Journal of Personality Disorders, 28(6), 853-863, 2014 © 2014 The Guilford Press ADOLESCENT DEPRESSION AND AXIS II DISORDERS STRANDHOLM ET AL.
TREATMENT CHARACTERISTICS AND OUTCOME OF DEPRESSION AMONG DEPRESSED ADOLESCENT OUTPATIENTS WITH AND WITHOUT COMORBID AXIS II DISORDERS Thea Strandholm, MA, Linnea Karlsson, MD, PhD, Olli Kiviruusu, MSocSc, Mirjami Pelkonen, PhD, and Mauri Marttunen, MD, PhD
In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.
Reportedly, 15% of adolescent psychiatric depressed outpatients meet both Axis I and Axis II diagnostic criteria in a cross-sectional assessment (Karlsson et al., 2006). The level of impairment has been shown to be higher among adolescents diagnosed with a comorbid personality disorder (Bernstein et al., 1993; Korenblum, Marton, Golombeck, & Stein, 1990) with, for example, a higher risk for recurrent depressive episodes (Karlsson et al., 2008) and suicide (Brent et al., 1994) in follow-up studies. For adults, research has shown a larger occurrence of Axis I and Axis II comorbidity than would be expected by chance (e.g., Oldham et al., 1995; Zimmerman & Mattia, 1999), with the comorbidity ranging from 18% to 86% in clinical samples of adult depressive patients (Candrian, Farabaugh, Pizzagalli, Baer, & Fava, 2007; Melartin et al., 2002). This article was accepted under the editorshiop of Paul S. Links. From National Institute for Health and Welfare, Helsinki, Finland (T. S., L. K., O. K., M. P., M. M.); Turku University Central Hospital, Turku, Finland (L. K.); Helsinki University Central Hospital, Helsinki, Finland (M. M); and University of Helsinki, Finland (T. S., M. M.). Address correspondence to Thea Strandholm, National Institute for Health and Welfare, Department of Mental Health and Substance Abuse Services, PO Box 30, FI 00271 Helsinki, Finland; E-mail: thea. [email protected]
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Treatment response among depressed patients with and without Axis II comorbidity has been a topic of discussion in the psychiatric literature. Several studies have shown poor treatment response and poor recovery rates for depression in cases of comorbid Axis II pathology in adults (e.g., NewtonHowes, Tyrer, & Johnson, 2006). The rates of Axis II personality disorder comorbidity have also been higher in adult patients suffering from chronic forms of depression (Russell et al., 2003). A growing number of studies have also questioned the view that comorbid Axis II pathology will negatively impact treatment outcome (De Bolle et al., 2011; Fava et al., 1994; Mulder, Joyce, & Luty, 2003) or negatively impact the treatment outcome of pharmacotherapy for depression (Kool et al., 2005) when comparing those with and without Axis II disorders. These contrasting results for adults show the need to better understand how the link between Axis I and Axis II disorders might also impact treatment response also for adolescents. One problem in studies among adolescents is the debated question of whether a personality disorder diagnosis in adolescence is valid. Some studies have questioned the diagnoses of Axis II in adolescence (e.g., Lofgren, Bemporad, King, Lindem, & O’Driscoll, 1991; Shapiro, 1990) because of the still developing personality. A rather large amount of evidence has, however, shown that adolescent personality disorder diagnoses have concurrent validity (Levy et al., 1999) and are thereby diagnosable in adolescence (e.g., Bernstein, Cohen, Skodol, Bezirganian, & Brooks, 1996; Durrett & Westen, 2005; Johnson et al., 1999; Westen & Muderrisoglu, 2003). Few studies have focused on investigating the impact of Axis II comorbidity on the outcome of adolescent depression and treatment characteristics related to the outcome. It seems that it would be especially important to assess this issue because it is known that many common psychiatric conditions actually have their onset in adolescence (e.g., Kessler et al., 2005), with high rates of continuity into adulthood (Copeland, Shanahan, Costello, & Angold, 2009). We have previously published a finding that while severity of depression was the strongest predictor of 1-year outcome of depressive disorder, Axis II comorbidity predicted a recurrence of adolescent depression (Karlsson et al., 2008). In the present study, we further investigated the effect of comorbid Axis II disorders on the short-term outcome of depression and compared treatment characteristics, such as length, intensity, and breadth, between those with and without Axis II comorbidity. Furthermore, we investigated whether the offered and implemented treatment impacted the outcome of depression differently for those with or without Axis II in a naturalistic follow-up study of depressed adolescent outpatients. METHODS PARTICIPANTS AND PROCEDURES
This study is part of the Adolescent Depression Study (ADS), a collaborative study by the Department of Adolescent Psychiatry of Peijas Medical Health Care District (PMCD), Helsinki University Central Hospital, and the De-
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 855
partment of Mental Health and Alcohol Research Unit of the National Institute of Health and Welfare (a merger of the National Public Health Institute and the National Research and Development Centre for Welfare and Health) in Finland. The ADS is a naturalistic, clinical follow-up study of adolescent depressive mood disorders. The outpatient clinics were located in the area of PMCD, which serves approximately 210,000 inhabitants in the Helsinki region in southern Finland. The patients were originally screened by the Beck Depression Inventory-21 (BDI-21; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the General Health Questionnaire-36 (GHQ-36; Goldberg, 1972). The sum scores ≥ 10 on the BDI-21 and ≥ 5 on the GHQ-36 were considered as screen positives (n = 373). After a complete description of the study was given to the screen positives and, if under 18 years of age, to their legal guardians, written informed consent was obtained. Out of the screened adolescents, 118 refused, 34 dropped out, and 3 did not meet the criterion of an ongoing depressive episode, giving a final number of 218 participants. A more detailed description of the study protocol is published elsewhere (Karlsson et al., 2006). Participants in the ADS (n = 218) were consecutive adolescent psychiatric outpatients (ages 13–19 years) interviewed for DSM-IV Axis I and Axis II diagnoses. Data were obtained by interviewing the adolescents at baseline (T1) and at 1-year follow-up (T2), using the Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime version (K-SADS-PL), a semistructured interview with a high level of reliability and validity (Kaufman et al., 1997). DSM-IV Axis II disorders were assessed with the Structured Clinical Interview and Screen for DSM-IV Axis II disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Smith, 1997). Studies (e.g., Salbach-Andrae et al., 2008) have given support for the suitability of using the SCID-II as a diagnostic instrument among adolescents, while the structure of personality pathology as assessed by Axis II criteria in adolescents has been shown to resemble that outlined in DSM-IV Axis II for adults, suggesting that personality disorders can be assessed in adolescents as in adults (Durrett & Westen, 2005). In the present study, the total count of depressive symptoms, measured with the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960) at the time of the interviews, was used as the outcome variable. The HDRS is a widely used 17-item clinician-rated interview of depressive severity. The Global Assessment of Functioning Scale (GAF) provides a single rating of functioning and symptoms and was used according to the DSM-IV Axis V. Scores range from 10 (e.g., need full-time supervision) to 100 (e.g., superior functioning, no symptoms). All the research diagnoses (covering Axes I–V) were confirmed in a diagnostic consensus meeting where the original investigators and at least one senior clinician reached a consensus on all the measures included in the interview. Interrater reliabilities were assessed using 13 randomly selected videotaped interviews. For mood disorder diagnoses (MDD, other mood disorder, no mood disorder) weighted kappa was 0.87 (95% CI 0.81, 0.93), and for the HDRS the single measures intraclass correlation coefficient using absolute agreement between raters as the criterion was 0.76 (95% CI 0.52, 0.91). The study protocol of the ADS
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was approved by the ethics committees of Helsinki University Central Hospital and PMCD. In the present study, 151 patients were drawn from the 218 subjects in Axis I and Axis II comparisons. Subjects not participating at T2 (n = 29, 13.3%), missing data (n = 6, 4.1%), and those with Axis II diagnosis at T1 only (n = 23 outpatients, 10.6%) or T2 only (n = 9, 4.1%) were excluded from these analyses. Out of the 151 outpatients included, the Axis II group (i.e., Axis II diagnosis at both T1 and T2) comprised 53 outpatients (35.1%), and the group without Axis II comorbidity comprised 98 outpatients (64.9%). TREATMENT
Because the study was naturalistic, the treatment received was the regular, best available treatment in outpatient clinics with possible periods of hospitalizations. Treatment teams in Finnish secondary health care at psychiatric outpatient clinics consist of an adolescent psychiatrist in charge of the treatment, one or more psychologists, a social worker, and one or more psychiatric nurses. The psychosocial treatment consists of individual sessions (e.g., supportive therapy, psychotherapy) as the basis of treatment and family and network meetings. A multiprofessional network (including social welfare and school personnel) is arranged when needed. The need for psychotropic medication or inpatient treatment is assessed by the treating adolescent psychiatrist. TREATMENT CHARACTERISTICS
In this study, treatment received was evaluated by the length of treatment, counted as treatment days from the first treatment sessions after the baseline interview to the last before 1-year follow-up; the intensity of treatment, indicated by treatment sessions per month; and breadth of treatment, defined as (1) only individual appointments, (2) individual and family and/or network appointments, (3) individual appointments and medication, and (4) individual appointments, family and/or network meetings, and medication. The frequency of nonappearance, both informed and noninformed, was considered in the analyses. Hospitalization during the follow-up period was recorded as hospital days during the treatment. The follow-up data for treatment variables were gathered from the medical records. Treatment variables were calculated for the whole period of treatment (between T1 and T2). OUTCOME VARIABLES
Because this study involves a sample of patients suffering from depressive symptoms at baseline (T1), the outcome measure was depressive symptoms. The clinician-rated HDRS was used because it is a dimensional measure and is therefore more sensitive to change than categorical diagnostic data when investigating outcome.
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 857 TABLE 1. Baseline Characteristics and Diagnostic Comorbidity in Groups with (n = 53) and Without (n = 98) Axis II Comorbidity in an Outpatient Depressed Adolescent Sample (n = 151) Axis II n (%)
Axis I n (%)
Statistics
Age over 15
40 (75.5)
62 (63.3)
.147
.088
Females
40 (75.5)
82 (83.7)
.279
.157
.453
.926
15 (28.3)
29 (29.6)
Parental socioeconomic status Working class
p value
Lower middle class
22 (41.5)
38 (38.8)
Upper middle class
14 (26.4)
25 (25.5)
2 (3.8)
6 (6.1)
Anxiety disorders
42 (79.3)
42 (42.9)
18.452
.000
Eating disorders
9 (16.9)
6 (6.1)
4.533
.035
Unknown Comorbid Axis I diagnoses
Substance use disorders
12 (22.6)
8 (8.2)
6.275
.014
Conduct disorders
10 (18.9)
8 (8.2)
3.754
.049
Psychosis Other
0
2 (2)
1.096
.420
5 (9.4)
7 (7.1)
247
.418
−4.084
.000
1 (1.9)
14 (14.4)
14.054
.000
HDRS score 0–7 p 8–15p
16 (30.2)
51 (52.6)
16–p
36 (67.9)
32 (33.0)
2 (3.8)
29 (29.6)
Axis V over 60
STATISTICAL ANALYSES
Data analyses were done using the Statistical Package for the Social Sciences (SPSS Version 16.0). Comparisons between study groups were conducted with the chi-square test for categorical variables and with the Mann–Whitney U test and the t test for nonnormally and normally distributed continuous variables, respectively. A hierarchical linear regression model was constructed for the analyses of outcome and treatment effects. Statistical significance was set at a p value < 0.05. RESULTS SOCIODEMOGRAPHIC CHARACTERISTICS AND PSYCHIATRIC DIAGNOSES
The depressed adolescents with Axis II comorbidity differed significantly in their diagnostic profile at T1 from those without. Axis II comorbidity was related to an elevated frequency of many Axis I categories (e.g., anxiety disorders, eating disorders, and substance use disorders) (Table 1). A lower level of psychosocial functioning was also observed among the subjects with Axis II comorbidity (Table 1).
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TABLE 2. Treatment Characteristics of Axis I (N = 98) and Comorbid Axis I and II Depressed Adolescent Outpatients (N = 53) from Baseline to 1-Year Follow-up Characteristic
Axis II
Axis I
Statistics
p value
21.64 (16.67); 17.00
19.18 (11.71); 16.50
−.363
.717
−.374
.708
23 (46.0)
47 (48.4)
−.690
.490
.712
.477
Psychosocial treatment Kept individual appointments, mean (SD); median a Contents of the appointments (N = 50, 97) No. (%) Counseling Therapy (> 6 months)
3 (6.0)
9 (9.3)
Therapy (< 6 months)
23 (46.0)
41 (4t2.3)
2.12 (5.14); 1
1.30 (2.13); 0
25 (50.0)
42 (43.3)
Kept family/network appointments, mean (SD); median a Contents of the appointments (N = 50, 97) No. (%) Family counseling Family therapy Other Intensity (individual appoint./month), mean (SD); mediana Attendance % (individual appoint.), mean (SD); mediana
1 (2.0)
3 (3.1)
24 (48.0)
52 (53.6)
1.75 (1.14); 1.47
1.71 (0.94); 1.58
−.113
.910
82.06 (13.14); 83.33
80.12 (17.99); 84.62
−.018
.986
Psychotropic medications Any, No. (%)
38 (71.7)
55 (56.1)
−1.872
.061
Antidepressants
36 (67.9)
47 (48)
−2.346
.019
SSRIs
32 (60.4)
45 (45.9)
Treatment breadth, N (%) (1) individual appointments
7 (13.2)
26 (26.5)
+(2) family/network counseling
10 (18.9)
25 (25.5)
-1.891
.091
−2.392
.017
+(3) medication
17 (32.1)
23 (23.5)
+(2)+(3)
19 (35.8)
24 (24.5)
Hospitalization, No. (%)a
9 (17.0)
16 (16.3)
.011
.544
10.30 (74.96; 0)
9.54 (30.61; 0)
−.349
.727
-.801
.423
no treatment
22 (41.5)
48 (49.0)
psychiatric outpatient
28 (52.8)
48 (49.0)
3 (5.7)
2 (2.0)
Number of hospitalizationa days, mean (SD; median) Treatment status at the 1-year follow-up, No. (%)
psychiatric inpatient a
Mann-Whitney U test.
TREATMENT CHARACTERISTICS
No significant differences were found between the two groups in treatment status (χ2 = 4.21, p = .24) at the 1-year follow-up. At T2, 22 (41.5%) of those with Axis II and 48 (49%) of the group without Axis II were no longer in outpatient treatment.
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 859 TABLE 3. Hierarchical Linear Regression Analyses of the Effect of Baseline Characteristics, Axis II Comorbidity, and Treatment Variables on Depression Outcome (HDRS T2) in a Sample of Depressed Outpatients Step 1
Step 2
Step 3
Step 4
B
p
B
p
B
p
B
p
Age
.492
.168
.213
.519
.258
.434
.242
.462
Sex
.780
.600
.383
.781
.776
.573
1.425
.320
HDRS T1
.264
.005
.092
.314
.026
.790
-.039
.719
6.510
.000
6.279
.000
5.728
.000
.000
.932
-.001
.895
Axis II Treatment length intensity
.177
.746
.139
.804
breadth
1.181
.026
1.077
.052
Comorbiditya
1.122
.112
GAF
.417
.790
R2
.07
.23
.26
∆R2
.07
.16
.03
.01
∆F
3.59*
29.28**
1.9
1.31
a
.27
Number of diagnostic main categories in baseline. *p < .05; **p < .01.
Treatment attendance did not differ between the two groups at a statistically significant level (Table 2). No statistically significant differences were found in length or intensity of treatment. The breadth of treatment was higher among subjects with Axis II disorders (Table 2) because they were treated with a larger variety of treatment methods simultaneously (e.g., individual appointments, family meetings, and medication). The group with Axis II comorbidity was more often treated with psychotropic medication compared to the non-Axis II group (Table 2). RECEIVED TREATMENT, OUTCOME AT T1, AND AXIS II COMORBIDITY
The group with Axis II comorbidity had higher depression scores (HDRS) at T1 (mean = 17.70, SD = 5.90) compared to those without Axis II comorbidity (mean = 13.27, SD = 6.02) (t = −4.364, p < .001). Also at T2, the depression scores were higher for the group with Axis II (mean = 13.70, SD = 7.88) compared to those without Axis II comorbidity (mean = 6.66, SD = 5.47) (t = −5.79, p < .001). The hierarchical linear regression model results are presented in Table 3. Axis II comorbidity had the strongest impact on depression outcome of the selected independent variables. In the initial model, at Step 1, the Hamilton score at T1 predicted the Hamilton score at T2, but this effect disappeared when Axis II comorbidity was entered in the linear regression model at Step 2. The effect of Axis II comorbidity on poorer depression outcome was strong and decreased only slightly when first treatment variables (Step 3) and then Axis I comorbidity and GAF (Step 4) were entered into the model. When
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entered, treatment breadth was associated with poorer depression outcome, but this association fell short of statistical significance in the final model. To analyze whether the offered treatment had a different impact on depression outcome among those with and without Axis II comorbidity, interactions between Axis II comorbidity and treatment variables on depression outcome were analyzed. No statistically significant results were found in these analyses. For descriptive purposes, the effect of treatment variables on depression was further analyzed separately for those with Axis II comorbidity and those without. The results showed that while the treatment variables were not related to depression outcome at the 1-year follow-up among those with Axis II comorbidity, the breadth of treatment was associated with better depression outcome among those without Axis II comorbidity. DISCUSSION DIAGNOSTIC PROFILE
Multiple comorbid diagnoses are problematic because of diagnostic overlap, but they show the breadth of the overall psychopathology and are therefore important to recognize. The results of this study indicate that there is a significant difference between those depressed adolescents identified as having an Axis II pathology and those without in terms of the number of comorbid diagnoses and consequently the overall severity of the psychiatric condition. These analyses on dimensional, symptomatic outcomes of depression are in line with our previous report analyzing the outcome of diagnosed depressive disorder (Karlsson et al., 2008), but they add the important notions of differences in treatment outcome for those with and without Axis II disorders. Differences were not found in psychosocial treatment content or length, while treatment breadth distinguished the group without Axis II comorbidity from those with Axis II comorbidity. Those with Axis II comorbidity were more often treated with psychotropic medication. Comorbid personality disorder in the treatment of depression among adults has been shown to be associated with an increased risk of nonremission following antidepressant treatment in adults (Bock, Bukh, Vinberg, Gether, & Kessing, 2010), but opposite results also have been published (Kool et al., 2005). Our results indicate that in order to improve the treatment outcome of adolescent depression, the identification of personality traits or pathology is important during the adolescent years. TREATMENT OUTCOME/IMPROVEMENT
In contrast to some studies for adults (e.g., Fava et al., 1994; Mulder et al., 2003) but in line with others (e.g., Newton-Howes et al., 2006), the naturalistic treatment outcome for adolescents with comorbid Axis II disorders was poorer than for those without Axis II disorders. Only a few associations were observed between the treatment variables and depression outcome in the present study, and none were identified among those with Axis II comorbidity. The results indicate that time was too short, or appointments were too
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 861
few, or there was not enough treatment of the right kind for a decrease to take place in depressive symptoms in subjects with Axis II disorders. Gunderson et al. (2004) have shown that to affect the course of depression in BPD, the patients should receive treatment targeted for their borderline psychopathology because improvement in BPD often leads to subsequent resolution of MDD. As for the comparison group of those without Axis II comorbidity, a larger decrease was found in the same follow-up time of treatment in depressive symptoms. Notably, the compliance did not differ between the two groups. There were few differences in the kind of treatment methods offered to the two groups, even though the Axis II group was more impaired. Therefore, it is recommended that the grade of impairment and personality traits or disorders should be taken into account when planning treatment for depressed adolescents. If the treatment for depression has limited impact, the diagnostics should be reconsidered. LIMITATIONS AND STRENGTHS OF THE STUDY
The present study consisted of depressed adolescent outpatients whose psychiatric diagnoses, symptoms, and clinical characteristics were assessed using reliable interview instruments and rating scales. The problem in studying treatment in naturalistic outpatient settings is that it cannot be fully controlled. Treatment in an outpatient clinic is given by psychologists, social workers, psychiatrists, and psychiatric nurses. It can therefore be assumed that there are individual differences between the outcomes of patients depending on individual differences in the workers in the outpatient clinics in terms of personalities, education, and so forth. That groups with personality pathology might receive different kinds of treatment in naturalistic treatment studies was pointed out by Mulder et al. (2003). The fact that in the present study the two groups did receive almost similar treatment in terms of length, intensity, and hospitalization serves to control this possible source of bias. Therefore, while this is a methodological weakness in many studies, it does not fully apply in the present study. The assessment of personality disorder in adolescents could be viewed as controversial. However, we performed the Axis II assessment for research purposes based on previous publications that indicated that the assessments of various Axis II diagnoses have shown concurrent and in part predictive validity (Levy et al., 1999). Furthermore, the core elements of personality disorders are relatively stable and already identifiable before adulthood and even before adolescence (Stepp, Pilkonis, Hipwell, Loeber, & StouthamerLoeber, 2010), while long-term stability during adulthood appears weaker (Melartin, Haukka, Leskelä, Jylhä, & Isometsä, 2009) than was earlier thought. The refusal rate in the follow-up was rather high. It has been reported earlier that in our study population, those who participated in the follow-up assessment had more severe depressive and other psychological symptoms than those refusing to participate (Karlsson et al., 2006). Furthermore, in the Finnish health care system, ADHD, substance use disorders, and the more severe eating disorders are often treated in specialized units (e.g., welfare for
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intoxicant/drug abusers). Therefore the proportion of adolescents suffering from these disorders might be lower in our population than the actual proportion of treated subjects in the target area. CONCLUSIONS
The symptomatic recovery from depression remained largely incomplete among adolescents with comorbid Axis II pathology. One year may not be a long enough period to gain positive treatment results. Also, the methods in regular outpatient treatment of adolescents may not meet the needs of patients with an overall more serious pathology with a greater number of diagnoses and especially Axis II comorbidity. The outcome was better for the group without Axis II comorbidity. It is possible that nonrecognition of personality pathology among adolescents in treatment settings increases the risk for chronic depression in young people. The impact of the identification of personality disorder traits on the treatment and outcomes of adolescent depression should be studied further. REFERENCES Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Bernstein, D. P., Cohen, P., Skodol, A., Bezirganian, S., & Brooks, J. S. (1996). Childhood antecedents of adolescent personality disorders. American Journal of Psychiatry, 153, 907–913. Bernstein, D. P., Cohen, P., Velez, C. N., SchwabStone, M., Siever, L. J., & Shinsato, L. (1993). Prevalence and stability of DSMIII-R personality disorders in communitybased survey of adolescents. American Journal of Psychiatry, 150, 1237–1243. Bock, C., Bukh, J. D., Vinberg, M., Gether, U., & Kessing, L. V. (2010). The influence of comorbid personality disorder and neuroticism on treatment outcome in first episode depression. Psychopathology, 43(3), 197– 204. Brent, D. A., Johnson, B. A., Perper, J., Connolly, J., Bridge, J., Bartle, S., et al. (1994). Personality disorder, personality traits, impulsive violence and completed suicide in adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 33, 1080–1086. Candrian, M., Farabaugh, A., Pizzagalli, D. A., Baer, L., & Fava, M. (2007). Perceived stress and cognitive vulnerability mediate the effects of personality disorder comorbidity on treatment outcome in major depressive disorder: A path analysis study.
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ADOLESCENT DEPRESSION AND AXIS II DISORDERS 863 psychotic psychiatric illness. New York: Oxford University Press. Gunderson, J. G., Morey, L. C., Stout, R. L., Skodol, A. E., Shea, T. M., McGlashan, T. H., et al. (2004). Major depressive disorder and borderline personality revisited: Longitudinal interactions. Journal of Clinical Psychiatry, 65, 1049–1056. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56–62. Johnson, J. G., Cohen, P., Skodol, A. E., Oldham, J. M., Kasen, S., & Brook, J. S. (1999). Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Archives of General Psychiatry, 56, 805–811. Karlsson, L., Kiviruusu, O., Miettunen, J., Holi, M., Ruuttu, T., Pelkonen, M., et al. (2008). One-year course and predictors of outcome of adolescent depression: A case-control study in Finland. Journal of Clinical Psychiatry, 69(5), 844–853. Karlsson, L., Pelkonen, M., Ruuttu, T., Kiviruusu, O., Heilä, H., Holi, M., et al. (2006). Current comorbidity among consecutive adolescent psychiatric outpatients with DSMIV mood disorders. European Child and Adolescent Psychiatry, 15, 220–231. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 980–988. Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K., & Walters, E. (2005). Lifetime prevalence and age-onset distributions of DSM-IV disorders in the comorbidity survey replication. Archives of General Psychiatry, 62, 593–602. Kool, S., Schoevers, R., de Maat, S., Van, R., Molenaar, P., Vink, A., 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. Korenblum, M., Marton, P., Golombeck, H., & Stein, B. (1990). Personality status: Changes through adolescence. Adolescence, 13, 389–399. Levy, K. N., Becker, D. F., Grilo, C. M, Mattanah, J. J., Garnet, K. E., Quinlan, D. M., et al. (1999). Concurrent and predictive validity of the personality disorder diagnosis in adolescent inpatients. American Journal of Psychiatry, 156(10), 1522–1528. Lofgren, D. P., Bemporad, J., King, J., Lindem, K., & O’Driscoll, G. (1991). A prospective follow-up study of so-called borderline chil-
dren. American Journal of Psychiatry, 148, 1541–1547. Melartin, T. K., Haukka, J., Leskelä, U. S., Jylhä, P. J., & Isometsä, E. T. (2009). Categorical and dimensional stability of comorbid personality disorder symptoms in DSM-IV major depressive disorders: A prospective study. Journal of Clinical Psychiatry, 71(3), 287–295. Melartin, T. K., Rytsälä, H. J., Leskelä, U. S., Lestelä-Mielonen, P. S., Sokero, T. P., & Isometsä, E. T. (2002). Current comorbidity of psychiatric disorders among DSMIV major depressive disorder patients in psychiatric care in the Vantaa Depression Study. Journal of Clinical Psychiatry, 63(2), 126–134. 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(3), 259–264. Newton-Howes, G., Tyrer, P., & Johnson, T. (2006). Personality disorder and the outcome of depression: Meta-analysis of published studies. British Journal of Psychiatry, 188, 13–20. Oldham, J. M., Skodol, A. E., Kellman, H. D., Hyler, S. E., Doidge, N., Rosnick, L., et al. (1995). Comorbidity of Axis I and Axis II disorders. American Journal of Psychiatry, 152(4), 571–578. Russell, J. M., Kornstein, S. G., Shea, M. T., McCullough, J. P., Harrison, W. M., Hirschfeld, R. M., et al. (2003). Chronic depression and comorbid personality disorders: Response to sertraline versus imipramine. Journal of Clinical Psychiatry, 64(5), 554–561. Salbach-Andrae, H., Byrger, A., Klinkowski, N., Lenz, K., Pfeiffer, E., Fydrich, T., et al. (2008). Diagnostic of personality disorders in adolescence according to SCID-II. Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie, 36(2), 117–125. Shapiro, T. (1990). Resolved. Borderline personality exists in children under twelve: Negative. Journal of the American Academy of Child & Adolescent Psychiatry, 29(3), 480–482. Stepp, S. D., Pilkonis, P. A., Hipwell, A. E., Loeber, R., & Stouthamer-Loeber, M. (2010). Stability of borderline personality disorder features in girls. Journal of Personality Disorders, 24(4), 460–472. Westen, D., & Muderrisoglu, S. (2003). Assessing personality disorders using a systematic clinical interview: Evaluation of an alternative to structured interviews. Journal of Personality Disorders, 17(4), 351–369. Zimmerman, M., & Mattia, J. I. (1999). Axis I diagnostic comorbidity and borderline personality disorder. Comprehensive Psychiatry, 40(4), 245–252.
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TREATMENT CHARACTERISTICS AND OUTCOME OF DEPRESSION AMONG DEPRESSED ADOLESCENT OUTPATIENTS WITH AND WITHOUT COMORBID AXIS II DISORDERS Thea Strandholm, MA, Linnea Karlsson, MD, PhD, Olli Kiviruusu, MSocSc, Mirjami Pelkonen, PhD, and Mauri Marttunen, MD, PhD
In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.
Reportedly, 15% of adolescent psychiatric depressed outpatients meet both Axis I and Axis II diagnostic criteria in a cross-sectional assessment (Karlsson et al., 2006). The level of impairment has been shown to be higher among adolescents diagnosed with a comorbid personality disorder (Bernstein et al., 1993; Korenblum, Marton, Golombeck, & Stein, 1990) with, for example, a higher risk for recurrent depressive episodes (Karlsson et al., 2008) and suicide (Brent et al., 1994) in follow-up studies. For adults, research has shown a larger occurrence of Axis I and Axis II comorbidity than would be expected by chance (e.g., Oldham et al., 1995; Zimmerman & Mattia, 1999), with the comorbidity ranging from 18% to 86% in clinical samples of adult depressive patients (Candrian, Farabaugh, Pizzagalli, Baer, & Fava, 2007; Melartin et al., 2002). This article was accepted under the editorshiop of Paul S. Links. From National Institute for Health and Welfare, Helsinki, Finland (T. S., L. K., O. K., M. P., M. M.); Turku University Central Hospital, Turku, Finland (L. K.); Helsinki University Central Hospital, Helsinki, Finland (M. M); and University of Helsinki, Finland (T. S., M. M.). Address correspondence to Thea Strandholm, National Institute for Health and Welfare, Department of Mental Health and Substance Abuse Services, PO Box 30, FI 00271 Helsinki, Finland; E-mail: thea. [email protected]
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Treatment response among depressed patients with and without Axis II comorbidity has been a topic of discussion in the psychiatric literature. Several studies have shown poor treatment response and poor recovery rates for depression in cases of comorbid Axis II pathology in adults (e.g., NewtonHowes, Tyrer, & Johnson, 2006). The rates of Axis II personality disorder comorbidity have also been higher in adult patients suffering from chronic forms of depression (Russell et al., 2003). A growing number of studies have also questioned the view that comorbid Axis II pathology will negatively impact treatment outcome (De Bolle et al., 2011; Fava et al., 1994; Mulder, Joyce, & Luty, 2003) or negatively impact the treatment outcome of pharmacotherapy for depression (Kool et al., 2005) when comparing those with and without Axis II disorders. These contrasting results for adults show the need to better understand how the link between Axis I and Axis II disorders might also impact treatment response also for adolescents. One problem in studies among adolescents is the debated question of whether a personality disorder diagnosis in adolescence is valid. Some studies have questioned the diagnoses of Axis II in adolescence (e.g., Lofgren, Bemporad, King, Lindem, & O’Driscoll, 1991; Shapiro, 1990) because of the still developing personality. A rather large amount of evidence has, however, shown that adolescent personality disorder diagnoses have concurrent validity (Levy et al., 1999) and are thereby diagnosable in adolescence (e.g., Bernstein, Cohen, Skodol, Bezirganian, & Brooks, 1996; Durrett & Westen, 2005; Johnson et al., 1999; Westen & Muderrisoglu, 2003). Few studies have focused on investigating the impact of Axis II comorbidity on the outcome of adolescent depression and treatment characteristics related to the outcome. It seems that it would be especially important to assess this issue because it is known that many common psychiatric conditions actually have their onset in adolescence (e.g., Kessler et al., 2005), with high rates of continuity into adulthood (Copeland, Shanahan, Costello, & Angold, 2009). We have previously published a finding that while severity of depression was the strongest predictor of 1-year outcome of depressive disorder, Axis II comorbidity predicted a recurrence of adolescent depression (Karlsson et al., 2008). In the present study, we further investigated the effect of comorbid Axis II disorders on the short-term outcome of depression and compared treatment characteristics, such as length, intensity, and breadth, between those with and without Axis II comorbidity. Furthermore, we investigated whether the offered and implemented treatment impacted the outcome of depression differently for those with or without Axis II in a naturalistic follow-up study of depressed adolescent outpatients. METHODS PARTICIPANTS AND PROCEDURES
This study is part of the Adolescent Depression Study (ADS), a collaborative study by the Department of Adolescent Psychiatry of Peijas Medical Health Care District (PMCD), Helsinki University Central Hospital, and the De-
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 855
partment of Mental Health and Alcohol Research Unit of the National Institute of Health and Welfare (a merger of the National Public Health Institute and the National Research and Development Centre for Welfare and Health) in Finland. The ADS is a naturalistic, clinical follow-up study of adolescent depressive mood disorders. The outpatient clinics were located in the area of PMCD, which serves approximately 210,000 inhabitants in the Helsinki region in southern Finland. The patients were originally screened by the Beck Depression Inventory-21 (BDI-21; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the General Health Questionnaire-36 (GHQ-36; Goldberg, 1972). The sum scores ≥ 10 on the BDI-21 and ≥ 5 on the GHQ-36 were considered as screen positives (n = 373). After a complete description of the study was given to the screen positives and, if under 18 years of age, to their legal guardians, written informed consent was obtained. Out of the screened adolescents, 118 refused, 34 dropped out, and 3 did not meet the criterion of an ongoing depressive episode, giving a final number of 218 participants. A more detailed description of the study protocol is published elsewhere (Karlsson et al., 2006). Participants in the ADS (n = 218) were consecutive adolescent psychiatric outpatients (ages 13–19 years) interviewed for DSM-IV Axis I and Axis II diagnoses. Data were obtained by interviewing the adolescents at baseline (T1) and at 1-year follow-up (T2), using the Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime version (K-SADS-PL), a semistructured interview with a high level of reliability and validity (Kaufman et al., 1997). DSM-IV Axis II disorders were assessed with the Structured Clinical Interview and Screen for DSM-IV Axis II disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Smith, 1997). Studies (e.g., Salbach-Andrae et al., 2008) have given support for the suitability of using the SCID-II as a diagnostic instrument among adolescents, while the structure of personality pathology as assessed by Axis II criteria in adolescents has been shown to resemble that outlined in DSM-IV Axis II for adults, suggesting that personality disorders can be assessed in adolescents as in adults (Durrett & Westen, 2005). In the present study, the total count of depressive symptoms, measured with the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960) at the time of the interviews, was used as the outcome variable. The HDRS is a widely used 17-item clinician-rated interview of depressive severity. The Global Assessment of Functioning Scale (GAF) provides a single rating of functioning and symptoms and was used according to the DSM-IV Axis V. Scores range from 10 (e.g., need full-time supervision) to 100 (e.g., superior functioning, no symptoms). All the research diagnoses (covering Axes I–V) were confirmed in a diagnostic consensus meeting where the original investigators and at least one senior clinician reached a consensus on all the measures included in the interview. Interrater reliabilities were assessed using 13 randomly selected videotaped interviews. For mood disorder diagnoses (MDD, other mood disorder, no mood disorder) weighted kappa was 0.87 (95% CI 0.81, 0.93), and for the HDRS the single measures intraclass correlation coefficient using absolute agreement between raters as the criterion was 0.76 (95% CI 0.52, 0.91). The study protocol of the ADS
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was approved by the ethics committees of Helsinki University Central Hospital and PMCD. In the present study, 151 patients were drawn from the 218 subjects in Axis I and Axis II comparisons. Subjects not participating at T2 (n = 29, 13.3%), missing data (n = 6, 4.1%), and those with Axis II diagnosis at T1 only (n = 23 outpatients, 10.6%) or T2 only (n = 9, 4.1%) were excluded from these analyses. Out of the 151 outpatients included, the Axis II group (i.e., Axis II diagnosis at both T1 and T2) comprised 53 outpatients (35.1%), and the group without Axis II comorbidity comprised 98 outpatients (64.9%). TREATMENT
Because the study was naturalistic, the treatment received was the regular, best available treatment in outpatient clinics with possible periods of hospitalizations. Treatment teams in Finnish secondary health care at psychiatric outpatient clinics consist of an adolescent psychiatrist in charge of the treatment, one or more psychologists, a social worker, and one or more psychiatric nurses. The psychosocial treatment consists of individual sessions (e.g., supportive therapy, psychotherapy) as the basis of treatment and family and network meetings. A multiprofessional network (including social welfare and school personnel) is arranged when needed. The need for psychotropic medication or inpatient treatment is assessed by the treating adolescent psychiatrist. TREATMENT CHARACTERISTICS
In this study, treatment received was evaluated by the length of treatment, counted as treatment days from the first treatment sessions after the baseline interview to the last before 1-year follow-up; the intensity of treatment, indicated by treatment sessions per month; and breadth of treatment, defined as (1) only individual appointments, (2) individual and family and/or network appointments, (3) individual appointments and medication, and (4) individual appointments, family and/or network meetings, and medication. The frequency of nonappearance, both informed and noninformed, was considered in the analyses. Hospitalization during the follow-up period was recorded as hospital days during the treatment. The follow-up data for treatment variables were gathered from the medical records. Treatment variables were calculated for the whole period of treatment (between T1 and T2). OUTCOME VARIABLES
Because this study involves a sample of patients suffering from depressive symptoms at baseline (T1), the outcome measure was depressive symptoms. The clinician-rated HDRS was used because it is a dimensional measure and is therefore more sensitive to change than categorical diagnostic data when investigating outcome.
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 857 TABLE 1. Baseline Characteristics and Diagnostic Comorbidity in Groups with (n = 53) and Without (n = 98) Axis II Comorbidity in an Outpatient Depressed Adolescent Sample (n = 151) Axis II n (%)
Axis I n (%)
Statistics
Age over 15
40 (75.5)
62 (63.3)
.147
.088
Females
40 (75.5)
82 (83.7)
.279
.157
.453
.926
15 (28.3)
29 (29.6)
Parental socioeconomic status Working class
p value
Lower middle class
22 (41.5)
38 (38.8)
Upper middle class
14 (26.4)
25 (25.5)
2 (3.8)
6 (6.1)
Anxiety disorders
42 (79.3)
42 (42.9)
18.452
.000
Eating disorders
9 (16.9)
6 (6.1)
4.533
.035
Unknown Comorbid Axis I diagnoses
Substance use disorders
12 (22.6)
8 (8.2)
6.275
.014
Conduct disorders
10 (18.9)
8 (8.2)
3.754
.049
Psychosis Other
0
2 (2)
1.096
.420
5 (9.4)
7 (7.1)
247
.418
−4.084
.000
1 (1.9)
14 (14.4)
14.054
.000
HDRS score 0–7 p 8–15p
16 (30.2)
51 (52.6)
16–p
36 (67.9)
32 (33.0)
2 (3.8)
29 (29.6)
Axis V over 60
STATISTICAL ANALYSES
Data analyses were done using the Statistical Package for the Social Sciences (SPSS Version 16.0). Comparisons between study groups were conducted with the chi-square test for categorical variables and with the Mann–Whitney U test and the t test for nonnormally and normally distributed continuous variables, respectively. A hierarchical linear regression model was constructed for the analyses of outcome and treatment effects. Statistical significance was set at a p value < 0.05. RESULTS SOCIODEMOGRAPHIC CHARACTERISTICS AND PSYCHIATRIC DIAGNOSES
The depressed adolescents with Axis II comorbidity differed significantly in their diagnostic profile at T1 from those without. Axis II comorbidity was related to an elevated frequency of many Axis I categories (e.g., anxiety disorders, eating disorders, and substance use disorders) (Table 1). A lower level of psychosocial functioning was also observed among the subjects with Axis II comorbidity (Table 1).
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TABLE 2. Treatment Characteristics of Axis I (N = 98) and Comorbid Axis I and II Depressed Adolescent Outpatients (N = 53) from Baseline to 1-Year Follow-up Characteristic
Axis II
Axis I
Statistics
p value
21.64 (16.67); 17.00
19.18 (11.71); 16.50
−.363
.717
−.374
.708
23 (46.0)
47 (48.4)
−.690
.490
.712
.477
Psychosocial treatment Kept individual appointments, mean (SD); median a Contents of the appointments (N = 50, 97) No. (%) Counseling Therapy (> 6 months)
3 (6.0)
9 (9.3)
Therapy (< 6 months)
23 (46.0)
41 (4t2.3)
2.12 (5.14); 1
1.30 (2.13); 0
25 (50.0)
42 (43.3)
Kept family/network appointments, mean (SD); median a Contents of the appointments (N = 50, 97) No. (%) Family counseling Family therapy Other Intensity (individual appoint./month), mean (SD); mediana Attendance % (individual appoint.), mean (SD); mediana
1 (2.0)
3 (3.1)
24 (48.0)
52 (53.6)
1.75 (1.14); 1.47
1.71 (0.94); 1.58
−.113
.910
82.06 (13.14); 83.33
80.12 (17.99); 84.62
−.018
.986
Psychotropic medications Any, No. (%)
38 (71.7)
55 (56.1)
−1.872
.061
Antidepressants
36 (67.9)
47 (48)
−2.346
.019
SSRIs
32 (60.4)
45 (45.9)
Treatment breadth, N (%) (1) individual appointments
7 (13.2)
26 (26.5)
+(2) family/network counseling
10 (18.9)
25 (25.5)
-1.891
.091
−2.392
.017
+(3) medication
17 (32.1)
23 (23.5)
+(2)+(3)
19 (35.8)
24 (24.5)
Hospitalization, No. (%)a
9 (17.0)
16 (16.3)
.011
.544
10.30 (74.96; 0)
9.54 (30.61; 0)
−.349
.727
-.801
.423
no treatment
22 (41.5)
48 (49.0)
psychiatric outpatient
28 (52.8)
48 (49.0)
3 (5.7)
2 (2.0)
Number of hospitalizationa days, mean (SD; median) Treatment status at the 1-year follow-up, No. (%)
psychiatric inpatient a
Mann-Whitney U test.
TREATMENT CHARACTERISTICS
No significant differences were found between the two groups in treatment status (χ2 = 4.21, p = .24) at the 1-year follow-up. At T2, 22 (41.5%) of those with Axis II and 48 (49%) of the group without Axis II were no longer in outpatient treatment.
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 859 TABLE 3. Hierarchical Linear Regression Analyses of the Effect of Baseline Characteristics, Axis II Comorbidity, and Treatment Variables on Depression Outcome (HDRS T2) in a Sample of Depressed Outpatients Step 1
Step 2
Step 3
Step 4
B
p
B
p
B
p
B
p
Age
.492
.168
.213
.519
.258
.434
.242
.462
Sex
.780
.600
.383
.781
.776
.573
1.425
.320
HDRS T1
.264
.005
.092
.314
.026
.790
-.039
.719
6.510
.000
6.279
.000
5.728
.000
.000
.932
-.001
.895
Axis II Treatment length intensity
.177
.746
.139
.804
breadth
1.181
.026
1.077
.052
Comorbiditya
1.122
.112
GAF
.417
.790
R2
.07
.23
.26
∆R2
.07
.16
.03
.01
∆F
3.59*
29.28**
1.9
1.31
a
.27
Number of diagnostic main categories in baseline. *p < .05; **p < .01.
Treatment attendance did not differ between the two groups at a statistically significant level (Table 2). No statistically significant differences were found in length or intensity of treatment. The breadth of treatment was higher among subjects with Axis II disorders (Table 2) because they were treated with a larger variety of treatment methods simultaneously (e.g., individual appointments, family meetings, and medication). The group with Axis II comorbidity was more often treated with psychotropic medication compared to the non-Axis II group (Table 2). RECEIVED TREATMENT, OUTCOME AT T1, AND AXIS II COMORBIDITY
The group with Axis II comorbidity had higher depression scores (HDRS) at T1 (mean = 17.70, SD = 5.90) compared to those without Axis II comorbidity (mean = 13.27, SD = 6.02) (t = −4.364, p < .001). Also at T2, the depression scores were higher for the group with Axis II (mean = 13.70, SD = 7.88) compared to those without Axis II comorbidity (mean = 6.66, SD = 5.47) (t = −5.79, p < .001). The hierarchical linear regression model results are presented in Table 3. Axis II comorbidity had the strongest impact on depression outcome of the selected independent variables. In the initial model, at Step 1, the Hamilton score at T1 predicted the Hamilton score at T2, but this effect disappeared when Axis II comorbidity was entered in the linear regression model at Step 2. The effect of Axis II comorbidity on poorer depression outcome was strong and decreased only slightly when first treatment variables (Step 3) and then Axis I comorbidity and GAF (Step 4) were entered into the model. When
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entered, treatment breadth was associated with poorer depression outcome, but this association fell short of statistical significance in the final model. To analyze whether the offered treatment had a different impact on depression outcome among those with and without Axis II comorbidity, interactions between Axis II comorbidity and treatment variables on depression outcome were analyzed. No statistically significant results were found in these analyses. For descriptive purposes, the effect of treatment variables on depression was further analyzed separately for those with Axis II comorbidity and those without. The results showed that while the treatment variables were not related to depression outcome at the 1-year follow-up among those with Axis II comorbidity, the breadth of treatment was associated with better depression outcome among those without Axis II comorbidity. DISCUSSION DIAGNOSTIC PROFILE
Multiple comorbid diagnoses are problematic because of diagnostic overlap, but they show the breadth of the overall psychopathology and are therefore important to recognize. The results of this study indicate that there is a significant difference between those depressed adolescents identified as having an Axis II pathology and those without in terms of the number of comorbid diagnoses and consequently the overall severity of the psychiatric condition. These analyses on dimensional, symptomatic outcomes of depression are in line with our previous report analyzing the outcome of diagnosed depressive disorder (Karlsson et al., 2008), but they add the important notions of differences in treatment outcome for those with and without Axis II disorders. Differences were not found in psychosocial treatment content or length, while treatment breadth distinguished the group without Axis II comorbidity from those with Axis II comorbidity. Those with Axis II comorbidity were more often treated with psychotropic medication. Comorbid personality disorder in the treatment of depression among adults has been shown to be associated with an increased risk of nonremission following antidepressant treatment in adults (Bock, Bukh, Vinberg, Gether, & Kessing, 2010), but opposite results also have been published (Kool et al., 2005). Our results indicate that in order to improve the treatment outcome of adolescent depression, the identification of personality traits or pathology is important during the adolescent years. TREATMENT OUTCOME/IMPROVEMENT
In contrast to some studies for adults (e.g., Fava et al., 1994; Mulder et al., 2003) but in line with others (e.g., Newton-Howes et al., 2006), the naturalistic treatment outcome for adolescents with comorbid Axis II disorders was poorer than for those without Axis II disorders. Only a few associations were observed between the treatment variables and depression outcome in the present study, and none were identified among those with Axis II comorbidity. The results indicate that time was too short, or appointments were too
ADOLESCENT DEPRESSION AND AXIS II DISORDERS 861
few, or there was not enough treatment of the right kind for a decrease to take place in depressive symptoms in subjects with Axis II disorders. Gunderson et al. (2004) have shown that to affect the course of depression in BPD, the patients should receive treatment targeted for their borderline psychopathology because improvement in BPD often leads to subsequent resolution of MDD. As for the comparison group of those without Axis II comorbidity, a larger decrease was found in the same follow-up time of treatment in depressive symptoms. Notably, the compliance did not differ between the two groups. There were few differences in the kind of treatment methods offered to the two groups, even though the Axis II group was more impaired. Therefore, it is recommended that the grade of impairment and personality traits or disorders should be taken into account when planning treatment for depressed adolescents. If the treatment for depression has limited impact, the diagnostics should be reconsidered. LIMITATIONS AND STRENGTHS OF THE STUDY
The present study consisted of depressed adolescent outpatients whose psychiatric diagnoses, symptoms, and clinical characteristics were assessed using reliable interview instruments and rating scales. The problem in studying treatment in naturalistic outpatient settings is that it cannot be fully controlled. Treatment in an outpatient clinic is given by psychologists, social workers, psychiatrists, and psychiatric nurses. It can therefore be assumed that there are individual differences between the outcomes of patients depending on individual differences in the workers in the outpatient clinics in terms of personalities, education, and so forth. That groups with personality pathology might receive different kinds of treatment in naturalistic treatment studies was pointed out by Mulder et al. (2003). The fact that in the present study the two groups did receive almost similar treatment in terms of length, intensity, and hospitalization serves to control this possible source of bias. Therefore, while this is a methodological weakness in many studies, it does not fully apply in the present study. The assessment of personality disorder in adolescents could be viewed as controversial. However, we performed the Axis II assessment for research purposes based on previous publications that indicated that the assessments of various Axis II diagnoses have shown concurrent and in part predictive validity (Levy et al., 1999). Furthermore, the core elements of personality disorders are relatively stable and already identifiable before adulthood and even before adolescence (Stepp, Pilkonis, Hipwell, Loeber, & StouthamerLoeber, 2010), while long-term stability during adulthood appears weaker (Melartin, Haukka, Leskelä, Jylhä, & Isometsä, 2009) than was earlier thought. The refusal rate in the follow-up was rather high. It has been reported earlier that in our study population, those who participated in the follow-up assessment had more severe depressive and other psychological symptoms than those refusing to participate (Karlsson et al., 2006). Furthermore, in the Finnish health care system, ADHD, substance use disorders, and the more severe eating disorders are often treated in specialized units (e.g., welfare for
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