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Authors' reply

Department of Psychological Medicine, Imperial College London, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK

P. Tyrer

Department of Psychological Medicine, Division of Neuroscience and Psychological Medicine, Imperial College, London W6 8RP, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK. Email: p.tyrer{at}imperial.ac.uk

T. Johnson

Department of Psychological Medicine, Imperial College London, and MRC Biostatistics Unit, Institute of Public Health, Cambridge, 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 letter.

We did not set out to provide a definitive answer to a specific question; our objective was to provide a comprehensive synthesis of all available studies and, by using a systematic approach to data collection with limited exclusion criteria and a robust statistical analysis, we have produced the best summary available to date. Although data from RCTs are valuable, they are not the sole arbiters of association and so our information covers much more than the necessarily short-term span of an RCT. Even if we confine our analysis to the 14 RCTs in our review, we obtain an odds ratio of 1.60 (95% CI 1.25-2.06), indicating better resolution of a depressive episode without comorbid personality disorder. Both cohort studies and case series support this finding, with all groups identifying a poorer outcome in those with a personality disorder.

The overview by Kool et al (2005) included just six RCTs, all of which involved drug treatment with antidepressants and none of which extended beyond 24 weeks. The judgement that these were the only trials of `high quality' may be suspect, as it is difficult to assess quality from published papers (Soares et al, 2004). In addition, despite their claim that studies were excluded when `they presented reanalyses of a study population that was already included', we believe that their two largest studies (Hirschfeld et al, 1998; Russell et al, 2003) both stem from the same trial (albeit with different outcomes) first reported by Rush et al (1998). Excluding Russell et al (2003), from their meta-analysis slightly widens the 95% CI for the reported (inverted) odds ratio of 1.14 from 0.93-1.39 to 0.88-1.45, neither of which are inconsistent with our own estimate above.

Our review also suggested that there may be a better response to the treatment of comorbid depression and personality disorder with antidepressant drugs than with other treatments, which is consistent with Kool et al (2005). We remain optimistic about treating personality pathology successfully in this group, and think that newer treatments which focus on personality should be compared with aggressive pharmacotherapy for those who are regarded as having `resistant' depression.

REFERENCES

Hirschfeld, R. M. A., 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, 69, 669 -675.

Kool, S., Schoevers, R. A., de Maat, S., et al (2005) Efficacy of pharmacotherapy in depressed patients with and without personality disorders: a systematic review and meta-analysis. Journal of Affective Disorders, 88, 269 -278.[CrossRef][Medline]

Rush, A. J., Koran, L. M., Keller, M. B., et al (1998) The treatment of chronic depression, part 1: study design and rationale for evaluating the comparative efficacy of sertraline and imipramine as acute, crossover, continuation, and maintenance phase therapies. Journal of Clinical Psychiatry, 59, 589 -597.[Medline]

Russell, J. M., Kornstein, S. G., Shea, M. T., et al (2003) Chronic depression and comorbid personality disorders: response to sertraline versus imipramine. Journal of Clinical Psychiatry, 64, 554 -561.

Soares, H. P., Daniels, S., Kumar, A., et al (2004) Bad reporting does not mean bad methods for randomised trials: observational study of randomised controlled trials performed by the Radiation Therapy Oncology Group. BMJ, 328, 22-25.[Abstract/Free Full Text]

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