Prediction of the 10-year course of borderline personality disorder

OBJECTIVE: The purpose of this study was to determine the most clinically relevant baseline predictors of time to remission for patients with borderline personality disorder. METHOD: A total of 290 inpatients meeting criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R for borderline personality disorder were assessed during their index admission with a series of semistructured interviews and self-report measures. Diagnostic status was reassessed at five contiguous 2-year time periods. Discrete survival analytic methods, which controlled for baseline severity of borderline psychopathology and time, were used to estimate hazard ratios. RESULTS: Eighty-eight percent of the patients with borderline personality disorder studied achieved remission. In terms of time to remission, 39.3% of the 242 patients who experienced a remission of their disorder first remitted by their 2-year follow-up, an additional 22.3% first remitted by their 4-year follow-up, an additional 21.9% by their 6-year follow-up, an additional 12.8% by their 8-year follow-up, and another 3.7% by their 10-year follow-up. Sixteen variables were found to be significant bivariate predictors of earlier time to remission. Seven of these remained significant in multivariate analyses: younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness. CONCLUSIONS: The results of this study suggest that prediction of time to remission from borderline personality disorder is multifactorial in nature, involving factors that are routinely assessed in clinical practice and factors, particularly aspects of temperament, that are not.     

Phobic postural vertigo: a first follow-up

Seventy-eight patients with phobic postural vertigo (PPV) and 17 patients with psychogenic disorder of stance and gait (PSG) were asked to evaluate their condition 6 months to 5.5 years after their original referral and short-term psychotherapy. Two results seem most important: (1) PPV had a favourable course with a 72% improvement rate (22% of patients becoming symptom free), whereas the majority of patients with PSG (52%) remained unchanged; (2) the majority of patients with PPV experienced complete remission or considerable improvement even if their condition had lasted between 1 and 20 years prior to diagnosis. Complete remission of PSG was observed only if the disorder had been present less than 4 months; there was no improvement if it had lasted longer than 2 years. PPV can be defined as a distinct clinical entity with a relatively benign course. It can be reliably diagnosed on the basis of typical features.     

Characterization of the longitudinal course of improvement in generalized anxiety disorder during long-term treatment with venlafaxine XR

OBJECTIVE: To characterize the response to the serotonin and norepinephrine reuptake inhibitor, venlafaxine extended release (XR), during the long-term treatment of generalized anxiety disorder. METHODS: Data from two double-blind, placebo-controlled, 6-month trials of venlafaxine XR for the treatment of generalised anxiety disorder were pooled. Criteria for response (> or = 50% improvement from baseline HAM-A score) and remission (HAM-A score < or = 7) and their temporal profile were used to characterize patient improvement over 6 months of treatment with venlafaxine XR and placebo. RESULTS: Venlafaxine XR was associated with significantly (P<0.001) higher response and remission rates (66 and 43%, respectively) compared with placebo (39 and 19%), regardless of the level of baseline anxiety. In the venlafaxine XR group, 61% of the patients who had responded but not remitted by week 8 showed remission by the end of 6 months. In comparison, only 39% of placebo responders who did not qualify for remission at the end of the first 8 weeks of therapy remitted by the end of the 6 months (P=0.007). Relapse occurred in 6% of venlafaxine XR-treated patients and 15% of placebo-treated patients (P<0.01). CONCLUSION: This analysis provides further insight into the outcome of long-term treatment of generalised anxiety disorder with venlafaxine XR and shows for the first time that long-term treatment might be necessary to achieve and maintain remission of symptoms.     

Light treatment for seasonal Winter depression in African-American vs Caucasian outpatients

AIM: To compare adherence, response, and remission with light treatment in African-American and Caucasian patients with Seasonal Affective Disorder.METHODS: Seventy-eight study participants, age range 18-64 (51 African-Americans and 27 Caucasians) recruited from the Greater Baltimore Metropolitan area, with diagnoses of recurrent mood disorder with seasonal pattern, and confirmed by a Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV, were enrolled in an open label study of daily bright light treatment. The trial lasted 6 wk with flexible dosing of light starting with 10000 lux bright light for 60 min daily in the morning. At the end of six weeks there were 65 completers. Three patients had Bipolar II disorder and the remainder had Major depressive disorder. Outcome measures were remission (score ≤ 8) and response (50% reduction) in symptoms on the Structured Interview Guide for the Hamilton Rating Scale for Depression (SIGH-SAD) as well as symptomatic improvement on SIGH-SAD and Beck Depression Inventory-II. Adherence was measured using participant daily log. Participant groups were compared using t-tests, chi square, linear and logistic regressions.RESULTS: The study did not find any significant group difference between African-Americans and their Caucasian counterparts in adherence with light treatment as well as in symptomatic improvement. While symptomatic improvement and rate of treatment response were not different between the two groups, African-Americans, after adjustment for age, gender and adherence, achieved a significantly lower remission rate (African-Americans 46.3%; Caucasians 75%; P = 0.02).CONCLUSION: This is the first study of light treatment in African-Americans, continuing our previous work reporting a similar frequency but a lower awareness of SAD and its treatment in African-Americans. Similar rates of adherence, symptomatic improvement and treatment response suggest that light treatment is a feasible, acceptable, and beneficial treatment for SAD in African-American patients. These results should lead to intensifying education initiatives to increase awareness of SAD and its treatment in African-American communities to increased SAD treatment engagement. In African-American vs Caucasian SAD patients a remission gap was identified, as reported before with antidepressant medications for non-seasonal depression, demanding sustained efforts to investigate and then address its causes.     

Effectiveness of electroconvulsive therapy in community settings.

BACKGROUND: Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined. METHODS: In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables. RESULTS: The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%-90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%-46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up. CONCLUSIONS: The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.     

Factors associated with electroencephalographic and clinical remission of benign childhood epilepsy with centrotemporal spikes

Purpose

Benign childhood epilepsy with centrotemporal spikes (BECTS) is strongly related to age, both to age at the time of seizure onset and to age at remission. However, the age of remission varies. The present study analyzed factors associated with remission of BECTS.

The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder

OBJECTIVE: The syndromal and subsyndromal phenomenology of borderline personality disorder was tracked over 6 years of prospective follow-up. METHOD: The psychopathology of 362 inpatients with personality disorders was assessed with the Revised Diagnostic Interview for Borderlines (DIB-R) and borderline personality disorder module of the Revised Diagnostic Interview for DSM-III-R Personality Disorders. Of these patients, 290 met DIB-R and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for other axis II disorders (and neither criteria set for borderline personality disorder). Most of the borderline patients received multiple treatments before the index admission and during the study. Over 94% of the total surviving subjects were reassessed at 2, 4, and 6 years by interviewers blind to previously collected information. RESULTS: Of the subjects with borderline personality disorder, 34.5% met the criteria for remission at 2 years, 49.4% at 4 years, 68.6% at 6 years, and 73.5% over the entire follow-up. Only 5.9% of those with remissions experienced recurrences. None of the comparison subjects with other axis II disorders developed borderline personality disorder during follow-up. The patients with borderline personality disorder had declining rates of 24 symptom patterns but remained symptomatically distinct from the comparison subjects. Impulsive symptoms resolved the most quickly, affective symptoms were the most chronic, and cognitive and interpersonal symptoms were intermediate. CONCLUSIONS: These results suggest that symptomatic improvement is both common and stable, even among the most disturbed borderline patients, and that the symptomatic prognosis for most, but not all, severely ill borderline patients is better than previously recognized.     

Course of social functioning after remission from panic disorder

While symptom status and social functioning have been observed to be correlated in many cross-sectional studies, little is known about the time course of change in functioning after a change in diagnostic status. Using data from a large longitudinal study of anxiety disorders, we present analyses of the time course of seven domains of social functioning up to 18 months before and after remission from panic disorder with or without agoraphobia. The effect of remission from panic disorder varies by domain. Four domains show a change in outcome, usually positive, after remission. The presence of major depressive disorder (MDD) affects the course of functioning for two domains. Generalized anxiety disorder (GAD) was observed to have effects on five of seven domains. For some domains there is improvement at approximately the same time as change in diagnostic status, although progressive change was seen in others. The amount of improvement was modest on average, indicating that other factors beyond panic symptoms may limit post-remission improvement in social functioning.     

Epilepsy treatment in Rett syndrome

Rett syndrome is a neurodevelopmental disorder predominately affecting females. The majority of patients have epilepsy in the early stages of the disease. This study evaluates the clinical course of epilepsy and the effect of antiepileptic drug treatment in Rett syndrome using retrospective data analysis. Epilepsy was present in 16 of 19 (84%) patients with Rett syndrome in this series. The mean age of seizure onset was 4 years. Remission of seizures was achieved after the first monotherapy in 56% and after the second monotherapy in 18.5% of patients. Valproate, lamotrigine, and carbamazepine were the drugs used most frequently as monotherapy. Valproate monotherapy was highly effective as 75% of treated patients achieved seizure remission. Monotherapy with lamotrigine or carbamazepine was effective in half of the treated patients. There was a clear tendency toward seizure remission after the age of 15 years.     

Partial remission in major depression: a two-phase, 12-month prospective study

We conducted an interview-based survey to predict the clinical course of major depressive disorder during a follow-up period of 12 months. Altogether 86 patients were investigated. A SCID I interview for DSM-III-R axis-I diagnosis was conducted at baseline and a SCID II interview for personality disorders at the 6-month follow-up. Beck Depression Inventory scores indicated the level of depression and were compiled at baseline and at 6 and 12 months. A BDI score between 9 and 14 was considered to indicate partial remission, and score of 0-8 indicated remission. At the 6-month assessment 33% of the patients had remission, 20% were in partial remission, and 47% were in the depressive phase. Older age, personality disorder, and alexithymia were associated with poor response at 6 months. At 12 months 37% had remission, 28% were in partial remission, and 35% were still in the depressive phase. Treatment at the early stage should be effective enough to achieve remission. If the response is not satisfactory within 6 months, a renewed search should be conducted for factors hindering recovery. Comorbid personality disorder is the main factor predicting a poor short-term response in major depressive disorder.     

Early improvement during duloxetine treatment of generalized anxiety disorder predicts response and remission at endpoint

Because many patients do not respond to pharmacotherapy for generalized anxiety disorder (GAD), it would be beneficial to know if early response is predictive of final outcome so that timely clinical decisions can be made about augmentation or alternative treatments. This topic has not been examined with the now recommended first-line treatments (selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors) for GAD. Combined data from three 9 to 10week acute treatment, multi-center, randomized, placebo-controlled studies of duloxetine for GAD were used to explore early improvement on the Hamilton Anxiety Rating Scale (HAMA) in relation to endpoint HAMA response (> or = 50% improvement from baseline), HAMA remission (< or = 7), Clinical Global Impression-Improvement (CGI-I) response (< or = 2), and functional remission as measured by the Sheehan Disability Scale Global Functional Improvement (< or = 5). For duloxetine-treated patients (n=668), the relationships between the proportion of patients who achieved each category of early (week 2 and week 4) HAMA improvement (> or = 20%, > or = 40%, > or = 60%, and > or = 80%) and achievement of endpoint HAMA response, HAMA remission, CGI response, and SDS remission status were all statistically significant (all P's < or = 0.003). One hundred percent of the duloxetine-treated patients who showed substantial HAMA improvement (>80%) at week 2, and 93% at week 4, were HAMA responders at endpoint. At week 2, 79% of the duloxetine-treated patients who achieved a HAMA improvement of 40-59% were HAMA responders at endpoint. About half of duloxetine-treated patient showing 40-59% early HAMA improvement were remitters on the SDS at endpoint. These data suggest a connection between early improvement and endpoint response and remission status that can be used to guide clinical decision-making.     

Secondary agoraphobia: two case reports

Two patients with agoraphobic symptoms and major depressive disorder exhibited dexamethasone nonsuppression. Antidepressant pharmacotherapy was associated with remission of depressive symptoms and DST normalization. This improvement predated remission of agoraphobic symptoms by 1-2 months. It is suggested that agoraphobia was secondary to the depression in both cases.     

Chronic depression and comorbid personality disorders: response to sertraline versus imipramine

BACKGROUND: Chronic subtypes of depression appear to be associated with high rates of Axis II personality disorder comorbidity. Few studies, though, have systematically examined the clinical correlates of Axis II personality disorder comorbidity or its effect on treatment response or time to response. METHOD: 635 patients diagnosed with DSM-III-R chronic major depression or "double depression" (dysthymia with concurrent major depression) were randomized to 12 weeks of double-blind treatment with either sertraline or imipramine between February 1993 and December 1994. Axis II diagnoses were made using the personality disorders version of the DSM-III-R Structured Clinical Interview. The effect of study treatment was measured utilizing the Hamilton Rating Scale for Depression and the Clinical Global Impressions scale. RESULTS: Forty-six percent of patients met criteria for at least 1 comorbid Axis II personality disorder, with cluster C diagnoses being the most frequent at 39%; 21% met criteria for at least 2 Axis II personality disorders. A cluster C diagnosis was associated with significantly higher rates of early-onset depression (before age 21; 47% vs. 32% for no cluster C; p =.005) and comorbid anxiety disorder (34% vs. 18% for no cluster C; p <.001). Overall, the presence of Axis II personality disorder comorbidity had minimal-to-no effect on the ability to achieve either an antidepressant response or remission and had inconsistent effects on time to response. The presence of Axis II personality disorder comorbidity did not appear to reduce functional and quality-of-life improvements among patients responding to acute treatment with sertraline or imipramine. CONCLUSION: In this treatment sample, rates of Axis II personality disorder comorbidity were substantial in patients suffering from chronic forms of depression. Axis II personality disorder comorbidity did not appear to diminish symptomatic response to acute treatment or associated improvement in functioning and quality of life.     

A retrospective follow-up study of body dysmorphic disorder

BACKGROUND: Although research on body dysmorphic disorder (BDD) is increasing, no follow-up studies of this disorder's course of illness have been published. METHODS: The status of 95 outpatients with BDD treated in a clinical practice was assessed by chart review. Standard scales were used to rate subjects at baseline and the most recent clinic visit (mean duration of follow-up, 1.7 +/- 1.1; range, 0.5-6.4 years). Ratings were also done at 6-month intervals over the first 4 years of follow-up. RESULTS: Allowing for censoring, life table analysis estimated that the proportion of subjects who achieved full remission from BDD at the 6-month and/or 12-month assessment was 24.7%; the proportion who attained partial or full remission at 6 months and/or 12 months was 57.8%. After 4 years of follow-up, 58.2% had experienced full remission, and 83.8% had experienced partial or full remission, at one or more 6-month assessment points. Of those subjects who attained partial or full remission at one or more assessment points, 28.6% subsequently relapsed. Between baseline and the most recent assessment, BDD severity and functioning significantly improved: at the most recent assessment, 16.7% of subjects were in full remission, 37.8% were in partial remission, and 45.6% met full criteria for BDD. Greater severity of BDD symptoms and the presence of major depression or social phobia at baseline were associated with more severe BDD symptoms at study end point. All subjects received at least one medication trial, and 34.3% received some type of therapy during the follow-up period. CONCLUSIONS: A majority of treated patients with BDD improved, although improvement was usually partial. Prospective longitudinal studies are needed to further elucidate the course of BDD.     

Predictors of depression outcomes in medical inpatients with chronic pulmonary disease.

OBJECTIVE: Baseline patient characteristics and depression treatments were examined as predictors of speed of depression remission in hospitalized medical patients with chronic pulmonary disease (CPD). METHODS: Consecutively admitted patients over age 50 years with CPD were screened for major and minor depression using the Structured Clinical Interview for Depression. Patients with minor depression were followed up over 12-24 weeks with the Longitudinal Interview Follow-up Evaluation. Course of depression and predictors of remission were examined. RESULTS: Seven hundred eleven depressed patients with CPD (410 with minor, 301 with major depression) were identified and assessed over time. Two-thirds with minor depression had remitted by 12 weeks compared with 26.9% with major depression at 12 weeks and 49.2% at 24 weeks. Predictors of faster remission for minor depression were black race, community hospital admission, less severe depression, less medical comorbidity, less severe CPD, more social support, and no antidepressant treatment. For major depression, less severe depression, no past antidepressant drug treatment, and less intense current antidepressant treatment predicted faster remission. CONCLUSIONS: The course of depressive disorder after discharge in patients hospitalized with CPD can be predicted by characteristics during admission. Although patients with minor depression may be followed and treatment initiated only if depression persists, those with major depression need more aggressive treatment and psychiatric consultation if improvement does not occur.     

Initial rate of improvement in relation to remission of major depressive disorder in primary care

Objective: In depression treatment, switching treatment after lack of initial improvement, e.g., after 6 weeks, may result in a better outcome. The extent of the lack of initial improvement, as well as the timing of its assessment on the basis of which treatment change may be considered, remains unclear. This study compared the relationships of several grades of symptom improvement after 2 and 6 weeks with remission after 10 weeks in depressed patients treated with antidepressants in primary care.Method: This was a prospective cohort study, conducted between January 1999 and September 2001 in primary care practices in the Netherlands, of 172 patients starting selective serotonin reup-take inhibitor (SSRI) treatment for major depressive disorder, diagnosed according to DSM-IV criteria. At weeks 2 and 6, patients were classified as unimproved, partially improved, or improved. For each category, we calculated the proportion of remission at week 10. The primary outcome measure was the Beck Depression Inventory.Results: Of the unimproved or partially improved patients at week 6, 29% (95% CI = 18 to 43) and 27% (95% CI = 17 to 40) attained remission at week 10, respectively.Conclusion: These data suggest that, in primary care, depression treatment with an SSRI should be reconsidered in depressed patients who are unimproved or partially improved by week 6.     

Remission and relapse in subjects with panic disorder and panic with agoraphobia: a prospective short-interval naturalistic follow-up

This article reports on the course of uncomplicated panic disorder and panic with agoraphobia on 309 patients participating in the Harvard/Brown Anxiety Research Project, a prospective longitudinal study of patients with DSM-III-R-defined anxiety disorders. At 1 year, there was a .39 probability of full remission for uncomplicated panic disorder and a .17 probability of full remission for panic disorder with agoraphobia Similar differences in time to remission for these syndromes were still found when criteria for remission were made less stringent. However, even requiring less improvement for remission left a large percentage of subjects in an episode, and for those that remitted, relapse occurred quickly, indicating a chronic and recurrent course of illness. This is the first longitudinal, prospective, naturalistic study on a large cohort of subjects with anxiety disorders to have regular, structured, short-interval follow-up. Our results are consistent with the view that panic disorder has a chronic course with high rates of relapse after remission and longer episodes when agoraphobia is a part of the constellation of symptoms.     

Prospective, long-term, multicenter study of the naturalistic outcomes of patients with treatment-resistant depression

BACKGROUND: Treatment-resistant depression (TRD) is a long-term, disabling illness. We report on the characteristics and outcomes of a large cohort of patients with a level of treatment resistance that is very substantial and who were treated for 2 years with standard care. METHOD: This 2-year prospective, multicenter, observational study (patients enrolled from January 2001 through July 2004) tracked the outcomes of 124 patients with treatment-resistant, nonpsychotic major depressive disorder (N = 109) or bipolar depressed phase disorder (N = 15) who received treatment as usual (TAU) (i.e., any therapeutic regimen agreed to by patients and psychiatrists, including medications, electroconvulsive therapy [ECT], and psychotherapy). Treatments could be adjusted, started, and stopped as necessary. The primary outcome, treatment response, was defined a priori as > or = 50% improvement from baseline as measured by the 30-item Inventory of Depressive Symptomatology-Self-Report (IDS-SR-30). Remission was defined as an IDS-SR-30 score of < or = 14. The Medical Outcomes Study (MOS) 36-item Short Form Health Survey (SF-36) was used to monitor quality-of-life changes. RESULTS: The 12- and 24-month IDS-SR-30 response rates were 11.6% (13/112) and 18.4% (19/103), respectively. Of the 13 responders at 12 months, only 5 were responders at 24 months. The 12- and 24-month IDS-SR-30 remission rates were 3.6% (4/112) and 7.8% (8/103), respectively. Only 1 of the 4 12-month remitters was also a remitter at 24 months. The SF-36 indicated globally poor quality of life in this sample. CONCLUSIONS: Despite the wide range of treatment options available for depression, the response rates, remission rates, and quality-of-life results in this study show that most patients with a substantial degree of treatment resistance continue to have significant symptomatology and functional disability when receiving TAU.     

Personality disorders and time to remission in generalized anxiety disorder, social phobia, and panic disorder

BACKGROUND: This investigation assessed the effect of personality disorders (PersDs) on time to remission in patients with generalized anxiety disorder, social phobia, or panic disorder. METHODS: Selected Axis I and II predictors of time to remission during 5 years of follow-up were assessed in 514 patients with 1 or more of these anxiety disorders who participated in the Harvard/Brown Anxiety Research Program, a multisite, prospective, longitudinal, naturalistic study. RESULTS: The presence of a PersD predicted a 30% lower likelihood of generalized anxiety disorder remission, a 39% lower likelihood of social phobia remission, and no difference in likelihood of panic disorder remission. More specifically, a lower likelihood of remission from generalized anxiety disorder was predicted by the presence of avoidant PersD (34% lower) and dependent PersD (14% lower). The presence of avoidant PersD predicted a 41% lower likelihood of social phobia remission. The presence of major depressive disorder did not account for these findings. CONCLUSIONS: Our findings provide new data on the pernicious effect of PersDs on the course of generalized anxiety disorder and social phobia but not panic disorder, suggesting that PersDs have a differential effect on the outcome of anxiety disorders.     

Children and adolescents with psychotic disorder not otherwise specified: a 2- to 8-year follow-up study.

Although psychotic phenomena in children with disruptive behavior disorders are more common than expected, their prognostic significance is unknown. To examine the outcome of pediatric patients with atypical psychoses, a group of 26 patients with transient psychotic symptoms were evaluated with clinical and structured interviews at the time of initial contact (mean age, 11.6 +/- 2.7 years) and at follow-up 2 to 8 years later. Measures of functioning and psychopathology were also completed at their initial assessment. Risk factors associated with adult psychotic disorders (familial psychopathology, eyetracking dysfunction in patients and their relatives, obstetrical complications, and premorbid developmental course in the proband) had been obtained at study entry. On follow-up examination (mean age, 15.7 +/- 3.4 years), 13 patients (50%) met diagnostic criteria for a major axis I disorder: three for schizoaffective disorder, four for bipolar disorder, and six for major depressive disorder. The remaining 13 patients again received a diagnosis of psychotic disorder not otherwise specified (NOS), with most being in remission from their psychotic symptoms. Among this group who had not developed a mood or psychotic disorder, disruptive behavior disorders were exceedingly common at follow-up and were the focus of their treatment. Higher initial levels of psychopathology, lower cognitive abilities, and more developmental motor abnormalities were found in patients with a poor outcome. Obstetrical, educational, and family histories did not differ significantly between the groups. Through systematic diagnostic evaluation, children and adolescents with atypical psychotic disorders can be distinguished from those with schizophrenia, a difference with important treatment and prognostic implications. Further research is needed to delineate the course and outcome of childhood-onset atypical psychoses, but preliminary data indicate improvement in psychotic symptoms in the majority of patients and the development of chronic mood disorders in a substantial subgroup.