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When you think about posttraumatic stress disorder (PTSD) and depression, what is the primary commonality that comes to mind? Like most clinicians, you’d be correct to note their comorbidity; but is this due to the fact that PTSD and depression share diagnostic symptoms (e.g., diminished interest in activities, impaired concentration, guilt, and sleep problems)? Also, does one affect the other? These questions remain unanswered to a large extent.

As it has become widely known, PTSD and depression often go hand-in-hand among civilians and Service members alike, but particularly so among veterans. Specifically, there is an estimated comorbidity rate of 50% between PTSD and major depressive disorder (MDD) among civilians (Rytwinski, Scur, Feeny, & Youngstrom, 2013) and Active Duty Service Members (Walter, Levine, Highfill-McRoy, Navarro, & Thomsen, 2018), with slightly higher rates among veterans (Rytwinski et al., 2013). What is less known, though, is if the severity of an individual’s depression affects how well they respond to PTSD treatment. In fact, a multitude of studies have demonstrated divergent findings in this area. This may be due, in part, to the fact that evidence-based PTSD treatment providers typically address depression symptoms in the context of an intervention already being delivered. Also, treatment strategies like exposure and cognitive restructuring tend to generalize to depression symptoms even as they target PTSD symptoms. These are just a few of the nuanced ways that co-occurring depression symptoms can influence PTSD treatment. Further, only a limited number of these studies were conducted using veteran samples and none with older adult Veterans. This study aimed to dig deeper.

In our recent Journal of Traumatic Stress publication, the research team examined the influence of pre-treatment depression severity on PTSD and depression symptoms over time. As part of a randomized controlled trial, 85 older male veterans (>60 years old) suffering from military-related PTSD received either prolonged exposure (PE) therapy or relaxation training (RT). Veterans were classified according to their depression severity in two groups: 23 veterans in the no/mild depression group and 62 veterans in the moderate/severe depression group. Participants completed the PTSD Checklist (PCL-S) and the Patient Health Questionnaire (PHQ-9) once at pre-treatment, at each of their therapy sessions, at post-treatment, and at their 6-month follow-up. The team used Multilevel Modeling (MLM) to analyze the impact of pre-treatment depression severity on PTSD and depression symptoms over time. The goal was to determine if pre-treatment depression symptom severity impacted the veterans’ treatment outcomes during active treatment and the follow-up periods, and if the treatment condition (PE or relaxation training) further affected response to treatment.


Results showed the following:

  1. The higher a veterans’ pre-treatment depression severity score was, the higher their PTSD (B = 15.24, p =.05) and depression symptom severity scores (B = 7.09, p = .001) were over time.
  2. The two groups (no/mild depression and moderate/severe depression) did not have significantly different PTSD and depression symptom trajectories across time.
  3. The trajectories of PTSD and depression symptoms that veterans reported were not impacted by the type of treatment they received (PE or RT).
  4. A pattern was observed wherein PTSD and depression symptoms significantly decreased during the active treatment period (pretreatment through session 12), but returned in the follow-up period (post-treatment through 6-month follow-up).

What Can We Extract?

These results tell us a number of things. First, even though older Veterans with greater depression severity reported higher PTSD and depression scores across time, greater pre-treatment depression severity did not limit how much they would ultimately improve. This replicates and extends previous findings from other populations. Second, both types of treatments (PE and RT) may be beneficial for older male veterans, which may have great implications for available treatment options given access to care for older veterans. Third, for older adults with PTSD, regardless of depression severity or treatment condition, follow-up treatment might be necessary to keep symptoms at bay.

Our findings underscore the need for ongoing research for individuals suffering from comorbid PTSD and depression, to not only pinpoint etiology and course, but also to extend or modify treatment options, specifically for older adults, as this particular population may be further impacted by cognitive impairments, perceived stigma about mental health treatments, and medical conditions that could limit the effectiveness of treatment. Addressing both PTSD and depression in novel ways can create unique opportunities for identifying and treating comorbid depression and PTSD for civilians and service members alike.


Rytwinski, N. K., Scur, M. D., Feeny, N. C., & Youngstrom, E. A. (2013). The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: A meta-analysis. Journal of Traumatic Stress, 26, 299-309. doi: 10.1002/jts.21814

Walter, K. H., Levine, J. A., Highfill-McRoy, R. M., Navarro, M., & Thomsen, C. J. (2018). The Prevalence of PTSD and psychological comorbidities among U.S. active duty service members, 2006-2013. Journal of Traumatic Stress, 31, 837-844. doi:10.1002/jts.22337


Reference Article

Walter, K.H., Glassman, L.H., Wells, S.Y., Thorp, S.R. and Morland, L.A. (2020), The Impact of Depression Severity on Treatment Outcomes Among Older Male Combat Veterans with Posttraumatic Stress Disorder. Journal of Traumatic Stress

Questions for Discussion

  1. Do existing PTSD treatments sufficiently address symptoms of comorbid depression, or are adjunctive approaches or additional follow-up treatment warranted?
  2. What are some potential ways to accelerate the trajectory for people with moderate/severe comorbid depression to further reduce symptom levels and related impairment?
  3. How can we increase access to aftercare for older adult veterans following PTSD treatment

About the Author

Kristen H. Walter, PhD is a Clinical Research Psychologist at the Naval Health Research Center in San Diego, CA, where she investigates the treatment of posttraumatic stress disorder (PTSD) and conditions that commonly comorbid with PTSD, such as major depressive disorder. She explores both evidence-based treatments for PTSD and co-occurring conditions, as well as complementary and alternative approaches.