Psychiatry, 40, 203 -209.[CrossRef][Medline]
Patience, D. A., McGuire, R. J., Scott, A. I., et al
(1995) The Edinburgh Primary Care Depression Study:
personality disorder and outcome. British Journal of
Psychiatry, 167, 324
-330.
Pfohl, B., Stangl, D. & Zimmerman, M. (1984) The implications of DSM-III personality disorders for patients with major depression. Journal of Affective Disorders, 7, 309 -318.[CrossRef][Medline]
Pfohl, B., Coryell, W., Zimmerman, B., et al (1987) Prognostic validity of self report and interview measures of personality disorder in depressed inpatients. Journal of Clinical Psychiatry, 48, 468 -472.
Pilkonis, P. A. & Frank, E. (1988)
Personality pathology in recurrent depression: nature, prevalence, and
relationship to treatment response. American Journal of
Psychiatry, 145, 435
-441.
Reich, J. H. (1990) Effect of DSM-III personality disorders on outcome of tricyclic antidepressant-treated nonpsychotic outpatients with major or minor depressive disorder. Psychiatry Research, 32, 175 -181.[CrossRef][Medline]
Sato, T., Sakado, K. & Sato, S. (1993) Is there any specific personality disorder or personality cluster that worsens the short-term treatment outcome of major depression? Acta Psychiatrica Scandinavica, 88, 342 -349.[Medline]
Sauer, H., Kick, H., Minne, H. W., et al (1986) Prediction of the amitryptiline response: psychopathology versus neuroendocrinology. International Clinical Psychopharmacology, 1, 284 -295.[Medline]
Shawcross, C. R. & Tyrer, P. (1985) Influence of personality on response to monoamine oxidase inhibitors and antidepressants. Journal of Psychiatric Research, 19, 557 -562.[CrossRef][Medline]
Shea, M. T., Pilkonis, P. A., Beckham, E., et al
(1990) Personality disorders and treatment outcome in the
NIMH treatment of depression collaborative research program.
American Journal of Psychiatry,
147, 711
-718.
Stuart, S., Simons, A. D., Thase, M. E., et al (1992) Are personality assessments valid in acute major depression? Journal of Affective Disorders, 24, 281 -290.[CrossRef][Medline]
Sullivan, P F., Joyce, P. R. & Mulder, R. T. (1994) Borderline personality disorder in major depression. Journal of Nervous and Mental Disease, 182, 508 -516.[Medline]
Thompson, L.W., Gallagher, D. & Czirr, R. (1988) Personality disorder and outcome in the treatment of late-life depression. Journal of Geriatric Psychiatry, 21, 133 -153.[Medline]
Tyrer, P., Casey, P. & Gall, J. (1983)
Relationship between neurosis and personality disorder. British
Journal of Psychiatry, 142, 404
-408.
Tyrer, P., Seivewright, N., Ferguson, B., et al (1990) The Nottingham study of neurotic disorder: relationship between personality status and symptoms. Psychological Medicine, 20, 423 -431.[Medline]
Viinamaki, H., Hintikka, J., Honkalampi, K., et al (2002) Cluster C personality disorder impedes alleviation of symptoms in major depression. Journal of Affective Disorders, 71, 35 -41.[Medline]
Zimmerman, M., Coryell, W., Pfohl, B., et al
(1986) ECT response in depressed patients with and without a
DSM-III personality disorder. American Journal of
Psychiatry, 143, 1030
-1032.
|
|
REFERENCES |
|---|
|
|
|---|
Bateman, A. & Fonagy, P. (1999)
Effectiveness of partial hospitalisation in the treatment of borderline
personality disorder: a randomised controlled trial. American
Journal of Psychiatry, 156, 1563
-1569.
Beck, A.T., Ward, C. H. & Mendelson, M., et al (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.[Medline]
Brieger, P., Ehrt, U., Bloeink, R., et al (2002) Consequences of comorbid personality disorders in major depression. Journal of Nervous and Mental Disease, 190, 304 -309.[Medline]
Cloninger, C. R. (1987) A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry, 44, 573 -588.[Abstract]
Corruble, E., Ginester, D. & Guelfi, J.D. (1996) Comorbidity of personality disorders and unipolar major depression: a review. Journal of Affective Disorders, 37, 157 -170.[CrossRef][Medline]
Cyranowski, J. M., Frank, E. & Winter, E., et al (2004) Personality pathology and outcome in recurrently depressed women over 2 years of maintenance interpersonal psychotherapy. Psychological Medicine, 34, 659 -669.[Medline]
De Jonghe, F., Hendriksen, M., van Alst, G., et al (2004) Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. British Journal of Psyciatry, 185, 35 -45.
Dreessen, L. & Arntz, A. (1998) The impact of personality disorders on treatment outcome of anxiety disorders: best-evidence synthesis. Behaviour Research and Therapy, 36, 483 -504.[Medline]
Eysenck, H. J. (1959) The Maudsley Personality Inventory. London: University of London Press.
Eysenck, H. J. & Eysenck, S. B. G. (1964) Manual of the Eysenck Personality Inventory. London: University of London Press.
Greer, H. S. & Cawley, R. H. (1966) Some observations on the natural history of neurotic illness. In Australian Medical Association, Mervyn Archdall Medical Monograph No. 3. Glebe, Australia: Australasian Medical Publishing Company.
Hamilton, M. (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56 -62.[Medline]
Ilardi, S. S. & Craighead, W. E. (1995) Personality pathology and response to somatic treatments for major depression: a critical review. Depression, 2, 200-217.
Kennedy, N., Abbott, R. & Paykel, E. S.
(2004) Longitudinal syndromal and sub-syndromal symptoms
after severe depression: 10-year follow-up study. British Journal
of Psychiatry, 184, 330
-336.
Leichsenring, F. & Leibing, E. (2003) The
effectiveness of psychodynamic therapy and cognitive behavior therapy in the
treatment of personality disorders: a meta-analysis. American
Journal of Psychiatry, 160, 1223
-1232.
Linehan, M. M., Armstrong, H. E., Suarez, A., et al (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060 -1064.[Abstract]
Livesley, W. J. (1991) Classifying personality disorders: ideal types, prototypes, or dimensions? Journal of Personality Disorders, 5, 52 -59.
McGlashan, T. H. (1987) Borderline personality disorder and unipolar affective disorder: long-term effects and comorbidity. Journal of Nervous and Mental Disease, 175, 467 -473.[Medline]
Montgomery, S. A. & Åsberg, M. (1979)
A new depression scale designed to be sensitive to change. British
Journal of Psychiatry, 134, 382
-389.
Mulder, R. (2002) Personality pathology and
treatment outcome in major depression: a review. American Journal
of Psychiatry, 159, 359
-371.
Mulder, R. T., Joyce, P. R. & Luty, S. E. (2003) The relationship of personality disorders to treatment outcome in depressed outpatients. Journal of Clinical Psychiatry, 64, 259 -264.
Newton-Howes, G. & Tyrer, P. (2003) Pharmacotherapy for personality disorders. Expert Opinion on Pharmacotherapy, 4, 1643 -1649.[Medline]
Reich, J. H. & Green, A. I. (1991) Effect of personality disorders on outcome of treatment. Journal of Nervous and Mental Disease, 179, 74 -82.[CrossRef][Medline]
Reich, J. H. & Vasile, R. G. (1993) Effect of personality disorders on the treatment outcome of axis I conditions: an update. Journal of Nervous and Mental Disease, 181, 475 -484.[CrossRef][Medline]
Sargant, W. (1966) Psychiatric treatment in general teaching hospitals: a plea for a mechanistic approach. BMJ, 2, 257 -262.[Medline]
Shea, M. T., Widiger, T. A. & Klein, M. H. (1992) Comorbidity of personality disorders and depression: implications for treatment. Journal of Consulting and Clinical Psychology, 60, 857 -868.[CrossRef][Medline]
Tyrer, P., Sensky, T. & Mitchard, S. (2003) The principles of nidotherapy in the treatment of persistent mental and personality disorders. Psychotherapy and Psychosomatics, 72, 350 -356.[CrossRef][Medline]
Tyrer, P., Seivewright, H. & Johnson, T. (2004) The Nottingham Study of Neurotic Disorder: predictors of 12-year outcome of dysthymic, panic and generalized anxiety disorder. Psychological Medicine, 34, 1385 -1394.[CrossRef][Medline]
Verheul, R., van den Bosch, L. M. C., Koeter, M. J.W., et
al (2003) Dialectical behaviour therapy for women with
borderline personality disorder: 12-month, randomised clinical trial in The
Netherlands. British Journal of Psychiatry,
182, 135
-140.
Whitehead, A., Bailey, A. J. & Elbourne, D. (1999) Combining summaries of binary outcomes with those of continuous outcomes in a meta-analysis. Journal of Biopharmaceutical Statistics, 9, 1 -16.[CrossRef][Medline]
Received for publication April 30, 2004. Revision received November 11, 2004. Accepted for publication December 8, 2004.
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