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Defence styles and social adaptation during a depressive episode: Bipolar depression vs. major depression
Abstract
Objective: The aim of this study was to perform a comparative investigation of defense styles in major and bipolar depression patients and to determine the relationship between defense styles and social functions. Method: Patients in an acute depressive episode diagnosed with major depressive disorder or bipolar disorder were included, along with healthy controls. The Defense Styles Questionnaire-40 was used to determine participants' defense styles and the Social Adaptation Self-evaluation Scale to determine social adaptation. Results: Total mature defense scores were lower in both depression groups than in the controls. Total immature defense scores were higher in the bipolar group than in the controls. A positive correlation was determined between social adaptation and mature defense in both depression groups. Self-esteem emerged as a predictor for social adaptation in both depression groups, and depression level as a predictor for social adaptation in the bipolar group. Conclusion: Focus on mature defenses, self-esteem and severity of depression is required in order to enhance social adaptation in depressive episodes.
... euthymic, hypo/manic and mixed) and also healthy controls (Lyon, Startup, & Bentall, 1999;Scott & Pope, 2003;Van der Gucht, Morriss, Lancaster, Kinderman, & Bentall, 2009). Sarısoy et al. (2014) recruited acutely depressed participants with either a diagnosis of BD or major depressive disorder and showed that trait self-esteem was lower in the BD sample. One study also reported that a combined BD sample during either a manic or mixed state showed a lower level of self-esteem than healthy controls, although the former did not differ from euthymic individuals with BD (Van der Gucht, Morriss, Lancaster, Kinderman, & Bentall, 2009). ...
The role of self‐concept in bipolar disorder (BD) has not been well understood. The present review utilises the notion of self‐schema, and interrogates existing research concerning evidence for cross‐sectional and prospective associations between four schema‐like constructs (i.e., trait self‐esteem, dysfunctional beliefs concerning contingent self‐worth, early maladaptive schemas, implicit self‐esteem) and various facets of BD. Existing findings demonstrate various types of involvement of self‐schemas in BD. Of particular clinical relevance, the present review suggests that low trait self‐esteem and dysfunctional beliefs concerning contingent self‐worth are risk factors for ongoing BD symptoms and mood episodes. The present review also yields important yet unaddressed questions with respect to the evaluative content of self‐schemas associated with the hypo/manic phase of BD.
... These results in part contradict the earlier research findings associating low anxiety and depression with mature defenses and higher depression and anxiety with immature defenses [7,30]. It is interesting to note that the low achievers scored low on the depression severity despite the notion that the use of immature defense mechanisms is linked with depression [31,32], which can be explained by clustering of some mature defense mechanisms [21]. ...
Objective: The clusters of participants with a homogeneous psychological make-up can be identified using sophis- ticated machine learning techniques such as the two-step clustering algorithm. It can also help us to identify the synergistic and additive effects of a range of psychometric variables. The identification of synergistic effect of this clus- tering of defense mechanism has significant practical implications as they share a certain variance. This study aims to identify the clusters of ego defenses and their relationship with academic performance and mental health outcome in medical students.
Results: The high achievers scored higher on mature and neurotic defense styles and lower on immature than their counter parts. A higher proportion of medical students in high achievers group had normal scores on depressive symptoms than low achievers. While a majority among low achievers suffered from severe anxiety levels than high achievers group. High achievers scored higher on sublimation, humor, anticipation, suppression, pseudo-altruism, idealization, reaction formation, autistic fantasy, denial, and rationalization.
... Had the sample of depressive patients (n = 30) and the control group (n = 30) been larger, this last result could well have proved statistically significant. This would be in line with most previous research, which demonstrates that participants with major depressive disorders make more use of immature defense mechanisms than healthy controls (Akkerman et al., 1999;Bronnec et al., 2005;Kneepkens and Oakley, 1996;Sarisoy et al., 2014;Spinhoven and Kooiman, 1997). ...
Our study was intended to test whether there are any differences in the way defense mechanisms are used by patients suffering from pure anxiety and those with pure depressive disorders. The sample size was as follows: depressive disorders without psychotic symptoms 30, anxiety disorders 30, and the healthy control group 30. The assessment of defense mechanisms was made using the DSQ-40 questionnaire. Our findings show that "pure" anxiety disorders differ from "pure" depressive disorders only in the use of immature defense mechanisms. The group with depressive disorders was significantly more prone to use immature defense mechanisms than the group with anxiety disorders (p = 0.005), primarily projection (p = 0.001) and devaluation (p = 0.003). These defense mechanisms may therefore be used both to differentiate between anxiety and depressive disorders and also to determine which symptoms (anxiety or depressive disorders) are dominant at any given stage of treatment.
... Instead, I worked harder and became a better person to meet up to his expectations" (sublimation). Similarly, the findings of low depression and anxiety with the use of mature mechanisms and high depression and anxiety with immature defense mechanisms are supported by several studies, including those by Spinhoven and Kooiman, Blaya, et al., Carvalho,et al.,and Sarisoy [22,[53][54][55]. Bowins, in a review of defense mechanisms, explains the reason for this finding [56]. ...
Background: Ego defense mechanisms are unconscious psychological processes that help an individual to prevent anxiety when exposed to a stressful situation. These mechanisms are important in psychiatric practice to assess an individual’s personality dynamics, psychopathologies, and modes of coping with stressful situations, and hence, to design appropriate individualized treatment. Our study delineates the relationship of ego defense mechanisms with anxiety, depression, and academic performance of Pakistani medical students.
Methods: This cross-sectional study was done at CMH Lahore Medical College and Fatima Memorial Hospital Medical and Dental College, both in Lahore, Pakistan, from December 1, 2014 to January 15, 2015. Convenience sampling was used and only students who agreed to take part in this study were included. The questionnaire consisted of three sections: 1) Demographics, documenting demographic data and academic scores on participants’ most recent exams; 2) Hospital Anxiety and Depression Scale (HADS); and 3) Defense Style Questionnaire-40 (DSQ-40). The data were analyzed with SPSS v. 20. Mean scores and frequencies were calculated for demographic variables and ego defense mechanisms. Bivariate correlations, one-way ANOVA, and multiple linear regression were used to identify associations between academic scores, demographics, ego defense mechanisms, anxiety, and depression.
Results: A total of 409 medical students participated, of whom 286 (70%) were females and 123 (30%) were males. Mean percentage score on the most recent exams was 75.6% in medical students. Bivariate correlation revealed a direct association between mature and neurotic ego defense mechanisms and academic performance, and an indirect association between immature mechanisms and academic performance. One-way ANOVA showed that moderate levels of anxiety (P < .05) and low levels of depression (P < .05) were associated with higher academic performance.
Conclusion: There was a significant association between academic performance and ego defense mechanisms, anxiety, and depression levels in our sample of Pakistani medical students.
The relationship between personality, social functioning, and depression remains unclear. The present study employs structural equation modeling to examine the mediating role of social functioning between harm avoidance (HA), self-directedness (SD), and depression. A sample of 902 individuals completed a self-report questionnaire consisting of the following scales: HA and SD subscales of the Temperament and Character Inventory (TCI), Beck Depression Inventory (BDI), and Social Adaptation Self-Evaluation Scale (SASS). Structural equation modeling via analysis of moment structure was used to estimate the fit of nine related models. Results indicated that social functioning is a mediator between harm avoidance or self-directness and depression. Self-directedness was also shown to have direct effects on depression. The results support the social reinforcement theory of depression and provide a theoretical account of how the variables are related based on correlation methods. Suggestions are offered for future experimental and longitudinal research.
This study explored the predictive value of observer-rated and self-reported defensive functioning on the outcome of psychotherapy for the treatment of depression. Defense styles were measured according to the Developmental Profile (DP) and the Defense Style Questionnaire (DSQ) in 81 moderately severely depressed patients. All patients were treated with Short-term Psychodynamic Supportive Psychotherapy (SPSP). At baseline, women appeared to have a more mature level of overall defensive functioning. A lower level of defensive function was found in patients with recurrent depressions. We also found a rather modest relationship between self-reported and observer-rated defense. Remitted patients had a more mature overall defensive functioning on the DP and the DSQ. In particular, patients with a symbiotic defense style (giving up, apathetic withdrawal) were at risk for poor outcome. This exploratory study provides further evidence of the relevance of defense styles for depression. It suggests a differential predictive value of separate defense levels, which may help to tailor psychotherapeutic strategies.
Interest in the community adjustment of psychiatric patients has led to the development of rating techniques for its evaluation. Selection of an appropriate scale for the task should include a review of its item content, anchor points, coverage, method of obtaining information, informant, psychometric properties, precision, cost, scoring, and instructional material. While no scale is without limitations, this report describes 15 currently available scales that meet many of the important criteria for assessing social adjustment and are sufficiently developed to be useful in evaluative research. This review also contains a list of pertinent references to the scales and guide to the literature on behavioral rating scales.
Defense styles may discriminate between depressed patients with or without recent suicide attempts. The aim of the present study was to identify which defense mechanisms are associated with recent suicide attempts in depression. The Defense Style Questionnaire (DSQ) was rated at admission by 156 depressed inpatients with (n = 60) or without (n = 96) recent suicide attempt. Depression intensity was correlated negatively with mature style, humor and sublimation and positively with projection. Although it was not significantly different in terms of sociodemographic and depression variables, recent suicide attempters had higher scores on immature style, especially acting out, passive agression, autistic fantasy and projection. Prospective assessment of defense styles and suicide attempts should be carried out to determine whether these differences are a cause of imminent suicide attempts in depression. If so, the DSQ may be used in clinical practice to help discriminate depressed patients with high risk of imminent suicide attempt.
Depression is the most commonly present psychiatric entity in clinical practice, accompanied by significant impairment of both social and professional functioning. In addition, depression frequently develops as complication of other psychiatric disorders and various somatic diseases.
To investigate subjective perception of quality of life and social adjustment, severity of depressive symptoms as well as level of correlation of severity of depressive symptoms and quality of life and social adjustment of patients with recurrent depression in comparison to the group of patients with diabetes and healthy subjects.
The study included 45 subjects of both sexes, ranging from 18 to 60 years of age, divided in three groups of 15 subjects each. The experimental group comprised the patients diagnosed with recurrent depression in remission (DSM-IV), one control group was consisted of patients diagnosed with Type 2 Diabetes mellitus and another one comprised healthy subjects. The instruments of assessment were: The Beck Depression Inventory-BDI, The Social Adaptation Self -evaluation scale -SASS, The Psychological General Well-Being Scale-WBQ. RESULTS Significant difference of both BDI and WBQ scales was found between the experimental and the control group of healthy subjects (ANOVA, Mann Whitney; p < 0.01), as well as between two control groups (p < or = 0.02). The level of inverse correlation of mean score values of BDI and SASS scales was significant in the control group of patients with diabetes while such levels of BDI and WBQ scales (Spearman correlation coefficient, p < 0.01) were found in all groups of our study.
In the group of patients with recurrent depression, significant decline of quality of life and significantly higher severity of depressive symptoms were present in comparison to the group of healthy subjects as well as significant level of inverse correlation of severity of depressive symptoms and quality of life.
DSM-IV has recommended use of the Social and Occupational Functioning Scale (SOFAS) as a clinician-rated global assessment scale for measuring social functioning; this scale is analogous to the Clinical Global Impression (CGI) scale traditionally used as a secondary outcome measure in patients with depressive symptoms. However, we believe that health-related quality of life is the most appropriate indicator of social functioning when considering this dimension as an endpoint in clinical trials of antidepressants. As health-related quality of life is a purely subjective measure, patient-rated questionnaires have been found to be most important in this context. In this respect, the Sheehan Disability Scale has been recommended as the most relevant global self-reported assessment of social functioning in trials of antidepressants.
A review of questionnaires found that the three most frequently used scales selectively directed at obtaining information about social functioning in trials of antidepressants are the Social Adjustment Scale — Self Report (SAS-SR), the Social Adaptation Self-Evaluation Scale (SASS) and the Short-Form Health Survey (SF-36). However, the number of placebo-controlled trials of antidepressants that have used these scales is still too limited to allow comparisons in terms of responsiveness.
Health-related quality of life includes dimensions other than social functioning, e.g. physical health and mental health (including both cognitive and affective problems). The SF-36 includes subscales relating to physical and mental health, which, like the social functioning subscales, are measured in terms of degrees of well being. Another quality-of-life questionnaire, the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), covers social, mental and physical problems, in this case measured in terms of degrees of satisfaction. Recently, the Q-LES-Q has been reduced from a comprehensive scale including 60–92 items to a brief version including 15 items. An additional item measures overall life satisfaction. As most of the items in the brief Q-LES-Q include social functioning, the scale can be considered as an alternative to SF-36 or the Sheehan Disability Scale when the focus is on satisfaction with treatment. However, there are insufficient numbers of trials of antidepressants using these questionnaires to allow comparisons.
The examples of trials of antidepressants with the SF-36 subscales discussed in this review have mostly involved SSRIs. These trials have demonstrated that although antidepressants improve social functioning compared with placebo over a 6-week treatment period, the endpoint scores are still significantly below the national norms at this point. Only after 12 weeks of therapy are the endpoint scores of the social functioning scales within the limits of the national norms. In relapse prevention trials or in maintenance trials to prevent recurrence of depression, comparisons of social functioning scores with national norms can be important supplementary indicators of the need for treatment.
In conclusion, social functioning as part of the health-related concept of the patient-reported quality-of-life measure should constitute an endpoint in trials of antidepressants to help clarify the goals of treatment in patients with major depression. In medium- and long-term trials, SF-36 subscales should be used as a supplement to symptom-orientated scales. In trials of shorter (6–8 weeks) duration, use of other scales such as the SAS-SR, the Q-LES-Q or the Sheehan Disability Scale should be considered. These scales should be considered as supplementary to each other rather than alternatives; it may be necessary to use more than one of these scales in a trial.
Return of functional ability is a central goal in the treatment of major depressive disorder. We conducted two trials with the same protocol that was designed to assess functioning after 8 Weeks of treatment with duloxetine.
The a priori primary outcome was improvement in the Hamilton Depression Rating Scale (HAMD) item 7 (work/activities). Secondary outcomes included improvement in depressive symptoms assessed by the HAMD Maier subscale, and improvement in functioning assessed by the Sheehan Disability Scale (SDS), and the Social Adaptation Self-evaluation Scale (SASS). Patients were randomly assigned to duloxetine 60 mg/day (Trial I, n = 257; Trial II, n = 261) or placebo (Trial I, n = 127; Trial II, n = 131). Changes from baseline were analyzed using a mixed-effects model repeated measures approach.
At Week 8, duloxetine was superior to placebo in improving HAMD work/activities (p < 0.001) in Trial II, but not Trial I (p = 0.051), and Maier scores (p < 0.01) in both trials. At Week 12, duloxetine was superior to placebo on improving SASS scores in both trials, and the SDS in Trial II.
Treatment with duloxetine was associated with significant improvement in depressive symptoms compared with placebo, but improvement in HAMD work/activities was inconsistent at 8 weeks.
The aim of this study was to investigate the effects of temperament on quality of life and social adaptation in depressive patients with mood disorder.
Forty-six consecutive depressive outpatients were investigated by using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version, the Munich Personality Test, the World Health Organization Quality of Life 26 (WHO QOL 26), and the Social Adaptation Self-evaluation Scale (SASS). The unpaired t-test, Pearson's r and multiple regression analysis were used to assess three variables (age, the number of temperaments and/or personality types, and Hamilton Depression Rating Scale scores) as independent variables with the scores of WHO QOL 26 and SASS as the dependent variables.
The number of temperaments and/or personalities and Hamilton Depression Rating Scale scores were significantly and negatively associated with WHO QOL 26 scores while only the number of temperaments and/or personalities was significantly and negatively associated with SASS scores.
The findings suggest that the combination of temperaments and/or personality types assessed with the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version and the Munich Personality Test may worsen both quality of life and social adaptation and that some temperaments and/or personality types in combination may be subclinical manifestations of mood disorders.
Psychosocial outcomes from the Prevention of Recurrent Episodes of Depression with Venlafaxine ER for Two Years (PREVENT) study were evaluated.
Adult outpatients with recurrent major depressive disorder (MDD) and response or remission following 6-month continuation treatment with venlafaxine extended release (ER) were randomized to receive venlafaxine ER or placebo for 1 year. Patients without recurrence on venlafaxine ER during year 1 were randomized to venlafaxine ER or placebo for year 2. Psychosocial functioning was assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q), Life Enjoyment Scale-Short Version (LES-S), Social Adjustment Scale-Self-Report (SAS-SR) total and individual factors, Short Form Health Survey (SF-36) (vitality, social functioning, and role function-emotional items), and Longitudinal Interval Follow-up Evaluation (LIFE).
At year 1 end, better overall psychosocial functioning was seen among patients randomly assigned to venlafaxine ER (n=129) vs placebo (n=129), with significant differences at end point on SF-36 role function-emotional, Q-LES-Q, and SAS-SR total, and work, house work, social/leisure, and extended-family factor scores (p≤0.05). At year 2 end, significant differences favored venlafaxine ER (n=43) vs placebo (n=40) on SF-36 vitality and role function-emotional, Q-LES-Q, LES-S, LIFE, and SAS-SR total, social/leisure, and extended-family factor scores (p≤0.05).
Patients with chronic MDD or treatment resistance were excluded and long-term specialist care was a financial incentive for treatment compliance. Discontinuation-related adverse events may have compromised the integrity of the treatment blind.
For patients with recurrent MDD, 2 years' maintenance therapy with venlafaxine ER may improve psychosocial functioning vs placebo.
The issue of defence mechanisms is of great importance in clinical practice. The aim of this meta-analysis is to compare different defence styles (Mature, Neurotic, and Immature), assessed using the three-factor defence style questionnaire (DSQ), in major depressive disorder (MDD), and panic disorder (PD) in order to evaluate potential differences in defence profiles among these disorders.
We assessed all publications listed in PubMed, PsycINFO, ISI, and Lilacs databases focusing on DSQ defence styles in MDD and PD. To be included studies had to be published in English, to include psychiatric patients, to provide defence style mean scores, and to employ the three-factor DSQ versions. Data were entered into the Cochrane Collaboration Review Manager Software and analysed by RevMan version 4.2.
MDD patients reported significantly lower scores in Mature style and both MDD and PD patients reported significantly higher scores in Neurotic and Immature styles.
A dissimilarity between depressive and anxious profiles emerged, since the former profile was characterized by low Mature and high Neurotic and Immature scores while the latter by high Neurotic and Immature scores only. These results could indicate the use of specific strategies in clinical and psychotherapeutic management of patients with these diagnoses. Nevertheless, present results should be considered with caution because of the high heterogeneity of the studies and some weaknesses in the psychometric properties of the DSQ.
The Defense Style Questionnaire has proven of interest as the first questionnaire to reliably describe defense styles. The 72-item DSM-III-R-labeled Defense Style Questionnaire was administered to 388 controls and 324 patients. Eight statistical and two a priori criteria were used in choosing two items to represent each of the 20 defenses. A new 40-item Defense Style Questionnaire is published together with normative and reliability data on a normal population, patients with anxiety disorders, and child-abusing parents. The scores are unaffected by the sex of the respondent, but the endorsement of immature defense styles decreases with age.
The purpose of this study was to determine whether the defense style of hospitalized depressed adults improved over the course of treatment. Thirty-one inpatients (24 women and 7 men) with an admitting diagnosis of major depression completed the 40-item Defense Style Questionnaire and the 20-item Center for Epidemiologic Studies-Depression Scale. Participants completed the Defense Style Questionnaire and the Center for Epidemiologic Studies-Depression Scale within 48 hours after admission and within 24 hours before or after discharge. The average admission and discharge Center for Epidemiologic Studies-Depression Scale ratings (+/-SD) were 41.93+/-9.93 and 26.45+/-12.19, respectively. The average hospital length of stay was 7.1+/-2.8 days. Two-tailed t-test comparisons of the Defense Style Questionnaire admission and discharge ratings showed significantly higher discharge mature ratings, significantly lower discharge immature ratings, and stable neurotic ratings. We concluded that for some depressed women and men, improvement in defense style can occur within days after the initiation of standard inpatient treatment.
The long-term stability of ego defenses was examined in a group of 68 patients with major depression being treated in a rural private psychiatric practice. Current symptomatology and dispositional characteristics, including defense style (40-item Defense Style Questionnaire), were assessed pretreatment and at approximately 6 months and 2 years after treatment commenced. Age- and gender-matched comparison groups were also selected from two community-based studies that utilized similar instruments and time periods. The major depression group reported significantly lower usage of mature defenses initially, but with recovery they moved progressively toward the range of mature defenses displayed by the nonpatient comparison group. Neurotic defenses were relatively stable throughout the study, as were immature defenses during the first 6 months. Comparisons between patients who discontinued treatment (N = 24) and those who remained in treatment (N = 33) revealed similar rates of symptom reduction; however, the latter group reported continuing reductions in their use of immature defenses, to a level below that of the nonpatient comparison group.
Impairment of social functioning is a significant aspect of depression distinct from the symptoms of depression. Social functioning defines an individual's interactions with their environment and the ability to fulfill their role within such environments as work, social activities, and relationships with partners and family. The analysis of social functioning has arisen from a growing interest in measuring the consequences of depression and antidepressant therapy. Impairment often persists long after the resolution of symptoms by pharmacotherapy, and is not extensively assessed by the traditional scales to measure the intensity of depressive symptoms. Assessment is influenced by the method used, and there is an increased awareness that the patient's perspective should be foremost. Several scales for the evaluation of social functioning have already been developed, ranging from those requiring a structured interview with a trained assessor to self-assessment scales. In constructing such tools, a balance must be found between the amount of detail required to produce a clear account of the patient's social functioning and the ease of use in large multicenter studies. The newest scale is the Social Adaptation Self-evaluation Scale (SASS), specifically for self-assessment of social functioning by patients with depression. It contains 21 items covering the different aspects of social interactions, global social attitude, and self-perception. The SASS has been validated and found to be simple to use and sensitive to changes in the different areas of social functioning. Recently, the SASS was used to demonstrate the greater efficacy of reboxetine, a new selective noradrenaline reuptake inhibitor (selective NRI), compared with the selective serotonin reuptake inhibitor (SSRI) fluoxetine, in improving social functioning in patients with depression. Specifically, the SASS was able to show that reboxetine improved patient motivation and self-perception. The SASS is another tool for the evaluation of the extent and quality of the response to treatment and may also help to elucidate the roles of noradrenaline and serotonin in depressive illness.
Social impairment is a common feature of depressive illness, often causing substantial and clinically meaningful dysfunction. Although the depressive symptoms and social impairment are linked, the naturalistic course and response to treatment of these two aspects of depression do not necessarily correlate. A variety of self-report and clinician-administered assessment scales which are specific for the measurement of social functioning and have good psychometric properties have been developed in the past 40 years. The most recent of these instruments is the Social Adaptation Self-evaluation Scale (SASS), a 21-item scale designed in 1989 to assess patient response to antidepressant treatment. SASS was used in two clinical trials comparing reboxetine, the new selective noradrenaline reuptake inhibitor (selective NRI), with fluoxetine. While no difference in efficacy was detectable by traditional assessments of symptoms, reboxetine proved to be significantly more effective than fluoxetine in improving social functioning in patients with depression. Reboxetine was also more effective than fluoxetine in rectifying social functioning in the subset of patients who remitted from an episode of major depression. Specifically, reboxetine improved patient motivation, energy and self-perception. These results indicate that antidepressant therapy can achieve more than symptom relief in depression. It is speculated that there may be a difference in the roles played by serotonin and noradrenaline in social functioning.
Social dysfunction is often associated with depressive disorders and its evaluation is an important measure of treatment outcome. The aim of this study was to assess the effect of two treatments, venlafaxine and amitriptyline, on the social functioning of depressed patients. Twenty-eight outpatients, meeting criteria for recurrent or single major depressive episodes, took part in a double-blind, 8-week trial with amitriptyline or venlafaxine (maximum of 150 mg/day) and were assessed by the Self-Report Social Adjustment Scale (SAS-SR) before and at the end of treatment. The scale was also applied to a carefully selected non-psychiatric sample. Both drugs showed the same efficacy on a clinical scale, but venlafaxine improved social functioning more than amitriptyline as only venlafaxine-treated patients reached SAS-SR values estimated for normal subjects. This effect might be linked to the higher rate of side-effects observed with amitriptyline.
The aim of the study was to look at efficacy and the safety profile of high dose (450-600 mg) venlafaxine XL in five patients with treatment resistant major depressive illness.
Five patients with treatment resistant depression were treated with high dose venlafaxine XL. Efficacy was evaluated using the Montgomery-Asberg depression rating scale (MADRS), the 21-item Hamilton rating scale for depression (HAM-D-21) and the clinical global impressions (CGI) scale. Level of functioning was evaluated by social adaptation self-evaluation scale (SASS). Body weight, supine pulse and blood pressure were recorded.
The response rate was based on a 50% decrease in MADRS and HAM-D scores between weeks 1 and 24. There was a more than 50% decrease in MADRS scores in 3 of 5 patients and 4 of 5 patients in HAM-D scores. There was a trend to improvement of SASS scores in three of the study patients and in two of them the mean scores were within the normal range. Supine pulse and blood pressure remained stable in four patients, except in one patient where there was a slight increase although the final reading at week 24 was normal. Weight was relatively stable in all three patients where it was recorded, but in one patient there was a slight increase which may have been due to an atypical neuroleptic the patient was taking at the time.
High dose venlafaxine was safe, well tolerated and effective in this small number of severe treatment resistant patients with major depression and it also improved social functioning.
The aim of our study was to identify if defense mechanisms are associated with impulsivity and lifetime suicide attempts in depressed patients.
The Defense Style Questionnaire, the Impulsivity Rating Scale and the Impulse Control Scale were used in 77 depressed inpatients.
Impulsivity was correlated positively with immature and neurotic styles and negatively with mature style. Some but not all defense mechanisms were relevant in this respect. The number of lifetime suicide attempts was positively correlated not only with impulsivity, but also with immature style and to a lesser extent with neurotic style. Several defense mechanisms were involved in these correlations: undoing, projection, passive aggression, acting out, splitting and somatization.
Like impulsivity, defense styles may be relevant to discriminate recurrent suicide attempters in depression. Prospective assessment of defense styles and suicide attempts in depression is needed.
Major depressive disorder (MDD) is associated with significant disability, having a profound impact on psychosocial functioning. Therefore, studying the impact of treatment on psychosocial functioning in MDD could help further improve the standard of care.
Two hundred twenty-two MDD outpatients were treated openly with 20 mg fluoxetine for 8 weeks. The self-report version of the Social Adjustment Scale was administered at baseline and during the final visit. We then tested for the relationships between (1) self-report version of the Social Adjustment Scale scores at baseline and clinical response, (2) nonresponse, response and remission status and overall psychosocial adjustment at end point, (3) the number/severity of residual depressive symptoms and overall psychosocial adjustment at end point in responders, and (4) the time to onset of response and overall psychosocial adjustment at end point.
An earlier onset of clinical response predicted better overall psychosocial functioning at end point (P = 0.0440). Responders (n = 128) demonstrated better overall psychosocial adjustment at end point than nonresponders (P = 0.0003), while remitters (n = 64) demonstrated better overall psychosocial adjustment at end point than nonremitted responders (P = 0.0031). In fact, a greater number/severity of residual symptoms predicted poorer overall psychosocial adjustment at end point in responders (P = 0.0011). Psychosocial functioning at baseline did not predict response.
While MDD patients appear equally likely to respond to treatment with fluoxetine, regardless of their level of functioning immediately before treatment, the above results stress the importance of achieving early symptom improvement then followed by full remission of depressive symptoms with respect to restoring psychosocial functioning in MDD.
The Defense Style Questionnaire (DSQ) is a widely used self-report measure of empirically derived groupings of defense mechanisms ranked on an adaptive hierarchy. A review of published studies indicates strong evidence that adaptiveness of defense style correlates with mental health and that some diagnoses are correlated with specific defense patterns-for example, borderline personality disorder with greater use of both maladaptive and image-distorting defenses and less use of adaptive defenses. For other diagnoses, the pattern of defenses is less clear but often reinforces theoretical formulations. Defense styles become more adaptive with improvement in symptoms, but intermediate defenses tend to be stable (traitlike) over time. Defenses are sometimes predictive of the quality of the therapeutic alliance. Although one might speculate that assessment of defenses can be useful in planning treatment, there are no studies supporting this hypothesis.
'State effect' of depression on personality makes its assessment during depression difficult. Many clinicians do not only refer to the patient, but use additional information sources, especially reports from close informants. Our hypothesis was that an informant could assess the defensive functioning of the depressed patient. The objective of this study was to investigate the validity of the informants' assessment of defense styles in depressed patients.
Sixty-three inpatients with DSM-IV major depression as primary diagnosis were included. They were administered the Defense Style Questionnaire (DSQ) at admission (D0) and 28 days after treatment (D28) according to their current state. At the same time, informants rated an adapted version of the DSQ (INF-DSQ), according to the patient's current (D0 and D28) and premorbid defensive functioning (D0). Otherwise, severity of depression was assessed using the 17-item Hamilton Depression Rating Scale at D0 and D28.
Agreement between patient's and informant's DSQ scores was moderate, both at D0 and D28, even if comparison of mean defense scores does not show significant difference. Mature defense scores significantly increased between D0 and D28, whereas immature defense scores significantly decreased, with both the DSQ and INF-DSQ. During the episode, informants are able to discriminate premorbid from current D0 defenses, but not from current D28 defenses.
Even if this study has strong limitations, our results argue for the interest of close informants to assess premorbid personality. Before it could be validated, the INF-DSQ should be further studied in other subgroups of patients, especially its ability to give accurate descriptions of patient's premorbid defenses during an acute episode.