Research report Comorbidity of posttraumatic stress disorder, anxiety and depression: A 20-year longitudinal study of war veterans Karni Ginzburg a, ⁎, Tsachi Ein-Dor b , Zahava Solomon a a Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv 69978, Israel b The New School of Psychology, Interdisciplinary Center (IDC) Herzliya, Israel article info abstract Article history: Received 20 January 2009 Received in revised form 11 August 2009 Accepted 11 August 2009 Available online 18 September 2009 Background: This study aims to: (a) follow-up the prevalence of comorbidity of posttraumatic stress disorder (PTSD), anxiety and depression; (b) determine the chronological relations between these disorder; and (c) examine whether PTSD comorbid with anxiety and depression is implicated in more impaired functioning than PTSD by itself. Methods: 664 war veterans were followed up 1, 2, and 20 years after their participation in the 1982 Lebanon War. Comorbidity was assessed by self reported PTSD, anxiety, and depression symptoms; impairment in psychosocial functioning was assessed by self reported problems in occupational, social, sexual and family functioning. Results: At each point of assessment, rates of triple comorbidity (PTSD, anxiety and depression; 26.7–30.1%) were higher than rates of PTSD, either by itself (9.3–11.1%), or comorbid with depression (1.2–4.5%) or anxiety (2.9–4.5%). PTSD predicted depression, anxiety, and comorbid disorders, but not vice versa. At time 1 and 2 assessments, triple comorbidity was associated with more impaired functioning than PTSD alone. In addition, triple comorbidity at Time 2 was associated with more impaired functioning than double comorbidity. Limitations: Since measurements did not cover the entire span of 20 years since the war, the entire spectrum of changes could not be monitored. Conclusions: Almost one half of war veterans would endorse a lifetime triple comorbidity, and those who do, are likely to have more impaired functioning. The findings support the perspective that views PTSD as the dominant disorder following traumatic events, which impels the development of comorbid anxiety and depression. © 2009 Elsevier B.V. All rights reserved. Keywords: Posttraumatic stress disorder (PTSD) Anxiety Depression Comorbidity 1. Introduction The exposure to war-related traumatic events has long since been found to potentially render long term psychiatric psychopathology (Grinker and Spiegel, 1945). Posttraumatic stress disorder (PTSD) is considered as the most characteristic psychiatric sequelae of traumatic experiences. Yet, previous studies found that substantial proportions of PTSD casualties, ranging between 21% and 94%, suffer from co-morbid depression (e.g., Ginzburg, 2007; Mollica et al., 1999; Salcioglu et al., 2003; Sundquist et al., 2005; Frayne et al., 2005; Hashemian et al., 2006), 39–97% suffer from co-morbid anxiety (Sundquist et al., 2005; Hashemian et al., 2006; Zayfert et al., 2002; Mayou et al., 2001; McFarlane and Papay, 1992), and 11–67% endorse a triple-comorbidity, namely having anxiety and depression in addition to the PTSD (Hashemian et al., 2006; Brady and Clary, 2004). Four exclusive mechanisms were offered to explain the phenomenon of comorbidity in PTSD (see Breslau, 2002; Solomon and Bleich, 1998). The first explanation is that pre- existing psychiatric disorders increase the risk for PTSD, either by increasing the risk for exposure to traumatic events or increase victims' susceptibility to the PTSD-inducing effects of trauma. This view received support from studies showing that among individuals suffering from both PTSD Journal of Affective Disorders 123 (2010) 249–257 ⁎ Corresponding author. Tel.: +972 3 6405917; fax: +972 3 6409182. E-mail address: karnig@post.tau.ac.il (K. Ginzburg). 0165-0327/$ – see front matter © 2009 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2009.08.006 Contents lists available at ScienceDirect Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad