This study was unique by examining the experience of traumatic events, PTSD, and MDD in a sample of health care-seeking urban women. In addition, this study reports the associations between PTSD development and also for nonremittance of PTSD symptoms to traumatic events that were assaultive. In addition, PTSD and MDD were highly related.
This study reports high rates of assaultive and nonassaultive traumatic events and PTSD in this health care-seeking sample of urban women. Although our reported rate of 14.8% for current and 19.6% for past PTSD is nearly triple that of the population rate for women,1
studies of health care-seeking civilian women have reported rates of 8% to 14% for current PTSD.18,33,34,35,36,37
The above-mentioned studies are not directly comparable, as samples were less urban and included fewer racial minorities than this study. In samples more similar to this study, extremely high rates of PTSD have been reported. Rates of PTSD as high as 23% for current and 33% for past cases were reported in samples of primarily African-American women seeking care at urban primary care clinics,19,38
supporting current study findings and indicating the high risk for PTSD development in urban health care-seeking women.
Assaultive violence was especially associated with PTSD development in this study. Repeated assaultive events by family members or intimate partners, including child abuse and IPV, and episodic assaultive events were differentiated and compared, both yielding associations with PTSD development. In addition, both repeated and episodic events were attributed to the majority of diagnosed PTSD cases (74%).
Compared to women without a childhood history of abuse, those who reported childhood abuse were more likely to experience IPV as an adult and also more likely to experience an adult rape than a woman without this history. Furthermore, of those women reporting IPV, almost half reported multiple IPV relationships. These findings suggest that assaultive traumatic events place women at risk to experience additional traumatic events, resulting in a group of extremely traumatized women who are at high risk to develop PTSD and MDD. The relationship between multiple traumatic events and PTSD risk has been reported in similar samples of women39,40
as well as other samples of women;19,38,41,42,43
however, this study is unique by reporting that the experience of assault is linked to experiencing additional assaults, and results in a high risk for PTSD development.
Although PTSD is often chronic,1,2,3,42
risk factors for chronicity have not been well-described. In this study, assaultive events resulted in more than twice the duration of symptoms and a tenfold increase in the risk to development PTSD in a chronic nature. Breslau et al.2
reported a similar trend, supporting the relationship of assaultive events to increased risk for both the development and nonremittance of PTSD in women. This study is unique by linking assault to diagnosed lifetime PTSD cases.
Our findings of high comorbidity of PTSD and MDD strengthen the assertion that these disorders are highly related, especially in women.3,44
Compared to PTSD subjects without MDD, those with comorbid depression have greater medical comorbidities,7,45
higher unemployment rates,46
and higher rates of suicide attempts,47
and may be more resistant to treatment.48
In primary care settings, MDD is often assessed, yet if only MDD is recognized, its comorbidity with PTSD may go undiagnosed. Two recent studies reported that more than a third of depressed primary care patients also screened positive for current PTSD.38,49
Lastly, in a study of primary care patients, only 11% of research participants diagnosed with current PTSD had a diagnosis of PTSD in their charts.38
Therefore, recognition and treatment of PTSD in primary care settings may be the most efficacious way to improve both mental and physical health of traumatized women. If women with these related chronic physical health problems are treated only with traditional medical remedies without addressing the underlying trauma response, the pattern of continued health visits without improvement of symptoms may be likely to continue.
This study provides further evidence of high rates of PTSD in health care-seeking urban women;6,38
however, it does not provide insight into the reasons for increased risk or how best to intervene. Previous studies have linked early trauma, multiple victimizations, chronic exposure to community violence, and also inadequate medical resources to high PTSD risk in low-income urban women.1,2,50,51
Understanding the reasons for elevated PTSD risk may lead to improved screening methods and the development of interventions targeted to low-income urban women. General interventions for PTSD in primary care settings include medication, short-term psychotherapy, and referral to psychiatric clinics,52,53
yet urban women may have unique needs. Social support,54
and integrated treatment for alcohol and drug abuse56,57
have been identified as needs of traumatized urban women. Integrating these or other unique needs may improve treatment of PTSD in urban women.
There are limitations in the current study that should be mentioned. First, this study was cross-sectional and only included urban health care-seeking women. In addition, the sample size limited the examination of other factors that may have influenced the associations among the experience of traumatic events and development and duration of PTSD. Lastly, by including only women, gender comparisons were not possible.
In conclusion, health care-seeking urban women displayed high rates of trauma and those who developed PTSD exhibited multiple health impairments. This study provides additional incentive for improved assessment and treatment of PTSD in primary care, the setting where women most often present with PTSD symptoms. By treating PTSD symptoms, physical health impairments may also improve; however, treating urban women with PTSD may require more than standard treatment approaches.