Double Trouble: Treatment Considerations for Patients with Comorbid PTSD and Depression

Abstract

Posttraumatic stress disorder (PTSD) rarely occurs alone, with an approximate 80% syndromal comorbidity rate of which 50% is major depression. Evidence-based psychotherapy is the first-line treatment for PTSD and is very efficacious in some, but is directed toward PTSD symptomatology not depression, and many do not fully recover. This review presents the evidence for psychotherapy, pharmacotherapy, neurostimulation, and combinations of these modalities in treating PTSD with comorbid depression. Modifications to evidence-based psychotherapy for PTSD and comorbid depression can be made to involve comorbid traumatic brain injury and early childhood adversity, and although effective, some studies show such adaptations may not be necessary. Burgeoning neuromodulation research holds promise for possible additions to the current first-line treatment and new core treatment options. Cognitive processing therapy and prolonged exposure are the most cited effective treatments for PTSD; arguments for adding an antidepressant in cases of significant comorbid depression are supported by research. Treating PTSD first when comorbid with depression is supported by evidence that trauma-focused therapies reduce depressive symptoms whereas depression-focused treatments do not show the same for comorbid PTSD. Future directions for study will involve new sequencing and combinations of current treatment modalities in addition to exploration of other factors including biomarkers, resiliency, and risk factors to inform novel treatment options for this population.