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Psychotherapy for Chronic Depression in Patients with Early Life Trauma

These patients had better outcomes with psychotherapy (with or without medication) than with medication alone.

Because psychotherapy is more costly in time and money than psychopharmacologic intervention for treatment of chronic major depressive disorder (MDD), identifying which MDD patients will do better with psychotherapy is an important public health challenge. In a partially manufacturer-sponsored study, investigators examined this issue by reanalyzing data from a trial involving 681 adults with MDD (age range, 18-75) who had been randomized to receive 12 weeks of nefazodone therapy, psychotherapy based on a cognitive-behavioral model, or a combination of the 2 treatments (see Journal Watch Psychiatry Jul 1 2000). Data were analyzed by whether subjects had experienced early childhood trauma; 33% had experienced parental loss; 45%, physical abuse; 16%, sexual abuse; and 10%, neglect.

In an analysis of treatment completers, the group of participants with no childhood trauma (n=181) had significantly better recovery with drug or combination treatment than with psychotherapy alone. In contrast, the group of 315 participants with early childhood trauma had significantly better outcomes with psychotherapy (with or without medication) than with medication alone. These effects were especially strong in patients with early parental loss.

Comment: As the authors note, these results are consistent with studies of depressed patients that found loss of hippocampal volume mainly in individuals with early childhood trauma, suggesting that they may constitute a unique subgroup of depressed patients. Hopefully, these data will inform health insurers' policies on reimbursements for psychotherapy. Clinically, the findings behoove psychiatrists to better direct intervention approaches by obtaining histories of early loss, abuse, and neglect. It is noteworthy that the psychotherapy did not involve dealing with the early trauma. An exciting prospect is investigating this treatment paradigm in children.

— Barbara Geller, MD

Published in Journal Watch Psychiatry January 14, 2004

Citation(s):

Nemeroff CB et al. Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci U S A 2003 Nov 25; 100:14293-6.

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