Verónica Vitriol

Depression remains one of the leading causes of disability worldwide despite the availability of effective pharmacological and psychological treatments. Collaborative care has consistently improved depression outcomes through coordinated, multidisciplinary, and measurement-based approaches, particularly in primary care. However, substantial heterogeneity in treatment response persists, especially among adults with histories of childhood maltreatment, who frequently present with earlier illness onset, greater symptom severity, increased psychiatric comorbidity, poorer treatment response, and a more chronic clinical course. Although collaborative care is effective, assessment of childhood maltreatment and trauma-informed developmental formulation are not consistently integrated into routine depression management within these models. In this Perspective, we propose Trauma-Informed Collaborative Care (TICC) as a conceptual framework for integrating trauma-informed and developmental principles into collaborative care for depression. Rather than replacing existing evidence-based interventions, TICC seeks to strengthen collaborative care by incorporating trauma-informed assessment, developmental case formulation, trusting therapeutic relationships, interdisciplinary supervision, recognition of patients’ strengths and resilience, and organizational practices that promote safety, trustworthiness, collaboration, and empowerment. We review complementary bodies of evidence that provide the rationale for this approach, summarize findings from a recent cluster randomized controlled trial conducted in Chile, and discuss key implementation challenges and future research priorities. Taken together, these distinct bodies of evidence provide a rationale for integrating trauma-informed principles into collaborative care, particularly for patients with histories of childhood maltreatment and greater clinical complexity, while the incremental clinical benefit of this integration within the proposed TICC framework remains to be established.

PURPOSE The purpose of this study was to evaluate the effectiveness of collaborative trauma-informed care (CTIC) for treating depression in primary care in Chile. METHODS From August 2021 through June 2023, 16 primary care teams in the Maule Region of Chile, were randomly assigned to either the CTIC or usual treatment (UT) group. At baseline, 3 months, and 6 months, 115 patients in the CTIC group, and 99 in the UT group, were blindly evaluated. The primary outcome was reduction in depressive symptoms. Secondary outcomes included improvement in anxiety symptoms, interpersonal and social functioning, emotional regulation, and adherence. Intention-to-treat data analysis, using analysis of covariance was conducted. RESULTS There were 214 patients recruited; 85% were women, and 61% had 4 or more adverse childhood experiences. At 6 months, depressive symptoms declined significantly in the CTIC arm relative to UT (adjusted mean difference [AMD]= −3.09, 95% CI, −4.94 to −1.23; d = −0.46, 95% CI,−0.73 to −0.18; P = .001). Anxiety symptoms exhibited a trend toward improvement in the CTIC vs UT group (AMD = −1.50, 95% CI, −3.03 to 0.31; P = .055). No significant differences were observed in other secondary outcomes, except for adherence, which was significantly higher in the CTIC vs UT groups (AMD = 2.59, 95% CI, 1.80-4.99; P = .035). CONCLUSIONS The CTIC approach demonstrated superior outcomes in treating depression and improving adherence compared with UT. Moreover, the observed trends in anxiety improvement warrant further exploration in future research with a larger sample size. It is necessary to assess the effectiveness of this approach in treating more complex, difficult-to-treat forms of depression.

Background Major depression (MD) is a prevalent and disabling condition in Chile, with most cases being treated at the primary care level. In Chilean primary care, the authors have identified key factors associated with more complex presentations of MD and a poorer prognosis, such as a history of childhood trauma, suicidality, and comorbidities. These findings underscore the need for a multidimensional, trauma-informed, and interprofessional approach to the treatment of depression. Methods This protocol is a two-arm, single-blinded, cluster RCT to compare the effectiveness of a collaborative multidimensional approach for depression (CMAD) versus usual care to treat MD in primary care clinics in Chile. In total, 394 depressed adults from 18 to 65 years of age in twelve clinics located in Chile’s Maule Region will be consented to participate in the study. Patients and care teams from each clinic will be randomized to the intervention or to the control arm. Interprofessional teams in the intervention arm will attend 27 hours of didactic and active learning sessions focused on clinical competences to effectively engage, treat and follow up patients with the factors associated to the complex presentation of MD. Team in the control arm will receive 27 didactic sessions on current clinical guidelines for MD. Patients of both arms will be blindly assessed at baseline, three months, and six months. The primary outcome will be the reduction in depressive symptoms, with secondary outcomes including improvements in anxiety symptoms, interpersonal and social functioning, and treatment adherence. Discussion This protocol proposes the evaluation of an intervention designed to improve depression symptoms by enhancing the clinical competencies of primary care teams. These competencies are structured around collaborative care and trauma-informed practices. Trial registration NCT05016388, registered on 16 August 2021 at ClinicalTrials.gov.

Objective: To compare the evolution of depressive symptoms among depressive subtypes based on clinical and functional variables in a sample of primary care in Chile. Methods: A longitudinal study was conducted in the Maule Region of Chile, focusing on 8 primary care from February 2014 to September 2015. Clinical and functional variables, including Mini International Neuro-psychiatric Interview, Outcome Questionnaire interpersonal and social sub-scales, were applied in a latent class analysis. This analysis categorized 210 patients into 3 subtypes: complex depression (N = 100), recurrent depression (n = 96), and unique depression (n = 14). Complex depression, exhibited a higher probability of suicide attempts, interpersonal and social dysfunction, and association with adverse childhood experiences according the Brief Physical and Sexual Abuse Questionnaire. Patients were monitored over 1 year with the Hamilton scale. The Kruskal-Wallis, non-parametric test, followed by paired Mann-Whitney test evaluated difference in the severity of depressive symptoms between the groups. Additionally, data on mental health interventions were collected. Results: Out of the 210 patients, 89% were women, with a median age of 50 (range 37-58), and 40.1% with only primary education. Sociodemographic characteristics not differ between groups. Significant differences in depressive symptom severity between the groups were found ( X² 90.06, P < .001, Kruskal-Wallis test, η² = 0.084). Post hoc analyses indicated higher depressive symptoms in complex depression compared to recurrent ( Z = −9.501, P < .001) and unique ( Z = −2.877, P = .004) depression, with no significant difference between recurrent and unique depression ( Z = −1.58, P = .113). There were no differences in the number of medical and psychological controls between the groups. The patients with complex depression required greater modifications in the pharmacological prescriptions than those belonging to the other groups. Conclusion: These results provide additional evidence of a complex depression subtype in primary care in Chile associated with adverse childhood experiences, that had worse resolution of depressive symptoms. Contrary to expectations, patients belonging to this group did not receive further medical and psychological interventions, probably due to a lack of specific clinical recommendations.

Background: Adding short-term psychodynamic psychotherapy (STPP) to antidepressants increases treatment efficacy, but it is unclear which patients benefit specifically. This study examined efficacy moderators of combined treatment (STPP + antidepressants) v. antidepressants for adults with depression.Methods: For this systematic review and meta-analysis (PROSPERO registration number: CRD42017056029), we searched PubMed, PsycINFO, Embase.com, and the Cochrane Library from inception to 1 January 2022. We included randomized clinical trials comparing combined treatment (antidepressants + individual outpatient STPP) v. antidepressants in the acute-phase treatment of depression in adults. Individual participant data were requested and analyzed combinedly using mixed-effects models (adding Cochrane risk of bias items as covariates) and an exploratory machine learning technique. The primary outcome was post-treatment depression symptom level.Results: Data were obtained for all seven trials identified (100%, n = 482, combined: n = 238, antidepressants: n = 244). Adding STPP to antidepressants was more efficacious for patients with high rather than low baseline depression levels [B = −0.49, 95% confidence interval (CI) −0.61 to −0.37, p < 0.0001] and for patients with a depressive episode duration of >2 years rather than B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) and than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). Heterogeneity was low. Effects were replicated in analyses controlling for risk of bias.Conclusions: To our knowledge, this is the first study that examines moderators across trials assessing the addition of STPP to antidepressants. These findings need validation but suggest that depression severity and episode duration are factors to consider when adding STPP to antidepressants and might contribute to personalizing treatment selection for depression.

Background: Major depression (MD) is a prevalent and disabling condition in Chile. Most MD cases are treated at the primary care level. In Chilean primary care, the authors have gathered evidence of a prevalent complex depression subtype associated with a worse prognosis and characterized by interpersonal difficulties, suicidality and trauma history. This MD presentation suggests the need for a multidimensional, trauma-informed and interprofessional approach. The present study protocol describes the context, hypotheses and methods for a cluster randomized control trial (RCT) comparing a collaborative multidimensional approach and usual care in treatment outcomes of MD in primary care in Chile. Methods: This is a two-arm, single-blinded, cluster RCT to compare the efficacy of a collaborative multidimensional approach for depression (CMAD) versus usual care to treat MD in primary care clinics in Chile. In total, 394 depressed adults from 18 to 65 years of age in twelve clinics located in Chile’s Maule Region will be consented to participate in the study. Patients and care teams from each clinic will be randomized to the intervention or to the control arm. Interprofessional teams in the intervention arm will attend 27 hours of didactic and active learning sessions focused on clinical competences to effectively engage, treat and follow up patients with complex presentation of MD. Team in the control arm will receive 27 didactic sessions on current clinical guidelines for MD, professionals in both arms will receive 27 hours of continued education. Discussion: To improve treatment outcomes of MD in Chile, primary care teams should develop clinical competencies relevant to complex, difficult-to-treat types of MD within collaborative and trauma-informed approaches.

Objective. To establish differentiated depressive subtypes using a latent class analysis (LCA), including clinical and functional indicators in a sample of depressed patients consulted in Chilean Primary Health Care. Methods. A LCA was performed on a sample of 297 depressed patients consulted in Chilean PHC. The Mini International Neuropsychiatric Interview, the Hamilton Depression Rating Scale, the Outcome Questionnaire -social role, and interpersonal subscales were as instruments. A regression analysis of the different subtypes with sociodemographic and adverse life experiences was performed. Results. In a sample characterized by 87.5% of women, two, three, and four latent class models were obtained. The three-class model likely represents the best clinical implications. In this model, the classes were labeled: “complex depression” (CD) (58% of the sample), “recurrent depression” (RD) (34%), and “single depression episode” (SD) (8%). Members of CD showed a higher probability of history of suicide attempts, interpersonal, and social dysfunction. Psychiatric comorbidities differentiated the RD from SD. According to a multinomial regression model, childhood trauma experiences, recent stressful life experiences, and intimate partner violence events were associated with the CD class ( p < 0.01 ). Limitations. The vast majority of participants were females from Chile and the sample studied was not random. So, the results may not necessarily represent outpatient clinics. Conclusions. This study can provide additional evidence that depression, specifically in female gender, could be better understood as a complex heterogeneous disorder when clinical and functional indicators are studied. Furthermore, adverse life experiences starting in childhood could lead to a differentiated complex depressive subtype.

Las experiencias infantiles adversas (EIAs) son un factor de riesgo para el desarrollo de las patologías mentales más prevalentes en la vida adulta, entre las que se incluye la depresión, y se asocian a una presentación clínica más compleja y severa que requiere de un abordaje diferenciado. En Chile, la depresión cuenta con garantías explícitas en salud y una guía ministerial de recomendaciones. Un 90% de los pacientes son tratados en la atención primaria de salud (APS). Un tercio de las muestras depresivas consultantes en la APS de la VII Región presenta una sintomatología caracterizada por mayor suicidalidad, exposición a EIAs e historia de violencia doméstica. Estos pacientes requieren de un tratamiento diferenciado que incorpore, al manejo de la depresión, los conocimientos de las consecuencias del trauma psíquico. Los resultados del Adverse Childhood Experiences Study, los hallazgos neurobiológicos derivados del estrés tóxico y el modelo de cuidado informado en trauma constituyen marcos de referencia que orientan la práctica clínica en consultantes con historia de EIAs en el contexto de los servicios de salud. El objetivo de este trabajo es revisar estas líneas conceptuales, en un intento por reformular un abordaje clínico y encauzar la investigación de este subgrupo de pacientes depresivos.

Objective. To identify the clinical and psychosocial factors associated with psychiatric comorbidity in patients consulting for depression in Primary Health Care (PHC) in Chile. Methods. 394 patients with a diagnosis of major depression being treated in a Chilean PHC were evaluated using a sociodemographic and clinical interview, the mini-international neuropsychiatric interview (MINI), a childhood trauma events (CTEs) screening, the intimate partner violence (IPV) scale, the Life Experiences Survey (LES), and the Hamilton Depression Rating Scale (HDRS). Results. Positive correlations were established between higher number of psychiatric comorbidities and severity of depressive symptoms (r = 0.358), frequency of CTEs (r = 0.228), frequency of IPV events (r = 0.218), frequency of recent stressful life events (r = 0.188), number of previous depressive episodes (r = 0.340), and duration of these (r = 0.120). Inverse correlations were determined with age at the time of the first consultation (r = -0.168), age of onset of depression (r = -0.320), and number of medical comorbidities (r = -0.140). Of all associated factors, early age of the first depressive episode, CTEs antecedents, and recent stressful life events explain 13.6% of total variability in psychiatric comorbidities. Conclusions. A higher prevalence of psychiatric comorbidity among subjects seeking help for depression in Chilean PHCs is associated with early onset of depression, clinical severity, chronicity, and interpersonal adversity experienced since childhood.

Objective: : To determine the factors associated with remission at 3, 6, 9 and 12 months among depressive adult patients in primary care [PHC] in Chile.Methods: : This is a one-year naturalistic study that followed 297 patients admitted for treatment of depression in eight primary care clinics in Chile. Initially, patients were evaluated using: the International Mini-Neuropsychiatric Interview [MINI], a screening for Childhood Trauma Events [CTEs], the Life Experiences Survey and a partner violence scale. The Hamilton Depression Scale [HDRS] was used to follow the patients during the observation time. Associations between the factors studied and the primary outcome remission [HDRS ≤ 7] were assessed using a dichotomous logistic regression and a multivariate Poisson regression. The significance level was 0.05.Results: : Remission [HDRS ≤ 7] ranged between 36.7% at 3 months and 53.9% at 12 months. Factors that predicted poor remission during the observation time were: CTEs [Wald X²= 4.88, Exp B=0.94, CI 0.90-0.92, p=0.27]; psychiatric comorbidities [Wald X²= 10.73, Exp B=0.90, CI 0.85-0.96, p=0.01]; suicidal tendencies [Wald X²= 4.66, Exp B=0.88, CI 0.79-0.98, p=0.03] and prior treatment for depression [Wald X²= 4.50, Exp B=0.81, CI 0.68-0.85, p=0.03]Discussion: : Almost 50% of this sample failed remission in depression at 12 months. Psychiatric comorbidities and CTEs are factors that should be considered for a poor outcome in depressed Chilean patients. These factors need more recognition and a better approach in PHC.