The contribution of early adverse stress to complex and severe depression in depressed outpatients.

BACKGROUND: To assess whether linear effects or threshold effects best describe the association between early adverse stress (EAS) and complex and severe depression (i.e., depression with treatment resistance, psychotic symptoms, and/or suicidal ideation), and to examine the attributable risk of complex and severe depression associated with EAS. METHODS: A cross-sectional study was conducted using deidentified clinical data (on demographics, presence of complex and severe depression, and exposure to seven types of EAS) from 1,013 adults who were seen in an outpatient mental health clinic in Santiago, Chile, for a major depressive episode. Multivariate logistic regressions were fitted to estimate odds ratios (ORs), using a bootstrap approach to compute 95% bias-corrected confidence intervals (95% BC CIs). A detailed examination of the cumulative risk score and calculations of the attributable risk was conducted. RESULTS: Exposure to at least five EASs was reported by 3.6% of the sample. In the multivariate logistic regression models, there was a marked increase in the odds of having complex and severe depression associated with exposure to at least five EASs (OR = 4.24; 95% BC CI: 1.25 to 9.09), according to a threshold effect. The attributable risk of complex and severe depression associated with exposure to at least one EAS was 36.8% (95% BC CI: 17.7 to 55.9). CONCLUSIONS: High levels of EAS distinctively contribute to complex clinical presentations of depression in adulthood. Patients with complex clinical presentations of depression and history of EAS should need a differentiated treatment approach, particularly those having high levels of EAS.

[Systematic review of treatment alternatives for depressed adults with early adverse stress]. / Tratamiento de la depresión en adultos con estrés adverso temprano: revisión sistemática de su efecto en síntomas relacionados a trauma, ansiedad, desajuste social y calidad de vida.

BACKGROUND: Early adverse stress is a risk factor for the appearance of mental health ailments during adulthood. AIM: To systematically review treatment outcomes on mental health symptoms and functional domains, and of interventions aimed at treating adults with depressive disorders and early adverse stress (EAS). MATERIAL AND METHODS: Systematic review and meta-analysis including experimental and quasi-experimental published studies indexed in the CINAHL, EMBASE, PubMed, and Web of Science databases, which explored the effectiveness of treatment interventions for depressive disorders in adults exposed to EAS. Data on outcomes was extracted from the included studies. A narrative, qualitative approach or a quality-effects model for meta-analysis were used for synthesizing these data. RESULTS: Thirteen studies were included. Psychological or combined treatment interventions for depression in adults exposed to EAS may be effective in reducing trauma-related symptoms and social dysfunction in the short-and mid-term, with small effect size and without substantive heterogeneity. The assessment of anxiety symptoms and health-related quality of life yielded mixed results. CONCLUSIONS: Despite the ubiquity of EAS and its adverse and long-lasting consequences for well-being and health, treatment alternatives are scant. This review suggests that there are treatment interventions for depression in adults exposed to EAS that may achieve integral mental health benefits, alleviating its impact on various symptoms and functional domains, when EAS is explicitly considered in the treatment intervention.

Population-attributable risk of adverse childhood experiences for high suicide risk, psychiatric admissions, and recurrent depression, in depressed outpatients.

Background: Population-attributable risk (PAR) may help estimate the potential contribution of adverse childhood experiences (ACEs) to serious clinical presentations of depression, characterized by suicidality, previous psychiatric admissions, and episode recurrence. Objective: To determine the PAR of ACEs for serious clinical presentations of depression (high suicide risk, previous psychiatric admissions, and recurrent depression) in outpatients with ICD-10 clinical depression. Method: Systematic chart review of 1,013 adults who were assessed and/or treated in a mental health clinic in Santiago, Chile for a major depressive episode. Data were collected on demographics and clinical characteristics of depression. Exposure to ACEs was determined with the Brief Physical and Sexual Abuse Questionnaire, assessing seven types of ACEs. Multivariable logistic regression analysis was used to assess the association between exposure to ACEs and suicidality, previous psychiatric admissions, and recurrence. Predicted probabilities were used for calculations of PAR. Results: Of the 1,001 study participants with complete data, 53.3% had recurrent depression, 13.5% had high suicide risk, and 5.0% had previous psychiatric admissions. Exposure to at least one ACE was recorded for 69.0% of the sample. Exposure to at least one ACE and specific types of ACEs (i.e. childhood sexual abuse and traumatic separation from caregiver) were associated with serious clinical presentations of depression. A dose-response relationship was observed between cumulative exposure to ACEs and the most serious clinical presentations of depression. ACEs were attributed to a significant proportion of disease: 61.6% of previous psychiatric admissions, 45.0% of high suicide risk, and 14.5% of recurrent depression. Conclusions: A substantial proportion of serious clinical presentations of depression among outpatients are associated with ACEs. Early detection of depressive episodes associated with ACEs, and tailored treatment for these patients, may potentially reduce the incidence of serious complications in this population.

Introducción: El riesgo atribuible poblacional (RAP) puede ayudar a estimar la potencial contribución de las experiencias adversas infantiles (EAIs) a las presentaciones clínicas serias de la depresión, caracterizadas por riesgo suicida, hospitalizaciones psiquiátricas previas y recurrencia de episodios.Objetivo: Determinar el RAP de las EAIs para las presentaciones clínicas serias de la depresión (alto riesgo suicida, hospitalizaciones psiquiátricas previas y depresión recurrente) en pacientes deprimidos ambulatorios.Método: Revisión sistemática de fichas clínicas de 1.013 adultos que fueron evaluados y/o tratados en una clínica de salud mental en Santiago, Chile por un episodio depresivo mayor. Se recolectaron datos demográficos y sobre características clínicas de la depresión. La exposición a EAIs se determinó con el Brief Physical and Sexual Abuse Questionnaire, evaluándose siete tipos de EAIs. Se usó análisis de regresión logística multivariada para evaluar la asociación entre exposición a EAIs y riesgo suicida, hospitalizaciones psiquiátricas previas y recurrencia. Las probabilidades predichas fueron utilizadas para los cálculos de los RAP.Resultados: De 1.001 participantes del estudio con datos completos, 53,3% tuvieron una depresión recurrente, 13,5% tuvieron alto riesgo suicida, y 5,0% tuvieron hospitalizaciones psiquiátricas previas. La exposición a al menos un EAI se registró en 69,0% de la muestra. La exposición a al menos un EAI y tipos específicos de EAIs (i.e. abuso sexual infantil y la separación traumática del cuidador), se asociaron con presentaciones clínicas serias de la depresión. Se observó una relación dosis-respuesta entre la exposición cumulativa a EAIs y las presentaciones clínicas más serias de la depresión. Las EAIs se atribuyeron una proporción significativa de la enfermedad: 61,6% de las hospitalizaciones psiquiátricas previas, 45,0% del alto riesgo suicida, y 14,5% de depresión recurrente.Conclusiones: Una proporción sustancial de presentaciones clínicas serias de la depresión en pacientes deprimidos ambulatorios se asocian con EAIs. La detección temprana de los episodios depresivos asociados con EAIs y el tratamiento a la medida para estos pacientes podrían potencialmente reducir la incidencia de complicaciones serias en esta población.

Early Adverse Stress and Depressive and Bipolar Disorders: A Systematic Review and Meta-Analysis of Treatment Interventions.

Introduction: A significant proportion of adults with depressive or bipolar disorders exposed to early adverse stressors do not adequately respond to standard treatments. This review aimed at synthesizing the evidence on the effectiveness of treatment interventions for depressive or bipolar disorders in adult individuals (aged 18 years or more) exposed to adverse stress early in life. Methods: Systematic review and meta-analysis including experimental and quasi-experimental published studies indexed in CINAHL, EMBASE, PubMed, and Web of Science databases and/or in reference lists. Data management and critical appraisal (with the Study Quality Assessment Tools) was conducted independently by multiple researchers. A quality-effects model for meta-analysis was used for data synthesis and publication bias was assessed using the Doi plot and LFK index. The main outcome was short-term reductions in depressive symptoms. Results: Eight randomized controlled trials, three controlled before-and-after (pre-post) studies, and three uncontrolled before-and-after studies were included. Studies lacked bipolar disorder patients. Unclear randomization procedures and reporting of blinded outcome assessor, and limited use of intention-to-treat analysis, were relevant potential sources of bias. Meta-analyses indicated that psychological, pharmacological, and combined interventions were effective in reducing depressive symptoms in the short- (Cohen's d = -0.55, 95% CI -0.75 to -0.36, I 2 = 0%) and mid-term (Cohen's d = -0.66, 95% CI -1.07 to -0.25, I 2 = 65.0%). However, a high risk of publication bias was detected for these outcomes. A small number of studies, with mixed results, reported interventions with long-term improvements in depressive symptomatology, and short- and mid-term response to treatment and remission. Conclusion: Despite the well-documented long-lasting, negative, and costly impact of early adverse stressors on adult psychopathology, evidence on treatment alternatives remains scant. Trauma-focused treatment interventions-whether psychological interventions alone or in combination with pharmacotherapy-may have the potential to reduce the severity of depressive symptom in adults who were exposed to early adverse stress. Findings must be interpreted with considerable caution, as important study and outcome-level limitations were observed and gray literature was not considered in this systematic review and meta-analysis.

Tratamiento de la depresión en adultos con estrés adverso temprano: revisión sistemática de su efecto en síntomas relacionados a trauma, ansiedad, desajuste social y calidad de vida / Systematic review of treatment alternatives for depressed adults with early adverse stress

BACKGROUND: Early adverse stress is a risk factor for the appearance of mental health ailments during adulthood. AIM: To systematically review treatment outcomes on mental health symptoms and functional domains, and of interventions aimed at treating adults with depressive disorders and early adverse stress (EAS). MATERIAL AND METHODS: Systematic review and meta-analysis including experimental and quasi-experimental published studies indexed in the CINAHL, EMBASE, PubMed, and Web of Science databases, which explored the effectiveness of treatment interventions for depressive disorders in adults exposed to EAS. Data on outcomes was extracted from the included studies. A narrative, qualitative approach or a quality-effects model for meta-analysis were used for synthesizing these data. RESULTS: Thirteen studies were included. Psychological or combined treatment interventions for depression in adults exposed to EAS may be effective in reducing trauma-related symptoms and social dysfunction in the short-and mid-term, with small effect size and without substantive heterogeneity. The assessment of anxiety symptoms and health-related quality of life yielded mixed results. CONCLUSIONS: Despite the ubiquity of EAS and its adverse and long-lasting consequences for well-being and health, treatment alternatives are scant. This review suggests that there are treatment interventions for depression in adults exposed to EAS that may achieve integral mental health benefits, alleviating its impact on various symptoms and functional domains, when EAS is explicitly considered in the treatment intervention.