Evolution of Depressive Symptoms Among Depression Subtypes of Clinical and Functional Variables in Primary Care in Chile.

OBJECTIVE: To compare the evolution of depressive symptoms among depressive subtypes based on clinical and functional variables in a sample of primary care in Chile. METHODS: A longitudinal study was conducted in the Maule Region of Chile, focusing on 8 primary care from February 2014 to September 2015. Clinical and functional variables, including Mini International Neuro-psychiatric Interview, Outcome Questionnaire interpersonal and social sub-scales, were applied in a latent class analysis. This analysis categorized 210 patients into 3 subtypes: complex depression (N = 100), recurrent depression (n = 96), and unique depression (n = 14). Complex depression, exhibited a higher probability of suicide attempts, interpersonal and social dysfunction, and association with adverse childhood experiences according the Brief Physical and Sexual Abuse Questionnaire. Patients were monitored over 1 year with the Hamilton scale. The Kruskal-Wallis, non-parametric test, followed by paired Mann-Whitney test evaluated difference in the severity of depressive symptoms between the groups. Additionally, data on mental health interventions were collected. RESULTS: Out of the 210 patients, 89% were women, with a median age of 50 (range 37-58), and 40.1% with only primary education. Sociodemographic characteristics not differ between groups. Significant differences in depressive symptom severity between the groups were found (X2 90.06, P < .001, Kruskal-Wallis test, η2 = 0.084). Post hoc analyses indicated higher depressive symptoms in complex depression compared to recurrent (Z = -9.501, P < .001) and unique (Z = -2.877, P = .004) depression, with no significant difference between recurrent and unique depression (Z = -1.58, P = .113). There were no differences in the number of medical and psychological controls between the groups. The patients with complex depression required greater modifications in the pharmacological prescriptions than those belonging to the other groups. CONCLUSION: These results provide additional evidence of a complex depression subtype in primary care in Chile associated with adverse childhood experiences, that had worse resolution of depressive symptoms. Contrary to expectations, patients belonging to this group did not receive further medical and psychological interventions, probably due to a lack of specific clinical recommendations.

Latent Class Analysis in Depression, Including Clinical and Functional Variables: Evidence of a Complex Depressive Subtype in Primary Care in Chile.

OBJECTIVE: To establish differentiated depressive subtypes using a latent class analysis (LCA), including clinical and functional indicators in a sample of depressed patients consulted in Chilean Primary Health Care. METHODS: A LCA was performed on a sample of 297 depressed patients consulted in Chilean PHC. The Mini International Neuropsychiatric Interview, the Hamilton Depression Rating Scale, the Outcome Questionnaire -social role, and interpersonal subscales were as instruments. A regression analysis of the different subtypes with sociodemographic and adverse life experiences was performed. RESULTS: In a sample characterized by 87.5% of women, two, three, and four latent class models were obtained. The three-class model likely represents the best clinical implications. In this model, the classes were labeled: "complex depression" (CD) (58% of the sample), "recurrent depression" (RD) (34%), and "single depression episode" (SD) (8%). Members of CD showed a higher probability of history of suicide attempts, interpersonal, and social dysfunction. Psychiatric comorbidities differentiated the RD from SD. According to a multinomial regression model, childhood trauma experiences, recent stressful life experiences, and intimate partner violence events were associated with the CD class (p < 0.01). Limitations. The vast majority of participants were females from Chile and the sample studied was not random. So, the results may not necessarily represent outpatient clinics. CONCLUSIONS: This study can provide additional evidence that depression, specifically in female gender, could be better understood as a complex heterogeneous disorder when clinical and functional indicators are studied. Furthermore, adverse life experiences starting in childhood could lead to a differentiated complex depressive subtype.

Cuidado informado en trauma: un modelo emergente para el abordaje del subtipo depresivo con historia de adversdad infantil / Informed care in trauma: an emerging model for the depression subtype with a history of childhood adversity

Resumen Las experiencias infantiles adversas (EIAs) son un factor de riesgo para el desarrollo de las patologías mentales más prevalentes en la vida adulta, entre las que se incluye la depresión, y se asocian a una presentación clínica más compleja y severa que requiere de un abordaje diferenciado. En Chile, la depresión cuenta con garantías explícitas en salud y una guía ministerial de recomendaciones. Un 90% de los pacientes son tratados en la atención primaria de salud (APS). Un tercio de las muestras depresivas consultantes en la APS de la VII Región presenta una sintomatología caracterizada por mayor suicidalidad, exposición a EIAs e historia de violencia doméstica. Estos pacientes requieren de un tratamiento diferenciado que incorpore, al manejo de la depresión, los conocimientos de las consecuencias del trauma psíquico. Los resultados del Adverse Childhood Experiences Study, los hallazgos neurobiológicos derivados del estrés tóxico y el modelo de cuidado informado en trauma constituyen marcos de referencia que orientan la práctica clínica en consultantes con historia de EIAs en el contexto de los servicios de salud. El objetivo de este trabajo es revisar estas líneas conceptuales, en un intento por reformular un abordaje clínico y encauzar la investigación de este subgrupo de pacientes depresivos.

Adverse childhood experiences (ACEs) are a risk factor for the development of the most prevalent mental disorders in adulthood, including major depression, and are associated with a more complex clinical presentation and increased severity, which requires a unique approach. In Chile, depression is subject to explicit legal mandates ensuring access to and guidelines for clinical care issued by the government. Ninety percent of depressed patients are treated in primary care. A third of primary patients presenting with depression in the VII Region are characterized by increased suicidality and histories of exposure to ACEs and violence within the family. These patients require a specialized treatment that incorporates research findings in the field of trauma, as applied to the treatment of depression. Together, results from the ACE Study, neurobiological evidence from exposure to toxic stress and the model of trauma-informed care comprise a framework that can orient clinical practice in healthcare settings. The purpose of this article is to review the literature with the goal of update the clinical approach and suggest future research in this subgroup of depressed patients.

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.

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 / Association between adverse childhood experiences with depression in adults consulting in primary care

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.

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.

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

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.

[Association between adverse childhood experiences with depression in adults consulting in primary care]. / 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.

Depresión y trauma temprano: hacia una caracterización clínica de perfiles de consulta en un servicio de salud secundario / Depression and early trauma: towards a characterization of clinical profiles of consultation in a secondary mental health service

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.

Existe suficiente evidencia que constata que los antecedentes de maltrato infantil se asocian al desarrollo de un subtipo depresivo en la vida adulta, de mayor severidad, cronicidad y peor respuesta a la terapia antidepresiva clásica. La conceptualización respecto a la clínica y al abordaje que requiere este subtipo ha sido poco sistematizada. En Chile, lo anterior adquiere relevancia dada la alta prevalencia de antecedentes de maltrato infantil en consultantes por depresión en los servicios de salud. Partiendo de la conceptualización que engloba la nosología de Estrés post-traumático (TEPT) complejo, el objetivo general de este artículo es proponer una posible caracterización de pacientes con depresión y trauma temprano en un servicio de salud secundario. Se plantea para el reconocimiento de esta clínica diferenciada, en el nivel secundario, que en la primera consulta en todos los pacientes depresivos, se indaguen activamente las siguientes variables: historia de eventos adversos tempranos, patrón de dificultades interpersonales, comorbilidad psiquiátrica con énfasis en la pesquisa activa de la clínica de cuadros ansiosos específicamente TEPT y presencia de síntomas o trastornos disociativos. Según cuál de las variables clínicas previamente expuestas, permite comprender mejor el motivo de consulta actual, y de acuerdo a la observación de 42 pacientes en la Unidad de Trauma del Hospital de Curicó postulamos la existencia de los siguientes perfiles de consulta en estos pacientes: depresivo, postraumático y disociativo. Se plantean las características clínicas centrales que pudiese caracterizar a cada uno de estos perfiles y el probable abordaje terapéutico

[Response of primary care teams to manage mental health problems after the 2010 earthquake]. / 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.

Respuesta de los centros de atención primaria en salud mental después del terremoto y tsunami del 2010 en la Región del Maule / Response of primary care teams to manage mental health problems after the 2010 earthquake

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.

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).