Therapeutic effects of short-term trauma stabilization techniques combined with escitalopram in treating adolescent major depressive disorder: a pilot randomised controlled trial

Abstract

Objective

To explore the efficacy of short-term trauma stabilization techniques combined with escitalopram in the treatment of adolescent major depressive disorder (MDD).

Methods

A total of 80 patients with MDD who were hospitalized in the Psychosomatic Department of our hospital were selected and randomly divided into two groups: the escitalopram combined with short-term trauma stabilization technique group (study group) and the escitalopram combined with mental health education group (control group). Upon hospitalization, patients completed the adolescent self-rating life events check list (ASLEC), impact of event scale-revised (IES-R), 17-item Hamilton depression scale (HAMD-17) and Hamilton anxiety scale (HAMA). After 2 and 4 weeks of treatment, the IES-R, HAMD-17-17 and HAMA scores were reevaluated.

Results

There were no significant differences in the ASLEC, IES-R, HAMD-17 or HAMA scores between the two groups at admission. Compared with that of the control group, the IES-R score of the study group was significantly improved at the 2nd week of treatment (P < 0.01). By the 4th week of treatment, the IES-R scores in the study group had further improved compared to the control group (P < 0.01). Additionally, the HAMD-17 and HAMA scores in the study group were significantly improved compared to the control group (P < 0.01).

Conclusion

Escitalopram combined with short-term trauma stabilization is more effective in the treatment of MDD than escitalopram with mental health education, warranting further exploration.

Introduction

Adolescent major depressive disorder (MDD) is becoming a serious social and psychological problem that has a serious impact on families, schools, and society. The condition not only causes pain for patients but also leads to a decline in their cognitive function, substantial degradation of social function, academic dropout, a heavy disease burden and a sense of shame, making it a major contributing factor for adolescent suicide [1, 2]. Although the incidence of MDD has increased in all age groups, the growth rate of this condition among adolescents currently exceeds that of adults [3]. In the United States, the lifetime prevalence rate of MDD among people aged 13–18 years is 11.0%, and the 12-month prevalence rate is 7.5% [4]. In a Chinese domestic epidemiological survey, 17,524 children and adolescents aged 6–17 years were screened in five provinces, and the point prevalence rate was 3.2%, with a 95% CI of 3.1–3.4% [4, 5]. The risk of MDD is affected by various factors, which can have probabilistic effects; among these, childhood abuse has been identified as a significant factor [6]. Studies have reported that the incidence of childhood abuse among MDD patients is very high, reaching up to 46%, as revealed in a recent meta-analysis [7]. Childhood trauma and abuse can lead to early onset, a more severe course, poor treatment effects, aggravated suicidal thoughts and repeated hospitalization in adolescent patients with MDD [7]. Addressing these types of trauma is especially important for the treatment of MDD. The World Health Organization (WHO) (2013) recommends Cognitive Behavioural Therapy (Trauma Focused) and Eye Movement Desensitization and Reprocessing (EMDR) Therapy as the most empirically supported psychological treatment interventions for posttraumatic stress disorder (PTSD) [8]. Trauma stabilization techniques are derived from the EMDR initiated by Shapiro, F [9–11]. Scheck MM et al. [12] randomly assigned 60 traumatized women between the ages of 16 and 25 to EMDR or active listening control group for short-term treatment, and the results showed that the EMDR treatment group did well after treatment. Chemtob CM et al. [13] administered EMDR therapy to 32 children who met clinical criteria for PTSD, showing significant reductions in scores on the Child Response Scale, Revised Child Manifest Anxiety Scale, and Child Depression Scale, and the therapeutic effect was maintained at six months of follow-up. In terms of medication, previous studies by Wagner KD [14] and Emslie GJ et al. [15] have shown that escitalopram is effective for the treatment of major depressive disorder in adolescents. Based on this medical treatment, we tried to combine short-range trauma stabilisation techniques to treat depression in adolescents.

Objects and methods

Participants

A total of 156 adolescents aged 12–18 years old who were hospitalized in the psychosomatic department of our hospital from May 2023 to May 2024 with depression, loss of interest or loss of pleasure as one of the main complaints were selected and diagnosed by 2 psychiatrists with attending or above professional titles. There were 124 patients who met the diagnostic criteria for MDD in the Diagnostic and Statistical Manual of Mental Disorders (5th Edition), of which 3 patients did not meet the inclusion criteria (3), 19 patients met the exclusion criteria, 22 patients did not agree to participate in the experiment, and 80 patients were enrolled (Fig. 1).

Fig. 1.

Flow diagram of the progress through the phases of a parallel randomised trial of two groups

Participants were randomly divided into a study group (39 patients) and a control group (41 patients) via the random number table method. The inclusion criteria were as follows: (1) were 12–18 years old; (2) met the diagnostic criteria for MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (5th edition); and (3) had HAMD-17 scores > 17. The exclusion criteria were as follows: (1) patients who suffered from serious physical or organic diseases, or other diseases that might interfere with the test and evaluation; (2) patients who were previously diagnosed with bipolar affective disorder, schizophrenia, personality disorder or other mental diseases; (3) patients who have attempted suicide; (4) patients who received treatment with electroconvulsive therapy within the previous 3 months; and (5) patients who were unable to complete the scale due to physical disabilities. This study was approved by the ethics committee of Taizhou Second People’s Hospital (ethics number: tzey-ky2021020), and all the participants and their families/guardians in this study signed the informed consent form.

Interventions

Study group: Escitalopram combined with short-term trauma stabilization techniques. The subjects were initially prescribed 10 mg/qd of oxalate escitalopram (trade name: Lexapro, H. Lundbeck A/S), with the dose adjusted based on changes in the patients’ conditions, up to a maximum dose of 20 mg/qd. The average dose of escitalopram was 13.4 ± 3.5 mg/qd. Patients with poor sleep were also prescribed lorazepam (1 mg/qn). Two psychotherapists, who were fully trained and qualified in EMDR stabilization techniques in China, were selected to provide short-term trauma stabilization technique-aided psychotherapy for the adolescents with MDD in the study group. The intervention included 6 sessions: twice a week for 60 min during the first two weeks (focusing on establishing safe/quiet places and container techniques) and once a week for 60 min during the following two weeks. The four key process of short-term trauma stabilization techniques are shown in Table 1. The first is establishing a safe/quiet place, which focuses on creating positive memories, with patients instructed to practice twice daily after guidance. The second is the container technique, which is aimed at helping patients master traumatic or negative experiences, such as invading images, scenes, emotions, or negative body feelings, that have caused significant distress. The third is the combination of four elements with the safe/quiet place, which aims to reduce the stress response of patients. Last is the optical flow technique, which is an exercise designed to reduce or eliminate physical discomfort. The control group received escitalopram combined with mental health education once a week. The subjects received the medicinal oxalate escitalopram (trade name: Lexapro, H. Lundbeck A/S) with an initial dose of 10 mg/qd, which was adjusted based on the changes in the patients’ conditions, with a maximum dose of 20 mg/qd. The final average dose of escitalopram was 14.1 ± 3.7 mg/time. Patients with poor sleep were prescribed lorazepam (1 mg/qn). No significant difference was observed in the final dose between the two groups.

Table 1.

The procedure of short-term trauma stabilization technique

	Trauma stabilization techniques	Schedule of treatment time	Main content
First week	Establishing safe/quiet places	Twice a week for 60 min	A positive exercise designed to construct a positive memory creates an inner mental space in which the patient feels completely safe, and if the experience triggers negative associations, allows the client to put the negative material aside and modify or alter the safe/calm place.
Second week	Container techniques	Twice a week for 60 min	It is designed to help patients learn to master traumatic/negative materials that cause them great distress (especially invasive materials, sensory materials such as flashbacks, sounds, smells and negative thoughts/beliefs, emotions, physical sensations, etc.). Build a safe container in your mind and place the traumatic/negative material that is causing the distress in this safe container and launch it in a relatively distant place so that it is properly isolated.
Third week	Four elements with the safe/quiet place	Once a week for 60 min	The aim is to reduce the stress response of patients and reduce the emotional response. Use "earth”, "air”, "water”, "fire/light" + safe/calm places, implant safe resources, then strengthen, share, and end.
Fourth week	Optical flow technique	Once a week for 60 min	Exercises that help to reduce or remove body discomfort, first identify the characteristics of the body discomfort, build the light flow, operate the light flow, repeat the above steps, expand to other parts of the body, and end.

Assessments

A general condition questionnaire, the Adolescent Self-rating Life Events Checklist (ASLEC), was used to evaluate the occurrence of adolescent life events and their degree of influence. The checklist included 27 items that asked subjects to answer whether the events presented have occurred to themselves or their family members at least once during the past 12 months. If such events occurred, they were rated based on their degree of impact on subjects, using a 5-point scale (0–4 points). Factor score (Each factor score is divided by the number of factors) ≥ 2 or total score ≥ 51 points is abnormal [16]. The Impact of Event Scale-Revised (IES-R) was used to assess the influence of life events on adolescent psychology, with 22 items evaluated on a 5-point scale (0–4 points). This scale includes three dimensions: intrusion, avoidance and hyperarousal, with more than 35 points being abnormal [17]. The HAMD-17 was used to evaluate the depressive emotions of patients, consisting of 17 items, with most items scored on a 5-point scale (0–4 points), while some are scored on a 3-point scale (0–2 points). A score of more than 17 on HAMD17 indicates likely mild or moderate depression, while a score of less than 7 indicates no depression [18]. The Hamilton Anxiety Scale (HAMA) was used to assess patients’ anxiety, and a 5-point scale (0–4 points) was used. Next, the baseline levels of patients in each group were evaluated. The HAMA score was higher than 14, indicating clinically significant anxiety symptoms [18]. After the treatment started, the IES-R, HAMD-17 and HAMA scores of the patients were assessed at the 2nd and 4th weeks.

Aim and hypothesis

In conclusion, we aim to study the benefits of adding short-term trauma stabilization techniques to pharmacological treatment for MDD in adolescents. Our hypothesis is that the treatment with escitalopram combined with short-term trauma stabilization techniques will be more effective to treat major depression in adolescents than escitalopram associated with psychoeducation.

Statistical analysis

The acquired data were statistically analysed via SPSS 27.0. Descriptive statistics and t-tests were used for subject’s demographic characteristics. The threshold of statistical significance was set at 0.01(P < 0.01). Repeated measures of Analysis of Variance were used for within and between group comparisons. Study group was serving as the between-subjects factor and time of assessment (baseline, 2th week and 4th week) was serving as the repeated within-subjects factor. Internal consistency was measured by Cronbach alpha Values of 0.7 or greater are acceptable.

Results

Demographic information analysis

A total of 39 patients were included in the study group, and 41 patients were included in the control group. At the end of the study, 3 patients were dropped from the study group by the end of the study, 3 patients dropped out—1 patient travelled to a relative’s house in another place, and 2 patients went to other hospitals for treatment—leaving 36 patients in the study group. In the control group, 4 patients dropped out—1 patient left due to a traffic accident, 1 patient was excluded because of suicidal behaviour, and 2 patients went to other hospitals for treatment—leaving 37 patients in the end. No significant differences were found in age, sex, years of education, duration of disease, or ASLEC, IES-R, HAMD-17 or HAMA scores between the two groups. See Table 2 for details.

Table 2.

Demographic and clinical data (mean ± SD)

	study group	control group	t/χ2value	P
	(n = 39)	(n = 41)
Demographics
Gender (M/F)	13/26	12/29	0.15	0.70
Age (year)	15.3 ± 2.5	14.9 ± 2.4	0.73	0.47
Education (year)	7.2 ± 2.3	7.1 ± 2.2	0.20	0.84
Clinical characteristics
Mean episode duration(year)	0.7 ± 1.8	0.6 ± 2.0	0.23	0.82
ASLEC	41.5 ± 10.3	39.9 ± 11.2	0.66	0.51
IES-R	19.6 ± 3.6	18.9 ± 4.4	0.78	0.44
HAMD-17	22.3 ± 3.9	21.8 ± 3.6	0.60	0.55
HAMA	18.8 ± 3.4	19.7 ± 4.3	1.04	0.30
Medication
Escitalopram (mg/qd)	13.4 ± 3.5	14.1 ± 3.7	0.87	0.39

Note ASLEC: Adolescent Self-Rating Life Events Checklist; IES-R: Impact of Event Scale-Revised; HAMD-17: 17-item Hamilton Depression Scale; HAMA: Hamilton Scale

Changes in the IES-R, HAMD-17 and HAMA scores before and after treatment

Internal consistency, as measured by Cronbach α, assesses the correlation of items within a scale. Both scales demonstrated acceptable internal consistency: The internal consistency of the IES-R scale was found to be 0.85 ~ 0.89 at different points in time. The internal consistency of the HAMD-17 scale was found to be 0.86 ~ 0.91 at different points in time. The internal consistency of the HAMA scale was found to be 0.83 ~ 0.86 at different points in time. Compared to baseline, the IES-R scores of the control group did not significantly change at the 2th week of treatment. Only after 4 weeks of treatment did the IES-R scores of the control group significantly declined. In contrast, the HAMD-17 and HAMA scores of both study and control groups were markedly decrease at the 2th and 4th weeks of treatment (Figs. 2, 3 and 4). These results indicate that both groups have effective therapeutic effects over time, and the effect of the treatment group is faster than that of the control group.

Fig. 2.

IES-R scores were compared at baseline, 2th week and 4th week

Fig. 3.

HAMD-17 scores were compared at baseline, 2th week and 4th week

Fig. 4.

HAMA scores were compared at baseline, 2th week and 4th week

Compared to the control group, the IES-R scores of the study group were significantly lower after 2 weeks of treatment (P < 0.01). After 4 weeks of treatment, the IES-R scores of the study group were further decreased in comparison with those of the control group, and the difference was statistically significant (P < 0.01). At the 2th week, the HAMD-17 and HAMA scores of the study group were not significantly different from those of the control group. However, at the 4th week, there was a significant different in the HAMD-17 and HAMA scores of the study group compared to those of the control group (P < 0.01). See the details in Table 3; Figs. 5, 6 and 7. These results illustrate that, compared with the control group, the severity of depressive symptoms in the escitalopram combined with short-term trauma stabilization technique group (study group) is significantly reduced, and the therapeutic changes are more prominent, indicating that the combined treatment approach is more effective.

Table 3.

Comparison of IES-R, HAMD-17 and HAMA scores between the study group and the control group (means ± SDs)

	baseline		2th week			4th week
	study group	control group	study group	control group		Study group	control group
	(n = 36)	(n = 37)	(n = 36)		(n = 37)	(n = 36)	(n = 37)
IES-R total scores	20.69 ± 3.46	19.38 ± 4.23	15.43 ± 2.74***		18.36 ± 3.37	10.68 ± 2.84****	15.59 ± 3.77
HAMD-17 total scores	22.42 ± 3.06	21.92 ± 2.63	18.50 ± 2.55		19.00 ± 2.20	12.36 ± 2.31***	14.35 ± 2.19
HAMA total scores	18.83 ± 2.70	19.54 ± 2.74	15.25 ± 2.48		16.11 ± 2.29	10.58 ± 1.92***	12.43 ± 1.85

Note ** intergroup comparisons, P < 0.01 through t test analysis; *** intergroup comparisons, P < 0.001 through t test analysis; **** intergroup comparisons, P < 0.0001 through t test analysis.

Fig. 5.

Comparison of IES-R scores between the study group and the control group

Fig. 6.

Comparison of HAMD-17 scores between the study group and the control group

Fig. 7.

Comparison of HAMA scores between the study group and the control group

Discussion

The incidence of adolescents with MDD is high, and the effectiveness rate reaches only 61% when patients are treated with first-line antidepressants at full doses throughout the entire course of treatment [19]. Importantly, adolescent patients with MDD experience various types of trauma during childhood. Through meta-analysis, Humphreys KL et al. [20] reported that child abuse is correlated with a diagnosis of MDD in adulthood (g = 1.07, 95% CI, 0.95–1.19). Additionally, the incidence of depressive symptoms is also relatively high (Z = 0.35, 95% CI, 0.32–0.38). In a meta-analysis of Chinese people, Lai C J et al. [21] reported that childhood adversity has a combined effect on MDD (r = 0.24, p < 0.001, 95% CI 95% CI, 0.20–0.27). Due to the combination of life events during adolescence and adolescent MDD episodes, antidepressants are less effective. The patients in the study group and control group were assessed using the ASLEC scale, with scores of 41.5 ± 10.3 and 39.9 ± 11.2, respectively; these scores are considered elevated in comparison with normative scores [16]. These findings suggest that adolescent patients with MDD also experience many life events, such as trauma and abuse during childhood, which can affect the recovery and remission of the illness, lengthen the course of the disease, lead to poor therapeutic effects, aggravate suicidal thoughts and result in repeated hospitalizations [7, 20]. Or the ASLEC scores are influenced by the perception of these events, perhaps patients with depression are more prone to perceive events as more negative (cognitive distortions). The IES-R total scores revealed that the scores of patients in both groups were much higher than those in the normative group, the three dimensions of intrusion, avoidance and hyperarousal also increased, indicating that patients have some traumatic experience [17, 21].

Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are often recommended for the psychotherapy of adolescent patients with MDD [1, 6]. CBT primarily teaches teenagers to identify negative thoughts, redefine them as realistic thoughts, and then weigh the evidence supporting or denying these thoughts. IPT focuses primarily on the relationship between depression and interpersonal interaction, and strives to help patients improve their interpersonal communication and problem-solving skills to reduce depressive symptoms and improve function [1]. However, these two therapies do not consider the childhood traumatic events that adolescent patients with MDD may have experienced or the current high incidence of life events, nor do they address these events from a psychological perspective. IPT, which focuses on improving interpersonal communication, might be perceived by some teenagers as a way to express their own grievances. Pierre Janet [22] was the first psychologist to formulate a systematic phase-orientated approach to post-traumatic pathology– these involved three stages: (1) Stabilisation, symptom orientated treatment and preparation for liquidation of trauma memories– Trauma Stabilisation. (2) Identification, exploration and modification of traumatic memories– Trauma Confrontation. (3) Relapse prevention, relief of residual symptoms, personality integration and rehabilitation– Post-traumatic Growth and Resilience. Arne Hofmann [23] believes that stabilization is the foundation of an ideal trauma treatment process, not only a part of the treatment initiation but also an important aspect of the trauma processing. Stabilization includes social stability, relationship stability, psychological stability, and physical stability. Common placation techniques, isolation techniques, and improving emotional tolerance and enhancing emotional regulation are used to assist patients in accepting traumatic events, mastering traumatic/negative materials that cause them great distress, constructing positive memories, reducing patients’ stress reactions, alleviating emotional reactions, and reducing or removing physical discomfort. For traumatic events or reactions that are overly sensitive to life events, it can be independently applied to the treatment of PTSD patients [17]. The trauma stabilization technique has shown promising results when applied to traumatised asylum seekers in various studies, with some researchers believing that it is more important than the EMDR technique itself [24–27]. Wagner KD and Emslie GJ et al. have validated that escitalopram is effective for the treatment of major depressive disorder in adolescents [14, 15]. Based on the above, the short-term trauma stabilization technique was combined with antidepressants to treat adolescent patients with MDD. After 2 weeks of treatment, the IES-R scores of patients decreased compared with those of the control group; however, no evident differences were found in the HAMD-17 and HAMA scores between the two groups. After 4 weeks of treatment, the IES-R scores of the study group had further decreased compared to the control group. Additionally, significant improvements were observed in the HAMD-17 and HAMA scores in the study group compared to the control group. These findings indicate that the affective symptoms of adolescent patients with MDD can be alleviated using antidepressants combined with short-term trauma stabilization techniques, which provides a good therapeutic idea for the treatment of MDD.

Study limitations

Our study is an exploratory study and has several limitations. First, it remains to be analysed whether this psychotherapy technique is effective only for adolescent patients with high ASLEC and IES-R scores or if can be used for general adolescent depression. Second, the current study is based only on the short-term impacts of a psychological intervention; the long-term impacts of such an intervention on adolescents remain unclear. Third, the sample size was relatively small, and a multicentre study was not conducted. Four, the study group received more frequent and higher number of sessions than the control group. The frequency and number of sessions may increase the efficacy of the therapy, creating a bias [28]. Given these limitations, further analysis will be needed with a larger sample size.

Abbreviations

MDD

Major depressive disorder

ASLEC

Adolescent self-rating life events checklist

IES-R

Impact of event scale-revised

HAMA

Hamilton anxiety scale

CBT

Cognitive behavioral therapy

IPT

Interpersonal psychotherapy

EMDR

Eye movement desensitization and reprocessing

PTSD

Posttraumatic stress disorder

Author contributions

JTX were the major contributors to the writing and revision of the manuscript. JJW, XJW and QQC completed the data collection and drafted the manuscript. RZX and YYX analyzed the data. XCG and YPT provided critical revision of the manuscript. XCG was involved in the production of the figures and tables. XCG and YPT made substantial contributions to the conception or design of the work. All authors contributed to revising the manuscript and approving the final manuscript.

Funding

This study was supported by Zhejiang Provincial Natural Science Foundation of China (Grant No. LTGY24C060003); The special project of “Provincial and Municipal Cooperation” of Zhejiang Philosophy and Social Science Planning Project in 2024 (Grant No. 24SSHZ203YB); The Zhejiang Medical and Health Science and Technology Plan Project (Grant No. 2022KY438); Project of Taizhou Science and Technology Department (Grant No. 21ywb64); Taizhou University Teaching Reform Research project; Course Ideological and Political Education Project of Taizhou University.

Data availability

Data is provided within the manuscript. All data and materials are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the ethics committee of Taizhou Second People’ s Hospital (ethics number: tzey-ky2021020), and all the participants and their families/guardians in this study signed the informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.