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G.K.Vankar
Girish Banwari*
Viral Parikh
Hemang Shah
Department of Psychiatry
B.J.Medical College and
Civil Hospital
Ahmedabad 380016
_____________________________________________________________
*Presenter
Correspondence:
Dept. of Psychiatry, Ward E1, Civil Hospital, Ahmedabad 380016
e-mail: drgirishbanwari@yahoo.com
Cell: 9824388958
PTSD and major depression in Children and Adolescents
Abstract
Methods: Children and adolescents who had lost one of their parents in
communal violence in 2002 were evaluated in 2006 i.e. four years after the event
for PTSD and major depression. UCLA Index for PTSD was used to screen for
PTSD, while Brief PHQ was used to screen for major depression.
Results: Out of 255 subjects studied, 25 had PTSD (9.8%), 19 had PTSD
co morbid with major depression (7.4%), and 8 had major depression (3.1%).
Psychiatric morbidity was associated with female gender, age older than 12 and
residence in Ahmedabad (the worst affected city). PTSD was not associated with
10.5% children and adolescents. This emphasizes need for assessment and
trauma.
that 25% to more than 90% develop PTSD depending on the type of stressor, the
length of time since exposure (rates tend to rise over first several months to two
years with a gradual reduction over time) and the method used to assess
[1]
symptomatology. Level of exposure and lack of social support tend to predict
Several studies indicate that majority of children with exposure to trauma develop
a PTSD diagnosis. Most studies have found girls to score higher than boys on
[2-5]
PTSD measures while one study found girls to report greater subjective
appraisal of danger. [6] With regard to age, Green et al did not find any significant
difference in the diagnosis of “probable PTSD” among three age groups (2–7, 8–
[7]
11, and 12–15 years) after the Buffalo Creek disaster. However, there was a
years were more likely to test positive for posttraumatic stress syndrome than
older children. [4] After the earthquake in Armenia, there was no association found
[8]
between the severity of PTSD and age among students 8–16 years old. In a
With regard to post disaster adversities, La Greca et al reported that “major life
End of February, 2002 struck Ahmedabad and state of Gujarat with communal
violence that continued for three months and beyond. As per estimations, over
1200 people were killed, several thousands were injured, more than 30000
households were destroyed and about one lakh people were forced to take
definitely talked about agony and distress of young children and adolescents who
These children besides witnessing communal violence had lost either parent in
the violence. The grass root workers of SEWA were trained by the principal
author and his team to provide psychosocial care to these women and children
one year after the riots. The staff felt that there was need for working with
children and adolescents who had survived the riots. SEWA requested
• To find out frequency of PTSD and major depression among children and
The study team with data collectors visited Shantipath Centres (community
was used or applied. All such children and adolescents brought to our knowledge
Study instruments
UCLA Child PTSD Index, UCLA Adolescent PTSD Index and UCLA PTSD
[12]
Index (current version) were used as appropriate (Rodriguez et al, 2001).
The instruments are almost similar with minor changes in phrasing of questions
The next section contains statements about PTSD manifestations (21 statements
some, 3=much, 4=most). The time frame for which the question is asked is last
The Brief PHQ consists of nine items corresponding to the nine criteria for major
[13]
depression as per DSM-IV for the time frame of last two weeks to be rated on
a 4-point scale (0= not at all, 1=frequently, 2= more than half of the days,
3=almost daily).
[14]
The PRIME-MD was the first mental health diagnostic test that could be
problem.
PHQ consists of 9 items for time frame of last two weeks to be rated on 4-point
scale (0 = Not At All, 1= Frequently, 2 = More than half of the days, 3 =Almost
criteria. Persons who have these essential criteria present plus 2 or 3 responses
rated 2 or 3 were considered as having major depressive disorder. The ninth item
related to suicidal ideas was rated as present even if it were present for less than
In a study of 3,000 patients who used the Brief PHQ, about 30% had a mental
[15]
disorder according to the questionnaire. It took the doctors about 3 minutes on
an average to review the questionnaire and most of the doctors agreed with the
PHQ result.
This instrument is extensively used in India and has been translated in all major
languages.
carefully noted.
Data analysis:
The subjects who had PTSD and major depression and those who didn’t
associated factors. SPSS X version 2002 (SPSS Institute, 2002) was used to
Categorical data was assessed using Chi Square test and quantitative data was
assessed using ‘t’ test. Correlation coefficient was calculated to find total number
of trauma related events and UCLA PTSD index scores. Principal component
1. Demographic characteristics:
Total 255 children and adolescents were interviewed whose ages ranged from 5-
21 years. There were 135 boys and 120 girls (52.9 vs. 47.1%). One hundred and
seventy three subjects (67.4%) had monthly income less than Rs. 1000 and a
vast majority, 198 (77.6%) were Muslims. Most had mother who was a
shopkeeper. One hundred and seventy (66.7%) children and adolescents were
2. Psychiatric morbidity: Out of the 255 subjects studied, 25 had PTSD (9.8%),
19 had PTSD co morbid with major depression (7.4%), and 8 had major
depression (3.1%). Thus 17.2% children and adolescents had PTSD, 4 years
For the subsequent discussion, the subjects with PTSD are referred as index
characteristics.
morbidity.
The index group was exposed to 1-8 events with mean of 4.25(SD1.86) events
whereas the comparison group was exposed to 0-8 events with mean of
4.0(SD1.82).
Table 3 compares both the groups regarding the events. Seeing a dead body
and getting to know about a loved one’s (apart from parents) death or serious
injury were objective trauma related events associated with higher PTSD and
major depression. None of the other trauma related events were associated with
The number of trauma related events the subjects were exposed to was
7. Manifestations of PTSD:
25 subjects had PTSD while 19 had PTSD co morbid with major depression.
The manifestations which were present in more than 50% PTSD subjects
physical symptoms. Survivor guilt, emotional blunting and feeling estranged were
absent.
Factor 1 explained greatest variance i.e. 37.4% and the items Hyper vigilance,
people, places, things related to the event, Physical symptoms, Impending doom,
Frequent quarrels, Gloomy future outlook and Fear that the event would happen
loading on this.
Factor 4 explains 5.1% of variance and has high loading on item Loss of
Thus this study reveals that in child and adolescent population- re experiencing,
avoidance and hyper arousal are inter related and contribute most to clinical
study furthers our knowledge that PTSD can occur even in children and
adolescents who are exposed to traumatic events in India and possibly in some
may run a chronic course. Earlier in earthquake affected and riots affected
20-22.5%. Most PTSD onset occurs soon after exposure to trauma, the
manifestations gradually reduce over 2-year period and in some, they become
[1]
chronic. Studies have indicated that children and adolescents exposed to the
In this work, there was significant gender difference in the rate of PTSD and
major depression. This is in agreement with most other studies on gender and
[2-5]
PTSD.
Adolescents older than 12 years of age had higher psychiatric morbidity in this
study; this is in contrast to other studies that found younger children having
who lived with their parents had fewer acute PTSD symptoms.
A few objective trauma events were associated with psychiatric morbidity. This
study also confirms a dose response relationship, i.e. greater the number of
trauma related events, higher the PTSD score. This is also in harmony with our
Manifestations of PTSD:
[1]
The manifestations of PTSD were similar to those described in literature.
Irritability was the commonest manifestation reported. It has been mentioned that
Survivor guilt was absent in children and adolescents in this study, perhaps
because the traumatic events were manmade on which they did not have control.
Factor structure of PTSD revealed the largest one factor indicating that the
PTSD and grief: The more sudden, unexpected and unnatural the death, the
reactions. Indeed, in the most traumatic situations, both grief and PTSD are likely
to co-occur. A study conducted two years after the communal violence in Gujarat
on 110 widows who lost their husbands in the riots found 12.7% of the women
Delayed onset PTSD: Ten case studies and 19 group studies have consistently
showed that delayed-onset PTSD in the absence of any prior symptoms was
military and civilian cases of PTSD.[24] Little is known about what distinguishes the
adopt a definition that explicitly accepts the likelihood of at least some prior
symptoms.
Limitations of this study: We did not have PTSD data at baseline, sooner after
exposure to trauma to compare. Such data would throw more light on the natural
history of the disorder, suggesting whether the PTSD was chronic or delayed
onset in nature.
The traumatic event was 4 years prior to the study; this may lead to recall bias on
This study has not explored sub threshold PTSD (which though do not meet
DSM IV criteria of PTSD but cause comparable distress and disability) and
communal violence may suffer from PTSD and major depression, even
Risk factors for PTSD included female gender, being adolescent rather
4. Shannon MP, Lonigan CJ, Finch AJ Jr, et al: Children exposed to disaster, I:
children after the 1988 Armenian earthquake. British Journal of Psychiatry 1993;
163:239–47.
9. Chen S-H, Lin Y-H, Tseng H-M, et al. Posttraumatic stress reactions in
children and adolescents one year after the 1999 Taiwan Chi-Chi earthquake. J
10.La Greca AM, Silverman WK, Vernberg EM, et al. Symptoms of posttraumatic
exposed to disaster, II: risk factors for the development of post traumatic
Association.
version of PRIME-MD: the PHQ Primary Care Study. JAMA 1999; 282:1737-
1744.
15.Spitzer R.l. Williams JBW,Kroenke et al. Validity and utility of the PRIME MD
17. Mehta K, Vankar G., Patel V (2005) Validity of the construct of posttraumatic
18. Goenjian AK, Karayan I, Pynoos RS, et al: Outcome of psychotherapy among
42.
19. Najarian LM, Goenjian AK, Pelcovitz D, et al.: Relocation after a disaster:
22. Mehta K and Vankar GK. Post traumatic stress disorder among adolescent
164:1319-26.
Table 1: Psychiatric Morbidity
Diagnosis N=255
N (%)
Post Traumatic Stress Disorder (PTSD) 25 (9.8)
MDD + PTSD 19 (7.4)
SD 3.4 3.5
Upto 12 25 (48.1) 147 (72.4) χ2=11.2, df=1,
p=0.0008
>12 27 (51.9) 56 (29.6)
OR= 0.35(0.18-0.69)
Gender Boys 21 (40.4) 114 (56.2) χ2=4.13, df=1, p=0.04
SD 2.8 3.1
Religion Hindu 9 (17.3) 38 (18.7) χ2=0.05, df=1, p=0.81
Table 3:
OR= 1.10(0.57-2.12)
Damage to house 19 (36.5) 89 (43.8) χ2=0.90,df=1, p=0.34
OR= 0.74(0.37-1.44)
Table 4:
Psychiatric No Significance
Morbidity Psychiatric
N=52 Morbidity
N (%) N=203
N (%)
Scared that he or she will 44 (84.6) 118 (58.1) χ2=12.53, df=1,
be killed
p=0.004
OR= 3.96(1.69-6.94)
Scared that he or she will 44 (84.6) 97 (47.8) χ2=22.72, df=1,
be seriously injured
p=0.000002
OR= 6.01(2.56-14.60)
Sustained serious injury 6 (11.5) 19 (09.4) χ2=0.22, df=1, p=0.64
OR= 1.26(0.39-3.53)
Scared that someone else 42 (80.8) 86 (42.4) χ2=24.42, df=1,
will be killed
p=0.0000008
OR= 5.71(2.59-12.92)
Scared that someone else 46 (88.5) 127 (62.6) χ2=12.73, df=1,
will be seriously injured
p=0.0036
OR= 1.83(4.59-13.71)
Scared that someone else 33 (63.5) 96 (47.3) χ2=4.33, df=1, p=0.04
was seriously injured
OR= 1.94(0.99-3.81)
Someone died 47 (90.4) 96 (47.3) χ2=29.49, df=1,
p=0.0000001
OR= 10.48(3.93-34.8)
Worst fear of lifetime 48 (92.3) 61 (30.1) χ2=63.04, df=1,
p=0.0000000
OR= 27.93(9.4-109.8)
Helplessness, wished 47 (90.4) 123 (63.5) χ2=16.54, df=1,
someone should help p=0.0005
OR= 6.11(2.29-20.43)
Watching gruesome scenes 34 (65.4) 99 (48.8) χ2=4.58, df=1, p=0.032
OR= 1.98(1.01-3.93)
Restless 40 (76.9) 119 (58.6) χ2=5.91, df=1, p=0.015
OR= 2.35(1.11-5.06)
Confused, didn’t know what 43 (82.7) 117 (57.6) χ2=11.12, df=1,
to do
p=0.0008
OR= 3.51(1.55-8.20)
Feeling of unreality 37 (71.2) 64 (31.5) χ2=27.18, df=1,
p=0.0000002
OR= 5.36(2.62-11.07)
Table 5: Manifestations of PTSD
Component Matrix
Componen
t
1 2 3 4 5
VAR0000 .59 .25 1.930E-02 -.12 .38
1
VAR0000 .71 .16 5.973E-03 -.29 6.558E-02
2
VAR0000 .67 .21 -.24= -.11 2.427E-02
3
VAR0000 .60 -.36-4.620E-02-8.750E-02 7.136E-02
4
VAR0000 .56 .20 -.28 -.19 -.16
5
VAR0000 .64 2.184E-02 .12 -.24 -.20
6
VAR0000 .41-2.239E-02 .13 .19 .42
7
VAR0000 .62 -.15 .56 -.19 -.21
8
VAR0000 .58 1.893E-02 .18 .12 .36
9
VAR0001 .58 -.30 .56 -.16 -.15
0
VAR0001 .27 .56 .25 3.434E-02 .14
1
VAR0001 .67 .15 -.21-8.957E-02 .14
2
VAR0001 .63 -.14 -.22 .13 -.11
3
VAR0001 .41 .38 .10 .21 -.45
4
VAR0001 .25 .27 .23 .70 -.10
5
VAR0001 .64 -.28-9.699E-02 .32 .14
6
VAR0001 .65 .19 .12 -.12 .16
7
VAR0001 .735-2.684E-02-7.950E-02-3.311E-02-6.012E-02
8
VAR0001 .69 -.17 -.16 .25 -.13
9
VAR0002 .63 -.43 -.18 7.934E-02 5.406E-02
0
VAR0002 .77 -.13-4.902E-03 .16-7.831E-02
1
VAR0002 .63 .19 -.31-3.736E-02 -.26
2
Extraction Method: Principal Component Analysis.
5 components extracted.