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Wojcik KD, Cox DW, Kealy D, Zumbo B. The Effect of Cognitive Fusion on Change in PTSD and Depression Symptom Severity in Veterans Engaged in Group Psychotherapy. J Cogn Psychother 2024; 38:169-184. [PMID: 38631715 DOI: 10.1891/jcp-2022-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Cognitive fusion occurs when people experience their thoughts as literally true and allow them to dictate behavior. Fusion has been shown to be associated with increased symptoms of post-traumatic stress disorder (PTSD) and depression; however, the association between change in cognitive fusion, PTSD, and depression symptoms has been relatively uninvestigated. Our study aims to examine the associations between PTSD, depression symptoms, and cognitive fusion in Canadian veterans from pre- to post-treatment. Clients (N = 287) completed measures of PTSD symptom severity, depression symptom severity, and cognitive fusion at pre- and post-treatment. Our results supported that pretreatment PTSD and depression symptom severity were found to be negatively associated with changes in pre- to post-treatment cognitive fusion, while pretreatment cognitive fusion was not associated with changes in depression or PTSD symptoms. Furthermore, pretreatment depression symptoms predicted pre- to post-treatment changes in PTSD symptoms. However, pretreatment PTSD symptoms did not predict changes in depression symptoms. These findings highlight the importance of understanding the bidirectional associations between PTSD, depression, and cognitive fusion. Furthermore, our results are indicative of PTSD and depression symptoms playing a role in the change in cognitive fusion (e.g., defusion) and of depression playing a larger role in the maintenance of PTSD symptoms. Theoretical and practical implications are discussed.
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Affiliation(s)
- Katharine D Wojcik
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Daniel W Cox
- Counselling Psychology Program, University of British Columbia, Vancouver, BC, Canada
| | - David Kealy
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bruno Zumbo
- Measurement, Evaluation, and Research Methodology, University of British Columbia, Vancouver, BC, Canada
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Eghaneyan BH, Killian MO, Sanchez K. The Integration of Behavioral Health and Primary Care for Hispanic/Latino Patients with Depression and Comorbid PTSD. J Behav Health Serv Res 2023; 50:95-107. [PMID: 36352161 PMCID: PMC9646280 DOI: 10.1007/s11414-022-09824-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Comorbid PTSD and depression are notably high within primary care settings serving low-income and/or immigrant Hispanic/Latino populations. There is limited research examining how comorbid PTSD impacts the response to depression treatment for patients within these settings. The purpose of this study was to examine PTSD-depression comorbidity and its association with treatment outcomes among Hispanic/Latino patients enrolled in an integrated behavioral health intervention for depression. Participants were Hispanic/Latino adult primary care patients who met the criteria for depression and were not currently in treatment. Depression and anxiety severity were assessed at baseline and the 6 and 12 month follow-ups. Outcomes were compared between participants who met the criteria for a PTSD diagnosis and those that did not. Depression and anxiety scores significantly decreased through the 1-year intervention period regardless of PTSD diagnosis. More research is needed to understand what elements of culturally adapted, linguistically concordant treatment benefit diverse patients the most.
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Affiliation(s)
- Brittany H. Eghaneyan
- Department of Social Work, California State University, Fullerton, 800 N. State College Blvd, Fullerton, CA 92831 USA
| | - Michael O. Killian
- College of Social Work, Florida State University, 296 Champions Way, Tallahassee, FL 32306 USA
| | - Katherine Sanchez
- School of Social Work, University of Texas at Arlington, 211 South Cooper Street, Box 19129, Arlington, TX 76019 USA
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Fung HW, Chien WT, Lam SKK, Ross CA. Investigating post-traumatic stress disorder (PTSD) and complex PTSD among people with self-reported depressive symptoms. Front Psychiatry 2022; 13:953001. [PMID: 36339839 PMCID: PMC9627202 DOI: 10.3389/fpsyt.2022.953001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Trauma has been increasingly linked to depression. Previous studies have suggested that comorbid post-traumatic stress disorder (PTSD) may be associated with poor outcomes in depression treatment. However, the prevalence and correlates of ICD-11 PTSD and complex PTSD (CPTSD) in people with depression remain unclear. METHODS This study examined the prevalence and correlates of ICD-11 PTSD and CPTSD in an online convenience sample of 410 adults from 18 different countries/regions who reported clinically significant levels of depressive symptoms (indicated by a Patient Health Questionnaire-9 score ≥10). RESULTS According to the International Trauma Questionnaire results, 62.68% of participants met the ICD-11 criteria for PTSD/CPTSD (5.6% PTSD, 57.1% CPTSD). Participants with CPTSD reported more types of trauma and higher levels of interpersonal stress than those without PTSD. Participants with CPTSD also reported higher levels of mental health problems, including depressive, dissociative and psychotic symptoms, than those without PTSD. Only disturbances in self-organization (DSO) symptoms but not classical PTSD symptoms had a significant relationship with depressive symptoms, when other major variables (including trauma, interpersonal stress, and comorbid psychotic and dissociative symptoms) were controlled for. CONCLUSIONS Trauma-related symptoms should be regularly screened for in clients who report depressive symptoms. Depressed clients who have comorbid trauma disorders have more trauma and interpersonal stress and exhibit more severe mental health problems. They may require specific trauma-focused interventions in addition to standard depression treatments.
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Affiliation(s)
- Hong Wang Fung
- Department of Social Work, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Stanley Kam Ki Lam
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Colin A Ross
- The Colin A. Ross Institute for Psychological Trauma, Richardson, TX, United States
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Angelakis S, Weber N, Nixon RDV. Comorbid posttraumatic stress disorder and major depressive disorder: The usefulness of a sequential treatment approach within a randomised design. J Anxiety Disord 2020; 76:102324. [PMID: 33137600 DOI: 10.1016/j.janxdis.2020.102324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/30/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
Cognitive Processing Therapy (CPT) and Behavioural Activation Therapy (BA) were used to treat individuals with comorbid posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Fifty-two individuals (48 women, 4 men) were randomized to CPT alone (n = 18), CPT then BA for MDD (n = 17), or BA then CPT (n = 17). Presenting trauma was primarily interpersonal (87 %). Participants were assessed at pre-, posttreatment, and 6-month follow-up. PTSD and MDD symptoms were the main outcome of interest; trauma cognitions, rumination, and emotional numbing were secondary outcomes. All groups showed sizeable reductions in PTSD and depression (effect sizes at follow-up ranging between 1.02-2.54). A pattern of findings indicated CPT/BA showed better outcomes in terms of larger effect sizes and loss of diagnoses relative to CPT alone and BA/CPT. At follow-up greater numbers of the CPT/BA group were estimated to have achieved good end-state for remission of both PTSD and depression (49 %, CI95 [.26, .73]) relative to CPT alone (18 %, CI95 [.03, .38]) and BA/CPT (11 %, CI95 [.01, .29]). Although tempered by the modest sample size, the findings suggest that individuals with comorbid PTSD and MDD may benefit from having PTSD targeted first before remaining MDD symptoms are addressed.
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Affiliation(s)
- Samantha Angelakis
- School of Psychology, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Nathan Weber
- School of Psychology, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Reginald D V Nixon
- School of Psychology, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.
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Abas MA, Weiss HA, Simms V, Verhey R, Rusakaniko S, Araya R, Chibanda D. The effect of co-morbid anxiety on remission from depression for people participating in a randomised controlled trial of the Friendship Bench intervention in Zimbabwe. EClinicalMedicine 2020; 23:100333. [PMID: 32637890 PMCID: PMC7329733 DOI: 10.1016/j.eclinm.2020.100333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There is a lack of data from low- and middle-income countries on whether anxiety independently predicts a more chronic course for depression. METHODS We undertook secondary data analysis of a cluster randomised controlled trial in Zimbabwe which had tested the effectiveness of the Friendship Bench intervention for common mental disorders compared to enhanced usual care. Inclusion for the current study was participants from the trial who had probable major depression at baseline, defined as scoring => 11 on the locally validated Patient Health Questionnaire (PHQ9). This emerged to be 354 of the original 573 (61.78%) of the original trial sample. Anxiety was measured using the locally validated cut-point on the Generalised Anxiety Disorder scale (GAD-7). Persistent depression was defined as scoring => 11 on the PHQ-9 at six-months follow-up. Analysis in Stata 15 used random-effects logistic regression to adjust for clustering by clinic. OUTCOMES Of the 354 participants who were eligible for treatment, 329 (92·9%) completed 6-month follow-up assessment. 37% of the trial sample had persistent depression at 6-months follow-up; 59% in the control arm and 17% in the intervention arm. Co-morbid anxiety present at trial baseline was independently associated with persistent depression after adjusting for age, gender and baseline depression severity (adjusted OR = 2·83, 95% CI 1·32-6·07). There was no evidence of effect modification by trial arm. Baseline depression severity also predicted persistent depression. Interpretation Treatment for depression in low and middle-income countries (LMIC) should be directed towards those with greatest need. This includes people with co-morbid anxiety and greater depression severity at initial assessment who are less likely to remit at six months. Advice on coping with anxiety, psychological treatments which target common anxiety symptoms such as fear, avoidance, excessive worry and intrusive thoughts, and Selective Serotonin Reuptake Inhibitors (SSRIs) should be made more widely available in LMIC and offered to those with persistent mixed depression and anxiety.
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Affiliation(s)
- Melanie Amna Abas
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust, London, UK
- Corresponding author at: King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Helen Anne Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Victoria Simms
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Ruth Verhey
- Research Support Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Simbarashe Rusakaniko
- Zimbabwe AIDS Prevention Project-University of Zimbabwe Department of Community Medicine, Harare, Zimbabwe
| | - Ricardo Araya
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Dixon Chibanda
- Research Support Centre, University of Zimbabwe, Harare, Zimbabwe
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
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McAllister-Williams RH, Arango C, Blier P, Demyttenaere K, Falkai P, Gorwood P, Hopwood M, Javed A, Kasper S, Malhi GS, Soares JC, Vieta E, Young AH, Papadopoulos A, Rush AJ. The identification, assessment and management of difficult-to-treat depression: An international consensus statement. J Affect Disord 2020; 267:264-282. [PMID: 32217227 DOI: 10.1016/j.jad.2020.02.023] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/07/2020] [Accepted: 02/06/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered. METHODS A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. RESULTS The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. LIMITATIONS The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. CONCLUSIONS DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.
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Affiliation(s)
- R H McAllister-Williams
- Northern Centre for Mood Disorders, Newcastle University, UK; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - C Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - P Blier
- Royal Ottawa Institute of Mental Health Research, University of Ottawa, Canada
| | - K Demyttenaere
- University Psychiatric Center KU Leuven, Faculty of Medicine KU Leuven, Belgium
| | - P Falkai
- Clinic for Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - P Gorwood
- CMME, Hopital Sainte-Anne (GHU Paris et Neurosciences). Paris-Descartes University, INSERM U1266, Paris, France
| | - M Hopwood
- University of Melbourne, Melbourne, Australia
| | - A Javed
- Faculty of the University of Warwick, UK
| | - S Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - G S Malhi
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, New South Wales, Australia; Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia; CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia
| | - J C Soares
- University of Texas Health Science Center, Houston, TX, USA
| | - E Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - A H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London & South London and Maudsley NHS Foundation Trust, UK
| | | | - A J Rush
- Duke University School of Medicine, Durham, NC, USA; Texas Tech University Health Sciences Center, Permian Basin, Midland, TX, USA; Duke-NUS Medical School, Singapore
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George MP, Garrison GM, Merten Z, Heredia D, Gonzales C, Angstman KB. Impact of Personality Disorder Cluster on Depression Outcomes Within Collaborative Care Management Model of Care. J Prim Care Community Health 2019; 9:2150132718776877. [PMID: 29785866 PMCID: PMC5967151 DOI: 10.1177/2150132718776877] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence of specific PD cluster types. The purpose of the current study is to compare depression outcomes between cluster A, cluster B, and cluster C PD patients treated within a collaborative care management (CCM), relative to CCM patients without a PD diagnosis. The overarching goal was to identify cluster types that might confer a worse clinical prognosis. METHODS This retrospective chart review study examined 2826 adult patients with depression enrolled in CCM. The cohort was divided into 4 groups based on the presence of a comorbid PD diagnosis (cluster A/nonspecified, cluster B, cluster C, or no PD). Baseline clinical and demographic variables, along with 6-month follow-up Patient Health Questionnaire-9 (PHQ-9) scores were obtained for all groups. Depression remission was defined as a PHQ-9 score <5 at 6 months, and persistent depressive symptoms (PDS) was defined as a PHQ-9 score ≥10 at 6 months. Adjusted odds ratios (AORs) were determined for both remission and PDS using logistic regression modeling for the 6-month PHQ-9 outcome, while retaining all study variables. RESULTS A total of 59 patients (2.1%) had a cluster A or nonspecified PD diagnosis, 122 patients (4.3%) had a cluster B diagnosis, 35 patients (1.2%) had a cluster C diagnosis, and 2610 patients (92.4%) did not have any PD diagnosis. The presence of a cluster A/nonspecified PD diagnosis was associated with a 62% lower likelihood of remission at 6 months (AOR = 0.38; 95% CI 0.20-0.70). The presence of a cluster B PD diagnosis was associated with a 71% lower likelihood of remission at 6 months (AOR = 0.29; 95% CI 0.18-0.47). Conversely, having a cluster C diagnosis was not associated with a significantly lower likelihood of remission at 6 months (AOR = 0.83; 95% CI 0.42-1.65). Increased odds of having PDS at 6-month follow-up were seen with cluster A/nonspecified PD patients (AOR = 3.35; 95% CI 1.92-5.84) as well as cluster B patients (AOR = 3.66; 95% CI 2.45-5.47). However, cluster C patents did not have significantly increased odds of experiencing persistent depressive symptoms at 6-month follow-up (AOR = 0.95; 95% CI 0.45-2.00). CONCLUSIONS Out of the 3 clusters, the presence of a cluster B PD diagnosis was most significantly associated with poorer depression outcomes at 6-month follow-up, including reduced remission rates and increased risk for PDS. The cluster A/nonspecified PD group also showed poor outcomes; however, the heterogeneity of this subgroup with regard to PD features must be noted. The development of novel targeted interventions for at-risk clusters may be warranted in order to improve outcomes of these patients within the CCM model of care.
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Arenson MB, McCaslin SE, Cohen BE. Predictors of multiple domains of functioning in Veterans with posttraumatic stress disorder: Results from the Mind Your Heart Study. Depress Anxiety 2019; 36:1026-1035. [PMID: 31356711 DOI: 10.1002/da.22945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/11/2019] [Accepted: 06/26/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Those with posttraumatic stress disorder (PTSD) have lower overall functioning than healthy controls. However, this population is not homogenous, and those with PTSD have a wide range of functional outcomes. To our knowledge, only one other study has evaluated the predictors of better functioning within patients with PTSD. METHODS We examined 254 veterans with likely PTSD, using the Clinician-Administered PTSD Scale to assess PTSD symptom severity, and the SF-36 and single-item question to assess aspects of current functioning and quality of life. RESULTS In fully adjusted models (controlling for age, gender, and PTSD score, and including all significant psychosocial predictors of the outcome of interest), greater sleep quality (p = .03), lower C-reactive protein (p < .01), and lower erythrocyte sedimentation rate (p = 0.04) were associated with greater physical functioning; lower depression (p < .01) and greater perceived social support (p = .05) were associated with greater social functioning; lower depression (p = .02) was associated with greater occupational functioning; and greater combat exposure (p = .04), greater optimism (p < .01) and greater perceived social support (p = .05) were associated with greater quality of life. CONCLUSIONS These findings highlight the differential impact of psychosocial predictors on multiple functional outcomes. As such, they provide important information for clinicians about aspects of veterans' lives that can be targeted during the treatment to improve specific types of functioning.
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Affiliation(s)
- Melanie B Arenson
- Department of Psychology, University of Maryland, College Park, Maryland.,San Francisco VA Medical Center, San Francisco, California
| | - Shannon E McCaslin
- Dissemination and Training Division, National Center for PTSD, Menlo Park, California.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Beth E Cohen
- San Francisco VA Medical Center, San Francisco, California.,Department of Medicine, University of California, San Francisco, California
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Arenson MB, Whooley MA, Neylan TC, Maguen S, Metzler TJ, Cohen BE. Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study. Psychiatry Res 2018; 265:224-230. [PMID: 29753254 DOI: 10.1016/j.psychres.2018.04.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 01/14/2023]
Abstract
Veterans with PTSD or depression are at increased risk for suicidal ideation. However, few studies have examined that risk in those with comorbid PTSD and depression, instead focusing on these disorders individually. This study investigates the association of suicidal ideation with comorbid PTSD and depression and examines the role of military and psychosocial covariates. We evaluated 746 veterans using the CAPS to assess PTSD and the PHQ-9 to measure depression and suicidal ideation. Covariates were assessed via validated self-report measures. 49% of veterans with comorbid PTSD and depression endorsed suicidal ideation, making them more likely to do so than those with depression alone (34%), PTSD alone (11%), or neither (2%). In multivariate logistic regression models, this association remained significant after controlling for demographics and symptom severity. Anger, hostility, anxiety, alcohol use, optimism and social support did not explain the elevated risk of suicidal ideation in the comorbid group in fully adjusted models. As suicidal ideation is a known risk factor for suicide attempts and completions, veterans with comorbid PTSD and depression represent a vulnerable group who may need more intensive monitoring and treatment to reduce risk of suicide.
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Affiliation(s)
- Melanie B Arenson
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA.
| | - Mary A Whooley
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA
| | - Thomas C Neylan
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA
| | - Shira Maguen
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA
| | - Thomas J Metzler
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- San Francisco VA Medical Center, San Francisco, CA, USA; University of California, San Francisco, San Francisco, CA, USA.
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Kaster TS, Goldbloom DS, Daskalakis ZJ, Mulsant BH, Blumberger DM. Electroconvulsive therapy for depression with comorbid borderline personality disorder or post-traumatic stress disorder: A matched retrospective cohort study. Brain Stimul 2017; 11:204-212. [PMID: 29111076 DOI: 10.1016/j.brs.2017.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/27/2017] [Accepted: 10/15/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The impact of comorbid borderline personality disorder (BPD) or post-traumatic stress disorder (PTSD) on clinical and cognitive outcomes of electroconvulsive therapy (ECT) in patients with major depressive episodes (MDE) is unknown. OBJECTIVE Compare clinical response and adverse cognitive effects for MDE patients with comorbid BPD or PTSD to MDE only. METHODS In a matched retrospective cohort study of 75 patients treated with ECT at an academic psychiatric hospital with DSM-IV MDE and either comorbid BPD, PTSD or both (MDE + BPD/PTSD), 75 MDE patients without BPD or PTSD (MDE-only) were matched. We reviewed clinical records to determine treatment response by estimating clinical global impression of improvement (c-CGI) and presence of adverse cognitive effects based on subjective distress or objective impairment. We explored factors associated with response and cognitive effects in the MDE + BPD/PTSD group. RESULTS There was no difference in c-CGI response rates between groups (p > 0.017). Secondary analysis of inpatients found lower response rates for MDE + BPD (55.4%) and MDE + BPD + PTSD (55.8%) than MDE-only (82.5%), but not MDE + PTSD (65.0%). There was no difference in adverse cognitive effects in the MDE + BPD/PTSD (23.3%-26.8%) group compared to MDE-only (25.0%). In the MDE + BPD/PTSD group, factors associated with higher response rate were: referral indications other than failed pharmacotherapy, greater number of ECT treatments, presence of adverse cognitive effects, and seizure duration >30 s. CONCLUSIONS Despite a lower c-CGI response for inpatients with MDE + BPD, ECT is a viable treatment option for patients in the MDE + BPD/PTSD group with similar adverse cognitive effect profiles to MDE-only.
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Affiliation(s)
- Tyler S Kaster
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David S Goldbloom
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zafiris J Daskalakis
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benoit H Mulsant
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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11
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Angstman KB, Seshadri A, Marcelin A, Gonzalez CA, Garrison GM, Allen JS. Personality Disorders in Primary Care: Impact on Depression Outcomes Within Collaborative Care. J Prim Care Community Health 2017; 8:233-238. [PMID: 28613090 PMCID: PMC5932731 DOI: 10.1177/2150131917714929] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background:Individuals with personality disorders (PDs) are high utilizers of primary care and mental health services; however, they struggle to utilize the care effectively and studies have shown a strong association between having a PD and higher impairment in social role functioning. This is especially important because PDs are highly comorbid with a wide range of other mental health disorders. The collaborative care model (CCM) for depression was developed with an emphasis on patient engagement and aimed to reduce health care utilization, while improving treatment outcomes in primary care. We hypothesized that the diagnosis of a personality disorder in primary care patients will negatively affect 6-month depression outcomes after enrollment into a CCM. Methods: This retrospective chart review study was conducted on patients enrolled into CCM over a period of 7 years with collection of 6-month follow-up data. A total of 2826 patients were enrolled into CCM with a clinical diagnosis of depression and a baseline Patient Health Questionnaire–9 (PHQ-9) ≥10 were included in the study cohort. Using the depression database, baseline and 6-month follow-up data were obtained. Adjusted odds ratios (AORs) were determined for both remission and persistent depressive symptoms using logistic regression modeling for the 6-month PHQ-9 outcome; while retaining all the study variables. Results: Of the 2826 CCM patients with depression in our study, 216 (7.6%) were found to have a PD. Patients with PD were younger (37.7 vs 42.5 years, P < .001) and more likely to be unmarried (36.1% vs 55.6%, P < .001) than patients without a PD. While age, marital status, clinical diagnosis, and Mood Disorders Questionnaire (MDQ) score were significant predictors of remission; anxiety symptoms, gender, and race were not. The presence of a PD diagnosis was associated with a 60% lower likelihood of remission at 6 months (AOR = 0.39; 95% CI 0.28-0.54). Conversely, patients without a PD were 2.5 times as likely to experience remission at 6-month remission compared to patients with PD (AOR =2.57; 95% CI 1.85-3.56). Conclusion: Patients with a personality disorder were more likely to have a recurrent depressive disorder diagnosis, an abnormal MDQ score, increased anxiety symptoms, and higher baseline PHQ-9 score. Patients with PD had worse CCM outcomes at 6 months with only 25.0% able to achieve remission versus 54.3% (P < .001) without a PD. The presence of a PD with depression was associated with poor outcomes (reduced remission rates and increased persistent depressive symptoms rates) in comparison to patients without a diagnosis of PD, while treated within CCM.
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