Childhood emotional trauma and chronic posttraumatic stress disorder in adult outpatients with treatment-resistant depression

The complexity of treatment-resistant depression: A data-driven approach

BACKGROUND

Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample.

METHODS

As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events.

RESULTS

Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience.

LIMITATIONS

Potential for recall bias, not examining possible interactions, and absence of a control group.

CONCLUSIONS

Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

Treatment resistant late-life depression: A narrative review of psychosocial risk factors, non-pharmacological interventions, and the role of clinical phenotyping

BACKGROUND

Treatment resistant depression (TRD) is a subset of major depressive disorder (MDD) in which symptoms do not respond to front line therapies. In older adults, the assessment and treatment of TRD is complicated by psychosocial risk factors unique to this population, as well as a relative paucity of research.

METHODS

Narrative review aimed at (1) defining TRLLD for clinical practice and research; (2) describing psychosocial risk factors; (3) reviewing psychological and non-pharmacological treatments; (4) discussing the role of clinical phenotyping for personalized treatment; and (5) outlining research priorities.

RESULTS

Our definition of TRLLD centers on response to medication and neuromodulation in primary depressive disorders. Psychosocial risk factors include trauma and early life adversity, chronic physical illness, social isolation, personality, and barriers to care. Promising non-pharmacological treatments include cognitive training, psychotherapy, and lifestyle interventions. The utility of clinical phenotyping is highlighted by studies examining the impact of comorbidities, symptom dimensions (e.g., apathy), and structural/functional brain changes.

LIMITATIONS

There is a relative paucity of TRLLD research. This limits the scope of empirical data from which to derive reliable patterns and complicates efforts to evaluate the literature quantitatively.

CONCLUSIONS

TRLLD is a complex disorder that demands further investigation given our aging population. While this review highlights the promising breadth of TRLLD research to date, more research is needed to help elucidate, for example, the optimal timing for implementing risk mitigation strategies, the value of collaborative care approaches, specific treatment components associated with more robust response, and phenotyping to help inform treatment decisions.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Esketamine-induced post-traumatic stress disorder flashbacks during treatment-resistant depression indication: is it just a side effect?

Background

Posttraumatic stress disorder (PTSD) is a severe and frequent affection that is highly comorbid to major depressive disorder. Comorbid PTSD and depression are usually treatment-resistant, with a high risk of functional impairment and suicide. Esketamine nasal spray is a recent validated treatment for treatment-resistant depression (TRD), but its efficacy on comorbid TRD-PTSD remains insufficiently documented. In particular, flashbacks can occur during esketamine administration and their influence on clinical outcomes is unknown.

Objectives

Our main objective was to describe esketamine-induced traumatic flashbacks and their impact on clinical trajectories within a sample of patients with comorbid TRD-PTSD.

Methods

We retrospectively collected clinical data of patients receiving esketamine nasal spray for TRD with comorbid PTSD who experienced at least one flashback of their trauma during esketamine sessions across 11 psychiatric departments.

Results

Between February 2020 and March 2023, 22 adult patients with TRD met inclusion criteria. In sixteen patients (72.7%) flashbacks disappeared as the sessions progressed. In six patients (27.3%), esketamine treatment was stopped because of persistent flashbacks. When esketamine was continued, clinical response was observed both for depression and PTSD (depression response rate: 45.5% and remission rate: 22.7%; PTSD response rate: 45.5% and remission: 18.2%).

Limitations

The retrospective design of the study and the absence of a comparator group are the main limitations of our study.

Conclusions

Our results suggest that the occurrence of esketamine-induced traumatic flashbacks does not hinder clinical response. On the contrary, when managed appropriately and combined with targeted psychotherapy, it could even contribute to positive outcomes.

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

Repeated oral esketamine in patients with treatment resistant depression and comorbid posttraumatic stress disorder

Introduction

Ketamine and its S-enantiomer esketamine are novel pharmacotherapeutic options for treatment resistant depression (TRD). There is growing evidence on the efficacy for other psychiatric disorders, including posttraumatic stress disorder (PTSD). It is hypothesized that psychotherapy may further potentiate the effects of (es)ketamine in psychiatric disorders.

Methods

Repeated oral esketamine was prescribed once or twice weekly in five patients suffering from TRD and comorbid PTSD. We describe the clinical effects of esketamine and report data from psychometric instruments and patients' perspectives.

Results

Esketamine treatment duration ranged from six weeks to a year. In four patients, we observed improvement in depressive symptoms, increased resilience and more receptiveness to psychotherapy. One patient experienced symptom worsening in response to a threatening situation during esketamine treatment, highlighting the need for a safe setting.

Discussion

(Es)ketamine treatment within a psychotherapeutic framework appears promising in patients with treatment resistant symptoms of depression and PTSD. Controlled trials are warranted to validate these results and to elucidate the optimal treatment methods.

Integrating genetics and transcriptomics to study major depressive disorder: a conceptual framework, bioinformatic approaches, and recent findings

Major depressive disorder (MDD) is a complex and heterogeneous psychiatric syndrome with genetic and environmental influences. In addition to neuroanatomical and circuit-level disturbances, dysregulation of the brain transcriptome is a key phenotypic signature of MDD. Postmortem brain gene expression data are uniquely valuable resources for identifying this signature and key genomic drivers in human depression; however, the scarcity of brain tissue limits our capacity to observe the dynamic transcriptional landscape of MDD. It is therefore crucial to explore and integrate depression and stress transcriptomic data from numerous, complementary perspectives to construct a richer understanding of the pathophysiology of depression. In this review, we discuss multiple approaches for exploring the brain transcriptome reflecting dynamic stages of MDD: predisposition, onset, and illness. We next highlight bioinformatic approaches for hypothesis-free, genome-wide analyses of genomic and transcriptomic data and their integration. Last, we summarize the findings of recent genetic and transcriptomic studies within this conceptual framework.

Anxiolytic reversal of classically conditioned / chronic stress-induced gene expression and learning in the Stress Alternatives Model

Social decision-making is critically influenced by neurocircuitries that regulate stress responsiveness. Adaptive choices, therefore, are altered by stress-related neuromodulatory peptide systems, such as corticotropin releasing factor (CRF). Experimental designs that take advantage of ecologically salient fear-inducing stimuli allow for revelation of neural mechanisms that regulate the balance between pro- and anti-stress responsiveness. To accomplish this, we developed a social stress and conditioning protocol, the Stress Alternatives Model (SAM), that utilizes a simple dichotomous choice, and produces distinctive behavioral phenotypes (Escape or Stay). The experiments involve repeated social aggression, a potent unconditioned stimulus (US), from a novel larger conspecific (a 3X larger Rainbow trout). Prior to the social interaction, the smaller test fish is presented with an auditory conditioning stimulus (water off = CS). During the social aggression, an escape route is available, but is only large enough for the smaller test animal. Surprisingly, although the new aggressor provides vigorous attacks each day, only 50% of the test fish choose Escape. Stay fish, treated with the CRF1 antagonist antalarmin, a potent anxiolytic drug, on day 4, promotes Escape behavior for the last 4 days of the SAM protocol. The results suggest that the decision to Escape, required a reduction in stress reactivity. The Stay fish that chose Escape following anxiolytic treatment, learned how to use the escape route prior to stress reduction, as the Escape latency in these fish was significantly faster than first time escapers. In Escape fish, the use of the escape route is learned over several days, reducing the Escape latency over time in the SAM. Fear conditioning (water off + aggression) resulted in elevated hippocampal (DL) Bdnf mRNA levels, with coincident reduction in the AMPA receptor subunit Glua1 expression, a result that is reversed following a one-time treatment (during SAM aggression on day 4) with the anxiolytic CRF1 receptor antagonist antalarmin.

Drug-facilitated sexual assault, impaired trauma memory, and implications for mental health treatment

BACKGROUND

Sexual assault (SA) is a highly prevalent global public health problem and a robust predictor of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and suicidality. A large percentage are drug or alcohol facilitated (DFSA), impairing trauma memory and affecting the application of evidence-based treatments. Despite these problems, few have investigated DFSA-specific mental health (MH) needs.

OBJECTIVE

Goals of this study were (1) to identify psychological sequelae characterizing DFSA towards explaining why symptoms have been treatment-refractory, comparing survivors with involuntary substance ingestion (forced, covert: DFSA-I), voluntary ingestion (DFSA-V), and non-DFSA; and (2) to determine how impaired trauma memory relates to the development of PTSD and depression symptoms.

METHOD

Data from a retrospective chart review of 74 adults receiving SA MH services at an outpatient trauma center are presented. The sample includes a 2-year cohort seen acutely at an urban rape treatment center. The study is one of the first to examine therapy records beyond case studies for DFSA. Logistic, Poisson, and negative binomial regression analyses of quantitative data and qualitative thematic analysis of trauma cognitions and treatment foci were conducted.

RESULTS

DFSA-V had five times greater odds of SUD, and notable substance-related self-blame compared to DFSA-I. DFSA-I had prominent relationship distress and self-blame for missing danger of perpetrator drugging. Survivors with impaired trauma memory had significantly fewer hyper-arousal and overall PTSD symptoms, and specifically less hypervigilance. No differences were found in re-experiencing symptoms.

CONCLUSION

Impaired trauma memory is common in DFSA and is associated with fewer baseline hyper-arousal and overall PTS. Despite this, DFSA issues including re-experiencing symptoms that are particularly distressing without the ability to cognitively connect the intrusions contribute to increased treatment needs. Impaired memory limits the application of evidence-based treatments, and collectively these findings call for the development of trauma-specific treatment protocols to enhance recovery for DFSA survivors.

HIGHLIGHTS

Survivors of drug-facilitated sexual assault have prominent PTSD including reexperiencing, though trauma memory may not be encoded. • Those absent trauma memory have less hyperarousal, but DFSA complications explain why it is treatment refractory and inform treatment development.

Efficacy and Safety of Intranasal Esketamine in Patients With Treatment-Resistant Depression and Comorbid Chronic Post-traumatic Stress Disorder: Open-Label Single-Arm Pilot Study

INTRODUCTION

Major depressive disorder (MDD) is more likely to resist to usual treatment when it is associated with post-traumatic stress disorder (PTSD). Capitalizing on the effect of ketamine in both treatment-resistant depression (TRD) and PTSD, we conducted a study in order to assess the efficacy of intranasal (IN) Esketamine in patients having TRD with comorbid PTSD.

MATERIALS AND METHODS

In this open-label, single arm, retrospective pilot study, 11 patients were treated with IN Esketamine (56 or 84 mg) with a longitudinal follow-up of 6 months. IN Esketamine was administered twice weekly during the first month, once weekly during the second month, and then once every 1 or 2 weeks. Patients were assessed with Montgomery-Åsberg Depression Rating Scale (MADRS), Patient Health Questionnaire 9 items, Global Assessment of Functioning (GAF), and Clinical Global Impression-Suicide Scale (CGI-SS).

RESULTS

We included 9 women and 2 men (mean age 47.3 ± 11.1 years). The mean (SD) MADRS scores decreased significantly from 38.6 (6.4) at baseline to 18.2 (10.03) after 6 months of IN Esketamine; 7 patients were responders and 3 patients were in remission. The percentage of patients who were moderately to severely suicidal declined from 63.6% at baseline to 27.3% after 1 month of IN Esketamine sessions. No serious adverse reactions were observed.

CONCLUSION

This study reports the outcomes of 11 severely ill patients with comorbid TRD and PTSD after IN Esketamine treatment. Esketamine significantly improved depression symptoms, suggesting that it is likely to be a treatment of choice in this specific population.

ACE domains and depression: Investigating which specific domains are associated with depression in adulthood

BACKGROUND

The study of adverse childhood experiences (ACEs) has shown deleterious effects throughout adulthood. Little attention, however, is given to specific ACE domains as they relate to mental health outcomes, as most studies use cumulative ACE score models.

OBJECTIVE

The current study disaggregates ACEs domains to investigate their independent effect (while controlling for each other and other demographic covariates) on receiving a depression diagnosis as an adult.

PARTICIPANTS AND SETTING

Data were obtained from the Behavioral Risk Factor Surveillance Survey (BRFSS; N = 52,971).

METHODS

To control and account for the numerical number of ACEs, separate models were run among each ACE score (e.g., those with an ACE score of exactly two, three, etc.). An aggregate model with all participants is also included.

RESULTS

Across all ACE scores, those with a history of family mental illness had the highest likelihood of receiving a depression diagnosis. The second strongest association were those with sexual abuse. No other trends were found among the six other domains. Further, those with a combination of family mental illness and sexual abuse had the highest odds of depression.

CONCLUSIONS

Mental health providers should consider the numerical number of ACEs as well as the specific ACE domains (specifically, family mental illness and sexual abuse). Additionally, this provides evidence for a possible weighting schema for the ACEs scale.

PCOS and Depression: Common Links and Potential Targets

PCOS or polycystic ovary syndrome is a common endocrine disorder that occurs during the reproductive age in females. It manifests in the form of a wide range of symptoms including (but not limited to) hirsutism, amenorrhea, oligomenorrhea, obesity, acne vulgaris, infertility, alopecia, and insulin resistance. The incidence of depression in PCOS population is increasing as compared to the general population. Increased depression in PCOS significantly alters the quality of life (QOL) of affected females. Also, self-esteem is found to be low in both depression and PCOS. The loss in self-esteem in such patients can be largely attributed to the associated factors including (but not limited to) obesity, acne, androgenic alopecia, and hirsutism. The reason behind the occurrence of depression in PCOS remains elusive to date. Literature suggests that there is an overlap of clinical symptoms between depression and PCOS. As the symptoms overlap, there is a possibility of common associations between depression, PCOS, and PCOS-associated abnormalities including insulin resistance (IR), obesity, CVD, and androgen excess. Studies demonstrate that depression is an inflammatory disorder marked with increased levels of inflammatory markers. On the other hand, PCOS is also regarded as a pro-inflammatory state that is characterized by increased levels of pro-inflammatory markers. Thus, there is a possibility of an inflammatory relationship existing between depression and PCOS. It is also possible that the inflammatory markers in PCOS can cross the blood-brain barrier (BBB) leading to the development of depression. Through the present review, we have attempted to shed light on common associations/shared links between depression and PCOS with respect to the levels of cortisol, androgen, vitamin D, neurotransmitters, monoaminoxidase (MAO), and insulin-like growth factor-1 (IGF-1). Tracking down common associations between depression and PCOS will help find potential drug therapies and improve the QOL of females with depression in PCOS.

Randomized trial of promoting first relationships for new mothers who received community mental health services in pregnancy

The effectiveness of Promoting First Relationships (PFR), a 10-week home visiting program with video feedback, was tested in a randomized controlled trial involving 252 mothers and their 8- to 12-week-old infants. Mothers were eligible if they initiated treatment after mental health screening (depression, anxiety, posttraumatic stress disorder [PTSD]) at a community or public health primary care center in pregnancy. At baseline, 51% had mild to severe depression symptoms, 54% had mild to severe anxiety, and 35% had PTSD. Their ages ranged from 18 to 42 years. Mothers were 66% White, 18% Black, and 16% other races. Forty-seven percent identified as Hispanic, and 33% preferred to read and speak in Spanish. The median family annual income was less than $20,000. The PFR program or receipt of a resource packet (control condition) followed the baseline assessment and randomization; we assessed outcomes when infants were age 6 and 12 months. Compared to mothers in the control condition, mothers in the PFR condition had significantly (ps < .05) higher observed sensitivity scores at both follow-up time points (d = .25, d = .26), had improved understanding of infant-toddler social-emotional needs at both time points (d = .21, d = .45), and reported less infant externalizing behavior at age 12 months (d = .28). This study is the fourth completed randomized controlled trial of the PFR program, all involving populations experiencing adversity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Early life and adult stress promote sex dependent changes in hypothalamic miRNAs and environmental enrichment prevents stress-induced miRNA and gene expression changes in rats

BACKGROUND

The hypothalamus plays a key role in the stress response. While early life stress (ELS) increases susceptibility to psychiatric disorders including major depressive disorder (MDD), acute stress during adulthood can also precipitate MDD after ELS.

AIM

Here, we tested the expression of miRNAs following ELS and susceptibility to depression-like behavior and whether sex or acute stress exacerbates this response. We also tested whether environmental enrichment (Enr) promotes early life and adult behavioral stress resilience and its effect on hypothalamic miRNA and gene expression. Following rat maternal separation (MS) as an ELS model, Enr from weaning through adulthood, and restraint (RS) as acute adult stress, we tested both animal behavior and miRNA expression in the hypothalamus. Target genes and their enrichment and ontology were analyzed using bioinformatic tools. Target gene expression changes were tested using qPCR, and miRNA promoter methylation was studied using methylated-DNA immunoprecipitation qPCR.

RESULTS

MS, Enr, RS, and sex altered hypothalamic miRNAs, including several previously reported in MS literature: miRs-29, - 124, - 132, - 144, - 504. Sex had a significant effect on the greatest number of miRNAs. Also, Enr reversed downregulation of miR-29b-1-5p and -301b-3p in MS. qPCR showed that MAPK6 and MMP19, targets of miR-301b-3p, were upregulated in MS and reversed by Enr. Additionally, miR-219a was hypermethylated in MS coinciding with decreased miR-219a expression.

CONCLUSIONS

This study found that sex plays a critical role in the hypothalamic miRNA response to both ELS and acute stress, with males expressing greater changes following postnatal stress. Moreover, enrichment significantly altered behavior as well as hypothalamic miRNA expression and their gene targets. Because of its role as the initiator of the autonomic stress response and connection to hedonic and motivational behavior, the hypothalamic miRNA landscape may significantly alter both the short and long-term behavioral response to stress.

Impact of Screening for Sexual Trauma in a Gynecologic Oncology Setting

OBJECTIVES

Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman's risk of developing cancer, in particular cervical cancer. We analyzed the impact of screening for sexual abuse in a gynecologic oncology population.

METHODS

Patients were screened for sexual trauma in a gynecologic oncology clinic over 5 and a half years (April 1, 2011, to September 30, 2016) in this cohort study. The screening questions were selected by behavioral oncology physicians and integrated into the gynecologic history component of the new patient assessment. Patients who screened positive for a history of sexual abuse or intimate partner violence were offered a behavioral oncology referral. Providers were also questioned about the effect of screening on their practice.

RESULTS

Of the 1,423 consecutive patients screened for sexual trauma, a total of 164 patients (12%) disclosed a history of sexual abuse. Of the 133 patients who specified their age at the sexual trauma, the majority (107 [80%]) responded that they were a young child or early teen. Most patients (92%) declined counseling. Among individuals presenting with cancer, the distribution of cancer type was statistically different between those patients with and without a sexual trauma history (p = 0.0001).

CONCLUSION

Screening for sexual trauma in a gynecologic oncologic population serves as a valuable opportunity to uncover a history of abuse that may increase a woman's susceptibility to cancer. This study demonstrates that screening for sexual abuse in a gynecologic oncology setting may be integrated into new patient interviews with minimal disruption. Identification of an undisclosed sexual trauma history allows for an opportunity to offer counseling and minimize the emotional distress that may be precipitated by treatment and exams.

Relationship between childhood physical abuse and clinical severity of treatment-resistant depression in a geriatric population

Introduction

We assessed the correlation between childhood maltreatment (CM) and severity of depression in an elderly unipolar Treatment-Resistant Depression (TRD) sample.

Methods

Patients were enrolled from a longitudinal cohort (FACE-DR) of the French Network of Expert TRD Centres.

Results

Our sample included 96 patients (33% of the overall cohort) aged 60 years or above, with a mean age of 67.2 (SD = 5.7). The majority of the patients were female (62.5%). The Montgomery and Asberg Depression Rating Scale (MADRS) and Quick Inventory Depression Scale-Self Report (QIDS-SR) mean scores were high, 28.2 (SD = 7.49) [MADRS score range: 0–60; moderate severity≥20, high severity≥35] and 16.5 (SD = 4.94) [IDS-SR score range: 0–27; moderate severity≥11, high severity≥16], respectively. Mean self-esteem scores were 22.47 (SD = 6.26) [range 0–30]. In an age- and sex-adjusted model, we found a positive correlation between childhood trauma (CTQ scores) and depressive symptom severity [MADRS (β = 0.274; p = 0.07) and QIDS-SR (β = 0.302; p = 0.005) scores]. We detected a statistically significant correlation between physical abuse and depressive symptom severity [MADRS (β = 0.304; p = 0.03) and QIDS-SR (β = 0.362; p = 0.005) scores]. We did not observe any significant correlation between other types of trauma and depressive symptom severity. We showed that self-esteem (Rosenberg scale) mediated the effect of physical abuse (PA) on the intensity of depressive symptoms [MADRS: b = 0.318, 95% BCa C.I. [0.07, 0.62]; QIDS-SR: b = 0.177, 95% BCa C.I. [0.04, 0.37]]. Preacher & Kelly’s Kappa Squared values of 19.1% (k² = 0.191) and 16% (k² = 0.16), respectively for the two scales, indicate a moderate effect.

Conclusion

To our knowledge, this is the first study conducted in a geriatric TRD population documenting an association between childhood trauma (mainly relating to PA) and the intensity of depressive symptoms.

How often were you traumatized? Reconceptualizing adverse childhood experiences for sexual and gender minorities

INTRODUCTION

The manifold consequences of adverse childhood experiences (ACEs) are well-documented. Recent research has demonstrated that sexual and gender minorities (SGMs) typically encounter ACEs more often than cisgender heterosexual individuals. Given the higher exposure rate, the measurement of frequency of exposure to traumatic events may be relevant for SGMs.

METHODS

We changed the response options of the ACEs index from dichotomous to a five-point Likert scale that described frequency of exposure. As part of a larger community-based participatory research study, the Likert ACEs measure was distributed to a large and diverse sample of SGM participants in San Antonio.

RESULTS

A cross-validation design demonstrated that the Likert ACEs scores outperformed the traditional ACEs index in predicting self-reported anxiety and post-traumatic stress disorder. Half of the SGMs in this sample experienced 3 or more ACEs, compared to only 10% of Americans in a nationally representative sample.

LIMITATIONS

These analyses were based on retrospective self-report data instead of structured clinical interviews. Since only the Likert ACEs was administered, we had to assume that any response other than "never" on Likert ACEs corresponded to "yes" on the ACEs Index.

CONCLUSIONS

Future research may assess the utility of the Likert ACEs approach with other minoritized or intersectional populations. For clinical practitioners, these results suggest that a better way to measure ACEs for SGMs is to ask them how often they were exposed, rather than asking whether they were exposed.

Characterization of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder Using Ketamine as an Experimental Medicine Probe

Comorbid posttraumatic stress disorder and major depressive disorder (PTSD + MDD) is the most common pathological response to trauma, yet despite their synergistic detriment to health, knowledge regarding the neurobiological mechanism underlying PTSD + MDD is extremely limited. This study proposes a novel model of PTSD + MDD that is built on biological systems shown to underlay PTSD + MDD and takes advantage of ketamine’s unique suitability to probe PTSD + MDD due to its rescue of stress-related neuroplasticity deficits. The central hypothesis is that changes in PTSD + MDD clinical symptoms are associated with functional connectivity changes and cognitive dysfunction and that ketamine infusions improve clinical symptoms by correction of functional connectivity changes and improvement in cognition. Participants with PTSD + MDD (n = 42) will be randomized to receive a series of six ketamine infusions or saline-placebo over three weeks. Pre/post-measures will include: (1) neuroimaging; (2) cognitive functioning task performance; and (3) PTSD, MDD, and rumination self-report measures. These measures will also be collected once in a trauma-exposed group including PTSD-only (n = 10), trauma-exposed-MDD (TE-MDD; n = 10), and healthy controls (HC, n = 21). Successful completion of the study will strongly support the concept of a biologically-based model of PTSD + MDD. The results will (1) identify functional imaging signatures of the mechanisms underpinning pathological responses to trauma, (2) shift focus from mono-diagnostic silos to unified biological and behavioral disease processes and, thus, (3) inform interventions to correct dysregulation of PTSD + MDD symptom clusters thereby supporting more precise treatments and better outcomes.

Childhood trauma, HPA axis activity and antidepressant response in patients with depression

Childhood trauma is among the most potent contributing risk factors for depression and is associated with poor treatment response. Hypothalamic-pituitary-adrenal (HPA) axis abnormalities have been linked to both childhood trauma and depression, but the underlying mechanisms are poorly understood. The present study aimed to investigate the link between childhood trauma, HPA axis activity and antidepressant response in patients with depression. As part of the Wellcome Trust NIMA consortium, 163 depressed patients and 55 healthy volunteers were included in this study. Adult patients meeting Structured Clinical Interview for Diagnostic and Statistical Manual Version-5 criteria for major depression were categorised into subgroups of treatment responder (n = 42), treatment non-responder (n = 80) and untreated depressed (n = 41) based on current depressive symptom severity measured by the 17-item Hamilton Rating Scale for Depression and exposure to antidepressant medications established by Antidepressant Treatment Response Questionnaire. Childhood Trauma Questionnaire was obtained. Baseline serum C-reactive protein was measured using turbidimetric detection. Salivary cortisol was analyzed at multiple time points during the day using the ELISA technique. Glucocorticoid resistance was defined as the coexistence of hypercortisolemia and inflammation. Our results show that treatment non-responder patients had higher exposure to childhood trauma than responders. No specific HPA axis abnormalities were found in treatment non-responder depressed patients. Untreated depressed showed increased diurnal cortisol levels compared with patients on antidepressant medication, and higher prevalence of glucocorticoid resistance than medicated patients and controls. The severity of childhood trauma was associated with increased diurnal cortisol levels only in individuals with glucocorticoid resistance. Therefore, our findings suggest that the severity of childhood trauma experience contributes to a lack of response to antidepressant treatment. The effects of childhood trauma on increased cortisol levels are specifically evident in patients with glucocorticoid resistance and suggest glucocorticoid resistance as a target for the development of personalized treatment for a subgroup of depressed patients with a history of childhood trauma rather than for all patients with resistance to antidepressant treatment.

Childhood maltreatment and clinical severity of treatment-resistant depression in a French cohort of outpatients (FACE-DR): One-year follow-up

BACKGROUND

Childhood maltreatment is associated with major depressive disorder (MDD). It not only increases the risk of lifetime MDD, but it also aggravates its course. Among depressed patients, 20-30% of them experience treatment-resistance depression (TRD). We aimed to assess the association between childhood maltreatment, severity of depression in a unipolar TRD sample, and patient outcomes after one-year of follow-up.

METHODS

Patients were recruited for a prospective cohort from the French network of TRD expert centers. Depressive symptom severity was assessed with the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Quick Inventory of Depressive Symptomatology self-report (QIDS-SR). Childhood maltreatment was evaluated with the Childhood Trauma Questionnaire (CTQ).

RESULTS

In total, 256 patients filled in the CTQ at baseline between 2012 and 2019. At baseline, the MADRS score was associated with CTQ score (β = .185; p = .004). QIDS was also associated with CTQ scores (β = .27; p < .001). Regarding the different subtypes of childhood maltreatment, MADRS was associated with physical (β = .21; p = .005) and sexual abuse (β = .22; p = .002), while QIDS with physical abuse (β = .304; p < .001) and physical neglect (β = .254; p < .001). However, we did not find any significant association focusing on the other types of traumas. During a 1-year follow-up focusing on remission, CTQ scores (baseline) were less important in remittent patients [n = 38; CTQ score = 39.26 (9.68)] than in nonremittent ones [n = 92; CTQ score = 46.02 (17.53)] (p = .027). There was no significant difference among remitters and nonremitters based on trauma subtypes. At baseline, CTQ scores had a significant influence on remission at 1 year (χ² (1) = 5.57; p < .05). We lost this influence adding MADRS scores at baseline in the model (p = .063).

CONCLUSION

We highlighted a significant association between the severity of depressive disorders and childhood maltreatment in the TRD population. Information about a history of childhood maltreatment helps in identifying individuals who could be less likely to go into remission after treatment.

Online sexual solicitation in adolescents; socio-demographic risk factors and association with psychiatric disorders, especially posttraumatic stress disorder

Technological developments and increased use of the internet created some risks for adolescents, such as online sexual solicitation (OSS). The aim of this study is to examine the sociodemographic risk factors of OSS and the association between OSS and psychiatric disorders in a psychiatric clinical sample. The study was conducted with 189 adolescents. The psychiatric evaluation was performed with DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) based psychiatric interviews and the Strengths and Difficulties Questionnaire was used. OSS was defined by questions that are used in previous studies and that predict exposure to OSS. The participants were divided into two groups and compared. In addition, the Child Post-Traumatic Stress Disorder Reaction Index was answered by the participants who exposed to OSS. The prevalence of OSS was determined as 21.1%. Depressive disorder, borderline personality disorder, and secondary psychiatric diagnosis are significantly higher in adolescents who exposed to OSS. The rate of post-traumatic stress disorder (PTSD) development after exposure to OSS was determined as 57.8%. These results indicate that OSS is a severe trauma that occurs at a high rate, and it is associated with psychiatric problems, especially PTSD.

The left dorsolateral prefrontal cortex volume is reduced in adults reporting childhood trauma independent of depression diagnosis

Both major depressive disorder (MDD) and childhood trauma have been linked with brain structural changes. As childhood trauma is more highly prevalent in MDD patients, previous morphometric findings in MDD therefore might have been confounded by childhood trauma. This study aimed to differentiate the impact of childhood trauma from the influence of MDD diagnosis on gray matter volume (GMV). Seventy-eight subjects were recruited into four study groups (n = 16, MDD patients with childhood trauma exposures, CTE/MDD; n = 14, MDD patients without CTE, non-CTE/MDD; n = 24, healthy controls with CTE, CTE/HC; and n = 24, HCs without CTE, non-CTE/HC). All participants underwent high-resolution structural magnetic resonance scans. Voxel-based morphometry was used to investigate GM alterations, and a 2 × 2 analysis of variance was performed to identify the main effects of diagnosis, childhood trauma, and their interactions. The main effects of diagnosis displayed abnormal GMV located in the left superior parietal lobule (MDD < HC) and right middle occipital gyrus (MDD > HC). While the left dorsolateral prefrontal cortex (DLPFC) volume revealed a significant main effect of childhood trauma, as shown by decreased GMV of the left DLPFC in subjects with CTE, regardless of diagnosis. A negative correlation was also found between the left DLPFC volume and emotional neglect in individuals reporting CTE. The present findings suggest that decreased GMV of the left DLPFC is a function of childhood trauma rather than MDD, which may represent the biological risk for developing MDD.

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.

Higher concentration of interleukin 6 - A possible link between major depressive disorder and childhood abuse

Little is known about the correlation between IL-6 and childhood abuse and neglect which may be risk factors for the development of affective disorders in adulthood. The aim of this study was to analyze differences in serum concentrations of IL-6 between patients with major depressive disorder and healthy controls, and to investigate possible correlations with adverse childhood experiences. Peripheral venous blood samples were obtained from 64 patients who fulfilled DSM-IV-R criteria for a current major depressive episode without psychotic symptoms (MDD) and 53 healthy controls, matched for age and gender. Participants were assessed by the Beck Depression Inventory (BDI), Childhood Trauma Questionnaire (CTQ), Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS). The concentration of IL-6 was significantly higher in patients with major depressive disorder compared to healthy controls. The total score of childhood trauma questionnaire highly statistically significantly correlated with IL-6 levels in patient group. Persons who were physically abused, physically neglected and emotionally abused had higher levels of IL-6. Interleukin 6 as a pro-inflammatory immune marker could be an important developmental mediator linking physical and emotional abuse in early life with the development of depressive disorder in adulthood.

EMDR as a treatment for long-term depression: A feasibility study

OBJECTIVE

Current treatments for long-term depression - medication and psychotherapy - are effective for some but not all clients. New approaches need to be developed to complement the ones already available. This study was designed to test the feasibility of using an effective post-traumatic stress disorder treatment for people with long-term depression.

DESIGN

A single-case experimental design with replications was undertaken as a feasibility study of eye movement desensitization and reprocessing (EMDR) in treating long-term depression.

METHODS

Thirteen people with recurrent and/or long-term depression were recruited from primary care mental health services and given standard protocol EMDR for a maximum of 20 sessions. Levels of depression were measured before and after treatment and at follow-up, clients also rated their mood each day.

RESULTS

Eight people engaged with the treatment; seven of these had clinically significant and statistically reliable improvement on the Hamilton Rating Scale for Depression. Daily mood ratings were highly variable both during baseline and intervention.

CONCLUSIONS

EMDR is a feasible treatment for recurrent and/or long-term depression. Research on treatment efficacy and effectiveness is now required.

PRACTITIONER POINTS

EMDR may be an effective treatment for depression. EMDR could be considered if first-line approaches (CBT and counselling) have been tried and failed. EMDR may be particularly helpful for service users with a history of trauma.

A Review of the Conceptualisation and Risk Factors Associated with Treatment-Resistant Depression

Major depression does not always remit. Difficult-to-treat depression is thought to contribute to the large disease burden posed by depression. Treatment-resistant depression (TRD) is the conventional term for nonresponse to treatment in individuals with major depression. Indicators of the phenomenon are the poor response rates to antidepressants in clinical practice and the overestimation of the efficacy of antidepressants in medical scientific literature. Current TRD staging models are based on anecdotal evidence without an empirical rationale to rank one treatment strategy above another. Many factors have been associated with TRD such as inflammatory system activation, abnormal neural activity, neurotransmitter dysfunction, melancholic clinical features, bipolarity, and a higher traumatic load. This narrative review provides an overview of this complex clinical problem and discusses the reconceptualization of depression using an illness staging model in line with other medical fields such as oncology.

Animal models to improve our understanding and treatment of suicidal behavior

Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.

Childhood trauma and mixed episodes are associated with poor response to lithium in bipolar disorders

OBJECTIVES

Reliable predictors of response to lithium are still lacking in bipolar disorders (BDs). However, childhood trauma has been hypothesized to be associated with poor response to lithium.

METHODS

We included 148 patients with BD, euthymic when retrospectively and clinically assessed for response to lithium and childhood trauma using reliable scales.

RESULTS

According to the 'Alda scale', the sample consisted in 20.3% of excellent responders, 49.3% of partial responders and 30.4% of non-responders to lithium. A higher level of physical abuse significantly correlated with a lower level of response to lithium (P = 0.009). As compared to patients not exposed to any abuse, patients with at least two trauma abuses (emotional, physical or sexual) were more at risk of belonging to the non-responders group (OR = 4.91 95% CI (1.01-27.02)). Among investigated clinical variables, lifetime presence of mixed episodes and alcohol misuse were associated with non-response to lithium. Multivariate analyses demonstrated that physical abuse and mixed episodes were independently associated with poor response to lithium (P = 0.005 and P = 0.013 respectively).

CONCLUSIONS

Childhood physical abuse might be involved in a poor future response to lithium prophylaxis, this effect being independent of the association between clinical expression of BD and poor response to lithium.

Indicators of patients with major depressive disorder in need of highly specialized care: A systematic review

Objectives

Early identification of patients with major depressive disorder (MDD) that cannot be managed by secondary mental health services and who require highly specialized mental healthcare could enhance need-based patient stratification. This, in turn, may reduce the number of treatment steps needed to achieve and sustain an adequate treatment response. The development of a valid tool to identify patients with MDD in need of highly specialized care is hampered by the lack of a comprehensive understanding of indicators that distinguish patients with and without a need for highly specialized MDD care. The aim of this study, therefore, was to systematically review studies on indicators of patients with MDD likely in need of highly specialized care.

Methods

A structured literature search was performed on the PubMed and PsycINFO databases following PRISMA guidelines. Two reviewers independently assessed study eligibility and determined the quality of the identified studies. Three reviewers independently executed data extraction by using a pre-piloted, standardized extraction form. The resulting indicators were grouped by topical similarity, creating a concise summary of the findings.

Results

The systematic search of all databases yielded a total of 7,360 references, of which sixteen were eligible for inclusion. The sixteen papers yielded a total of 48 unique indicators. Overall, a more pronounced depression severity, a younger age of onset, a history of prior poor treatment response, psychiatric comorbidity, somatic comorbidity, childhood trauma, psychosocial impairment, older age, and a socioeconomically disadvantaged status were found to be associated with proxies of need for highly specialized MDD care.

Conclusions

Several indicators are associated with the need for highly specialized MDD care. These indicators provide easily measurable factors that may serve as a starting point for the development of a valid tool to identify patients with MDD in need of highly specialized care.

Collaborative Care of a Patient With Multiple, Chronic Physical and Emotional Health Problems

For patients with complex, multisystem chronic illness, traditional models of care that emphasize diagnosis, prescription, and cure are inadequate. The complexities of such conditions require coordinated work with other specialists. The authors argue in this article that providing optimal health care for management of psychosocial and behavioral health concerns of the chronically ill patient calls for a collaborative approach that goes beyond coordination of care. Key elements of extended collaboration include (a) developing and implementing a team approach to patient care, (b) mutual professional socialization and education, (c) open, frequent communication between practitioners and the patient, and (d) establishing appropriate and realistic care goals. Goals must be identified that facilitate effective coping and improve quality of life in the context of chronic, multisystem illness and disability. Achieving treatment objectives should help the patient lead a rewarding life and help both the patient and providers to experience satisfaction with the provider-patient relationship and the collaborators’ individual achievements.

Development of the C4 inventory: a measure of common characteristics that complicate care in outpatient psychiatry

Background

Psychiatric syndromes are complicated by comorbidity and other factors that burden patients, making guideline-informed psychiatric care challenging, and negatively affecting outcome. A comprehensive intake tool could improve the quality of care. Existing tools to quantify these characteristics do not identify specific complications and may not be sensitive to phenomena that are common in psychiatric outpatients.

Objective

To develop a practical inventory to capture observations related to complex care in psychiatric outpatients and quantify the overall burden of complicating factors.

Design

We developed a checklist inventory through literature review and clinical experience. The inventory was tested and compared with related measures in a cross-sectional study of 410 consenting outpatients at the time of initial assessment.

Results

The summed score of inventory checklist items was significantly correlated with patient-assessed measures of distress (K10, r=0.36) and function (WHODAS 2.0, r=0.31), and physician-assessed measures of function (GAF, r=−0.42), number of psychiatric diagnoses [F(df3)=33.6], and most complex diagnosis [F(df3)=37.4]. In 53 patients whose assessment was observed by two clinicians, inter-rater reliability was acceptable for both total inventory score (intraclass correlation, single measures = 0.74) and agreement on specific items (mean agreement score = 90%).

Conclusions

The Psychiatric C4 Inventory is a reliable instrument for psychiatrists that captures information that may be useful for quality improvement and resource planning. It demonstrates convergent validity with measures of patient distress, function, and complexity. Further tests of validity and replication in other settings are warranted.

Prevalence and symptomatic correlates of interpersonal trauma in South Korean outpatients with major depressive disorder

BACKGROUND

There is growing evidence that exposure to severe interpersonal trauma (IPT) has a pivotal role in the development and manifestation of depression. However, it is not clearly understood whether patients with major depressive disorder (MDD) have specifically increased prevalence of IPT than other non-interpersonal traumatic events and whether those with IPT have unique symptom profile within depressed groups. In this study, we investigated the prevalence of past traumatic events and symptomatic features of treatment-seeking outpatients with MDD.

METHODS

A consecutive sample of 111 South Korean outpatients with MDD was recruited on their first visit to a psychiatric department of a university-affiliated hospital. Participants completed the Life Events Checklist (LEC), the Symptom Checklist-90-Revised (SCL-90-R), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Dissociative Experience Scale (DES) and Impact of Event Scale-Revised (IES-R). The prevalence of past traumatic events on LEC was compared to medical outpatients.

RESULTS

Compared to medical outpatients, MDD patients had significantly higher rates of IPT (physical and sexual) but not other traumatic events of non-interpersonal origin such as accidents or disaster. Compared to MDD patients without IPT (n=44, 40%), those with IPT (n=67, 60%) had higher subscale scores on hostility in SCL-90-R, as well as greater depressive and post-traumatic symptoms. However, multivariate analysis revealed that the best model to discriminate those with IPT was interaction of depressive and posttraumatic symptoms.

LIMITATIONS

Limitations include sample characteristics (treatment-seeking outpatients) and possible effects of comorbid conditions, which were not investigated.

CONCLUSIONS

Clinicians managing individuals with depressive disorder need to include the assessment of lifetime IPT and its impact on presenting symptoms.

Effects of persisting emotional impact from child abuse and norepinephrine transporter genetic variation on antidepressant efficacy in major depression: a pilot study

Objective

Previous studies suggest child abuse and serotonergic polymorphism influence depression susceptibility and anti-depressant efficacy. Polymorphisms of the norepinephrine transporter (NET) may also be involved. Research in the area is possibly clouded by under reporting of abuse in researcher trials.

Methods

Adults (n=51) with major depressive disorder has 8 weeks treatment with escitalopram or venlafaxine. Abuse history was obtained, the ongoing emotional impact of which was measured with the 15-item impact of event scale (IES-15). The 17-item Hamilton Depression Rating Scale (HDRS) was applied serially. Two NET polymorphisms (rs2242446 and rs5569) were assayed, blinded to HDRS ratings and abuse history.

Results

No subjects reporting abuse with high impact in adulthood (IES-15 ≥26, n=12) remitted; whereas 77% reporting low impact (IES-15 <26; n=26) remitted (p<0.001). Subjects reporting high impact abuse (n=12) had a 50-fold (95% confidence interval=4.85–514.6) greater odds of carrying rs2242446-TT genotype, but the small sample size leaves this finding vulnerable to type I error.

Conclusion

The level of persisting impact of child abuse appears relevant to antidepressant efficacy, with susceptibility to such possibly being influence by NET rs2242446 polymorphism. Larger studies may be merited to expand on this pilot level finding given potential for biomarker utility.

Modeling the dynamics of disease states in depression

Major depressive disorder (MDD) is a common and costly disorder associated with considerable morbidity, disability, and risk for suicide. The disorder is clinically and etiologically heterogeneous. Despite intense research efforts, the response rates of antidepressant treatments are relatively low and the etiology and progression of MDD remain poorly understood. Here we use computational modeling to advance our understanding of MDD. First, we propose a systematic and comprehensive definition of disease states, which is based on a type of mathematical model called a finite-state machine. Second, we propose a dynamical systems model for the progression, or dynamics, of MDD. The model is abstract and combines several major factors (mechanisms) that influence the dynamics of MDD. We study under what conditions the model can account for the occurrence and recurrence of depressive episodes and how we can model the effects of antidepressant treatments and cognitive behavioral therapy within the same dynamical systems model through changing a small subset of parameters. Our computational modeling suggests several predictions about MDD. Patients who suffer from depression can be divided into two sub-populations: a high-risk sub-population that has a high risk of developing chronic depression and a low-risk sub-population, in which patients develop depression stochastically with low probability. The success of antidepressant treatment is stochastic, leading to widely different times-to-remission in otherwise identical patients. While the specific details of our model might be subjected to criticism and revisions, our approach shows the potential power of computationally modeling depression and the need for different type of quantitative data for understanding depression.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study

BACKGROUND

Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS).

METHODS

Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum).

BASELINE RESULTS

168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy.

CONCLUSIONS

A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

Depression and psychological trauma: an overview integrating current research and specific evidence of studies in the treatment of depression in public mental health services in chile

In the last two decades, different research has demonstrated the high prevalence of childhood trauma, including sexual abuse, among depressive women. These findings are associated with a complex, severe, and chronic psychopathology. This can be explained considering the neurobiological changes secondary to early trauma that can provoke a neuroendocrine failure to compensate in response to challenge. It suggests the existence of a distinguishable clinical-neurobiological subtype of depression as a function of childhood trauma that requires specific treatments. Among women with depression and early trauma receiving treatment in a public mental health service in Chile, it was demonstrated that a brief outpatient intervention (that screened for and focused on childhood trauma and helped patients to understand current psychosocial difficulties as a repetition of past trauma) was effective in reducing psychiatric symptoms and improving interpersonal relationships. However, in this population, this intervention did not prevent posttraumatic stress disorder secondary to the extreme earthquake that occurred in February 2010. Therefore in adults with depression and early trauma, it is necessary to evaluate prolonged multimodal treatments that integrate pharmacotherapy, social support, and interpersonal psychotherapies with trauma focused interventions (specific interventions for specific traumas).

Depression among patients with diabetes attending a safety-net primary care clinic: relationship with disease control

BACKGROUND

Depression and diabetes are highly comorbid, with depression increasing risk of diabetes-related complications and mortality. Few studies have examined the relationship between depression and diabetes in safety-net populations with high rates of trauma exposure, anxiety, and substance use disorders.

METHODS

Using a cross-sectional survey of 261 patients with diabetes attending safety-net clinics, associations between depression and key diabetes control parameters were examined in bivariate and multivariable analyses adjusting for relevant confounders and significant interactions.

RESULTS

Among the participants, 57% were men, 51% were white, and the average age was 57 years. Most respondents were unemployed (81%) and earned less than $10,000 per year (51%). Overall, 28% screened positive for depression, with a high overlap of posttraumatic stress (58%) and generalized anxiety (77%) symptoms. After adjustment for socioeconomic and clinical variables, depression was associated with higher mean body mass index (p = 0.01), severe obesity (body mass index ≥ 35kg/m(2)) (odds ratio = 2.34, 95% CI: 1.09-5.04, p = 0.03) and uncontrolled diastolic blood pressure (odds ratio = 2.49, 95% CI: 1.15-5.39, p = 0.02). There was a nonsignificant trend for those with depression to have worse control of blood glucose. Associations with depression and diabetes clinical outcomes were not significantly worsened in the presence of comorbid anxiety disorders.

CONCLUSIONS

Within a highly comorbid safety-net population, significant associations between depression and key diabetes outcomes remained after accounting for relevant covariates. Further research will help elucidate the relationship between depression and diabetes control measures in safety-net populations.

Developmental and contextual factors in the role of severe childhood trauma in geriatric depression: the sample case of former indentured child laborers

The purpose of this study was to quantify the association between childhood traumatic experiences and geriatric depression (GDS) in a population of elderly who were exposed to severe childhood trauma. We aimed to identify the role of childhood maltreatment exposure in geriatric depression and the developmental and contextual factors that exacerbate this relationship. We interviewed 141 former indentured child laborers (58 females) about their experiences as children and their current depressive symptoms (Mage=77, SD=6.8). Participants provided their age, the year they were first indentured, duration indentured, current physical health, completed the Childhood Trauma Questionnaire (CTQ) and the Geriatric Depression Scale (GDS). Child maltreatment, specifically emotional abuse, was strongly associated with geriatric depression symptoms. These effects were specific to individuals who were removed from their biological families between the ages of 3 and 9 years, and for children who were indentured for 6-12 years. Finally, depression partially mediated the association between medical conditions and daily health impairment, but not for individuals "at risk" for depression by virtue of their maltreatment experiences. This study was conducted with a specific subpopulation of elderly and therefore may not generalize to all geriatric depression, nor to all generations or populations with exposure to childhood adversity. This study demonstrates the importance of using a developmental framework to understand how childhood maltreatment facilitates increased risk for the development of depression in late life.

Association of SLC6A4 methylation with early adversity, characteristics and outcomes in depression

Childhood adversities have been associated with onset and worse clinical presentations of depression. Epigenetic changes may reflect childhood adversities, while their effects on clinical characteristics of depression are unknown. This study aimed to investigate whether epigenetic changes were associated with childhood adversities, pretreatment characteristics, and treatment outcomes in depressive patients. In 108 patients with major depressive disorders, the methylation status in the promoter of gene encoding serotonin transporter (SLC6A4) was measured. Childhood adversities, socio-demographic and clinical characteristics including assessment scales for depression (Hamilton Depression Rating Scale, HAMD), anxiety (Hamilton Anxiety Rating Scale, HAMA), functioning (Social and Occupational Functioning Assessment Scale, SOFAS), disability (World Health Organization Disability Assessment Schedule-12, WHODAS-12), and quality of life (World Health Organization Quality of Life-Abbreviated form, WHOQOL-BREF) were evaluated at baseline. After a 12-week treatment with antidepressants, the assessment scales were reevaluated. To avoid type I error by multiple comparisons, Bonferroni corrections were applied. Higher SLC6A4 promoter methylation status was significantly associated with childhood adversities, worse clinical presentation (family history of depression, higher perceived stress, and more severe psychopathology assessed by SOFAS, WHODAS-12, and WHOQOL-BREF), but was not associated with treatment outcomes after considering multiple comparisons. SLC6A4 methylation status could be a proxy marker for childhood adversities and a clinical biomarker for certain presentations of depression.

Effects of childhood trauma on somatization in major depressive disorder: The role of alexithymia

BACKGROUND

Childhood trauma (CT) is often associated with later psychopathology, including depression, somatization, and alexithymia. The aim of the present study was to investigate the relationships of CT with somatization and alexithymia. Moreover, the effect of specific subtypes of trauma on alexithymia and somatization was also investigated.

METHODS

The present study was conducted on 100 outpatients with major depressive disorder (MDD) and 50 age and gender matched healthy controls (HC). Data were collected on each of the participants, including the Childhood Trauma Questionnaire (CTQ-28), the Hamilton Anxiety Rating Scale (HARS), the Hamilton Depression Rating Scale (HDRS), a 20-item Toronto Alexithymia Scale (TAS), and a somatization subscale of the Symptom Check List-Revised Form (SCL-90 R). Patient groups were divided into two categories according to the TAS-20 cut-off score. Reliability and validity were assessed, and factor analyses were conducted on the CTQ-28. Next, the relationships among CT subtypes, alexithymia, and somatization were investigated using Pearson's and partial correlation analysis. Additionally, the types of CT that predict alexithymia and somatization were also investigated.

RESULTS

Significantly higher scores on the clinical variables were noted in the patient group compared with the control group, except for physical neglect on the CTQ. The partial correlation of the CT types with somatization and alexithymia showed that the HARS, HDRS, somatization subscale of the SCL-90 R (for alexithymia), and the TAS-total (for somatization) were covariates. None of the CT types was correlated with somatization, whereas physical abuse and emotional neglect were correlated with alexithymia. Moreover, emotional abuse and emotional neglect predicted scores on the TAS and on the somatization subscale of the SCL-90 R. Conclusions CT is associated with alexithymia and ongoing somatic complaints. Alexithymia contributes to the emergence of somatic symptoms in MDD, particularly following CT. Somatization also contributes to alexithymia. Interestingly, the present study found that the relationship of emotional neglect and physical abuse with alexithymia was independent from somatization. Taken together, these results indicate that emotional abuse and neglect predict the later emergence of alexithymia and somatization.

The effect of childhood trauma on pharmacological treatment response in depressed inpatients

Childhood trauma and its association with pharmacological treatment response were examined in depressed inpatients. Treatment non-responders (n=31) reported significantly more severe trauma than treatment responders (n=25) and healthy controls (n=49), suggesting that the experience of childhood trauma in those hospitalised with depression can be detrimental to treatment success.

Gene-environment interaction in major depression and antidepressant treatment response

Response to antidepressants is interindividually variable. It has been suggested that this variability is a direct consequence of etiological heterogeneity. Therefore, the same genes, environments, and gene-environment interactions implicated in different etiological pathways to depression may also predict response to treatment. This article reviews the evidence relevant to this hypothesis by first outlining the roles of genes, environments, and gene-environment interplay in the etiology of depression, and then considering the same factors in treatment response. Environmental exposures, such as childhood maltreatment, are potent predictors of both depression and treatment response. Although alone genetic factors have failed to consistently predict either phenotype, several polymorphisms have been shown to moderate the effects of environmental adversity on the development of depression and treatment response. These findings suggest that the dissection of etiological pathways to depression may provide the key to understanding and predicting response to antidepressants.

The sexual abuse of female children in Hungary: 20 years' experience

INTRODUCTION

The purpose of this study is to describe the characteristics of female children who experience sexual abuse and explore common features that may assist in developing prevention strategies.

MATERIALS AND METHODS

Between 1990 and 2010, 266 girls under the age of 18 years, suspected of being sexually abused, visited the Department of Adolescent Gynecology. We retrospectively collected data illustrating the features of all cases. Seventy-eight percent of the victims were primary school students, and 45% of them were between 11 and 14 years of age.

RESULTS

The perpetrator knew the victim in 67% of the cases and was a stranger in 33%. Seventy-five (28%) perpetrators were members of the victims' families. In 14% of cases, the perpetrator was the victim's father and in 9% her stepfather. The abuse had occurred on multiple occasions in 29% of the cases. The occurrence rate of abuse was highest in the summer season (54%). As much as 63% of children experienced vaginal penetration, while 37% experienced a variety of sexual contact that did not involve penetration. Eighty-five victims were physically injured, and in 40 cases the presence of sperm was confirmed in vulvo-vaginal smears. A high proportion of female child sexual abuse takes place within the family and is revealed only after multiple episodes. The true prevalence of sexual abuse is being appreciated now that Hungarian law and society have recognized this societal problem.

CONCLUSION

Prevention requires a systematic and lifelong approach to educating children about personal space and privacy and is the responsibility of parents and professionals.

Etiology of depression: genetic and environmental factors

In summary, depressed patients with a history of childhood trauma may have a distinct depression endophenotype characterized by a specific neurobiology and risk genotype that may be responsive to different treatment strategies than depressed patients without childhood adversity. Based on current findings, treatment strategies should be multimodal and include the following: 1. Psychotherapy that addresses a number of domains, such as emotional regulation, cognitive reframing, careful exploration of past traumatic events, attachment, and interpersonal relationships in a safe and trusting therapeutic environment. 2. The therapy should likely be longer term in order to effectively impact those domains. 3. Pharmacotherapy that will be effective in quieting the body’s hyperresponsiveness to stress and reverse epigenetic modifications induced by trauma and stress. 4. Environmental interventions that provide a support network (maternal care, a positive family environment, the support of a close friend) have all been shown to attenuate the impact of childhood abuse. In addition, there is great potential in the identification of genomic biomarkers to help guide us in the identification of traumatized individuals who are susceptible to depression. These indices may also help identify those for whom the immediate provision of treatment may have a preventive effect and may someday guide us in the development of novel pharmacologic approaches.

Genetic variation in the calcium/calmodulin-dependent protein kinase (CaMK) pathway is associated with antidepressant response in females

OBJECTIVE

Antidepressant effects on monoamine neurotransmission may be influenced by genetic variation in intracellular signal transduction pathways, such as the cyclic adenosine monophosphate (cAMP)--protein kinase A (PKA) pathway, Ras-mitogen activated protein kinase (MAPK) pathway and calcium/calmodulin-dependent protein kinase (CaMK) pathway. The aims of this study were to examine the association of polymorphisms in candidate genes of these three signal transduction pathways with response to antidepressant treatment, and to determine the effects of, and interactions with, environment factors.

METHODS

We recruited 412 patients who met diagnosis criteria for major depressive disorder (MDD) (DSM-IV Axis I). 284 patients completed 8 weeks treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin and noradrenergic reuptake inhibitors (SNRIs). Severity of depression was measured with the Hamilton Depression Rating Scale (HDRS) before and after 8 weeks antidepressant treatment. 209 patients completed the Childhood Trauma Questionnaire, 28 item Short Form (CTQ-SF) which was used to evaluate childhood adverse events. 218 patients completed the Life Events Scale (LES) which were used to evaluate life stress before onset. 155 SNPs in 66 candidate genes were genotyping by Illumina GoldenGate, including 28 SNPs in 15 genes of cAMP-PKA pathway, 37 SNPs in 17 genes of Ras-MAPK pathway and 90 SNPs in 34 genes of CaMK pathway. The remission criterion was HDRS score equal to or less than 7. Single SNP and haplotype associations were analyzed by UNPHASED 3.3.13. Gene-environment interactions were analyzed by binary logistic regression with SPSS 11.0 software.

RESULTS

The rs2230372 SNP in ITPR2, rs2280272 in PRKCZ, rs17109671, and rs17109674 in PLCE1 were significant associated with remission, as were haplotypes in PRKCZ and PLCE1. All these positive associations were found in genes of the CaMK pathway, but not the cAMP-PKA or Ras-MAPK pathways. There were no significant differences in CTQ scores and LES scores between remitters and non-remitters. No significantly interactions between candidate genes and environment effects were observed.

CONCLUSION

The CaMK pathway may be important in determining antidepressant response. But recent adverse life events, childhood adversity, and interactions between candidate genes and environment factors appear not to influence short term antidepressant outcome.