Depression is becoming an increasingly significant public health concern worldwide. The situation is exacerbated by the fact that treatment and management strategies in clinical settings fall short of yielding expected positive patient outcomes. Harkness, Bagby, and Kennedy (2012) asserted that a substantial number of patients treated for major depressive disorder fail to respond to treatment and exhibit high recurrence rates. Similar sentiments are echoed by Paterniti, Sterner, Caldwell et al. (2017) who noted about the poor prognosis of depression in clinical settings compared to the general population. The causes of depression are diverse, but it is evident that weighty concerns about the disorder stems from the ineffectiveness of clinical therapeutic models, with most patients experiencing recurrent episodes after undergoing treatment. There is a consensus among psychologists and researchers about an underlying element acting as a precursor to failure of treatment approaches in clinical settings. Harkness et al. (2012) conceptualized their study based on the growing body of evidence showing maltreatment during childhood to be a predictor of poor clinical prognosis of depression. In the same vein, Paterniti et al. (2017) posited that childhood maltreatment is a predictor of response to treatment for major depressive disorder (MMD). On the contrary, little focus has been placed on examining the role of childhood maltreatment in depression treatment outcomes. This paper contends that there is sufficient empirical evidence linking childhood maltreatment to recurrence and severity of depression in adulthood, and association may affect how patients respond to treatment.
Summary of the Articles Reviewed
The study by Harkness et al. (2012) sought to explore the existence of a causal relationship between childhood maltreatment and adulthood depression. It examined the history of severe child abuse and its role as a moderator of patient outcome in a 16-week treatment trial, and recurrence of depression over a 12-month follow-up. Harkness et al. (2012) drew on a number of concepts to corroborate and justify their study including literature on efficacy of treatment strategies. Techniques such as Cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and antidepressant medication (ADM) that have demonstrated superiority over placebos in randomized control trials of MDD. However, the benefits of these treatment methods are overshadowed by failure of many MDD patients to respond and observed tendency of the disorder to reoccur. Therefore, Harkness et al. (2012) conceptualized the study based on existing empirical evidence associating childhood maltreatment with both response to treatment and the risk of depression relapse.
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To examine the association between childhood maltreatment and treatment response and risk of relapse, Harkness et al. (2012) recruited 203 participants who were MDD outpatients including 74 men and 129 women. The randomized control trials were conducted at the Centre for Addiction and Mental Health, University of Toronto from July 2001 to April 2007. The inclusion criteria was through assessment using the Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM–IV. Participants were aged between 18 and 60, and were required to have a minimum score of 16 on the Hamilton Rating Scale for Depression. They were also required to be free of ADM and were not to have received electroconvulsive therapy in the past 6 months, or have concurrent medical illness. The patients were randomized to treatment and underwent psychotherapy and pharmacotherapy. A total of 140 patients completed treatment and 94 who responded were entered into the follow-up phase. Childhood maltreatment interview was administered at the end of treatment. Data analysis included estimation of missing values particularly for childhood maltreatment through multiple imputations and completer analyses.
The findings showed that in patients randomized to IPT, CBT, or ADM, severe childhood maltreatment was associated with a significantly lower response rate to IPT compared to the other two. Those who responded to treatment also predicted a higher risk for depression relapse. The findings answer Harkness et al. (2012) research question by corroborating the influence of childhood maltreatment on treatment response and the risk of depression relapse among patients treated for depression.
The study by Paterniti et al. (2017) was informed by two issues of a grave concern in the treatment and management of depression. First, there is a body of literature in support of the poor prognosis of depression in psychiatric settings than in the general population or primary care. Second, is the growing body of evidence on the effects of child abuse and neglect on the treatment outcomes of psychiatric problems in adulthood, specifically an anxiety and depressive disorders. There is fairly consistent evidence linking childhood maltreatment to poop treatment outcomes of depression in adulthood, and it has been demonstrated to independent of a large range of factors. Based on the conceptualizations, Paterniti et al. (2017) sought “to investigate the course of depression in a sample of tertiary care depressed patients using a 2–5-year naturalistic follow-up, and to examine the independent role of clinical variables, sociodemographic variables, and childhood abuse and neglect in predicting the course of severe treatment resistant depression” (p. 4). The hypotheses of the study were drawn from these research objectives.
Paterniti et al. (2017) conducted the study at the Assessment and Treatment Clinic (ATC) offering outpatient service. The selection criteria was consistent with that used in Paterniti’s previous study by the title, Pharmacotherapy for bipolar disorder and concordance with treatment guidelines: survey of a general population sample referred to a tertiary care service. Paterniti et al. (2017) conducted the study between 2008 and 2012 and recruited 238 participants during the baseline. Participants were included because they all manifested with current episodes of MDD. Slightly more than half (N=119) of those recruited were entered into the follow-up phase. They were subjected to assessments on sociodemographic and clinical variables, the history of childhood abuse and neglect (using the Adverse Childhood Experience questionnaire), and the course of depression between baseline and follow-up interview (using the Life Chart method). Analysis of data was done using life table survival method and Cox proportional hazard regression tests.
Paterniti et al. (2017) established that of those entered into the follow-up phase, 45.5% did not recover or remit. This is consistent with the hypothesis that “the course of depression in a treatment-resistant sample is poorer than in the general population, with slower remission time and higher recurrence rate” (p. 3). In addition, the presence of three or more previous depression episodes and a childhood history of emotional neglect were independent predictors of depressive recurrences. Therefore, the results of the study support the theory on poor prognosis of depression in clinical settings that in the general population, and linkages between childhood maltreatment and efficacy of treatment methods. Paterniti et al. (2017) concluded that childhood maltreatment has a negative effect on response to treatment and heightens the risk of remission in MDD during adulthood, thereby affecting management efforts.
Synthesis and Critique of the Sources
The two studies by Harkness et al. (2012) and Paterniti et al. (2017) have important contributions in understanding the linkages between childhood maltreatment and outcomes of depression management in adulthood. The most evident aspects are the influence of childhood abuses and neglect on response to treatment, and the risk to remit. Therefore, the studies establish a consensus about the challenges in the management of MDD, a phenomenon attributed to an understanding that childhood maltreatment is an independent mediator of depression in adulthood. There are no variations in the theoretical conceptualizations of the two studies, particularly in relation to response to treatment. Harkness et al. (2012) and Paterniti et al. (2017) are in agreement on the growing body of evidence showing ineffectiveness of psychotherapy and pharmacotherapy in the treatment of MDD, and an elevated risk of relapse among patients who were victims of child abuse and neglect. The findings are of pertinent concern to practitioners and other stakeholders because of the counterproductive effect on the success of management strategies for psychiatric disorders.
The two studies share many similarities in their methodological designs, and are almost replicas. The consistency in the methodological approaches enhances credibility and generalizability of the findings. It is important to point out that sample characteristics in the two studies are similar in terms of demographics and clinical conditions, implying they are representative of the target population segment. The studies were conducted in similar clinical settings that facilitated randomized administration of treatment regiments. Psychotherapy and pharmacotherapy were used in both studies as treatment approaches. In addition, both studies entailed recruitment of participants in a baseline study before being entered into the follow-up phases. Similar measures were used in the collection of data (DMS-IV, childhood maltreatment scores, and MDD scores). On the contrary, the analyses of data in the two studies diverged to some extent. The use of multiple imputation analyses and completer analyses in Harkness et al. (2012) as a means of generating missing data raises questions about the credibility and reliability of the findings. On the contrary, Paterniti et al. (2017) were able to account for all data to each of variable without resorting to prediction. It is important to note that the two studies may have employed different statistical tools, but the objectives were the same.
Conclusion
The studies reviewed herein provide a strong basis in support of the role of childhood maltreatment in the efficacy of treatment and remission of depression in adulthood. There is a consensus about psychotherapeutic and pharmacotherapeutic regiments failing to produce expected positive outcomes in adult patients with MDD. In the same note, patients with childhood experiences of abuse and neglect were demonstrated to have a higher risk of relapse to depression after treatment. The studies corroborate the growing body of evidence on the same and justify calls for a shift in depression management strategies.
References
Harkness, K. L., Bagby, R. M., & Kennedy, S. H. (2012). Childhood maltreatment and differential treatment response and recurrence in adult major depressive disorder. Journal of consulting and clinical psychology , 80 (3), 342-353.
Paterniti, S., Sterner, I., Caldwell, C., & Bisserbe, J. C. (2017). Childhood neglect predicts the course of major depression in a tertiary care sample: a follow-up study. BMC psychiatry , 17 (1), 113.
