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Background

In literature, comorbidity between depressive disorder and personality disorder (PD) is common and varies from 18 to 51% [1]. It’s often responsible of impaired outcome and makes difficulties in treatment [2,3]. The aim of this study was to determine the impact of personality disorders on the clinical characteristics and evolution of recurrent major depressive disorders.

Methods

This is a retrospective descriptive study. It concern 211 female inpatients with recurrent depressive disorders according to DSM-IV during the period from 1999 to 2019. All these patients were admitted in psychiatric unit in Farhat Hached General Hospital (Sousse) because of depressive symptoms and/or suicidal ideation or attempts. Exclusion criteria were: a diagnosis of bipolar disorder, other psychotic disorders and mental retardation. All these female inpatients were followed up for a period of 24 months.

To evaluate impact of personality disorders on outcome of these female inpatients with recurrent major depressive disorder, we have compared two groups:

- First group (G1): inpatients with recurrent depression and having comorbid personality disorder (n = 120).
- Second group (G2): inpatients with recurrent depression without personality disorder (n = 91).

Statistical comparisons were performed between the two groups and based on demographic, clinical and outcome features available in patients’ medical charts. Comparisons were carried out with χ2 and t-test statistics. Reported differences were significant at 0.05 or less.

Results

The mean age of our sample was 43.3 ± 13.1 years. They were married in 61% of cases and third of them had regular professional activity. 44% of our inpatient with recurrent depression had history of organic pathology and 34% of them had other comorbid psychiatric illness such us generalized anxiety disorder. The mean age of onset of depressive disorder was 31.5 ± 11.5 years.

The mean number of admission in psychiatric unit was 2.1 ± 1.1.

The prevalence of personality disorder in patients with recurrent major depressive disorders was 56.9%. The most frequent was respectively histrionic (40.8%), dependant (16.6%) and borderline (15.8%).

In the group of patients with recurrent depression and having personality disorder, the beginning of the first depressive episode and age of first medical visit and admission in psychiatry were earlier (p <10-3). Similarly, we found they had more suicide attempts in their history (p <10-3).

After a period of follow up, we found that they have more residual symptoms (p = 0.01), a larger number of relapses (p = 0.042) and subsequent suicidal recurrence (p = 0.001) (Table 1).

Discussion

Clinical factors

Depressed inpatients with PD, in our study, had lower age at the onset of depressive illness than patients without personality disorders. This result is noticed in many previous studies [2,3,4]. According to Ramklint and al., early onset of depression is a major predictor for personality disorder comorbidity [4].

PD were associated with more suicide attempts in our depressed patients, as it was regularly noticed by authors [5,6]. Cluster B personality types, particularly borderline and antisocial ones, were the most prevalent in depressive patients with suicide attempts [5,6,7]. Many data assumed that specific traits of these personality types, such as impulsivity, hostility and aggressiveness may facilitate suicidal behavior [5,6,7]. Hansen and al. notified that personality disorder increase the number of suicidal attempts [8].

Many studies had found that PD were associated with many axis I comorbid disorders like alcohol and substance abuse [2,3]. Joyce and al. reported that depressed patients with PD had significantly more alcohol and cannabis abuse or dependence and social phobia than those without PD [9].

Outcome factors

Feske and al. noticed that patients with major depressive disorder and PD had more partial remission and more relapses [10]. In the same way, Shea and al. had reported more residual depressive symptoms in depressed patients with PD and an impaired outcome in social functioning [11].

About recurrence, Alnaes and al. admitted that PD was responsible of recurrence in depression [12]. This result was contested by Joyce who didn’t find this association [9].

Conclusion

Almost half of our inpatients followed for recurrent depressive disorders have associated personality disorder. The most frequent was respectively histrionic, borderline and dependant personality.

This comorbidity is associated with earlier age of first depressive episode, more suicide attempts, residual symptoms and relapses. Standardized assessment of personality disorder should be used in clinical practice to ensure adequate care. Other multicenter studies recruiting more patients with major depressive disorders are needed.