Posttraumatic stress disorder (PTSD) and depression severity in sexually assaulted women: hypothalamic-pituitary-adrenal (HPA) axis alterations.

BACKGROUND: Sexual assault is implicated in several adverse psychological and physical health outcomes, including posttraumatic stress disorder (PTSD) and depression. Neurobiological research has shown variations related to the hypothalamic-pituitary-adrenal (HPA) axis, immune alterations, metabolic function, and brain circuitry. Although these mechanisms have been extensively studied, the results have demonstrated different outcomes in PTSD. METHODS: We compared the plasma adrenocorticotropin (ACTH) and salivary cortisol levels of fifty-eight women with PTSD developed after sexual assault to those of forty-four female controls with no history of trauma. We also evaluated the psychiatric diagnosis and symptom severity of PTSD and depression. The participants' clinical conditions were associated with their hormonal levels to assess whether symptom severity was related to hormonal imbalance. RESULTS: A large percentage of sexually assaulted women had PTSD and comorbid depression. The ACTH levels were higher in the PTSD group than the control group and increased as PTSD severity increased, considering depressive symptoms, measured by the Beck Depression Inventory (BDI) (p < 0.0001), as well as PTSD symptoms, measured by subscale D of the Clinician-Administered PTSD Scale (CAPS-5) (p = 0.045) and the CAPS-5 total scale (p = 0.026). Cortisol levels measured at 10 pm were higher for the PTSD group than the control group (p = 0.045, p = 0.037, respectively), and the cortisol awakening response showed elevated cortisol levels for the PTSD group. CONCLUSIONS: These results show a correlation between symptom severity and HPA axis imbalance in patients with PTSD. Elevated ACTH and an elevated cortisol response in patients with comorbid depressive symptoms were the opposite of the expected response for patients with PTSD only. This association leads to the hypothesis that the neurobiological alterations of PTSD are related to the type of symptoms presented and their severity. These manifestations likely influence the disease course, prognosis and response to treatment. These outcomes highlight the need to discuss particular neurobiological alterations in patients with PTSD developed after sexual assault, mainly those with severe depressive symptoms.

Mental health of children who work on the streets in Brazil after enrollment in a psychosocial program.

PURPOSE: To evaluate the mental health status of children working on the streets in Sao Paulo City, Brazil, two years after their participation in a psychosocial program, and to identify factors associated with their mental health status. METHODS: From a total sample of 126 children working on the streets, 107 (85%) were re-evaluated two years after the initiation of a psychosocial program which aimed to cease their work on the streets. The focus was the presence of mental health problems, defined based on a screening instrument (Strengths and Difficulties Questionnaire). Logistic regression models tested factors related to the probability that a child would not present mental health problems at follow-up. RESULTS: The likelihood of a child presenting mental health problems was higher at baseline compared to the two-year follow-up (67.5 and 56.1%, respectively). Absence of mental health problems two years after a psychosocial intervention was significantly correlated with the following baseline factors: lower level of caregiver's psychiatric symptoms as measured by the SRQ (Self-Report Questionnaire) (AOR = 0.84, p = 0.0065), absence of child physical neglect (AOR = 0.38, p = 0.0705) and parental Protestant religion affiliation, compared to other religions (AOR = 4.06; p = 0.0107). CONCLUSIONS: Different factors are related to the absence of mental health problems of children working on the streets after enrollment in a two-year psychosocial program. Our findings suggest that interventions that aim to improve child mental health should consider the detection of psychiatric symptoms in caregivers, provide treatment when it is needed, and also assess other problems such as neglect in the family setting.

Children working on the streets in Brazil: predictors of mental health problems.

The objective of this study was to determine which factors predict higher risk for mental health problems in children working on the streets. We studied a sample of families that had at least one child working on the streets, from October 2008 to March 2009. The instruments applied were the parent version strengths and difficulties questionnaire (SDQ), the childhood trauma questionnaire (CTQ) for children and caregivers, the WorldSAFE core questionnaire, the global assessment of relational functioning scale (GARF), the schedule for affective disorders and schizophrenia for school-age children (K-SADS), and a socio-demographic questionnaire. 191 children between 7 and 14 years of age were analyzed; 126 (66%) were working on the streets, and 65 were siblings who did not work on the streets. Multivariate analysis showed that mental health problems in the caregivers, violent behaviors of the caregivers toward the children, absence of a partner living in the house, and lower levels of family functioning increased the risk of mental health problems in the children. Caregivers reported severe forms of physical punishment against their children in 62% of cases. Caregivers who had suffered sexual abuse and emotional negligence in childhood were more violent with their children. Factors that increased risk for mental health symptoms in these children were caregivers' psychopathology, physical punishment at home, single-parent structure, and poor family functioning. Work on the streets did not influence the children's mental health, when multiple risk factors were considered; family characteristics were the most significant in this sample.

Peri-Traumatic Dissociation and Tonic Immobility as Severity Predictors of Posttraumatic Stress Disorder After Rape.

Some individuals show abnormal reactions to extreme fear and life-threatening situations, including tonic immobility (TI) and peri-traumatic dissociation (PTD). We aimed to investigate the association of TI and PTD with posttraumatic stress disorder (PTSD) in women who experienced sexual violence and the risk factors for PTD occurrence. We compared PTSD severity in 86 young adult women with PTSD after a sexual violence exposure grouped according to the presence of PTD and TI. In addition, we investigated whether PTD is associated with depression and anxiety symptoms and assessed potential risk factors for PTD reaction. We found a significant positive correlation between PTSD severity and PTD occurrence (R2 = .132; p = .001). PTD was also positively correlated with all clusters of PTSD symptoms except the Clinician-Administered PTSD Scale avoidance cluster (p = .058). PTD was strongly correlated with anxiety (R2 = .619; p < .001) and depressive symptoms (R2 = .547; p < .001). Multiple logistic regression showed that history of physical abuse (odds ratio [OR]: 1.386; p = .011) and sexual abuse (OR: 1.947; p = .004) during childhood were associated with PTD occurrence. Other risk factors for PTD were having less years of study (OR: 0.216; p = .016) and lower income (OR: 7.403; p = .028). TI measures were available for a subsample of 29 women. We found no association between TI and PTSD severity. PTD, but not TI, is significantly associated with more severe PTSD, depressive, and anxiety symptoms. Less-educated women with a history of childhood abuse and a lower income are at risk of PTD occurrence during a sexual violence episode.

The positive impact of maternal depression intervention on children's emotional and behavioral symptoms in a low-resource setting.

OBJECTIVE: Children of depressed mothers are at risk of developing mental health problems. We sought to determine whether treatment for maternal depression delivered by community health workers (CHW) would decrease behavioral/emotional symptoms in their child. An intervention treating maternal depressive symptoms in a low-middle-income country can have a high global impact. METHODS: CHW were trained to deliver a psychosocial intervention for mothers with depression in a primary care setting. 49 mothers and 60 children were assessed pre-intervention, post-intervention, and at a 6-months follow-up. Child behavioral/emotional symptoms were evaluated by type of change in maternal depressive symptoms: remission and response. RESULTS: An overall decrease in maternal depressive symptoms from baseline to post-intervention and 6-month follow-up were found. Remission and response of maternal depression was associated with better outcomes related to child´s behavioral/emotional symptoms at the 6-month follow-up (p = 0.0247, Cohen's d: 0.76; p = 0.0224, Cohen's f: 0.44) but not at post-intervention (p = 0.1636, Cohen's d: 0.48; p = 0.0720, Cohen's f: 0.33). CONCLUSION: Maternal depression improvement was related to their child's decreased behavioral/emotional symptoms. Our results suggest that interventions addressing maternal depression in primary care is a viable strategy to prevent behavioral/emotional symptoms in the next generation.

Increased immuno-inflammatory mediators in women with post-traumatic stress disorder after sexual assault: 1-Year follow-up.

BACKGROUND: Sexual violence is a traumatic event that can trigger post-traumatic stress disorder (PTSD) and generate biological responses to stress characterized by inhibiting the hypothalamic-pituitary axis (HPA), altering immune activity, and changing the structure and function of the brain. PTSD is associated with increased levels of inflammatory markers. This study aimed to measure differences in inflammatory markers and HPA hormone levels between women with PTSD due to sexual violence and controls at baseline and after 1-year follow-up. METHODS: Fifty-eight women with PTSD resulting from sexual assault occurring up to 6 months prior were compared to 41 female controls. The patients were followed for 1 year. At baseline (T1), we measured inflammatory biomarkers. We also applied the Mini International Neuropsychiatric Interview (MINI), the Clinician-Administered Post-Traumatic Stress Disorder Scale-5, the Beck Depression Inventory, the Beck Anxiety Inventory, and the Childhood Trauma Questionnaire. The patients were randomized to receive treatment with sertraline or interpersonal psychotherapy for 14 weeks (T2) and then continued the usual treatment if deemed necessary for 1 year. The same interviews and examinations were repeated after 1 year (T3). RESULTS: At baseline, the patients had significantly higher adrenocorticotropic hormone levels, compared to controls; however, there was no baseline difference in inflammatory markers or cortisol. After 1 year, there were significantly higher levels of interleukin-1ß (p < 0.0001), monocyte chemoattractant protein-1 (p < 0.0001), tumor necrosis factor-α (p < 0.0001), c-reactive protein (p < 0.0001), and cortisol (p = 0.046) in the patient group. In addition to PTSD, 56 patients presented with a major depressive episode at T1 (according to the MINI). At the end of 1 year, there was a significant improvement in depressive (p < 0.001), anxiety (p = 0.03), and PTSD symptoms (p < 0.001) regardless of the treatment received. DISCUSSION: The increase of the inflammatory markers after 1 year, even with symptomatic improvement, may indicate that PTSD following sexual violence is associated with high depressive symptoms. This association may have a different pattern of immunoendocrine alterations than PTSD only. Furthermore, these alterations may persist in the long term, even with the improvement of the symptoms, probably generating an immunological imprint that can lead to future clinical consequences. This study adds to the current knowledge of PTSD neurobiology and contributes to broadening approaches to this disorder.

Interpersonal psychotherapy versus sertraline for women with posttraumatic stress disorder following recent sexual assault: a randomized clinical trial.

Background: Sexual assault often triggers posttraumatic stress disorder (PTSD), a potentially chronic severe mental disorder. Most guidelines recommend selective serotonin reuptake inhibitors (SSRIs) and trauma-focused psychotherapies as treatment options. Interpersonal Psychotherapy (IPT), adapted for PTSD (IPT-PTSD), focuses on interpersonal consequences of trauma rather than confronting the trauma itself. Studies have found IPT-PTSD efficaciously reduced PTSD symptoms with limited attrition. No efficacy trials have compared IPT-PTSD and SSRI. We hypothesized IPT would reduce PTSD, anxiety, and depressive symptoms more than sertraline among women with PTSD following a recent sexual assault. Objectives: To compare the efficacy of IPT-PTSD to SSRI sertraline in a 14-week randomized clinical trial for women with PTSD following a recent sexual assault. Methods: Seventy-four women with PTSD who had suffered sexual assault in the last six months were randomly assigned to 14 weeks of IPT-PTSD (n = 39) or sertraline (n = 35). Instruments assessed PTSD, anxiety, and depressive symptoms. This randomized clinical trial was conducted in São Paulo, Brazil, using the Clinician-Administered PTSD Scale-5 (CAPS-5) as the primary outcome measure. Results: Both treatments significantly reduced PTSD, anxiety, and depressive symptoms, without between-group outcome differences. CAPS-5 mean decreased from 42.5 (SD = 9.4) to 27.1 (SD = 15.9) with sertraline and from 42.6 (SD = 9.1) to 29.1 (SD = 15.5) with IPT-PTSD. Attrition was high in both arms (p = .40). Conclusions: This trial showed within-group improvements without differences between IPT-PTSD and sertraline treatment of PTSD. Our findings suggest that non-exposure-based psychotherapies may benefit patients with PTSD, although we did not directly compare these treatments to an exposure therapy. Brazilian Clinical Trials Registry RBR-3z474z.

Antecedentes: La agresión sexual con frecuencia gatilla un trastorno de estrés postraumático (TEPT), un trastorno mental severo potencialmente crónico. La mayoría de las guías clínicas recomiendan los inhibidores selectivos de la receptación de serotonina (ISRSs) y psicoterapias focalizadas en trauma como opciones de tratamiento. La Psicoterapia Interpersonal (PIP), adaptada para TEPT (PIP-TEPT), se focaliza en las consecuencias interpersonales del trauma en lugar de confrontar el trauma en sí. Los estudios han encontrado que la PIP-TEPT eficazmente redujo los síntomas de TEPT con una deserción limitada. Ningún ensayo de eficacia ha comparado PIP-TEPT e ISRS. Hipotetizamos que la PIP-TEPT puede reducir los síntomas de TEPT, ansiedad y depresión más que la sertralina entre las mujeres con TEPT después de una agresión sexual reciente.Objetivos: Comparar la eficacia de la PIP-TEPT con sertralina, un ISRS en un ensayo clínico aleatorizado de 14 semanas para mujeres con TEPT después de una agresión sexual reciente.Métodos: Setenta y cuatro mujeres con TEPT que habían sufrido de una agresión sexual en los últimos seis meses fueron asignadas aleatoriamente a 14 semanas de PIP-TEPT (n = 39) o sertralina (n = 35). Los instrumentos evaluaron síntomas de TEPT, ansiedad y depresión. Este ensayo clínico aleatorizado se realizó en San Pablo, Brasil, utilizando la Escala de TEPT administrada por el clínico (CAPS-5, por sus siglas en inglés) como medida de resultado primaria.Resultados: Ambos tratamientos redujeron significativamente los síntomas de TEPT, ansiedad y depresión, sin diferencias de resultados entre los grupos. La media del CAPS-5 se redujo de 42.5 (DE = 9.4) a 27.1 (DE = 15.9) con sertralina y de 42.6 (DE = 9.1) a 29.1 (DE = 15.5) con la PIP-TEPT. La deserción fue alta en ambos tratamientos (p = .40).Conclusiones: Este ensayo mostro mejoría entre grupos sin diferencias entre la PIP-TEPT y sertralina en el tratamiento del TEPT. Nuestros hallazgos sugieren que las psicoterapias no basadas en la exposición pueden beneficiar a los pacientes con TEPT, aunque no comparamos directamente estos tratamientos con una terapia de exposición.Registro Brasileño de Ensayos Clínicos RBR-3z474z.

[Childhood maltreatment and adult psychopathology: pathways to hypothalamic-pituitary-adrenal axis dysfunction]. / Maus-tratos na infância e psicopatologia no adulto: caminhos para a disfunção do eixo hipotálamo-pituitária-adrenal.

OBJECTIVE: The aim of this paper was to examine the relationship between childhood maltreatment and adult psychopathology, as reflected in hypothalamic-pituitary-adrenal axis dysfunction. METHOD: A selective review of the relevant literature was undertaken in order to identify key and illustrative research findings. RESULTS: There is now a substantial body of preclinical and clinical evidence derived from a variety of experimental paradigms showing how early-life stress is related to hypothalamic-pituitary-adrenal axis function and psychological state in adulthood, and how that relationship can be modulated by other factors. DISCUSSION: The risk for adult psychopathology and hypothalamic-pituitary-adrenal axis dysfunction is related to a complex interaction among multiple experiential factors, as well as to susceptibility genes that interact with those factors. Although acute hypothalamic-pituitary-adrenal axis responses to stress are generally adaptive, excessive responses can lead to deleterious effects. Early-life stress alters hypothalamic-pituitary-adrenal axis function and behavior, but the pattern of hypothalamic-pituitary-adrenal dysfunction and psychological outcome in adulthood reflect both the characteristics of the stressor and other modifying factors. CONCLUSION: Research to date has identified multiple determinants of the hypothalamic-pituitary-adrenal axis dysfunction seen in adults with a history of childhood maltreatment or other early-life stress. Further work is needed to establish whether hypothalamic-pituitary-adrenal axis abnormalities in this context can be used to develop risk endophenotypes for psychiatric and physical illnesses.

[Study review of biological, social and environmental factors associated with aggressive behavior]. / Estudo de revisão dos fatores biológicos, sociais e ambientais associados com o comportamento agressivo.

OBJECTIVES: To study the risk factors related to the development of aggressive behavior. METHOD: A search was carried out in two electronic databases, Medline and SciElo by retrospective studies, longitudinal and review that assessed risk factors for the development of aggressive behavior. RESULTS: There were selected 11 longitudinal studies (8 prospective and 3 case-control studies) and a cross sectional study that evaluated the risk factors and socio-biological related to aggressive behavior. Five studies have evaluated gene expression, five evaluated exposure to tobacco, alcohol and cocaine in the prenatal period, one evaluated the effect of early malnutrition on the development of aggressive behavior and one assessed the impact of child maltreatment. CONCLUSION: The main biological factors were: genetic (low expression of the monoamine oxidase gene and serotonin transporter gene, variations in transporter and dopamine receptor genes), exposure to substances during intrauterine development (tobacco, alcohol and cocaine) and nutrition (malnutrition). The main environmental factors were: child abuse, poverty, crime and antisocial behavior in childhood, while the highest level of evidence was related to early neglect. The interaction between biological and environmental factors can be catalyzed by a hostile environment, increasing the risk for the development of aggressive behavior.

Revictimization as a high-risk factor for development of posttraumatic stress disorder: a systematic review of the literature.

OBJECTIVE: Much research has been published on the role of sexual revictimization in the emergence of mental disorders in adulthood, but findings have sometimes been contradictory. The present systematic review sought to assess the state of the evidence on revictimization as a potential factor for the emergence of posttraumatic stress disorder (PTSD). METHODS: Electronic searches were conducted in five databases (MEDLINE/PubMed, Cochrane Library, Campbell Library, PsycINFO, and LILACS), using the terms PTSD, posttraumatic stress disorder, child abuse, and rape. RESULTS: We identified nine articles that established a connection among childhood sexual abuse (CSA), sexual revictimization in adulthood, and development of PTSD. Eight of the nine papers included were classified as having strong methodological quality (grade VI). One was classified as IV, with an average quality-of-evidence rating. The mean methodological quality score of the articles was 5.5, and the quality of evidence was deemed strong. CONCLUSION: In the included studies, PTSD symptoms were most prevalent in the CSA + adult sexual assault groups, providing further evidence for the revictimization hypothesis.

Attrition in Interpersonal Psychotherapy Among Women With Post-traumatic Stress Disorder Following Sexual Assault.

BACKGROUND: An estimated 16.9% of adult Brazilian women experience sexual assault in their lifetime. Almost half of women who suffer such trauma develop post-traumatic stress disorder (PTSD). Markowitz et al. (2015) found that an affect-focused non-exposure therapy, Interpersonal Psychotherapy (IPT), adapted to treat PTSD (IPT-PTSD) had similar efficacy to and lower dropout rates than Prolonged Exposure (PE), the "gold standard," most studied exposure therapy for PTSD. OBJECTIVE: To assess attrition rates in IPT of sexually assaulted women recently diagnosed with PTSD. METHODS: The current study derives from a two-arm, randomized controlled clinical trial of sexually assaulted women with PTSD who received 14 weeks of standardized treatment with either IPT-PTSD or sertraline. Sample: The 32 patients in the IPT treatment arm were analyzed. RESULTS: Overall attrition was 29%. One patient was withdrawn because of suicidal risk; four dropped out pre-treatment, and five dropped out during IPT-PTSD. If the excluded patient is considered a dropout, the rate increases to 31%. DISCUSSION: This is the first formal study of IPT for PTSD specifically due to sexual assault. IPT attrition approximated dropout rates in PE studies, which are often around 30%, and to the sertraline group in our study (34.5%). Further research should compare IPT and PE among sexually assaulted women to clarify our hypothesis that IPT could be an attractive alternative approach for this patient group.

Interplay between childhood maltreatment, parental bonding, and gender effects: impact on quality of life.

OBJECTIVE: The aim of this study was to examine associations between childhood adversity, parental bonding, gender, depressive symptoms, and quality of life in non-treatment-seeking adults from the community. METHOD: Effects of differential parental rearing were compared in adults who reported a high degree of childhood maltreatment (n=72) and those who reported no significant adverse events in childhood (n=69). Subjects completed retrospective measures of childhood maltreatment and perceived parenting style, as well as measures of current depressive symptoms and quality of life. RESULTS: The subjects without childhood maltreatment were younger and endorsed less current depressive symptomatology than did subjects with childhood maltreatment. While the subjects without a history of maltreatment reported more "optimal" bonding experiences with their parents, the maltreatment group members were more likely to characterize their early parental bonding experiences in terms of "affectionless control" (p<.001 for both maternal and paternal parenting), "affectionate constraint" (p=.025 for maternal parenting and p=.004 for paternal parenting), or "weak or absent" bonding (p<.001 for both maternal and paternal parenting). Results of a multiple regression analysis revealed that overall quality of paternal care (p=.015) and current level of depressive symptoms (p<.001) were significant independent predictors of adult quality of life. Gender effects between subjects providing parental bonding data were limited to the group with childhood maltreatment. CONCLUSION: These findings extend previous work documenting a relationship between early life maltreatment and suboptimal parental bonding, suggesting gender-specific effects of maternal and paternal care. Effects of childhood maltreatment on quality of life in adulthood appear to be linked with the quality of childhood paternal care and the occurrence of depressive symptomatology in adulthood, suggesting possible targets for primary or secondary prevention.

Childhood Sexual Abuse and Indicators of Immune Activity: A Systematic Review.

Background: Childhood sexual abuse (CSA) is a prevalent subtype of early life stress associated with changes in immunological and neuroendocrine systems leading to inflammatory responses of the organism and increasing several inflammatory and immune markers. We aimed to conduct a systematic review concerning the association between CSA and indicators of immune activity. Methods: We conducted a search for articles in PubMed, Scopus, PsycINFO, and Web of Science, using the key words: ("Child sexual abuse" OR "childhood maltreatment" OR "sexual violence" OR "posttraumatic stress disorder" OR "rape") AND ("cytokines" OR "inflammatory markers" OR "interleukin" OR "tumor necrosis factor" OR "C-reactive protein"). PRISMA guidelines were used in order to improve the quality of this research, and MeSH terms were used in PubMed. Results: A total of 3,583 studies were found and, after application of the exclusion criteria, 17 studies were included in this review. Most studies reported an increase of inflammatory activity associated with the presence of early abuse. IL-6, TNF- α, and C-reactive protein were the most frequently analyzed markers and some studies showed higher levels in individuals that suffered CSA compared with controls, although the results were heterogeneous, as was the assessment of CSA, repeated trauma, and time of occurrence. It was not possible to perform a meta-analysis because the results were diversified. Conclusion: CSA is associated with changes in inflammatory markers levels. Improving the assessment of subtypes of trauma is important to further understand the complex correlations of CSA and its biological consequences such as psychiatric and physical illness in later life.

Decreased adrenocorticotropic hormone and cortisol responses to stress in healthy adults reporting significant childhood maltreatment.

BACKGROUND: Preclinical research findings suggest that exposure to stress and concomitant hypothalamus-pituitary-adrenal (HPA) axis activation during early development can have permanent and potentially deleterious effects. A history of early-life abuse or neglect appears to increase risk for mood and anxiety disorders. Abnormal HPA response to stress challenge has been reported in adult patients with major depressive disorder and posttraumatic stress disorder. METHODS: Plasma adrenocorticotropin hormone (ACTH) and cortisol reactivity to the Trier Social Stress Test were examined in healthy adults (n = 50) without current psychopathology. Subjects with a self-reported history of moderate to severe childhood maltreatment (MAL) (n = 23) as measured by the Childhood Trauma Questionnaire were compared with subjects without such a history (CTL) (n = 27). RESULTS: Compared with CTLs, MAL subjects exhibited significantly lower cortisol and ACTH baseline-to-peak deltas. A significant group effect was seen in the (repeated measures) cortisol response to the stress challenge, reflecting lower concentrations among MAL subjects. A significant group x time effect characterized the relatively blunted ACTH response of the MAL group. Emotional neglect (-.34, p = .02) and sexual abuse (.31, p = .03) strongly predicted maximal cortisol release. CONCLUSIONS: In adults without diagnosable psychopathology, childhood maltreatment is associated with diminished HPA axis response to a psychosocial stressor. Possible explanations for the finding are discussed.

The relationship between childhood abuse and adult personality disorder symptoms.

This study assessed personality disorder symptomatology in a community sample of healthy adults without diagnosable DSM-IV-TR Axis I psychiatric disorders who reported a history of childhood abuse. Twenty-eight subjects with a history of moderate to severe physical, sexual, and/or emotional abuse according to the Childhood Trauma Questionnaire were compared to 33 subjects without an abuse history on symptoms of personality disorders. Subjects in the Abuse group were more likely to report subclinical symptoms of paranoid, narcissistic, borderline, antisocial, obsessive compulsive, passive-aggressive, and depressive personality disorders. These findings link reports of childhood abuse with symptoms of personality disorders in the absence of Axis I psychiatric disorders in a community sample of healthy adults.

The positive impact of an intervention for maternal depression on child emotional and behavioral symptoms in a low-resource setting

Objectives: Children of depressed mothers are at risk of developing mental health problems. We sought to determine whether treatment for maternal depression by community-based health workers would decrease behavioral/emotional symptoms in their children. Interventions for maternal depressive symptoms in a low/middle-income country can have a high global impact. Methods: Community-based health workers were trained to deliver a psychosocial intervention for mothers with depression in a primary care setting. A total of 49 mothers and 60 children were assessed pre-intervention, post-intervention, and at 6 months follow-up. Child behavioral/emotional symptoms were evaluated according to type of change in maternal depressive symptoms: response or remission. Results: An overall decrease in maternal depressive symptoms from baseline to post-intervention and 6 months follow-up were found. Response or remission was associated with better outcomes in child behavioral/emotional symptoms at 6 months follow-up (p = 0.0247, Cohen's d: 0.76; p = 0.0224, Cohen's f: 0.44) but not at post-intervention (p = 0.1636, Cohen's d: 0.48; p = 0.0720, Cohen's f: 0.33). Conclusions: Improvement in maternal depression was related to decreased behavioral/emotional symptoms in their children. Our results suggest that providing interventions for maternal depression in primary care is a viable strategy to prevent behavioral/emotional symptoms in the next generation. Clinical Trial registration: Brazilian Clinical Trials, number RBR-5qhmb5.

Temperament and hypothalamic-pituitary-adrenal axis function in healthy adults.

BACKGROUND: Traits such as behavioral inhibition and neuroticism have been linked to the development of mood and anxiety disorders. Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, a manifestation of the stress response, is often seen in major depression and has also been demonstrated in animals and humans with inhibited temperaments. A recent study found HPA hyperactivity in adults with high levels of neuroticism. The present study investigated associations of temperament and HPA function in 31 healthy adults. METHODS AND MATERIALS: Subjects completed diagnostic interviews, questionnaires, and the dexamethasone-/corticotropin-releasing hormone (Dex/CRH) test. Temperament was assessed using the Tridimensional Personality Questionnaire (TPQ). RESULTS: Novelty Seeking was inversely related to plasma cortisol concentrations in the Dex/CRH test. Harm Avoidance and Reward Dependence were not significantly associated with cortisol responses in the Dex/CRH test. The results were not accounted for by psychiatric symptoms or a history of stress or childhood maltreatment. CONCLUSIONS: These findings are consistent with previous reports associating temperament factors with HPA axis hyperactivity. Further work is needed to replicate these observations and determine whether HPA axis dysfunction might account for some of the previously reported association of personality factors with mood and anxiety disorders.

Open-label tiagabine monotherapy for major depressive disorder with anxiety.

OBJECTIVE: Gamma-aminobutyric acid (GABA) plays a key role in the pathophysiology and treatment of depression and anxiety. Tiagabine, a selective GABA reuptake inhibitor (SGRI) that enhances normal GABA tone, was evaluated for its efficacy and safety in the treatment of depression comorbid with significant anxiety. METHOD: In this 8-week, single-center, open-label study, adults with DSM-IV-diagnosed major depressive disorder and significant anxiety (i.e., "anxious depression") received tiagabine monotherapy, initiated at 4 mg/day and titrated for optimum response as tolerated to a maximum dose of 20 mg/day. Symptoms, function, and adverse events were assessed at regular intervals. Patients were entered from April 2002 to February 2003. RESULTS: Nineteen patients entered the study and 15 met criteria for intent-to-treat analyses. Of those, 6 (40%) discontinued treatment and 9 (60%) completed the 8-week protocol. Tiagabine significantly improved depression, as shown by a reduction in mean +/- SD Hamilton Rating Scale for Depression scores from baseline (31.9 +/- 6.1) to endpoint (17.0 +/- 12.4; p = .002). Categorical response rate was 47% (N = 7). Tiagabine also significantly improved anxiety (Hamilton Rating Scale for Anxiety baseline score of 22.7 +/- 4.9 vs. endpoint score of 12.5 +/- 8.8; p = .002). The mean +/- SD final daily dose was 12.8 +/- 5.8 mg. The most commonly reported adverse events were dizziness, headache, and gastrointestinal upset/nausea. CONCLUSION: These results suggest the potential of the SGRI tiagabine in the treatment of depression with anxiety. Large, placebo-controlled trials are needed.

Psychotic major depression: a benefit-risk assessment of treatment options.

Numerous studies in the past three decades have characterised 'psychotic major depression', a subtype of major depression which is accompanied by delusions or other psychotic features. Evidence from phenomenological and neurobiological investigations indicates that this is a unique disorder with clinical and biological characteristics that are distinct from those of nonpsychotic depression and from other psychotic disorders. Treatment studies have provided evidence of small placebo effects and good responses to electroconvulsive therapy or combination treatment with an antidepressant plus an antipsychotic agent. However, until recently, there were only a few small, prospective, double-blind, controlled trials investigating the efficacy of antidepressant-antipsychotic combination pharmacotherapy, yet this constitutes the currently accepted and most universally applied 'standard of care' for psychotic depression. Treatment guidelines have been based largely on uncontrolled investigations of electroconvulsive therapy and studies using tricyclic antidepressants and first-generation antipsychotic drugs, which are not frequently chosen as first-line agents today because of concerns regarding tolerability and risks. However, recent open-label studies and large controlled trials of newer antidepressants and antipsychotics have yielded very divergent results thus far, so that the best treatment approach remains elusive. This review discusses the phenomenology and treatment of psychotic depression with a focus on the benefits and risks of various treatment approaches. Problems with this literature are highlighted, and strategies for future research are suggested.

Revictimization as a high-risk factor for development of posttraumatic stress disorder: a systematic review of the literature

Objective: Much research has been published on the role of sexual revictimization in the emergence of mental disorders in adulthood, but findings have sometimes been contradictory. The present systematic review sought to assess the state of the evidence on revictimization as a potential factor for the emergence of posttraumatic stress disorder (PTSD). Methods: Electronic searches were conducted in five databases (MEDLINE/PubMed, Cochrane Library, Campbell Library, PsycINFO, and LILACS), using the terms PTSD, posttraumatic stress disorder, child abuse, and rape. Results: We identified nine articles that established a connection among childhood sexual abuse (CSA), sexual revictimization in adulthood, and development of PTSD. Eight of the nine papers included were classified as having strong methodological quality (grade VI). One was classified as IV, with an average quality-of-evidence rating. The mean methodological quality score of the articles was 5.5, and the quality of evidence was deemed strong. Conclusion: In the included studies, PTSD symptoms were most prevalent in the CSA + adult sexual assault groups, providing further evidence for the revictimization hypothesis.