Co-occurring Major Depression Research Articles

Trends and Disparities in Treatment for Co-occurring Major Depression and Substance Use Disorders Among US Adolescents From 2011 to 2019

Major depression and substance use disorders (SUD) commonly co-occur among adolescents, yet little is known about treatment use among adolescents with both conditions. Given the reciprocal influence of these conditions on each other and low prevalence of treatment overall, current information on quantification and trends in treatment of co-occurring depression and SUD is critical toward assessing how the field is performing in reaching youth in need of these services, and among youth with sociodemographic risk factors. To examine temporal trends and sociodemographic disparities in the treatment of co-occurring major depression and SUD among US adolescents. This survey study used publicly available data for adolescents aged 12 to 17 years from the annual cross-sectional surveys of the National Survey on Drug Use and Health from 2011 to 2019 to assess co-occurrence of major depressive episodes (MDE) and SUD through time and prevalence of treatment for either or both of these conditions. Data were analyzed between October 2020 and February 2021. Survey years, adolescent age, gender, race and ethnicity, type of insurance, annual household income, family structure, and residential stability. Presence and treatment of co-occurring 12-month MDE and SUD. In total, 136 262 adolescents participated in the 2011 to 2019 surveys, among whom 69 584 (51.1%) were boys and 66 678 (49.0%) were girls, 46 548 (34.1%) were aged 16 to 17 years, and 18 173 (13.8%) were Black, 28 687 (23.2%) were Hispanic, and 74 512 (53.6%) were White. From 2011 to 2019, the annual prevalence of co-occurring MDE and SUD remained stable, at between 1.4% and 1.7%. Among adolescents with co-occurring MDE and SUD, the prevalence of treatment use for MDE only increased significantly from 28.5% in 2011 to 42.5% in 2019 (odds ratio [OR], 1.07; 95% CI, 1.02-1.11; P = .005), whereas the prevalence of treatment use for SUD only decreased from 4.8% to 1.5% (OR, 0.92; 95% CI, 0.85-0.99; P = .04). Overall, the prevalence of treatment use for both conditions fluctuated between 4.5% and 11.6%, without a significant linear trend over time (OR, 0.95; 95% CI, 0.87-1.03; P = .24). Extensive disparities in treatment use were found among boys for SUD and both conditions, older adolescents for MDE, Hispanic adolescents for co-occurring conditions (adjusted OR, 0.52; 95% CI, 0.27-0.98; P = .04), and Asian, Native Hawaiian, or Pacific Islander adolescents for MDE (adjusted OR, 0.24; 95% CI, 0.10-0.58; P = .002) and co-occurring conditions (adjusted OR, 0.04; 95% CI, 0.01-0.33; P = .003). Moving households 3 or more times in the past 12 months was associated with higher odds that adolescents received treatment for both conditions (adjusted OR, 2.52; 95% CI, 1.26-5.05; P = .009). This survey study found that from 2011 to 2019, less than 12% of adolescents with major depression and SUD received treatment for both conditions from 2011 to 2019. Findings from this study call for expanded service provision for adolescents with co-occurring conditions, improved coordination between service delivery systems, and enhanced policy and funding support for adolescents with unmet treatment needs.

Dissecting the heterogeneity of posttraumatic stress disorder: differences in polygenic risk, stress exposures, and course of PTSD subtypes.

Definition of disorder subtypes may facilitate precision treatment for posttraumatic stress disorder (PTSD). We aimed to identify PTSD subtypes and evaluate their associations with genetic risk factors, types of stress exposures, comorbidity, and course of PTSD. Data came from a prospective study of three U.S. Army Brigade Combat Teams that deployed to Afghanistan in 2012. Soldiers with probable PTSD (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition ≥31) at three months postdeployment comprised the sample (N = 423) for latent profile analysis using Gaussian mixture modeling and PTSD symptom ratings as indicators. PTSD profiles were compared on polygenic risk scores (derived from external genomewide association study summary statistics), experiences during deployment, comorbidity at three months postdeployment, and persistence of PTSD at nine months postdeployment. Latent profile analysis revealed profiles characterized by prominent intrusions, avoidance, and hyperarousal (threat-reactivity profile; n = 129), anhedonia and negative affect (dysphoric profile; n = 195), and high levels of all PTSD symptoms (high-symptom profile; n = 99). The threat-reactivity profile had the most combat exposure and the least comorbidity. The dysphoric profile had the highest polygenic risk for major depression, and more personal life stress and co-occurring major depression than the threat-reactivity profile. The high-symptom profile had the highest rates of concurrent mental disorders and persistence of PTSD. Genetic and trauma-related factors likely contribute to PTSD heterogeneity, which can be parsed into subtypes that differ in symptom expression, comorbidity, and course. Future studies should evaluate whether PTSD typology modifies treatment response and should clarify distinctions between the dysphoric profile and depressive disorders.

Potential determinants of unique and co-occurring major depression and nonmedical use of prescription opioids

Aims: Reductions in illicit drug use during opioid agonist treatment (OAT) can result in improved health. The Veterans Aging Cohort Index (VACS) is a validated prognostic measure of health in HIV research that includes assessments of liver, kidney, hematologic function, age, CD4 count and HIV viral load. In HIV-infected (HIV+) individuals the VACS Index reflects abstinence in patients entering OAT, including those with an undetectable viral load. We sought to evaluate its performance in HIV uninfected patients. Methods:HIV uninfected patients initiating OAT between 2000 and 2011 were identified. Eligible patients had a VACS Index (with assumptions that CD4 count was >500 cells/ L and viral load was 1 opioid positive urine during the 6 weeks preceding each VACS Index score. We assessed the association between non-abstinent/abstinent intervals and VACS Index scores with linear mixed models using a univariate model and a multivariate model that adjusted for pre-treatment VACS Index score, age, and race/ethnicity. Patient was specified as a random effect to account for multiple observations per patient. Results: Among the 592 patients entering OAT, the mean age was 52 years, 99% were male, and 68% African-American. Sixteen percent initiated buprenorphine; 84%methadone.Mean VACS Index scores were 18.3 for abstinent intervals and 18.1 for nonabstinent intervals. Based on univariate and multivariate models, VACS Index scores did not differ between abstinent and nonabstinent intervals (p= .7, p= .4, respectively). Conclusions: Despite responsiveness to abstinence in HIV+ individuals, the VACS Index does not appear to reflect the health benefits of efficacious OAT in those uninfected. Financial support: R01DA035616, U01AA020790.

The Clustering of Psychopathology Among Adults Seeking Treatment for Alcohol and Drug Addiction

Beyond the high prevalence of co-occurring mental and substance use disorders, little is known about more complex patterns of psychopathology and multimorbidity, particularly in treatment populations. We sought to identify a parsimonious set of latent classes to describe the structure of mental disorder comorbidity among adults entering outpatient addiction treatment, and explore differences in the structure and prevalence of classes across sociodemographic characteristics. Participants (N=544) completed the Psychiatric Diagnostic Screening Questionnaire at treatment admission. We used latent class analysis to identify classes of clients with specific patterns of co-occurring mental disorders. The best-fitting solution identified 3 classes, characterized by no comorbidity (i.e., substance use disorders only), co-occurring major depression, and multimorbidity or a high degree of psychopathology. Older age was associated with lower probability of being in the class with co-occurring major depression, women were more likely than men to be in the multimorbid class, and being married or partnered was associated with a lower probability of being in either of the comorbid classes. These results are consistent with general population research on the patterning of psychiatric disorders, implying that while clients in addiction treatment may have extraordinarily high levels of psychopathology, the patterns of symptoms and the groups most affected are not markedly different than in other settings. By capturing the complexity of interrelationships among the many factors that are known to influence prognosis and outcomes, latent class analysis offers a useful way to examine and represent case-mix in clinical populations.

Health Insurance and Treatment of Adolescents With Co-Occurring Major Depression and Substance Use Disorders

The goals of this study were to identify treatment rates among adolescents with co-occurring major depressive episode (MDE) and substance use disorder (SUD), and to examine the role of health insurance in the treatment of these disorders. Seven years of cross-sectional data (2004-2010) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 2,111 adolescents who had both a past-year MDE and SUD and whose insurance status was known. The associations of public and private insurance with MDE and SUD treatment were examined using multinomial logistic regressions that controlled for health status and sociodemographic variables. Less than one-half (48%) of adolescents received any form of MDE treatment in the past year, and only 10% received any form of SUD treatment. Only 16% of adolescents who received MDE treatment also received SUD treatment. Relative to no insurance, public insurance was associated with an increased likelihood of receiving MDE treatment alone, but not with an increasedlikelihood of receiving both MDE and SUD treatment. Involvement in the criminal justice system was the major factor affecting the likelihood that an adolescent would receivebothMDEand SUD treatment, as opposed to either no treatment or treatment for MDEalone. Exceptionally low rates of SUD treatment were observed in this high-risk sample. Study findings highlight a missed opportunity to assess and to treat SUDamong adolescents with co-occurring MDE and SUD who have received some form of MDE treatment in the past year.

A Pilot Study of Interpersonal Psychotherapy for Alcohol-Dependent Women With Co-Occurring Major Depression

ABSTRACT. Background: Co-occurring major depression is prevalent among alcohol-dependent women and is a risk factor for poor treatment outcomes. This uncontrolled pilot study tested the feasibility, acceptability, and initial effects of interpersonal psychotherapy (IPT) for women with co-occurring alcohol dependence and major depression (AD-MD) in an outpatient community addiction treatment program. Methods: Fourteen female patients with concurrent diagnoses of alcohol dependence and major depression participated. Assessments were conducted at baseline, midtreatment (8 and 16 weeks), posttreatment (24 weeks), and follow-up (32 weeks). Results: Participants attended a mode of 8 out of 8 possible sessions of IPT in addition to their routine addiction care, and reported high treatment satisfaction on the Client Satisfaction Questionnaire-8. Women's drinking behavior, depressive symptoms, and interpersonal functioning improved significantly over the treatment period and were sustained at follow-up. Conclusions: These preliminary findings suggest that IPT is a feasible, highly acceptable adjunctive behavioral intervention for AD-MD women.

“Dwelling in the Past”: The Role of Rumination in the Treatment of Posttraumatic Stress Disorder

Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an “optimal dose” of exposure during treatment.

Premature Conclusions About Psychotherapy for Dysthymia

3on later-life depression reported that pharmacotherapy was less effective than psychotherapy for dysthymia. The strength of conclusions derived from meta-analyses stems directly from the quality and quantity of data available to address the research question. Unfortunately, the scientific literature on comparative trials of psychotherapy for dysthymia is not well enough established at this point to answer this question. Cuijpers and colleagues’ conclusion about psychotherapy for dysthymic patients was based on just 5 clinical trials of psychological interventions that differed in content, length, and treatment setting. Two trials 4,5 compared problem-solving therapy (PST) versus paroxetine for primary care patients with dysthymia. Psychotherapy in these trials consisted of just 4 to 6 sessions of PST delivered for 30 minutes each using a highly structured protocol that quite likely does not generalize well to psychotherapy delivered in the community. In the Williams et al 4 study, patients receiving PST showed an increasing rate of improvement over the course of the 11-week trial. Thus, the length or frequency of PST may not have been adequate to determine its full benefits. Furthermore, as most primary care patients report a treatment preference for psychotherapy over antidepressants, 6 medication trials in these settings may suffer from sample selection bias. Two other trials 7,8 reported that interpersonal psychotherapy (IPT) was significantly less effective than sertraline at posttreatment. The poorer outcomes for IPT may stem from the fact that IPT was originally designed for acute depressive illness and may require further adaptation for chronically depressed patients. 8 The last trial 9 included in the meta-analysis was the only one of cognitive-behavioral therapy (CBT) for dysthymia. Although the sample size was small and differences were not significant, retention in the CBT condition was 91% versus only 67% in the medication condition. If nonresponders are more likely than responders to drop out, the higher discontinuation rate in the medication arm may have made this condition appear more efficacious than it actually was. Previous reports suggest that psychotherapy for dysthymia may require a greater number of sessions than typically used in acute depression treatment and specific adaptation for chronic illness. 10 Adapted CBT appears effective: in another large trial, 11 the cognitive-behavioral analysis system of psychotherapy for chronic depression was found to be as effective as medication alone for patients with co-occurring major depression and dysthymia. A more appropriate interpretation of the evidence to date is that comprehensive CBT adapted for chronic depression is a promising treatment for dysthymia and that brief psychotherapy or IPT specifically may be less effective than antidepressants during acute treatment. Further research is needed to determine the efficacy of different types of psychotherapy versus antidepressants for dysthymia, especially for longer-term outcomes. Until such trials are conducted, meta-analyses of these data are premature, and definitive conclusions about the efficacy of “psychotherapy” for dysthymia appear unwarranted.

Electroconvulsive Therapy for Comorbid Major Depressive Disorder and Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) and major depressive disorder frequently co-occur. Electroconvulsive therapy (ECT) is the most effective treatment for refractory major depressive disorder. We examined the effect of ECT in patients with co-occurring major depression and PTSD. Using a retrospective chart review, we examined the outcome of the cases of 26 patients with major depression and co-occurring PTSD who received a course of ECT. The patients received either suprathreshold right unilateral, bilateral, or a combination of both. Using paired t test analysis, we compared the pretreatment and the posttreatment symptoms using the Montgomery-Asberg Depression Rating Scale and the PTSD Checklist. The patients receiving ECT had a significant reduction in the symptoms of major depression and some amelioration in PTSD symptoms. Electroconvulsive therapy may be an effective treatment for patients with refractory depression and co-occurring PTSD.

Assessing Motivation to Change Among Problem Drinkers with and without Co-occurring Major Depression

The University of Rhode Island Change Assessment Scale (URICA) is a widely used measure of readiness to change. To evaluate the URICA's ability to discriminate among alcohol abusers with and without co-occurring major depression, the authors administered it to 193 outpatients court-referred for alcohol treatment. Estimates of internal consistency suggest that scoring the URICA using its traditional factors, as well as using the newer Readiness to Change index, produced variable yet adequately reliable scores. Further, the URICA detected statistically significant differences in motivation to change an alcohol problem between an alcohol use disorder group (AD; n = 131) and an alcohol use disorder with co-occurring depression group (AD/D; n = 62) with the AD/D group showing greater readiness to change. For the AD/D group, separate URICAs were given for alcohol use and depressed mood. Confirming previous findings, results suggest the URICA may lack sensitivity to discriminate among two simultaneously occurring psychological disorders.

What came first, major depression or substance use disorder? Clinical characteristics and substance use comparing teens in a treatment cohort

This study utilized data on a treatment cohort from a randomized clinical trial that recruited adolescents with co-occurring major depression and substance use disorder ( N = 126). The purpose of this study was to compare adolescents for whom the onset of depression was first versus those for whom the onset of substance use disorder was first or in the same year as depression. Intake clinical evaluations were abstracted to yield common stressors that included childhood abuse, early loss or death, exposure to violence, and attachment problems. Tobacco, alcohol, and cannabis initiation and dependence were compared for the depression first and substance use disorder first groups, and within those groups by gender. Among the substances studied, only cannabis dependence was significantly more prevalent among those with depression first. Comparisons suggest some differences in the developmental path toward comorbid depression and substance use disorders, but remarkable similarity in measures of dependence and severity. Although small samples limited statistical significance, observed differences suggest possible avenues for prevention or intervention.

Salivary Cortisol Responses to Dexamethasone in Adolescents With Posttraumatic Stress Disorder

Previous studies of adults with posttraumatic stress disorder (PTSD) have found various abnormalities in the regulation of the hypothalamic-pituitary-adrenal axis, including enhanced suppression of cortisol following low-dose dexamethasone. The purpose of the present study was to investigate salivary cortisol responses to low-dose dexamethasone in adolescents with PTSD. Forty-eight adolescents (20 with current PTSD, 9 trauma controls without PTSD, and 19 healthy nontraumatized controls) were enrolled in the study. On day 1, baseline saliva samples were obtained at 8 a.m. and 0.5 mg of dexamethasone was administered at 11 p.m. Cortisol and dexamethasone levels were assessed at 8 a.m. the following day. Adolescents with current PTSD showed no difference in the suppression of salivary cortisol in response to low-dose (0.5 mg) dexamethasone compared to trauma controls without PTSD and nontraumatized controls. More severely affected PTSD subjects with co-occurring major depression showed higher pre- and post-dexamethasone salivary cortisol levels compared to controls. The present study did not find evidence for enhanced suppression of salivary cortisol at 8 a.m. following low-dose dexamethasone in multiply traumatized adolescents with PTSD. This result differs from findings in adults with PTSD. Further investigations of hypothalamic-pituitary-adrenal axis abnormalities in traumatized children and adolescents are needed.

Suicidal and Death Ideation in Older Primary Care Patients With Depression, Anxiety, and At-Risk Alcohol Use

The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race. The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race.

Suicidal and Death Ideation in Older Primary Care Patients With Depression, Anxiety, and At-Risk Alcohol Use

The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race.

Panic and suicidal ideation in primary care.

The objective of this article is to examine the relationship between panic attacks, panic disorder, and suicidal ideation among primary care patients. A probability sample of 1,007 primary care attenders from a large urban university practice was assessed for current mental disorders and suicidal ideation (past 2 week prevalence) with the PRIME-MD Patient Health Questionnaire. Controlling for major depression, substance use disorders, and sociodemographic variables simultaneously, patients with either panic attacks or panic disorder had significantly increased risks of suicidal ideation. Suicidal ideation was highly associated with major depression and comorbid panic disorder (OR = 15.4) or panic attacks (OR = 7.9). There is need for detection and possible treatment of patients with panic attacks or disorder in primary care, especially among those with co-occurring major depression.