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Three Part Question

In [assault victims] does the [presence of affective disorder] have [any affect on the development of PTSD]?

Clinical Scenario

A 30 year old woman comes into the Emergency Department having been the victim of a vicious non-sexual assault. She has suffered from depression since the age of 18. The Mental Health liaison nurse says that you should refer her for psychological support straight away as she has a predisposition to develop PTSD. Although it seems likely that someone with a known depressive disorder is more likely to get post assault psychological problems, you wonder whether there is any evidence to show that this really does occur.

Search Strategy

OVID Medline 1966to September week 2 2006 and PsychINFO 1806 to 1966 using multifile searching
The Cochrane Library Issue 3 2006
Medline/PsychINFO: [exp Crime Victims/ OR exp violence/ or exp domestic violence/ OR assault adj3 victim.mp.] AND [affective disorders.mp. or exp Mood Disorders/] AND [PTSD.mp. or exp Stress Disorders, Post-Traumatic/] Limit to human, English Language and "all adult (19 plus years)"
Cochrane: Mood disorders [MeSH] AND Stress Disorders, Post-Traumatic [MeSH} – 0 records

Search Outcome

133 articles. 8 addressed the question indirectly, but are included as they all relate to PTSD and affective disorder.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
West CG et al, 1990, USA	30 physically abused women were randomly selected from a women's shelter and evaluated by psychiatric interview and psychiatric rating scales	PRCT	Prevalence of MDD and PTSD	37% MDD found and 47% PTSD determined. Disorders were found to be positively associated
Van Velsen C et al, 1996, UK	60 patients, with a history of torture or other repressive state violence, referred to a psychiatrist were assessed using a standard instrument.	Survey	Diagnosis of PTSD and MDD	31 met the diagnostic criteria for PTSD and 21 met the criteria for MDD. The two were found to be positively associated.
Duncan RD et al, 1996, USA	National sample of women screened for physical assault in childhood, major depressive episode, PTSD and sustanance abuse	Survey	Frequency of assaults in childhood	2.6% reported having experienced serious assaults in childhood
			Lifetime and current episodes of depression, post traumatic stress and substance abuse	Compared with women experiencing no victimisation, these women experienced more lifetime and current episodes of depression, PTSD and substance abuse
Lispsky et al, 2005, USA	182 female patients taken from larger study, identified as intimate partner violence victims (IPV), interviewed using standardized survey instrument	Survey	Comorbidity of MDD and exacerbation of severity of chronicity of PTSD	80% abused women with PTSD had comorbid MDD. Women with PTSD were 4 times more likely to be depressed.	Cross-sectional design. Non-representative sample.
Nixon et al, 2004, USA	142 women with experience of physical abuse within the last 6 months recruited from local DV agencies, evaluated by structured interview, psychiatric rating scales and questionnaire.	Survey / structured interview	PTSD and comorbid MDD	75% met diagnostic criteria for PTSD and 54% for MDD, but schemas measured did not predict comorbidity	Non-representative sample Accuracy of pre-reports of pre-abuse functioning questionable
Scher and Resick, 2005, USA	202 physically abused or raped women responded to recruitment postcards using self-report and psychiatric rating scales.	Survey	Relationship between hopelessness and PTSD	Relationship between self-reported and interviewer rated hopelessness and PTSD due to shared variance with depression. Hopelessness positively associated with both PTSD and MDD	Non-representative sample Self-report limitations
Shalev et al, 1998, Israel	28 adult patients attending an ED who had experienced an event meeting the criteria for PTSD, assessed using structured clinical interviews, self-report and psychiatric rating scales.	Interview/Survey	Prevalence of PTSD and MDD following trauma	PTSD, MDD and comorbid PTSD and MDD more prevalent in patients with prior depression than those without. Patients with comorbid PTSD and MDD reported more symptoms.	Short follow-up Non-generalisable sample.
Stein and Kennedy, 2001, USA	44 females drawn from larger sample from study examining the effects of trauma. Structured clinical interview and psychiatric rating scale.	Interview/survey	Prevalence of PTSD and MDD	42.9% of patients with IPV related PTSD also had MDD. On a lifetime basis, MDD and PTSD were highly prevalent (68.2% and 31.8% respectively).	Non-representative sample Cross-sectional design.

Comment(s)

There is clear evidence that in assault victims depression and PTSD are linked, but it is unclear whether affective disorder predisposes a person to developing PTSD. Some of the evidence above comes from individuals assaulted as children which seems to have a greater effect on the development of symptoms than assault in later life.

Clinical Bottom Line

PTSD and affective disorder are related and often occur concurrently.

References

1. West CG, Fernandez A, Hillard JR, et al. Psychiatric disorders of abused women at a shelter. Psychiatr Q 1990;61(4):295-301.
2. Van Velsen C, Gorst-Unsworth C, Turner S. Survivors of torture and organized violence: demography and diagnosis. J Trauma Stress 1996;9(2):181-193.
3. Duncan RD, Saunders BE, Kilpatrick DG, et al. Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: findings from a national survey.[published erratum appears in Am J Orthopsychiatry 1997;67(1):161.] Am J Orthopsychiatry 1996;66(3):437-48.
4. Lipsky S. Field CA. Caetano R et al. Posttraumatic stress disorder symptomatology and comorbid depressive symptoms among abused women referred from emergency department care. Violence & Victims. 20(6):645-59, 2005 Dec.
5. Nixon RD. Resick PA. Nishith P. An exploration of comorbid depression among female victims of intimate partner violence with posttraumatic stress disorder. Journal of Affective Disorders. 82(2):315-20, 2004 Oct 15.
6. Scher CD. Resick PA. Hopelessness as a risk factor for post-traumatic stress disorder symptoms among interpersonal violence survivors. Cognitive Behaviour Therapy. 34(2):99-107, 2005.
7. Shalev AY. Freedman S. Peri T et al. Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry. 155(5):630-7, 1998 May.
8. Stein MB. Kennedy C. Major depressive and post-traumatic stress disorder comorbidity in female victims of intimate partner violence. Journal of Affective Disorders. 66(2-3):133-8, 2001 Oct.