What is the best course of action for a patient with depression and significant medical trauma?

Referral for Depression with Medical Trauma

For a patient with depression and significant medical trauma, refer to a mental health professional trained in trauma-focused psychotherapy—specifically Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), or Eye Movement Desensitization and Reprocessing (EMDR)—as these evidence-based treatments show 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions and provide more durable benefits than medication alone. 1, 2, 3

Specific Referral Targets

First-Line Referral Options

• Psychologists or licensed therapists specifically trained in trauma-focused cognitive behavioral therapy (CBT), as this is the most effective treatment for both depression and trauma symptoms simultaneously 1, 2
• Psychiatrists with trauma specialization if medication management is needed alongside psychotherapy, though psychotherapy alone should be attempted first 1, 3
• The most effective approach involves on-site mental health services or a "warm handoff" (direct communication with mental health colleagues at time of referral) rather than simply providing a list of names 4

Evidence-Based Treatment Modalities to Request

The referral should specifically request providers trained in:

• Cognitive Processing Therapy (CPT) 1, 3
• Prolonged Exposure (PE) 1, 3
• Eye Movement Desensitization and Reprocessing (EMDR) 1, 3
• Trauma-focused CBT that directly addresses traumatic memories 1

Critical Clinical Considerations

What NOT to Do

• Do not delay trauma-focused treatment by requiring a prolonged "stabilization phase"—evidence shows patients can tolerate and benefit from immediate trauma processing 1, 2
• Avoid labeling the patient as "too complex" for standard trauma treatment, as this may inadvertently communicate they are incapable of dealing with traumatic memories and delay effective care 1
• Do not refer for "psychological debriefing" within 24-72 hours post-trauma, as this approach is not supported by evidence and may be harmful 3

Addressing Caregiver Trauma

• If caregivers have their own trauma history, provide a separate list of adult mental health providers who address trauma, as caregiver treatment improves outcomes 4

Medication Considerations During Referral

If Psychotherapy Unavailable or Delayed

• Consider starting a second-generation antidepressant (sertraline 50mg daily or paroxetine) while awaiting psychotherapy referral 1, 5
• Combination therapy (CBT plus antidepressant) is recommended for moderate to severe depression with trauma history 1

Medications to Avoid

• Never prescribe benzodiazepines for trauma-related symptoms—63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 2, 3

Alternative Access Points

When Traditional Referrals Are Unavailable

• Telehealth trauma-focused therapy produces similar effect sizes to in-person treatment and may improve access in underserved areas 3
• Video or computerized interventions can be effective alternatives when in-person specialists are unavailable 3
• In rural or underresourced communities, telehealth mechanisms can provide evidence-based treatment 4

Follow-Up Responsibilities

Your Role After Referral

• Maintain commitment to working with the family over time to prevent feelings of abandonment, especially when mental health resources are in short supply 4
• Obtain consent to share information with the mental health provider for coordinated care 4
• Continue to listen attentively and offer practical trauma-informed advice that reinforces resilience building even after mental health linkage is established 4
• Screen for depression using PHQ-9 at initial visit, appropriate intervals, and with changes in disease status 4

Expected Treatment Duration

• Trauma-focused psychotherapy typically requires 9-15 sessions for significant improvement 1, 2, 3
• If medication is used, continue for at least 6-12 months after symptom remission before considering discontinuation 3
• Relapse rates are significantly lower after completing trauma-focused psychotherapy (5-16%) compared to medication discontinuation (26-52%) 1, 3

Screening Tools to Use Before Referral

Depression Assessment

• PHQ-9 (9 items): scores ≥10 indicate moderate depression requiring referral; scores ≥15 indicate moderately severe to severe depression requiring urgent referral 4

Trauma Screening

• PTSD Reaction Index Brief Form for known trauma exposure 4
• Psychosocial Assessment Tool for medical trauma specifically 4