Research Associate Professor, School of Social Work, University of Washington, Campus Box 354900, 4101 15th Ave NE, Seattle, WA 98105.
School of Social Work, University of Washington, Seattle, Washington, USA.
J Clin Psychiatry. 2016 Nov;77(11):1527-1537. doi: 10.4088/JCP.15m10477.
The comorbidity of posttraumatic stress disorder (PTSD) with antenatal depression poses increased risks for postpartum depression and may delay or diminish response to evidence-based depression care. In a secondary analysis of an 18-month study of collaborative care for perinatal depression, the authors hypothesized that pregnant, depressed, socioeconomically disadvantaged women with comorbid PTSD would show more improvement in the MOMCare intervention providing Brief Interpersonal Psychotherapy and/or antidepressants, compared to intensive public health Maternity Support Services (MSS-Plus).
A multisite randomized controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System, July 2009-January 2014. Pregnant women were recruited who met criteria for a probable diagnosis of major depressive disorder (MDD) on the Patient Health Questionnaire-9 and/or dysthymia on the MINI-International Neuropsychiatric Interview (5.0.0). The primary outcome was depression severity at 3-, 6-, 12-and 18-month follow-ups; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care.
Sixty-five percent of the sample of 164 met criteria for probable comorbid PTSD. The treatment effect was significantly associated with PTSD status in a group-by-PTSD severity interaction, controlling for baseline depression severity (Wald χ²₁ = 4.52, P = .03). Over the 18-month follow-up, those with comorbid PTSD in MOMCare (n = 48), versus MSS-Plus (n = 58), showed greater improvement in depression severity (Wald χ²₁ = 8.51, P < .004), PTSD severity (Wald χ²₁ = 5.55, P < .02), and functioning (Wald χ²₁ = 4.40, P < .04); higher rates of depression response (Wald χ²₁ = 4.13, P < .04) and remission (Wald χ²₁ = 5.17, P < .02); and increased use of mental health services (Wald χ²₁ = 39.87, P < .0001) and antidepressant medication (Wald χ²₁ = 8.07, P < .005). Participants without comorbid PTSD in MOMCare (n = 33) and MSS-Plus (n = 25) showed equivalent improvement on these outcomes.
Collaborative depression care had a greater impact on perinatal depressive outcomes for socioeconomically disadvantaged women with comorbid PTSD than for those without PTSD. Findings suggest that a stepped care treatment model for high-risk pregnant women with both MDD and PTSD could be integrated into public health systems in the United States.
ClinicalTrials.gov identifier: NCT01045655.
创伤后应激障碍（PTSD）与产前抑郁症并存会增加产后抑郁症的风险，并可能延迟或降低对基于证据的抑郁症治疗的反应。在对围产期抑郁症协作护理进行的为期 18 个月的研究的二次分析中，作者假设患有 PTSD 的患有产前抑郁症的社会经济劣势妇女在接受 MOMCare 干预（提供简要人际心理治疗和/或抗抑郁药）时，与接受强化公共卫生产妇支持服务（MSS-Plus）相比，在 MOMCare 干预中会有更多的改善。
2009 年 7 月至 2014 年 1 月，在西雅图-金县公共卫生系统进行了一项多地点随机对照试验，结果评估采用盲法。招募了符合主要抑郁障碍（MDD）患者健康问卷-9 标准和/或经 MINI-国际神经精神访谈（5.0.0）诊断为心境恶劣障碍的孕妇。主要结局是产后 3、6、12 和 18 个月的抑郁严重程度；次要结局包括功能改善、PTSD 严重程度、抑郁反应和缓解以及抑郁症护理质量。
164 名样本中 65%符合 PTSD 合并症的标准。在控制基线抑郁严重程度的情况下，治疗效果与 PTSD 状态的群组间-PTSD 严重程度交互作用显著相关（Wald χ²₁=4.52，P=0.03）。在 18 个月的随访中，与 MSS-Plus（n=58）相比，MOMCare（n=48）中患有 PTSD 合并症的患者在抑郁严重程度（Wald χ²₁=8.51，P<.004）、PTSD 严重程度（Wald χ²₁=5.55，P<.02）和功能（Wald χ²₁=4.40，P<.04）方面有更大的改善；抑郁反应（Wald χ²₁=4.13，P<.04）和缓解（Wald χ²₁=5.17，P<.02）的比例更高；以及心理健康服务（Wald χ²₁=39.87，P<.0001）和抗抑郁药（Wald χ²₁=8.07，P<.005）的使用率增加。MOMCare（n=33）和 MSS-Plus（n=25）中没有合并 PTSD 的参与者在这些结果上表现出相当的改善。
协作性抑郁症护理对患有 PTSD 的社会经济劣势围产期抑郁症女性的围产期抑郁结局的影响大于没有 PTSD 的女性。研究结果表明，针对患有 MDD 和 PTSD 的高危孕妇的阶梯式护理模式可以整合到美国的公共卫生系统中。
ClinicalTrials.gov 标识符：NCT01045655。
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