Post on 11-Sep-2021
Running head: PERSONALITY FACETS AND DEPRESSION
Personality Facets in Patients with Major Depressive Disorder: Differential Change across
Treatment and Association with Relapse and Recurrence
By
Tara Michelle Gralnick
A thesis submitted to the University of Toronto in conformity
with the requirements for the degree of Masters of Arts
Psychological Clinical Science
University of Toronto Scarborough
© Copyright by Tara Michelle Gralnick 2015
PERSONALITY FACETS AND DEPRESSION ii
Personality Facets in Patients with Major Depressive Disorder: Differential Change across
Treatment and Association with Relapse and Recurrence
Tara Michelle Gralnick
Masters of Arts
Psychological Clinical Science
University of Toronto Scarborough
2015
Abstract
Personality assessed at a higher-order, “domain” level has shown to be predictive of the
treatment response and course of major depressive disorder (MDD). Personality domains have
also shown mean-level change (i.e., absolute change) and rank-order stability (i.e., relative
stability) across treatment. The nature and prognostic significance of personality change at a
lower-order, “facet” level has yet to be evaluated. The present study investigated absolute and
relative change of personality facets across cognitive-behavioural therapy (CBT), interpersonal
psychotherapy (IPT), and antidepressant medication (ADM) for MDD, and the effect of
personality change and pre-treatment personality traits on relapse/recurrence. A total of 150
outpatients with the MDD were randomized to receive either CBT, IPT, or ADM. Remitted
patients (n = 92) were assessed on a weekly basis for a maximum of 18 months following
treatment. Findings support absolute change and relative stability of personality facets, indicating
that both components of personality have prognostic significance.
PERSONALITY FACETS AND DEPRESSION iii
Acknowledgments
“Simplicity does not precede complexity, but follows it” - Alan Perlis. In writing my thesis, I
have learned how to embrace this sense of complexity. I wish to thank my supervisors Drs. R.
Michael Bagby and Lena Quilty for giving me the opportunity to carry out this project and for
providing me with invaluable guidance throughout the process. I would like to extend my
gratitude to the members of Personality, Psychopathology, and Psychodiagnostics Laboratory for
their valued assistance and support. I thank my cohort for all that they have taught me, but most
importantly for their enduring confidence in me. I would also like to thank my committee
member, Dr. Zindel Segal for his important contributions to the project’s conceptualization.
Finally, I thank my friends and family for their unyielding support and Crema Coffee for being
the perfect thesis writing environment. This study was supported by an Ontario Mental Health
Foundation (OMHF) grant awarded to Dr. R. Michael Bagby.
PERSONALITY FACETS AND DEPRESSION iv
Table of Contents
Personality and Depression ...........................................................................................................1
Conceptual Overview ...................................................................................................................1
The Five-Factor Model of Personality .........................................................................................3
Major Depressive Disorder ..........................................................................................................4
Relationships between Personality Domains and Major Depressive Disorder ............................5
Absolute vs. Relative Change and the “State-Trait” Issue ........................................................12
Merits of Considering Facets vs. Domains ................................................................................13
Relationships between Personality Facets and Major Depressive Disorder ..............................15
The Present Study.......................................................................................................................19
Method ..........................................................................................................................................21
Overview ....................................................................................................................................21
Participants .................................................................................................................................22
Measures.....................................................................................................................................23
Procedure ....................................................................................................................................25
Treatment of Missing Data ........................................................................................................29
Results ...........................................................................................................................................29
Study Goal 1: Personality Stability and Change across Treatment ...........................................29
Study Goal 2: The Predictive Utility of Personality Change Over 18-Month Follow-up .........32
Study Goal 3: The Predictive Utility of Pre-Treatment Personality Traits Over 18-Month
Follow-up ..................................................................................................................................33
Discussion......................................................................................................................................34
Study Goal 1: Personality Stability and Change across Treatment ............................................35
Study Goal 2: The Predictive Utility of Personality Change Over 18-Month Follow-up..........40
Study Goal 3: The Predictive Utility of Pre-Treatment Personality Traits Over 18-Month
Follow-up ..................................................................................................................................43
Limitations and Strengths...........................................................................................................44
Future Directions ........................................................................................................................45
Conclusions ................................................................................................................................45
References .....................................................................................................................................47
PERSONALITY FACETS AND DEPRESSION v
List of Figures
Figure 1. Paired samples t-tests reflecting differential change in Depression according to
treatment condition ........................................................................................................................69
Figure 2. Paired samples t-tests reflecting differential change in Impulsiveness according to
treatment condition ........................................................................................................................70
Figure 3. Paired samples t-tests reflecting differential change in Angry Hostility according to
treatment condition ........................................................................................................................71
Figure 4. Paired samples t-tests reflecting differential change in Excitement-seeking according to
treatment condition ........................................................................................................................72
Figure 5. Paired samples t-tests reflecting differential change in Trust according to treatment
condition ........................................................................................................................................73
Figure 6. Paired samples t-tests reflecting differential change in Modesty according to treatment
condition ........................................................................................................................................74
Figure 7. Paired samples t-tests reflecting differential change in Values according to treatment
condition ........................................................................................................................................75
PERSONALITY FACETS AND DEPRESSION vi
List of Tables
Table 1. Summary of the personality depression relationship in the literature .............................63
Table 2. Demographic and Clinical Characteristics by Treatment Type and Relapse/Recurrence
Status ..............................................................................................................................................65
Table 3. Descriptives, Reliability Estimates, Correlations, and Difference Scores of Facets at Pre
and Post-Treatment ........................................................................................................................66
Table 4. ANCOVAs Predicting Personality Change across Treatment when Controlling for
Depression Severity .......................................................................................................................68
PERSONALITY FACETS AND DEPRESSION 1
Personality and Depression
Conceptual Overview
In the 19th
century, poet Henry Longfellow noted that “often times we call a man cold
when he is only sad” (Thompson, 1938). In contemporary psychological and psychiatric
research, the terms introverted and depressed have replaced cold and sad, but views about the
personality-depression relationship that have been the subject of literary work for centuries
persist. Personality and psychopathology are similar in that they both, by definition, have a
marked influence on human functioning. They differ in that personality refers to an individual's
“characteristic patterns of cognition, emotion, and behaviour” (Funder, 2007, p. 5), whereas
psychopathology refers to a “clinically significant disturbance in an individual's cognition,
emotion regulation, or behaviour” (American Psychiatric Association [APA], 2013, p. 20).
Although the personality-depression relationship might reflect different conceptual models (e.g.,
Bagby, Quilty, & Ryder, 2008a), efforts to elucidate the role of personality in the development
and symptom expression of depression are of clinical interest, carrying the potential to inform
diagnosis, prognosis, and treatment (Klein, Kotov, & Bufferd, 2011).
Five principal conceptual models have been proposed to characterize the personality-
depression relationship: the vulnerability model, the common-cause model, the pathoplasty
model, the complication/scar model, and the spectrum model (Bagby et al., 2008a; Klein et al.,
2011; Klein, Wonderlich, & Shea, 1993). The vulnerability model posits that personality
predisposes individuals to develop depression. This model is typically supported by findings
demonstrating that personality predicts onset of depression in never-depressed populations. The
common cause model posits that a shared diathesis predisposes individuals to certain personality
traits and to depression. This model is typically supported by evidence suggesting that the same
PERSONALITY FACETS AND DEPRESSION 2
etiological factor is associated with personality traits and with depression. The pathoplasty model
posits that personality influences the expression of depression. This model is typically supported
by evidence demonstrating that personality predicts the course and prognosis of depression.
Whereas vulnerability, common-cause, and pathoplasty models suggest that personality affects
depression, the complication/scar model posits that depression affects personality (with the
complication model suggesting that personality restores to premorbid levels following remission
and the scar model suggesting that depression effects lasting personality change). The
complication/scar model is typically supported by findings demonstrating that personality
changes in conjunction with depression. The spectrum model posits that certain personality traits
reflect a subclinical manifestation of depression. It differs from aforementioned four conceptual
models in that it suggests that personality is qualitatively indistinguishable from depression, with
both constructs differing only in degree (Bagby et al., 2008a; Klein et al., 2011).
The present investigation is based on principals outlined in two conceptual models: the
pathoplasty model and the complication/scar model. Extant literature utilizing prospective
designs has supported the pathoplasty model by demonstrating that personality predicts treatment
outcomes, relapse, and recurrence of depression (e.g., Bagby et al., 2008b, Hees, Koeter, and
Schene, 2013; Ormel, Oldehinkel, & Vollebergh, 2004). As such, these findings suggest that
personality influences the course and prognosis of depression. A body of research also supports
the complication/scar model by demonstrating that personality changes in conjunction with
depression (e.g., Karsten et al., 2012). Given that personality has shown to influence the course
of depression and to change in concomitance with the disorder (e.g., Bagby et al., 2008b, Hees,
et al. 2013, Karsten et al., 2012), personality traits and their changes across treatment may serve
to predict long-term outcomes. As such, the present study investigated: (1) the stability and
PERSONALITY FACETS AND DEPRESSION 3
differential change of personality across various treatments for depression, (2) the effect of
personality change on relapse and recurrence, and (3) the effect of pre-treatment personality on
relapse and recurrence. In light of evidence demonstrating an increased predictive utility of
lower-order personality facets compared to higher-order domains (Paunonen & Ashton, 2001),
this investigation focused on personality at the facet-level.
The introduction will begin with a description of the Five-Factor Model (FFM) of
Personality and of Major Depressive Disorder (MDD). Given that the majority of research in the
area has focused on personality domains as opposed to facets, literature examining the
relationship between personality domains and MDD will first be reviewed. The introduction will
conclude with a review of findings at the facet level-of resolution and a description of the present
investigation.
The Five-Factor Model of Personality
The FFM is a comprehensive classification of universal traits that is currently the most
widely used and accepted dimensional model of personality (McCrae & Costa, 2008). Although
there are various measures of the FFM (e.g., Goldberg, 1999, John & Srivastava, 1999), the
current description focuses on the FFM as conceptualized and operationalized by Costa and
McCrae’s family of NEO Inventories (including the NEO Personality Inventory [NEO-PI], the
Revised NEO Personality Inventory [NEO PI-R], the NEO Five-Factor Inventory [NEO-FFI],
and the NEO Personality Inventory 3 [NEO PI-3]; Costa & McCrae, 1988; Costa &
McCrae,1992, McCrae & Costa, 2005). This class of measures operationalizes personality
dimensions as hierarchical constructs, with broad, higher-order traits (known as domains)
situated at the top of the hierarchy, and narrower, lower-order traits (known as facets) situated at
the bottom (Costa & McCrae, 1992). The five personality domains of the model (as
PERSONALITY FACETS AND DEPRESSION 4
conceptualized using the NEO Inventories) include: neuroticism (characterized by anxiety, angry
hostility, depression, self-consciousness, impulsiveness, and vulnerability), extraversion
(characterized by warmth, gregariousness, assertiveness, activity, excitement-seeking , and
positive emotions), conscientiousness (characterized by competence, order, dutifulness,
achievement striving, self-discipline, and deliberation), agreeableness (characterized by trust,
straightforwardness, altruism, compliance, modesty, and tender-mindedness), and openness
(characterized by fantasy, aesthetics, feelings, actions, ideas, and values; Costa & McCrae,
1992).
Derived from factor analyses of questionnaire items (Costa & McCrae, 1992), the five
domains have been replicated across participants of different ages, languages, and cultural
backgrounds (McCrae & Allik, 2002). Personality traits in the model have been found to be
heritable (e.g., all 5 domains and 26 of 30 facets; Jang, Livesley, Angleitner, Reimann, &
Vernon, 2002) and physiologically-rooted (Canli, 2008; Laceulle, Ormel, Aggen, Neale, &
Kendler, 2013), and have also shown to be present in clinical contexts (Costa, Bagby, Herbst, &
McCrae, 2005). There is not a consensus among FFM instruments regarding the nature of the
facets within each domain, with only certain facets shared across instruments (Costa, McCrae,
1992; Goldberg, 1999).
Major Depressive Disorder
Major depressive disorder is a pressing public health concern, affecting approximately
3.2 million Canadians, and costing the Canadian economy approximately $14.4 billion each year
(Statistics Canada, 2012; Stephens & Joubert, 2001). The Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) defines MDD by either a manifest low mood or a
diminished enjoyment in most activities for a period of at least two weeks, which is accompanied
PERSONALITY FACETS AND DEPRESSION 5
by somatic and cognitive symptoms (APA, 2013). The core features of the disorder have
remained unchanged since the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM IV-TR; APA, 2000). Despite the development of empirically
validated treatments (e.g., cognitive behavioural therapy [CBT]; interpersonal psychotherapy
[IPT]; antidepressant medication [ADM]), up to 80% of remitted patients experience a recurrent
depressive episode within two years (Beshai, Dobson, Bockting, & Quigley, 2011; Dobson et al.,
2008). Efforts to elucidate factors contributing to cycles that maintain the disorder following
treatment are therefore of critical importance.
Relationships between Personality Domains and Major Depressive Disorder
Cross-Sectional Associations
An extensive literature has accumulated examining the association between FFM
personality domains and MDD (see Table 1 for a review of findings). Kotov, Gamez, Schmidt,
and Watson’s (2010) meta-analysis indicated that individuals with the disorder possess
heightened levels of neuroticism and decreased levels of conscientiousness compared to healthy
controls. Because extraversion demonstrated inconsistent associations with MDD across studies,
it was not highly related to the disorder in the context of the meta-analysis. Moreover, results did
not support consistent relationships between MDD status and agreeableness or openness (Kotov
et al., 2010). It is of note that although high neuroticism, low conscientiousness and low
extraversion are common features of many psychological disorders (Kotov et al., 2010), high
neuroticism and low extraversion have been associated with MDD irrespective of comorbid
diagnoses (Spinhoven, Vad Der Does, Ormen, Zitman, & Penninx, 2013). Although such
findings contribute to a preliminary understanding of the personality-MDD relationship, their
cross-sectional designs do not allow for the causal basis of associations to be inferred.
PERSONALITY FACETS AND DEPRESSION 6
The sections that follow review literature that examines the relationship between FFM
personality traits and depression using prospective designs (e.g., least two time points). A
comprehensive approach to the review was taken, despite the fact that much of the relevant
literature is dated. In incidences in which prospective investigations using FFM measures were
not available, relevant investigations conceptualizing FFM domains utilizing other personality
models were reported, with the models included specified.
Personality in the Treatment of Major Depressive Disorder
A general evaluation of the literature supports all five factors as having predictive utility
in the context of treatment for MDD (Bagby et al., 1995; Canuto et al., 2009; Du, Bakish,
Ravindran, & Hrdina; Quilty et al., 2008), though the specific domains related to treatment
responsiveness have shown to vary across studies. One investigation (Blom et al., 2007) did not
support the predictive utility of any of the FFM domains following ADM as well as
psychotherapy in patients with MDD, with only severity of depressive episode, duration of
depressive episode, and use of medical services predictive of treatment outcomes.
Neuroticism
Neuroticism has most consistently been found to predict treatment responsiveness (Bagby
et al., 2008b; Canuto et al., 2009; Quilty et al., 2008). Canuto et al. (2009) investigated the role
of FFM personality traits in predicting response to day hospital treatment (consisting of a
combination of group therapy, individual therapy, ADM, as well as family and network
meetings) in older adults with either MDD or a depressive episode of bipolar disorder.
Neuroticism was the only dimension predictive of treatment outcomes, with this domain
associated with reduced or slower improvement in depressive symptoms over the course
treatment. Quilty et al. (2008) examined the association between FFM personality domains and
PERSONALITY FACETS AND DEPRESSION 7
treatment response following a combined ADM and psychotherapy regimen for MDD. Patients
were randomly assigned to ADM condition, and designated to receive either supportive,
cognitive-behavioural, or psychodynamic interventions. Analyses that accounted for common
variance across personality dimensions indicated that low neuroticism was uniquely predictive of
treatment response. In a related study, Bagby et al. (2008b) examined the role FFM personality
traits in the differential treatment response to either CBT or ADM for MDD. Patients with high
levels of neuroticism showed an improved response to ADM compared to CBT. The authors
suggested that patients with high levels of neuroticism may be too emotionally dysregulated to
effectively engage in CBT; as such, they may be more responsive to ADM because this treatment
targets affective symptoms associated with MDD without relying on the patient’s regulative
capacity (Knutson et al., 1998). Results of this investigation highlight the importance of
considering differential influences of treatment types when examining associations between
personality and treatment response (Bagby et al., 2008b)
Extraversion
Findings supporting the role of extraversion in treatment contexts are mixed. Bagby et al.
(1995) found low extraversion to predict poor responsiveness to ADM after controlling for
baseline depression severity. Although the authors acknowledged that their inferences were
limited by the fact that other treatment conditions were not included in their investigation, they
suggested that their findings in combination with previous research (e.g., Miller, 1991) may
indicate that extraversion reflects a nonspecific predictor of treatment response. Conversely, in
an examination of the relationship between FFM domains and ADM adherence in patients with
MDD, high extraversion predicted reduced treatment compliance (Cohen et al., 2004). The
PERSONALITY FACETS AND DEPRESSION 8
authors opined that patients high in extraversion may be too engaged in other activities to
prioritize their medication.
Conscientiousness
In Quilty et al.’s (2008) aforementioned investigation (examining the association between
FFM personality domains and treatment response following a combined ADM and
psychotherapy regimen for MDD), analyses that accounted for common variance across
personality dimensions indicated that high conscientiousness was uniquely predictive of
treatment response. Additional analyses in both treatment-completer and intent-to-treat samples
indicated that conscientiousness consistently interacted with extraversion in the prediction of
treatment response, with patients high in conscientiousness more likely to respond to treatment
when they were also high in extraversion. The authors suggested that high conscientiousness and
extraversion may reflect a particularly useful combination of characteristics required for
treatment gains, perhaps facilitating the ease with which patients foster a therapeutic relationship,
maintain involvement in therapy sessions, and/or fulfill treatment requirements (Quilty et al.,
2008).
Agreeableness
Du et al. (2002) found agreeableness to be exclusively predictive of response to ADM,
with high agreeableness positively related to treatment outcomes. The authors suggested that
agreeable patients may have a tendency to believe in the possibility of improvement, which may
increase their responsiveness (Du et al., 2002). Others have speculated that agreeableness may
enhance treatment outcomes by improving the therapeutic relationship (Feeley, De Rubeis, &
Gelfand,1999; Klein et al., 2003).
Openness
PERSONALITY FACETS AND DEPRESSION 9
Bagby et al. (2008b) found that patients with high levels of openness showed an
improved response across both CBT and ADM. The authors suggested that openness, reflecting a
need to contemplate experience and a tendency to maintain a flexible position towards novel
ideas (McCrae & Costa, 1997), may interfere with receptivity to treatment (Bagby et al., 2008b).
Summary
Overall, studies examining the predictive value of personality domains in the context of
treatment for MDD support the prognostic utility of FFM domains, though mixed findings
suggest that the relationship may be largely determined by the research design and statistical
analyses employed. Despite divergences in research design and statistical analyses across
investigations, consideration to these features (e.g., type of treatment, recruitment procedures,
and sample size) does not appear to reveal a distinct pattern of domains predictive of treatment
outcomes. Such findings therefore underscore the complex nature of the relationship between
personality and treatment for MDD, suggesting that considering domains in isolation may be
insufficient. It is also of note that whereas all reported studies have utilized prospective designs,
none have included a follow-up phase; as such, little is known regarding the role of personality
on sustained treatment outcomes.
Personality in the Course of Major Depressive Disorder
To our knowledge, one study to date has prospectively examined the relationship
between FFM personality traits and sustained treatment outcomes. Hees et al. (2013) investigated
predictors of symptom remission (defined by a Hamilton Depression Rating Scale Score [HDRS]
< 8) and return to work in patients who have taken time off work due to MDD. Patients
completed either treatment as usual or a combination of treatment as usual and occupational
therapy, and were assessed at 18-month follow-up. None of the FFM personality domains
PERSONALITY FACETS AND DEPRESSION 10
predicted symptom remission following both treatments. Higher levels of conscientiousness,
however, predicted an increased likelihood of follow-up return to work.
A number of investigations have utilized prospective designs in order to examine the
relationship between personality and MDD relapse or recurrence using models other than the
FFM. To this end, treatment studies (Berlanga, Heinze, Torres, Apiquian, & Cabellero, 1999;
Duggan, Lee, & Murray, 1990; Faravelli, Ambonetti, Pallanti, & Pazzagli, 1986; Surtees &
Wainwright, 1996) and longitudinal studies (Ormel et al., 2004) that have operationalized
personality using Eysenck’s Three Factor Model of personality (Eysenck, 1967, 1982) have
indicated that high levels of neuroticism were associated with an increased risk of MDD relapse
or recurrence. Although neuroticism as operationalized by the FFM and by Eysenck’s Three
Factor Model have been found to capture similar constructs, differences between both constructs
have been identified (e.g., impulsivity is captured in FFM neuroticism but not in Three Factor
Model neuroticism; Zuckerman, Kuhlman, Joireman, Teta, & Kraft, 1993). It is of note that the
paucity of FFM research examining the role of personality in the long-term course of MDD may
be explained by the fact that personality has shown to change in conjunction with MDD (e.g.,
Karsten et al., 2012), complicating the explanatory value of personality in the prediction of MDD
at any given time point.
Personality Change in Conjunction with Depression
While findings reviewed up until this point have supported the presumed causal influence
of personality on the expression and course of MDD, evidence also suggests that MDD changes
personality (Klein et al., 2011). Although personality traits were originally described as
remaining stable in adulthood (McCrae & Costa, 1999), they have later shown to be amenable to
gradual change over time (Srivastava, John, Gosling, & Potter, 2003; Roberts, Walton, &
PERSONALITY FACETS AND DEPRESSION 11
Viechtbauer, 2006) and to acute change in the advent of depressive episodes (with effect sizes
for changes generally between 1 and 1.5 standard deviations in magnitude; e.g., Costa et al.,
2005; De Fruyt, van Leeuwen, Bagby, Rolland, & Rouillon, 2006; Santor, Bagby, & Joffe, 1997;
Zinbarg, Uliaszek, and Adler, 2008). Such findings counter the commonly held misconception
that after the age of 30 personality ‘‘has set like plaster and will never soften again’’ (James,
cited in Costa & McCrae, 1994, p. 21).
Personality Change across Time
A number of prospective longitudinal investigations to date have suggested that
neuroticism changes in conjunction with MDD. Karsten et al (2012) examined the effect of
depression and anxiety on FFM personality traits over a two-year time span. Recovery from a
depressive episode was found to predict decreases in neuroticism and onset of a depressive
episode was found to predict increases in neuroticism. In Weber et al.’s (2012) study examining
the stability of personality traits, cognitive processes, and brain volumes in older adults with and
without early-onset MDD across a two-year time period, heightened neuroticism scores observed
in this group at baseline showed to decrease to levels comparable to healthy controls at follow-
up. Chow and Roberts (2014) similarly found depressive symptoms to be prospectively related to
decreases in neuroticism scores in older adults, with levels of life satisfaction and stress found to
partially mediate this relationship.
One prospective longitudinal investigation to date has suggested that FFM domains other
than neuroticism change in concomitance with MDD. In Karsten et al.’s (2012) investigation of
the effect of depression and anxiety on personality traits over a two-year time span, recovery
from depression predicted increases in extraversion and in conscientiousness (with onset of
depression also predicting decreases in these domains). While both depressive and anxiety
PERSONALITY FACETS AND DEPRESSION 12
disorders (corrected for one another) have shown associations with changes in neuroticism,
depressive symptoms demonstrated stronger associations with changes in extraversion and
conscientiousness, compared to anxiety symptoms (Karsten et al., 2012).
Personality Change in Treatment
Treatment studies have consistently indicated that FFM neuroticism decreases and FFM
extraversion increases in response to ADM for MDD (Bagby et al., 1995; Costa et al., 2005; Du
et al., 2002; De Fruyt et al., 2006; Santor et al., 1997; Tang et al., 2009). In addition, changes in
neuroticism and extraversion have been observed following a treatment involving ADM alone,
psychotherapy alone, or a combination of both in patients with depressive disorders (Griens,
Jonker, Spinhoven & Blomb, 2002; Quilty et al., 2008). Whereas most studies have not included
a placebo control group, Tang et al. (2009) found greater personality change associated with
ADM compared to those patients in the placebo condition. Increases in conscientiousness (Costa
et al., 2005; De Fruyt et al., 2006; Quilty et al., 2008) agreeableness (De Fruyt et al., 2006;
Quilty et al., 2008), and openness (Costa et al., 2005; De Fruyt et al., 2006; Quilty et al., 2008)
have also been observed across treatments, however changes in these domains are less consistent
compared to changes in neuroticism and extraversion.
Absolute vs. Relative Change and the “State-Trait” Issue
When interpreting findings relevant to personality change, it is necessary to consider the
distinction between absolute and relative change (De Fruyt et al., 2006; Santor et al., 1997). To
this end, evidence suggests that personality scores change at the mean-level across treatment
(i.e., absolute change), but the rank-order of personality scores are maintained (i.e., relative
stability; De Fruyt et al. 2006). Zinbarg et al., (2008) interpreted absolute changes of personality
as reflecting a component of personality variance that is alterable and interpreted the relative
PERSONALITY FACETS AND DEPRESSION 13
stability of personality as reflecting a component of personality variance that persists throughout
adulthood.
It is also of consideration that many researchers have asserted that personality is
systematically confounded by depressive symptoms and therefore has no meaning when assessed
in the presence of depression (Hirschfeld, Klerman, Clayton, & Keller, 1983; Joffe & Regan,
1988; Liebowitz, Stallone, Dunner, & Fieve, 1979; Wetzler, Kahn, Cahn, Van Praag, & Asnis,
1990). In fact, this “state trait issue” (Costa et al., 2005, p. 46) has been the subject of
contentious debate in the field. Costa et al. (2005) empirically addressed this issue by comparing
trait scores on the NEO PI-R (Costa & McCrae, 1992) when administered to patients prior to and
following 14 to 26 weeks of ADM. Although trait scores showed to change at the mean-level, the
reliability, validity, and factor structure of the NEO PI-R were maintained following successful
ADM. Findings suggested that personality levels assessed during the active phases of MDD
should be regarded as accurate assessments of an individual’s existing condition instead of as
distortions exclusively due to state effects of the disorder. In support of these findings, Quilty et
al. (2008) found that changes in the five FFM domains following a combined ADM and
psychotherapy regimen for MDD were only modestly associated with changes in depressive
symptoms (with effects either small or non-significant), indicating that they reflect changes in
personality rather than proxies to state effects.
Merits of Considering Facets vs. Domains
Given that personality domains have shown to predict onset, treatment responsiveness,
and recurrence of MDD, personality dimensions at pre-treatment as well as personality changes
across treatment may reflect trait vulnerabilities that contribute to the high rates of relapse and
recurrence (Harkness, Bagby, Joffe, & Levitt, 2002). It is important, however, to consider the
PERSONALITY FACETS AND DEPRESSION 14
resolution of personality that is likely to most effectively predict relapse and recurrence. In this
regard, while there are psychometric benefits in examining the association between personality
and MDD at the domain-level (e.g., improved scale reliability; Cronbach & Gleser, 1965), such
investigations are limited in two critical respects: (1) they do not allow for precise explanations
of the personality-MDD relationship to be provided (e.g., Ashton, 1998), and (2) their broad
nature risks masking or tempering the influence of relevant specific personality dimensions (e.g.,
Chmielewski & Watson, 2009; Paunonen & Ashton, 2001; Reynolds & Clark, 2001).
To this end, the improved reliability of broad trait scales does not necessarily indicate
that they demonstrate improved predictive power (Ashton, 1998; Ones & Viswesvaran, 1996;
Paunonen & Ashton, 2001). In particular, although it is commonly believed that the reliability of
a scale places an inflexible limit on its maximum capacity for validity (Anastasi & Urbina,
1997), Ashton et al. (1998) challenged this notion by suggesting that “the question to be asked is
whether or not the improved reliability derived by aggregating the subscales provides a gain in
validity that outweighs the loss in validity due to the dilution of variance specific to certain
subscales which (sic) relate to the criterion of interest” (p. 289).
In accordance with this assertion, several researchers have called for the identification of
facets that may be responsible for relations between personality and psychopathology at the
domain-level (Klein et al., 2011; Kotov et al., 2010; Naragon-Gainey, Watson, & Markon, 2009;
Rector, Bagby, Huta, & Ayearst, 2012; Zinbarg et al., 2008), having also demonstrated the
predictive and explanatory benefits of conducting personality research at the facet-level
(Paunonen, Rothstein, & Jackson; Paunonen & Nicol, 2001; Quilty, Pelletier, DeYoung, &
Bagby, 2013; Reynolds & Clark, 2001). As examples, Weiss and Costa (2005) found that the
relationship between conscientiousness and longevity is primarily due to increases in the self-
PERSONALITY FACETS AND DEPRESSION 15
discipline facet, enhancing our understanding of this domain-outcome relationship. In addition,
positive emotionality was found b primarily responsible for the association between extraversion
and depression (Naragon-Gainey et al., 2009), suggesting that observed inconsistencies in the
relationship between extraversion and MDD (e.g., Kotov et al., 2010) may be due to the fact that
various FFM instruments differentially emphasize the influence of this facet (Naragon-Gainey &
Watson, 2014).
Relationships between Personality Facets and Major Depressive Disorder
Cross-Sectional Associations
Compared to research at the domain-level, few studies have examined the relationship
between FFM facets and MDD. With that said, cross-sectional investigations have indicated that
all neuroticism facets are elevated in patients with a diagnosis of MDD and in remission (Bagby
et al., 1995; Bagby et al., 1996; Bagby et al., 1997; Bienvenu et al., 2004; Chopra et al., 2005;
Harkness et al., 2002; Rector et al., 2012; Hayward, Taylor, Smoski, Steffens, & Payne, 2013;
Hood, Richter, & Bagby, 2002). Such findings are consistent with evidence revealing heightened
levels of this domain in individuals with MDD (e.g., Kotov et al., 2010). Moreover, depression,
anxiety, and angry hostility facets of neuroticism have demonstrated unique associations with
MDD (i.e., associations while controlling for other FFM facets; Chioqueta & Stiles, 2005; Costa
et al., 2005). Importantly, depression is the only facet of neuroticism that has found to overlap in
content with state depression (Uliaszek et al., 2009).
For extraversion facets, decreased levels of positive emotions, assertiveness, and warmth
have been observed in patients with a current and remitted diagnosis of MDD (Bagby et al.,
1995; Bagby et al., 1997; Bienvenu et al., 2004; Chioqueta & Stiles, 2005; Chopra et al., 2005;
Costa et al., 2005; Harkness et al., 2002; Hayward et al., 2013; Rector et al., 2002; Rector et al.,
PERSONALITY FACETS AND DEPRESSION 16
2012). Whereas a majority of facets within conscientiousness, agreeableness and openness have
not been consistently related to MDD, low levels self-discipline (facet of conscientiousness) and
actions (facet of openness) have demonstrated associations with depression across several studies
(Bagby et al., 1995; Bienvenu et al., 2004; Chioqueta & Stiles, 2005; Costa et al., 2005; Rector et
al., 2012; Hayward et al., 2013).
Personality in the Treatment of Major Depressive Disorder
One treatment investigation to date has found a facet of neuroticism to be predictive of
treatment outcomes. In Canuto et al.’s (2009) investigation of the role of FFM personality traits
on response to day hospital treatment in older adults experiencing a major depressive episode,
vulnerability was found to predict decreased treatment responsiveness. This finding may indicate
that a difficulty coping with stress serves as a negative prognostic indictor. With respect to
extraversion, Bagby et al. (1995) found that gregariousness was associated with responsiveness
to ADM, suggesting that “specific alterations in behavior [were] associated with recovery from
depression” (p.231). In terms of agreeableness, Bagby et al. (2008b) found that patients with low
trust, low straightforwardness, and high tendermindedness were more likely to respond to ADM,
compared to CBT. Such findings indicate that patients’ characteristic interpersonal receptivity
may influence the psychotherapy process. Given that agreeableness was not associated with
treatment outcomes, such findings also support Paunonen & Ashton’s (2001) contention that
limiting investigations to the domain level of analysis can mask findings driven by narrowly
acting mechanisms. For openness, Bagby et al. (2008b) found that heightened levels of fantasy,
aesthetics, actions and values predicted increased responsiveness across both CBT and ADM.
Such findings suggest that introspective and flexible dispositions may improve outcomes across
PERSONALITY FACETS AND DEPRESSION 17
treatment types (Bagby et al., 2008b). No treatment investigation to date has found facets of
FFM conscientiousness to predict treatment outcomes.
Personality in the Course of Major Depressive Disorder
One study to date investigated the relationship between FFM facets and depression using
a prospective design. Naragon-Gainey and Watson (2014) examined if personality facets
predicted levels of depression in a community sample over a five-year time span. Facets were
selected from a factor analyses of six facet scales (e.g., the NEO PI-R, Multidimensional
Personality Questionnaire, Sixteen Personality Factor Questionnaire, Six Factor Personality
Questionnaire, Jackson Personality Inventory–Revised, and the Hogan Personality Inventory;
Conn & Rieke, 1994; Costa & McCrae, 1992; Hogan & Hogan, 1995; Jackson,1994; Jackson,
Paunonen, & Tremblay, 2000; Tellegen, in press) in order to broadly capture each FFM domain.
High anger (facet of neuroticism similar to FFM angry hostility), low positive emotionality (facet
of extraversion similar to FFM positive emotions), low conventionality (facet of
conscientiousness similar to dutifulness), and low culture (facet of openness similar to ideas)
predicted depressive symptoms after controlling for baseline levels of depression. Findings
suggest that personality facets at baseline may influence to the prognosis and course of MDD.
Personality Change
Costa et al. (2005) conducted the only investigation to date examining FFM facet-level
changes across treatment for MDD. With regard to neuroticism, patients were found to decrease
in anxiety, depression, self-consciousness, and vulnerability in response to ADM; for
extraversion, patients were found to increase in warmth, assertiveness, and positive emotions in
response to ADM; with respect to conscientiousness, patients were found to increase in
competence, achievement striving and self-discipline in response to ADM; for agreeableness,
PERSONALITY FACETS AND DEPRESSION 18
patients were found to decrease in modesty in response to ADM; no facets of openness were
found to change following response to ADM.
Although many facets that have changed in response to ADM in Costa et al.’s (2005)
investigation were also found to be associated with MDD in cross-sectional investigations (e.g.,
anxiety [facet of neuroticism], depression [facet of neuroticism], self-consciousness [facet of
neuroticism], vulnerability [facet of neuroticism], warmth [facet of extraversion], assertiveness
[facet of extraversion], positive emotions [facet of extraversion], and self-discipline [facet of
conscientiousness]), some facets that have demonstrated consistent associations with the disorder
in cross-sectional investigations were not found to change (e.g., impulsiveness [facet of
neuroticism], angry hostility [facet of neuroticism], actions [facet of extraversion]). Furthermore,
some facets that have not consistently exhibited cross-sectional relations with MDD were found
to change in response to ADM in Costa et al.’s (2005) investigation (e.g., competence [facet of
conscientiousness], achievement striving [facet of conscientiousness], and modesty [facet of
agreeableness]). This suggests that changes in personality facets in conjunction with MDD are
likely due to factors other than state effects.
In light of findings supporting pathoplastic and complication/scar effects at domain- and
facet- levels, it is reasonable to question if personality facets that persist or change following
treatment are implicated in cycles that maintain MDD following treatment. Given evidence
supporting the relative stability of personality across treatment for the disorder (De Fruyt et al.,
2006), pre-treatment personality traits may also predict sustained treatment effects.
PERSONALITY FACETS AND DEPRESSION 19
The Present Study
Study Goal 1
The first goal of the present study is to investigate relative and absolute changes in
personality facets in patients receiving either CBT, IPT, or ADM for MDD. In light of research
supporting the relative stability of personality (e.g., De Fruyt et al., 2006), it is hypothesized that
all facets at pre-treatment will correlate with their respective facets at post-treatment. Given that
mean-level changes in personality have been observed across treatments (e.g., Bagby et al.,
2008b) and personality measured during the active phases of MDD is conceptualized as partially
reflecting trait effects (Costa et al., 2005), it is expected that certain personality facets will
change independent of changes in depression severity. It is also expected that certain personality
facets will differentially change by treatment type, with each therapeutic modality targeting
MDD using different techniques. In this regard, CBT aims to alter dysfunctional cognitions and
behaviours (Greenberger & Padesky, 1995), IPT aims to promote a healthy interpersonal
environment (Weissman, Markowitz, Klerman, 2000), and ADM aims to alter biological
processes associated with MDD (Rothschild, 2012).
Specifically, it is hypothesized that all six facets of neuroticism will decrease across all
treatment types, reflecting change in different components of the neuroticism domain. With
respect to extraversion, it is hypothesized that positive emotions will increase across all treatment
types, reflecting an increased tendency to experience emotions such as joy, happiness, love, and
excitement; it is also hypothesized that activity and excitement-seeking will increase across CBT
and IPT, as these treatments often aim to foster an active lifestyle (Greenberger & Padesky,
1995; Weissman, 2000). For conscientiousness, it is hypothesized that self-discipline will
increase across all treatment types, reflecting an enhanced motivation and capacity to carry out
PERSONALITY FACETS AND DEPRESSION 20
tasks; it is also hypothesized that competence will increase across psychotherapy (both CBT and
IPT), reflecting an improved confidence in one’s capabilities. In terms of agreeableness, it is
hypothesized that modesty will decrease across all treatment types, reflecting an improved sense
of confidence in oneself; it is also hypothesized that trust will increase across psychotherapy,
reflecting an enhanced perception of others’ positive or neutral intentions (resulting from a
positive therapeutic relationship). For openness, it is hypothesized that actions and ideas will
increase across CBT, as this treatment modality may foster a sense of intellectual curiosity and a
willingness to consider novel activities.
Study Goal 2
The second goal of the present study is to examine if changes in personality facets across
treatment predict relapse/recurrence of MDD over an 18-month period following treatment
(above and beyond post-treatment depression severity). Given that high levels of neuroticism
have been found to predict relapse and recurrence of MDD (e.g., Ormel et al., 2004), it is
hypothesized that the absence of (or minimal) decreases of all six of its facets will be associated
with an increased risk of relapse/recurrence. For extraversion, it is hypothesized that increases in
warmth, gregariousness, activity, excitement-seeking, and positive emotions will be associated
with a decreased risk of relapse/recurrence by facilitating interpersonal intimacy and
accessibility to pleasurable experiences. With respect to conscientiousness, it is hypothesized
that increases in competence and achievement striving will be associated with a decreased risk of
relapse/recurrence by promoting a sense of self-efficacy and purpose. In terms of agreeableness,
it is hypothesized that decreases in modesty will be associated with a decreased risk of
relapse/recurrence by promoting an improved confidence in oneself. For openness, it is
PERSONALITY FACETS AND DEPRESSION 21
hypothesized that increases in actions and ideas will be associated with a decreased risk of
relapse/recurrence by promoting an ongoing receptivity to experiential and intellectual learning.
Study Goal 3
The third goal of the present study is to extend findings supporting the predictive utility
of pre-treatment personality dimensions on treatment response for MDD (e.g., Bagby et al.,
2008b, Quilty et al., 2008) by examining the sustained prognostic value of pre-treatment
personality facets over an 18-month period following treatment (above and beyond post-
treatment depression severity). As such, all facets that are expected to predict relapse/recurrence
by way of change across treatment (as described in the second study goal) are hypothesized to
predict relapse/recurrence when assessed at pre-treatment. Specifically, with respect to
neuroticism, is hypothesized that heightened levels of all six facets will increase risk of
relapse/recurrence. For extraversion, it is hypothesized that heightened levels of warmth,
gregariousness, activity, excitement-seeking, and positive emotions will reduce risk of a
relapse/recurrence. In terms of conscientiousness, it is hypothesized that heightened levels of
competence and achievement striving will reduce risk of relapse/recurrence. With respect to
agreeableness, it is hypothesized that heightened levels of modesty will reduce the risk of
relapse/recurrence. For openness, it is hypothesized that increases in actions and ideas will
reduce risk of relapse/recurrence.
Method
Overview
This study consists of two components or phases – a treatment phase and a follow-up
phase. All participants in the follow-up phase required an adequate “dose” treatment resulting in
successful remission for each of the three interventions delivered. As not all participants in the
PERSONALITY FACETS AND DEPRESSION 22
treatment phase received an adequate dose of intervention and not all who did remitted, the
characteristics of the participants are reported separately for the treatment and follow-up phase as
they “flowed” through the study.
Participants
The sample was composed of 150 outpatients (95 [63.3%] women, 55 [36.6%] men) with
a current primary diagnosis of MDD and who had consented to participate in a randomized
controlled trial (RCT) conducted at an university-affiliated, tertiary care addiction and mental
health hospital in a large, predominantly English-speaking metropolis (population = 5.6 million)
in Canada. All participants took part in the trial between July, 2001 and March, 2004. At the
treatment phase of the study, a total of 2460 participants were assessed for eligibility; 2251 were
excluded at this phase of the trial for various reasons – some (n = 1252; 56.6%) were excluded
because they did not meet the eligibility criteria (see study inclusion/exclusion criteria below);
others (n = 534; 23.7%) did not agree to participate following the description of the trial
provided during the consent process; still others (n = 306; 13.6%) fell out of contact with the
study coordinators; and some (n = 159; 7.1%) did not, or otherwise could not participate for
other unspecified reasons. The remaining 209 participants were randomized to receive either
CBT (n = 74), IPT (n = 65), or ADM (n = 70), with 150 (71.8%) participants completing at least
eight weeks of treatment: n = 38 [51.4%]) for CBT; n = 44 [67.7%] for IPT; n = 37 [52.9%] for
ADM.
Of the 150 participants who received at least eight weeks of treatment, 92 (34 [37%, men
and 58 [63%] women) or a total of 61.3% met criteria for a sustained response (i.e., remission)
after treatment and agreed to take part in the follow-up phase of the study. The mean age of the
follow-up sample was 41.45 years (SD = 12.12). The mean years of education was 16.24 (SD =
PERSONALITY FACETS AND DEPRESSION 23
2.42). The mean Blishen Index score (a standard and valid measure of socio-demographic status
for Canada) was 41.21 (SD = 20.78), indicating that the sample is best characterized as “middle
class” by Canadian standards (Blishen, Carroll, & Moore, 1987). The mean number of previous
depressive episodes was 1.81 (SD = 2.70).
Inclusion/Exclusion Criteria
Participants were eligible for study inclusion if they: (1) met DSM-IV diagnostic criteria
for MDD, as determined by the Structured Clinical Interview for DSM-IV, Axis I Disorders –
Patient Version (SCID-I/P; First, Spitzer, Gibbon, & William, 1995), (2) were between 18-60
years of age, (3) had not taken antidepressant medication for at least four weeks, and (4) were
fluent in English, with a minimum of eight years of education. Patients were not eligible for
study inclusion if they: (1) met DSM-IV diagnostic criteria for bipolar disorder (past or current),
psychotic disorders, substance abuse or dependence disorders (over the past six months), or
organic brain syndrome; (2) met DSM-IV criteria for either borderline or antisocial personality
disorder as assessed by the Structured Clinical Interview for DSM–IV-Axis II Personality
Disorders (SCID–II; First, Spitzer, Gibbon, Williams, & Benjamin, 1997); (3) had been
administered electroconvulsive therapy over the past six months; or (4) had an active medical
illness.
Measures
The SCID-I/P (First et al., 1995) is a semi-structured interview that can be used to
diagnose MDD and other psychiatric disorders based on DSM-IV criteria. The SCID-I/P has
demonstrated strong psychometric properties in psychiatric patient samples (including adequate
to good interrater reliability, good retest reliability and adequate convergent and discriminant
PERSONALITY FACETS AND DEPRESSION 24
diagnostic validity; Kranzler, Kadden, Babor, Tennen, Rounsaville, 1996; Zanarini &
Frankenburg, 2001).
The SCID-II (First et al., 1997) is designed to assess systemically for the 10 personality
disorder in the DSM-IV. The SCID-II has demonstrated adequate to good psychometric
properties in psychiatric patient samples (including adequate convergent validity and good retest
reliability; Maffei et al., 1997; Skodol, Rosnick, Kellman, Oldham, 1988).
The Beck Depression Inventory - Second Edition (BDI-II; Beck, Steer, & Brown, 1996) is
a 21-item self-report measure of depression severity. The items on this instrument are rated on a
4-point scale ranging from 0 to 3, with some items comprising of differently worded “anchors.”
The total score is the sum of item ratings and yielding scores ranging from 0 to 63 (0-13
reflecting “normal” mood; 14-20 reflecting mild depression; 21-30 reflecting moderate
depression; 30-63 reflecting severe depression). The BDI–II has strong psychometric properties
(including excellent internal consistency, test-retest reliability, construct, convergent, and
discriminant validity) in undergraduate student, community, and psychiatric patient samples
(Beck et al., 1996; Whisman, Perez, & Ramel, 2000; Wang & Gorenstein, 2013).
The 17-item HRSD (Hamilton, 1967) is an interview-rated measure of depression
severity. This HRSD is the most commonly and frequently used measure of depression in
clinical trials (Bagby, Ryder, Schuller, & Marshall, 2004). This 17-item semi-structured
interview is rated on a 3- or 5-point scale (depending on the item).The total score is the sum of
item ratings, yielding scores ranging from 0 to 52 (0-7 reflecting normal mood; 8-16 reflecting
mild depression; 17-23 reflecting moderate depression; 24-52 reflecting severe depression;
Zimmerman, Martinez, Young, Chelminski, & Dalrymple, 2013). The HRSD has demonstrated
strong psychometric properties (including good internal consistency, retest reliability, content
PERSONALITY FACETS AND DEPRESSION 25
validity, convergent validity, and discriminant validity) in undergraduate, community, and
psychiatric patient samples (Bagby et al., 2004; López-Pina, Sánchez-Meca, & Rosa-Alcázar,
2009).
Personality
The revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992) was used to
assess the personality facets in the FFM. It is the most widely and frequently used instrument to
assess the FFM. Each item on this 240-item self-report measure (8 items for each of the 30
facets) are rated on a 5-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). The
total facet score is the sum of item ratings, yielding raw scores ranging from 0 to 32.The NEO
PI-R has demonstrated strong psychometric properties, including good-to-excellent internal
consistencies, retest reliability, content, convergent, and discriminant validity among
undergraduate, community, and clinical samples (Costa & McCrae, 1992; Costa et al., 2005; De
Fruyt et al., 2006). In the current sample, coefficient alphas for facets ranged from .54
(dutifulness) to .86 (straightforwardness) at pre-treatment and .51 (dutifulness) to .83
(straightforwardness) at post-treatment; the mean inter-item correlations (MICs) ranged from .13
(post-treatment dutifulness and actions) to .36 (pre-treatment aesthetics and post-treatment
anxiety; see Table 3).
Procedure
Participant Recruitment
Participants were primarily recruited through advertisements in local newspapers.
Information about the treatment study was also disseminated to community mental health
professionals and general practitioners, who were asked to convey information about the
treatment study to their patients. The recruitment process was coordinated via a clinical research
PERSONALITY FACETS AND DEPRESSION 26
laboratory at the hospital. Participants who contacted the laboratory were informed of the study
protocol (including randomization into treatment conditions and the duration of treatment) and
were administered a preliminary telephone interview to assess for eligibility criteria. Those who
passed the initial screening were asked to attend an in-person screening appointment, where they
were administered the SCID–I/P and the SCID–II. Doctoral students in clinical psychology
administered the SCID–I/P under the supervision of a licensed clinical psychologist, and were
trained to obtain “gold-standard” reliability status concerning diagnoses. Following this, a team
meeting involving the doctoral student who administered the interviews and two licensed
psychologists took place to determine eligibility (consensus between the two psychologists was
required for study entry).
Treatment Phase
Participants who were eligible and who provided written consent were then randomly
assigned to receive 16 weeks of CBT, IPT, or ADM. No significant differences were found
between patients in each treatment condition at pre-treatment for the sample’s demographic and
clinical characteristics (all ps > .19; see Table 2). For patients assigned to a psychotherapy
condition, treatment was extended to a maximum of 20 sessions if patients did not respond by
the 16th
week. Patients in each treatment condition who were retained in the present study did not
significantly differ in the amount of weeks for which they remained in treatment (for CBT: M =
15.75, SD = 3.35; for IPT: M = 16.48; SD = 2.45; for ADM: M = 15.82, SD = 1.21). The BDI-II,
the HRSD, and the NEO PI-R were administered at intake and within one week of the final
treatment consultation.
Cognitive-behavioural therapy was based on Greenberger and Padesky’s (1995)
PERSONALITY FACETS AND DEPRESSION 27
manual, IPT was based on Weissman et al.’s (2000) manual, and ADM was based on the
Canadian Network for Mood and Anxiety Treatment guidelines (Kennedy & Lam, 2001). The
medication provided consisted of one or more of several medications and dosages – bupropion
(100–450 mg), citalopram (20–300 mg), fluoxetine (20–60 mg), paroxetine (20–40 mg),
phenelizine (60–90 mg), venlafaxine (37.5–150 mg), or sertraline (50–200 mg). Patients in the
ADM condition consulted with a psychiatrist every two weeks, who monitored their symptoms
and adjusted medication as needed.
All therapists administering CBT and IPT were found to be adherent to their respective
treatment protocols, as assessed by a Ph.D.-level psychologist who used the Study
Psychotherapy Rating Scale (Hollon et al., 1988) to evaluate treatment fidelity in each session. In
the CBT condition, 8 different therapists administered treatment (1 Ph.D.-level clinical
psychologist and 7 graduate trainees in clinical psychology), in the IPT condition, 11 different
therapists administered treatment (3 medical doctors, 2 social workers, 3 graduate trainees in
clinical psychology, and 3 graduate trainees in disciplines other than clinical psychology), and in
the ADM condition, 4 different psychiatrists managed medication (all with experience treating
patients with MDD). Within the CBT condition, post-treatment BDI-II scores did not
significantly differ by treatment provider after controlling for pre-treatment BDI-II scores.
Within the IPT and ADM conditions, however, post-treatment BDI-II scores significantly
differed by treatment provider after controlling for pre-treatment BDI-II scores [for IPT: F(10,
42) = 2.31, p = .03, partial η2 = .35; for ADM: F(3, 39) = 12.55, p < .01, partial η
2 = .49]. Such
findings are likely accounted for by high discrepancies in the number of patients that each health
care practitioner treated. For IPT, 1 therapist treated 26 patients, 1 therapist treated 11 patients, 3
therapists treated 3 patients, 2 therapists treated 2 patients, and 4 therapists treated 1 patient. For
PERSONALITY FACETS AND DEPRESSION 28
ADM, 1 psychiatrist treated 26 patients, 1 psychiatrist treated 14 patients, 1 psychiatrist treated 3
patients, and 1 psychiatrist treated 1 patient.
Follow-up Phase
Patients who exhibited a sustained response to treatment were recruited to participate in
the follow-up phase of the study. Based on current standards (e.g., Frank et al., 1991; Rush et al.,
2006), treatment response was considered to occur when (1) patients experienced ≥ 50%
reduction in HRSD scores from pre- to post- treatment, (2) patients’ post-treatment HRSD scores
were < 8, and (3) patients’ post-treatment HRSD scores < 8 were maintained for ≥ 3 weeks.
The follow-up phase did not include any further psychotherapy, although patients in the
ADM condition were free to continue their medication regimen if they chose to do so. The 92
patients who agreed to take part in this phase were administered the HRSD on a weekly basis via
telephone for a maximum of 72 weeks following the treatment phase. If HRSD scores were
indicative of a relapse (i.e., a score > 8 occurring during the 4 month period from the start of the
follow-up phase) or a recurrence (i.e., a score > 8 occurring 4 months after the start of the
follow-up phase), patients discontinued study participation. A total of 21 patients experienced a
relapse/recurrence over the follow up phase. The mean time to relapse/recurrence for patients in
was 56.53 weeks (SD = 14.31), with a minimum number of weeks to relapse/recurrence of 5 and
a maximum number of weeks to relapse/recurrence of 62. In Table 2 the demographic and
clinical descriptives are displayed separately for the group of patients who experienced a
relapse/recurrence and the group of patients who did not. No significant differences for any pre-
treatment demographic or clinical characteristics were found between patients who experienced a
relapse/recurrence and patients who did not (all ps > .07).
PERSONALITY FACETS AND DEPRESSION 29
Treatment of Missing Data
In the treatment phase sample, a total of 5.55% of observations were missing, with
31/150 (20.67%) patients who completed at least eight weeks of treatment containing missing
observations. Eight weeks was selected (DeRubeis et al., 2005) as this is consistent with previous
investigations of the role of personality in treatment outcomes for MDD (Vittengl, Clark, Thase,
& Jarrett, 2013). Missing HRSD data in the follow-up period was expected in all patients
following a relapse/recurrence. No observations were missing from pre-treatment BDI-II scores,
2.67% of observations were missing from pre-treatment NEO PI-R scores, .67% of observations
were missing from post-treatment BDI-II scores, and 18.0% of observations were missing from
post-treatment NEO-PI-R scores. The data was not found to be missing completely at random
[χ²(9) = 21.00, p = .03]. Because excluding patients with missing values would therefore likely
bias results and reduce statistical power, a multiple imputation procedure was used when
analyzing treatment phase data. In accordance with imputation guidelines (e.g., Schafer &
Graham, 2002), 10 datasets were imputed via the automatic method using IBM SPSS Statistics
version 20 software (IBM SPSS, 2013).
Results
Study Goal 1: Personality Stability and Change across Treatment
To address the first study goal, correlations between facets at pre- and post- treatment
across treatment conditions were calculated. All facets at pre-treatment were significantly
correlated with their respective facet at post-treatment (see Table 3 for means, standard
deviations, reliability estimates, correlations, and difference scores of facets at pre- and post-
treatment). Repeated measures analyses of covariance (ANCOVAs) were conducted separately
for each personality facet controlling for BDI-II pre-treatment scores. Personality facets served
PERSONALITY FACETS AND DEPRESSION 30
as the dependent variable, and treatment condition served as the independent variable. These
analyses computed a main effect of time (indicating whether the facet changed over the course of
treatment beyond changes in depression) and an interaction with treatment group (indicating
whether changes in the facet differed across treatment condition).
Results for ANCOVAs are presented in Table 4. As outlined by Field (2013) and Pallant
(2007), large effects were defined by a partial η2 ≥ .14, medium effects were defined by a partial
η2 ≥ .06 and < .14, and small effects were defined by a partial η2 < .06. For neuroticism, main
effects were large for decreases in Angry Hostility [F (1, 147) = 49.67, p < .01, partial η2
= .25]
and Vulnerability [F (1, 147) = 54.54, p < .01, partial η2 = .27], main effects were medium for
decreases in Impulsiveness [F (1, 147) = 14.08, p < .01, partial η2
= .09], and main effects were
small for decreases in Depression [F (1, 147) = 5.53 , p = .02, partial η2
= 04] and Self-
consciousness [F (1, 147) = 7.09, p < .01, partial η2
= 05]. Two medium effects were observed
for time x treatment type interactions [Depression: F = 4.35(2, 147), p = .02, partial η2 = .06;
Impulsiveness: F (2, 147) = 5.00, p < .01, partial η2
= .06], and one small effect was observed for
a time x treatment type interaction [Angry Hostility: F = 3.26 (2, 147), p = .04, partial η2 = .04].
Independent samples t-tests were conducted to delineate significant facet x treatment type
interactions. All follow-up t-tests were conducted without controlling for depression severity in
order to preserve the ecological validity of personality constructs. Patients receiving ADM
demonstrated greater decreases in Impulsiveness compared to patients receiving CBT or IPT (t =
2.16, p = .03, d = .42). No significant between group differences were observed for Depression
or Angry Hostility. As exhibited in Figures 1, 2, and 3, paired samples t-tests indicated that
Depression significantly decreased in patients receiving CBT (t = 4.65, p < .01, d = .66), IPT (t =
5.78, p < .01, d = .93), and ADM (t = 4.83, p < .01, d = .79), Impulsiveness significantly
PERSONALITY FACETS AND DEPRESSION 31
decreased in patients receiving ADM (t = 3.33, p < .01, d = .27), and Angry Hostility
significantly decreased in patients receiving CBT (t = 2.98, p < .01, d = .35) and IPT (t = 2.53, p
= .02, d = .33).
For extraversion, main effects were large for increases in Gregariousness [F (1, 147) =
53.85, p < .01, partial η2 = .27], Assertiveness [F (1, 147) = 92.23, p < .01, partial η
2 = .39],
Activity [F (1, 147) = 66.03, p < .01, partial η2 = .31], Excitement-seeking [F (1, 147) = 5.34, p <
.01, partial η2 = .26], and Positive Emotions [F (1, 147) = 49.74, p < .01, partial η
2 = .25]. One
small effect was observed for a time x treatment type interaction [Excitement-seeking: F = 3.21
(2, 147), p = .04, partial η2 = .04]. Independent samples t-tests indicated that patients receiving
IPT demonstrated greater increases in Excitement-seeking compared to patients receiving ADM
(t = 2.04, p = .04, d = .28). As exhibited in Figure 4, paired samples t-tests indicated that
Excitement-seeking significantly decreased in patients receiving IPT (t = 2.41, p = .02, d = .25).
For conscientiousness, main effects were large for increases in Order [F (1, 147) = 47.61,
p < .01, partial η2 = .25], Achievement Striving [F (1, 147) = 46.98, p < .01, partial η
2 = .24],
Self-discipline [F (1, 147) = 61.87, p < .01, partial η2 = .30], and Deliberation [F (1, 147) =
32.73, p < .01, partial η2 = .18]. The main effect was medium for increases in Competence [F (1,
147) = 9.35, p < .01, partial η2 = .06].
For agreeableness, main effects were medium for increases in Trust [F (1, 147) = 12.49, p
< .01, partial η2 = .08] and Compliance [F (1, 147) = 16.29, p < .01, partial η
2 = .10], and main
effects were small for increases in Altruism [F (1, 147) = 4.68, p = .03, partial η2 = .03]. Two
small effects were observed for time x treatment type interactions [Trust: F = 3.19 (2, 147), p =
.04, partial η2 = .04; Modesty: F = 4.10 (2, 147), p = .02, partial η
2 = .05]. Independent samples t-
tests were conducted to delineate significant time x treatment type interactions. No significant
PERSONALITY FACETS AND DEPRESSION 32
between group differences were observed for Trust or Modesty. As exhibited in Figures 5 and 6,
paired samples t-tests indicated that Trust significantly increased in patients receiving CBT (t =
3.22, p < .01, d = .32) and IPT (t = 3.07, p < .01, d = .28; see Figure 5) and Modesty significantly
increased in patients receiving CBT (t = 2.43, p = .02, d = .24).
For openness, main effects were large for increases in Actions [F (1, 147) = 35.08, p <
.01, partial η2 = .19], main effects were medium for increases in Values [F (1, 147) = 1.21, p <
.01, partial η2 = .07], and main effects were small for increases in Fantasy [F (1, 147) = 7.32, p <
.01, partial η2 = .05] and Aesthetics [F (1, 147) = 5.30, p < .01, partial η
2 = .04]. A small effect
was observed for time x treatment type interaction [Values: F = 3.91 (2, 147), p = .02, partial η2
= .05]. Independent samples t-tests were conducted to delineate the significant facet x treatment
type interactions. No significant between group differences were observed for Values. As
exhibited in Figure 7, paired samples t-tests indicated that Values significantly increased in
patients receiving CBT (t = 2.01, p = .05, d = .25).
Study Goal 2: The Predictive Utility of Personality Change Over 18-Month Follow-up
There were no differences in relapse/recurrence rates across CBT [n = 4/28, 14.29%), IPT
(n = 11/34, 32.35%), or ADM (n = 6/30, 20.00%; χ² (2) = 3.05, p = .22]. Because such rates did
not significantly differ by treatment condition, study goal 2 was tested by conducting Cox
regression survival analyses predicting time to relapse/recurrence from residualized change facet
scores, with analyses collapsed across treatment conditions. Residualized change scores were
utilized as they describe the direction and magnitude of change while ensuring that changes are
not accounted for by heightened baseline values (Robins, Fraley, & Krueger, 2009). After
controlling for BDI-II scores, three models were significant. The first [χ² (1, N = 80) = 4.12, p =
.05] pertained to gregariousness (facet of extraversion), with the estimate for the hazard ratio
PERSONALITY FACETS AND DEPRESSION 33
indicating that patients who demonstrated increases in Gregariousness were .61 times less at risk
of experiencing a relapse/recurrence than those who did not (95% CI [.37, 1.00]). The second [χ²
(1, N = 80) = 8.85, p < .01] pertained to Dutifulness (facet of conscientiousness), with the
estimate for the hazard ratio indicating that patients who demonstrated increases in Dutifulness
were 1.74 times more at risk of experiencing a relapse/recurrence than those who did not (95%
CI [1.22, 2.49]). The third [χ² (1, N = 80) = 3.94, p = .05] pertained to Fantasy (facet of
openness), with the estimate for the hazard ratio indicating that patients who demonstrated
increases in Fantasy were .67 times less at risk of experiencing a relapse/recurrence than those
who did not (95% CI [.45, .99]). Such effects are considered to be small in magnitude by current
standards (Chen, Cohen, & Chen, 2010).
Study Goal 3: The Predictive Utility of Pre-Treatment Personality Traits Over 18-Month
Follow-up
Study goal 3 was tested by conducting Cox regression survival analyses predicting time
to relapse/recurrence from pre-treatment facet scores, with analyses collapsed across treatment
conditions. After controlling for BDI-II scores, two models were significant. The first [χ² (1, N =
92) = 4.46, p = .04] pertained to Straightforwardness (facet of agreeableness), with the estimate
for the hazard ratio indicating that patients with heightened levels of Straightforwardness were
1.12 times more at risk of experiencing a relapse/recurrence than those without (95% CI [1.01,
1.25]). The second [χ² (1, N = 92) = 6.89, p < .01] pertained to Aesthetics (facet of openness),
with the estimate for the hazard ratio indicating that patients with heightened levels of Aesthetics
were 1.11 times more at risk of experiencing a relapse/recurrence than those without (95% CI
[1.02, 1.21]). Such effects are considered to be small in magnitude by current standards (Chen et
al., 2010).
PERSONALITY FACETS AND DEPRESSION 34
Discussion
Summary of Findings
The present study investigated (1) absolute and relative stability of FFM personality traits
across three treatments for MDD (CBT, IPT, and ADM), (2) the effect of personality changes on
relapse/recurrence following treatment, (3) and the effect of pre-treatment personality traits on
relapse/recurrence following treatment. Findings indicated that all pre-treatment facets correlated
with their respective facets at post-treatment. Personality facets spanning the five domains were
also found to change across treatment independent of depression severity, with certain facets
found to change differentially by treatment type. Specifically, five neuroticism facets decreased
(angry hostility, depression, self-consciousness, impulsiveness and vulnerability), five
extraversion facets increased (gregariousness, assertiveness, activity, excitement-seeking, and
positive emotions), five conscientiousness facets increased (competence, order, achievement
striving, self-discipline, and deliberation), three agreeableness facets increased (trust, altruism,
and compliance), and four openness facets increased (fantasy, aesthetics, actions, and values)
across all treatments. In addition, three neuroticism facets (angry hostility, depression, and
impulsiveness), one extraversion facet (excitement-seeking), two agreeableness facets (trust and
modesty) and one openness facet (values) differentially changed by treatment type. Personality
changes and pre-treatment personality traits were also found to predict risk of relapse/recurrence
after controlling for the influence of post-treatment depression severity. Specifically, increases in
gregariousness and fantasy were associated with an increased risk for relapse/recurrence, and
increases in dutifulness were associated with a reduced risk for relapse/recurrence. Further,
heightened levels of pre-treatment straightforwardness and aesthetics were associated with an
increased risk of relapse/recurrence. Findings support the relative stability as well as absolute
PERSONALITY FACETS AND DEPRESSION 35
change of personality across treatments, indicating that both components of personality have
pathoplastic effects.
Study Goal 1: Personality Stability and Change across Treatment
Relative-Stability Across Treatments
It was hypothesized that all facets at pre-treatment would correlate with their respective
facets at post-treatment. This hypothesis was supported, validating the relative stability of
personality across treatments for MDD (e.g., De Fruyt et al. 2006). Given that treatment contexts
have been described as reflecting circumstances most likely to yield personality change
(Piedmont, 1998), such findings support views suggesting that a component of personality
variance remains stable over time (Zinbarg et al., 2008).
Absolute Change Across Treatments
Neuroticism
It was hypothesized that all six facets of neuroticism would decrease across treatments.
This hypothesis was largely supported, with five of the six neuroticism facets decreasing
significantly across treatments (large effects found for decreases in angry hostility and
vulnerability, medium effects found for decreases in impulsiveness, and small effects found for
decreases in depression). Findings are generally in line with research indicating that neuroticism
changes in conjunction with MDD (e.g., Karsten et al., 2012; Bagby et al., 1995; Costa et al.,
2005; Du et al., 2002; De Fruyt et al., 2006; Quity et a., 2008; Santor et al., 1997; Tang et al.,
2009; Weber et al., 2012), but differ from Costa et al.’s (2005) investigation which found facet
anxiety to decrease following successful ADM. Treating MDD appears to improve a number of
specific features of neuroticism, with facet anxiety possibly more resistant to change without
direct targeting in treatment. It is also possible that anxiety did not show to change across
PERSONALITY FACETS AND DEPRESSION 36
treatment because of minimal variance of this facet at pre-treatment (in light of high levels of co-
occurrence between anxiety and depression; e.g., Barlow, Allen, Choate, 2004). In this regard,
the mean T-score (M = 62.39, SD = 9.99) of this facet in the present investigation was higher
than that observed in the normative sample (by definition, M = 50, SD = 10), but comparable to
mean neuroticism T-scores in psychiatric patient samples (e.g., M = 65.87; SD =14.72; Bagby et
al., 1999).
In addition, impulsiveness, angry hostility, and depression were found to differentially
change by treatment type (effects were medium for impulsiveness and depression and small for
angry hostility). Specifically, patients receiving ADM demonstrated greater decreases in
impulsiveness compared to patients receiving CBT or IPT. This finding is in line with research
indicating that ADM directly targets neurobiological mechanisms associated with impulsiveness
(Prado-Lima, 2009), but differ from Costa et al. (2005) who did not find impulsiveness to change
across ADM. This discrepancy may be due to the fact that medications differed across study
designs, with some medications administered in the present study not administered in Costa’s et
al.’s (2005) investigation (e.g., Citalopram), and vice versa (e.g., Desipramine, Moclobemide,
and Nefazodone).
Angry hostility was found to significantly decrease in patients receiving CBT and IPT,
but not in patients receiving ADM. This finding is consistent with Costa et al. (2005), who did
not find angry hostility to change across ADM. It may be that psychotherapy skill development
has the capacity to impact neuroticism facets. Specifically, CBT may challenge cognitive
distortions underlying anger (e.g., perceptions of injustice; Greenberger & Padesky, 1995) and
IPT may promote tempered and effective communication skills (Weissman et al., 2000). It is of
note that facet depression was found to significantly decrease following all three treatment types.
PERSONALITY FACETS AND DEPRESSION 37
This finding, however, was observed when marginal means (controlling for depression severity)
were taken into account. In light of research demonstrating content overlap between state and
facet depression (e.g., Uliaszek et al., 2009), this finding may reflect a statistical artifact due to
the inclusion of state depression as a covariate in analyses.
Extraversion
It was hypothesized that positive emotions would increase across all treatment types, and
activity and excitement-seeking would increase across CBT. This hypothesis was partially
supported. Gregariousness, assertiveness, activity, excitement-seeking, and positive emotions
increased across all treatment types (effects were large for all facets). These findings are
generally consistent with research indicating that extraversion changes in conjunction with MDD
(e.g., Karsten et al., 2012; Bagby et al., 1995; Costa et al., 2005; Du et al., 2002; De Fruyt et al.,
2006; Quity et a., 2008; Santor et al., 1997; Tang et al., 2009). It is possible that treating MDD
may indirectly serve to increase dispositional features of sociability and sensation seeking, in
addition to positive emotions. Further, excitement-seeking showed to differentially change by
treatment type (effect was small), with patients receiving IPT demonstrating greater increases in
excitement-seeking compared to patients receiving ADM. Although in need of further
exploration, patients treated with IPT may gain an enhanced sense of social activation by
increasing their satisfaction from interpersonal exchanges.
Conscientiousness
It was hypothesized that self-discipline would increase across all treatment types, and
competence would increase across both CBT and IPT. This hypothesis was partially supported.
Competence, order, achievement striving, self-discipline, and deliberation increased across all
treatment types (effect sizes were large for order, achievement striving, self-discipline, and
PERSONALITY FACETS AND DEPRESSION 38
deliberation and medium for competence). Findings are generally in line with research indicating
that conscientiousness changes in conjunction with MDD (Costa et al., 2005; De Fruyt et al.,
2006; Karsten et al., 2012, Quilty et al., 2008). One explanation for this finding is that treating
MDD may have the effect of increasing a dispositional capacity to carry out tasks and to actively
control impulses.
Agreeableness
It was hypothesized that modesty would decrease across all treatment types, and trust
would increase across CBT and IPT. This hypothesis was largely supported. Modesty showed to
differentially change by treatment type (effect was small), with this facet significantly decreasing
in patients receiving CBT, but not in patients receiving IPT or ADM. Findings counter Costa et
al. (2005), who found modesty to decrease across ADM. Given that NEO PI-R modesty items
appear to reflect low self-esteem (“I have a very high opinion of myself”, reverse scored), it may
be that CBT techniques (e.g., cognitive restructuring and behavioural experiments) serve to
promote a balanced opinion of the self (Greenberger & Padesky, 1995).
In addition, trust, altruism, and compliance decreased across all treatment types (effects
were medium for trust and compliance and small for altruism). Findings are generally in line
with research indicating that agreeableness increases across treatment for MDD (De Fruyt et al.,
2006; Quilty et al., 2008). Treating MDD may have the effect of enhancing a tendency to
cooperate and empathize with others. As hypothesized, trust also significantly increased in
patients receiving CBT and IPT, but not in patients receiving ADM. Although further
exploration is needed, findings may support perspectives suggesting that aspects of the
therapeutic relationship operate to repair primary attachment styles (Bowlby, 1977; Daniel,
2006).
PERSONALITY FACETS AND DEPRESSION 39
Openness
It was hypothesized that ideas would increase across CBT. This hypothesis was not
supported. Instead, fantasy, aesthetics, actions, and values increased across all treatment types
(effects were large for actions, medium for values, and small for fantasy and aesthetics).
Findings are generally in line with research indicating that openness increases across treatment
for MDD (Costa et al., 2005; De Fruyt et al., 2006; Quilty et al., 2008). Treating MDD may have
the effect of promoting a dispositional flexibility towards activities, beliefs, and emotions, rather
than promoting an intellectual curiosity. It is of note that previous research has found that
patients in RCTs exhibit heightened pre-treatment levels of actions compared to patients
receiving treatment in clinics (Kushner, Quilty, McBride, & Bagby, 2009). In light of such
discrepancies, further research is needed supporting the generalizability of findings concerning
this facet to clinical settings.
In addition, values showed to differentially change by treatment type (effect was small),
with this trait significantly increasing in patients receiving CBT, but not in patients receiving IPT
or ADM. One explanation for this is that CBT may serve to promote an open-minded attitude
towards social, political, and religious beliefs by targeting “black and white” thinking styles
(Greenberger & Padesky, 1995).
Additional Considerations
It is of note that depression severity was not controlled for in our descriptive account of
raw difference scores and in analyses conducted to follow up on significant time x treatment type
interactions. As such, the directionality of change observed in raw-difference scores differed
from that observed in ANCOVAs for certain facets (e.g., for order, deliberation, and fantasy).
PERSONALITY FACETS AND DEPRESSION 40
It was decided, however, to conduct follow-up t-tests using raw difference scores instead of
using marginal mean difference scores in order to preserve the unconfounded nature of
personality constructs (for enhanced utility of findings beyond the present investigation). In
addition, follow-up t-tests for significant time x treatment type interactions did not demonstrate
significant differences in personality change between treatment groups for all facets (e.g.,
significant between treatment group differences were not found for angry hostility, trust,
modesty, or values). With that said, within treatment group t-tests served to explain significant
time x treatment type interactions for all facets, with the exception of facet depression.
Discrepancies between follow-up t-tests and ANCOVAs may be accounted for by a reduction of
power in t-tests (e.g., Borm, Fransen, Lemmens, & 2007) in addition to the discrepant influence
of depression severity.
Taken together, findings addressing the first study goal support both the stability and
differential change of personality facets across treatment, possibly suggesting that treating MDD
serves to alter patients’ personalities within the confines of a limited range (e.g., Piedmont,
1998). As such, findings suggest that a patient who enters treatment for MDD with low levels of
gregariousness is likely to experience increases in their levels of gregariousness following
treatment (in support of absolute change). However, this patient is likely to exhibit lower levels
of gregariousness following treatment compared to a patient who entered treatment with higher
levels of gregariousness (in support of relative stability).
Study Goal 2: The Predictive Utility of Personality Change Over 18-Month Follow-up
It was hypothesized that changes in personality facets across treatment would predict
relapse/recurrence in the 18-month follow-up phase. Specifically, the absence of (or minimal)
decreases of all six neuroticism facets were expected to predict an increased risk of
PERSONALITY FACETS AND DEPRESSION 41
relapse/recurrence, increases in five extraversion facets (warmth, gregariousness, activity,
excitement-seeking, and positive emotions) were expected predict a decreased risk of
relapse/recurrence, increases in two conscientiousness facets (competence and achievement
striving) were expected predict a decreased risk of relapse/recurrence, decreases in one
agreeableness facet (modesty) was expected to predict a decreased risk of relapse/recurrence, and
increases in two openness facets (actions and ideas) were expected to predict a decreased risk
relapse/recurrence. Hypotheses were minimally supported, with changes in a total of three facets
found to predict risk of relapse/recurrence above and beyond depression severity (effects were
small for all relationships): gregariousness, dutifulness, and fantasy.
Specifically, patients who increased in gregariousness across treatment were found to
have a reduced risk of experiencing a relapse/recurrence in the follow-up phase. Gregariousness
reflects a tendency to enjoy spending time with others and to actively pursue social stimulation
(Costa & McCrae, 1992). This finding therefore supports and extends Bagby et al.’s (1995)
results by suggesting that depressed patients who successfully develop an appreciation for the
company of others over the course of treatment are likely to experience prolonged treatment
effects. This finding also appears to be line with research demonstrating the protective influence
of social support in individuals with MDD (Lin, Dean, & Ensel, 2013).
Patients who increased in dutifulness across treatment were found to have a reduced risk
of experiencing a relapse/recurrence in the follow-up phase. Dutifulness reflects a strict and
careful adherence to one’s obligations and principals (Costa & McCrae, 1992). As such, it may
approximate perfectionism, which involves a rigid, relentless, and counter-productive form of
over-striving (Hewitt, & Flett, 1991). This finding appears to therefore be consistent with a body
of literature indicating that perfectionism serves as a negative short- and long-term prognostic
PERSONALITY FACETS AND DEPRESSION 42
indicator for patients receiving treatment for MDD (e.g., Blatt, Zuroff, Hawley, Auerbach, 2010;
Enns, Cox, & Pidlubny, 2002).
Patients who increased in fantasy across treatment were found to have a reduced risk of
experiencing a relapse/recurrence in the follow-up phase. Individuals high on fantasy tend to
enjoy imagining and to have a rich inner world (Costa & McCrae, 1992). As such, it appears to
approximate self-reflection, which is a form of self-focussed attention that is driven by an
epistemic curiosity in the self (Takano & Tanno, 2009). Self-reflection has been found to have
both adaptive and maladaptive effects on psychological functioning. In the absence of negative
emotions, it is commonly associated increases in self-awareness, problem solving, and the
promotion of psychological functioning. In the context of depression, however, it has been
associated with self-rumination and negative outcomes (see Watkins, 2008 for a review). As
such, it is particularly noteworthy that depression severity at post-treatment was controlled for in
analyses. Consistent with the reflection literature, the present investigation suggests that an
inclination to introspect serves as a positive prognostic indicator following treatment for MDD in
the absence of depressive symptoms.
Although precise hypotheses were minimally supported for the second study goal,
findings suggest that personality changes in the context of treatment predict relapse/recurrence of
MDD. Given that gregariousness and fantasy have been found to increase across treatment (as
assessed by the first study goal), such increases may serve to protect against relapse/recurrence
following treatment. With dutifulness not having been found to significantly change across
treatment for MDD, decreasing (or minimizing increases) in dutifulness across treatment may
have the effect of improving long-term treatment outcomes.
PERSONALITY FACETS AND DEPRESSION 43
Study Goal 3: The Predictive Utility of Pre-Treatment Personality Traits Over 18-Month
Follow-up
All personality facets that were expected to predict relapse/recurrence by way of change
across treatment were also hypothesized to predict relapse/recurrence when considered at pre-
treatment. Such hypotheses were minimally supported, with changes in a total of two facets
found to predict risk of relapse/recurrence above and beyond depression severity (effects were
small for all relationships): straightforwardness and aesthetics. Such findings extend the
personality and treatment outcome literature (e.g., Bagby et al., 2008b, Quilty et al., 2008) by
suggesting that pre-treatment personality may have long-term prognostic influence.
Specifically, heightened levels of straightforwardness at pre-treatment were found to
predict risk of relapse/recurrence in the follow-up phase. Straightforwardness reflects a tendency
to be sincere and ingenuous, with individuals low in this trait described as having manipulative
tendencies (Costa & McCrae, 1992). Although labelled “straightforwardness”, this facet appears
to more fittingly reflect a construct denoting naiveté vs. shrewdness. In this regard, seven of the
eight items in the scale reflect a tendency to trick or deceive others (e.g., “if necessary, I am
willing to manipulate people to get what I want”, reverse scored; Costa & McCrae, 1992). As
such, it may be that individuals high in this trait are emotionally reactive to negative life events
due to their credulous nature.
Heightened levels of aesthetics at pre-treatment were also found to predict risk of
relapse/recurrence in the follow-up phase. Aesthetics reflects a sensitivity to art and beauty, with
individuals high in this trait described as likely to be moved by poetry, captivated by music, and
affected by art (Costa & McCrae, 1992). This fining may appear inconsistent with Bagby et al.
(2008b), who found that heightened levels of aesthetics predicted increased responsiveness to
PERSONALITY FACETS AND DEPRESSION 44
both CBT and ADM. It is possible, however, that this trait may reflect an inherent tendency to
attach emotional valance to experiences, perhaps denoting a vulnerability towards negative mood
states over time (Desseilles, Chang, Piguet, Bertschy, Dayer, 2012).
Limitations and Strengths
The current results should be interpreted in the context of the following limitations. The
first limitation is that I did not control for multiple comparisons. Given the preliminary nature of
the investigation, our analyses were designed with the intention of minimizing Type II error (i.e.,
the error of accepting a null hypothesis that is false) at the expense of Type 1 error (i.e., the error
of rejecting a null hypothesis that is true). Second, in light of the many analyses conducted, the
sample size, and the anticipation of small effects, the current investigation may have lacked
sufficient power to detect effects. Third, a relatively low frequency of patients experienced a
relapse/recurrence following treatment (30%), which may not have allowed for sufficient power
in follow-up analyses. Fourth, the patient sample in the current investigation may have been
biased by attrition due to the fact that 43% of patients who met eligibility criteria did not
participate in the treatment phase of the investigation. Fifth, it is questionable to what extent
findings are generalizable to real-world patients who may not have met inclusion/exclusion
criteria. Sixth, given that the study design did not include a control group, it cannot be
guaranteed that facet-level changes across treatments were a function of the interventions, as
opposed to a function of life events over time. In this regard, personality changes have been
found to occur over time following career and relationship changes (e.g., Scollon & Diener,
2006). Finally, our investigation relied on a single measure of universal personality traits.
Although many facets of the NEO PI-R are regarded as maladaptive at their extreme ends (e.g.,
angry/hostility, positive emotionality; Costa & McCrae, 1992), a measure designed to capture the
PERSONALITY FACETS AND DEPRESSION 45
full range of pathological personality facets (e.g., the Personality Inventory for DSM-5; Krueger,
Derringer, Markon, Watson, & Skodol, 2012) or the use of multiple measures of personality
(e.g., Naragon-Gainey & Watson, 2014) may have been optimal for our purposes. In light of
aforementioned limitations, replication of results is necessary.
Methodological Strengths of the present investigation include: (1) the use of a clinical
sample that was randomly assigned to receive a range of empirically supported treatments for
MDD; (2) a multi-method approach to the assessment of depression (including interviews and
self-reports), and (3) the assessment of personality at the facet-level (Paunonen & Ashton, 2001).
Future Directions
It was beyond the scope of the current study to explore the causal basis of personality
changes across treatment. There are likely two potential explanations for observed changes in
personality: (1) reductions of MDD symptoms may have caused changes in personality following
treatment; (2) features of treatment may have caused changes in personality. Delineating
mechanisms of personality change and their effects on relapse/recurrence remains an important
area of future research.
Conclusions
Results support the relative stability and absolute change of personality facets across
treatments, indicating that both components of personality predict relapse/recurrence. Findings
are consistent with the complication/scar model by indicating that personality traits change in
conjunction with MDD; findings are also consistent with the pathoplasty model by suggesting
that pre-treatment personality traits predict the course of MDD following treatment. Further, with
changes in personality traits found to predict relapse/recurrence, findings suggest that
complication/scar effects likely also have pathoplastic effects. It is hoped that findings have shed
PERSONALITY FACETS AND DEPRESSION 46
light unto the complex interplay between personality and psychopathology in the context of
treatment for MDD, and encourage therapists to broaden desired treatment goals to include
changes in personality facets.
PERSONALITY FACETS AND DEPRESSION 47
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Table 1. Summary of the Personality Depression Relationship in the Literature. Blank Boxes Indicate No Research or Null Findings.
Cross-sectional Associations of
the personality-depression
relationship
Personality in the prediction of
treatment outcomes for depression
across treatment types
Personality in the prediction of
the course of depression
Personality change in conjunction
with depression
Domains Positively associated
with neuroticism
Negatively associated
with extraversion
Negatively associated
with conscientiousness
Positively associated
neuroticism
Negatively associated
with extraversion
Negatively associated
with conscientiousness
Negatively associated
with agreeableness
Negatively associated
with openness
Positively associated
neuroticism
Positively associated
with changes in
neuroticism
Negatively associated
with changes in
extraversion
Negatively associated
with conscientiousness
Negatively associated
with changes in
agreeableness
Negatively associated
with changes in openness
Facets of neuroticism
Positively associated
with anxiety
Positively associated
with angry hostility
Positively associated
with depression
Positively associated
with self-consciousness
Positively associated
with impulsiveness
Positively associated
with vulnerability
Positively associated
with vulnerability
Positively associated
with anger (facet of
neuroticism similar to
FFM angry hostility)
Negative association
with changes in anxiety
Positively associated
with changes in
depression
Positively associated
with changes in self-
consciousness
Positively associated
with changes in
vulnerability
PERSONALITY FACETS AND DEPRESSION 64
Facets of extraversion
Negatively associated
with positive emotions
Negatively associated
with assertiveness
Negatively associated
with warmth
Negatively associated
with gregariousness
Negatively associated
with positive
emotionality (facet of
extraversion similar to
FFM positive emotions)
Negatively associated
with changes in warmth
Negatively associated
with changes in
assertiveness
Negatively associated
with changes in positive
emotions
Facets of
conscientiousness Negatively associated
with self-discipline
Negatively associated
with conventionality
(facet of
conscientiousness similar
to dutifulness)
Negatively associated
with changes in
competence
Negatively associated
with changes in
achievement striving
Negatively associated
with changes in self-
discipline
Facets of
agreeableness Negatively associated
with actions
Positively associated
with changes in modesty
Facets of openness Negatively associated
with fantasy
Negatively associated
with aesthetics
Negatively associated
with actions
Negatively associated
with values
Negatively associated
with culture (facet of
openness similar to
ideas)
PERSONALITY FACETS AND DEPRESSION 65
Table 2
Demographic and Clinical Characteristics by Treatment Type and Relapse/Recurrence Status
Variable Treatment phase (n = 150) Follow-up phase (n = 92)
CBT
(n = 52)
IPT
(n = 54)
ADM
(n = 44)
F No relapse/
recurrence
(n = 71)
Relapse/
recurrence
(n = 21)
t/ Χ2
Female sex, n (%) 38 (73.10) 32 (59.26) 25 (56.82) 1.66 45 (63.38) 13 (61.90) .02
Age, M (SD) 41.46 (11.84) 40.63 (13.04) 42.41 (11.51) .25 40.94 (12.61) 44.43 (12.25) 1.12
Years of education, M (SD) 16.29 (2.48) 16.33 (2.32) 16.07 (2.52) .15 16.21 (2.39) 16.75 (2.57) .88
Blishen index, M (SD) 40.44 (21.29) 41.91 (20.21) 41.23 (21.33) .06 43.48 (20.74) 32.14 (25.43) 1.82
# of previous depressive episodes, M (SD) 1.43 (1.88) 1.82 (2.04) 2.22 (3.93) .91 1.65 (1.84) 2.71 (5.44) .88
Pre-treatment BDI-II score, M (SD) 28.80 (8.13) 31.63 (8.00) 29.88 (8.06) 1.67 28.72 (7.46) 32.05 (7.04) 1.82
Pre-treatment HDRS score, M (SD) 17.94 (3.56) 18.19 (3.93) 17.75 (3.53) .17 17.61 (3.26) 19.10 (4.74) 1.35
PERSONALITY FACETS AND DEPRESSION 66
Table 3
Descriptives, Reliability Estimates, Correlations, and Difference Scores of Facets at Pre- and Post-Treatment
Facet Pre-treatment Post-treatment r Difference scorea
M (SD) α MIC M (SD) α MIC
Neuroticism
Anxiety 21.06 (5.10) .80 .34 19.03 (5.49) .82 .36 .54** -2.03
Angry Hostility 16.75 (5.09) .78 .30 15.73 (4.89) .77 .29 .65** -1.02
Depression 23.82 (4.04) .68 .20 19.84 (5.33) .78 .30 .27* -3.98
Self-consciousness 19.96 (4.95) .71 .23 17.80 (5.10) .74 .25 .60** -2.16
Impulsiveness 18.49 (5.14) .72 .24 17.74 (5.09) .75 .27 .73** -.75
Vulnerability 17.02 (4.48) .70 .23 14.74 (4.71) .77 .30 .61** -2.28
Extraversion
Warmth 18.68 (5.21) .78 .32 20.07 (5.02) .81 .35 .66** 1.39
Gregariousness 14.66 (5.69) .80 .33 15.59 (5.45) .78 .31 .76** .93
Assertiveness 13.07 (5.13) .78 .30 14.36 (5.50) .82 .36 .78** 1.29
Activity 14.51 (4.27) .67 .21 15.43 (4.08) .62 .18 .60** .92
Excitement-seeking 14.91 (4.75) .61 .17 15.56 (4.34) .53 .14 .77** .65
Positive Emotions 13.62 (5.34) .77 .30 16.07 (5.60) .81 .35 .63** 2.45
Conscientiousness
Competence 17.79 (4.29) .67 .22 19.06 (4.19) .66 .21 .62** 1.27
Order 15.74 (4.79) .67 .21 15.72 (4.81) .69 .22 .72** -.02
Dutifulness 20.21 (4.16) .54 .14 20.40 (3.86) .51 .13 .70** .19
Achievement Striving 15.12 (4.94) .74 .26 16.02 (4.62) .71 .24 .59** .90
Self-discipline 13.73 (5.39) .81 .35 15.37 (5.25) .80 .34 .69** 1.64
Deliberation 16.36 (4.73) .74 .27 16.28 (4.46) .72 .25 .63** -.08
Agreeableness
Trust 17.20 (5.50) .86 .43 18.23 (4.99) .83 .39 .74** 1.03
Straightforwardness 20.63 (4.49) .69 .21 20.11 (4.58) .71 .23 .57** -.52
Altruism 21.99 (3.90) .67 .21 22.17 (3.30) .62 .16 .61** .18
Compliance 17.60 (4.58) .69 .22 17.62 (4.02) .64 .18 .66** .02
Modesty 20.46 (4.50) .73 .25 19.80 (4.26) .73 .25 .66** -.66
Tender-mindedness 20.66 (3.63) .61 .17 20.97 (3.31) .55 .14 .64** .31
PERSONALITY FACETS AND DEPRESSION 67
Openness
Fantasy 19.01 (5.05) .78 .30 18.23 (4.75) .76 .28 .65** -.78
Aesthetics 18.77 (6.05) .82 .36 19.08 (5.56) .78 .31 .78** .31
Feelings 21.10 (4.42) .69 .22 21.36 (3.98) .66 .20 .65** .26
Actions 16.14 (4.29) .65 .19 16.98 (3.78) .57 .13 .72** .84
Ideas 19.53 (5.42) .79 .32 20.13 (5.14) .77 .29 .80** .60
Values 22.58 (3.56) .62 .17 22.89 (3.22) .57 .15 .61** .31
Note. ** p < .01, * p < .05. a Difference score = post-treatment facet score - pre-treatment facet score.
PERSONALITY FACETS AND DEPRESSION 68
Table 4
ANCOVAs Predicting Personality Change across Treatment when Controlling for Depression
Severity
Time Time × Treatment Condition
F partial η2 F partial η
2
Neuroticism
Anxiety 1.10 .01 2.51 .03
Angry Hostility 49.67** .25 3.26* .04
Depression 5.53* .04 4.35* .06
Self-consciousness 7.09** .05 .79 .01
Impulsiveness 14.08** .09 5.00* .06
Vulnerability 54.54** .27 2.37 .03
Extraversion
Warmth 2.51 .02 .85 .01
Gregariousness 53.85** .27 1.23 .02
Assertiveness 92.23** .39 1.85 .02
Activity 66.03** .31 1.97 .03
Excitement-seeking 5.34** .26 3.21* .04
Positive Emotions 49.74** .25 1.52 .02
Conscientiousness
Competence 9.35** .06 2.71 .04
Order 47.61** .24 2.36 .03
Dutifulness .23 .00 2.64 .04
Achievement Striving 46.98** .24 1.75 .02
Self-discipline 61.87** .30 1.28 .02
Deliberation 32.73** .18 2.14 .03
Agreeableness
Trust 12.49** .08 3.19* .04
Straightforwardness .12 .00 2.56 .03
Altruism 4.68* .03 2.62 .04
Compliance 16.29** .10 2.27 .03
Modesty .29 .00 4.10* .05
Tender-mindedness .13 .00 2.81 .04
Openness
Fantasy 7.32** .05 1.23 .02
Aesthetics 5.30* .04 .88 .01
Feelings .71 .01 2.56 .03
Actions 35.08** .19 2.30 .03
Ideas 1.64 .01 1.37 .02
Values 1.21** .07 3.91* .05
Note. ** p < .01, * p < .05. Medium and large effects (partial η2 ≥ .06) are in boldface.
PERSONALITY FACETS AND DEPRESSION 69
Figure 1. Paired samples t-tests reflecting differential change in Depression according to
treatment condition. Standard errors are represented in the figure by the error bars attached to
each column.
-6
-5
-4
-3
-2
-1
0
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 70
Figure 2. Paired samples t-tests reflecting differential change in Impulsiveness according to
treatment condition. Standard errors are represented in the figure by the error bars attached to
each column.
-3
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 71
Figure 3. Paired samples t-tests reflecting differential change in Angry Hostility according to
treatment condition. Standard errors are represented in the figure by the error bars attached to
each column.
-3
-2.5
-2
-1.5
-1
-0.5
0
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 72
Figure 4. Paired samples t-tests reflecting differential change in Excitement-seeking according to
treatment condition. Standard errors are represented in the figure by the error bars attached to
each column.
-1.5
-1
-0.5
0
0.5
1
1.5
2
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 73
Figure 5. Paired samples t-tests reflecting differential change in Trust according to treatment
condition. Standard errors are represented in the figure by the error bars attached to each column.
0
0.5
1
1.5
2
2.5
3
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 74
Figure 6. Paired samples t-tests reflecting differential change in Modesty according to treatment
condition. Standard errors are represented in the figure by the error bars attached to each column.
-2
-1.5
-1
-0.5
0
0.5
1
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition
PERSONALITY FACETS AND DEPRESSION 75
Figure 7. Paired samples t-tests reflecting differential change in Values according to treatment
condition. Standard errors are represented in the figure by the error bars attached to each column.
-1
-0.5
0
0.5
1
1.5
CBT IPT ADM
Dif
feren
ce S
core
Treatment Condition