PERSONALITY FACETS AND DEPRESSION Personality Facets in Patients with Major Depressive

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


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


Figure 3. Paired samples t-tests reflecting differential change in Angry Hostility according to


Figure 4. Paired samples t-tests reflecting differential change in Excitement-seeking according to


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


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


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


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


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.


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


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


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


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


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, &


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


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


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


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-


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.,


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


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,


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.


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


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


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


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 =


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


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


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


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)


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


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).


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


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


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


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


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).


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).


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


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


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.


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


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).


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).


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


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


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.



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


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


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


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.


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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


with conscientiousness

Positively associated

neuroticism


with extraversion




with agreeableness


with openness


neuroticism


with changes in

neuroticism


with changes in

extraversion




with changes in

agreeableness


with changes in openness

Facets of neuroticism


with anxiety


with angry hostility


with depression


with self-consciousness


with impulsiveness


with vulnerability


with vulnerability


with anger (facet of

neuroticism similar to

FFM angry hostility)

Negative association

with changes in anxiety


with changes in

depression


with changes in self-

consciousness


with changes in

vulnerability


Facets of extraversion


with positive emotions


with assertiveness


with warmth


with gregariousness


with positive

emotionality (facet of

extraversion similar to

FFM positive emotions)


with changes in warmth


with changes in

assertiveness


with changes in positive

emotions

Facets of

conscientiousness Negatively associated

with self-discipline


with conventionality

(facet of

conscientiousness similar

to dutifulness)


with changes in

competence


with changes in

achievement striving


with changes in self-

discipline

Facets of

agreeableness Negatively associated

with actions


with changes in modesty

Facets of openness Negatively associated

with fantasy


with aesthetics


with actions


with values


with culture (facet of

openness similar to

ideas)


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


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


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.


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.


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

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-2

-1

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CBT IPT ADM

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Treatment Condition


Figure 2. Paired samples t-tests reflecting differential change in Impulsiveness according to


each column.

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Figure 3. Paired samples t-tests reflecting differential change in Angry Hostility according to


each column.

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Treatment Condition


Figure 4. Paired samples t-tests reflecting differential change in Excitement-seeking according to


each column.

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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.

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Figure 6. Paired samples t-tests reflecting differential change in Modesty according to treatment


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Figure 7. Paired samples t-tests reflecting differential change in Values according to treatment


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Treatment Condition

PERSONALITY FACETS AND DEPRESSION Personality Facets in Patients with Major Depressive

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