How to Choose PTSD Psychotherapy When Major Depressive Disorder Is Present
How should clinicians use current major depressive disorder status when choosing between interpersonal psychotherapy and prolonged exposure for veterans with PTSD?
Veterans with PTSD commonly also have major depressive disorder, and that comorbidity can affect how well some psychotherapies work. This guide applies to veterans with military-related PTSD who are candidates for either interpersonal psychotherapy or prolonged exposure and helps clinicians incorporate MDD status into treatment selection.
-
Confirm PTSD and assess current MDD
Identify patients who meet DSM-5 criteria for current PTSD and assess whether they also meet criteria for current DSM-5 MDD. In the study, PTSD severity was established with the CAPS-5 and MDD was defined by current DSM-5 MDD on the SCID-5-RV.
-
Establish whether the patient is eligible for the studied psychotherapy context
The study population consisted of veterans with war-zone trauma exposure, current PTSD with CAPS-5 severity of at least 23, and at least 1 area of relationship dysfunction. Exclusion criteria included severe substance use disorder, psychotic symptoms, mania, imminent suicidal or homicidal threat, and severe domestic violence in the prior 12 months.
-
Recognize that MDD changes expected outcomes in prolonged exposure
If PE is being considered, incorporate that veterans with comorbid MDD had significantly less improvement in PTSD symptom severity than those without MDD. Within PE, patients with MDD were also significantly less likely to achieve loss of PTSD diagnosis and remission.
-
Recognize that IPT outcomes were not worsened by MDD status
If IPT is being considered, note that in this study veterans with and without MDD did not differ in noncompletion or PTSD symptom outcomes within IPT. The article therefore supports IPT as a non-trauma-focused option whose PTSD outcomes appeared less affected by comorbid MDD.
-
Use MDD presence to favor IPT when concern about PE response is high
For veterans with both PTSD and MDD, consider IPT when concern is high that trauma-focused treatment may yield less PTSD improvement. Between treatments in the MDD subgroup, IPT showed a clinically meaningful but nonsignificant advantage over PE, including a higher response rate of 48% versus 19% and a trend toward greater CAPS-5 improvement.
-
Do not choose IPT over PE solely to target depressive symptoms
The exploratory analyses did not show a significant advantage for IPT over PE on PHQ-9 depression change in patients with or without MDD. If IPT is selected in a patient with MDD, the article supports that choice primarily on PTSD outcome considerations rather than superior depression symptom reduction.
Clinical Considerations
- This was a post hoc analysis of a randomized trial that was not designed or powered to definitively test treatment-by-MDD interactions.
- The sample was restricted to veterans with war-zone service and was nearly all male, limiting generalizability to women and nonveteran populations.
- The apparent IPT advantage in veterans with MDD was clinically meaningful but not statistically significant on between-treatment comparisons.
- Depression was defined only as current DSM-5 MDD, so the findings do not address other definitions or severity measures of depression.
Bottom Line
When a veteran with PTSD also has current MDD, the study supports considering IPT as a reasonable non-trauma-focused option because MDD was linked to poorer PTSD outcomes in PE but not in IPT.
