Diagnosis and Treatment Challenges of PTSD and Comorbid Depression

The daily news is full of traumatic events, occurring around the globe and close to home, the victims of which may go on to experience crippling symptoms of post-traumatic stress disorder , depression, or both.

Post-traumatic stress disorder (PTSD) is an anxiety disorder involving re-experiencing trauma through vivid flashbacks, nightmares, and terrifying thoughts, avoidance of trigger events, psychological disassociation or “numbing,” and hyper-intense reactions to everyday events.

Anyone can develop PTSD at any time after experiencing a traumatic event or series of events like a violent attack, rape, or child abuse, a car, plane, or train crash, or natural disaster such as a tornado, fire, flood, or earthquake. It is also commonly seen following combat, acts of terrorism, and mass shootings. An estimated lifetime prevalence of PTSD of 6.8% was reported by a community-based study conducted from 2001 to 2003.¹

By far, the highest risk of PTSD is among combat veterans, whose likelihood of exposure to severely traumatizing events is much higher than the average person. The National Vietnam Veterans Readjustment Study (NVVRS), a large-scale survey conducted among Vietnam War veterans between 1986 and 1988, reported an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women.²

Depression is also a common response to trauma. A survey of survivors from the Oklahoma City bombing demonstrated an increase in depression from 13% before the bombing to 23% after the bombing.³

Comorbid PTSD and Depression

Large-scale studies of war veterans with PTSD have demonstrated that it is highly likely to be accompanied by depression.⁴ Results from a large national survey showed that depression is nearly 3 to 5 times more likely to emerge in those with PTSD than those without PTSD.⁵ A recent large meta-analysis composed of 57 studies, across both military and civilian samples, reported a comorbidity rate of 52%.⁶

When the two conditions overlap, it can form a powerful psychological cocktail preventing people from functioning in many aspects of their lives. The effects are long lasting, and unlike physical disabilities, hard to quantify.

For both the patient and clinician, understanding and diagnosing PTSD and comorbid depression can be challenging, as many symptoms overlap. Those who suffer from both PTSD and depression may have difficulty sleeping or staying focused, may be more irritable, and feel overwhelming guilt or regret towards a certain situation or how they currently feel. They may also lose interest in things that they previously enjoyed, and may disassociate from people and activities.

The long-term complications of PTSD often lead to depression. “PTSD has always overlapped with depression and vice versa,” according to Peter Tuerk, PhD, Associate Professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina and Section Chief, PTSD Clinical and Telehealth Teams at the Ralph H. Johnson VAMC. The main challenge to making treatment decisions for trauma victims presenting with these conditions is isolating the differences between them as single conditions, he said.

“Obviously, it’s very difficult to have PTSD and not become depressed, because it’s a very intrusive disorder that impacts almost every area of a person’s function,” explained Dr. Tuerk, adding that “the other side of that is that people who have depression are more likely to get PTSD, given a traumatic stressor.”

Diminished Quality of Life

Both PTSD and depression can have profound impacts on quality of life in terms of satisfaction and ability to engage in work and home life, although it is not clear which condition dominates. A recent study found that the most significant impact came from PTSD symptoms of dissociative behaviors, most prominently “numbing,” involving subconscious avoidance of potential negative emotional triggers.⁷ A number of studies have shown a significant PTSD impact on loss of employment and inability to function at work and a general lack of life satisfaction,^8-11 while other studies have clearly implicated depression as the major impact on QOL,^12,13 making treatment decisions more complicated in the face of both conditions.

Whether to Treat PTSD, Depression—or Both?

Aside from funding long-term treatment resulting from trauma, the presence of both conditions is likely to complicate the treatment plan. Dr. Tuerk explained that cognitive behavioral therapy, specifically exposure therapy, works really well for PTSD, suggesting this may be an effective approach to treating both conditions presenting comorbidly.

“The major consensus among scientists is to go ahead and treat the PTSD first with a behavioral intervention and if depression symptoms don’t remit, then you can consider following up with either a medication or behavioral activation, which is a successful therapy used for depression,” he said.

References:

Gros DF, Price M, Magruder KM, et al. Symptom overlap in posttraumatic stress disorder and major depression. Psychiatry Res. 2012;196:267-70.
Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych. 2005;62:617-627.
Kulka RA., Schlenger WA, Fairbanks, et al. Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. 2001; New York: Brunner/Mazel.
North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA.1999;282:755-762.
Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psych. 1995;52:1048-1060.
Rytwinski NK, Scur MD, Feeny NC, et al. The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: A meta-analysis. J Trauma Stress. 2013;26:299-309.
Raab, PA, Mackintosh MA, Gros DF. Impact of comorbid depression on quality of life in male combat Veterans with posttraumatic stress disorder. JRRD. 2015;52:563-576.
Magruder KM, Frueh BC, Knapp RG, et al. PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. J Trauma Stress. 2004;17:293-301.
Rona RJ, Jones M, Iversen A, et al. The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war. J Psychiatr Res. 2009;43:649-55.
Breslau N, Lucia VC, Davis GC. Partial PTSD versus full PTSD: An empirical examination of associated impairment. Psychol Med. 2004;34:1205-14.
Lunney CA, Schnurr PP. Domains of quality of life and symptoms in male veterans treated for posttraumatic stress disorder. J Trauma Stress. 2007;20:955-64.
Elbogen EB, Johnson SC, Wagner HR, Newton VM, Beckham JC. Financial well-being and postdeployment adjustment among Iraq and Afghanistan war veterans. Mil Med. 2012;177:669-75.
Rapaport MH, Clary C, Fayyad R, et al. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry. 2005;162:1171-78.