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 INDEX

VOLUME 47 • NUMBER 4 • 2020

Original articles
Prevalence and associated factors with depression and anxiety in prisoners in South of Brazil................... 89
Caroline Ribeiro Costa, Raúl Andrés Mendoza Sassi, Vinícius de Souza Tímbola, Talita Rubin Lazzari, Ana Julia Reis, Carla Vitola Gonçalves

What are the factors that contribute to aggression in patients with co-occurring antisocial personality
disorder and substance abuse?...................................................................................................................................... 95
Bülent Devrim Akçay, Duygu Akçay

Clinical characteristics of cognitive deficits in major depressive disorder:

a 6-month prospective study......................................................................................................................................... 101
Yajuan Ji, Weihui Li, Bangshan Liu, Jin Liu, Yumeng Ju, Mi Wang, Yanchao Chen, Lingjiang Li

Prevalence and associated risk factors of postpartum depression: a cross sectional study.......................... 106
Reda Goweda, Tayseer Metwally

Brief report
Cross-cultural adaptation of the City Birth Trauma Scale for the Brazilian context.......................................... 110
Mariana Fortunata Donadon, Ana Carolina R. Darwin, Eduardo A. Bombonatti, Karina Pereira-Lima, Rafael Guimarães Santos,
João Paulo Machado-de-Sousa, Thiago Dornela Apolinário da Silva, Omero B. Poli Neto, Claudia Maria Gaspardo, Amaury Cantilino,
Luciano Dias de Mattos Souza, Susan Ayres, Flávia L. Osório

Letters to the editor

Paliperidone-induced mania: a case report.............................................................................................................. 119
NesÇe B. Bal, Meryem G. Teksin Bakir, Ali Çayköylü, Elvan Özalp, Çag6la Koçberber, Bahriye E. Yılmazog6lu

Lithium-induced asymptomatic dose-related elevation of serum creatine kinase: a case report.................. 121
Mao-Hsiu Hua, Shen-Chieh Chang, Mong-Liang Lu
 Original article

Prevalence and associated factors with depression and anxiety in prisoners in South
of Brazil
Caroline Ribeiro Costa1
https://orcid.org/0000-0003-0889-8030

Raúl Andrés Mendoza Sassi1

https://orcid.org/0000-0002-4641-9056

Vinícius de Souza Tímbola1

https://orcid.org/0000-0001-6851-8445

Talita Rubin Lazzari1

https://orcid.org/0000-0002-7262-7027

Ana Julia Reis1

https://orcid.org/0000-0002-0317-9179

Carla Vitola Gonçalves1

https://orcid.org/0000-0003-4344-6355

1 Graduate Program in Health Sciences, Federal University of Rio Grande (FURG), Rio Grande, RS, Brazil.

Received: 09/13/2018 – Accepted: 04/15/2020

DOI: 10.1590/0101-60830000000239

Abstract
Background: Brazil has the third largest prison population in the world. Research in the world has confirmed a high prevalence of mental disorders in this
population. Objective: To identify prevalence and associated factors with depression and anxiety in prisoners of the closed prison system. Methods: This is a
cross-sectional study with 643 prisoners were interviewed in six prisons in Rio Grande do Sul, Brazil. To evaluate depression and anxiety, the Mini International
Neuropsychiatric Interview 5.0 (MINI) was used and sociodemographic, inprisonment and lifestyle habits variables were also collected. Results: The prevalence
of depression found in the study was 20.6% (95% CI: 17.5-23.8) and of anxiety was 19.9% (95% CI: 16.8-23.0). The following were identified as risk factors
for depression: being female, having a history of mental illness, non-white skin color, having a religion, not receiving visits, smoking, using drugs and not
performing physical activities. Risk factors for anxiety were: being female, having a history of mental illness, a family history of mental illness, smoking and
using drugs. Discussion: The study confirmed the high rates of depression and anxiety in the population deprived of liberty. In addition, women were twice
as likely to have both disorders compared to men.

Costa CR et al. / Arch Clin Psychiatry. 2020;47(4):89-94

Keywords: Epidemiology, depression, anxiety, prisoners, MINI.

Introduction from 13 to 80%, surpassing the rates of the general population6,15,16.

The health of the population deprived of liberty has been a frequent
subject of study, as more than 10 million people are in prison
worldwide1. Brazil has the third largest prison population in the
world, with nearly 726,000 persons deprived of their liberty2.
Research on mental health of prisoners in the world confirmed a
high prevalence of mental disorders in this population, which ranges
from 25% to 60%3-5 and can reach up to 80%6.
Major Depressive Episode is characterized primarily by
depressed mood and loss of interest or pleasure for at least two
weeks. Other symptoms are significant weight loss or gain, insomnia
or hypersomnia, restlessness or psychomotor retardation, fatigue,
feelings of worthlessness or guilt, decreased concentration and
attention, recurrent thoughts about death, suicidal ideation or
attempted suicide7. For didactic purposes in this article, we will use
the term “depression” as a synonym for Major Depressive Episode.
According to the World Health Organization (WHO), the
prevalence of depression in the world population is 4.4% and in
Brazil, it is 5.8%8. According to the Brazilian Institute of Geography
and Statistics (IBGE)9, the prevalence of people diagnosed with
depression in the state of Rio Grande do Sul is of 13.2%. In a
study with 3,391 low-income residents of Rio Grande do Sul10, the
prevalence of depression was 16.1%. Although there is no consent
on the prevalence of depression among prisoners, the number varies
between 16.7 and 72.6% among men11-14, and among women it ranges
The wide range of estimates found in literature can be because of the
use of different instruments for the diagnosis of mental disorders. The
main factors associated with depression in the population deprived
of liberty were chronic lack of physical health, physical attacks,
having children, regular or poor attachment to family members17
and having been sexually victimized at some point in life15. Receiving
recent visitors was identified as the main protective factor14,18,19.
Another frequent disturb among prisoners is Generalized
Anxiety Disorder, which is characterized by anxiety and excessive
worries occurring on most days for at least six months. Other
common symptoms are restlessness, fatigability, difficulty
concentrating, irritability, muscle tension and sleep disturbances7.
According to the WHO, the prevalence of people with anxiety in the
general population is of 3.4%8, whereas in the imprisoned population
it ranges from 8.3% to 77.8%12,13,20-22. The main factors associated with
anxiety among prisoners were being a smoker19, being arrested for the
first time23 and a having history of domestic violence in childhood12.
In Brazil, there are still few studies on the mental health of the
population deprived of liberty. It is important to understand the
panorama of mental health in this context so that effective actions
can be articulated aiming to minimize factors that can aggravate or
trigger mental disorders. The present study aimed to identify the
prevalence of depression and anxiety and their associated factors
among the prison population in Southern Brazil.

Address for correspondence: Caroline Ribeiro Costa. Universidade Federal de Rio Grande. Rua Visconde de Paranaguá, 102, Centro – 96200-190, Rio Grande, RS, Brasil.
E-mail: carolinecosta.psi@gmail.com
90 Costa CR et al. / Arch Clin Psychiatry. 2020;47(4):89-94
Methods
This work is part of a larger project entitled “Prison Health”, which
aimed to evaluate the health of the prison population concerning
mental health, nutritional health, tuberculosis and knowledge and/
or diagnosis of sexually transmitted infections (STIs). The study
was performed from May 2017 to January 2018 in the 5th Regional
Penitentiary Station – South Region (5th RPS), which comprises the
State Prisons of Camaquã, Pelotas, Jaguarão, Canguçu, Rio Grande
and Santa Vitória do Palmar, and consisted of a cross-sectional study
with random sample stratified by prison.
When we started the survey, the prison population in closed
system in the 5th RPS was of 1,407 men and 100 women. The eligible
population for the study consisted of all men and women who at the
time of the interview were serving their sentences under a closed
regime in regional prisons of Southern Brazil. Prisoners who had
some cognitive impairment that prevented them from understanding
the questions were excluded.
Due to the wide prevalence range found in the scientific literature,
a first calculation of sample size was performed using all mean values
found. Subsequently, a new sample calculation was performed based
on the prevalence detected in a pilot study, which was performed with
35 prisoners from the semi-open system of the Rio Grande Prison.
We used a margin of error of 5%, a 95% confidence interval and 10%
were added for losses and refusals. For depression, using a prevalence
of 23%, the N found was of 376 inmates, while for anxiety, using a
prevalence of 17%, the N found was of 310 inmates.
For the calculation of associated factors, we also used the
prevalence rates found in the pilot study, 95% confidence interval,
relative risk of 2.0 and statistical power of 80%, adding 10% for losses
and 40% for confounding factors. After calculating the associated
factors we opted for the largest N found, that was of 755 inmates.
For the male inmates we performed a stratified random sample
proportional to population size and logistics of each prison. This
sampling process was based was based on lists provided by each
prison. A “leap of three” was used for the selection of the prisoners
to be interviewed. The expression “leap of three” means that the first
name was randomly chosen from a list, and the following names were
always selected with an interval of three individuals until completing
the N defined in that prison. All imprisoned women were included.
A total of 643 (77%) inmates participated in the study, distributed
as follows: Rio Grande (243), Pelotas (233), Camaquã (93), Canguçu
(29), Jaguarão (23) and Santa Vitória do Palmar (22). There were
188 (22.5%) refusals and four (0.5%) losses during the interviews.
Data collection took place according to the structure, logistics
and security of each prison, and it was carried out in classrooms,
outpatient clinics and in galleries’ corridors, most of them occurring
behind bars. Each inmate was individually informed about the
research and later presented to the Informed Consent Form (ICF).
Interviews were conducted using a pre-coded questionnaire
containing sociodemographic variables (age, skin color, marital
status, education and income), prison situation (time of penalty,
type of crime and occurrence of visitations), mental health (family
and personal history of mental health), life habits (religion,
physical activity and use of tobacco, alcohol and other drugs). For
the evaluation of mental disorders, we used the modules Major
Depressive Episode and Generalized Anxiety Disorder of the Mini
International Neuropsychiatric Interview (MINI Plus), validated for
the Brazilian population21. MINI Plus is a standardized diagnostic
clinical interview with diagnostic criteria of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-V) and the
International Statistical Classification of Diseases (ICD-10). All
interviewers were trained to apply this instrument accordingly.
Data was codified and later double typed from the questionnaires
in a database created in the software Epidata 3.1. Data analysis was
performed using STATA 14.0. For the bivariate analysis of the sample,
Prevalence Ratio (PR), 95% confidence intervals and Pearson’s chi-
square test were calculated, adopting a p-value < 0.05 of a two-tailed
test. Adjusted analysis was performed using Poisson regression
according to a 3-level hierarchy model for causal effects24. The first
and most distal level comprised demographic and socioeconomic
variables. Variables associated with prison conditions were included
in the second level. In the third level, the most proximal, were
included variables related to the history of mental health and life
habits. Variables were selected for the final model using the backward
Euler method. Following this method, the variables were placed in
the model according to their hierarchical level, and those that had a
value p ≤ 0.20 were maintained.
This study was authorized by the 5th RPS and approved by
the Research Ethics Committee in the Health Area (Cepas) of the
Federal University of Rio Grande (FURG) under the nº 05/2017. The
participation was voluntary and happened following accordance to
the Informed Consent Form (ICF).
Results
Among the 643 people interviewed for this research, 90.2% were
male, with a mean age of 33.2 years (SD ± 9.2 years), 62.3% had
no partner, 60.9% were white and 57.5% had a religion, being
Catholicism the most prevalent one (48%). The income of 53.9%
of the sample was of at least 1.1 minimum wages and the average
study-years were 6.3 years (SD ± 2.8 years). The average length of
the sentence, including all convictions, was of 73 months (SD ± 69
months), 66.8% were recidivist prisoners and 61.3% did not work
in prison (Table 1).
Regarding mental health, 9.6% of the interviewees reported
having a history of mental illness and 18.2% reported having a family
member with history of mental illness. Smokers accounted for 60.3%
of the sample and the average number of cigarettes per day was of 17.4
cigarettes (SD ± 12.5 cigarettes). Concerning alcohol consumption,
56.2% of the sample stated that they did not consume alcohol before
arrest, and among those who consumed it, the average frequency
was of 2.9 days per week (SD ± 2.1 days). Drug usage was reported
by 76.2% of the inmates, being marijuana (80.2%), cocaine (62.8%)
and crack (44%) the most prevalent ones (Table 1).
The prevalence of depression among studied prisoners was of
20.6% (CI 95%: 17.5-23.8) (Table 2). After adjusted analysis it was
observed that being a woman (RP: 2.14; 95% CI: 1.52-3.01) and having
a history of mental illness (RP: 2.15; CI 95%: 1.56-2.95) increased
probability of depression by 114 and 115%, respectively. Having
black or brown skin color (PR: 1.37; CI 95% 1.02-1.86) increased
the probability of depression by 37% over those of white skin color.
Not having a religion (PR: 0.67; CI 95%: 0.49-0.92) decreased the
probability of having depression by 33%, while not receiving visits
(PR: 1.36; CI 95%: 1.00-1.86) increased the probability by 36%. Drug
use (PR: 1.77; CI 95%: 1.14-2.75) and smoking (PR: 1.89; CI 95%:
1.30-2.76) increased the probability of having depression in 77% and
89%, respectively. In addition, not practicing physical activities in
prison (PR: 1.44; CI95%: 1.06-1.96) also increased the probability
of having depression by 44% (Table 3).
Generalized anxiety was reported by 19.9% (CI 95%: 16.8-23.0) of
the interviewees (Table 2). After adjusted analysis it was observed that
being female (RP 2.34; CI 95%: 1.66-3.30) increased the probability
of having anxiety in 134%. History of mental illness (RP: 1.62; CI
95%: 1.09-2.40) or family history of mental illness (RP: 1.50; CI 95%:
1.07 - 2.11) increased the probability of having anxiety by 62 and
50%, respectively. Smoking (RP: 1.59; CI 95%: 1.10-2.28) and drug
use (RP: 1.54; CI 95%: 1.02-2.34) also increased the probability of
having anxiety in 59 and 54%, respectively (Table 4).
Discussion
The prevalence of depression found in this study was of 20.6%
among 643 interviewees, using the MINI plus questionnaire25. In
international literature, rates of depression among prisoners range
from 5 to 72.6%13,16. It is believed that these differences can be
explained due to different methodologies and cultural aspects of the
 Costa CR et al. / Arch Clin Psychiatry. 2020;47(4):89-94 91

Table 1. Population description of the prevalence study and factors associa- Table 3. Crude and adjusted analyses of factors associated with depression
ted with depression and anxiety in prisoners in southern Brazil. 2018 (n = 643) in prison population in southern Brazil, 2018 (n = 643)
Variables N % Variables % Crude PR (95% CI) Adjusted PR
Sex (95% CI)
Male 580 90.2 Sex p < 0.001 P < 0.001
Female 63 9.8 Male 18.4 1.00 1.00
Age (years) Female 41.3 2.24 (1.59-3.15) 2.14 (1.52-3.01)
≤25 140 21.8 Age (years) p = 0.643 p = 0.511
26-35 281 43.8 ≤25 19.3 1.00 1.00
≥36 221 34.4 26-35 22.4 1.16 (0.78-1.74) 1.18 (0.78-1.79)
≥36 19.5 1. 01 (0.65-1.55) 0.98 (0.61-1.57)
Skin Color
White 380 60.9 Skin Color p = 0.024 p = 0.036
Not White 244 39.1 White 17.9 1.00 1.00
Not White 25.4 1. 42 (1.05-1.93) 1.37 (1.02-1.86)
Marital status
Single 400 37.7 Marital status p = 0.406 p = 0.307
Married 242 62.3 Single 21.8 1.00 1.00
Married 19.0 1.14 (0.83-1.58) 1.18 (0.85-1.64)
Remuneration (before arrested)
Remuneration (before arrested) p = 0.221 p = 0.100
≥1.1 minimum wage 342 53.9
≥1.1 minimum wage 22.8 1.00 1.00
≤1 minimum wage 292 46.1
≤1 minimum wage 18.8 0.83 (0.61-1.12) 0.77 (0.56-1.05)
Study (in years) Study (in years) p = 0.358 p = 0.257
≥9 112 17.6 21.4 1.00 1.00
≥9
6-8 264 41.5 23.1 1.08 (0.71-1.64) 1.19 (0.79-1.80)
6-8
≤5 260 40.9 18.1 0.84 (0.54-1.31) 0.90 (0.59-1.39)
≤5
Work in prison Work in prison p = 0.138 p = 0.215
Yes 247 38.7 Yes 22.7 1.00 1.00
No 392 61.3 No 17.8 1.27 (0.92-1.76) 1.22 (0.88-1.69)
Crime Crime p = 0.208 p = 0.312
Homicide 97 15.3 Homicide 13.4 1.00 1.00
Robbery 159 25.0 Robbery 20.8 1.55 (0.86-2.79) 1.70 (0.92-3.13)
Drug 217 34.1 Drug 24.0 1.79 (1.02-3.13) 1.70 (0.95-3.03)
Traffic 163 25.6 Traffic 20.9 1.56 (0.86-2.80) 1.54 (0.84-2.82)
Others* Others*
Time in prison (in months) Time in prison (in months) p = 0.554 p = 0.553
≥61 263 42.4 ≥61 18.6 1.00 1.0
31-60 140 22.5 31-60 22.9 1.23 (0.83-1.82) 1.24 (0.83-1.84)
≤30 218 35.1 ≤30 21.6 1.16 (0.81-1.65) 1.08 (0.75-1.55)
Receives visits Receives visits p = 0.013 p = 0.048
Yes 447 69.7 Yes 18.1 1.00 1.00
No 194 30.3 No 26.8 1.48 (1.09-2.01) 1.36 (1.00-1.86)
Religion Religion p = 0.014 p = 0.013
No 368 57.5 No 16.2 1.00 1.00
Yes 272 42.5 Yes 24.2 1.50 (1.08-2.07) 1.63 (1.07-2.48)
History of mental illness History of mental illness p < 0.001 p = <0.001
No 577 90.4 No 17.5 1.00 1.00
Yes 61 9.6 Yes 50.8 2.90 (2.14-3.93) 2.15 (1.56-2.95)
History of mental illness in
History of mental illness in the Family
the Family p=0.002 p=0.087
No 520 81.8
No 18.5 1.00 1.00
Yes 116 18.2
Yes 31.0 1.68 (1.21-2.33) 1.33 (0.95-1.85)
Smoker
Smoker p<0.001 p=0.001
No 254 39.7
No 11.4 1.00 1.00
Yes 386 60.3
Yes 26.9 2.36 (1.61-3.45) 1.89 (1.30-2.76)
Alcohol use (in a lifetime) Alcohol use (in a lifetime) p=0.604 p=0.541
No 358 56.2 No 19.8 1.00 1.00
Yes 279 43.8 Yes 21.5 1.08 (0.80-1.47) 0.91 (0.68-1.22)
Illicit drug use (in a lifetime) Illicit drug use (in a lifetime) p=0.018 p=0.011
No 151 23.6 No 13.9 1.00 1.00
Yes 490 76.4 Yes 22.9 1.64 (1.07-2.52) 1.77 (1.14-2.75)
Physical Activities Physical Activities p<0.001 p=0.018
Yes 386 39.7 Yes 16.3 1.00 1.00
No 254 60.3 No 27.6 1.69 (1.25-2.28) 1.44 (1.06-1.96)
Subtitles: * Sexual crimes, gun possession, receiving, rustling and bodily injury. Subtitles: * Sexual crimes, gun possession, receiving, rustling and bodily injury.

Table 2. Prevalence of depression and anxiety in prisoners in southern Brazil, 2018 (n = 643)
Mental Disorders % CI 95%
Depression 20.6 17.5-23.8
Anxiety 19.9 16.8-23.0
92 Costa CR et al. / Arch Clin Psychiatry. 2020;47(4):89-94

Table 4. Crude and adjusted analyses of factors associated with anxiety in population. However, a survey with 1,809 prisoners in the city of São
prison population in southern Brazil, 2018 (n = 643) Paulo using the same methodology of this study reported a prevalence
Variables % Crude PR (95% CI) Adjusted PR of 14.7% for depression4. A study with 497 men in Salvador, also
(95% CI)
using the MINI questionnaire, found a rate of depression of 17.6%26.
In Santa Catarina, when interviewing 557 inmates with same
Sex p<0.001 p=<0.001
questionnaire, the reported prevalence of depression was of 16%27.
Male 17.6 1.00 1.00
It is observed that when the same instrument for mental disorder
Female 41.3 2.35 (1.66-3.31) 2.34 (1.66-3.30)
evaluation is used, the proportion of disease detection presents
Age (years) p=0.612 p=0.371 variations probably related to transculturality and not methodology.
≤25 18.6 1.00 1.00 In addition, it is pointed out that the prevalence found in this study
26-35 21.7 1.17 (0.77-1.76) 1.13 (0.75-1.71)
confirms that depression is more frequent among the population
≥36 18.6 1.00 (0.64-1.56) 0.88 (0.56-1.37)
deprived of liberty, being almost four times higher than in the general
Skin Color p=0.398 p=0.637 Brazilian population, which is of 5.8%8. This fact can be justified
White 18.9 1.00 1.00 by greater exposure of this population to risk factors such as low
Not White 21.7 1.15 (0.84-1.57) 1.07 (0.78-1.48) socioeconomic status, unemployment, substance abuse and violence6.
Marital status p=0.114 p=0.233 Another disorder investigated in this study was generalized
Single 18.0 1.00 1.00 anxiety, which had a predominance of 19.9%. As observed in
Married 23.1 1.29 (0.94-1.75) 0.82 (0.60-1.12) depression, prevalence of anxiety among the population deprived
Remuneration (before arrested) p=0.698 p=0.345 of liberty also varies widely among studies, from 6.9 to 77.8%. The
≥1.1 minimum wage 20.8 1.00 1.00 use of different methodologies and instruments make it difficult to
≤1 minimum wage 19.5 1.06 (0.78-1.45) 0.85 (0.62-1.17) compare findings. Brazilian studies that used the same methodology
Study (in years) p=0.168 p=0.724 as ours reported anxiety rates that ranged from 6.9 to 27.7%. One
≥9 20.5 1.00 1.00 of the reasons for this variation might be because these studies were
6-8 23.1 1.40 (0.98-1.98) 1.26 (0.82-1.94) performed in different regions of the country. For example, in major
≤5 16.5 0.81 (0.51-1.27) 0.92 (0.57-1.46) urban centers the organized crime commands prisons and conflicts
Work in prison p=0.529 p=0.451 are frequent, which differs from what is observed in smaller cities.
Yes 18.6 1.00 1.00 This study also corroborates that anxiety among prisoners is more
No 20.7 1.11 (0.80-1.54) 1.13 (0.81-1.56) prevalent than in the general population, reaching twice the ratio of
Crime p=0.796 p=0. 574 the Brazilian citizens, which is of 9.3%8. The more widespread anxiety
Homicide 16.5 1.00 1.00 among prisoners can be a result of increased exposure to factors such
Robbery 21.4 1.30 (0.76-2.22) 1.39 (0.81-2.41) as deprivation of social interaction, deprivation of liberty, rigid rules
Drug 1.26 (0.75-2.11) 1.09 (0.65-1.84) and the constant control of the individuals, changes of environment
20.7
Traffic 19.6 1.19 (0.69-2.05) 1.17 (0.68-2.04) and stressful situations28.
Others* Being a woman was identified as a major risk factor for depression
Time in prison (in months) p=0.926 p=0.917 and anxiety, doubling the probability of suffering from these diseases
≥61 19.4 1.00 1.00 when compared to men. This phenomenon is also observed in the
31-60 20.7 1.07 (0.71-1.60) 1.09 (0.72-1.64) general population8, which probably is reflected in female population
≤30 20.6 1.06 (0.74-1.52) 1.02 (0.71-1.46) deprived of liberty. In one of the mentioned studies27, where 466 men
Receives visits p=0.352 p=0.942 and 91 women were interviewed, twice as many mental disorders
Yes 19.0 1.00 1.00 were found in women, and the prevalence of depression reported was
No 22.2 1.17 (0.84-1.62) 1.01 (0.72-1.42) of 13.7% in men and 27.5% in women. Another study that included
with 1110 men and 463 women in Rio de Janeiro found that the
Religion p=0.780 p=0.741
No 19.5 1.00 1.00
depression rate among women was 16% higher than among men17.
Yes 20.4 1.05 (0.76-1.43) 0.99 (0.65-1.49) There might be several reasons for this, such as constant hormonal
influence in women, more exposure to domestic and sexual violence
History of mental illness p<0.001 p=0.016
and especially the societal role assigned to women as caregiver.
No 17.9 1.00 1.00
39.3
Another important factor for the occurrence of the depression
Yes 1.77 (1.28-2.46) 1.62 (1.09-2.40)
and anxiety was having a personal history of mental illness,
History of mental illness in increasing probability of having depression by 115% and anxiety
the Family p<0.001 p=0.016
by 62%. A study carried out in Rio Grande do Sul, Brazil, with
No 17.5 1.00 1.00
287 women, found that the odds of suffering from depression was
Yes 31.0 2.20 (1.54-3.15) 1.50 (1.07-2.11)
three times higher among inmates with personal history of mental
Smoker p<0.001 p=0.012 illness6. Another study conducted in Egypt with 1,350 prisoners also
No 13.4 1.00 1.00
reported that inmates with a history of mental illness showed twice
Yes 24.4 1.82 (1.27-2.60) 1.59 (1.10-2.28)
the probability of developing some psychiatric disorder19. There are
Alcohol use (in a lifetime) p=0.140 p=0.452 few studies in literature that associate depression and anxiety with
No 17.9 1.00 1.00 having a history of mental illness, possibly due to the difficulty of
Yes 22.6 1.26 (0.93-1.72) 1.12 (0.82-1.52) accessing medical records from before arrest. In our study we used
Illicit drug use (in a lifetime) p=0.096 p=0.039 the question “Have you ever had any mental illness?” to collect this
No 15.2 1.00 1.00 data. It is believed that it is important to collect this information
Yes 21.4 1.41 (0.93-2.13) 1.54 (1.02-2.34) when assessing the presence current disorders, as there is a possibility
Physical Activities p=0.014 p=0.165 that some prisoners may have previous mental illnesses worsened
Yes 16.8 1.0 1.00 due to a lack of adequate diagnosis and treatment. Having previous
No 24.9 1.47 (1.08-2.00) 1.24 (0.91-1.70) mental illnesses can increase the probability of having depression
Subtitles: * Sexual crimes, gun possession, receiving, rustling and bodily injury. during incarceration for various reasons, including interruption
of treatment. Other factors associated with prison life can also be
identified as triggers, such as withdrawal from family life, limited
access to leisure activities, exposure to an unhealthy environment
and difficulty to receive appropriate treatment.
 Costa CR et al. / Arch Clin Psychiatry. 2020;47(4):89-94
In addition to being a woman and having a history of mental
illness, smoking and drug use were also risk factors for depression,
increasing the odds by 89% and 77%, respectively, and for anxiety,
by 59% and 49%. Another study in India comparing 122 psychiatric
prisoners with 122 non-psychiatric prisoners also confirmed a 21%
increase in smoking among those who had some mental illness29.
Concerning anxiety, a survey of 649 prisoners in Ethiopia found that
smoking increased 2.6 times the probability of having the disorder22.
In another study conducted with 60 prisoners in Rio Grande do
Sul30, a strong correlation was found between depressive symptoms
and drug use. The study also states that the higher the drug use, the
higher the irritation, aggressiveness, level of depressive symptoms
and recurrence of crimes, and vice versa. However, in both cases
it is not possible to state whether this is a relationship of cause or
effect. We believe that depressed and anxious people are at greater
risk of consuming cigarettes and drugs as an attempt to reduce their
symptoms, entering in a vicious cycle.
Factors that presented an increased risk only for depression were
having brown/black skin color, not receiving visits and not practicing
physical activity. Supporting these results, a systematic review that
included 14 Brazilian studies showed a higher prevalence of mental
disorders in non-white people. The study also concludes that there is
no biological relationship between race and mental health. However,
it is necessary to investigate the populations that are more likely
to suffer from mental diseases, aiming to investigate risk factors
related to environment or social context in order to prevent them31.
In this research, the majority of prisoners were white-skinned,
which is consistent with the profile of prisoners in southern Brazil,
but contrasts with the profile of prison populations in rest of the
country, where majority of the inmates have brown and black skin
colors. We did not identify any study in the literature that associated
skin color with depression in the population deprived of liberty. We
believe that perhaps because the non-white population is a minority,
it may be more exposed to discrimination, marginalization and
consequent social vulnerability both outside and inside prison, which
could increase the probability of having depression. Not receiving
visits was also identified as a risk factor for depression, and this is
widely discussed in literature. Studies in Mexico and Egypt state
that receiving visits reduces the risk of having some mental disorder
in 37% and 50%, respectively14,19. Frequent visits represent strong
support network and family bond, both fundamental elements for
the promotion of mental health. Another risk factor for depression
was not practicing physical activity. A case-control study with
64 Italian prisoners subjected to a nine-month exercise program
showed that physical activity significantly reduced the prevalence
of depression when compared to the control group, among which
the disease even became more prevalent32. Physical activity is an
important ally in the prevention and promotion of mental health,
considering its potential in regulating mood and promoting physical
and psychological well-being.
Having family history of mental illness increased the probability
of having anxiety by 50%. We did not identify in the literature any
study that directly related these factors, however a study carried out in
Brazil with female prisoners associated the occurrence of depression
both with individual and familiar history of mental illness6. One
hypothesis is that it occurs because the inmates have limited
contact with family members, and they are unable to financially
or emotionally contribute with family care. It is known that having
parents with a history of mental illness during childhood can increase
the probability of developing mental disorders in adulthood33. In
addition to the genetic factor, living from early age with a relative
that suffers from a severe mental disorder can have influence in the
development, personality and family structure of the individuals,
also increasing their exposure to risk factors such as violence and
negligence.
As discussed previously, there are some limitations in the
acquisition of these data. However, it is important to seek them
whenever possible, in order to direct actions of prevention and
promotion of mental health focused on those identified with this
risk factor.
93
Not having a religion was a protective factor in this study
for depression, decreasing the probability of reporting it by 33%.
However, literature points to religion as a protective factor for mental
illness17,34. A study of 1,573 prisoners in Rio de Janeiro showed that
having no religion increased the risk of depression in 79%17. Another
study with 213 women in United States of America showed that
inmates participating in religious groups had lower depression
scale scores than those who were not religious34. In our study, the
prevalence of prisoners who reported having a religion was of 57.2%,
which is considerably lower in comparison to the rates found in
literature, that varied from 70.3 to 79.6%17,33. In addition, we may have
faced a reverse causality effect, where depressed prisoners pursued a
religion more than those without the disease.
Based on the obtained results, the implementation of preventive
actions for depression and anxiety are suggested, especially among
prisoners that are women and that have a history of mental illness,
considering that these risk factors doubled the probability of suffering
from these disorders. We suggest that the patients with history of
mental illnesses are identified when imprisoned, being monitored
by the local health professionals. Prisoners without history of mental
illnesses that start showing symptoms for these complications should
also be evaluated and receive proper treatment.
It is believed that the need to implement strategies to strengthen
family bonds and support networks are essential to avoid or reduce
mental illness during imprisonment and during the process
of resocialization. Another suggestion is to offer actions that
contribute against the use of tobacco and other drugs, such as the
National Program of Tobacco Control, that is already offered by the
Basic Health Units of some of the researched cities, as well as the
rehabilitation treatment for chemical dependency that is offered
in partnership with services such as the Centers of Psychosocial
Attention (CAPS). However, one of the main challenges faced
during the study was the lack of structure of the prisons. Due to
overcrowding, places that were originally intended to be used as
classrooms or libraries were assigned to other uses, which hinders
the realization of group activities. This is the main challenge for the
realization of actions aiming to promote health and prevent illnesses
inside the prisons included in our research.
It is also worth noting the relevance of the present study, as it
was carried out in six different cities, in a region where there are
still no published data on this topic and for using the MINI-Plus,
an individual clinical interview instrument based on the DSM V
criteria for diagnostics. Even though it is one of the most complete
instruments, MINI-Plus is seldom used in prison context due to
logistical difficulties. However, it is necessary to consider some
limitations. Because it presents a cross-sectional design, it prevents
the establishment relationships of cause and effect. Some examples
are the variables for religion and drug use. The first case leads us
to hypothesize a case of reverse causality, where depressed people
would be more likely to seek support in religion. In the second case,
it is not possible to say whether drug use increases the prevalence of
anxiety and depression or if it is a symptom of the disorder. Despite
the limitations, the results suggest the viability of the adopted
methodology, since other studies on mental disorders have used
this same method.
The present study confirmed the high prevalence of mental
disorders in population deprived of liberty and pointed out
several risk factors that can help in planning effective strategies for
prevention and promotion of mental health. Other studies are needed
to explore this topic, given its complexity and scarcity of scientific
knowledge on the subject.
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 Original article

What are the factors that contribute to aggression in patients with co-occurring
antisocial personality disorder and substance abuse?
Bülent Devrim Akçay1
https://orcid.org/0000-0002-6308-9327

Duygu Akçay2
https://orcid.org/0000-0001-9030-6879

1 Department of Mental Health and Diseases, Gülhane Education and Research Hospital, Ankara, Turkey.
2 Department of Military Health Services, Ministry of National Defense, Ankara, Turkey.

Received: 05/12/2018 – Accepted: 04/15/2020

DOI: 10.1590/0101-60830000000240

Abstract
Background: A significant number of individuals with high levels of aggression have substance use disorder problems. Objective: This study aimed to evaluate
the effect of substance use disorder on aggression in young men with Antisocial personality disorder (ASPD). Methods: This cross-sectional study included
328 patients and were diagnosed with ASPD with a comorbidity of substance use disorder, along with 111 healthy young male subjects. Results: The total
aggression scores of the patients with a diagnosis of ASPD were significantly higher than those of the healthy group (p < 0.001). Mean scores of aggression
subscale, except for indirect aggression, were higher in patients diagnosed with ASPD (p < 0.05). There was a positive correlation between aggression scores
and total API scores in patients diagnosed with ASPD (p < 0.001). Aggression scores were higher when subjects were using volatile substances compared to
other substances (p < 0.05). Aggression scores increased with duration of substance use disorder (p < 0.001). Discussion: Substance use disorder should be
treated first to mitigate aggression in individuals with ASPD. Patients with severe addiction to volatile substances should be given treatment priority. Further
studies are necessary to determine the cause of aggression in individuals who abuse substances.

Akçay BD, Akçay D. / Arch Clin Psychiatry. 2020;47(4):95-100

Keywords: Antisocial personality disorder, substance use disorder, aggression, young men.

Introduction
Aggression, or behavior intended to cause harm, is a common
symptom of many psychiatric and personality disorders, particularly
antisocial personality disorder (ASPD) – a condition that is
significantly hard to treat due to patient- and provider-related
difficulties1. Studies have shown that ASPD is frequently associated
with violent behavior and abuse of alcohol and other substances2-4.
The use of addictive substances is a global public health problem
that leads to increased morbidity and mortality for the user, serious
problems in the society and economic burden5. In 2015, the World
Health Organization reported that approximately 5% of the global
adult population had used a substance at least once and 0.6%
suffered from substance use disorders6. Despite the adoption of
various measures for prevention in developed countries, which have
a higher frequency of substance abuse 6, studies show that relapses
are frequent and adherence to treatment is poor7. According to
the European Drug Report8, it is estimated that cannabis, the most
commonly used substance, is used by 13.9% of young adults aged
15-34. In young adults, substance use disorder can lead to changes
in attitude and may provoke new behavior including violence, lying,
stealing, damaging property, refusing to comply with rules in the
school, home or society; they are also known to have a tendency for
aggression, demonstrate confrontational behavior against authority
figures and look for excuses to fight9-11. Considering these effects and
the fact that persons with ASPD are at higher risk for substance abuse,
the evaluation of the relationships between ASPD, substance abuse
and aggression may increase our understanding of the conditions
and may prove useful for the determination of risk factors.
As problems such as violent behavior and substance use disorder
are more common among young adults and men, this study was
planned with an aim to evaluate the effect of substance use disorder
on aggression in young males with ASPD.
Methods
This cross-sectional study was conducted from April 13, 2015 to
June 30, 2016 in the psychiatry outpatient clinic of Konya Military
Hospital. The study population consisted of ASPD patients with a
comorbidity of substance use disorder (n = 567) and healthy young
male volunteers (n = 210). Among these, those who met inclusion
criteria were included in the study. A final total of 328 ASPD patients
with substance use disorder and 111 healthy young men were
included in the study.
The inclusion criteria for the patient group was as follows:
• Being clinically diagnosed with ASPD according to DSM-
IV-TR diagnostic criteria, and having substance use disorder
determined by the Turkish version 12 of the SCID-II 13
according to DSM-V diagnostic criteria 5.
• Not having any psychiatric symptoms or any other general
condition that causes an Axis-I disorder which is associated
with aggression (mental retardation, schizophrenia,
schizoaffective disorder, bipolar disorder, major depression,
post-traumatic stress disorder, intermittent explosive
disorder, and organic psychiatric disorder) according to the
Turkish version14 of SCID-I15.
• Being literate and voluntarily choosing to participate in the
study.
• Not having an active psychotic symptom and not being under
the influence of a substance.
• Not meeting diagnostic criteria for mood disorder and not
having mental disorders due to psychiatric or organic causes
that could cause impulsivity/behavior disorder (other than
ASPD).
• Not being under the ongoing influence of a traumatic
situation before the interview.

Address for correspondence: Bülent Devrim Akçay. Ministry of Health Gülhane Education Research Hospital. Gülhane Loj. General Tevfik Fikret cad. Emrah Mah. Tokat Sok. Keskingil apt. B blok 60
No: 26 Basinevler/Etlik Ankara, Turkey. Telephone: + 9(0312) 3044501. Fax: +9(0312) 3044500. E-mail: drbulentakcay@gmail.com
Duygu Akçay. Public Health Nursing. National Defense Department. Telephone: 0 505 5947466. Email: dakcay2010@hotmail.com
96 Akçay BD, Akçay D. / Arch Clin Psychiatry. 2020;47(4):95-100
Healthy men that met the following criteria were included in
the control group.
• Those without a chronic medical condition.
• Those who had never received neurological or psychiatric
treatment.
• Those who voluntarily chose to participate in the study and
were literate.
• Those without Axis I disorders according to SCID-I.
The research commenced after obtaining ethical approval from
the Local Ethics Committee of Konya Military Hospital (decree
number 2015/01/4). Before inclusion into the study, all participants
were informed of the purpose of the research and written consent
was obtained.
Data collection
The demographic characteristics and other data of the patients were
recorded during interviews. Aggression and substance abuse were
evaluated via the Aggression Scale and Addiction Profile Index (API)
questionnaires which were explained and applied to patients by 1 of
3 psychiatrists who all followed a standardized procedure. Before the
interview began, the patients were asked if they were currently under
the influence of a substance and whether they had recently suffered
a traumatic event. In the event that an interview did not conform to
prior data, or the patient was considered to be under the influence of
a substance (through examination of consciousness when necessary),
or the patient became unresponsive, the interview was cancelled and
scheduled with another psychiatrist at a later date.
SCID-I: A structured clinical interview scale developed by the
American Psychiatric Association for DSM-IV Axis-I diagnoses15.
A Turkish validity and reliability study of SCID-I was performed by
Çorapçioglu et al.14.
SCID-II: A structured clinical interview scale developed by the
American Psychiatric Association for DSM-III-R Axis-II diagnoses13.
A Turkish validity and reliability study of SCID-II was performed
by Sorias et al.16
Aggression Scale: The Aggression Scale was developed by Buss
and Peryy (1992), updated by Buss and Waren (1992), and adapted
to the Turkish language by Can17. The scale consists of 34 items
which evaluate five sub-dimensions including physical aggression,
verbal aggression, anger, hostility, and indirect aggression. The scale
includes a five-point Likert-type rating organized as: 1 = Extremely
uncharacteristic of me, 2 = Somewhat characteristic of me, 3 =
Slightly characteristic of me, 4 = Completely characteristic of me,
5 = Extremely characteristic of me. The lowest score is 34 and the
highest score is 170. The evaluation of the scores is performed on a
factor basis and not all scores obtained from the scale are used. A high
score within a subscale indicates that the individual has aggressive
behavior related to that factor.
Addiction Profile Index (API)
The API is a scale developed by Ögel et al.18 for the assessment
of different dimensions of addiction and to determine addiction
severity. It is a self-reported scale consisting of 37 questions and
5 subscales which measure the characteristics of substance use,
diagnostic criteria of addiction, the effect of substance use on
the person’s life, the strength of desire for substance use, and the
motivation to discontinue substance use.
Data evaluation
The SPSS 15.00 program was used for the analysis of all data obtained
in the study. Frequency, mean, and standard deviation were used to
assess sociodemographic data (age, socio-economic status, marital
status and education). The Chi-square test was used to compare
categorical data between patients and controls. Pearson’s correlation
analysis was used to evaluate associations between aggression scale
scores and API scores. The Independent Samples t-test was used to
compare normally distributed continuous variables among binary
groups, while the ANOVA or Tukey tests were used as post-hoc tests
to compare three or more groups. The results were evaluated at the
95% confidence interval with a 5% significance level.
Results
The patient and control groups were similar in terms of age, marital
status, education, and socioeconomic status (p > 0.05) (Table 1). The
mean total aggression score (103.85 ± 31.59) of the patient group was
found to be significantly higher than that of the healthy group (90.85
± 21.93) (p < 0.001). When the subsections of the aggression scale
were compared, the patient group was found to have significantly
higher scores in all subscales except for indirect aggression (Table 2).
There was a significant positive correlation between the total API
scores and the scores of physical aggression, verbal aggression, anger,
hostility, and indirect aggression in patients (r = .513, r = .517, r =
.454, r = .589, r = .537, and r = .568, respectively) (p < 0.001) (Table 3).
Total aggression score showed moderate positive correlations
with the scores obtained from 3 of the API subsections (characteristics
of substance use, impact of substance use on the person’s life, and
strength of the desire for substance use) (r = .683, r = .621, and r .691,
respectively) (p < 0.001). Additionally, total aggression scores were
correlated positively with diagnostic criteria of addiction score and
negatively with motivation to discontinue substance use score (r =
.491 and r= -.393, respectively) (Table 3).
When we examined the substances used by the sample group
and their respective mean aggression scores, a significant variance
was observed. The Games-Howell test (based on homogeneity) was
performed to determine which substances caused a difference in
aggression scores; significantly higher aggression scores were noted
with use of volatile substances compared to other substances (p <
0.05). Synthetic cannabinoid users had significantly higher aggression
scores than cannabis and heroin users (p < 0.05).
Out of the patients diagnosed with ASPD with a comorbidity of
substance use disorder, those who used a single substance had a mean
aggression score of 69.55 ± 29.67, those who used multiple substances
had a mean aggression score of 110.47 ± 27.43. Furthermore, those
who harmed themselves had a mean aggression score of 116.04
± 27.00, while those who did not harm themselves had a mean
aggression score of 82.45 ± 27.46; however, this difference was not
statistically significant (p > 0.05). Mean aggression scores were
significantly higher in those with intravenous drug use compared
to those who did not use intravenous drugs (p < 0.001), and higher
in those with legal problems compared to those without (p < 0.001).
Finally, we also found that aggression scores increased with the
duration of substance use disorder (p < 0.001) (Table 4).
Discussion
In the current study, young men with ASPD and a comorbid
substance use disorder were found to have significantly higher
aggression compared to controls, as measured by the Buss-Perry
Aggression Scale. We also found that all subsections of the aggression
and API scales showed significant correlations with total API score
and total aggression score. Further analyses demonstrated that using
synthetic cannabinoids, ecstasy and volatile substances, intravenous
use, having a legal problem and duration of substance use were
associated with higher aggression scores.
Our findings conform to prior studies in which substance use
was associated with aggressive behavior19-23. In the current study,
the patient group was found to have higher scores in anger, hostility,
and physical and verbal aggression, while indirect aggression
was similar with controls. In a very similar study to ours, which
compared aggression levels in patients with substance use disorder
and patients with comorbid ASPD and substance use disorder, it was
 Akçay BD, Akçay D. / Arch Clin Psychiatry. 2020;47(4):95-100 97

Table 1. Sociodemographic comparison between patients diagnosed with ASPD with a comorbidity of substance use disorder and healthy participants
Substance use disorders (n = 328) Healthy group (n = 111) Significance*
n % n % p
Age
20 97 29.6 35 31.5 0.627
21 141 43.0 51 45.9
22 45 13.7 16 14.4
23 24 7.3 4 3.6
24 21 6.4 5 4.5
Socio-economic status
Low 107 32.6 32 28.8 0.669
Medium 188 57.3 69 62.2
High 33 10.1 10 9.0
Marital status
Married 78 23.8 20 18.0 0.446
Single 240 73.2 87 78.4
Divorced/Separated 10 3.0 4 3.6
Educational status
Primary school graduate 62 18.9 18 16.2 0.661
Secondary school graduate 212 64.6 77 69.4
High school graduate 54 16.5 16 14.4
* Chi-square test.

Table 2. Aggression status comparison between patients diagnosed with ASPD with a comorbidity of substance use disorder and healthy participants
Buss-Perry Aggression Scale Substance use disorders (n = Healthy group (n = 111) Significance*
328)
xx ± ss xx ± ss F p
Physical aggression 26.42 ± 10.73 22.05 ± 6.37 94.178 0.000
Verbal aggression 15.52 ± 5.13 14.44 ± 4.22 10.114 0.002
Anger 24.63 ± 6.72 21.07 ± 5.52 7.447 0.007
Hostility 22.45 ± 6.59 18.04 ± 5.15 6.160 0.013
Indirect aggression 14.84 ± 5.30 15.24 ± 4.82 3.353 0.068
Total aggression score 103.85 ± 31.59 90.85 ± 21.93 34.064 0.000
* T-test in independent groups.

Table 3. Correlation between aggression scores and API scores in patients diagnosed with ASPD with a comorbidity of substance use disorder
Buss-Perry Aggression Scale Total API scores
r p*
Physical aggression 0.513 0.000
Verbal aggression 0.517 0.000
Anger 0.454 0.000
Hostility 0.589 0.000
Indirect aggression 0.537 0.000
Buss-Perry Aggression Scale Total aggression scores
r p*
Substance use disorder characteristics 0.683 0.000
Diagnosis 0.491 0.000
Impact on life 0.621 0.000
Strong urge 0.691 0.000
Motivation -0.393 0.000
Total API scores 0.568 0.000
* Significant correlation at 0.001.
98 Akçay BD, Akçay D. / Arch Clin Psychiatry. 2020;47(4):95-100

Table 4. Comparison of aggression scores of patients diagnosed with ASPD with a comorbidity of substance use disorder with certain descriptive information
Total aggression score Significance*
n (%) xx ± ss F p
Most frequently used substance 11.171 0.000**
Cannabis 158 (48.2) 95.80 ± 32.42
Heroin 79 (24.1) 100.53 ± 28.89
Synthetic cannabinoid 56 (17.1) 119.64 ± 28.93
Pill (Ecstasy) 20 (6.1) 115.10 ± 22.40
Volatile substance (Thinner, Bally) 15 (4.6) 132.20 ± 8.08
Substance use disorder characteristics
Single substance use disorder 53 (16.2) 69.55 ± 29.67 0.483 0.487*
Multiple substance use disorder 275 (83.8) 110.47 ± 27.43
Intravenous substance use disorder status
Yes 41 (12.5) 117.44 ± 23.04 13.145 0.000*
No 287 (87.5) 101.91 ± 32.19
Legal problem status
Yes 161 (49.1) 111.92 ± 27.53 17.277 0.000*
No 167 (50.9) 96.08 ± 33.33
Self-harm
Yes 209 (63.7) 116.04 ± 27.00 0.470 0.494*
No 119 (36.3) 82.45 ± 27.46
Duration of substance use disorder
0-1 year 38 (11.6) 81.03 ± 33.35 24.259 0.000**
2-5 year 199 (60.7) 101.23 ± 30.96
6-12 year 91 (27.7) 119.12 ± 24.81
* T-test in independent groups. ** Analysis of variance.

found that patients with the comorbid condition were significantly
more aggressive than those with only substance abuse24. This finding
is supported by the fact that both conditions elevate impulsivity
and decrease inhibitory control25,26, suggesting that ASPD and
substance abuse both contribute to the aggression of patients. A
study by Sökmen et al., which was performed on adolescents with
substance addiction, reported that physical aggression and hostility
scores were higher among adolescents with addiction, while verbal
aggression, anger, and indirect aggression scores were surprisingly
lower, revealing a contrast to our study11. However, all of our patients
had comorbid ASPD and substance abuse, therefore the aggressive
characteristics of our patients would be expected to be higher than
those without ASPD. Furthermore, Hyde et al. reported that antisocial
behavior during the adolescence was associated with a higher risk
of ASPD diagnosis in adulthood27, which may show that earlier
substance abuse that causes aggression and/or antisocial behavior
may transform to ASPD later on in life, further increasing aggression.
In agreement with this hypothesis, comorbid ASPD and substance
abuse has been reported to be associated with predisposition to
aggressive behavior28,29. The key point in this association may be
the fact that ASPD patients and those with substance abuse have
similar characteristics in terms of seeking stimulus, suggesting a bi-
directional relationship between the conditions and therefore leading
to the age old question “which comes first?”. Although the literature is
limited in this aspect, it may be reasonable to suggest that the search
for stimulus may be the initial reason that adolescents succumb to
drug use, leading to antisocial/violent behavior and finally forming
a vicious cycle embodied by ASPD. However, this train of thought
is in no way the only explanation of the relationship between the
conditions and requires confirmation. Therefore, we believe that
treating stimulus seeking behavior before starting direct therapy
for substance abuse may increase the likelihood of positive clinical
outcome. Although the overwhelming majority of studies in this
field demonstrate that ASPD and substance abuse both contribute
to aggression, contrasting findings also exist. For instance, a study
by Shorey et al. showed that aggressive behavior was not associated
with alcohol or substance abuse in patients with ASPD30.
The fact that indirect aggression was not significantly increased
in the patient group may be associated with the features of indirect
aggression itself. Indirect aggression requires more advanced
cognitive skills compared to other forms of aggression31,32. The
similarity between indirect aggression behavior score of the groups
may be attributed to the fact that the majority of the study group was
comprised of males with low education levels, while the impairment
of social-cognitive abilities among those with substance use disorders
may also be another explanation to the lack of difference.
Ekinci et al.33 found that the scores obtained in subsections of the
API, such as the effect of substance use on the person’s life, the desire
for substance use, and the motivation to discontinue substance use,
were higher among those with higher aggression scores. The same
study stated that, with increased anger levels, the impact of substance
use disorder on the person’s life increases, along with the desire to
use the substance. However, Kaplan et al. reported no statistically
significant relationship between aggression level and API, among
children living in the streets34. Contrastingly, the current study
found that aggression scores were significantly correlated with API.
When examining the correlations between total aggression scores
and the API subscales, it can be seen that motivation to discontinue
substance use decreases as aggression scores increase. It is assumed
that the level of aggression increases when motivation to discontinue
substance use decreases, caused by the inability to decide to make a
change or not, a situation with which they cannot cope. Therefore,
close follow-up and supportive conduct during treatment may be
beneficial for patients with high motivation to discontinue drug use.
In the current study, the type of substance was found to be
a significant contributor to aggression scores. Those who used
synthetic cannabinoids, ecstasy and volatile substances were found
to have higher mean total aggression scores. A large meta-analysis
study reported cocaine was the substance with the strongest link to
psychological, physical, and sexual aggression. Cannabis was also
associated with aggression towards a partner35. Other studies also
reported higher aggression scores among those who used volatile
substances 36. Although earlier studies have associated cannabis with
 Akçay BD, Akçay D. / Arch Clin Psychiatry. 2020;47(4):95-100
increased aggression37, our findings show that the control group and
cannabis users had comparable total aggression scores (90.85 ± 6.37
vs. 95.80 ± 32.42). However, the variance in scores among those
using cannabis demonstrate that the effects of cannabis cannot be
considered uniform among all users.
Similar to the study by Kaplan, the aggression level of patients
were found to increase with longer duration of substance use
in our study group, and the aggression scores of those who had
legal problems were significantly higher than those who had no
legal problems34. As these substances weaken inhibitory control
mechanisms and lead to higher activity, individuals are prone to
exerting more aggressive and uncontrolled behaviors20. Substance use
disorder encourages individuals to disobey rules and exert destructive
behaviors such as harming themselves and the environment,
increasing their tendency to commit crimes.
Violent acts and aggressive behavior in patients with substance
abuse may also be associated to the fact that users commit crimes
to acquire money for access to the substance20. This possibility is
an important contributor to the high level of aggression among
the young men that participated in this study. One of the study
limitations is that the majority of patients were soldiers who were
aged between 20-25 years; therefore, the findings can be generalized
only for young males aged 20 to 25 years of age. Similar studies with
larger sample sizes are needed to obtained more conclusive results.
Our findings suggest that substance use disorder is mediated by
aggression. Therefore, aggression is an important factor that should
be evaluated in the treatment of substance addiction. Particularly
in the intervention studies to be conducted, those with high
addiction severity and patients who use volatile substances should
be considered as the priority treatment group. Further studies are
necessary to determine the causes of aggression in substance use
disorders and to evaluate the relationships between ASPD and
substance abuse.
Disclosure
The authors report no conflicts of interest.
Research support
This study wasn’t received funded.
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 Original article

Clinical characteristics of cognitive deficits in major depressive disorder: a 6-month

prospective study
Yajuan Ji1,2
https://orcid.org/0000-0001-8722-2682

Weihui Li2
https://orcid.org/0000-0001-5257-6122

Bangshan Liu2
https://orcid.org/0000-0002-9355-2183

Jin Liu2
https://orcid.org/0000-0001-7959-1541

Yumeng Ju2
https://orcid.org/0000-0002-9745-9840

Mi Wang2
https://orcid.org/0000-0002-4205-9831

Yanchao Chen2
https://orcid.org/0000-0003-2222-5633

Lingjiang Li2
https://orcid.org/0000-0002-8775-7852

1Department of Psychiatry, Xiamen Xianyue Hospital, Xiamen, Fujian, China.

2Mental Health Institute of Central South University, China National Clinical Research Center on Mental Disorders (Xiangya), China National Technology Institute on Mental Disorders,
Hunan Technology Institute of Psychiatry, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, Hunan, China.

Received: 02/01/2019 – Accepted: 06/04/2020

DOI: 10.1590/0101-60830000000241

Abstract
Background: Previous studies have shown that major depressive disorder (MDD) is associated with a variety of cognitive deficits, which can persist even in
remitted states. Nevertheless, the relationship between the cognitive and affective symptoms in depression remains obscure. The aim of the present study was
to explore the clinical characteristics and correlates of the cognitive deficits in patients with MDD. Methods: Clinical and neuropsychological assessments
were conducted at baseline and 6-month follow-ups. The severity of the disease and the effect of treatment were assessed with the Hamilton Depression
Scale-17. Neuropsychological tests, including the digital symbol substitution test and digit span test, were administered to 67 depressed patients and 56
healthy participants. Results: MDD patients showed impairments in memory, attention, and executive function at baseline. After the 6-month treatment
phase, patients in remission showed significant alleviation of these cognitive deficits, although impairments in attention and executive function were still
present when compared to controls. Discussion: Significant cognitive deficits are present in MDD. The speed of remission of cognitive functions seems to be
slower than and inconsistent with emotional symptoms, which provides new support for the argument that cognitive deficits are independent factors from
the emotional symptoms in MDD.

Ji Y et al. / Arch Clin Psychiatry. 2020;47(4):101-5

Keywords: Major depressive disorder, cognitive deficits, executive function, remission.

Introduction high risk of developing depression7-9. All of these findings suggest

Major depressive disorder (MDD) is a common psychiatric disease
with a high frequency of recurrence, affecting millions of people
worldwide. In addition to the well- defined depressive symptoms,
such as low mood, patients suffering from MDD consistently
complain about cognitive disturbances, which significantly
exacerbate the burden of this illness 1-3. Among the cognitive
symptoms, impairments in attention, working memory, processing
speed, and executive function are often reported.
A considerable number of studies have shown that cognitive
deficits are promising candidates for the core symptoms of MDD,
and independent risk factors for poor prognosis4-6. Specifically, some
studies have found that the progression of cognitive symptoms is
inconsistent with that of depressive symptoms, that the recovery of
cognitive deficits is slower than the remission of emotional symptoms,
and finally, cognitive symptoms have been repeatedly reported in
participants with subclinical depression as well as participants at
that the cognitive symptoms are independent of the emotional
symptoms in MDD. Therefore, some researchers have proposed that
cognitive deficits are trait rather than state characteristics, namely
endophenotypes, in MDD10,11. Wieland-Fiedler et al. observed
deficits in executive function and sustained attention when residual
symptoms were controlled for statistically, suggesting that they may
represent trait markers for MDD12.
Nevertheless, existing studies have generally focused on pre-
treatment cognitive function assessments and have mostly been
comparative studies with healthy controls. To date, there are few
prospective studies comparing cognitive function before and after
treatment. Furthermore, most studies have not restricted the types of
medication taken by participants, thus making it difficult to control
for the effect of multi-drug combinations on cognitive function.
Given the above considerations, our study aimed to explore the
relationship between cognitive function and depressive symptoms in
MDD by assessing participant performance on neuropsychological

Address for correspondence: Lingjiang Li. Central South University – Mental Health Institute of the Second Xiangya Hospital. 139 Middle Renmin Road, Changsha, Hunan 410011, People’s Republic
of China Changsha 410083, China. E-mail: llj2920@163.com
102 Ji Y et al. / Arch Clin Psychiatry. 2020;47(4):101-5
tests before and after treatment with a single antidepressant. In
addition, we analyzed the relationship between cognitive deficits
and gender, level of education, severity of depression, age of onset,
episodes, and illness duration to explore the potential correlate
affecting cognitive function in MDD.
Methods
Participants
MDD group
A total of 67 drug-naive MDD patients were recruited from the
outpatient clinic at the Second Xiangya Hospital of Central South
University. Participants had to meet the following inclusion criteria:
(1) outpatients; (2) aged 18-65 years old; (3) meeting the International
Statistical Classification of Diseases and Related Health Problems 10
criteria for a single or recurrent major depressive episode with no
history of mania or hypomania (the diagnosis was established by a
consultant psychiatrist after assessment with the Mini International
Neuropsychiatric Interview); (4) starting a new antidepressant
monotherapy (either the first one or an altered one) with a washout
period of at least four weeks; (5) willing to provide informed consent.
Patients were excluded if they had any of the following conditions:
(1) any other primary psychiatric disorder; (2) hyperthyroidism or
hypothyroidism; (3) receiving electroconvulsive therapy or repeated
transcranial magnetic stimulation; (4) women who were pregnant,
less than 6 months post-childbirth, or lactating; (5) experiencing
severe suicidal tendencies.
Healthy control group
A total of 56 healthy controls were recruited during the same period.
The inclusion criteria were (1) aged 18-65 years old (male or female);
(2) having a Hamilton Depression Scale-17 (HAMD-17) score lower
than 7. The remaining criteria were the same as in the MDD group.
All research protocols were approved by the Xiangya second
hospital of central south university, and all participants gave written
informed consent.
Measurements
Assessment tools
(1) Clinical assessment
The HAMD-1713 was used to assess the severity of depression. It
includes five subfactors: relating to retardation, insomnia, cognitive
dysfunction, anxiety/somatization, and weight loss.
(2) Neuropsychological testing
The digit span test14 measures participants’ attention and short-term
memory. It consists of recalling digit spans forward and backward.
The forward test mainly assesses working memory, while the
backward test assesses attention switching capacity.
The digital symbol substitution test (DSST)14,15 is part of the
Wechsler Intelligence Scale (digital symbol coding). It measures
cognitive function, including executive function, visual orienting,
processing speed, attention, and memory function, which in
combination represent the ability to conduct complex cognitive
multitasking.
Assessment methods
The MDD group received one type of selective serotonin reuptake
inhibitors (SSRIs) from baseline for a period of 6 months. The
HAMD-17 score was used to assess the severity of depression,
and neuropsychological tests were employed to measure cognitive
function in MDD before and after the treatment (i.e., at the
8- week and 6-month follow-up assessments). The control group
also completed the above assessments. The clinical assessments and
cognitive tests were completed by two researchers, with a consensus
(Kappa) coefficient of 0.90.
Remission was defined as a period of at least 2 months during
which the individual was diagnosed as being in clinical remission
with a HAMD-17 score ≤7. After the 6-month period of treatment,
we successfully conducted follow-up assessments with 44 patients.
Among these, 17 patients had achieved remission whereas the
remaining 27 patients did not meet the criterion for remission.
Statistical analysis
SPSS 22.0 statistical software was used to conduct chi-square tests,
independent sample t tests, paired t tests, covariance analyses, and
linear regression analyses. The significance level for all analyses was
set at P < 0.05.
Results
Characteristics of cognitive function in MDD
As shown in Table 1, the total sample was composed of 67 MDD
patients and 56 healthy controls. Except for the severity of the
illness, no statistical differences were found between the MDD
patients and healthy controls in terms of demographic and clinical
characteristics at baseline. At the 8-week follow-up, data could not
be obtained from 19 patients. At the 6-month follow-up, data could
not be obtained from 4 patients. Further analyses were conducted
on 44 patients, 27 of whom were in clinical remission. As can be
seen in Table 2, at baseline the depressed patients experienced more
severe emotional symptoms and demonstrated poorer performance
on each neuropsychological test compared to the healthy controls.
At the 8-week follow-up assessment, the emotional symptoms
and cognitive deficits in the patients showed obvious alleviation
relative to baseline, although the DSST and backward digit span
performance were both still significantly poorer than in controls.
At the 6-month follow-up assessment, the depressed patients still
had poorer performance on the DSST and backward digit span
than the controls.
As shown in Table 3, the non-remitted patients demonstrated
poorer performance on all neuropsychological tests except the
forward digit span at the 6-month follow-up as compared to healthy
controls. However, the remitted patients had poorer performance
only on the DSST, achieving a comparable level of performance to
that of the healthy controls on the forward and backward digit span
at the 6-month follow-up.
Clinical correlates of the cognitive deficits in MDD
We used linear regression analysis with cognitive function at baseline
as the dependent variable and various clinical characteristics of the
patients (gender, age at onset, level of education, number of episodes,
illness duration, and severity of depression) as the independent
variables.
As shown in Table 4, DSST performance was positively
correlated with level of education and negatively correlated with
the age of depression onset and illness duration. The forward
digit span was positively correlated with level of education and
negatively correlated with the age of depression onset and number
of episodes. The backward digit span was positively correlated
with level of education and negatively correlated with HAMD-17
scores. Linear regression analysis showed that level of education,
age of depression onset, and illness duration explained 37.0%
of the variance in DSST performance; level of education, age of
depression onset, and number of episodes explained 30.6% of the
variance in forward digit span performance; and level of education
and HAMD-17 scores explained 14.2% of the variance in backward
digit span performance.
 Ji Y et al. / Arch Clin Psychiatry. 2020;47(4):101-5 103

Table 1. Demographic and clinical characteristics for all participants (mean ± SD)
MDD (N=67) Controls (N=56) Statistics (t/χ2) P
Age (years) 31.00 ± 9.84 33.83 ± 12.83 1.385 0.169
Sex (male/female) 30/37 25/31 1.374 0.241
Education (years) 13.18 ± 3.08 13.30 ± 4.70 0.169 0.886
Duration (months) 16.96 ± 15.21 - - -
Age of onset (years) 22.36 ± 5.39 - - -
Number of episodes 3.72 ± 2.17 - - -
First-episode/total 27/67 - - -
HAMD-17 20.91 ± 2.51 2.46 ± 1.94 45.934 0.000

Table 2. Cognitive characteristics of the depressed patients at baseline and after treatment
Baseline Follow-up (8-week) Follow-up (6- month) Controls Statistics
(N=67) (N=48) (N=44) (N=56) F P
HAMD-17 20.91±2.51# 9.73±2.91*# 7.57± 3.37*# 2.46±1.94 523.578 <0.001
Digital symbol substitution test (DSST)
Correct 49.79±10.93# 58.02±9.80*# 60.64±11.05*# 65.82±13.60 20.852 <0.001
Digit Span Test
Forward 8.64±1.08# 9.31±0.75* 9.59±0.92* 9.64±1.17 12.656 <0.001
Backward 4.85±0.97# 5.48±1.01*# 5.48±0.90*# 6.36±1.54 17.665 <0.001
Note: *P < 0.05 vs. baseline. #P < 0.05 vs. controls.

Table 3. Cognitive characteristics of the remitted and non-remitted depressed patients at 6-month follow-up
Non-remitted Remitted Controls Statistics
(N=17) (N=27) (N=56) F P
Digital symbol substitution test (DSST)
Correct 54.06±11.65* 64.85±8.37 65.82±13.60 6.392 0.002
Digit span test
Forward 9.29±0.85 9.74±0.94 9.64±1.17 0.982 0.193
Backward 5.06±0.90* 5.81±0.83* 6.36±1.54 6.926 0.002
Note: *P < 0.05 vs. controls.

Table 4. Linear regression analyses of clinical predictors and cognitive deficits at baseline
Independent variables Dependent variables B β Constant R2 F P
DSST Age of onset −0.465 −0.407 82.233 0.370 9.192 0.001
Duration −0.176 −0.249 0.040
Education −7.842 −0.377 0.002
Forward digit span Age of onset −0.141 −0.300 7.670 0.306 8. 259 0.020
Education 0.182 0.444 <0.001
Frequency −0.521 −0.241 0.040
Backward digit span Education 0.082 0.260 3.964 0.142 5.298 0.030
HAMD −0.416 −0.235 0.049

Discussion
The characteristics of cognitive deficits in MDD
The results of the present study indicate that significant cognitive
deficits are present in MDD, including deficits in executive
function, attention, and memory. At 6-month follow-up after
treatment, patients demonstrated significant improvement on all
three neuropsychological tests, among which the forward digit
span recovered to the level of healthy control, while the backward
digit span and digit symbol substitution test performance remained
suboptimal. These findings suggest that the trajectories of different
aspects of cognitive function in MDD are asynchronous, and some
may be independent of emotional symptoms. Specifically, the
improvement in working memory (as tested by the forward digit span
task) was the most obvious, as patients exhibited improvement in this
function even when they did not achieve clinical remission. The speed
of the improvement in executive function (as tested by the DSST) was
slower since only patients with clinical remission showed recovery
from impairment on this task. Meanwhile, the recovery of attention
switching (as tested by backward digit span) was minimal and had
little relation to emotional symptoms, since the deficits in attention
persisted even in the patients who had achieved clinical remission.
Our results are consistent with a considerable number of previous
literature reviews
and longitudinal studies. For instance, Lee and colleagues found
that attention and executive functioning deficits were not associated
with depression severity, suggesting that they may function as
important trait markers for MDD16. This is consistent with a recent
104 Ji Y et al. / Arch Clin Psychiatry. 2020;47(4):101-5
study by Douglas et al. demonstrating that psychomotor speed
improved in successfully-treated in-patients with severe depression
whereas attention and executive dysfunction persisted despite
remission of depressive symptoms17.
However, the findings of some studies are inconsistent with the
present results. For instance, a recent study found that executive
dysfunction appeared to be a state-specific marker of MDD that
is related to depression severity and is not present in remission18,19.
Maalouf et al. found that the executive dysfunction of adolescent
patients was correlated with the severity of depression and gradually
returned to normal level in remission20. One possibility is that the
adolescent brain may be better able to recover from executive
function deficits associated with depression. These inconsistencies
in findings could be partly due to the testing of cognitive dysfunction
in MDD being limited by heterogeneous demographic features (such
as age and educational attainment), clinical characteristics (such as
first, multi-episode, or chronic depression, severity of symptoms, age
of disease onset, substance use, and comorbid medical conditions),
and treatment assignments. In our study, some patients were given
benzodiazepines, while Buffett’s study found that benzodiazepines
produce profound increases in subjective sedation, slow psychomotor
and cognitive processing speed, and lead to attentional impairments21.
Together, these variables likely play a major role in contributing to the
inconclusive findings reported in the existing studies. In addition, the
lack of standard tools for assessing cognition in MDD and the variety
of neuropsychological tests employed in different investigations
hinder clear comparisons between studies.
The correlates of cognitive deficits in MDD
We found that education level and age of depression onset are major
factors associated with cognitive deficits in MDD. Similarly, there
are different degrees of correlation between cognitive deficits and
episodes, illness duration, and severity of symptoms.
As shown in the present study, working memory, attention
switching, and executive function are consistently associated with
level of education, which indicates that more highly educated patients
show enhanced cognitive reserve capacity Many previous studies are
consistent with our results. For instance, Jarema et al. showed that
more highly educated patients demonstrated better performance
on all the assessed measures of cognitive function22. In addition,
a study focusing on cognitive functioning in healthy older adults
found that participants with a medium or high level of education
performed better on cognitive tests than participants with a low level
of education. In other words, people with a high level of education
may have a greater cognitive reserve capacity than people with a
lower level of education23.
Since the age of depression onset is closely correlated with
different aspects of cognitive function, late-onset depression may
be associated with more severe cognitive impairments24,25. A meta-
analysis found that patients with late-onset depression showed greater
reductions in processing speed and executive function than patients
with early-onset depression and controls16,26. One explanation for
this may be that cognitive function, especially executive function,
may gradually decrease with age. In addition, late-onset depression
has been associated with cerebrovascular disease risk factors, which
may also play an important role in the development of cognitive
impairment27.
However, several limitations must be acknowledged. In this
study, patients were treated with a single antidepressant, meanwhile
some also received benzodiazepine in combination, but we did not
specifically discuss the type and dose of antidepressant used, which
may impact negatively on cognitive function. We did not discuss
comorbidities, marital status and family history of mental illness. The
above factors may affect cognitive function and social function to
some extent. The neuropsychological assessment tools in this study
are relatively limited, involving only executive function, attention
and memory, which cannot comprehensively evaluate the cognitive
function of patients with depression. Therefore, more comprehensive
assessment tools should be included in future studies.
In conclusion, patients with MDD may exhibit impairments in
various cognitive domains, including attention, executive function,
and memory. While, the trajectories of different aspects of cognitive
function in MDD are asynchronous during remission, and some
may be independent of emotional symptoms. Cognition is thus a
key target in the treatment of depression especially with respect to
early recognition and intervention. In view of the above findings,
it is appropriate to conclude that attention deficits and executive
dysfunction may serve as trait markers of MDD, while working
memory deficits may be regarded as a state marker of MDD. Whether
cognitive dysfunction is a state- or trait-related phenomenon in
depression is a subject of ongoing debate. A promising approach
to clarifying this matter is the additional consideration of clinical
and demographic factors that are known to be related to cognitive
performance. This is an important goal since cognitive deficits
contribute to long-term functional outcomes, and MDD patients
experiencing deficits may show less compliance with treatment and
an increased risk for suicide.
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Original article

Prevalence and associated risk factors of postpartum depression: a cross

sectional study
Reda Goweda1
https://orcid.org/0000-0001-5514-1407

Tayseer Metwally2
https://orcid.org/0000-0002-1972-2981

1 Family Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
2 Family Medicine Department, Faculty of Medicine, Suez University, Suez, Egypt.

Received: 12/28/2019 – Accepted: 03/03/2020

DOI: 10.1590/0101-60830000000242

Abstract
Background: Postpartum mood disturbance affects up to 85% of women, with most symptoms of this disturbance being temporary and mild. However
up to one in seven women experience a persistent type of depression which is associated with major maternal and neonatal morbidity if it is not managed.
Objective: To estimate the prevalence of postpartum depression and to identify the associated risk factors. Methods: A cross sectional study was conducted in
randomly selected 3 primary health care centers affiliated to Suez governorate, Egypt. An interviewed questionnaire was used containing potential risk factors
for postpartum depression. An Arabic version of the Edinburgh postnatal depression scale (EPDS) was used to screen for postpartum depression symptoms.
Results: A total of 237 postpartum mothers were included in the study. 139 (58.6%) of the mothers completed secondary level of education, 195 (82.3%) of
them were housewives and 181 (76.4%) had cesarean section. The estimated postpartum depression prevalence was 26.6% and suicidal ideation accounted
for 4.6%. Factors significantly associated with high EPDS scores were bad relationship with the husband, having >2 children, an unplanned pregnancy and
unhealthy newborn; with P-values of 0.000, 0.004, 0.000, and 0.018, respectively. Discussion: the prevalence of postpartum depression among Egyptian women
is considered slightly high with its negative and long term consequences on the mothers and their children, accordingly screening, proper management &
referral to specialist care is highly recommended.

Goweda R, Metwally T / Arch Clin Psychiatry. 2020;47(4):106-9

Keywords: Postpartum, depression, risk factors.

Introduction
Postpartum depression (PPD) is a common health problem that
occurs after preg­nancy and affects up to 10%-15% of women1,2.
PPD is associated with negative effects on the mother-infant
relationship and those affected women are more likely to stop
breastfeeding early3. Children of depressed mothers are more likely
to have behavioral problems, failure to thrive, attachment disorder,
cognitive delay, emotional and social problems and developmental
delay4.
Although the cause of postpartum depression is unclear,
hormonal, biologic, genetic predisposition, social and psychological
factors are considered to be risk factors for all susceptible women5.
PPD was classified by the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) as a major depressive disorder that is
found during pregnancy or within 4 weeks after delivery6. These
four weeks may be extended to be within one year postpartum as
mentioned by some experts7.
The U.S. Preventive Services Task Force (USPSTF) recommends
screening postpartum PPD of all women in places with adequate
systems to ensure correct diag­nosis, effective management and
suitable follow-up8. There are different screening tests for PPD, the
most commonly used validated screening tool for PPD is the 10-item
Edinburgh Postnatal Depression Scale (EPDS)9.
Mild to moderate PPD can be treated with psychotherapy as a
first line, whereas combination therapy is recommended for moderate
to severe depression10.
Methods
This cross sectional prospective study was conducted in randomly
selected 3 primary health care centers which is affiliated with Suez
governorate, Egypt, between May and October 2019.
After oral consent from all the volunteered mothers, the current
study recruited 237 women who attended the child vaccination
clinic, family planning clinic, or for follow up at 4th to12th week
postpartum and were interviewed face to face by a trained nurse.
Females with known mental illness and on treatment or on follow-
up in a psychiatric clinic as well as those who gave birth to children
with severe illness such as congenital diseases and malformations
were excluded.
An Arabic version of EPDS was used to screen for PPD symptoms.
EPDS is the most commonly used validated screening tool for postpartum
depression and has a sensitivity of 75% to 100% and a specificity of 76%
to 97% in English-speaking populations11. EPDS consists of 10 questions
on the women’s feelings over the last seven days. Although 10 is the cutoff
score in English-speaking populations for probable depression, scores of
more than 12 were the optimum cut-off scores for probable depression
as validated in Arabic-speaking cultures12-14.
Questions were asked for assessment of possible risk factors
of PPD such as age, education, occupation, duration of marriage,
bond with the husband, number of children, gender of the newborn,
smoking status, planning for pregnancy, obstetric complications,
fear of labour, labour complications, newborn complications, type
of labour, place of labour, type of anesthesia and infant feeding.
SPSS (20.0) was used for data analysis of this study. For
quantitative data, t-test was used. Chi-square test (Fisher’s exact
test) was used to examine the relation between qualitative variables
and P < 0.05 was considered statistically significant.
Results
A total of 237 postpartum women who completed the socio-
demographic and obstetric variables section and the EPDS
questionnaire were included in our study. The mean age was 27.9
years (SD = 5.9), ranging from 17 to 45 years. 139 (58.6%), or more

Address for correspondence: Reda Goweda. Suez Canal University Faculty of Medicine, Ismailia, 8099 Egypt. E-mail: redagoweda@yahoo.com
 Goweda R, Metwally T / Arch Clin Psychiatry. 2020;47(4):106-9 107

than half of the mothers completed either elementary or secondary Table 1. General characteristics of the participants
level of education, 34 (14.3%) achieved higher education, 56 (23.6%) N (%)
could read and write, and only 8 (3.4%) were illiterate. 195 (82.3%),
Marital status Married 231 (97.5)
the majority of the mothers were housewives, and 148 (62.4%) of
the mothers fell under the category of passive second-hand smokers Widowed 4 (1.7)
with none being an active smoker. 159 (67.1%) of the mothers had ≤2 Divorced 2 (0.8)
children. Regarding the sex of children in the family 80 (33.8%) of the Spousal Relationship Good quality 226 (95.4)
mothers had boys only, 55 (23.2%) had girls only, 102 (43.0%) had
Poor quality 11 (4.6)
both gender. Few of the mothers reported that their pregnancies were
unplanned pregnancies 31 (13.1%). Fifty six (23.6%) of the mothers Educational level Higher education 34 (14.3)
reported health problems during pregnancy. Out of 237 women, 181 Secondary schooling 139 (58.6)
(76.4%) had cesarean section and 56 (23.6%) had normal vaginal Can read and write 56 (23.6)
delivery. The estimated PPD prevalence in our study was 26.6% and
Illiterate 8 (3.4)
suicidal ideation accounted for 4.6% (Table 1).
Young mothers were less likely to have depressive symptoms. Occupation House-wife 195 (82.3)
Mean ± SD age of depressed women was 30.5 ± 6.5 while non Working 42 (17.7)
depressed mothers were 26.9 ± 5.5 with a p value of 0.000. Neither 89 (37.6)
Years of marriage had no significant effect on EPDS scores; depressed
Number of children ≤2 159 (67.1)
mothers were married for 6.61 years (±5.52) whereas non-depressed
were married 5.28 (±4.44) with a p value of 0.057 (Table 2). >2 78 (32.9)
Factors significantly associated with high EPDS scores were a Sex of children Males 80 (33.8)
poor relationship with the husband, having more than 2 children, Females 55 (23.2)
unplanned pregnancies and unhealthy newborns, with P-values of
Both 102 (43.0)
0.000, 0.004, 0.000, and 0.018, respectively. Factors not significantly
influencing EPDS scores were educational level, maternal occupation, Passive smoking Yes 148 (62.4)
infant gender, smoking status, obstetric health problems, type of No 89 (37.6)
labour, whether received anesthesia, fear of labour, and infant feeding, Planned pregnancy Yes 206 (86.9)
with p-values of 0.517, 0.275, 0.573, 0.310, 0.077, 0.836, 0.067, 0.094,
No 31 (13.1)
0.335 and 0.602, respectively (Table 3).
Obstetric health Yes 56 (23.6)
problems No 181 (76.4)
Discussion
Place of labour Hospital 206 (86.9)
Prevalence of PPD has a very wide range worldwide. This was clearly
Home 5 (2.1)
shown in a review by Siti et al. who found that the prevalence of PPD
ranged from 4.0%-63.9% with Japan and America recording the lowest Clinic/Medical center 26 (11.0)
and highest rates of PPD respectively15. This finding is consistent with Type of labour Normal vaginal 56 (23.6%)
an earlier finding of a review of 143 studies across 40 countries that Cesarean Section 181 (76.4%)
identified that the prevalence of PPD ranged from 0-60%16.
Received anesthesia Yes 114 (48.1)
The findings of the current study demonstrated the estimated
prevalence of PPD is 26.6% which is higher than figures reported No 123 (51.9)
by other studies in western countries as in Canada and United Fear of labour Yes 212 (89.5)
Kingdom were 10%-15% and 12.8% respectively17,18. A Meta analysis No 7 (3.0)
by O’Hara & Swain included 59 studies from North America, Europe,
Labour complications Yes 23 (9.7)
and Australasia scored an overall prevalence rate of PPD of 13%19.
On the other hand most of studies conducted in Arab countries No 214 (90.3)
recorded a higher prevalence of PPD than in more developed Newborn’s sex Male 112 (47.3)
countries. The estimated PPD prevalence in Lebanon is 21%20, United Female 125 (52.7)
Arab Emirates (UAE) 22%21, Tunisia 19.2%22, Jordan 22%23, Saudi
Newborn’s health Yes 35 (14.8)
Arabia 33.2%24, Bahrain 37.1%25, and Oman 10%14. The reasons for
problems No 202 (85.2)
the wide range of prevalence may be explained by many reasons such
as cross-cultural differences26, the way in which women understand Feeding of the Breast feeding 179 (75.5)
and interpret items in the EPDS, postpartum time of screening and Newborn Artificial feeding 26 (11)
cutoff scores for screening.
Both 32 (13.5)
In the current study older women were at a higher risk of
depression than younger women, which is similar to previous studies Postpartum Depressed (EPDS scores ≥12) 63 (26.6)
stating advanced and very young maternal age are risk factors for depression Not depressed (EPDS scores ≥12) 174 (73.4)
PPD24,27,28. This finding varies from results reported in many previous Suicidal ideation Yes 11 (4.6)
studies29, such as by Stowe et al. showing mothers between the ages
No 226 (95.4)
of 15 and 19 years had more risk for PPD30.

Table 2. Effect of maternal age and marriage duration on EPDS scores

Mean ± SD 95% Confidence Interval P value
Lower Upper
Maternal Age Depressed 30.53 ± 6.46 1.89245 5.22140 0.000
Not depressed 26.98 ± 5.46
Duration of Marriage Depressed 6.61 ± 5.52 -.04218 2.71131 0.057
Not depressed 5.28 ± 4.44
108 Goweda R, Metwally T / Arch Clin Psychiatry. 2020;47(4):106-9

Table 3. Evaluation of various factors affecting EPDS scores

Depression P value
Depressed Not depressed (N = 174)
(N = 63)
Education Highly educated 12 (19.0%) 22 (12.6%) 0.517
Secondary schooling 35 (55.6%) 104 (59.8%)
Read & write 13 (20.6%) 43 (24.7%)
Illiterate 3 (4.8%) 5 (2.9%)
Occupation House wife 49 (77.8%) 146 (83.9%) 0.275
working 14 (22.2%) 28 (16.1%)
Marital status Married 58 (92.1%) 173 (99.4%) 0.005
Divorced 3 (4.8%) 1 (0.6%)
widow 2 (3.2%) 0 (0%)
Spousal Relationship Good 53 (84.1%) 173 (99.4%) 0.000
Bad 10 (15.9%) 1 (0.6%)
Number of children ≤2 33 (52.4%) 126 (72.4%) 0.004
>2 30 (47.6%) 48 (27.6%)
Sex of children Males 18 (28.6%) 62 (35.6%) 0.573
Females 15 (23.8%) 40 (23.0%)
Both 30 (47.6%) 72 (41.4%)
Passive smoking Yes 36 (57.1%) 112 (64.4%) 0.310
No 27 (42.9%) 62 (35.6%)
Planned pregnancy Yes 42 (66.7%) 164 (94.3%) 0.000
No 21 (33.3%) 10 (5.7%)
Obstetric health problems Yes 20 (31.7%) 36 (20.7%) 0.077
No 43 (68.3%) 138 (79.3%)
Place of Labour Hospital 54 (85.7%) 152 (87.4%) 0.836
Home 1 (1.6%) 4 (2.3%)
Clinic/Medical center 8 (12.7%) 18 (10.3%)
Type of Labour Normal vaginal 30 (47.6%) 106 (60.9%) 0.067
C.S. 33 (52.4%) 68 (39.1%)
Received anesthesia Yes 36 (57.1%) 78 (44.8%) 0.094
No 27 (42.9%) 96 (55.2%)
Fear of labour Yes 56 (94.9%) 156 (97.5%) 0.335
No 3 (5.1%) 4 (2.5%)
Labour complications Yes 12 (19.0%) 11 (6.3%) 0.003
No 51 (81.0%) 163 (93.7%)
Newborn’s sex Male 28 (44.4%) 84 (48.3%) 0.602
Female 35 (55.6%) 90 (51.7%)
Newborn’s health problems Yes 15 (23.8%) 20 (11.5%) 0.018
No 48 (76.2%) 154 (88.5%)
Feeding of the Newborn Breast 42 (66.7%) 137 (78.7%) 0.157
Artificial 9 (14.3%) 17 (9.8%)
Both 12 (19%) 20 (11.5%)

Conflict and poor spousal relationship increased the risk of
depression which agrees with findings by Chan et al.31. Additionally
previous research has illustrated a positive association between
informal structural social support, essentially that given by a
partner32.
This study has shown that mothers having more than two
children are likely to be more depressed than being a first-time
mother or having two children. This is in agreement with low-income
countries such as Nepal and Pakistan33,34. Multi-parity increases
family stress and the risk of PPD due to the physical and financial
burden associated with childcare. In the UAE, multi-parity is a
protective factor for PPD21.
The current study showed that there is a significant relation
between depression and marital status as divorced or widowed
women were more likely to be depressed which is in disagreement
with a study by Watson JP35 who found that there is no correlation
between PPD and marital status
Beside previous factors increasing risk of depression, unplanned
pregnancy was found to be one of the significant factors in the current
study to increase EPDS scores.
In the current study it was found that there is no significant
relationship between method of delivery and PPD which is consistent
with the results of Johnstone et al. who reported a non significant
trend between postpartum depression and caesarean section36.
Additionally Warner et al.37 found no significant association between
elective or emergency caesarean section and subsequent postpartum
depression while Fisher and colleagues reported that cesarean section
was associated with increased risk of PPD38.
This study discovered the risk of PPD is nearly equal among
housewives compared to those who were working away from their
homes. However, in contrast to our finding, other studies have
reported an excess risk of PPD among housewives39-40. Our study
did not find maternal level of education as a risk factor for PPD,
which is consistent with the finding of another study41, but differs
 Goweda R, Metwally T / Arch Clin Psychiatry. 2020;47(4):106-9
from some other reports42. No differences were observed regarding
risk of PPD with regard to the sex of the child, which is in line with
some other studies43. This study has shown that there is no significant
association between EPDS scores and whether the patient had
obstetric complications, the smoking status, or whether the infant
was breast fed or formula fed.
Lastly, we can conclude relatively older females, a fragile spousal
relationship, multi-parity, and unplanned pregnancies were associ­
ated with higher risk of PPD.
Conflict of interests
There are no conflicts of interest.
Financial support and sponsorship
None.
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Brief report

Cross-cultural adaptation of the City Birth Trauma Scale for the Brazilian context
Mariana Fortunata Donadon1
https://orcid.org/0000-0002-0759-3879

Ana Carolina R. Darwin1

https://orcid.org/0000-0001-5398-6692

Eduardo A. Bombonatti1
https://orcid.org/0000-0003-1137-1977

Karina Pereira-Lima1
https://orcid.org/0000-0003-4313-743X

Rafael Guimarães Santos1

https://orcid.org/0000-0003-2388-4745

João Paulo Machado-de-Sousa1

https://orcid.org/0000-0002-2141-8487

Thiago Dornela Apolinário da Silva1

https://orcid.org/0000-0002-1950-0449

Omero B. Poli Neto2

https://orcid.org/0000-0003-0270-5496

Claudia Maria Gaspardo1

https://orcid.org/0000-0002-5319-5484

Amaury Cantilino3
https://orcid.org/0000-0002-4382-1218

Luciano Dias de Mattos Souza4

http://orcid.org/0000-0001-9965-4837

Susan Ayres5
https://orcid.org/0000-0001-7065-0779

Flávia L. Osório1,6
https://orcid.org/0000-0003-1396-555X

1 Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
2 Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
3 Federal University of Pernambuco, Recife, PE, Brazil.

4 Catholic University of Pelotas, Pelotas, RS, Brazil.

5 Division of Midwifery and Radiography, School of Health Sciences, City, University of London, London, United Kingdom.

6 National Institute of Science and Technology – Translational Medicine, Ribeirão Preto, SP, Brazil.

Institution where the study was conducted: Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto.

Received: 02/02/2020 – Accepted: 02/21/2020

DOI: 10.1590/0101-60830000000243

Abstract
Background: Posttraumatic stress disorder consists of a set of symptoms that occurs in response to one or more traumatic events and can occur in postpartum,
from traumatic situations related to the birth or to the baby’s health in the first days of life. It is important tracking the presence of birth trauma, but there is
not available instruments in the Brazilian context for this purpose. Objectives: To present the cross-cultural adaptation of City Birth Trauma Scale (BiTS)
into Brazilian portuguese. Methods: Cross-cultural adaptation involved independent translations, synthesis,back-translation, and submission to the original
author’s appreciation. After the scale was subjected to face validity, followed by a pilot study with postpartum mothers. Results: All steps were performed
for the cross-cultural adaptation. Regarding face validity, items evaluated concerning different types of equivalence, presented satisfactory agreement values
(≥4.20). Most of the expert’s suggestions were followed, being the main ones related to adjustments in prepositions, pronouns and verbal subjects. Pilot study
showed that the mothers had been able to understand and respond to the instrument without adjustments. Discussion: BiTS’s Brazilian version proved to be
cross-culturally adapted, ensuring the possibility of intercultural data comparison from the semantic, idiomatic, cultural, and conceptual perspectives. New
studies are being conducted to attest its psychometric adequacy.

Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

Keywords: Trauma, birth, cross-cultural adaptation, psychometrics.

Introduction or witnessed; b) presence of intrusive symptoms such as recurrent

Posttraumatic stress disorder (PTSD) can be characterized according
to the 5th edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) as a set of symptoms that occur in response to
traumatic events lasting longer than one month which involve: a)
exposure to one or more traumatic episodes experienced directly
and involuntary memories, dreams, flashbacks, intense suffering or
physiological reactions; c) a persistent avoidance pattern to stimuli
associated with the traumatic event; d) negative changes in cognition and
mood; e) changes in arousal and reactivity associated with the traumatic
event; f) experience of suffering and social or professional losses1.

Address for correspondence: Flávia de Lima Osório. Avenida dos Bandeirantes, 3.900 – 14048-900 – Ribeirão Preto, SP, Brasil. Telephone: +55 (16) 3602-2530. E-mail: flaliosorio@gmail.com.br
 Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8
When experienced in the postpartum period, PTSD may arise
from traumatic situations related to the moment of the delivery or the
baby’s and/or mother’s health after the first days of life2. A traumatic
birth can be defined according Scarabotto & Riesco3, as one or
more events that occur during labor and/or childbirth, in which the
postpartum woman faces intense fear, helplessness, loss of control
and involves injury (real/imaginary) and/or death of the newborn4.
Prevalence studies in Brazil show that postpartum PTSD affects
about 5%-9% of women with high-risk pregnancies and 3% of those
with low-risk pregnancies2,5,6. The impacts associated with PTSD in
the postpartum period are multiple, highlighted among them: intense
feelings of distress and helplessness experienced by the mother,
impairment of maternal and child bonding, besides the appearance
of diverse comorbidities, such as generalized anxiety, panic, and
substance abuse disorders7,8.
Given the severity and the countless losses associated with
this type of trauma, the need to identify and treat it is becoming
increasingly urgent. However, until recently there were no specific
instruments for screening and/or assessment of trauma at birth.
This assessment was made through more general instruments, as in
the study by Henriques et al.2, which assessed the presence of PTSD
at birth using the Trauma History Questionnaire and Posttraumatic
Stress Disorder Checklist.
More recently this gap was filled by the City Birth Trauma Scale
(BiTS) that had been proposed by Ayers et al.9. It is a self-report
instrument, composed of 35 items, and the higher the scores, the
higher the PTSD severity indicators. It stands out for being based
on the DSM-5 criteria and has the specific objective of assessing the
presence/absence of PTSD symptoms at birth, as well as its severity.
The original psychometric study, conducted with 950 postpartum
women, showed bifactorial structure (birth-related/general
symptoms), excellent reliability (α = 0.92) and a high association
with distress, unpaired functioning, and desire for treatment (r =
0.50-0.61)10. Other than that, it had already been translated and
validated into Hebrew11 and Croatian10, in which their psychometric
qualities were also replicated.
To our knowledge, there are no available instruments to
assess PTSD associated with birth in the Brazilian context. Thus,
considering the severity and negative impact of this condition,
resources are needed to briefly track and direct potential cases. In
this context, BiTS becomes a promising instrument, which justifies
its translation and conducting psychometric studies for Brazil. This
study aimed to perform the cross-cultural adaptation of BiTS to
the Brazilian context, as well as evaluating its content/face validity.
Methods
The study was approved by the local Ethics Committee (No.17646/
2014), and the cross-cultural adaptation was initiated after approval
by the original author of the scale.
The translation and adaptation process of BiTS into Brazilian
Portuguese was based on Beaton et al.12: initial translation, synthesis
of translations, back-translation, peer review, and pre-test. The
translation phase was assisted by three bilingual professionals
specialized in different fields: psychology(KPL), neuroscience(RGS)
and linguistics (JTS), who independently translated the instrument
from English to Portuguese. A summary version of the three
translations (VS1) was later made to resolve discrepancies and
to select the terms considered most appropriate to the Brazilian
context by two psychologists with previous experience in the fields
of psychometrics and psychological evaluation, who filled the role
of judge (FLO/MFD). VS1 was back-translated by another bilingual
Brazilian psychologist with experience in psychopathology (JPMS).
The back-translated version was submitted for initial consideration
by the original author of the scale. After the author’s considerations,
and her endorsement, we moved to the content validity stage.
To this end, a committee of experts was created, composed of
a psychologist (CMG) and four psychiatrists, researchers and
university professors (TAD/PNOB/AC/LDMS), who analyzed the
111
conceptual, semantic, idiomatic, and cultural equivalence of each
structure of the instrument. Analyzes were performed independently
by each expert, who were instructed to rate each item according to
the following scale: 1 (“not equivalent”) to 5 (“very equivalent”),
besides commenting/suggesting changes or adjustments based on
that scoring. The content validity coefficient (CVC)13 was calculated
for each item of the instrument and the instrument as a whole. The
cutoff score of ≥ 0.70 was adopted as satisfactory14.
The experts’ comments were examined by the judges and the
relevant suggestions were accepted, and the final version of the
instrument was drafted, which was again appreciated and approved
by the original author.
Pilot study was conducted with the target population (mothers
with gestation in the last year). For this purpose, a sample of 16
women aged 19 to 39 years old (mean = 30.81; SD = 6.34) and
different educational levels (18.8% ≥ 9 years of study) to respond
to the instrument. The participants were instructed to read the
instructions, response alternatives, and each item on the scale.
Afterward, the comprehension/understanding was verified, as well
as the adjustment suggestions.
Results
All BiTS translation process from English to Brazilian Portuguese
can be viewed in Supplementary Material S1.
Regarding content validity conducted by the experts, all items
evaluated concerning the different types of equivalence presented
average agreement values higher than 4.20.
As shown in Table 1, all evaluated structures had a CVC ≥ 0.84,
regardless of the equivalence type evaluated. The total CVC of the
instrument for the different equivalences was 0.98.
Regarding the suggestions made by the experts, these were few.
Below are those incorporated in the original version. In the title in
Portuguese, the expression “Traumas no Nascimento” was changed
to “Traumas no Nascimento” to fit the preposition to time in the
English version. In the structures with the expression “nascimento
do bebê” only the word “nascimento” was used to remain faithful
to the original instrument (“after birth”) (instruction 1, question 2,
observation 1, 2, items 3, 4, 6-12).
In items 3, 5, 6, 7, 9, 11, 13-15, 17-20, 23, 33, the subject of the
sentence was changed to the third-person singular to maintain
coherence with the other items of the instrument.
In question 2, fits were made to maintain the temporal clarity of
the events, leaving the final formulation for “Durante o trabalho de
parto, nascimento e imediatamente após”.
In the Portuguese version, the verb “pensou” in items 1 and 2 was
replaced with the verb “acreditou” since the latter more accurately
portrays the meaning of the word “belief” (being convinced of the
truth, existence, or occurrence of a fact). In item 13, this change
was made inversely, to remain true to the meaning of the original
word “thinking”.
The word “relembrar” in item 5 was replaced with the original
English term “flashbacks” since this word was also adopted in the
portuguese version of the DSM-5. Although the manual is mainly
used by professionals with a higher educational level, the pilot project
signaled its understanding by the target audience.
In item 34, the word “socializar” was replaced with the expression
“estar com as pessoas” to detail the meaning of the term. Finally, items
28 and 32 included the personal pronoun “Eu” at the beginning of
the sentence to be faithful to the original version in English.
Given these fits, the new version was once again sent to the
original author, who recognized it as the instrument’s official version
for brazilian portuguese. The Brazilian version was called the “City
Escala de Trauma ao Nascimento” and is in full in the Supplementary
Material S2.
In the pilot study, no suggestion of major modification was
indicated by the respondent sample. All participants showed an
understanding of all structures and considered the scale presentation
and layout appropriate.
112 Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

Table 1. Experts agreement for the Brazilian version of the City Birth Trauma Scale
Equivalence
Semantic Idiomatic Cultural Conceptual
Estrutura X SD CVC X SD CVC X SD CVC X SD CVC
Title 4,80 0,45 0,96 4,40 0,89 0,88 4,20 1,30 0,84 4,20 1,30 0,84
Instruction 1 4,60 0,89 0,92 4,40 0,55 0,88 4,60 0,55 0,92 4,60 0,55 0,92
Question 1 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction 2 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 1 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 2 4,80 0,45 0,96 5,00 0,00 1,00 5,00 0,00 1,00 4,80 0,45 0,96
Instruction 3 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Statement 1 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Statement 2 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Statement 3 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Statement 4 4,60 0,89 0,92 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96
Statement 5 4,40 0,89 0,88 4,60 0,55 0,92 4,20 0,84 0,84 4,40 0,89 0,88
Statement 6 4,80 0,45 0,96 4,60 0,00 1,00 4,80 0,45 0,96 5,00 0,00 1,00
Statement 7 4,40 0,89 0,88 4,40 0,55 0,88 4,40 0,89 0,88 4,80 0,45 0,96
Statement 8 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction 4 4,80 0,45 0,96 4,80 0,45 0,96 5,00 0,00 1,00 5,00 0,00 1,00
Item 3 4,80 0,45 0,96 4,80 0,45 0,96 5,00 0,00 1,00 5,00 0,00 1,00
Item 4 5,00 0,00 1,00 4,60 0,55 0,92 5,00 0,00 1,00 5,00 0,00 1,00
Item 5 4,20 0,84 0,84 4,60 0,89 0,92 4,60 0,89 0,92 4,20 0,84 0,84
Item 6 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 7 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 8 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 9 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 10 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 11 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 12 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction 5 4,60 0,55 0,92 4,60 0,55 0,92 4,80 0,45 0,96 4,80 0,45 0,96
Item 13 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 14 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 15 4,60 0,55 0,92 4,80 0,45 0,96 5,00 0,00 1,00 5,00 0,00 1,00
Item 16 4,80 0,45 0,96 4,80 0,45 0,96 4,60 0,55 0,92 4,80 0,45 0,96
Item 17 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 18 4,80 0,45 0,96 4,80 0,45 0,96 5,00 0,00 1,00 4,80 0,45 0,96
Item 19 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 20 5,00 0,00 1,00 4,80 0,45 0,96 5,00 0,00 1,00 4,60 0,89 0,92
Item 21 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 22 5,00 0,00 1,00 5,00 0,00 1,00 4,60 0,55 0,92 5,00 0,00 1,00
Item 23 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96 4,60 0,89 0,92
Item 24 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction 6 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction7 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 25 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96
Item 26 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 27 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 28 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Instruction 8 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96 5,00 0,00 1,00
Item 29 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 30 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 31 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 32 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 33 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96 4,80 0,45 0,96
Item 34 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
Item 35 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00 5,00 0,00 1,00
TOTAL 4,89 0,20 0,98 4,89 0,18 0,98 4,90 0,17 0,98 4,90 0,17 0,98
CVC: Content Validity Coefficient; SD: standard desviation; X: mean.
 Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8
Discussion
The BiTS is designed to evaluate PTSD symptoms associated with
childbirth according to DSM-5 criteria. It is the only specific scale
for assessing the disorder associated with this type of traumatic
situation and has already been of interest to researchers from other
cultures, who have also performed the instrument’s cross-cultural
adaptation to Hebrew and Croatian10,11, signaling cross-cultural
evidence as presented herein.
For the process of cross-cultural adaptation of this instrument,
we followed all steps of the method proposed by Beaton et al.12, which
is considered the gold standard for health studied mainly because
it involves a series of methodological care to ensure the adequacy
of the process. These include the translation team composed of
translators with different backgrounds, which favors the adjustment
to the great Brazilian cultural diversity. The experts’ suggestions
were included in the final version of the instrument and, although
few, they contributed to the better cross-cultural adaptation of the
scale to the Brazilian context. Furthermore, the evaluated structures
in the instrument had a CVC value ≥ 0.83, which reinforces the
evidence of the adaptation stages adequacy, now from the quantitative
perspective. Besides, the original author’s guidance and contributions
at different stages were very important for the development of this
procedure, as was the pilot test in the target population.
As a conclusion, the BiTS scale was adapted to the Brazilian
context and had its content validity measured. As a next step, it
is necessary to test the other validity and reliability indicators to
confirm the broader psychometric adequacy of the instrument.
BiTS in its Brazilian Portuguese version can be used without the
author’s permission, either for the clinical context or for research,
by quoting the source.
Research support
National Council for Scientific and Technological Development
(CNPq – Productivity Research Fellows – Process No. 301321/2016-7).
Conflicts of interests
The authors declare no conflicts of interest.
113
References
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Association; 2013.
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Figueira ILV. Postpartum posttraumatic stress disorder in a fetal high-
risk maternity hospital in the city of Rio de Janeiro, Brazil. Cad Saúde
Pública. 2015;31(12):2523-34.
3. Scarabotto LB, Riesco MLG. Factors related to perineal trauma in normal
births in nulliparous. Rev Esc Enferm USP. 2006;40(3):389-95.
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for perineal trauma at birth. Femina. 2004;32(7):605-10.
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associated with post-traumatic stress disorder in a sample of postpartum
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6. Grekin R, O’Hara MW. Prevalence and risk factors of postpartum
posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev.
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baby relationship. J Bras Psiquiatr. 2014;63(4):290-8.
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9. Ayers S, Wright DB, Thornton A. Development of a measure of postpar-
tum PTSD: the City Birth Trauma Scale. Front Psychiatry. 2018;9:409.
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conceptualizing PTSD following childbirth: Validation of the City Birth
Trauma Scale. Psychol Trauma. 2020;12(2):147-55.
11. Handelzalts JE, Hairston IS, Matatyahu A. Construct Validity and Psy-
chometric Properties of the Hebrew Version of the City Birth Trauma
Scale. Front Psychol. 2018;9:1726.
12. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the
Process of Cross-Cultural Adaptation of Self-Report Measures. Spine.
2000;25(24):3186-91.
13. Hernández-Nieto RA. Contributions To Statistical Analysis. Mérida:
Universidad de los Andes; 2002. p. 119.
14. Morales JC, Greco PJ, Andrade RL. Content validity of the instrument
for assessment of the tactical procedural knowledge in basketball. CPD.
2012;12(1):31-6.
Supplementary Material S1. Process of cross-cultural adaptation into Brazilian Portuguese from City Birth Trauma Scale
Structure Original English Version Translator Translator Translator Summary Backtranslation Final
114

1 2 3 Version* Version*
Title CITY Birth Trauma Scale CITY Escala de Trauma no CITY Escala de Trauma de CITY Escala de Trauma ao CITY Escala de Trauma no CITY Birth Trauma Scale CITY Escala de Trauma ao
Nascimento Nascimento Nascimento Nascimento Nascimento
Instruction 1 This questionnaire asks Este questionário contém Este questionário pergunta Este questionário Este questionário contém This questionnaire contains Este questionário contém
about your experience perguntas sobre a sua sobre sua experiência investiga sua experiência perguntas sobre a sua questions about your perguntas sobre a sua
during the birth of your most experiência durante durante o nascimento do durante o nascimento experiência durante experience during the experiência durante
recent baby. It asks about o nascimento do seu seu bebê mais recente. Ele do seu último bebê. Ele o nascimento do seu birth of your last child. o nascimento do seu
potential traumatic events último bebê. Ele pergunta pergunta sobre possíveis investiga possíveis eventos último bebê. Ele investiga It investigates possible último bebê. Ele investiga
during (or immediately sobre possíveis eventos eventos traumáticos durante traumáticos durante o sobre possíveis eventos traumatic events that may possíveis eventos
after) the labour and birth, traumáticos que ocorreram (ou imediatamente após) parto e nascimento de seu traumáticos que ocorreram have occurred during (or traumáticos que ocorreram
and whether you are durante (ou imediatamente o parto e nascimento, e se bebê (ou imediatamente durante (ou imediatamente immediately after) the durante (ou imediatamente
experiencing symptoms após) o parto e nascimento você está experimentando após), e se você está após) o parto e nascimento delivery and birth of your após) o trabalho de parto e
that are reported by some de seu bebê, e se você está sintomas que são relatados experimentando sintomas de seu bebê, e se você está baby, and whether you are nascimento, e se você está
women after birth. Please experimentando sintomas por algumas mulheres após que são relatados por experimentando sintomas experiencing symptoms experimentando sintomas
tick the responses closest to que são relatados por o nascimento. Por favor algumas mulheres após o que são relatados por that are reported by some que são relatados por
your experience. algumas mulheres após marque as respostas mais nascimento do bebê. Por algumas mulheres após o women after giving birth. algumas mulheres após
o nascimento de seus(a) semelhantes a experiência. favor, assinale as respostas nascimento do bebê. Por Please, mark the answers o nascimento. Por favor,
filhos(a). Por favor, marque mais próximas de sua favor, assinale as respostas that are closer to your assinale as respostas que
as respostas que mais experiência. que mais se aproximam da experience. mais se aproximam da sua
se aproximam da sua sua experiência. experiência.
experiência.
Question 1 What date was your baby Em que data o seu bebê Em que dia o seu bebê Qual a data de nascimento
Em que data o seu bebê On what date was your Em que data o seu bebê
born? nasceu? nasceu? de seu bebê? nasceu? baby born? nasceu?
Instruction 2 During the labour, birth and Durante ou imediatamente Durante o parto, nascimento Durante o parto, nascimento
Durante ou imediatamente During or immediately after Durante o trabalho de
immediately afterwards: após o parto e nascimento e imediatamente depois e imediatamente depois após o parto e nascimento the delivery and birth of parto, nascimento e
de seu bebê: de seu bebê your baby imediatamente após
Item 1 Did you believe you or your Você pensou que você Você acreditava que Você acreditou que você Você pensou que você Have you thought that Você acreditou que você
baby would be seriously ou seu bebê estariam você ou seu bebê seriam ou seu bebê poderiam ser ou seu bebê estariam you or your baby would be ou o seu bebê seriam
injured? gravemente feridos? gravemente feridos? gravemente ferido? gravemente feridos? severely injured? gravemente feridos?
Item 2 Did you believe you or your Você pensou que seu bebê Você acreditava que você Você acreditou que você ou Você pensou que você ou Have you thought that you Você acreditou que você ou
baby would die? iria morrer? ou seu bebê morreriam? seu bebê poderiam morrer? seu bebê iriam morrer? or your baby would die? seu bebê iriam morrer?
Instruction 3 The next questions ask As próximas questões As próximas questões As próximas perguntas As próximas questões The following questions As próximas questões
about symptoms you might perguntam sobre sintomas perguntam sobre sintomas investigam sintomas investiguem sobre investigate about symptoms investigam sintomas
Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

have experienced. Please que você pode ter que você pode ter que você pode ter sintomas que você pode ter that you might have que você pode ter
indicate how often you have experimentado. Por favor, experimentado. Por favor experimentado. Por favor experimentado. Por favor, experienced. Please, experimentado. Por favor,
experienced the following indique com que frequência indique com que frequência indique com que frequência indique com que frequência indicate the frequency with indique com que frequência
symptoms in the last week: você experimentou os você experimentou os você experimentou os você experimentou os which you experienced the você experimentou os
seguintes sintomas na seguintes sintomas na seguintes sintomas na seguintes sintomas na following symptoms over seguintes sintomas na
última semana: última semana: última semana: última semana: the past week: última semana:

Statments Yes, no, not at all, once, Sim, não, nenhuma vez, Sim, não, nenhuma vez, Sim, não, nenhuma vez, Sim, não, nenhuma vez, Yes, no, not at all, once, Sim, não, nenhuma vez,
1 to 8 2-4times, 5 or more times, uma vez, 2 a 4 vezes, 5 ou uma vez, 2 a 4 vezes, 5 ou uma vez, 2 a 4 vezes, 5 ou uma vez, 2 a 4 vezes, 5 ou 2-4times, 5 or more times, uma vez, 2 a 4 vezes, 5 ou
sometimes, maybe mais vezes, algumas vezes, mais vezes, algumas vezes, mais vezes, algumas vezes, mais vezes, algumas vezes, sometimes, maybe mais vezes, algumas vezes,
talvez talvez talvez talvez talvez
Structure Original English Version
Instruction 4 Symptoms about the birth*
*Although these questions
refer to the birth, many
women have symptoms
about events that happened
just before or after birth.
If this is the case for you,
and the events were related
to pregnancy, birth or the
baby then please answer for
these events
Item 3 Recurrent unwanted
memories of the birth (or
parts of the birth) that you
can’t control
Item 4 Bad dreams or nightmares
about the birth (or related to
the birth)
Item 5 Flashbacks to the birth and/
or reliving the experience
Item 6 Getting upset when
reminded of the birth
Translator
1 2
Sintomas relacionados ao
nascimento do bebê*
*Embora essas questões
se refiram ao nascimento
de seu bebê, muitas
mulheres têm sintomas
relacionados a eventos que
aconteceram logo antes
ou após o nascimento do
bebê. Se este for o seu caso
e os eventos estiverem
relacionados à gravidez,
nascimento ou ao bebê, por
favor, responda de acordo
com esses eventos.
Recorrentes memórias
indesejadas sobre o
nascimento (ou partes do
nascimento) do meu bebê
que não consigo controlar
Sonhos ruins ou pesadelos
sobre o nascimento
(ou relacionados ao
nascimento) do meu bebê
Relembranças do
nascimento e/ou sentir
que estou revivendo essa
experiência
Ficar chateada quando
lembro do nascimento do
meu bebê
Translator Translator Summary Backtranslation Final
3 Version* Version*
Sintomas sobre o Sintomas sobre o Sintomas relacionados ao Symptoms related to birth* Sintomas relacionados ao
nascimento* nascimento* nascimento do bebê* *Although these questions nascimento*
*Embora essas perguntas *Embora essas questões *Embora essas questões refer to the birth of their * Embora essas questões
se refiram ao nascimento, se refiram ao nascimento,se refiram ao nascimento babies, many women se refiram ao nascimento,
muitas mulheres muitas mulheres têm de seu bebê, muitas have symptoms related to muitas mulheres têm
experimentam sintomas sintomas sobre eventos mulheres têm sintomas events occurring just before sintomas relacionados a
relacionados a eventos que que aconteceram um relacionados a eventos que or after the birth of their eventos que aconteceram
aconteceram logo antes pouco antes ou depois do aconteceram logo antes baby. If this is your case logo antes ou após o
ou depois do nascimento. nascimento. Se este for ou após o nascimento do and the events are related nascimento. Se este for
Se este for o seu caso, o seu caso, e os eventos bebê. Se este for o seu caso to pregnancy, birth, or to o seu caso e os eventos
e os eventos estavam foram relacionados à e os eventos estiverem the baby, please answer estiverem relacionados à
relacionados à gravidez, gravidez, ao nascimento ou
relacionados à gravidez, according to these events gravidez, nascimento ou ao
parto ou ao bebê, por favor, ao bebê, por favor responda
nascimento ou ao bebê, por bebê, por favor, responda de
responda por esses eventos. para estes eventos). favor, responda de acordo acordo com esses eventos.
com esses eventos.
Memórias indesejadas Memórias indesejadas Memórias indesejadas Recurrent undesired Memórias indesejadas
recorrentes do nascimento recorrentes do nascimento recorrentes sobre o memories about the birth recorrentes sobre o
(ou partes do nascimento) (ou partes do nascimento) nascimento (ou partes (or parts of the birth) of my nascimento (ou partes do
que você não pode controlar que você não pode controlar do nascimento) que não baby that I cannot control nascimento) que você não
consigo controlar consegue controlar
Sonhos ruins ou pesadelos Sonhos ruins ou pesadelos Sonhos ruins ou pesadelos Bad dreams or nightmares Sonhos ruins ou pesadelos
sobre o nascimento sobre o nascimento sobre o nascimento about the birth (or related to sobre o nascimento
(ou relacionados ao (ou relacionados ao (ou relacionados ao the birth) of my baby (ou relacionados ao
nascimento) nascimento) nascimento) do meu bebê nascimento)
Flashbacks do nascimento Flashbacks para o Relembrar o nascimento Recalling the birth and/or Flashbacks do nascimento
e/ou revivendo a nascimento e/ou revivendo e/ou sentir que estou feeling that I am reliving e/ou sensação de estar
experiência a experiência revivendo essa experiência this experience revivendo a experiência
Ficar chateada quando Ficando chateado quando Ficar chateada quando Getting upset when I recall Ficar chateada quando se
lembrada do nascimento lembrado do nascimento lembro do nascimento do my baby’s birth lembra do nascimento
meu bebê
Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

Item 7 Feeling tense or anxious
when reminded of the birth
Item 8 Trying to avoid thinking
about the birth
Item 9 Trying to avoid things that
remind me of the birth
(e.g. people, places, TV
programs)
Item 10 Not able to remember
details of the birth
Sentir-me tensa ou
ansiosa quando lembro do
nascimento do meu bebê
Tentar evitar pensar sobre o
nascimento do meu bebê
Tentar evitar coisas que me
lembram do nascimento
do meu bebê (por exemplo:
pessoas, lugares,
programas de TV)
Não conseguir lembrar
detalhes do nascimento do
meu bebê
Sentir-se tensa ou ansiosa
quando lembrada do
nascimento
Tentando evitar pensar no
nascimento
Tentando evitar coisas que
me lembram o nascimento
(por exemplo, pessoas,
lugares, programas de TV)
Não é capaz de lembrar
detalhes do nascimento
Sentindo-se tenso ou
ansioso quando lembrado
do nascimento
Tentando evitar pensar no
nascimento
Tentando evitar coisas que
me lembram o nascimento
(por ex.
pessoas, lugares,
programas de TV)
Não é capaz de lembrar
detalhes do nascimento
Sentir-me tensa ou
ansiosa quando lembro do
nascimento do meu bebê
Tentar evitar pensar sobre o
nascimento do meu bebê
Tentar evitar coisas que me
lembram do nascimento
do meu bebê (por exemplo:
pessoas, lugares,
programas de TV)
Não conseguir lembrar
detalhes do nascimento do
meu bebê
Feeling tense or anxious Sentir-se tensa ou ansiosa
when I recall my baby’s birth quando se lembra do
nascimento
Trying to avoid thinking Tentar evitar pensar sobre o
about my baby’s birth nascimento
Trying to avoid things that Tentar evitar coisas que a
remind me of my baby’s lembram do nascimento (por
birth (for example: people, exemplo: pessoas, lugares,
places, TV shows) programas de TV)
Being unable to recall Não conseguir lembrar
details of my baby’s birth detalhes do nascimento
115
Structure Original English Version Translator Translator Translator Summary Backtranslation Final
116

1 2 3 Version* Version*
Item 11 Blaming myself or others Culpar a mim mesma ou Culpando a mim mesmo Culpando a mim mesmo Culpar a mim mesma ou Blaming myself or others Culpar a si mesma ou
for what happened during a outras pessoas pelo ou aos outros pelo que ou aos outros pelo que a outras pessoas pelo over what happened during a outras pessoas pelo
the birth que aconteceu durante o aconteceu durante o aconteceu durante o que aconteceu durante o my baby’s birth que aconteceu durante o
nascimento de meu bebê nascimento nascimento nascimento de meu bebê nascimento
Item 12 Feeling strong negative Sentir fortes emoções Sentindo fortes emoções Sentir fortes emoções Sentir fortes emoções Having strong negative Sentir fortes emoções
emotions about the birth negativas relacionadas ao negativas sobre o negativas sobre o negativas relacionadas ao feelings related to my negativas relacionadas ao
(e.g. fear, anger, shame) nascimento de meu bebê nascimento (por exemplo, nascimento (por ex. medo, nascimento de meu bebê baby’s birth (for example: nascimento (por exemplo:
(por exemplo: medo, raiva, medo, raiva, vergonha) raiva, vergonha) (por exemplo: medo, raiva, fear, anger, shame) medo, raiva, vergonha)
vergonha) vergonha)
Instruction 5 Symptoms that began or got Sintomas que começaram Sintomas que começaram Sintomas que começaram Sintomas que começaram Symptoms that started or Sintomas que começaram
worse since the birth ou pioraram desde o ou pioraram desde o ou pioraram desde o ou pioraram desde o got worse after your baby’s ou pioraram desde o
nascimento de seu bebê nascimento nascimento nascimento de seu bebê birth nascimento
Item 13 Feeling negative about Sentir-me mal comigo Sentindo-se negativa sobre Sentir-se negativo sobre Sentir-me mal comigo Feeling bad about myself Sentir-se mal consigo
myself or thinking mesma ou achar que algo mim mesma ou pensando mim mesmo ou pensar em mesma ou achar que algo or feeling that something mesma ou pensar que algo
something awful will terrível irá acontecer que algo horrível acontecerá algo terrível irá acontecer terrible will happen terrível irá acontecer
happen terrível vai acontecer
Item 14 Lost interest in activities Perder o interesse em Perdendo interesse em Perdeu o interesse em Perder o interesse em Losing interest in activities Perder o interesse em
that were important to me atividades que eram atividades que eram atividades que eram atividades que eram that were important to me atividades que eram
importantes para mim importantes para mim importantes para mim importantes para mim importantes para você
Item 15 Feeling detached from other Sentir-me desconectada/ Sentindo-se distante de Sentindo-se separado das Sentir-me desconectada/ Feelling detached/distant Sentir-se desconectada/
people distante de outras pessoas outras pessoas outras pessoas distante de outras pessoas form other people distante de outras pessoas
Item 16 Not able to feel positive Não conseguir sentir Incapaz de sentir emoções Não é capaz de sentir Não conseguir sentir Being unable to feel Não conseguir sentir
emotions (e.g. happy, emoções positivas (por positivas (por exemplo, feliz, emoções positivas (por emoções positivas (por positive emotions (for emoções positivas (por
excited) exemplo: felicidade, animada) exemplo, feliz, animado) exemplo: felicidade, example: happiness, exemplo: felicidade,
animação) animação) excitement) animação)
Item 17 Feeling irritable or Sentir-me irritável ou Sentindo-se irritada ou Sentir-se irritado ou Sentir-me irritável ou Feeling irritable or Sentir-se irritável ou
aggressive agressiva agressiva agressivo agressiva aggressive agressiva
Item 18 Feeling self-destructive or Sentir-me autodestrutiva ou Sentindo-se autodestrutiva Sentindo-se auto-destrutivo Sentir-me autodestrutiva ou Feeling self-destructive or Sentir-se autodestrutiva ou
acting recklessly agindo de modo imprudente ou agindo de forma ou agindo de forma agindo de modo imprudente acting recklessly agindo de modo imprudente
imprudente imprudente
Item 19 Feeling tense and on edge Sentir-me tensa e no limite Sentindo-se tensa e no Sentindo-se tenso e na Sentir-me tensa e no limite Feeling tense and on the Sentir-se tensa e no limite
Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

limite borda edge

Item 20 Feeling jumpy or easily Sentir-me nervosa ou Sentindo-se nervosa ou Sentindo-se nervoso ou Sentir-me nervosa ou Feeling nervous or easily Sentir-se apreensiva ou
startled facilmente assustada facilmente assustada facilmente assustado facilmente assustada startled facilmente assustada
Item 21 Problems concentrating Problemas de concentração Tendo problemas de Problemas de concentração Problemas de concentração Concentration problems Problemas de concentração
concentração
Item 22 Not sleeping well because Não dormir bem por causa Não dormir bem por coisas Não dormir bem por causa Não dormir bem por causa Not sleeping well due to Não dormir bem por causa
of things that are not due to de coisas que não tem que não são relacionadas de coisas que não são de coisas que não tem things that bear no relation de coisas que não têm
the baby’s sleep pattern relação com o padrão de ao padrão de sono do bebê devidas ao padrão de sono relação com o padrão de with my baby’s sleeping relação com o padrão de
sono do meu bebê do bebê sono do bebê pattern sono do bebê
Item 23 Feeling detached or as if Sentir-me desconectada ou Sentindo-se distante ou Sentindo-se desapegado Sentir-me desconectada/ Feeling detached/distant as Sentir-se desconectada/
you are in a dream como se estivesse em um como se estivesse em um ou como se estivesse em distante ou como se if I were in a dream distante ou como se
sonho sonho um sonho estivesse em um sonho estivesse em um sonho
Item 24 Feeling things are distorted Sentir que as coisas estão Sentindo que as coisas são Sentindo que as coisas Sentir que as coisas estão Feeling that things are Sentir que as coisas estão
or not real distorcidas ou não são reais distorcidas ou não são reais estão distorcidas ou não distorcidas ou não são reais distorted or are not real distorcidas ou não são reais
são reais
 Structure Original English Version Translator Translator Translator Summary Backtranslation Final
1 2 3 Version* Version*
Instruction 6 If you have any of these Se você tem qualquer um Se você tiver algum destes Se você tiver algum destes Se você tem qualquer um If you have any of these Se você tem qualquer um
symptoms desses sintomas sintomas sintomas: desses sintomas symptoms desses sintomas
Instruction7 When did these symptoms Quando esses sintomas Quando esses sintomas Quando esses sintomas Quando esses sintomas When did the symptoms Quando esses sintomas
start? começaram? começaram? começaram? começaram? begin? começaram?

Item 25 Before the birth Antes do nascimento Antes do nascimento Antes do nascimento Antes do nascimento Before birth Antes do nascimento
Item 26 In the first 6 months after Nos primeiros 6 meses após Nos primeiros 6 meses após Nos primeiros 6 meses após Nos primeiros 6 meses após Within the first 6 months Nos primeiros 6 meses após
birth o nascimento o nascimento o nascimento o nascimento after birth o nascimento
Item 27 More than 6 months after Mais de 6 meses após o Mais de 6 meses após o Mais de 6 meses após o Mais de 6 meses após o Over 6 months after birth Mais de 6 meses após o
birth nascimento nascimento nascimento nascimento nascimento
Item 28 Not applicable (I have no Não se aplica (não tenho Não se aplica (não tenho Não aplicável (não tenho Não se aplica (não tenho Not applicable (I do not Não se aplica (Eu não tenho
symptoms) nenhum sintoma) sintomas) sintomas) nenhum sintoma) have any symptom) nenhum sintoma)
Instruction 8 How long have these Quanto esses sintomas Por quanto tempo esses Há quanto tempo esses Por quanto tempo você For how long have you had Quanto tempo esses
symptoms lasted? duraram? sintomas duraram? sintomas duram? teve/tem esses sintomas? these symptoms? sintomas duraram?
Item 29 Less than 1 month Menos de 1 mês Menos de 1 mês Menos de 1 mês Menos de 1 mês Less than 1 month Menos de 1 mês
Item 30 1 to 3 months Entre 1 e 3 meses Entre 1 e 3 meses Entre 1 e 3 meses Entre 1 e 3 meses Between 1 and 3 months Entre 1 e 3 meses
Item 31 3 months or more 3 meses ou mais 3 meses ou mais 3 meses ou mais 3 meses ou mais 3 months or more 3 meses ou mais
Item 32 Not applicable (I have no Não se aplica (não tenho Não se aplica (não tenho Não aplicável (não tenho Não se aplica (não tenho Not applicable (I do not Não se aplica (Eu não tenho
symptoms) nenhum sintoma) nenhum sintoma) sintomas) nenhum sintoma) have any symptom) nenhum sintoma)
Item 33 Do these symptoms cause Esses sintomas te causam Esses sintomas causam Esses sintomas lhe causam Esses sintomas lhe causam Do these symptoms cause Esses sintomas lhe causam
you a lot of distress? muito sofrimento? muito incômodo? muita angústia? muito sofrimento? you much distress? muito sofrimento?
Item 34 Do they prevent you doing Eles impedem que você Eles impedem que você faça Eles impedem que você faça Eles impedem que você faça Do they keep you from Eles impedem que você faça
things you usually do (e.g. faça coisas que você faz coisas que normalmente coisas que normalmente coisas que normalmente doing things that you coisas que normalmente
socialising, daily activities)? normalmente (por exemplo: faz (por exemplo, atividades faz (por exemplo, socializar, faz (por exemplo: socializar, usually do (for example: faz (por exemplo: estar com
socializar, realizar suas cotidianas de socialização)? atividades diárias)? realizar suas atividades socializing, performing your as pessoas, realizar suas
atividades diárias)? diárias)? daily activities)? atividades diárias)?
Item 35 Could any of these Algum desses sintomas Algum desses sintomas Algum desses sintomas Algum desses sintomas Could any of these Algum desses sintomas
symptoms be due to poderia estar sendo poderia ser causado por poderia ser causado por poderia estar sendo symptoms have been poderia estar sendo
medication, alcohol, drugs, causado por medicamentos, medicação, álcool, drogas medicação, álcool, drogas, causado por medicamentos, caused by medication, causado por medicamentos,
Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

or physical illness? álcool, drogas ou doença ou doença física? ou doença física? álcool, drogas ou doença alcohol, drugs or physical álcool, drogas ou doença
física? física? illness? física?
* (underlined): changes made
117
118 Donadon MF et al. / Arch Clin Psychiatry. 2020;47(4):110-8

Supplementary Material S2: Brazilian version of the City Birth Trauma Scale

Este questionário contém perguntas sobre a sua experiência durante o nascimento do seu último bebê. Ele investiga possíveis eventos traumáticos que ocorreram
durante (ou imediatamente após) o trabalho de parto e nascimento de seu bebê, e se você está experimentando sintomas que são relatados por algumas mulheres após o
nascimento. Por favor, assinale as respostas que mais se aproximam da sua experiência.
Em que data o seu bebê nasceu? _____________________________________

Durante o trabalho de parto, nascimento e imediatamente após:

Você acreditou que você ou o seu bebê seriam gravemente feridos? Sim Não
Você acreditou que você ou seu bebê iriam morrer? Sim Não

As próximas questões investigam sintomas que você pode ter experimentado. Por favor, indique com que frequência você experimentou os seguintes sintomas na última
semana:
Sintomas relacionados ao nascimento* Nunca Uma vez 2 a 4 vezes 5 ou mais vezes
Memórias indesejadas recorrentes sobre o nascimento (ou partes do nascimento) que você não consegue
controlar
Sonhos ruins ou pesadelos sobre o nascimento (ou relacionados ao nascimento)
Flashbacks do nascimento e/ou sensação de estar revivendo a experiência
Ficar chateada quando se lembra do nascimento
Sentir-se tensa ou ansiosa quando se lembra do nascimento
Tentar evitar pensar sobre o nascimento
Tentar evitar coisas que a lembram do nascimento (por exemplo: pessoas, lugares, programas de TV)
Não conseguir lembrar detalhes do nascimento
Culpar a si mesma ou a outras pessoas pelo que aconteceu durante o nascimento
Sentir fortes emoções negativas relacionadas ao nascimento (por exemplo: medo, raiva, vergonha)
* Embora essas questões se refiram ao nascimento, muitas mulheres têm sintomas relacionados a eventos que aconteceram logo antes ou após o nascimento. Se este for o seu caso e os eventos
estiverem relacionados à gravidez, nascimento ou ao bebê, por favor, responda de acordo com esses eventos.

Sintomas que começaram ou pioraram desde o nascimento Nunca Uma vez 2 a 4 vezes 5 ou mais vezes
Sentir-se mal consigo mesma ou pensar que algo terrível irá acontecer
Perder o interesse em atividades que eram importantes para você
Sentir-se desconectada/distante de outras pessoas
Não conseguir sentir emoções positivas (por exemplo: felicidade, animação)
Sentir-se irritável ou agressiva
Sentir-se autodestrutiva ou agindo de modo imprudente
Sentir-se tensa e no limite
Sentir-se apreensiva ou facilmente assustada
Problemas de concentração
Não dormir bem por causa de coisas que não têm relação com o padrão de sono do bebê
Sentir-se desconectada/distante ou como se estivesse em um sonho
Sentir que as coisas estão distorcidas ou não são reais

Se você tem qualquer um desses sintomas:

Quando esses sintomas começaram? Quanto tempo esses sintomas duraram?
Antes do nascimento Menos de 1 mês
Nos primeiros 6 meses após o nascimento Entre 1 e 3 meses
Mais de 6 meses após o nascimento 3 meses ou mais
Não se aplica (Eu não tenho nenhum sintoma) Não se aplica (Eu não tenho nenhum sintoma)

Esses sintomas lhe causam muito sofrimento? Sim Não Algumas vezes
Eles impedem que você faça coisas que normalmente faz (por exemplo: estar com as pessoas, realizar suas atividades diárias)? Sim Não Algumas vezes
Algum desses sintomas poderia estar sendo causado por medicamentos, álcool, drogas ou doença física? Sim Não Talvez

Obrigado(a) por responder a este questionário.

City Birth Scale© Avers, Wright & Thornton 2018. Frontiers in Psychiatry 9:409.
Versão adaptada para o português do Brasil, com permissão por Donadon MF, Pereira-Lima KP, Santos RG, Machado-de-Sousa JP, Silva TODA, Poli-Neto OB, Gaspardo CM, Cantilino A, Souza LDM,
Osório FL (2019).
 Letter to the editor

Paliperidone-induced mania: a case report

NesÇe B. Bal1
https://orcid.org/0000-0002-6445-9393

Meryem G. Teksin Bakır1

https://orcid.org/0000-0001-6080-2337

Ali Çayköylü1
https://orcid.org/0000-0003-1586-9334

Elvan Özalp1
https://orcid.org/ 0000-0001-9618-8148

Çag6la Koçberber1
https://orcid.org/0000-0002-7549-4143

Bahriye E. Yılmazog6lu1
https://orcid.org/0000-0002-8209-3583

1 Psychiatry Clinic, T.C.S.B. Dr. Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara, Turkey.

Received: 09/11/19 – Accepted: 01/29/20

DOI: 10.1590/0101-60830000000244

Bal NB et al. / Arch Clin Psychiatry. 2020;47(4):119-20

Introduction
Paliperidone is an atypical antipsychotic derived from
9-hydroxyrisperidone. Paliperidone shows antagonistic activity on
dopamine D2, serotonin 5HT2A, and histamine H1 receptors as
well as the alpha1 and alpha2 adrenergic receptors1. Paliperidone
palmitate is an injectable form of paliperidone that has long-lasting
potency and has been developed to improve treatment compliance in
patients who have schizophrenia. Paliperidone shows high binding
affinity to dopamine D2 and serotonin 5HT2A receptors. It also
shows significant binding affinity to α2a receptors. This leads to an
increase in serotonin release, which may also induce antidepressant
activity2. Although it seems to be paradoxical, manias that are
associated with atypical antipsychotic drugs have been reported in
the literature3. However, very little research has been published on
paliperidone- and paliperidone palmitate-induced mania1,4. This
report will discuss the case of a patient who was hospitalized with a
diagnosis of schizophrenia and manic symptoms during paliperidone
palmitate treatment.
Case report
A 27-year-old male was diagnosed with paranoid schizophrenia
six years ago. His initial complaints were social and emotional
withdrawal and referential, persecutory, and nihilistic delusions.
Treatment with oral haloperidol 20 mg was started, but his psychotic
symptoms did not improve so he was switched to olanzapine 15 mg/
day. His symptoms improved with the olanzapine treatment. In the
follow-up visits, the olanzapine dosage was reduced to 10 mg/day
because of the metabolic side effects of olanzapine, and the patient
was in remission for two years. However, his psychotic symptoms
began to worsen due to poor treatment compliance with regard
to taking the olanzapine. The patient was hospitalized, and the
olanzapine dose was increased to 30 mg/day. His psychotic symptoms
abated with this treatment regime, and he remained in remission
while taking the olanzapine 30 mg/day until 2018. However, his
psychotic symptoms worsened, once again due to poor medication
compliance, and he was involuntarily hospitalized. Because of his
reduced compliance to oral medication, long-acting paliperidone
palmitate treatment was planned. Treatment with oral paliperidone
6 mg/day was started, and a paliperidone palmitate injection was
scheduled for the 10th day of taking the oral paliperidone. Oral
paliperidone treatment was stopped at the 15th day of the initial
injection of paliperidone palmitate. The initial dose was set at 150
mg for the first treatment, increasing to 100 mg for the eighth,
and staying on a maintenance dose of 100 mg for the first month.
Because of the continuation of his symptoms after the maintenance
dose of 100 mg, the next paliperidone palmitate injection was set at
150 mg, and oral paliperidone 6 mg/day was added to the treatment
regime until the next injection. One week after he had been given
this treatment, the patient started to experience decreased sleep
requirements, logorrhoea, grandiosity, euphoria, and psychomotor
agitation. His score on the Young Mania Rating Scale (YMRS) was
30. Clonazepam 3 mg/day was added to control the manic symptoms.
Although the patient’s mobility decreased and his sleep improved, he
continued to experience grandiosity, and sodium valproate 500 mg
was started and gradually increased to 1,500 mg/day. Three weeks
after the addition of the sodium valproate (VPA: 117 mEq/lt), the
patient’s YMRS score had decreased to 26. The paliperidone palmitate
injections and oral paliperidone were discontinued and replaced
by clozapine. By the third week, the patient’s manic symptoms had
decreased with a dosage of clozapine 400 mg/per day (YMRS:16).
The clozapine was gradually increased to 700 mg/day, and his last
YMRS score before discharge from hospital was 6. After discharge,
the patient was treated with clozapine 700 mg and sodium valproate
1,500 mg/day and did not show any reoccurrence of psychotic, manic,
or hypomanic symptoms.
Discussion
Here we reported on the case of a patient who had a diagnosis of
schizophrenia and developed manic symptoms after being treated
with paliperidone palmitate. Although the patient had been taking
antipsychotic medication for six years, no manic symptoms had
been found during this time. The emergence of manic symptoms
after paliperidone palmitate treatment with no other combination
medication suggests causality: that the patient’s manic symptoms
were due to the paliperidone palmitate treatment. There have
been reports of cases of mania with atypical antipsychotics such as
risperidone, aripiprazole, and quetiapine3. However, reports of mania
cases that were induced by paliperidone are limited1,4,5.

Address for correspondence: Meryem G. Teksin Bakir. Psychiatry Clinic, T.C.S.B. Dr. Abdurrahman Yurtarslan Oncology Training and Research Hospital. Mehmet Akif Ersoy Mh. 13. Cadde No: 56,
Yenimahalle, 06200, Ankara, Turkey. Telephone: +90-312-4340990/6410. Fax: +90-312-4324915. E-mail: gulteksin@gmail.com
120 Bal NB et al. / Arch Clin Psychiatry. 2020;47(4):119-20
Paliperidone, is a new atypical antipsychotic drug. Although
risperidone has antimanic activity, it has also been reported to induce
mania in some cases4. Atypical antipsychotic-induced mania has
been reported as being associated with frontal dopamine release via
the 5HT2A receptor blockade3. Paliperidone also has D2 and 5HT2A
receptor blockade activity. In addition, paliperidone has significant
α2A antagonistic activity, and this antagonism tends to increase the
release of serotonin. This increase in serotonin is associated with the
antidepressant activity of paliperidone2,4 and it is believed that this
serotonergic effect might contribute to the development of manic
symptoms. After taking a single dose of paliperidone palmitate,
which has long-lasting potency, the plasma level gradually increases
and reaches Tmax on the 13th day. The release of paliperidone
palmitate into the plasma begins from the first day and continues
for four months. Furthermore, paliperidone palmitate rapidly
reaches therapeutic concentration in the first week following the
administration of the two initial doses, and adding oral paliperidone
is, therefore, not recommended due to the rapid therapeutic effect of
paliperidone palmitate after the onset of this regimen4. Although the
pharmacological properties and possible antidepressant efficacy of
paliperidone may have caused symptoms of mania in our case, it is
not possible to provide a full explanation of the relationship between
paliperidone palmitate treatment and mania from our case report alone.
Nevertheless, this case suggests that patients with schizophrenia
should be carefully monitored during the transition to paliperidone
palmitate with long-lasting potency, to watch for the development
of symptoms such as mania. Further studies are needed to clarify the
mechanisms of this clinical condition.
References
1. Demir S, İbiloğlu AO, Kaya MC, Güneş M. Mania associated with pali-
peridone treatment in schizophrenia: A case report. J Clin Exp Investig.
2015;6(3):321-3.
2. Wang WT, Chen CH, Lu ML, Lai TJ. Paliperidone-induced mania-like
symptoms: A case report. Progr Neuropsychopharmacol Biol Psychiatry.
2010;34(7):1351-2.
3. Benyamina A, Samalin L. Atypical antipsychotic-induced mania/hypo-
mania: a review of recent case reports and clinical studies. Int J Psychiatry
Clin Pract. 2012;16(1):2-7.
4. Demirci K, Keleş S, Demirdaş A, Korucu CÇ. Manic Symptoms during a
Switch from Paliperidone ER to Paliperidone Palmitate in a Patient with
Schizophrenia. Case Rep Psychiatry. 2015;528370.
5. Yang FW, Liang CS. Manic symptoms during a switch from risperi-
done to paliperidone: a case report. J Neuropsychiatry Clin Neurosci.
2011;23(3):E29.
 Letter to the editor

Lithium-induced asymptomatic dose-related elevation of serum creatine kinase: a

case report
Mao-Hsiu Hua1,2
https://orcid.org/0000-0002-1752-5984

Shen-Chieh Chang2
https://orcid.org/0000-0003-0165-9758

Mong-Liang Lu2,3
https://orcid.org/0000-0003-3184-6554

1 Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.

2 Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan.
3 Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.

Received: 09/30/2019 – Accepted: 02/10/2020

DOI: 10.1590/0101-60830000000245

Hua MH et al. / Arch Clin Psychiatry. 2020;47(4):121-2

Dear Editor,
Lithium has many adverse effects limiting its prescription1. Creatine Lithium level

Llithium concentration (meq/L)

kinase (CK) is released when skeletal muscle cells are damaged. 1.2
Psychiatric patients with remarkable CK elevations commonly 1
indicate to two life-threatening physical conditions, rhabdomyolysis
and neuroleptic malignant syndrome (NMS). Lithium use is related 0.8
to rhabdomyolysis and NMS2-4, but the association of lithium and 0.6
asymptomatic CK elevation had not been reported. Lithium
0.4
Mr. Y is a 17-year-old man presenting with hyperactivity and
agitation when he was brought to emergency department. He had 0.2
manic symptoms including elevated mood, decreased need of sleep, 0
grandiosity, hypertalkativeness lasting for one week. Upon emergency day 1 day 7 day 13 day 23 day 28
room visit his blood test showed increased levels of GOT/GPT
(208/63 U/L) and CK (8697 U/L). He was admitted to pediatric ward Time
due to rhabdomyolysis and then transferred to psychiatric ward after
the condition became stable (CK was 1215 U/L at the transferring Serum CK level
day). He was treated with quetiapine first but manic symptoms were 2,500
still active despite the dosage reached to 600 mg/day. His serum CK 2,000
level decreased to 644 U/L after two-week admission. We had tried
CK level (U/L)

to add mood stabilizers for combination treatment, but valporic 1,500

acid was discontinued due to allergic reaction and carbamazepine
was contraindicated because of his positive HLA-B1502 genotype.
Then, we prescribed lithium for him. We started with 300 mg/day
and gradually titrated to 900 mg/day. He had obvious response to
lithium (Young Mania Rating Scale total score from 43 to 12 after
the dose reaching 900 mg/day). When monitoring his laboratory
parameters and serum lithium concentration, we found the serum CK
level increased again after lithium treatment. Further, his serum CK
levels were positively correlated to serum lithium levels. Lithium was
then discontinued and his serum CK level returned to baseline (the
time trends are shown in Figure1). During the period of abnormal
CK level, he did not have hyperactivity and other physical complaints,
and his associated laboratory data were unremarkable (normal liver,
renal function and urine globulin).
Lithium interferences with the collecting tubules and suppress
antidiuretic hormone stimulation, which makes its polyuria and
polydipsia side effects1. Another case report assumed lithium might
induce hyperosmolar state3. These conditions might induce elevated
CK levels and even rhabdomyolysis. However, our patient did not
have the above states. Besides, the positive correlation between
lithium and CK concentration was not mentioned before. The
concentration-dependent relationship between lithium and CK needs
further investigations.
CK level
1,000
500
0
day 1 day 7 day 13 day 23 day 28
Time
Figure 1. The time trends of lithium and creatine kinase (CK) levels.
Massive Asymptomatic Creatine Kinase Elevation (MACKE) has
been discussed in youths using antipsychotics4. The article concluded
that MACKE is harmless and intensive CK monitor is unnecessary.
Whether lithium induced CK elevation is harmless like MACKE or
not need more studies to confirm. Furthermore, Gosling et al. found
the elevation of serum CK may indicate mania is under controlled5.
Our patient also showed obvious response during CK elevation. But
using serum CK level to detect lithium treatment efficacy is lack of
well-established evidence. Whether lithium induced asymptomatic
serum CK elevation is harmful, harmless, or treatment response
predictive needs more explorations.

Address for correspondence: Shen-Chieh Chang and Mong-Liang Lu. Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University. Taipei, Taiwan. E-mail: cjosef@gmail.com (Dr. Chang);
mongliang@hotmail.com (Dr. Lu)
122 Hua MH et al. / Arch Clin Psychiatry. 2020;47(4):121-2
In addition, studies revealed that higher CK level was found in
the manic patients compared with the depressed ones and the lack
of correlations between CK level and motor activity6. Further studies
need to explore the state-dependent differences in CK levels.
Financial support
None.
References
1. Gitlin M. Lithium side effects and toxicity: prevalence and management
strategies. Int J Bipolar Disord. 2016;4:27.
2. Voros V, Osvath P, Fekete S, Tenyi T. Elevated serum creatine kinase levels
in psychiatric practice: differential diagnosis and clinical significance:
A brief, practical guideline for clinicians. Int J Psychiatry Clin Pract.
2008;12(2):147-50.
3. Bateman AM, Larner AJ, McCartney SA, Rifkin IR. Rhabdomyolysis
associated with lithium-induced hyperosmolal state. Nephrol Dial
Transplant. 1991;6(3):203-5.
4. Masi G, Milone A, Viglione V, Mancini A, Pisano S. Massive asymptom-
atic creatine kinase elevation in youth during antipsychotic drug treat-
ment: case reports and critical review of the literature. J Child Adolesc
Psychopharmacol. 2014;24(10):536-42.
5. Gosling R, Kerry RJ, Owen G. Creatine phosphokinase activity during
lithium treatment. Br Med J. 1972;3(5822):327-9.
6. Segal M, Avital A, Drobot M, Lukanin A, Derevenski A, Sandbank S, et al.
CK levels in unmedicated bipolar patients. Eur Neuropsychopharmacol.
2007;17(12):763-7.