TREATMENT OUTCOMES IN LOW-INCOME DEPRESSED
WOMEN WITH AND WITHOUT POSTTRAUMATIC STRESS
DISORDER
Joyce Y. Chung, M.D., Juned Siddique, M.S., Bonnie Green,
Ph.D., Katherine Beebe, Ph.D., Erica Wetherhold, B.S.N., Jeanne
Miranda, Ph.D.
ABSTRACT
Objective: We evaluated treatment outcomes in low-income
depressed women with and without comorbid PTSD to determine
whether comorbidity affects treatment response.
Methods: The WECare study is a treatment intervention study for
MDD that focuses on low-income mostly minority women. We
report clinical outcomes for the first 61 subjects treated with either
CBT or paroxetine. Fifty-four percent had both MDD and PTSD at
the time of study enrollment. Ethnic representation: African
American 69%, Hispanic 25% and White 7%. Demographic
characteristics: mean age 30.6, mean number of children 2.4,
married 33%, uninsured 53%, Medicaid 22%. Baseline HAMD/HAM-A scores for CBT subjects were: MDD alone 15.1/16.1,
MDD+PTSD 16.6/14.2; for medication subjects: MDD alone
17.0/15.6, MDD+PTSD 19.2/17.6.
Results: CBT subjects’ 6 month mean change in HAM-D scores:
6.5 (MDD) and 9.9 (MDD+PTSD). Antidepressant subjects’ 6
month mean change in HAM-D scores: 8.4 (MDD) and 12.5
(MDD+PTSD). Six-month mean change in HAM-A scores for CBT
subjects: 5.5 (MDD) and 6.8 (MDD+PTSD). Six-month mean
change in HAM-A scores for medication subjects: 8.1 (MDD) and
11.9 (MDD+PTSD). SF-36 summary scores improved for all
subjects.
Conclusions: Subjects with MDD and comorbid PTSD treated
with either CBT or paroxetine did as well, if not better, than
subjects with MDD alone. Our findings support the effectiveness of
standard treatments for depression in low-income women with
complex psychiatric profiles.
INTRODUCTION
 Depressive and anxiety disorders often co-exist.
 Research is needed to examine the effectiveness of treatment
when more than one condition is present.
 Our study carefully evaluates subjects with Major Depressive
Disorder for trauma and the diagnosis of posttraumatic stress
disorder.
 The objective of this analysis is to examine whether comorbid
posttraumatic stress disorder in association with major
depressive disorder affects treatment outcome with standard
treatments for depression.
STUDY CHARACTERISTICS
 The WECare (Women Entering Care) study at Georgetown
University enrolls economically disadvantaged African
American, Hispanic and white women with Major Depressive
Disorder into a randomized trial of antidepressant medications,
cognitive behavioral group therapy or usual care.
 Study subjects are women 18 years or older who are recruited
from community based programs in the Washington, DC
metropolitan area that serve low-income women and families.
 The primary sites for recruitment are family planning clinics,
WIC (Women, Infant, Child) programs, and pediatric/primary
care clinics for indigent/under-insured patients.
 Patients qualify for the study if they screen positive for possible
depression using a version of the PRIME-MD, and then are
found to meet criteria for Major Depressive Disorder on a phone
administered CIDI.
 Depression severity is assessed using a modified version of the
HAM-D (6 additional items about atypical symptoms of
depression); subjects must enter the study with a score or 14 or
greater on the modified HAM-D.
 The WECare study population is unique and we have been
gathering data about characteristics of depressive and anxiety
disorders in this population as well as how to effectively treat
these problems.
 To date we have enrolled 216 women with major depressive
disorder in the study, 114 (53%) African American, 13 (6%)
white, and 89 (41%) Hispanic. In addition we have enrolled 54
non-depressed comparison subjects.
TREATMENT CHARACTERISTICS
After assignment to either treatment arm, subjects may be seen in
up to four education meetings to prepare them for treatment.
 Antidepressant treatment
 Subjects are offered treatment with 24 weeks of
antidepressant medication using AHCPR treatment
guidelines and administered by primary care nurse
practitioners supervised by a psychiatrist.
 The first-line medication offered is paroxetine; the secondline treatment is buproprion (if paroxetine is not tolerated or
effective).
 Dosing protocols of the medications were developed so that
antidepressant treatment is standardized.
 Increases in antidepressant medication dosage are made
according to the dosing protocols, side effects, and serial
scores on the modified HAM-D.
 Subjects are seen in face-to-face meetings every two to four
weeks during treatment with medications.
 There is weekly phone contact with the nurse practitioner
throughout the treatment phase.
 Psychotherapy treatment:
 Subjects are enrolled in group treatment consisting of eight
weekly sessions of cognitive behavioral therapy using a
standardized manual and conducted by psychologists
trained in CBT.
 For subjects who remain depressed or have partial
resolution of depression after eight weeks, a second eightweek module is offered.
 If group treatment is not feasible, individual CBT in eightweek modules is provided in lieu of group.
 Usual care condition
 Usual care consists of informing subjects about their
depression diagnosis, educating them about treatment for
depression, and offering assistance with a referral to mental
health services available in the community.
 Subjects assigned to usual care are followed via ten phone
interviews in the course of a year.
STUDY SAMPLE
 To date, 98 subjects have been assigned to treatment with CBT
or antidepressant medications and have been assessed at 3 or
6 months after study enrollment.
 In order to select subjects who received an adequate course of
treatment, we defined treatment in the following manner.
 Antidepressant treatment is defined as at least nine weeks of
medication (either paroxetine or buproprion).
 Psychotherapy is defined as at least five sessions of CBT in
either group or individual format.
 Using these definitions, 61 of the 98 subjects received
treatment for depression (62%).
 Thirty-three of the 61 subjects received antidepressant
medication with a mean duration of 21 weeks.
 Twenty-eight subjects received psychotherapy with a mean
number of sessions of 8.3.
DEMOGRAPHICS
 See Tables
TRAUMA EXPOSURE AND PTSD
 Multiple traumas were reported by 53 of 61 treated subjects
(86.9%).
 Interpersonal trauma, such as sexual or physical assault, was
the most common type of trauma reported.
 Twenty-seven (44.3%) of the women reported being physically
forced to have intercourse.
 Comorbid PTSD was present in 54.1% of our treated sample:
essentially the same rate as in the overall WECare study
population (55%).
 Baseline Hamilton depression and anxiety scores were similar
between subjects with MDD alone compared with those with
both MDD and PTSD (see tables).
RESULTS
 See Tables
 Subjects treated with CBT or antidepressant medications
improved on measures of depression and anxiety symptom
severity (HAM-D and HAM-A) as well as on measures of
functioning (SF-36).
 Contrary to our initial hypothesis, there were no significant
differences in mean depression score changes between CBT
subjects who had comorbid PTSD at either 3 or 6 months when
compared to subjects with MDD alone.
 The same was true for the comparison of subjects treated with
antidepressant medication.
 Similarly, 6-month mean changes in HAM-A scores for CBT
and antidepressant treated subjects were not significantly
different for those with MDD alone or both MDD and PTSD.
 SF-36 summary scores improved for all subjects regardless of
comorbidity.
 Medication subjects with both MDD and PTSD functioned
significantly better than those with MDD alone in measures of
role limitations due to emotional problems and emotional wellbeing.
CONCLUSIONS
 Subjects with MDD and comorbid PTSD treated with either CBT
or antidepressant medication did as well, if not better, than
subjects with MDD alone.
 In our study, women with major depressive disorder in the
context of current PTSD who were treated with antidepressant
medication responded particularly well despite having more
than one current psychiatric disorder.
 Our findings support the effectiveness of standard treatments
for depression in low-income women with complex psychiatric
profiles.
REFERENCES
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Patients with Comorbid Anxiety Disorders.” J Affective Disorder,
43(3):245-250, 1997.
2. Brown, G., Schulberg H., Madonia, M., Shear M., & Houck, P.
“Treatment Outcomes for Primary Care Patients with Major
Depression and Lifetime Anxiety Disorders.” American Journal
of Psychiatry, 153(10):1293-1300, 1996.