Quality of Life and Functioning in Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder After Treatment With Citalopram Monotherapy

Trastorno de estrés postraumático y calidad de vida del paciente post COVID-19 en atención primaria

Objetivo

Determinar la asociación entre los síntomas de trastorno por estrés postraumático (TEPT) con la calidad de vida relacionada con la salud (CVRS) del paciente post-COVID-19 en Atención Primaria.

Diseño

Estudio transversal, multicéntrico, con muestreo probabilístico aleatorizado.

Emplazamiento

Centros de Atención Primaria de Ica-Perú.

Participantes

Seiscientos treinta y seis pacientes con diagnóstico previo de COVID-19.

Mediciones principales

La variable síntomas de TEPT, fue medida con el cuestionario COVID-19-PTSD y la CVRS con la escala EuroQol (EQ-5D). Se analizaron factores sociodemográficos y de salud que incluyó el síndrome post-COVID-19. Se realizó un análisis descriptivo y se calcularon razones de prevalencia (RP) crudas y ajustadas, mediante modelos lineales generalizados de la familia Poisson, para buscar asociación entre las variables.

Resultados

De los participantes, el 21,4% presentó síntomas de TEPT; el 33,6%, síntomas de excitación disfórica y ansiosa; el 22,3%, intrusión, evitación y afecto negativo; 22,6%, anhedonia, y el 23,6%, comportamiento exteriorizante. El 50,3% reveló al menos un componente de la CVRS afectada; el 35,5%, problemas vinculados con ansiedad/depresión; el 34,9%, dolor/malestar; el 11%, actividad cotidiana; el 10,7%, movilidad y el 6,6%, cuidado personal. La presencia de síntomas de TEPT mostró asociación con la CVRS afectada (RP = 2,46: IC del 95%: 2,19-2,78). Asimismo, ciertas variables sociodemográficas y de salud se asociaron con los síntomas de TEPT y la CVRS afectada.

Conclusiones

Los síntomas de TEPT incrementan la probabilidad de afectar la CVRS del paciente post-COVID-19. Existen variables sociodemográficas y de salud potencialmente modificables que podrían mermar los síntomas de TEPT y mejorar la CVRS.

Examining well-being in posttraumatic stress disorder treatment: An explorative study

Although the importance of well-being in mental health is widely acknowledged, well-being as a predictor of and outcome in the treatment for posttraumatic stress disorder (PTSD) has received little attention. This naturalistic study aimed to investigate well-being in the context of care-as-usual treatment for PTSD. Patients with PTSD attending a community mental health center (N = 318) completed measures of well-being and PTSD symptoms before and after symptom-focused treatment. Following treatment, well-being increased among patients with PTSD, with emotional, d = -0.25, and psychological well-being, d = -0.24, showing the largest improvements relative to social well-being, d = -0.15. Although levels of well-being improved overall within the sample, participant scores on measures of well-being remained low compared with the general population. Well-being predicted treatment efficiency such that participants with more severe PTSD symptoms benefitted more from care-as-usual treatment when they reported relatively high levels of well-being at the start of treatment. The findings suggest a benefit to including well-being as a pretreatment and outcome variable when evaluating PTSD treatments.

Post-traumatic stress disorder and childhood emotional abuse are markers of subthreshold bipolarity and worse treatment outcome in major depressive disorder

Post-traumatic stress disorder (PTSD) and childhood maltreatment (CMT: parental neglect; emotional, physical and sexual abuse) have been linked to bipolar disorder but they are also common in major depressive disorder (MDD). Our objective was to investigate their association with the bipolar spectrum and antidepressant treatment outcome in 482 outpatients with DSM-IV MDD treated in the Combining Medications to Enhance Depression Outcomes trial for 28 weeks Bipolar spectrum score included age of onset <21 years, subthreshold hypomania (a period of elated or irritable mood with at least two concurrent hypomanic symptoms, which did not fulfill DSM criteria for hypomanic/manic episode) and depressive mixed state (DMX). PTSD subjects (n = 107; 22%) had more severe depression (P < 0.0001), work and social impairment (P = 0.0031), comorbid anxiety disorders (P < 0.0001) and increased suicidality (P = 0.0003). Bipolar spectrum score was higher with PTSD comorbidity (P = 0.0063) and childhood emotional abuse (P = 0.0001). PTSD comorbidity was associated with residual suicidality (P = 0.0218) after 6 weeks of antidepressant use whereas childhood emotional abuse [odds ratio (OR), 1.01-2.22], subthreshold hypomania (OR, 1.04-4.09) and DMX (OR, 1.00-4.19) were predictors of mood switch. These results corroborate the role of PTSD and childhood emotional abuse as markers of bipolar spectrum and prognostic factors during antidepressant treatment.

Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.

Depression in post-traumatic stress disorder

Major depressive disorder (MDD) symptoms commonly occur after trauma-exposure, both alone and in combination with post-traumatic stress disorder (PTSD). This article reviews recent research on comorbidity between these disorders, including its implications for symptom severity and response to treatment. Despite considerable symptom overlap, the two disorders represent distinct constructs and depend, at least in part, on separate biological mechanisms. Both, however, are also clearly related to stress psychopathology. We recommend that more research focus specifically on the study of individual differences in symptom expression in order to identify distinct subgroups of individuals and develop targeted treatments. However, a barrier to this line of inquiry is the trend of excluding particular patients from clinical trials of new interventions based on symptom severity or comorbidity. Another obstacle is the overreliance on self-report measures in human research. We argue that developing computer-based behavioral measures in order to supplement self-report can help address this challenge. Furthermore, we propose that these measures can help tie findings from human and non-human animal research. A number of paradigms have been used to model MDD-and PTSD-like behavior in animals. These models remain valuable for understanding the biological basis of these disorders in humans and for identifying potential interventions, but they have been underused for the study of comorbidity. Although the interpretation of animal behavior remains a concern, we propose that this can also be overcome through the development of close human analogs to animal paradigms.

Comorbid mental disorders, depression symptom severity, and role impairment among Veterans initiating depression treatment through the Veterans Health Administration

BACKGROUND

Psychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates.

METHODS

2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments.

RESULTS

Nearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities.

LIMITATIONS

The screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities.

CONCLUSIONS

Although positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.

The influence of depression-PTSD comorbidity on health-related quality of life in treatment-seeking veterans

OBJECTIVE

Posttraumatic stress disorder (PTSD) and depression substantially impair health-related quality of life (HRQOL) for many Canadian Armed Forces (CAF) veterans. Although PTSD and depression are highly comorbid, little is known about whether the disorders may interact in their association with HRQOL. We sought to investigate whether depressive symptoms modify the relation between PTSD and HRQOL in treatment-seeking veterans.

METHOD

We accessed the clinical data of 545 CAF veterans aged 18 to 65 years who were seeking treatment at a specialized clinic in London, Ontario. We used hierarchical linear regression to assess the additive and multiplicative relations between depression and PTSD symptoms on HRQOL, controlling for age and alcohol/substance abuse. Simple slopes were examined to probe significant interactions.

RESULTS

Probable PTSD and major depression were present in 77.4% and 85.3% of the sample, respectively, and 73.0% of the sample presented with probable PTSD-depression comorbidity. Depression symptoms significantly modified the relation between PTSD symptoms and overall mental HRQOL (β = 0.12, p <0.001, ∆R²  = 0.014), and role impairment due to emotional difficulties (β = 0.20, p <0.001, ∆R²  = 0.035). Simple slope analyses revealed the impact of PTSD was greater among those with lower depression symptoms and became weaker with greater depression symptom severity. In adjusted models, only depression was significantly associated with all mental and physical HRQOL domains; PTSD was not associated with physical HRQOL, role emotional impairment, or vitality.

CONCLUSIONS

For those with severe comorbid depression, PTSD symptoms were no longer associated with mental HRQOL, particularly in areas related to emotional functioning. Findings suggest the importance of targeting depression in patients presenting with PTSD-depression comorbidity.

Conceptualizing comorbid PTSD and depression among treatment-seeking, active duty military service members

BACKGROUND

Among active duty service members and veterans with PTSD, depression is the most commonly diagnosed comorbid psychiatric condition. More research is warranted to investigate the relationship between PTSD and depression to improve treatment approaches. Byllesby et al. (2017) used confirmatory factor analyses in a sample of trauma-exposed combat veterans with PTSD and found that only the general distress factor, and not any specific symptom cluster of PTSD, predicted depression. This study seeks to replicate Byllesby et al. (2017) in a sample of treatment-seeking active duty soldiers.

METHODS

Confirmatory factor analyses, bifactor modeling, and structural equation modeling (SEM) were used with data gathered at pretreatment and posttreatment as part of a large randomized clinical trial.

RESULTS

Confirmatory factor analyses and bifactor modeling demonstrated that PTSD symptom clusters, Negative Alterations in Cognition and Mood (NACM) and Alterations in Arousal and Reactivity (AAR), as well as the general distress factor significantly predicted depression at pretreatment and posttreatment.

LIMITATIONS

The current study was predominantly male, limiting the generalizability to female service members with PTSD. Also, self-report measures were used, which may introduce response-bias.

CONCLUSIONS

The current study did not replicate Byllesby et al. (2017). Results demonstrated that the relationship between PTSD and depression among active duty service members can be explained by both transdiagnostic factors and disorder-specific symptoms.

Quality of life and functioning of Hispanic patients with Major Depressive Disorder before and after treatment

BACKGROUND

Similar rates of remission from Major Depressive Disorder (MDD) have been documented between ethnic groups in response to antidepressant treatment. However, ethnic differences in functional outcomes, including patient-reported quality of life (QOL) and functioning, have not been well-characterized. We compared symptomatic and functional outcomes of antidepressant treatment in Hispanic and non-Hispanic patients with MDD.

METHODS

We analyzed 2280 nonpsychotic treatment-seeking adults with MDD who received citalopram monotherapy in Level 1 of the Sequenced Treatment Alternatives to Relieve Depression study. All subjects (239 Hispanic, 2041 non-Hispanic) completed QOL, functioning, and depressive symptom severity measures at entry and exit.

RESULTS

Hispanic participants had significantly worse QOL scores at entry and exit (p < 0.01). However, after controlling for baseline QOL, there was no difference between Hispanic and non-Hispanic patients' QOL at exit (p = 0.21). There were no significant between-group differences at entry or at exit for depressive symptom severity or functioning. Both groups had significant improvements in depressive symptom severity, QOL, and functioning from entry to exit (all p values < 0.01). Patients with private insurance had lower depressive symptom severity, greater QOL, and better functioning at exit compared to patients without private insurance.

LIMITATIONS

This study was a retrospective data analysis, and the Hispanic group was relatively small compared to the non-Hispanic group.

CONCLUSIONS

Hispanic and non-Hispanic participants with MDD had similar responses to antidepressant treatment as measured by depressive symptom severity scores, quality of life, and functioning. Nevertheless, Hispanic patients reported significantly worse quality of life at entry.

Quality of life and coping strategies of outpatients with a depressive disorder in maintenance therapy - a cross-sectional study

BACKGROUND

The quality of life (QoL) is a multidimensional view that represents all aspects of patient well-being in various areas of patient life. Specific coping strategies may be connected to both the QoL and the severity of mental disorder. The aim of this investigation was to examine the relationship between the QoL and the coping strategies of outpatients with a depressive disorder.

METHODS

Eighty-two outpatients, who met the criteria of the International Classification of Diseases, Tenth Revision, for a depressive disorder, were enrolled in the cross-sectional study. Data on sociodemographic and clinical variables were obtained from the medical records. Individuals filled the following standardized questionnaires: Quality of Life Satisfaction and Enjoyment Questionnaire, Stress Coping Style Questionnaire, and Clinical Global Impression. Multiple regression analyses with backward elimination were performed to discover the most influential factors contributing to QoL.

RESULTS

The participants with a depressive disorder showed an overuse of negative coping strategies, especially escape tendency and resignation. A positive self-instruction strategy was used by the patients less often. The coping strategies were significantly associated with the QoL. A more frequent use of positive coping strategies had a positive association with the QoL. The main factors related to QoL were the subjective severity of the disorder, employment, and positive coping strategies.

CONCLUSION

The study confirmed the relationship between QoL and the coping strategies of outpatients with a depressive disorder.