Childhood Trauma and Major Mental Illness Integration of Psychopharmacology with Psychological Treatments

Depression is the leading cause of disability worldwide and the global burden is increasing on a large scale, [1-4]. In 2010-2011, expenditure on mental health in Australia was $ 6.9 billion (ABS, 2013), and in the USA, the cost of depression alone exceeded US$ 83 billion [5]. Morbidity includes days lost from work, economic costs and emotional costs on family members, functional impairment and increased use of health services [6]. There has been an increasing reliance on psychotropic medication, particularly antipsychotics while corresponding benefits in patients’ quality of care remain limited. In a 10 year study [7] it was found that while the percentage of patients hospitalized for depression dropped from 9.1% to 5.1%, the percentage of individuals receiving psychotherapy decreased from 56.6% to 37.5%, the use of antidepressants increased from 80.6% to 86.8% and the use of antipsychotics increased significantly from 25.9% to 41.9%. Additionally, the percentage of acute-phase episodes in which patients received psychotherapy dropped from 42.6% to 26.9% and the prescription for antipsychotics remained relatively constant. This is indicative of the reliance placed on pharmacotherapy and the marginalization of psychological treatments including dynamic psychotherapy. Yet, there is no evidence that treatment outcomes are better than they were thirty years ago.

Treatment resistant depression

Treatment resistant depression which still awaits a universal definition [8] is generally seen as the failure of improvement after at least two adequate trials of different classes of antidepressants in a person who has adhered to the prescription. Guidelines on the treatment of depression generally stress the need for adequate dosages, follow-up and monitoring of side-effects with support. There is an implicit message here that the treatment of depression with antidepressants has both pharmacological and psychological components that are important [9]. However, guidelines provide in detail the need for increasing dosage, the therapeutic dose and sideeffects, methodology of switching from one antidepressant to another, adding another antidepressant or antipsychotic and lastly adding psychotherapy, if all else fails. If psychotherapy was a mandatory part of the process from the beginning, the possibilities would be many, for patients to respond to the therapeutic relationship as well as the antidepressant. A substantial number of patients do not achieve a clinically meaningful benefit, despite multiple antidepressant trials and augmentation [10,11] while psychotherapy improves outcome when combined with medication, compared to medication alone [12]. The demand for psychotherapy services was found to exceed service provision by a factor of four [13] which need to be acknowledged and remedied.

The word ‘trauma’ is used to indicate early childhood emotional, physical or sexual abuse and neglect, which may occur singly or in combination. Early childhood trauma is recognized as the best predictor of response to psychotherapy for severely depressed patients, and depressed people respond differently to pharmacotherapy whether they have experienced childhood trauma or not [14]. Preliminary data [15] describing the interim treatment outcome of 44 patients referred with treatment-resistant depression of significant duration, co-morbid personality disorders and histories of early childhood trauma with psychodynamic psychotherapy seems to illustrate this. Significant improvement in symptoms, self-esteem, general functioning and suicidality was noted after 12 months. The prevalence of early childhood trauma in these patients was noted, and more importantly the prevalence of multiple traumata in each individual.

If attachment insecurities are risk factors for psychopathology [16] then the creation, maintenance, or restoration of a sense of attachment security should increase resilience and improve mental health. Interactions with available and supportive attachment figures impart a sense of safety, trigger positive emotions (e.g. relief, satisfaction, gratitude, love) and provide psychological resources for dealing with problems and adversities. Secure individuals remain relatively unperturbed during times of stress, recover faster from episodes of distress, and experience longer periods of positive affect which contributes to their overall emotional well-being and mental health [17]. Early child abuse and attachment trauma deprive the individual of a sense of safety and trust in the environment and contribute to the development of personality disorders [18,19] and an increased risk for developing depression in adulthood [14,20]. Psychotherapy in such individuals seeks to improve the reflective capacity of such individuals through the provision of maturational capacities and trust in the other.

It is a matter of urgency to formulate a more comprehensive synthesis regarding the pathophysiology of mental illness in the light of more contemporary evidence and theories stemming from cellular, molecular, biology and evolutionary theory. The field of epigenetics has arisen as one of the most important scientific axis to understand developmental physiology and pathophysiology in all areas of medicine with a special impact on psychiatry, a field that has been historically dominated by obsolete biological models and theories [21]. Environmental factors such as childhood maltreatment and stressful life events in several studies showed independent effects of Specific Serotonergic Reuptake Inhibitors (SSRI’s) response, and in some cases, also in significant interaction with genetic polymorphisms [22].

It has long been appreciated that brain and behaviour are interrelated in a complex manner, and mental health care providers are used to seeing people whose thinking and behaviour are disturbed in some way, however the economics of delivery of mental health services almost always mandates medication as a first choice intervention [23]. We need to work on the cutting edge of the brain-mind interface, as evidenced in an Australian study [24-26] which has shown that psychotherapy combined with medication in some patients with personality disorders is cost-effective.

Psychosocial interactions influence the brain in the same way as its genetic, molecular and cellular organization and regulate biology and psychology. We must side-track this unidirectional, biological, reductionist view and recognize the powerful effects that psychosocial interactions exert; as in attachment in childhood and its disturbance by trauma which impacts the brain. The economics of delivery of mental health services almost always mandates medication as a first choice intervention. There is no doubt that medication has a vital place in psychiatry, however it is apparent that new knowledge is being neglected, the potential for integration has not been fulfilled, and though patients are better informed, they dare not question the wisdom of the treating psychiatrist.