Journal of Affective Disorders 66 (2001) 133–138

www.elsevier.com / locate / jad

Research report

Major depressive and post-traumatic stress disorder comorbidity in

female victims of intimate partner violence
a,b ,
Murray B. Stein *, Colleen Kennedy a,b
a
VA San Diego Healthcare System, San Diego, CA, USA
b
Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

Received 18 April 2000; accepted 26 July 2000

Abstract

Background & Methods: Victims of intimate partner violence (IPV) often develop psychiatric disorders. We examined the
extent and correlates of comorbidity between two of the disorders most frequently linked to trauma – major depressive
disorder (MDD) and post-traumatic stress disorder (PTSD) – in a group of 44 women who were victims of IPV within the
preceding 2 years. Results: MDD (68.2%) and PTSD (50.0%) were highly prevalent on a lifetime basis in female victims of
IPV. On a current basis, MDD (18.2%) and IPV-related PTSD (31.8%) were more frequently comorbid (42.9% of cases of
current IPV-related PTSD also had MDD) than would be expected by chance (P , 0.001). Most cases of current MDD
occurred in persons who also had current IPV-related PTSD. Severity of depressive and PTSD symptoms were highly
correlated (r 5 0.84). Although women with PTSD were significantly more disabled than women without PTSD, persons
with comorbid PTSD and MDD were not significantly more disabled than those with PTSD alone. Limitations: Cross-
sectional study; entry criteria for study may limit generalizability. Conclusions: PTSD and MDD symptoms are frequently
seen in the aftermath of IPV, and often co-occur. The usefulness of the distinction between PTSD and MDD in this context
remains to be determined, both in terms of diagnostic classification and prognostic implications.  2001 Elsevier Science
B.V. All rights reserved.

Keywords: Domestic violence; Intimate partner violence; Major depressive disorder; Post-traumatic stress disorder

1. Introduction survey of a nationally representative sample of

Domestic abuse, also known as intimate partner
violence (IPV), is a major public health problem of
alarming proportions (Bell et al., 1996). A recent
*Corresponding author. Tel.: 11-858-622-6112; fax: 11-858-
450-1491.
E-mail address: mstein@ucsd.edu (M.B. Stein).
women found that 8% of women who were married
or living with a domestic partner at the time of the
interview, said they had been physically abused by
their partners during the past 12 months (Plichta,
1996). The severity of this type of abuse is further
reflected in a 1994 statistic showing that 17% of all
persons treated in emergency rooms in the United
States had been injured by an intimate partner (Rand,

0165-0327 / 01 / $ – see front matter  2001 Elsevier Science B.V. All rights reserved.
PII: S0165-0327( 00 )00301-3
134 M.B. Stein, C. Kennedy / Journal of Affective Disorders 66 (2001) 133 – 138
1997). IPV often results not only in serious physical
injury but also puts women at risk for the develop-
ment of mental disorders (Golding, 1999).
Among the most commonly identified sequelae of
IPV are post-traumatic stress disorder (PTSD) (Astin
et al., 1993; Dutton, 1992; Gleason, 1993; Kemp et
al., 1995; Saunders, 1994) and major depressive
disorder (MDD) (Campbell et al., 1997; Gleason,
1993). Extensive comorbidity between PTSD and
MDD is the norm in studies of various traumatized
groups, including persons exposed to combat (Shalev
et al., 1998; Southwick et al., 1991), disasters (Green
and Lindy, 1994), and IPV (Cascardi et al., 1999).
Community studies also demonstrate a strong link
between these two disorders, with approximately
35–50% of cases of PTSD in the general population
being comorbid with MDD (Breslau et al., 1997;
Breslau et al., 1998; Kessler et al., 1995).
The purpose of the present investigation was to
further evaluate the co-occurrence and correlates of
PTSD and MDD in female victims of IPV. In
addition to determining the extent of comorbidity,
principal goals of this study were to identify possible
indicators of comorbidity, and to describe the impact
of comorbidity on functioning.
2. Methods
2.1. Subjects
Forty-four female victims of intimate partner
violence (IPV) were recruited through the use of
advertisements from agencies that provide services to
victims of domestic abuse and from community
medical clinics. All participants were part of a larger
study examining the psychological and neurobiologi-
cal effects of trauma in women. The IPV participants
were victims of physical and / or sexual abuse by an
intimate partner, and they had all extricated them-
selves from their abusive relationship at least 4
weeks, but no longer than 2 years, prior to enroll-
ment in the study. All participants were English
speaking and had at least an 8th grade reading
ability. No participant had a history of neurological
illness, head injury as indicated by loss of conscious-
ness greater than 10 min, learning disability, or a
history of psychosis.
Furthermore, individuals were excluded from the
study if any of the following applied: use of any
psychotropic medication within 6 weeks prior to
participation; use of oral or intramuscular steroids
within the past 4 months; drug or alcohol abuse or
dependence within the past year; or a history of
alcohol abuse for a period of greater than 2 years in
the past, as assessed by the Addiction Severity Index
(McClellan et al., 1985).
A total of 184 IPV victims contacted us in
response to our posted advertisements and were
screened for eligibility. Of these, 125 were deemed
ineligible for one or more of the following most
common reasons: English not their first language;
still in the abusive relationship; extensive substance
abuse history; serious head injury; current psycho-
tropic use. Of 59 eligible participants, 15 chose not
to participate or did not show up for the assessments,
leaving the current group of 44 participants with a
history of recent IPV.
Study participants ranged in age from 19 to 49
years (M 5 34.07, S.D. 5 9.25) and had an average
of 12.70 years (S.D. 5 2.25) of education. Holling-
shead scores (Hollingshead, 1975), where higher
scores reflect higher socioeconomic status, were M 5
31.86, S.D. 5 12.67. IPV participants were 48%
Caucasian, 22% African American, 14% Hispanic,
2% Native American, and 14% were from other
ethnic backgrounds.
2.2. Procedures
To assess presence or absence of PTSD and PTSD
severity, participants were administered the Clinician
Administered PTSD Scale for DSM-IV (CAPS)
(Blake et al., 1995), with questions directed spe-
cifically to experiences of domestic violence. High
scores on the CAPS indicate greater levels of PTSD
symptom severity. The CAPS Criterion F items were
used to examine overall level of functioning in daily
living. Participants were also administered the PTSD
module of the Structured Clinical Interview for the
DSM-IV (SCID-P) (First et al., 1997) to assess
presence or absence of lifetime PTSD for any
lifetime trauma other than domestic abuse. The
 M.B. Stein, C. Kennedy / Journal of Affective Disorders 66 (2001) 133 – 138
MDD, Panic Disorder, and Generalized Anxiety
Disorder modules of the SCID-P were also adminis-
tered to assess for the presence of these diagnoses.
The Impact of Event Scale-Revised (IES-R)
(Weiss and Marmar, 1997), a 22-item self-report
measure, was administered to examine severity of
PTSD symptoms over the past week. Subjects were
instructed to respond to each item, based on a five-
point Likert scale ranging from 0 5 not at all to
4 5 extremely, regarding their experience with IPV.
Severity of intimate partner violence was mea-
sured using the revised version of the Conflict
Tactics Scale (CTS-2) (Straus et al., 1996), a 39-
item self-report measure with five subscales
(Negotiation, Psychological Aggression, Physical
Assault, Sexual Coercion, and Injury) assessing
various aspects of the domestic abuse experience.
Level of depression was assessed in all subjects,
using the Center for Epidemiologic Studies-Depres-
sion Scale (CES-D) (Radloff, 1977), a 20-item self-
report measure examining depressive symptoms
within the past week.
2.3. Statistical analyses
The proportion of subjects meeting DSM-IV
criteria for the various diagnoses under considera-
tion, are reported using descriptive statistics. The
association between MDD and IPV-related PTSD
categorical diagnoses was examined using the Chi-
square test with continuity correction. The associa-
tion of continuous measures of symptoms and abuse
severity were examined using Pearson’s correlation
coefficient.
We next tested the hypothesis that more severe
abuse would be associated with a greater likelihood
of having comorbid IPV-related PTSD (from any
kind of trauma, including IPV) 1 MDD (rather than
IPV related PTSD alone) using hierarchical logistic
regression. We tested the hypothesis that participants
with comorbid PTSD (from any kind of trauma,
including IPV) 1 MDD would have more severe
PTSD symptoms and poorer functioning than those
with PTSD alone by comparing IES-R, CAPS-total
and the CAPS functioning items in the two groups
with Student’s t-tests. All statistical tests were two-
135
tailed, and P values , 0.05 were considered statisti-
cally significant.
3. Results
3.1. Prevalence of PTSD and other disorders
The prevalence of PTSD and other DSM-IV
disorders assessed in the study is shown in Table 1.
PTSD was the most common disorder on a current
(past 30 days) basis, but major depression was the
most common on a lifetime basis. Panic disorder was
somewhat less common both on a lifetime and
especially on a current basis. Generalized anxiety
disorder, which was assessed on only a lifetime
basis, was the least common of the disorders as-
sessed.
3.2. IPV-related PTSD and MDD comorbidity
Six subjects (13.6%) had current comorbid IPV-
related PTSD 1 MDD. The co-occurrence of current
PTSD and MDD took place on what was signifi-
cantly more than a chance basis (continuity-corrected
Chi-square 5 8.39, df 5 1, P , 0.004); six of 14
subjects (42.9%) with current IPV-related PTSD also
had MDD, whereas only one of 30 subjects without
current IPV-related PTSD (3.3%) also had MDD. On
a lifetime basis, cases of MDD were equally distrib-
uted among women with PTSD (72.7%) and women
without PTSD (63.6%; continuity-corrected Chi-
square 5 0.1, df 5 1, P , 0.75 [ns]). Both cases of
Table 1
Prevalence of assessed DSM-IV disorders in female victims
violence (N544)
DSM-IV diagnosis N (%)
Current IPV-related PTSD 14 (31.8%)
Current PTSD (from any trauma) 19 (45.2%)a
Lifetime PTSD (from any trauma) 22 (50.0%)
Current major depressive disorder 8 (18.2%)
Lifetime major depressive disorder 30 (68.2%)
Current panic disorder 2 (4.5%)
Lifetime panic disorder 6 (13.6%)
Lifetime generalized anxiety disorder 2 (4.5%)
a
Not assessed in two subjects; denominator is 42 subjects.
136 M.B. Stein, C. Kennedy / Journal of Affective Disorders 66 (2001) 133 – 138

current panic disorder were comorbid with IPV-
related PTSD.
3.3. Relationship between IPV severity and severity
of current IPV-related PTSD and depressive
symptoms
ical Assault and Injury, respectively) we believed
would be most strongly indicative of the distinction
between PTSD alone vs. comorbid PTSD1MDD,
did not turn out to have significant explanatory
power (Chi-square for the model51.26, df 52, P.
0.50 [ns]).

Severity of current IPV-related PTSD (as measured

by the CAPS) and depressive symptoms (as mea-
sured by the CES-D) were strongly correlated (r5
0.84, df 537, P,0.001). Interestingly, although a
modest association was seen between severity of the
domestic abuse as measured by the various CTS-2
subscales and severity of IPV-related PTSD symp-
toms (r values range from 0.40 to 0.43, all P values
,0.05, for the Psychological Aggression, Physical
Assault, Sexual Coercion, and Injury subscales), no
such relationship was seen for depressive symptoms
(r values range from 0.01 to 0.15, none statistically
significant).
3.4. Indicators of PTSD and comorbid PTSD1
MDD
We hypothesized that more severe IPV would be
associated with a greater likelihood of having de-
veloped comorbid IPV-related PTSD1MDD, rather
than IPV-related PTSD alone. Hierarchical logistic
regression, entering the two CTS-2 subscales (Phys-
3.5. Severity of symptoms and IPV in comorbid
cases
Scores on measures of Current PTSD symptoms
(CAPS and the IES-R), depressive symptoms (CES-
D), and severity of the domestic abuse experience
itself (CTS-2) are shown in Table 2. In this table,
victims of IPV are characterized as either having
Current PTSD without MDD (N512), Current PTSD
with MDD (N57), or No Current PTSD. We hypoth-
esized that women with current comorbid PTSD and
MDD would have more severe PTSD symptoms than
persons with PTSD alone. CTS-2 scores are included
for information purposes only, as we did not test for
differences in order to reduce the number of com-
parisons being made. For the same reason, we did
not test for differences with the group who did not
have PTSD, as these are obvious. In fact, the two
PTSD groups with and without comorbid MDD did
not differ significantly from one another on total
CAPS or CES-D scores.

Table 2
Symptom and domestic abuse severity in female victims of intimate partner violence a
Severity Current Current No Current
PTSD (-MDD) PTSD1MDD PTSD
mean (S.D.) mean (S.D.) mean (S.D.)
(N512) (N57) (N522)
CAPS total 60.5 (23.1) 74.3 (18.5) 24.9 (16.1)
IES-R 42.7 (20.8) 54.7 (13.4) 19.3 (13.8)
CES-D 28.6 (12.9) 39.0 (8.3) 14.1 (9.5)
CTS-2 negotiation 40.7 (31.3) 43.6 (41.8) 39.8 (37.4)
CTS-2 psychological aggression 13.4 (74.3) 82.4 (55.8) 65.7 (56.0)
CTS-2 physical assault 88.9 (96.6) 76.7 (84.4) 48.6 (61.04)
CTS-2 sexual coercion 34.2 (54.1) 30.1 (40.0) 20.0 (39.8)
CTS-2 injury 26.1 (32.6) 32.1 (44.1) 11.8 (15.8)
CAPS overall disability 2.7 (0.9) 2.7 (1.1) 1.4 (0.7)
CAPS social disability 2.5 (1.1) 2.4 (1.5) 1.5 (1.4)
CAPS occupational disability 2.1 (1.8) 2.9 (1.5) 0.9 (1.2)
a
Samp1e sizes vary for some measures due to missing data.
 M.B. Stein, C. Kennedy / Journal of Affective Disorders 66 (2001) 133 – 138
3.6. Functioning in IPV-related PTSD and
comorbid cases
Using the CAPS Section F items to assess func-
tioning, we compared scores of women without
PTSD or MDD, with PTSD alone, and with comor-
bid PTSD1MDD (these scores are also shown in
Table 2). ANOVA revealed significant group differ-
ences in Occupational Functioning (F 55.40, df 5
2,33, P,0.01) and Overall Functioning (F 510.08,
df 52,33, P,0.001), but not Social Functioning
(F 52.25, df 52,33, P,0.14). Post-hoc testing
showed that women with current PTSD (grouping
together those with and without current comorbid
MDD) reported poorer Occupational (P,0.05) and
Overall Functioning (P,0.005) than women without
PTSD. The PTSD alone and comorbid PTSD1MDD
groups did not differ significantly on these indices
(all P values .0.05), but power to detect such
differences was very low (,0.30).
4. Discussion
We found that many women who are victims of
IPV experience major depression and PTSD, often in
combination. Other anxiety disorders such as panic
and generalized anxiety disorder appear to be much
less common. These findings are consistent with
most other studies confirming the high rates of
psychopathology in women exposed to the psycho-
logical and physical trauma of battering (for review
see (Golding, 1999)).
In this study, nearly all cases (six of eight or 75%)
of current major depression occurred in the context
of current IPV-related PTSD. In other words, it was
rare to see major depression alone. This finding is
consistent with other studies suggesting that major
depression is often a later-occurring ‘complication’
of PTSD in victims of trauma (Mellman et al.,
1992). It is also consistent with the observation that
the causal pathways to PTSD and major depression
in the wake of exposure to trauma are not in-
dependent (Breslau et al., in press). Additional
prospective, longitudinal studies are required to
understand the temporal and etiologic relationships
between trauma, PTSD and major depression over
the life course.
137
Ratings of PTSD and depression were highly
correlated in victims of IPV. At this juncture, we
might speculate that PTSD and MDD symptoms are
highly intertwined in the aftermath of some sorts of
trauma (such as IPV), and that the additional diag-
nosis of MDD adds little to the explanation of
functional outcomes. But we must also consider the
strong possibility that our failure to find differences
might reflect type I error, and that larger samples
will be needed to detect relatively subtle between-
groups variations in functioning. This is an area in
need of further investigation.
We hypothesized that comorbid MDD and PTSD
would be more likely to occur in women who had
experienced more serious battering, but this hypoth-
esis was not upheld. It is possible that our failure to
see these expected differences was due to the small
sample sizes in these two groups and the resulting
low power to detect differences.
Participants were drawn from community agencies
providing services to battered women and from
general medical clinics in the community, rather than
from psychiatric or behavioral health service agen-
cies, in an attempt to maximize the generalizability
of our results. Still, we must acknowledge that our
sample may not be representative of most women
with IPV, in particular because of our exclusion of
persons with recent drug or alcohol abuse, and of
persons with serious head injury. Both of these
sequelae of IPV are common enough that additional
studies would be needed to determine whether or not
our findings can be extended to these groups.
In summary, we found that PTSD and MDD
frequently occur in the aftermath of intimate partner
violence. Moreover, MDD following IPV tends to
occur predominantly in persons who are also ex-
periencing IPV-related PTSD, raising questions about
the causal pathways to these two disorders. Indeed,
given the extensive symptom and syndromal overlap,
one must wonder whether PTSD and MDD occuring
in the wake of traumatic stress should be considered
distinct disorders at all. To inform this debate, it will
be useful to test an alternate model positing a
cascade of symptoms triggered by the traumatic
experiences – and therefore belonging to a single
disorder, rather than the two-disorder model implied
by DSM-IV criteria. Future studies should address
this issue by prospectively following victims of IPV,
138 M.B. Stein, C. Kennedy / Journal of Affective Disorders 66 (2001) 133 – 138
carefully documenting the temporal onset of different
dimensions of these syndromes.
Acknowledgements
This study was supported by a VA Merit Review
grant to Dr. Stein. The authors are grateful to Leila
Tarokh for assistance with data management and to
Traci Bergthold, M.A. for assistance with diagnostic
interviews. We also wish to express our appreciation
to the San Diego YWCA and the San Diego Center
for Community Solutions for their assistance with
this project.
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