Posttraumatic stress disorders comorbid with major depression in West Bank, Palestine: a general population cross sectional study

Background and Objectives: The prevalence of Post Traumatic Stress Disorders (PTSD) comorbid with Major Depressive Episodes (MDE) were explored in four areas of West Bank of Palestine in the aftermath of the second intifada. Methods: The sample consisted of 916 adult Palestinians representative of the general population. The interview was personal with the use of DSM IV criteria for PTSD and MDE (the SCID I modules). Results: The prevalence of chronic PTSD comorbid with lifetime MDE and chronic PTSD alone were found 18.7% and 26.5% respectively. Another 6.1% were diagnosed as suffering from lifetime MDE. Higher numbers of refugees were found to suffer from PTSD comorbid with MDE. The majority of respondents who reported previous suicidal behavior were comorbid cases of PTSD/MDE. The predictors differentiating between MDE alone and no diagnosis and between comorbid PTSD/MDE and no diagnosis were almost identical. Conclusions: This sample of adult Palestinians living under conditions of mass violence and continuous economic deprivation were found suffering from high rates of post PTSD and comorbid PTSD with MDE, a common finding among populations under serious traumatic exposure. Received: 6 November 2009 Revised: 4 August 2010 Accepted: 13 September 2010 20 MICHAEL G. MADIANOS, ADNAN LUFTI SARHAN AND EVMORFIA KOUKIA In the epidemiology of Posttraumatic Stress Disorder (PTSD) both clinical and general population surveys have shown that the majority of respondents who have been exposed in serious traumatic experiences and diagnosed as suffering from PTSD, meet the criteria for at least one other psychiatric disorder1-5. Breslau et al.2, reported that 83% of the diagnosed individuals as suffering from PTSD met criteria for at least one other psychiatric disorder. In the National Comorbidity Study4 88% of males and 79% of females respondents with chronic PTSD, had another psychiatric diagnosis. In the Australian National Survey of Mental Health and Well-Being, 85% of the males with PTSD and 80% of females were also found to meet the criteria for another DSM IV disorder for the past year6. One of the most frequent comorbid psychiatric disorder with lifetime PTSD, is the Major Depressive Episode (MDE)3-5, 7-11. PTSD and depressive symptoms occur frequently, following exposure to a traumatic event or events. In the studies by Breslau et al.2, Kessler et al.4 and Creamer et al.6 the most frequent psychiatric disorder comorbid with PTSD was found to be major depression. Additionally PTSD increases the risk of suicidal behavior12-14. The association between major depression including suicidality and PTSD could be explained by the possible triggering of onset of depression though the mechanism of trauma and vulnerability4,15. The preexistence of depressive symptomatology may also contribute to the incidence of PTSD after exposure to traumatic events16. In population under acute stress namely refugees, war veterans, victims of disasters (natural or manmade) or entire populations living in long lasting conflict zones, the rates of PTSD comorbid with MDE reported by several investigators, are higher than those recorded in general population surveys1, 17-22. For example Marshall et al.23 reported that 71% of Cambodian refugees, two decades after their resettlement in USA, met the criteria for MDE and 86% of those with major depression, met also criteria for PTSD. Palestine of West Bank of Jordan River and Gaza strip is the case of a country with high volume of a variety of sociopolitical adversities, duration of unresolved conflict and high volume of mass violence24,25. In adults, there were two studies on the prevalence of PTSD in a general population sample, both carried out in Gaza strip. In the first study focusing on gender specific trauma exposure and mental health symptoms among Palestinians living in Gaza strip conditions of military violence, 24% of males and 16% of females were diagnosed as suffering from PTSD by the use of PTSD module of CIDI schedule26. However the investigators did not provided data on comorbidity. In the second study on the prevalence of PTSD by the use also of CIDI, in countries facing mass violence (Algeria, Cambodia, Ethiopia and Gaza strip), the rates of PTSD found in the Gaza sample reached 28.4% the males reported more PTSD symptoms than females27. No data on comorbidity with major depression were also given. Finally, in the neighboring Lebanon, the effect of war events on the prevalence of major depression was examined by the application of D.I.S. schedule, and provided rates ranging from 16.3% to 41.9% with no reference to any comorbidity findings28. In a recent study by Elbedour et al.29, among Palestinian adolescents 12 to 18 years old, following the second intifada (uprising) of 2000-2007 in Gaza strip, 68.9% were classified as having developed PTSD and 40.0% reported moderate or severe levels of depression. PTSD was assessed by specific instrument with criteria-symptoms POSTTRAUMATIC STRESS DISORDERS COMORBID WITH MAJOR DEPRESSION... 21 matching with those of DSM IV of APA. It should be mentioned that during this period more than 30.000 Palestinians suffered from moderate or serious injuries. Finally Khamis30, in her study among injured Palestinian adolescents, reported that 76.5% of them had a DSM IV diagnosis of PTSD with chronic symptoms and comorbid with depression and anxiety. To our knowledge no systematic clinicoepidemiological study has ever been conducted in the adult general population of West Bank, to explore the dimensions of PTSD, MDE and the related comorbidity. The current study was carried out 1) to explore the dimensions of comorbidity of PTSD with MDE in a general population sample of Palestinians of West Bank at the end of second “intifada” 2) to investigate the prevalence of comorbidity of PTSD and MDE among those Palestinians were identified as refugees 3) to examine the suicidal behavior among each diagnostic category and 4) to delineate the possible differences in predictors of categorical diagnosis of PTSD, MDE and comorbid PTSD/MDE.