Can PTSD Overlap with Depression?
What is Depression?Depression is one of the mental disorders most commonly associated with exposure to trauma. It is quite common for people to go through short periods during which they feel ‘depressed’, which is a state of mind characterised by unhappiness, lack of motivation and hopelessness. Often, these periods of low mood occur after a negative experience such as failing an exam or not being successful at a job application. However, in the large majority of cases, these feelings are short-lived, and the individuals will return to their normal state of mind and wellbeing.Man sitting on a concrete bench. Source: Pexels.com
Clinical DepressionClinical depression is different from these natural periods of low mood and ‘depression’ in that it does not always have an identifiable cause, is much more long-lasting or pervasive, and it has an impact on an individual’s ability to go about their daily life.
Clinical depression is known as Major Depressive Disorder (MDD) in the DSM-5. The main symptoms of clinical depression are outlined below:
- Depressed mood
- Anhedonia – loss of interest or pleasure in all or most activities
- Anergia – lack of energy
- Sleep disturbances
- Weight and appetite changes
- Poor concentration and memory
- Negative thoughts and cognitions which may lead to feelings of worthlessness
- Suicidal thoughts or suicide attemptsThese symptoms must be sufficiently severe to cause an individual severe distress or impairment in completing tasks associated with their daily life, including at home and at work.
Depression and PTSDFollowing exposure to trauma, depression and PTSD frequently co-occur and are often not easily distinguishable, especially in the first few months following the traumatic experience (O’Donnell et al., 2004). Some evidence has suggested that approximately 50% of those diagnosed with PTSD also meet the criteria for MDD (Flory & Yehuda, 2015). The relationship between these disorders is not fully understood. The current evidence base suggests that PTSD may be a causal risk factor for the development of MDD (Frías et al., 2016). However, this relationship is likely to be bi-directional, meaning that pre-existing MDD may increase the risk of developing PTSD following exposure to trauma. There is also a suggestion that PTSD and MDD share common risk factors and vulnerabilities, meaning that if an individual possesses risk factors that predispose them to MDD, they would also be predisposed to PTSD. Frias and colleagues also reported that PTSD symptomatology is more severe in individuals with comorbid PTSD and MDD than in individuals with PTSD alone.A person talking to a therapist on a couch. Source: Pexels.com
Treatment ImplicationsFlory and Yehuda (2015) highlighted that the overlap between MDD and PTSD may have significant implications for treatment. Frías and colleagues (2016) outlined how comorbid MDD can affect the effectiveness of treatments for PTSD. The results of the review are summarised in the table below.
|PTSD Treatment||Impact of Comorbid MDD on Treatment Effectiveness|
|Cognitive Processing Therapy (CPT)||Many studies with small sample sizes have found that the presence of comorbid MDD does not impact on the effectiveness of Cognitive Processing Therapy for treating PTSD symptoms (Lloyd et al., 2014; Walter, et al., 2012). However, two larger randomised controlled trials (RCT) had conflicting results: one suggested that presence of comorbid MDD lowered therapeutic response to Cognitive Processing Therapy in individuals with PTSD (Stein et al., 2012), while the other found that higher depression severity was associated with increased effectiveness of Cognitive Processing Therapy in individuals with PTSD (Rizvi et al., 2009).|
|Prolonged Exposure Therapy (PET)||Research into the effectiveness of PET has produced inconsistent results. One RCT found that higher levels of depression was associated with decreased therapeutic effectiveness of PET (Stein et al, 2012), while another RCT found the opposite result (Rizvi et al., 2009). Other studies (Hagenaars et al., 2010; van Minnen et al., 2002) have also found that depression severity does not influence therapeutic effectiveness of PET when treating PTSD.|
|Cognitive-Behavioural Therapy (CBT)||Research has yielded inconclusive findings about the use of CBT for patients with such comorbidity. Two studies have found that higher baseline depression was positively associated with improvement in PTSD symptoms (Forbes et al., 2003; Taylor et al., 2001). However, other studies (Deblinger et al., 2006; Richardson et al., 2011) have found that depression severity does not predict the therapeutic effectiveness of CBT for the treatment of PTSD.|
|Anti-depressants||The literature has produced mixed results in relation to anti-depressant use in this population. In one RCT, veterans who had PTSD and experienced higher levels of depressive symptoms responded less positively to amitriptyline (Davidson et al., 1993). Another RCT found that comorbid MDD did not influence the effectiveness of sertraline in a sample of trauma-affected individuals (Brady & Clary, 2003).|
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Post-Traumatic Stress Disorder (PTSD) in the Global Context
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