Verónica Vitriol

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).

Factors Associated With Greater Severity of Depression in Chilean Primary Care Patients

Objective To determine clinical and psychosocial variables associated with increased depression severity in patients who consult public primary health care clinics (PHCs) in Chile. Methods The study included 394 patients diagnosed with major depressive disorder (MDD) according to ICD-10 criteria who were evaluated between February and September 2014 using a sociodemographic interview, the Mini-International Neuropsychiatric Interview (MINI), a screening for childhood trauma, a scale for partner violence, the Life Events Survey (LES), and the Hamilton Rating Scale for Depression (HRSD). Results Positive correlations were determined between greater severity of depression and more frequency of depressive episodes (r = 0.2, P < .01), psychiatric comorbidities (r = 0.36, P < .01), number of childhood traumatic events (r = 0.19, P < .01), intimate partner violence events (r = 0.155, P < .01), and stressful life events (r = 0.13, P < .05). Inverse correlation was determined with the age at first episode (r = -0.16, P < .01). The psychiatric comorbidities explained most of the variability of depressive symptoms (11.7%); addition of child abuse to the comorbidities increased the correlation to 12.7%. Conclusions The different covariates considered in this sample showed that psychiatric comorbidity played the principal role in explaining the severity of depression.

Remission in Depression and Associated Factors at Different Assessment Times in Primary Care in Chile

Objective: To determine the factors associated with remission at 3, 6, 9 and 12 months among depressive adult patients in primary care [PHC] in Chile. Methods: This is a one-year naturalistic study that followed 297 patients admitted for treatment of depression in eight primary care clinics in Chile. Initially, patients were evaluated using: the International Mini-Neuropsychiatric Interview [MINI], a screening for Childhood Trauma Events [CTEs], the Life Experiences Survey and a partner violence scale. The Hamilton Depression Scale [HDRS] was used to follow the patients during the observation time. Associations between the factors studied and the primary outcome remission [HDRS ≤ 7] were assessed using a dichotomous logistic regression and a multivariate Poisson regression. The significance level was 0.05. Results: Remission [HDRS ≤ 7] ranged between 36.7% at 3 months and 53.9% at 12 months. Factors that predicted poor remission during the observation time were: CTEs [Wald X2 = 4.88, Exp B=0.94, CI 0.90-0.92, p=0.27]; psychiatric comorbidities [Wald X2 = 10.73, Exp B=0.90, CI 0.85-0.96, p=0.01]; suicidal tendencies [Wald X2 = 4.66, Exp B=0.88, CI 0.79-0.98, p=0.03] and prior treatment for depression [Wald X2 = 4.50, Exp B=0.81, CI 0.68-0.85, p=0.03] Discussion: Almost 50% of this sample failed remission in depression at 12 months. Psychiatric comorbidities and CTEs are factors that should be considered for a poor outcome in depressed Chilean patients. These factors need more recognition and a better approach in PHC.

Depresión adulta y experiencias infantiles adversas: evidencia de un subtipo depresivo complejo en consultantes de la Atención Primaria en Chile

BACKGROUND Traumatic experiences during childhood may influence the development of mental disorders during adulthood. AIM To determine clinical and psychosocial variables that are associated with a higher frequency of adverse childhood experiences (ACE) in patients who consult for depression in Primary Health Care clinics in Chile. MATERIAL AND METHODS A socio-demographic interview, the mini international neuropsychiatric interview (MINI), a screening for ACE, a questionnaire for partner violence (PV), the Life Experiences Survey (LES) and the Hamilton Rating Scale for Depression (HRDS) were applied to 394 patients with major depression (87% women). RESULTS Eighty two percent of patients had experienced at least one ACE and 43% of them reported three or more. Positive correlations were observed between the number of ACE and severity of depressive symptoms (r = 0.19; p < 0.01), psychiatric comorbidities (r = 0.23; p < 0.01), partner violence events (r = 0.31; p < 0.01), vital stressful events (r = 0.12; p < 0.01), number of depressive episodes (r = 0.16; p < 0.01), duration of the longer depressive episode (r = 0.12; p < 0.05) and suicidal tendency according to HDRS (r = 0.16; p < 0.01). An inverse correlation was observed between frequency of ACE and age at the first depressive episode (r = -0.12; p < 0.05). CONCLUSIONS These data are consistent with the hypothesis that early trauma is associated with more severe and complex depressive episodes during adulthood.

Childhood trauma and psychiatric comorbidities in patients with depressive disorder in primary care in Chile.

ABSTRACT Childhood trauma is associated with different psychiatric disorders during adulthood. These disorders are often presented in comorbidity with depression. Objective: To establish the relationship between psychiatric comorbidities and childhood traumatic events in patients with depression in Chile. Methods: Three hundred and ninety-four patients with major depression were assessed using the MINI International Neuropsychiatric Interview and a screening for childhood trauma. Results: Social anxiety disorder was associated with having witnessed domestic violence during childhood (OR = 2.2, CI 1.2 - 3.8), childhood physical abuse (OR = 2.7, CI 1.6 - 4.4), physical injury associated with physical abuse (OR = 2.3, CI 1.3 - 4.7) and sexual abuse by a non-relative (OR = 2.7, CI 1.3 - 4.2). Posttraumatic stress disorder was associated with physical injury associated with physical abuse (OR = 1.9, CI 1.1 - 3.6), sexual abuse by a relative (OR = 3.2, IC 1.8 - 5.9) and sexual abuse by a non-relative (OR = 2.2, CI 1.2 - 4.1). Antisocial personality disorder was associated with traumatic separation from a caregiver (OR = 3.2, CI 1.2 - 8.5), alcohol abuse by a family member (OR = 3.1, CI 1.1 - 8.1), physical abuse (OR = 2.8, CI 1.1 - 6.9) and sexual abuse by a non-relative (OR = 4.8, CI 1.2 – 11.5). Panic disorder was associated with sexual abuse by a relative (OR = 1.9, CI 1.1 - 3.1). Generalized anxiety disorder was associated with sexual abuse by a non-relative (OR = 1.9, CI 1.1- 3.3). Conclusions: Further clinical recognition is required in patients seeking help for depression in primary care. This recognition must take into account the patient’s current psychiatric comorbidities and adverse childhood experiences.

Respuesta de los centros de atención primaria en salud mental después del terremoto y tsunami del 2010 en la Región del Maule

Background: Thirty to 50% of people exposed to a natural disaster suffer psychological problems in the ensuing months. Aim: To characterize the activities in mental health developed by Primary Health Care centers after the earthquake that affected Chile on February 27th, 2010. Material and methods: A cross-sectional study analyzing 16 urban centers of Maule Region, was carried out. A questionnaire was developed to know the preparatory and supportive activities directed to the community and the training and self-care activities directed to Health Care personnel that were made during the 12 months following the catastrophe. In addition, a questionnaire evaluating structural aspects was designed. Results: Only 1/3 of the centers made some preparatory activity and none of them made a diagnosis of population vulnerability. The average of protective Mental Health interventions coverage reached 35% of the population estimated to be most affected. The activities lasted 31 to 62% of the optimal duration standards set by experts (according to the type of action). Important differences between centers in economic and geographical accessibility, construction and professional resources were found. Conclusions: This study shows the difficulties faced by urban centers of Maule Region to deal with mental health problems caused by the earthquake, which were attributable to the absence of local planning and drills, and to the lack of intra and inter sectorial coordination.

Factors Associated with Psychiatric Comorbidity in Depression Patients in Primary Health Care in Chile

Objective To identify the clinical and psychosocial factors associated with psychiatric comorbidity in patients consulting for depression in Primary Health Care (PHC) in Chile. Methods 394 patients with a diagnosis of major depression being treated in a Chilean PHC were evaluated using a sociodemographic and clinical interview, the mini-international neuropsychiatric interview (MINI), a childhood trauma events (CTEs) screening, the intimate partner violence (IPV) scale, the Life Experiences Survey (LES), and the Hamilton Depression Rating Scale (HDRS). Results Positive correlations were established between higher number of psychiatric comorbidities and severity of depressive symptoms (r = 0.358), frequency of CTEs (r = 0.228), frequency of IPV events (r = 0.218), frequency of recent stressful life events (r = 0.188), number of previous depressive episodes (r = 0.340), and duration of these (r = 0.120). Inverse correlations were determined with age at the time of the first consultation (r = -0.168), age of onset of depression (r = -0.320), and number of medical comorbidities (r = -0.140). Of all associated factors, early age of the first depressive episode, CTEs antecedents, and recent stressful life events explain 13.6% of total variability in psychiatric comorbidities. Conclusions A higher prevalence of psychiatric comorbidity among subjects seeking help for depression in Chilean PHCs is associated with early onset of depression, clinical severity, chronicity, and interpersonal adversity experienced since childhood.

Depresión y trauma temprano: hacia una caracterización clínica de perfiles de consulta en un servicio de salud secundario

Patients with depression maltreated during childhood differ from those depressive patients without this background. In patients with early trauma the disease emerges earlier, it is more severe and does not respond to the classical antidepressant therapy. Despite this evidence, research regarding the clinical conceptualization and approach to these patients is still limited. The above becomes relevant in Chile, considering the high prevalence of depression and history of adverse childhood events among Chilean depressive consulting health services. Based on the conceptualization of complex Post traumatic stress disorder (PTSD), the overall objective of this article is to propose a conceptualization to the clinical characteristics presented in depressive patients with early abuse, who consult in a mental health service. We propose that in all these patients it needs to inquire actively about history of early adverse events, patterns of interpersonal difficulties, psychiatric comorbidity with emphasis on PTSD features and presence of dissociative symptoms. According to which of the areas is the most important to understand the reason of consultation and considering the observation of 41 patients treated in the context of the Psychic Tauma Unit in the Curicó Hospital, we postulate the existence of the following profiles: depressive, posttraumatic and dissociative. The main clinical characteristics of each profile are presented with a therapeutic approach.