Childhood Trauma and Major Mental Illness Integration of Psychopharmacology with Psychological Treatments
Received Date: Feb 29, 2016 / Accepted Date: Mar 16, 2016 / Published Date: Mar 21, 2016
Effective treatment of major mental illness in children, adolescents and adults poses a continuing challenge to psychiatry, and unaddressed childhood trauma plays an important role in this challenge. The aim of this communication is based on an earlier paper, is to highlight research that has been carried out on the relationship between childhood maltreatment and major mental illness, and the emphasis placed on treatment of mental illness almost exclusively with pharmacotherapy while paying lip-service to psychological therapies, including dynamic psychotherapy. This is in spite of the Adverse Childhood Experiences (ACE’s) Studies of 1998 and 2010, which demonstrate links between childhood trauma and mental illness. I have chosen to use depression as an example because of its common occurrence, increasing morbidity and cost to services globally.
Keywords: Trauma; Attachment; Pharmacotherapy; Psychotherapy; Mental illness
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 . Morbidity includes days lost from work, economic costs and emotional costs on family members, functional impairment and increased use of health services . 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  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  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 . 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 . The demand for psychotherapy services was found to exceed service provision by a factor of four  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 . Preliminary data  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.
Early Childhood Attachment and Health
If attachment insecurities are risk factors for psychopathology  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 . 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 . 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 .
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 . 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.
- Haliburn J (2014) The links between early childhood trauma and major mentalillness: Psychiatry response? Australian & New Zealand Journal of Psychiatry 48: 580-581.
- Centers for Disease Control and Prevention (CDC) (2010) Adverse childhood experiences reported by adultsfive states, 2009.MMWR Morb Mortal Wkly Rep 59: 1609-1613.
- Collins PY, Patel V, Joestl SS, March D, Insel TR, et al. (2011) Grand challenges in global mental health.Nature 475: 27-30.
- Rössler W, Salize HJ, van Os J, Riecher-Rössler A (2005) Size of burden of schizophrenia and psychotic disorders.Eur Neuropsychopharmacol 15: 399-409.
- Kessler RC (2012) The costs of depression.Psychiatr Clin North Am 35: 1-14.
- Scott J, Dickey B (2003) Global burden of depression: the intersection of culture and medicine.Br J Psychiatry 183: 92-94.
- Fullerton CA, Busch AB, Normand SL, McGuire TG, Epstein AM (2011) Ten-year trends in quality of care and spending for depression: 1996 through 2005.Arch Gen Psychiatry 68: 1218-1226.
- Ruhé HG, van Rooijen G, Spijker J, Peeters FP, Schene AH (2012) Staging methods for treatment resistant depression. A systematic review.J Affect Disord 137: 35-45.
- Ankarberg P, Falkenström F (2008) Treatment of depression with antidepressants is primarily a psychological treatment.Psychotherapy (Chic) 45: 329-339.
- Keitner GI, Mansfield AK (2012) Management of treatment-resistant depression.Psychiatr Clin North Am 35: 249-265.
- Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, et al. (2006) Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report.Am J Psychiatry 163: 1905-1917.
- Gabbard GO, Kay J (2001) The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist?Am J Psychiatry 158: 1956-1963.
- Kisely SR, Jones J (1999) An integrated treatment algorithm for pharmacotherapy and psychotherapy.Aust N Z J Psychiatry 33: 207-216.
- Nemeroff C, Heim C, Thase M, Klein D, Rush A, et al. (2003) Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci 100: 14293-14296.
- Stevenson J, Haliburn J, Halovic S (2015) Trauma, personality disorders and chronic depression the role of the conversational model of psychodynamic psychotherapy in treatment resistant depression. Psychoanalytic Psychotherapy.
- Bowlby J (1988) A secure base: Parent-Child Attachment and Healthy Human development. New York: Basic Books.
- Mikulincer M, Shaver PR (2012) An attachment perspective on psychopathology.World Psychiatry 11: 11-15.
- Bowlby J (1980) Separation and Depression. Basic Books, New York.
- Yen S, Shea MT, Battle CL, Johnson DM, Zlotnick C, et al. (2002) Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative longitudinal personality disorders study.J Nerv Ment Dis 190: 510-518.
- Cohen P, Brown J, Smaile E (2001) Child abuse and neglect and the development of mental disorders in the general population.Dev Psychopathol 13: 981-999.
- Pordeus V (2015) Mental illness arises epigenetically like all other diseases. Journal of Psychology and Psychotherapy Research 2: 23-24.
- Peyrot WJ, Middledorp CM, Jansen R, Smith JH, Hottenga JJ, et al. (2013) Strong effects of environmental factors on prevalence and course of Major Depressive Disorder are not moderated by 5-HTTLPR polymorphisms in a large Dutch sample. Journal of Affective Disorders 146: 91-99.
- Glick ID (2004) Adding psychotherapy to pharmacotherapy: data, benefits, and guidelines for integration.Am J Psychother 58: 186-208.
- Stevenson J, Meares R (1999) Psychotherapy with borderline patients: II. A preliminary cost benefit study.Aust N Z J Psychiatry 33: 473-477.
- Stevenson J, Meares R (1992) An outcome study of psychotherapy for patients with borderline personality disorder.Am J Psychiatry 149: 358-362.
- Meares R (2004) The conversational model: an outline. Am J Psychother 58: 51-66.
Citation: Haliburn J (2016) Childhood Trauma and Major Mental Illness – Integration of Psychopharmacology with Psychological Treatments. J Neuropsychopharmacol Mental Health 1: 107. Doi: 10.4172/2472-095X.1000107
Copyright: © 2016 Haliburn J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Select your language of interest to view the total content in your interested language
Share This Article
World Congress On Neurology and Mental Health
May 21-22, 2018 Melbourne, Singapore
World Summit on Alzheimer’s, Neurodegenerative Diseases and Therapeutics
August 31-September 01, 2018 Boston, USA
International Child & Adult Behavioural Health Conference
September 13-14, 2018 Dubai, UAE
6th International Conference on Brain Disorders and Therapeutics
September 13-15, 2018 Copenhagen, Denmark
World Brain Congress
December 5-7, 2018 Dubai, UAE
- Total views: 8113
- [From(publication date): 4-2016 - Dec 19, 2017]
- Breakdown by view type
- HTML page views: 8026
- PDF downloads: 87