Can SSRIs Change Personality?
Ever since Peter Kramer wrote Listening to Prozac, we have suspected that SSRIs do more than simply treat depression; that they can make some patients “better than well.” That is, that they actually transform our patients’ underlying characters or personalities. But this is a tricky question to test, because it is devilishly hard to distinguish improvement in personality from improvement in mood.
Recently, a group of researchers has made a valiant attempt to answer this question. In this study, 240 patients with major depressive disorder were randomized to either paroxetine for 16 weeks (120 patients); cognitive therapy (CT) for 16 weeks (60 patients), or placebo for eight weeks (60 patients). The paroxetine dose ranged from 10 mg/day to 50 mg/day, and the CT was administered in twice-weekly 50-minute sessions for four weeks, followed by once or twice weekly 50-minute sessions for eight weeks, followed by once-weekly sessions for four weeks.
The researchers measured improvement in depression with the standard Hamilton depression scale, and measured personality change with a well-validated scale called the NEO Five-Factor Inventory. They chose two factors, neuroticism and extraversion, which are closely related to depression. “Neuroticism” refers to a tendency to experience negative emotions, while “extraversion” refers to being social and experiencing positive emotions.
After eight weeks of treatment, patients assigned to both active treatments (paroxetine and CT) had greater improvement in depression scores than patients assigned to placebo. But in line with past studies, placebo was still a fairly effective antidepressant, producing 75% as much improvement in depression as the active treatments. The interesting finding was that while the active treatments robustly improved personality scores (“improved” here means a decrease in neuroticism scores and an increase in extraversion scores), placebo barely affected personality at all. In other words, both paroxetine and CT improved both personality and depression, whereas placebo improved depression without any personality change. The implication is that active antidepressant treatment—whether with medication or therapy—can tweak the underlying personality in some way.
The authors did other analyses to corroborate further the apparent independence of depression from personality scores. For example, for each placebo patient, they identified a matching paroxetine patient with the same amount of depression improvement. When they compared these two groups, the paroxetine group showed 3.5 times as much improvement on neuroticism as placebo, and 6.8 times as much improvement in extraversion (Tang TZ et al., Arch Gen Psychiatry 2009;66(12):1322–1330).
TCPR’s Take: SSRIs and cognitive therapy appear to work in part by tweaking basic elements of the personality. One clinical implication is that during our sessions with depressed patients, we should probe for these specific personality characteristics in an effort to decrease neuroticism and increase extroversion. This may work synergistically with other specific antidepressant techniques.
Marital Separation and Suicide Risk
Both prior research and clinical lore tell us that divorced men are at especially high risk for suicide. Two new studies add to our knowledge about this issue, focusing on a particularly painful phase of the divorce process: marital separation. The first study examined a large dataset of all suicides committed in Queensland, Australia, from 1994 to 2004 (total of 6,062 suicides). Marital separation was associated with the highest risk of suicide compared to all other marital statuses. For most age groups, separation was associated with at least twice the suicide risk of divorce (Wyder M et al., J Affect Disord 2009;116: 208–213). The increased risk associated with separation was highest among men aged 15–24 and decreased with age.
A separate study, again in Australia, explored this issue further by seeking to define factors that put separated people at higher risk for serious suicidal ideation, defined as having “thought seriously about suicide.” Based on interviews of 228 separated males and 142 separated females recruited from counseling services and self-help groups, researchers found that a prior suicide attempt, substance abuse in the past year, higher scores on measures of shame, and difficulties with financial or property issues predicted greater risk of serious suicidal ideation for men. For women, mood disorders in the past year, higher shame scores, and greater amounts of alcohol use predicted serious suicidal ideation (Kloves K et al., J Affect Disord 2010;120:48–53). The reliance on patient self-report for all information on mental health diagnoses is a clear limitation of this study.
TCPR’s Take: Marital separation is a particularly dangerous period for our patients, especially those with prior suicide attempts, alcohol or other substance abuse, a feeling of being ashamed of the separation, and, especially among men, financial worries. We would do well to ramp up the intensity of our treatment, medication and/or psychotherapy, for such patients.