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. Author manuscript; available in PMC: 2013 Apr 30.
Published in final edited form as: Psychiatry Res. 2012 Mar 6;196(2-3):261–266. doi: 10.1016/j.psychres.2011.11.010

Decreased suicidal ideation in depressed patients with or without comorbid posttraumatic stress disorder treated with selective serotonin reuptake inhibitors: an open study

Leo Sher 1,*, Barbara H Stanley 1, Kelly Posner 1, Mikkel Arendt 1, Michael F Grunebaum 1, Yuval Neria 1, J John Mann 1, Maria A Oquendo 1
PMCID: PMC3361617  NIHMSID: NIHMS357948  PMID: 22397913

Abstract

Comorbidity of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) is associated with higher morbidity including suicidal ideation and behavior. Selective serotonin reuptake inhibitors (SSRIs) are a known treatment for PTSD, MDD and comorbid PTSD and MDD. Since the patients with comorbid MDD and PTSD (PTSD-MDD) are sicker, we hypothesize a poorer response to treatment compared to patients with MDD only. Ninety-six MDD patients were included in the study: 76 with MDD only and 20 with PTSD-MDD. Demographic and clinical parameters at baseline were assessed. We examined clinical parameters before and after 3 months of open SSRI treatment in subjects with PTSD-MDD and compared this group to individuals with MDD only. At baseline, PTSD-MDD patients had higher Hamilton Depression Rating Scale and Buss-Durkee Hostility Scale scores compared with MDD only subjects. There was a significant decrease in scores on the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Hopelessness Scale, and Beck Scale for Suicidal Ideation after three months of treatment with SSRIs in both groups. The magnitude of improvement in Beck Scale for Suicidal Ideation scores was greater in the PTSD-MDD group compared to the MDD only subjects. Symptoms of depression including suicidal ideation improved in MDD patients with or without comorbid PTSD after 3 months of treatment with SSRIs but improvement in suicidal ideation was greater in the PTSD-MDD group. Our finding has not supported the hypothesis that a response to treatment is poorer in the PTSD-MDD group which may indicate that sicker patients benefit more from treatment.

Keywords: posttraumatic stress disorder, major depressive disorder, suicidal ideation, selective serotonin reuptake inhibitors

1. Introduction

Posttraumatic stress disorder (PTSD) occurs following a wide range of extreme life events (Saigh and Bremner, 1999; APA, 2004; Neria et al., 2008; Wittchen et al., 2009). U.S. population surveys reveal lifetime PTSD prevalence rates of 7% to 8% (Keane et al., 2006). According to the National Comorbidity Survey – Replication, the lifetime prevalence of major depressive disorder (MDD) in the United States is 16.6% (Kessler et al., 2005).

Depression and PTSD commonly co-occur (Bleich et al., 1997; Brown, 2001; APA, 2004; Sher, 2005). Significant depressive symptomatology affects 30% to 70% of persons diagnosed with PTSD (Brown et al., 2001; APA, 2004). Comorbidity of PTSD and MDD is associated with higher morbidity, including suicidal ideation and behavior (Skodol et al., 1996; Bleich et al., 1997; Karam, 1997; Oquendo et al., 2003a; Hawgood and DeLeo, 2008; Sher, 2009). Symptoms of PTSD and MDD overlap significantly and the following symptoms are included in both diagnoses: diminished interest or participation in significant activities, irritability, sleep disturbance, and difficulty concentrating. A number of other symptoms are also common in both conditions (e.g., restricted range of affect, detachment from others), thus, the threshold for meeting criteria for both diagnoses is by definition, lower.

SSRIs are widely used for the treatment of MDD, PTSD and comorbid PTSD and MDD. Since the patients with comorbid MDD and PTSD are sicker, they may show a poorer response to treatment compared to patients with MDD only. We have examined clinical parameters before and after three months of open SSRI treatment of comorbid PTSD and MDD (PTSD-MDD) compared with MDD alone. Our hypothesis was that MDD only patients would show a greater degree of improvement with regard to symptoms of depression including suicidal ideation compared to the PTSD-MDD subjects based on a more modest burden of illness.

2. Methods

2.1. Subjects

Participants were recruited through advertising and referrals and participated in mood disorders research in an urban university hospital. After complete description of the study, all subjects gave written informed consent as required by the Institutional Review Board. Ninety-six MDD patients were included in the study: 76 MDD only and 20 PTSD-MDD. The patients were treated openly for 3 month with SSRIs (Table 1). All subjects were free from alcohol or substance use disorder for at least 2 months prior to study entry. The duration of the drug-free status of the subjects was established by a combination of urine and blood toxicological screenings, observation in hospital, and a history obtained from the participant, the participant’s family and the referring physician. Patients with psychotic features were excluded. At enrollment, all subjects were free of acute or serious medical illness, based on history, physical examination and laboratory tests, including liver function tests, hematologic profile, thyroid function tests, urinalysis and toxicology.

Table 1.

SSRIs used in the treatment of depressed patients

Medication Number of patients treated with this medication Doses
paroxetine 47 10–60 mg/day
citalopram 17 20–80 mg/day
sertraline 17 50–200 mg/day
fluoxetine 12 20–60 mg/day
escitalopram 2 20–80 mg/day
fluvoxamine 1 50 mg/day
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2.2. Measures

Psychiatric disorders including MDD and PTSD were diagnosed using the Structured Clinical Interview (SCID) for DSM-IV (Spitzer et al., 1996). The following measures were administered at baseline and 3-month follow-up: current severity of depression was assessed by the Hamilton Depression Rating Scale (HDRS) (Hamilton, 1960) and the Beck Depression Inventory (BDI) (Beck et al., 1961), the Scale for Suicide Ideation (SSI) was used to measure the severity of suicidal ideation (Beck et al., 1979), and hopelessness during the previous week was measured with the Beck Hopelessness Scale (BHS) (Beck et al., 1974a).

At baseline, lifetime aggression and impulsivity were assessed with the Aggression History Scale (Brown-Goodwin, revised; Brown and Goodwin, 1986) and the Barratt Impulsivity Scale, respectively (Barratt, 1965). Hostility (lifetime) was rated with the Buss-Durkee Hostility Inventory (Buss and Durkee, 1957). A lifetime history of all suicide attempts, including number of attempts and the method of the attempt, was recorded on the Columbia Suicide History Form (Oquendo et al., 2003b). A suicide attempt was defined as a self-destructive act that was committed with some intent to end one’s life. Additionally, the Medical Lethality Rating Scale was used to measure the degree of medical damage caused by each suicide attempt (Beck et al., 1975). The scale was scored from 0 to 8 (0=no medical damage, 8=death), with anchor points for different suicide attempt methods. The degree of suicide intent for the worst attempt was rated with the Suicide Intent Scale (Beck et al., 1974b). Interviewers were Masters or PhD-level psychologists. Inter-rater reliability was good to excellent (ICC 0.71 – 0.97). A chart review to determine what stressors triggered PTSD in PTSD-MDD subjects was performed by a psychiatrist (L.S.).

2.3 Statistical analysis

Demographic data were compared using Student’s t-test and chi-square test, as appropriate. Clinical data at baseline and 3 months were compared using paired t-test. To evaluate whether a higher prevalence of borderline personality disorder (BPD) was related to the observed higher hostility at baseline in the PTSD-MDD group compared to the MDD group, we fit a regression model with hostility score as the dependent variable and PTSD and BPD diagnoses as predictor variables. To compare the magnitude of changes in the two patient groups, we fit a regression model with the outcome variable (a psychiatric scale score: HDRS, BDI, BHS, or SSI) at 3 months as response variable and the baseline value of the same variable, PTSD diagnosis, and their interaction as predictor variables. SPSS 18.0 program was used to perform statistical analyses.

3. Results

Demographic and clinical characteristics of MDD only and PTSD-MDD groups are presented in Tables 2, 3 and 4. Nine PTSD-MDD subjects experienced trauma leading to PTSD during their childhood, and 11 patients were traumatized during their adulthood. The traumas leading to PTSD in the PTSD-MDD group, as reported by subjects, were as follow: childhood sexual and/or physical abuse (n=8); violent crimes (n=7) (including rape as an adult (n=3) and domestic violence (n=1)); witnessing violence and war during childhood (n=1); physical injury as a result of an accident (n=1); loss of a child as a result of an accident (n=1); daughter’s rape (n=1); and other (n=1) (Table 5).

Table 2.

Demographic and clinical features of depressed subjects with and without a history of posttraumatic stress disorder

Variable Name Subjects without a history of PTSD (n = 76) Subjects with a history of PTSD (n = 20) Analysis
Mean or (N) SD or (%) Mean or (N) SD or (%) df t/χ2 p
Demographic features
Age (yrs) 39.0 12.3 40.9 12.3 94 0.6 0.51
Gender (%males) (33) (43.4) (4) (20.0) 1 3.7 0.06
Marital status (married) (16) (21.1) (5) (25.0) 1 0.1 0.69
Education (total years) 15.6 2.9 14.2 3.1 94 −1.9 0.61
Clinical features
Brown-Goodwin Aggression History Scale 17.7 5.4 18.6 5.2 92 0.6 0.59
Barrat Impulsivity Scale (BIS) 52.7 18.8 50.6 13.3 86 −0.4 0.72
Buss Durkee Hostility Scale 33.7 12.6 40.1 8.6 89 2.0 0.04
Age at first major depressive episode 24.7 13.1 24.1 15.3 92 0.3 0.91
Age at first outpatient psychotherapy 25.7 16.6 33.2 7.9 55 0.1 0.21
Age at first psychiatric hospitalization 31.0 14.0 34.3 8.9 50 0.1 0.53
Number of psychiatric hospitalizations 1.6 3.1 2.1 4.5 83 0.1 0.49
Number of patients with recurrent major depression (62) (81.6) (17) (85) 1 0.1 0.72
Suicide Attempt Status (% attempters) (27) (35.5) (10) (50) 1 1.4 0.21
Number of suicide attempts (in attempters) 1.9 1.2 2.4 1.6 35 1.1 0.17
Suicide Intent Scale (at the time of the most lethal suicide attempt) 15.0 5.5 15.8 5.7 34 0.4 0.71
Maximum lethality of suicide attempts 2.9 2.0 3.2 2.4 34 0.5 0.68
Smoking status (% smokers) (17) (22.4) (7) (35) 1 1.4 0.31
Prevalence of Borderline Personality Disorder (14) (18.4) (9) (45) 1 6.1 0.01
Number of patients who received benzodiazepines or zolpidem (21) (27.6) (8) (40) 1 1.2 0.28
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Table 3.

Depression, hopelessness and suicidal ideation scale scores in depressed subjects with and without a history of posttraumatic stress disorder at baseline and after 3 month treatment with SSRIs (intergroup comparisons)

Variable Name Subjects without a history of PTSD (n = 76) Subjects with a history of PTSD (n = 20) Analysis
Time point Mean (Median) SD (IQR) ** Mean (Median) SD (IQR) ** df t/z p
Hamilton Depression Rating Scale (HDRS) Baseline 24.0 7.8 29.2 9.8 91 2.5 0.01
3 month treatment 15.1 10.8 17.6 11.8 89 0.9 0.42
Beck Depression Inventory (BDI) Baseline 25.5 10.7 28.7 11.3 93 0.8 0.41
3 month treatment 15.3 13.0 15.2 14.4 84 −0.04 0.97
Beck Hopelessness Scale (BHI) Baseline 11.1 5.7 13.5 5.6 93 1.4 0.19
3 month treatment 7.6 6.2 8.5 6.9 84 0.6 0.62
Suicide Ideation Scale (SSI) Baseline (5) (14) (9.5) (22) 0.9 0.41*
3 month treatment (0) (4) (1) (7) −0.8 0.48*
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*

Mann-Whitney test

**

Interquartile range

Table 4.

Depression, hopelessness and suicidal ideation scale scores in depressed subjects with and without a history of posttraumatic stress disorder at baseline and after 3 month treatment with SSRIs (intra-group comparisons)

Variable Name Baseline 3 month treatment Analysis
Group Mean (Median) SD (IQR) ** Mean (Median) SD (IQR) ** df t/z p
Hamilton Depression Rating Scale (HDRS) Subjects without a history of PTSD 24.0 7.8 15.0 10.8 69 6.7 <0.001
Subjects with a history of PTSD 29.2 9.8 18.1 11.9 18 4.8 <0.001
Beck Depression Inventory (BDI) Subjects without a history of PTSD 25.5 10.7 15.0 13.0 64 7.2 <0.001
Subjects with a history of PTSD 28.7 11.3 15.2 14.4 19 3.7 0.01
Beck Hopelessness Scale (BHI) Subjects without a history of PTSD 11.1 5.7 7.5 6.1 64 5.1 <0.001
Subjects with a history of PTSD 13.5 5.6 8.5 6.9 19 3.6 0.02
Suicide Ideation Scale (SSI) Subjects without a history of PTSD (5) (14) (0) (4) −4.4 <0.001*
Subjects with a history of PTSD (9.5) (22) (1) (7) −2.4 0.02*
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*

Wilcoxon test

**

Interquartile range

Table 5.

Experience of trauma and subsequent medical history in depressed patients with posttraumatic stress disorder

Gender Age Traumatic experiences Recurrence of major depressive episodes History of suicide attempts (yes/no) Number of suicide attempts
Female 36 Childhood physical and sexual abuse Recurrent MDD Yes 2
Female 44 Childhood sexual abuse Recurrent MDD Yes 4
Male 43 Undetermined Recurrent MDD Yes 1
Female 22 Rape (adult) First episode No
Female 28 Witnessing violence and war during childhood Recurrent MDD Yes 5
Female 31 Childhood sexual abuse Recurrent MDD No
Female 45 Rape (adult) Recurrent MDD Yes 1
Female 34 Childhood sexual abuse Recurrent MDD Yes 5
Female 51 Childhood sexual abuse Recurrent MDD Yes 1
Female 42 Domestic violence (verbal and physical abuse) First episode No
Female 57 Physical assault by armed men (adult) Recurrent MDD No
Male 29 Was shot (adult) First episode No
Female 25 Victim of violent crimes (adolescent and adult) Recurrent MDD Yes 2
Male 61 Physical injury as a result of an accident (hit by a car) Recurrent MDD No
Male 64 Loss of son in a car accident Recurrent MDD No
Female 31 Childhood physical abuse Recurrent MDD No
Female 55 Rape (adult), physical assault (adult) Recurrent MDD Yes 2
Female 46 Daughter’s rape Recurrent MDD No
Female 29 Childhood sexual abuse Recurrent MDD No
Female 44 Childhood sexual abuse Recurrent MDD Yes 1
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At baseline, PTSD-MDD patients had higher Hamilton Depression Rating Scale and Buss-Durkee Hostility Scale scores compared with the MDD alone group (Tables 3 and 4). There was higher prevalence of borderline personality disorder (BPD) in the PTSD-MDD group compared to the MDD patients (Table 2). The regression analysis showed that higher hostility scores in the PTSD-MDD group were attributable to the higher prevalence of subjects with BPD in this group (df=1,91, F=4.45, p=0.04), but not to the PTSD diagnosis (df=1,91, F=1.94, df=1,91, p=0.17).

There was a significant decrease in scores on the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Hopelessness Scale, and Beck Scale for Suicidal Ideation after three months of treatment with SSRIs in both patient groups (Tables 3 and 4). However, patients remained significantly depressed.

The regression analysis indicated that the magnitude of improvement with regard to the Beck Scale for Suicidal Ideation was higher in the PTSD-MDD group compared to the MDD only subjects (Table 6). There was no difference in the magnitude of improvement on the Hamilton Depression Rating Scale, Beck Depression Inventory and Beck Hopelessness Scale between the two groups.

Table 6.

Comparison of the magnitude of changes in depression, hopelessness and suicidal ideation scale scores in depressed subjects with or without a history of posttraumatic stress disorder at baseline and after 3 month treatment with SSRIs

df F B t P
Hamilton Depression Rating Scale (HDRS) 1,89 0.6 0.2 0.8 0.4
Beck Depression Inventory (BDI) 1,86 1.5 −0.4 −1.2 0.2
Beck Hopelessness Scale (BHI) 1,85 0.8 0.6 4.8 0.8
Suicide Ideation Scale (SSI) 1,75 4.7 −1.7 −0.8 0.03
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A regression model with the outcome variable (a psychiatric scale score: HDRS, BDI, BHS, or SSI) at 3 months as response variable and the baseline value of the same variable, PTSD diagnosis, and their interaction as predictor variables.

4. Discussion

Three months of open SSRI treatment in the comorbid MDD and PTSD group produced more improvement in suicidal ideation compared with patients with MDD only. On measures of depressive symptoms and hopelessness the two groups improved to a similar extent. Our hypothesis, that MDD alone patients would have a better outcome, was not confirmed.

4.1. Baseline comparison

At baseline, the clinician ratings of depression (i.e., HDRS) and hostility were higher in PTSD-MDD compared with MDD alone. Our finding is consistent with previous observations suggesting that PTSD-MDD patients report more severe depression, less social support and more frequent outpatient health care visits compared with MDD-only patients (Campbell et al., 2007). A study of traumatized refugees found that comorbidity of PTSD and MDD was associated with more severe symptoms as well as higher levels of disability on all indices (global dysfunction, distress, social impairment and occupational disability) compared to individuals with PTSD only (Momartin et al., 2004).

The regression analysis indicates that the difference in hostility scores appears to be attributable to the higher prevalence of BPD in the PTSD-MDD group compared to the MDD only group. We have previously reported that a higher rate of comorbid cluster B personality disorder appears to be a salient factor contributing to greater risk for suicidal acts in PTSD-MDD subjects compared to MDD only (Oquendo et al., 2005). Cluster B personality disorders, particularly borderline personality disorder, are a risk factor for suicidal behavior in depressed patients (Soloff et al., 2000; Kotler et al., 2001; Soloff and Fabio, 2008; McGirr et al., 2009). Borderline personality disorder may have an additive effect with respect to suicidal behavior when it is comorbid with PTSD (Zlotnick et al., 2003). The additional comorbid diagnosis of BPD in patients with PTSD significantly increases the features of suicide proneness and impulsiveness (Zlotnick et al., 2003).

4.2. Clinical parameters after 3 months of treatment

After 3 months of treatment with SSRI, both groups demonstrated significant improvement with regard to both clinician-rated and subjective depression scores, hopelessness scores, and suicidal ideation. The improvement in suicidal ideation was more pronounced in PTSD-MDD subjects compared with the other group. The improvement in depression and hopelessness was comparable in both groups. Our findings may indicate that SSRIs are at least as helpful for patients with PTSD and MDD as for those with MDD only.

Among the antidepressants, the SSRIs are the most commonly prescribed pharmacological intervention for MDD, PTSD and comorbid PTSD and MDD (Ornstein et al., 2000; Stein et al., 2000; Albucher and Liberzon, 2002; Rihmer and Akiskal, 2006). The efficacy of SSRIs for the treatment of MDD is well established. Some (van der Kolk et al, 1994; Connor et al, 1999; Brady et al, 2000; Davidson et al, 2001; Marshall et al, 2001; Martenyi et al, 2002; Tucker et al, 2001; Ballenger et al, 2004; Robert et al, 2006) but not all (Friedman et al., 2007) controlled trials also indicate that this class of medications is effective in the treatment of PTSD and its associated problems. Several literature reviews and meta-analyses have recommended SSRIs as first-line treatment for PTSD (Davidson et al, 2006; Stein et al, 2006). There is limited evidence for the efficacy of SSRIs in the treatment of co-morbid depression and PTSD, and the studies that do exist, are all concerned with co-morbid depression in patients presenting for PTSD treatment. The existing randomized controlled trials show that symptoms of depression are significantly reduced following treatment with SSRIs in PTSD patients regardless of the patient meeting criteria for comorbid major depression or having sub-syndromal symptoms of depression (Davidson et al, 2006; Stein et al, 2006). Brady et al. (2000) observed significant improvement in symptoms of depression in PTSD patients following treatment with sertraline compared with placebo, and Tucker et al. (2001) reported that paroxetine improved symptoms of depression in a group of patients in treatment for chronic PTSD. Also, Brady and Clary (2003) found that PTSD patients with co-morbid depression responded well to treatment with sertraline, and Stein et al. (2003) found similar results for paroxetine. Regarding patients in treatment for major depression with co-morbid PTSD, little evidence has existed prior to the present study concerning the effectiveness of SSRIs. This underlines the significance of the finding that treatment with SSRI’s is comparably effective for depressive symptoms in patients with major depression and comorbid PTSD as in patients with major depression only.

Our study suggests that there is a cause-effect relationship between the baseline HDRS scores and the results, i.e., the improvement is related to the treatment. Although a placebo effect plays a role in the improvement of depressed patients, it is unlikely that such significant improvement in depressed subjects, especially in depressed patients with comorbid PTSD could be a result of a placebo effect.

This significance of the results is further underlined by the finding that comorbid patients improved more than MDD-only patients on the measure of suicidal ideation. It is that co-morbid group that is at greater risk for suicidal behavior (Oquendo et al., 2003a), and therefore the beneficial effect of SSRIs on suicidal ideation in that group is a particular clinical advantage. A number of studies have found a relationship between PTSD and the risk of suicide among survivors of a variety of traumatic events such as combat trauma (Hendin and Haas, 1991), battered women (Sharhabani-Arzy et al., 2003), sexual abuse (Zlotnick et al., 2001) and rape (Bridgeland et al., 2001). There is evidence that traumatic events such as sexual abuse, combat trauma, rape, and domestic violence generally increase a person’s suicide risk (Hendin & Haas, 1991; Sharhabani-Arzy et al, 2002; Zlotnick et al., 2001; Bridgeland et al., 2001). The results of our study are consistent with the observation by Zisook et al. (2009) that decreased suicidality was a function of treatment response.

Improvement of suicidal ideation scores with treatment is clinically important because suicidal ideation predicts suicidal behavior (Fawcett et al., 1990; Beck et al., 1999; Brown et al., 2000; Hatcher-Kay and King, 2003; Galfalvy et al., 2006; Reinherz et al., 2006; Galfalvy et al., 2008). For example, it has been shown that suicidal ideation predicts suicidal acts after major depression in bipolar disorder (Galfalvy et al., 2006).

This is a study of open treatment and needs to be replicated in a randomized placebo controlled clinical trial. Improvement after three months may be related to the natural course of illness or other factors, such as an opportunity to discuss psychological problems with psychiatrists and psychologists-raters. On the other hand, the main objective of the study was to compare MDD with comorbid PTSD to MDD without, and both groups had similar treatment experiences. Another limitation is that the patients were not evaluated using PTSD-specific instruments (such as Clinician-Administered PTSD Scale (CAPS)), i.e., symptoms of depression but not PTSD were evaluated. Other limitations of this study are: a small sample size of the PTSD-MDD group, that since it was as exploratory study, our observation that improvement in suicidal ideation was greater among patients with comorbid PTSD could be chance related to multiple testing.

In summary, our study indicates that the use of SSRIs is associated with improvement in symptoms of depression including suicidal ideation in MDD with or without comorbid PTSD. Our finding may indicate that sicker patients benefit more from treatment. There is a need for further studies of the effectiveness of SSRIs in comorbid PTSD-MDD patients using prospective controlled designs.

Acknowledgments

Supported by the Conte Center for the Neurobiology of Mental Disorders (5 P50 MH62185), MH48514, MH59710, AA15630, and the Nina Rahn Fund.

Footnotes

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References

  1. Albucher RC, Liberzon I. Psychopharmacological treatment in PTSD: a critical review. Journal of Psychiatric Research. 2002;36:355–67. doi: 10.1016/s0022-3956(02)00058-4. [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Washington, DC: APA Press; 1994. [Google Scholar]
  3. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB, Shalev AY, Yehuda R. Consensus statement update on posttraumatic stress disorder from the international consensus group on depression and anxiety. Journal of Clinical Psychiatry. 2004;65(Suppl 1):55–62. [PubMed] [Google Scholar]
  4. Barratt ES. Factor Analysis of Some Psychometric Measures of Impulsiveness and Anxiety. Psychological Reports. 1965;16:547–554. doi: 10.2466/pr0.1965.16.2.547. [DOI] [PubMed] [Google Scholar]
  5. Beck AT, Beck R, Kovacs M. Classification of suicidal behaviors: I. Quantifying intent and medical lethality. American Journal Psychiatry. 1975;132:285–287. doi: 10.1176/ajp.132.3.285. [DOI] [PubMed] [Google Scholar]
  6. Beck AT, Brown GK, Steer RA, Dahlsgaard KK, Grisham JR. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide and Life Threatening Behavior. 1999;29(1):1–9. [PubMed] [Google Scholar]
  7. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology. 1979;47:343–352. doi: 10.1037//0022-006x.47.2.343. [DOI] [PubMed] [Google Scholar]
  8. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry. 1961;4:561–571. doi: 10.1001/archpsyc.1961.01710120031004. [DOI] [PubMed] [Google Scholar]
  9. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology. 1974a;42:861–865. doi: 10.1037/h0037562. [DOI] [PubMed] [Google Scholar]
  10. Beck RW, Morris JB, Beck AT. Cross-validation of the Suicidal Intent Scale. Psychological Reports. 1974b;34:445–446. doi: 10.2466/pr0.1974.34.2.445. [DOI] [PubMed] [Google Scholar]
  11. Bleich A, Koslowsky M, Dolev A, Lerer B. Post-traumatic stress disorder and depression. An analysis of comorbidity. British Journal of Psychiatry. 1997;170:479–82. doi: 10.1192/bjp.170.5.479. [DOI] [PubMed] [Google Scholar]
  12. Brady K, Pearlstein T, Asnis GM, Baker D, Rothbaum B, Sikes CR, Farfel GM. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. Journal of the American Medical Association. 2000;283(14):1837–44. doi: 10.1001/jama.283.14.1837. [DOI] [PubMed] [Google Scholar]
  13. Brady KT, Clary CM. Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline. Comprehensive Psychiatry. 2003;44(5):360–9. doi: 10.1016/S0010-440X(03)00111-1. [DOI] [PubMed] [Google Scholar]
  14. Bridgeland W, Duane E, Stewart C. Victimization and attempted suicide among college students. College Student Journal. 2001;35:63–76. [Google Scholar]
  15. Brown CS. Depression and anxiety disorders. Obstetrics and Gynecology Clinics of North America. 2001;28(2):241–68. doi: 10.1016/s0889-8545(05)70199-6. [DOI] [PubMed] [Google Scholar]
  16. Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. Journal of Consulting and Clinical Psychology. 2000;68(3):371–7. [PubMed] [Google Scholar]
  17. Brown GL, Goodwin FK. Human aggression and suicide. Suicide and Life Threatening Behavior. 1986;16:223–243. doi: 10.1111/j.1943-278x.1986.tb00353.x. [DOI] [PubMed] [Google Scholar]
  18. Buss AH, Durkee A. An inventory for assessing different kinds of hostility. Journal of Consulting Psychology. 1957;21(4):343–9. doi: 10.1037/h0046900. [DOI] [PubMed] [Google Scholar]
  19. Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine. 2007;22(6):711–8. doi: 10.1007/s11606-006-0101-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Connor KM, Sutherland SM, Tupler LA, Malik ML, Davidson JR. Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study. British Journal of Psychiatry. 1999;175:17–22. doi: 10.1192/bjp.175.1.17. [DOI] [PubMed] [Google Scholar]
  21. Davidson J, Pearlstein T, Londborg P, Brady KT, Rothbaum B, Bell J, Maddock R, Hegel MT, Farfel G. Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: results of a 28-week double-blind, placebo-controlled study. American Journal of Psychiatry. 2001;158(12):1974–81. doi: 10.1176/appi.ajp.158.12.1974. [DOI] [PubMed] [Google Scholar]
  22. Davidson JR. Pharmacologic treatment of acute and chronic stress following trauma: 2006. Journal of Clinical Psychiatry. 2006;67(Suppl 2):34–9. [PubMed] [Google Scholar]
  23. Fawcett J, Scheftner WA, Fogg L, Clark DC, Young MA, Hedeker D, Gibbons R. Time-related predictors of suicide in major affective disorder. American Journal of Psychiatry. 1990;147(9):1189–94. doi: 10.1176/ajp.147.9.1189. [DOI] [PubMed] [Google Scholar]
  24. Friedman MJ, Marmar CR, Baker DG, Sikes CR, Farfel GM. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting. Journal of Clinical Psychiatry. 2007;68(5):711–20. doi: 10.4088/jcp.v68n0508. [DOI] [PubMed] [Google Scholar]
  25. Galfalvy H, Oquendo MA, Carballo JJ, Sher L, Grunebaum MF, Burke A, Mann JJ. Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study. Bipolar Disorders. 2006;8(5 Pt 2):586–95. doi: 10.1111/j.1399-5618.2006.00340.x. [DOI] [PubMed] [Google Scholar]
  26. Galfalvy HC, Oquendo MA, Mann JJ. Evaluation of clinical prognostic models for suicide attempts after a major depressive episode. Acta Psychiatrica Scandinavica. 2008;117(4):244–52. doi: 10.1111/j.1600-0447.2008.01162.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Hamilton M. A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry. 1960;23:56–62. doi: 10.1136/jnnp.23.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Hatcher-Kay C, King CA. Depression and suicide. Pediatrics in Review. 2003;24(11):363–71. [PubMed] [Google Scholar]
  29. Hawgood J, De Leo D. Anxiety disorders and suicidal behaviour: an update. Current Opinion in Psychiatry. 2008;21(1):51–64. doi: 10.1097/YCO.0b013e3282f2309d. [DOI] [PubMed] [Google Scholar]
  30. Hendin H, Haas AP. Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry. 1991;148(5):586–91. doi: 10.1176/ajp.148.5.586. [DOI] [PubMed] [Google Scholar]
  31. Karam EG, Noujeim JC, Saliba SE, Chami AH, Abi Rached S. PTSD: how frequently should the symptoms occur? The effect on epidemiologic research. Journal of Traumatic Stress. 1996;9(4):899–905. doi: 10.1007/BF02104112. [DOI] [PubMed] [Google Scholar]
  32. Keane TM, Marshall AD, Taft CT. Posttraumatic stress disorder: etiology, epidemiology, and treatment outcome. Annual Review of Clinical Psychology. 2006;2:161–97. doi: 10.1146/annurev.clinpsy.2.022305.095305. [DOI] [PubMed] [Google Scholar]
  33. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6):593–602. doi: 10.1001/archpsyc.62.6.593. [DOI] [PubMed] [Google Scholar]
  34. Kotler M, Iancu I, Efroni R, Amir M. Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous and Mental Disease. 2001;189(3):162–7. doi: 10.1097/00005053-200103000-00004. [DOI] [PubMed] [Google Scholar]
  35. Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. American Journal of Psychiatry. 2001;158(12):1982–8. doi: 10.1176/appi.ajp.158.12.1982. [DOI] [PubMed] [Google Scholar]
  36. Martenyi F, Brown EB, Zhang H, Prakash A, Koke SC. Fluoxetine versus placebo in posttraumatic stress disorder. Journal of Clinical Psychiatry. 2002;63(3):199–206. doi: 10.4088/jcp.v63n0305. [DOI] [PubMed] [Google Scholar]
  37. McGirr A, Paris J, Lesage A, Renaud J, Turecki G. An examination of DSM-IV borderline personality disorder symptoms and risk for death by suicide: a psychological autopsy study. Canadian Journal of Psychiatry. 2009;54(2):87–92. doi: 10.1177/070674370905400206. [DOI] [PubMed] [Google Scholar]
  38. Momartin S, Silove D, Manicavasagar V, Steel Z. Comorbidity of PTSD and depression: association with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. Journal of Affective Disorders. 2004;80:231–48. doi: 10.1016/S0165-0327(03)00131-9. [DOI] [PubMed] [Google Scholar]
  39. Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychological Medicine. 2008;38(4):467–80. doi: 10.1017/S0033291707001353. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Oquendo M, Brent DA, Birmaher B, Greenhill L, Kolko D, Stanley B, Zelazny J, Burke AK, Firinciogullari S, Ellis SP, Mann JJ. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. American Journal of Psychiatry. 2005;162(3):560–6. doi: 10.1176/appi.ajp.162.3.560. [DOI] [PubMed] [Google Scholar]
  41. Oquendo MA, Friend JM, Halberstam B, Brodsky BS, Burke AK, Grunebaum MF, Malone KM, Mann JJ. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. American Journal of Psychiatry. 2003a;160(3):580–2. doi: 10.1176/appi.ajp.160.3.580. [DOI] [PubMed] [Google Scholar]
  42. Oquendo MA, Halberstam B, Mann JJ. Risk factors for suicidal behavior: utility and limitations of research instruments. In: First MB, editor. Standardized Evaluation in Clinical Practice. Vol. 22 Washington, DC: APPI Press; 2003b. [Google Scholar]
  43. Ornstein S, Stuart G, Jenkins R. Depression diagnoses and antidepressant use in primary care practices: a study from the Practice Partner Research Network (PPRNet) Journal of Family Practice. 2000;49(1):68–72. [PubMed] [Google Scholar]
  44. Reinherz HZ, Tanner JL, Berger SR, Beardslee WR, Fitzmaurice GM. Adolescent suicidal ideation as predictive of psychopathology, suicidal behavior, and compromised functioning at age 30. American Journal of Psychiatry. 2006;163(7):1226–32. doi: 10.1176/ajp.2006.163.7.1226. [DOI] [PubMed] [Google Scholar]
  45. Rihmer Z, Akiskal H. Do antidepressants t(h)reat(en) depressives? Toward a clinically judicious formulation of the antidepressant-suicidality FDA advisory in light of declining national suicide statistics from many countries. Journal of Affective Disorders. 2006;94(1–3):3–13. doi: 10.1016/j.jad.2006.04.003. [DOI] [PubMed] [Google Scholar]
  46. Robert S, Hamner MB, Ulmer HG, Lorberbaum JP, Durkalski VL. Open-label trial of escitalopram in the treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry. 2006;67(10):1522–6. doi: 10.4088/jcp.v67n1005. [DOI] [PubMed] [Google Scholar]
  47. Saigh PA, Bremner JD. The history of posttraumatic stress disorder. In: Saigh PA, Bremner JD, editors. Posttraumatic Stress Disorder: A Comprehensive Text Ed. New York: Allyn & Bacon; 1998. pp. 1–17. [Google Scholar]
  48. Sharhabani-Arzy R, Amir M, Kotler M, Liran R. The toll of domestic violence. PTSD among battered women in an Israeli sample. Journal of Interpersonal Violence. 2003;18(11):1335–46. doi: 10.1177/0886260503256842. [DOI] [PubMed] [Google Scholar]
  49. Sher L. The concept of post-traumatic mood disorder. Medical Hypotheses. 2005;65(2):205–210. doi: 10.1016/j.mehy.2005.03.014. [DOI] [PubMed] [Google Scholar]
  50. Sher L. A model of suicidal behavior in war veterans with posttraumatic mood disorder. Medical Hypotheses. 2009;73(2):215–9. doi: 10.1016/j.mehy.2008.12.052. [DOI] [PubMed] [Google Scholar]
  51. Skodol AE, Schwartz S, Dohrenwend BP, Levav I, Shrout PE, Reiff M. PTSD symptoms and comorbid mental disorders in Israeli war veterans. British Journal of Psychiatry. 1996;169(6):717–25. doi: 10.1192/bjp.169.6.717. [DOI] [PubMed] [Google Scholar]
  52. Soloff PH, Fabio A. Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. Journal of Personality Disorders. 2008;22(2):123–34. doi: 10.1521/pedi.2008.22.2.123. [DOI] [PubMed] [Google Scholar]
  53. Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. American Journal of Psychiatry. 2000;157(4):601–8. doi: 10.1176/appi.ajp.157.4.601. [DOI] [PubMed] [Google Scholar]
  54. Spitzer RL, Williams JB, Gibbon M, First MB. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV) Washington, D.C: American Psychiatric Press, Inc; 1996. [Google Scholar]
  55. Stein DJ, Davidson J, Seedat S, Beebe K. Paroxetine in the treatment of post-traumatic stress disorder: pooled analysis of placebo-controlled studies. Expert Opinion in Pharmacotherapy. 2003;4(10):1829–38. doi: 10.1517/14656566.4.10.1829. [DOI] [PubMed] [Google Scholar]
  56. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD) Cochrane Database Systems Review. 2006;(1):CD002795. doi: 10.1002/14651858.CD002795.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Stein DJ, Seedat S, van der Linden GJ, Zungu-Dirwayi N. Selective serotonin reuptake inhibitors in the treatment of post-traumatic stress disorder: a meta-analysis of randomized controlled trials. International Clinical Psychopharmacology. 2000;15(Suppl 2):S31–9. doi: 10.1097/00004850-200008002-00006. [DOI] [PubMed] [Google Scholar]
  58. Tucker P, Zaninelli R, Yehuda R, Ruggiero L, Dillingham K, Pitts CD. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry. 2001;62(11):860–8. doi: 10.4088/jcp.v62n1105. [DOI] [PubMed] [Google Scholar]
  59. van der Kolk BA, Dreyfuss D, Michaels M, Shera D, Berkowitz R, Fisler R, Saxe G. Fluoxetine in posttraumatic stress disorder. Journal of Clinical Psychiatry. 1994;55(12):517–22. [PubMed] [Google Scholar]
  60. Wittchen HU, Gloster A, Beesdo K, Schönfeld S, Perkonigg A. Posttraumatic stress disorder: diagnostic and epidemiological perspectives. CNS Spectrum. 2009;14(1 Suppl 1):5–12. [PubMed] [Google Scholar]
  61. Zisook S, Trivedi MH, Warden D, Lebowitz B, Thase ME, Stewart JW, Moutier C, Fava M, Wisniewski SR, Luther J, Rush AJ. Clinical correlates of the worsening or emergence of suicidal ideation during SSRI treatment of depression: an examination of citalopram in the STAR*D study. J Affect Disord 2009. 2009;117(1–2):63–73. doi: 10.1016/j.jad.2009.01.002. [DOI] [PubMed] [Google Scholar]
  62. Zlotnick C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT. Clinical features and impairment in women with Borderline Personality Disorder (BPD) with Posttraumatic Stress Disorder (PTSD), BPD without PTSD, and other personality disorders with PTSD. Journal of Nervous and Mental Disease. 2003;191(11):706–13. doi: 10.1097/01.nmd.0000095122.29476.ff. [DOI] [PubMed] [Google Scholar]
  63. Zlotnick C, Mattia J, Zimmerman M. Clinical features of survivors of sexual abuse with major depression. Child Abuse and Neglect. 2001;25(3):357–67. doi: 10.1016/s0145-2134(00)00251-9. [DOI] [PubMed] [Google Scholar]

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