Depression as a moderator of STAIR Narrative Therapy for women with post-traumatic stress disorder related to childhood abuse

Marylene Cloitre, Donn W Garvert, Brandon J Weiss, Marylene Cloitre, Donn W Garvert, Brandon J Weiss

Abstract

Background: Depression among those who have experienced childhood abuse is associated with earlier onset, more persistent and severe symptoms, more frequent relapse, and poorer treatment outcomes across a variety of psychiatric disorders. In addition, individuals with a history of childhood abuse are more likely to develop post-traumatic stress disorder (PTSD) co-occurring with depression. Objective: This study evaluated whether severity of depression moderated the outcome in a PTSD treatment for childhood abuse survivors. Specifically, we assessed whether individuals with significant depression obtained better outcomes when provided with a two-module treatment which included a skills training component with behavioral activation interventions, Skills Training in Affective and Interpersonal Regulation (STAIR) followed by a trauma-focused component, Narrative Therapy, as compared to two control conditions where one component (STAIR or Narrative Therapy) was replaced with Supportive Counseling. Method: Participants were 104 women with PTSD related to childhood abuse. Participants were randomized into three conditions: (1) STAIR plus Narrative Therapy (SNT), (2) STAIR plus Supportive Counseling (SSC), and (3) Supportive Counseling plus Narrative Therapy (SCNT). Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) PTSD symptom severity was assessed at pre-treatment, post-treatment, and 3 and 6 month follow-up. Results: Participants with severe depression showed superior PTSD symptom reduction following SNT, while those in the other two conditions experienced a loss of improvement after treatment ended. A similar finding was obtained among those with moderate depression, while among those with low levels of depression, outcomes did not differ across the three treatment conditions. Conclusions: Childhood abuse survivors with severe depression obtained superior outcomes in a treatment that combined skills training with trauma-focused work. Skills packages which contain behavioral activation interventions in combination with trauma-focused work may be particularly beneficial for patients with childhood abuse and severe depression.

Keywords: Depression; PTSD; childhood abuse; psychotherapy; skills training; • Severe depression is a moderator of treatment outcome among women with PTSD and childhood abuse.• Those with severe depression obtained greater decreases in PTSD symptoms and more consistency in symptom improvement when provided with coping skills in combination with trauma-focused work (STAIR Narrative Therapy) as compared to treatments that provided only one or the other type of intervention.• Among those with low levels of depression, PTSD outcomes did not differ by treatment.• Skills training that supports behavioral activation such as engaging in physical, social, or pleasurable activities may be particularly beneficial to individuals with PTSD and comorbid depression.• Better understanding is needed of the underlying mechanisms which contribute to the severe, persistent, and relapsing depression associated with childhood abuse..

Conflict of interest statement

No potential conflict of interest was reported by the authors.

Figures

Figure 1.
Figure 1.
Predicted DSM-IV post-traumatic stress disorder (PTSD) severity [PTSD Symptom Scale Self-Report (PSS-SR)] scores over time by Beck Depression Inventory-II (BDI-II) depression severity and treatment condition. SNT, STAIR plus Narrative Therapy; SSC, STAIR plus Supportive Counseling; SCNT, Supportive Counseling plus Narrative Therapy; TX, treatment; FU, follow-up.

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