The relationship between post‐traumatic stress disorder and affective disorder

The relationship between post‐traumatic stress disorder and affective disorder

Report by Kate Roberts, Medical Student

Search checked by Suzanne Robbins, Clinical Psychologist

Abstract

A short‐cut review was carried out to establish whether the presence of affective disorder in victims of assault alters the chances of developing post‐traumatic stress disorder (PTSD). In all, 133 papers were found using the reported searches, of which 8 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that PTSD and affective disorder are related and often occur at the same time.

Clinical scenario

A 30‐year‐old woman who has been the victim of a vicious non‐sexual assault presents to the emergency department. She has had depression since the age of 18 years. 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 someone with a known depressive disorder is more likely to get postassault psychological problems, you wonder whether there is any evidence to show that this really does occur.

Three‐part question

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

Search strategy

Ovid Medline 1966 to September Week 2 2006 and PsychINFO 1806 to 1966 using multifile searching. [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)”

The Cochrane Library Issue 3 2006. Cochrane: Mood disorders [MeSH] and Stress Disorders, Post‐Traumatic [MeSH]

Outcome

A total of 133 papers were found. Eight dealt with the question indirectly, but are included as they all relate to PTSD and affective disorder.

Table 3.

Author, date and country	Patient group	Study type	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 substance 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
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 after 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 women drawn from a larger sample from a 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
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 the 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
Lispsky et al, 2005, USA	182 female patients taken from a larger study, identified as IPV victims, interviewed using a standardised 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
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

DV, domestoc violence; ED, emergency department; IPV, intimate partner violence; MDD, mood disorders; PTSD, post‐traumatic stress disorder.

Comments

Clear evidence suggests 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 cited above are 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.