Personality Disorders in Depressed Adolescent Outpatients : Impact on outcome and treatment of depression, changes in symptoms, and predictors into young adulthood

Background. Personality disorders (PDs) among depressed adolescents are common, but there is little research on how PDs impact the course of depression and the long-term development from adolescence into adulthood. The objective of this study was to examine the association between depression and PDs in a one-year follow-up of adolescents and in an eight-year follow-up from adolescence to adulthood, PD symptom change during adolescence, and the associations of PDs with defense mechanisms, social support, and comorbid psychiatric disorders among depressed adolescents. Methods. This study was part of the Adolescent Depression Study (ADS), a prospective, naturalistic research project. The sample comprised originally depressed adolescent outpatients (N=218) aged 13–19 years, who were interviewed and diagnosed at baseline and at six-month and one-year follow-ups using K-SADS- PL for DSM-IV psychiatric clinical disorders and SCID-II for PD diagnoses. The subjects were further assessed in an eight-year follow-up using diagnostic interviews (SCID-I and -II) and self-report scales, and observer-report rating scales were used at every assessment point. Results. Of the participants, 67% presented at least one depression recurrence. At the eight-year follow-up, 36% had a mood disorder, and anxiety (48%) and PDs (26%) were also frequent.Over half of the patients suffered from a mood disorder 25% or more of the follow-up time from adolescence into adulthood. If presenting with comorbid depression and PD, the short-term outcome in psychiatric treatment was worse. Treatment breadth did not impact positively on the outcome for depressed adolescents with a PD, but those without a PD gained from a larger variety of treatments. Decrease in both depression severity and comorbidity rate correlated positively with PD symptom decrease. Higher perceived social support was associated with a decrease in PD symptoms in the PD categories narcissistic, schizotypal, and paranoid. Immature defense mechanisms predicted PDs in adulthood, while mature defense style did not associate negatively with a later PD diagnosis. Displacement, isolation, and reaction formation were the strongest predictors of a PD in adulthood, all considered mental inhibitions. Conclusion. These results show the seriousness of depression in adolescence and its long-term impact on outcome. In patients presenting with a comorbid PD, the short- and long-term outcomes of depression were generally worse. Social support and thus the ability to connect with other people might impact clinical symptoms, higher perceived social support being a possible protective factor for symptoms. There was covariation between symptoms of PDs and other psychiatric symptoms, all clinically relevant in treatment planning. Adolescents with PD should be treated with specialized treatments for PDs. In line with earlier studies, the results suggest defense styles should be a focus in treatment planning and content. Also, attention should be directed to separate defenses, especially those having to do with mental inhibition.Persoonallisuushäiriöissä tyypillisiä ovat jäykät kokemisen ja käyttäytymisen tavat, jotka aiheuttavat henkilökohtaista kärsimystä ja usein myös haittaa. Persoonallisuushäiriöt ovat yleisiä nuoruusikäisillä, mutta niiden vaikutusta masennuksen kulkuun ja kehitykseen nuoruudesta aikuisuuteen on tutkittu toistaiseksi vähän. Väitöskirjan tavoitteena oli tutkia masennuksen ja persoonallisuushäiriöiden yhteyksiä vuoden seurannassa nuoruusiässä ja kahdeksan vuoden seurannassa nuoruudesta aikuisuuteen. Lisäksi tavoitteena oli tutkia persoonallisuushäiriöoireiden muutoksia nuoruusiässä sekä persoonallisuushäiriöiden yhteyttä puolustusmekanismeihin, sosiaaliseen tukeen ja samanaikaisiin psykiatrisiin häiriöihin masentuneilla nuorilla. Tutkimus oli osa Nuorten Depressio -tutkimusta (ADS). Aineisto koostui 218 masennusdiagnoosin saaneesta, nuorisopsykiatriseen avohoitoon hakeutuneesta 13–19-vuotiaasta nuoresta. Tutkimuksen mittauksissa (alkumittaus, 6 kk, 1 vuosi, 8 vuotta) nuoria haastateltiin diagnostisilla haastattelumenetelmillä. Näiden lisäksi käytettiin standardoituja kyselylomakkeita ja arviointiasteikkoja. Tutkimukseen osallistuneista 67 %:lla depressio uusiutui kahdeksan vuoden seuranta-aikana ja yli puolella oli mielialahäiriö vähintään 25 %:a seuranta-ajasta. Kahdeksan vuoden seurantamittauksessa 36 %:lla oli mielialahäiriö, 48 %:lla ahdistuneisuushäiriö ja 26 %:lla persoonallisuushäiriö. Vuoden seurannassa hoidon ennuste oli huomattavasti heikompi niillä nuorilla, joilla oli samanaikainen persoonallisuushäiriö. Heillä hoidon laajuus ei vaikuttanut hoidon tulokseen positiivisesti. Ne nuoret, joilla ei ollut persoonallisuushäiriötä, hyötyivät laajemmasta hoidosta. Oireissa oli useita yhteisvaikutuksia: esimerkiksi jos masennus ja muut psykiatriset oireet vähenivät, vähenivät usein myös persoonallisuushäiriöoireet. Korkeampi koettu sosiaalinen tuki oli yhteydessä useiden persoonallisuushäiriöoireiden vähenemiseen vuoden seurannassa. Puolustusmekanismien eli defenssien avulla ihminen säätelee mielentilaansa ja käyttäytymistään ylläpitääkseen psyykkistä tasapainoaan. Erityisesti niin sanotut kypsät defenssit palvelevat sopeutumista. Nuoruuden epäkypsät defenssit ennustivat tutkimuksessa persoonallisuushäiriödiagnoosia aikuisuudessa, kun taas kypsät defenssit eivät suojanneet myöhemmältä persoonallisuushäiriödiagnoosilta. Nuoruuden defensseistä kohteensiirto, eristäminen ja reaktionmuodostus olivat vahvimmat nuoren aikuisuuden persoonallisuushäiriödiagnoosia ennustavat yksittäiset puolustusmekanismit. Tutkimustulokset osoittavat nuoruusiän masennuksen vakavuuden ja sen pitkäaikaisen vaikutuksen ennusteeseen. Jos nuorella oli samanaikainen persoonallisuushäiriö, oli ennuste usein heikompi sekä lyhyessä että pitkässä seurannassa. Tutkimuksen perusteella sosiaalinen tuki on mahdollinen persoonallisuushäiriöoireilta suojaava tekijä. Persoonallisuushäiriöoireilla ja muilla kliinisillä oireilla oli yhteisvaikutuksia, mikä viittaa siihen, että kokonaiskuvan huomioiminen hoitoa suunnitellessa on tärkeää. Nuorta, jolla on todettu persoonallisuushäiriö, tulisi hoitaa kyseiseen häiriöön ja oirekuvaan fokusoiduilla hoidoilla. Tämän tutkimuksen tulokset tukevat aiempia tutkimustuloksia, joissa on todettu puolustusmekanismien huomioimisen tärkeys hoidon suunnittelussa ja hoidon aikana

Market Orientation And Performance: Does Organizational Strategy Matter?

Data from a survey of 159 hospitals was used to test the relationship between market orientation and firm performance for low cost and differentiation strategies. Hospitals pursuing a differentiation strategy had stronger market orientation than those pursuing a cost leadership strategy. Market orientation had a more positive impact on the performance of organizations pursuing a differentiation strategy than on those pursuing a cost leadership strategy. In the cost leader group, the inter-functional coordination component of market orientation significantly affected firm performance, while in the differentiator group the customer orientation and competitor orientation components of market orientation had significant impact on performance. The implications of these findings for managers also are discussed

Inducing Employees to Leave: A Comparison of Four Severance Options

This study examines the demographic, economic, and psychographic characteristics of 324 blue‐collar workers who were offered four options for either retirement or severance from the organization. Consistent with previous research, individuals who accepted retirement options have more organizational tenure and believed that the packages would provide stable financial futures. A key finding for those who accepted the nonretirement options is that comparable employment would be available. The study concludes with research limitations and suggestions for future research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97191/1/21526_ftp.pd

Differences in Characteristics and Treatment Received among Depressed Adolescent Psychiatric Outpatients with and without Co-Occuring Alcohol Misuse: A 1-Year Follow-Up Study

Objectives. We aimed at examining the differences between depressed psychiatric adolescent outpatients with and without cooccurring alcohol misuse in psychosocial background, clinical characteristics, and treatment received during one-year followup. Furthermore, we investigated factors related to nonattendance at treatment. Materials and Methods. Consecutive 156 adolescent (13–19 years) psychiatric outpatients with a unipolar depressive disorder at baseline were interviewed using structured measures at baseline and at 12 months. Alcohol misuse was defined as having an AUDIT score of 8 or more points. The outpatients received “treatment as usual” of clinically defined duration. Results. Among depressive outpatients, poor parental support, parental alcohol use and decreased attendance at treatment associated with alcohol misuse. The severity of alcohol use as measured by AUDIT-score was the strongest factor independently predicting nonattendance at treatment in multivariate analysis. Conclusions. Alcohol misuse indicates family problems, has a deleterious effect on treatment attendance, and should be taken into account when managing treatment for depressive adolescent outpatients

Nuorten itsetuhoisuuden ja epävakaiden piirteiden psykoterapeuttisten hoitomuotojen vaikuttavuus : Systemaattiseen hakuun perustuva kirjallisuuskatsaus

• Itsetuhoisten nuorten hoidossa suositellaan ensisijaisesti psykososiaalisia hoitoja. Myös tavanomainen hoito on tutkimuksissa vähentänyt itsetuhoisuutta, mutta ajankohtaisesti itsetuhoisille nuorille se ei yleensä ole riittävä. • Epävakaista piirteistä ja itsetuhoisuudesta kärsivät nuoret hyötyvät erityisesti dialektisesta käyttäytymis­terapiasta. Myös mentalisaatioon perustuvan terapian ja kognitiivis­analyyttisen psykoterapian vaikuttavuudesta on alustavaa tutkimusnäyttöä. • Nuorten itsetuhoisuuden ja myös epävakaiden piirteiden hoitomuodoissa perheterapeuttisten elementtien yhdistäminen psykoterapiaan on hyödyllistä. • Hoitosuositusten antamiseksi tarvitaan lisätutkimusta eri psykoterapiamuotojen vaikuttavuudesta.Peer reviewe

Nuorten depression psykoterapeuttisten hoitomuotojen vaikuttavuus : systemaattiseen hakuun perustuva kirjallisuuskatsaus

•Kognitiivinen käyttäytymisterapia ja interpersonaalinen psykoterapia ovat vaikuttavia hoitoja nuorten depressioissa. •Perheterapia soveltunee nuorten depressioiden hoitoon etenkin silloin, kun perheeseen liittyvät tekijät selvästi kuormittavat nuorta. •Muiden psykoterapiamuotojen vaikuttavuutta nuorten depressioissa ei ole toistaiseksi tutkittu riittävästi. •Vaikuttavuustutkimuksen perusteella nuorten depressioiden ensisijaisina psykoterapeuttisina hoitoina voidaan pitää kognitiivista käyttäytymisterapiaa ja interpersonaalista psykoterapiaa.Peer reviewe

Outcome of depressive mood disorder among adolescent outpatients in an eight-year follow-up

ObjectivesThis study investigated the eight-year course and outcomes of depressive mood disorders and the key outcome predictors among adolescent outpatients.MethodsDepressive adolescent outpatients (N = 148) in a naturalistic clinical setting were assessed at baseline, six months, 12 months and eight years using diagnostic and self-report instruments. Baseline predictors covered selected sociodemographic, clinical and treatment-related characteristics. The outcomes were time to recovery, recurrence, time spent being ill and longitudinal latent profiles of depressive symptoms.ResultsThe recovery rate from any depressive mood disorder was 73% at two years, 91% at five years and 94% by the end of the eight-year follow-up. Two thirds (67%) of the subjects presented at least one recurrence and 57% of them were depressed for 25% or more of the follow-up period. At the eight-year follow-up, 36% had a mood disorder, 48% suffered from anxiety and 26% had a personality disorder. Less severe depression at baseline predicted a shorter time to recovery, whereas recurrence was predicted by a younger age. A latent profile with initially moderate-level depressive symptoms but a poor distal outcome was associated with being female and borderline personality disorder.LimitationsThe female preponderance in the sample warrants caution when interpreting sex differences in the findings.ConclusionsAlthough the depression outcome for some adolescents making the transition to young adulthood is promising, many of them experience long, even chronic episodes, and recurrences are common. Personality-disorder characteristics appeared to be significant outcome predictors in this adolescent population.</div

Sleep complaints in adolescent depression : one year naturalistic follow-up study

Peer reviewe

Green Alliances: Are They Beneficial when Regulated Firms are Asymmetric?

Environmental groups (EGs) often collaborate with polluting firms to help them reduce their carbon footprint and, generally, to improve their environmental practices. One prominent example is the collaboration between McDonald’s and the Environmental Defense Fund which reduced restaurant waste by 30%, recycled 1 million tons of corrugated boxes, and eliminated over 300 million pounds of packaging in the decade following the partnership. Much of the literature on the impact of EGs has centered around four categories: (1) EGs take a confrontational approach through negative advertising campaigns and boycotts, (2) EGs invest in campaigns to increase consumers’ environmental awareness of the goods firms offer, (3) EGs use a lobbying approach for or against projects with environmental impacts, and (4) EGs provide green certificates to indicate certain environmental attributes of the good. In this paper, we build on existing literature and analyze the collaboration between an EG and polluting firms when the firms are asymmetric in their abatement (technology that reduces emissions) costs. We use a model with four stages: Stage 1. The EG chooses a collaboration level with each firm. Stage 2. Each firm, knowing the support they receive from the EG, chooses their abatement level. Stage 3. The regulator, knowing the abatement investment, sets the emission fee to maximize social welfare. Stage 4. Firms independently and simultaneously compete in the market by choosing their output levels (abatement and payment of the emission fee occurs). We find that, as firms become more asymmetric in their abatement costs, the EG collaborates more with the firm suffering from an abatement cost disadvantage. However, this additional collaboration does not overcome firms\u27 cost asymmetry, producing an overall decrease in total abatement and an increase in total emissions. We also evaluate the welfare effects of introducing an EG and/or a regulator, finding that the regulator generally yields larger welfare gains (from environmental regulation) than the EG when neither are present. Unlike previous studies, we show that the welfare benefit from a second agent (either the EG or regulator) is, under most settings, largest when firms are more asymmetric in their abatement costs. *Strandholm thanks the University of South Carolina Upstate Office of Sponsored Awards and Research Support for partial funding of the project through the Scholarly Course Reallocation Program under the title, “Picking green teams: how environmental groups form alliances within a market.