Psychotherapy, Pharmacotherapy Benefit Adults With MDD and Childhood Trauma

Patients with major depressive disorder (MDD) and childhood trauma show significant improvement following pharmacological and psychotherapeutic treatments, according to results of a meta-analysis published in Lancet Psychiatry.

Researchers conducted a systematic review and meta-analysis by searching the PubMed, PsycINFO, and Embase databases from November 2013 to March 2020 for randomized clinical trials (RCTs) and open trials in English and additional RCTs from other sources from 1966 to 2019. Included trials compared the efficacy of evidence-based psychotherapy, pharmacotherapy, or combination therapy among adult patients with depressive disorders with or without childhood trauma. The primary endpoint was change from baseline to the end of treatment in depression severity, measured as standardized effect size (ie, Hedge g).

Researchers included 20 RCTs and 9 open trials that comprised 6830 participants (age range, 18-85 years) with MDD. A total of 62% of these patients reported childhood trauma, and showed more severe depression at baseline (g=0.202, 95% CI, 0.145-0.258; I²=0%) than patients with MDD and no childhood trauma. Of the trials included in the meta-analysis, 52% were accomplished in Europe, 59% concentrated on MDD, and 38% concentrated on patients with chronic or treatment-resistant depression. Among the 29 included trials (trial groups, n=57), 47% of the trial groups received psychotherapy, 37% received pharmacotherapy, 2% received combination treatment, and 14% represented control conditions.

Efficacious reduction of depression severity was observed in patients with childhood trauma (g=1.272; 95% CI, 1.062-1.482; P <.0001) and those without childhood trauma (g=1.400; 95% CI, 1.114-1.685; P <.0001).

Patients with childhood trauma, despite having more severe depression symptoms at the start and end of treatment, benefited from active treatment similar to patients without childhood trauma (treatment effect difference between groups g=0.016; 95% CI, -0.094 to 0.125; I²=44.3%). There was no significant difference in active treatment effects compared with control condition between individuals with and without childhood trauma (childhood trauma g=0.605; 95% CI, 0.294-0.916; I²=58.0%; no childhood trauma g=0.178; 95% CI, -0.195 to 0.552; I²=67.5%; between-group difference P =.051), and similar dropout rates (risk ratio=1.063; 95% CI, 0.945-1.195; I²=0%).

Treatment type or length, year, study quality, assessment method of childhood trauma, depression diagnosis, study design, or childhood trauma type made no significant difference in findings. Larger treatment effects for patients with childhood trauma were shown only in North American studies. Most of the included studies (n=21) showed a moderate to high bias risk. The remaining 8 low-bias studies showed similar results in sensitivity analysis when all studies were included.

Limitations of the meta-analysis include moderate to high statistical heterogeneity, selection bias, unaccounted for sex-specific effects or control of confounding factors, and retrospective reporting of childhood trauma.

Researchers conclude, “[W]e found evidence that the symptoms of patients with major depressive disorder and childhood trauma significantly improve after pharmacological and psychotherapeutic treatments, notwithstanding their higher severity of depressive symptoms.” They urge patients with MDD, regardless of childhood trauma status, to be offered evidence-based psychotherapy and pharmacotherapy.