The treatment group prevalence of traumatic child abuse experiences in our sample of patients with chronic depression is presented in Table 1T1. In this population of patients with chronic forms of depression, approximately one-third experienced parental loss before age 15 years, 45% experienced childhood physical abuse, 16% experienced childhood sexual abuse, and 10% experienced neglect. These findings alone highlight the remarkably high prevalence rate of early life trauma in patients with chronic forms of major depression. Patients with early life adverse experiences did not differ from patients without early life trauma in drop-out rates during the study.
Results regarding treatment responses differed dramatically from those initially reported by Keller et al. (8), when groups were stratified according to the presence or absence of childhood trauma. There were significant interactions of effects of treatment type and parental loss (F=4.46, df=1,495, P=0.0121), physical abuse (F=3.25, df=1,495, P=0.03), neglect (F=4.82, df=1,495, P=0.0084), and any trauma (F=3.13, df=1,495, P=0.0446). Specifically, among patients with no history of childhood abuse/early trauma, there was a clear-cut stepwise order of treatment efficacy (combination > nefazodone ≅ CBASP). In contrast, patients who reported early life trauma exhibited a superior antidepressant response to psychotherapy (with or without nefazodone) when compared with those treated with antidepressant alone (shown in Fig. 1AF1). Moreover, the advantage of the combination of pharmacotherapy and psychotherapy (relative to psychotherapy alone) was modest and did not attain statistical significance in the subgroup of patients with early life trauma. The superiority of psychotherapy (with or without nefazodone) for patients reporting early life trauma persisted when the analyses were controlled for gender, age, race, and depression severity at baseline. Fig. 1BF1 reveals similar findings with remission of depression, the most stringent criterion for treatment response as the end point. For patients with chronic forms of depression and early life trauma who completed the study, remission was attained in 48.3% of the patients treated with CBASP, 32.9% treated with the antidepressant, and 53.9% treated with combination therapy. In these patients, but not in patients with chronic depression and no childhood trauma, the remission rate was significantly higher with psychotherapy compared to antidepressant treatment (Wald χ2=6.8912, df=1, P= 0.0087). The effect was confirmed when LOCF analysis was performed (Wald χ2=6.5315, df=1, P=0.0106). Based on the LOCF data, the likelihood of achieving remission in patients with chronic forms of major depression and any early adverse life event was estimated to be twice as high after treatment with psychotherapy when compared to antidepressant therapy (odds ratio=2.322, 95% confidence interval=1.225—4.066). Further analysis of type of early trauma indicates that this effect was particularly prominent in patients with chronic forms of depression and parental loss (odds ratio for remission after psychotherapy versus antidepressant=2.7857, 95% confidence interval=1.295—6.182).