Informed Care In Trauma: An Emerging Model For Addressing The Depressive Subtype With A History Of Child Adversity
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Adverse childhood experiences (ACEs) are a risk factor for the development of the most prevalent mental disorders in adulthood, including major depression, and are associated with a more complex clinical presentation and increased severity, which requires a unique approach. In Chile, depression is subject to explicit legal mandates ensuring access to and guidelines for clinical care issued by the government. Ninety percent of depressed patients are treated in primary care. A third of primary patients presenting with depression in the VII Region are characterized by increased suicidality and histories of exposure to ACEs and violence within the family. These patients require a specialized treatment that incorporates research findings in the field of trauma, as applied to the treatment of depression. Together, results from the ACE Study, neurobiological evidence from exposure to toxic stress and the model of trauma-informed care comprise a framework that can orient clinical practice in healthcare settings. The purpose of this article is to review the literature with the goal of update the clinical approach and suggest future research in this subgroup of depressed patients.
Key words: Depression, Adverse Childhood Experiences, Trauma Informed Care
During the last 30 years, significant evidence has been gathered about consequences of Adverse Childhood Experiences (ACEs) in mental & physical health in life.1
In mental health, ACEs are a risk factor for the development of most prevalent pathologies,2, 3 associated to a more complex/severe clinic case with no therapeutic response.2, 3 However, this knowledge has not been included in usual clinical practice.4
En Chile, depression has a guaranteed health treatment(GES) 5 There is national evidence about a subtype of depressive patients with a background of ACEs6 which, according to current knowledge would require a differentiated approach.2, 3
Results from the Adverse Childhood Experiences Study (ACES)7, the neurobiological findings derived from toxic stress during childhood8 and the Informed Patient´s Care in Trauma (IPC)9 are a referential framework for the interventions.
The objective of this work is to review the reference frameworks available, in order to lead clinical practice and investigation in a subgroup of depressive patients with a ACEs background as patients of our Health Services.
ADVERSE CHILDHOOD EXPERIENCES STUDY (ACES)
Between 1995 to 1998, Kaiser Health Institution, from San Diego, California, in cooperation with the Centers for Control and Prevention of Diseases of the Federal Government, USA, developed the ACES.7 This study investigated the correlation between medical records from more than 17,000 adults and a retrospective questionnaire of 10 ACEs: 5 on child abuse (physical/emotional/sexual abuse, emotional/physical negligence) and 5 on family dysfunction (mother victim of violence, substance abuse at home, person with a mental illness at home, separation or divorce of parents and imprisonment of one member of the family). 7
ACEs findings turned out to be amazing. Two thirds of the participants, most of them Caucasian, middle class and with college studies reported to have been exposed, at least, to 1 ACE. 10 Besides, the number of ACEs is positively correlated with chronic biomedical pathologies (ischemic heart disease, cancer, EBOC, musculoskeletal diseases, hetopathies, increasing hospitalizations) and mental illnesses (depression, suicidal attempt, anxiety, post-traumatic stress disorders, drugs abuse, personality disorders and oppositional disorder). 7 Besides, report on ACEs is associated to risk health conducts (alcoholism, drugs abuse, suicidal attempt, smoking habits, low perception of health, in general, sexually transmitted diseases (stds), obesity). Finally, people who reported 6 or more ACEs died, as an average, 20 years before than people with no ACEs. 7, 11
ACES has provided more than 70 scientific articles and has been replicated in countries, such as Philippines,12 England,13 Canada,14 Eastern Europe,15 and Saudi Arabia,16 which have been summarized in a systematic review and recent meta-analysis.17
Severe consequences of the ACEs are understood if we consider the effects of toxic stress during childhood-18, 19 Stress is the biological response of our body before danger. 20, 21 When a threat is detected, the sympathetic nervous system is activated, thus releasing catecholamines, and the hypothalamic-pituitary-adrenal axis, resulting in release of vasopressin and cortisol.20 This multiple activation allows the body to adapt to danger by means of responses to fighting, running away or getting frozen, followed by a quick deactivation once danger is gone.20 However, if the exposure to a threat (whether real or imagination) is very intense and/or prolonged, the biological response is no longer adaptative and becomes neurotoxic,22 thus increasing the risk of chronic diseases, such as cardiovascular disease,23 which seems to be at the base of the so called “social gradient in health”, that explains the increased prevalence of chronic diseases on low socioeconomic level people.24, 25
Even though during childhood modulated exposure to psychosocial stressors is fundamental for development, at that stage children are more vulnerable to develop non regulated biological responses to stress, depending on variables, such as constitution and early relationships.8, 19, 26 Some studies made on animals and humans have identified genetic and epigenetic factors explaining this individual variability.26-28 There is also evidence about the fundamental role of parental care on regulating biological responses before stress on cubs.26, 29
Toxic stress in children deal with biological disorders caused by exposure to one or various intense/permanent stressors (among which ACEs are included) without proper protection of an adult.18, 19 Among various consequences are: excessive release of cortisol and neuro-hormones, altered regulation of neuro-immune-endocrine systems and on cerebral neuro transmission, increase of the proinflammatory cytokines (such as c reactive protein), and structural changes en prefrontal cortex, tonsils and hippocampus.3, 30
These neurobiological findings allow to understand how ACEs are a risk factor for developing disorders, emotional deregulation and neurocognitive problems during childhood. 31, 32. In future stages in life, ACEs, mediated by epigenetic factors, predispose the development of metabolic chronic/cardiovascular/autoimmune/mental diseases, and deregulated responses before new stressful situations (Figure 1).30, 33, 34
INFORMED PATIENT´S CARE IN TRAUMA (IPC)
CIT is a emerging paradigm oriented to the integral assistance of people who have a history of traumas 35 promoting understanding of the response to the traumatic impact, emphasizing on physical/psychological/emotional safety, both for providers and for people affected, and creates opportunities for the survivors to be able to build a sense of control and empowerment.9, 36 The CIT tries to provide an answer to the survivors of psychological traumas, who historically have not been assisted, not considered and even re-traumatized in assistance contexts.37
The origin of the CIT starts back in the 1990s, when various studies in USA found in women with severe psychopathologies and drug addiction a high prevalence of sexual/physical traumas (above 90%), considered as normal episodes by the same consultants In many cases, these were never investigated by the providers and even more, women were retraumatized by the same providers or Health Systems when they were searching for help 38, 39
CIT boosts a perspective from which current symptoms are understood as manifestations of a response before a past adversity that currently is not adaptative any more.40 This involves a change in the interview, from “¿what is going?" (i.e., “¿what is your problem?”) to a compassionate questioning by using “¿what happened to you?”41 and a change from a assistance system which lives back the trauma to one aimed to avoid re-traumatization.37
The Substance Abuse and Mental Health Services Administration (SAMHSA) leads inclusion of this model in its organizational policies. 36 Figure 2 summarizes the CIT principles, according to a recent review 42, based on the previous works performed by Elliott and cols.43 There are some guidelines as well regarding its implementation by a general practitioner 9
CIT emphasizes autonomy of the patient and recognition of resilience43,44 as a fundamental factor explaining capabilities of human beings to overcome and even to develop psychological growth after being exposed to traumatic situations.45, 46 Being this an emerging paradigm, its practice is not very extended yet and the evidence regarding results of the intervention is still limited.37, 47
COMPLEX DEPRESSIVE SUBTYPE ASSOCIATED TO ACEs: NATIONAL EVIDENCE
There is enough evidence proving that ACEs are a risk factor for the development of depression associated to higher psychiatric comorbility, suicidal ideation, recurrence and therapeutical refractoriness.48-52 These findings are still neither integrated in the psychiatric nosology nor in current clinical guidelines.4, 5
An approach to clinical understanding of depressive patients and ACEs may be extrapolated from nosology, that has been recently included in the International Classification of Diseases, 11th Review, of the post-traumatic stress disorder (PTSD)53. This diagnosis is a clinically differentiated subtype of (PTSD) where the three classic symptoms are added to emotional deregulation, negative self concept and interpersonal problems.54 Other studies have documented higher prevalence of this diagnosis against traditional (PTSD), increasing risk of suicidal ideation and higher psychiatric comorbility.55
The (PTSD)-C arises in relation with the so called complex traumas, featured as they are multiple, chronic and interpersonal, such as the ACEs.54 Patients with (PTSD)-C do not respond to treatments validated for classic (PTSD). As per evidence and expert opinion, approach of emotional and interpersonal compromised areas must be prioritized in (PTSD)-C. 56-58
Even though (PTSD) is the most studied pathology regarding trauma, it is metaphorically speaking, just the tip of the iceberg regarding syndromes associated to trauma, ranging from psychosis to personality disorders, to mood disorders and eating disorders 59-62 Among them we highlight depressive disorders, which in the population have a double prevalence than (PTSD).63
According to the logics of the (PTSD)-C with respect to classic (PTSD) and considering clinical evidence patients with depression and ACEs have,64 we arrive at the conclusion of complex depression nosology. Just like patients with (PTSD)-C, these patients should have a differentiated approach.64
En Chile, just like all over the world, depression is a prevalent/chronic/ disabling illness, which from 2016 has a guaranteed treatment (GES) 5. Clinical guidelines provides search recommendations, diagnosis and treatment at the various levels of assistance.5, 29, 65
In studies performed in the VII Region, our teams have evidenced that ACEs are reported between 60% to 80% among people asking assistance on mental health problems.66 Recently, in a sample of 394 depressive patients being treated in 8 PHS Primary Care Units of the VII Region, the ACEs were associated to higher depressive severity, suicidal ideation, recurrence, psychiatric comorbility and lower remission per year of observation. 6, 48, 49, 67 These results confirm in the Chilean population that international evidence proves that ACEs background are associated to clinical depression of a higher complexity and severity.
A recent analysis of latent classes, performed on the same sample made on 394 patients (presented before the World Congress of Psychiatry 2019), evidenced that a third of the people belonged to a class with a suicidal attempt record, higher depressive severity, suicidal ideation with no current attempt, history of ACEs, psychiatric comorbility and violence in couples. These results suggest that ACEs are present in a differentiated depressive clinical subtype showing a higher severity. If properly recognized these patients could receive the benefits of an approach including managing depression with the knowledge of the impact of the psychological trauma, just as proposed by CIT.
COMPLEX DEPRESSIVE SUBTYPE IN GES CONTEXT: SUGGESTIONS FOR INCLUSION OF CIT
In a Public Health context, PHS is the first assistance instance for the recognition of clinical consequences on people exposed to psychological trauma, where most cases of depression are solved in GES context.5, 68 However, applying a universal screening of ACEs in PHS is something under discussion.69, 70 It is well known that general practitioners, both practitioners as interns, are not well trained to address the traumatic experiences of their patients71-73 and spontaneous revelation of ACEs in medical practice is low74, although patients would wish these data to be investigated.75
Active search for ACEs could facilitate revelations, but this also implies the risk to favor re-traumatization.69 According to Raja, recognizing people with traumatic background in a medical context may become a sort of pyramid(Figure 3), whose base is knowledge on trauma and skills development for an effective patient-physician communication.9
In clinical practice, the authors have observed that recognition of ACEs in adults asking for assistance on emotional symptom at PHS, allows to have a better understanding and reformulation of the reason for current advice, which in many cases is a therapeutic exercises by itself. 66
Figure 4 shows some suggestions on how and when to include an active search of ACEs in the GES context of depression en PHS. Considering that current Guidelines recommend that patients with current suicidal attempts, suspected bipolarity and/or psychotic symptoms are taken to a specialist, our suggestion is that in this group ACEs are investigated by a specialized team. In this way, directed search of ACEs at PHS should be made on those users who will continue with their treatment at PHS, with priority for those patients who have psychiatric comorbilities, suicidal ideation, history of VIF and other interpersonal disorders and, if possible, in a multi professional interview aimed to minimize the risk of retraumatization. It is important to consider patient´s autonomy regarding this research and the usefulness he/she thinks it has.
Among the suggestions to open search of ACEs is the initial idea of open questions regarding history and screening which allows to guide the questions. We also recommend to include, in a regular basis, questions about resilience, such as support networks, protective figures during childhood and confrontation styles.
From the CIT, the knowledge on trauma consequences Health teams should have facilitates acquiring skills to properly assist patients with traumatic history. For instance, it is well known that non processed traumatic experiences are symbolically stores as emotional moods which may be activated as a response to stimuli other than the primary trauma. 76 This is how in patients who do not spontaneously reveal their ACEs, some signals (lack of visual contact, unrest, hyperactivity when closeness appears, extreme sensitivity to certain verbal/paraverbal expressions of the provider, etc.) could suggest a traumatic history.37
Specifically, suicidal ideation evidenced on people with depression and traumatic history could be considered as an extreme clinical behavior of emotional deregulation, and possibly could reactivate a traumatic experience correlated with a current situation of stress.77 To show the patient that suicidal ideation may be related with difficulties to discriminate present from the traumatic past and to focus on not repeating a malfunctional link pattern which re evoke a victim-aggressor relationship are a clinical practice with evidence and could be useful to control suicidal ideation in these patients.78, 79,80
The statements represent a preliminary proposal and a guide aimed to facilitate detection, provide orientation in the investigation and to optimize assistance for a relevant subgroup of patients who seeks depression assistance in our area which, according to current knowledge, requires differentiated intervention.
In Chile, according to Unicef, child maltreatment reaches 73.6% of all children under 16 and estimated prevalence of sexual abuse range range between 8 to 10%.81,82 On the other hand, data of general population state that domestic violence affects between 41 to 50% of women in Chile once in their lives and, at PHS, between 15-22% during the last year .83 We still do not have data from representative samples which include frequency with which children are exposed to other IAs, such as bullying or to grow with a relative in prison who abuse of substances or has a mental illness.
If consequences of the ACEs on health in life span are confirmed in Chile, the knowledge arising from trauma investigation and the CIT statements could become the pillars of a more understanding intervention, strategically aimed to address not only depressive patients, but all patients requiring assistance, with high prevalence of chronic biomedical pathologies. Therefore these topics could be included in the subjects of a Health related career.84, 85
Considering interpersonal violence of our society,86 it is a priority to open ways for training and investigation in order to provide proper and timely answers in health services.
The authors declare they do not have conflicts of interest.
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