SciELO - Scientific Electronic Library Online

vol.24 número3Eating attitudes and weight concern among Chinese middle-age women: A comparison between different age and BMI groupsWilliams Syndrome: The extent of agreement between parent and self report of psychological difficulties índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados




Links relacionados

  • En proceso de indezaciónCitado por Google
  • No hay articulos similaresSimilares en SciELO
  • En proceso de indezaciónSimilares en Google


The European Journal of Psychiatry

versión impresa ISSN 0213-6163

Eur. J. Psychiat. vol.24 no.3 Zaragoza jul./sep. 2010




Late effect of the Second Lebanon War: Level of exposure and rates of comorbidity of posttraumatic stress symptoms and depresisve symptoms among Israelis from Northern and Center Israel



Menachem Ben-Ezra, PhD*; Yuval Palgi, PhD**; Amit Shira, M.A.**

* School of Social Work, Ariel University Center of Samaria, Ariel
** Department of Psychology, Tel Aviv University, Tel Aviv. Israel





Background and Objectives: The objective of the present study was to examine comorbidity of posttraumatic stress disorder symptoms and depressive symptoms in the aftermath of war related stress among two groups differentiated by their level of exposure to the war.
Methods: 336 Israeli citizens were assessed using a convenience sample creating two groups from Northern and Central Israel. The former were exposed to missile attacks while the latter were indirectly exposed to war-related stress. The participants provided demographical information and filled a battery of questionnaire that assessed their physical health, mental health, and subjective well-being.
Results: The Northern group exhibited higher level of comorbidity, depressive symptoms and past satisfaction. Moreover, higher levels of depressive symptoms, psychosomatic symptoms and lower satisfaction with life in the past were associated with higher levels of PTSD symptoms.
Conclusions: Our findings suggest that the long-term effect of war is more salient when examining comorbidity of PTSD and depressive symptoms rather than when examining PTSD or depressive symptoms alone. In line with the dose-response model, it can be assumed that higher exposure to war related stress is related to higher levels of exposure that may lead to a long lasting vulnerability as it appears in a combination of PTSD symptoms and depressive symptoms two years later.

Key words: Trauma; PTSD; Depression; Symptoms; Comorbidity; Well-being; War.



Exposure to traumatic events may results not only in post traumatic stress disorder (PTSD) but also in the development of other mental disorders, especially depression1. The U.S. national comorbidity study suggested that PTSD is associated with affective, anxiety and substance abuse disorders2,3. Most comorbidity studies focus on domestic trauma, especially violent crimes, sexually-related crimes, along with motor vehicle accidents4-8. One of the most prevalent psychiatric conditions that develop after traumatic exposure is depression9,10. There is a debate in the literature about the connection between PTSD and depression11. The general agreement is that in most cases of post traumatic exposure, depression is comorbid with PTSD. Moreover, there are some independent cases in which depression and posttraumatic symptoms are presented6,8.

While, there is a plethora of studies that measured comorbidity among soldiers and veterans12-16, the measurement of comorbidity estimates as a result of war-related exposure among civilians was previously done on hospital personnel17. However, there is a lacuna in psychiatric epidemiology with regard to the consequence of war on comorbidity estimates among civilians.

The basic conceptualization for our study is derived from the dose-response model for severe stress18,19. This model postulates that higher levels of traumatic stress exposure will lead to higher levels of post traumatic symptoms and stress-related illnesses. Thus, one can expect higher levels of comorbidity between PTSD symptoms and depressive symptoms among populations with higher war-related exposure. Another conceptual framework is derived from the resilience and vulnerability model for trauma exposure20. After exposure to traumatic event, the vulnerability model postulates that the psychological defense mechanisms are breached, thus making the individual more susceptible to future stress or traumatic event. In this case, there is a higher likelihood of mental health problems and an elevated risk for PTSD. Contrary to the vulnerability model, the resilience approach postulates that exposure to traumatic event can have an inoculation component by broadening one´s coping repertoire and by promoting views that perceive the traumatic event as a challenge rather than as a catastrophe. An integration of these models was proposed21 with reference to the combination of vulnerability and resilience, as both can exist at the same time, but in different functional domains. For example, an individual exposed to traumatic event can present psychiatric symptoms on the one hand, and still think that s/he prevailed adversity. In this case, we can expect that the individual will show a sign of vulnerability in certain psychiatric aspects but will not differ from unexposed individuals in other psychosocial and psychiatric domains.

The purpose of this study was to learn how exposure to different war-related stress is associated with different rates of comorbidity. To the best of our knowledge, no study examined the late effects of war on differential exposure in areas with different levels of exposure to war-related stress. The present study aimed to examine late effects of the Second Lebanon War in which Northern Israel was targeted by thousands of rockets (more than 4000) while Central Israel was not exposed to direct war-related stress. It should be noted that there are similar rates of domestic traumas (Motor vehicle accidents, crime rate and natural disasters) in Northern and Central Israel22, and there was no major national event from August 2006 (the end of the Second Lebanon War) till December 2008 (the date in which the study was performed). Therefore, it is possible that any differences in the rate of comorbidity between PTSD symptoms and depressive symptoms between Northern and Central Israel may be attributed to different exposure to war-related stress. Based on the does-response model and the vulnerability approach, we hypothesized that the level of PTSD symptoms and depressive symptoms would be higher among those who were exposed to direct war related stress (the Northern group). Our second hypothesis was more complex and was based on the combination of resilience and vulnerability approaches. The main argument of this hypothesis was that vulnerability would present itself in higher comorbidity rate of PTSD symptoms and depressive symptoms that would be hig-her in Northern Israel in comparison to Central Israel, while other psychosocial and psychiatric domains would remain similar bet-ween the groups. This will delineate the co-existence of vulnerability and resilience as a result of exposure to traumatic event.




On 12 July 2006 at 9:30 am, war erupted between Israel and Lebanon. Israel suffered 163 fatalities (44 civilians and 119 soldiers) and 2400 wounded (2000 civilians and 400 soldiers). During the war, Northern Israel was targeted by thousands of missiles (more than 4000). Most of the citizens in the north were in their shelters for a month, waiting for the war to end. Meanwhile, in Central Israel, the citizens continued with their daily routine, with only a minor stress as a result of threats from local flare-ups.


Participants were 336 Israeli citizens who were recruited using a convenience sample.

Each participant was contacted either by phone or personally and then interviewed face to face. The response rate was about 70%. The most common reason for refusal was "not interested". The study was conducted simultaneously in Northern and in Central Israel. The inclusion criteria of the Northern Israeli group were: 1) Being in Northern Israel during the Second Lebanon War in 2006 and being exposed to constant missile attacks for at least two weeks. 2) Age of 18 and above. The sample had two biases. One bias was as a result of the mass recruitment to the army reserve forces during the war that led to oversampling of women over men. A second bias was as a result of oversampling of participants from Central Israel in order to reflect the actual proportion of the Israeli population in Northern and Central Israel (ratio of 1:2.31). The participants were recruited during September-December 2008. All the participants were interviewed by trained social workers. The mean age of the entire sample was 27.25 (S.D. = 10.33), 74.1% of the sample were women (n = 241), 38.7% were married (n = 130), 30.7% were secular (n = 103), the mean years of education was 13.77 (2.27), and the salary based on the monthly average in Israel (7812 N.S = 1365 €) distributed as 82.4% (n = 234) below average, 9.9% (28) average, and 7.7% (n = 22) above average. The demographics along with other study variables are presented for each of the two study groups (North and Central Israelis) in Table 1.


There were demographic differences between the groups in marital status (χ2 = 3.835; p = 0.001) and education (t = -3.740; p = 0.001). These differences correspond with the demographic population distribution in Northern Israel in comparison to Central Israel. According to the Central Bureau of Statistics22, the population in Northern Israel is younger and less educated in comparison to Central Israel, an area that is considered much more socio-economically stronger22.

The study was approved by the Helsinki committee at School of Social Work in Ariel University Center of Samaria.


The respondents provided demographical information (age, gender, marital status, years of education, and income). Gender was coded as 1 (men), and 2 (women). Marital status was coded as 1 (no married) after aggregating the following options (bachelor, divorced or separated, widowed), and 2 (married or living in cohabitation). Following the demographic variables, participants answered a battery of questionnaires that assessed their physical health, mental health, and psychological well-being.

Subjective health was indicated by asking the participant to rate his/her health on a scale of 1 (bad), 2 (fair), 3 (good), and 4 (excellent). This measure is known as an excellent measure for predicting one´s health condition23.

PTSD symptoms were measured by The PTSD Checklist Civilian Version (PCL-C)24, which uses 17 items (e.g., 'having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?", "repeated, disturbing memories, thoughts, or images of a stressful experience from the past?", "repeated, disturbing dreams of a stressful experience from the past?") addressing the DSM-IV diagnostic criteria for PTSD. Respondents used a 5-point scale to evaluate each symptom. Higher scores indicate greater post-traumatic symptomatology. Cronbach´s alpha coefficient for the PCL-C for this sample was 0.97. A score of 50 and above is an indicator for an elevated level of PTSD symptoms24.

Depressive symptoms were measured by The Short Center for Epidemiologic Studies Depression Scale (SCES-D)25, which is a 10-item scale (e.g., "I did not feel like eating: my appetite was poor", "I felt that I could not shake off the blues even with help from my family or friends") intended to measure the severity of depressive symptoms caused by individual experiences. The items are rated by frequency on a 4-point scale, where higher scores reflect higher risk of depression. The Cronbach´s alpha coefficient in this sample was 0.92. A score of 10 or above is an indicator for an elevated level of depressive symptoms26.

Psychological distress was measured by the General Health Questionnaire (GHQ)27, which contains 12 items (e.g., "felt you couldn´t overcome your difficulties?", "been losing confidence in yourself?") for 12 specific psychological symptoms such as anhedonia and personal competence. Each item is rated by its frequency over the past few weeks on a 4-point scale. Higher scores indicate poorer mental health. Cronbach´s alpha coefficient for this sample was 0.93.

Subjective well-being was measured by the satisfaction with life scale (SWLS)28, a widely used measure of subjective well-being that contains 5-items (e.g., "in most ways my life is close to my ideal", "the conditions of my life are excellent"). The scale defines life satisfaction as a conscious cognitive judgment of life in which individuals compare their life circumstances to a self-imposed standard. The scale employs a seven-point Likert scale (1 - strongly disagree to 7 - strongly agree), with higher values corresponding to greater satisfaction. The SWLS has shown good reliability and validity29. Cronbach´s alpha coefficient for this sample was 0.93.

Psychosomatic symptoms were measured by the Psychosomatic Problems Scale (PSP)29. The PSP is an eight-item scale and it is constructed through summation of the participants responses (raw scores) across the following eight items (e.g., "had difficulty in concentrating", "had difficulty in sleeping"). The response categories for all of these items, which are in the form of questions, were coded as 0 (never), 1 (seldom), 2 (sometimes), 3 (often), and 4 (always). The categories are ordered in terms of implied frequency month and the greater the frequency, the greater the psychosomatic distress. The justification of the scoring procedure has been examined with psychometric analysis using the Rasch model29. Cronbach´s alpha coefficient for this sample was 0.84.

Statistical Analysis

We used descriptive statistics, t-tests and chi-square tests for measuring differences between respondents from Northern and Central Israel along with cross-tabulations of comorbidity for each region in Israel. Finally, we conducted a multiple regression in order to examine the association between the following variables: age, gender, marital status, religiosity, years of education, income, subjective health, GHQ scores, PSP scores, SWLS scores, and SCESD scores to PCLC scores. Finally, we have conducted two separate logistic regressions. The first logistic regression used the S-CESD cut off > 10 as elevated level of depressive symptoms as the independent variables whereas the dependent variable was elevated level of PTSD symptoms by measured by the PCLC cut off > 50. This logistic regression was used on Northern Israel group. The second logistic regression was the same as the first one and was used on the Central Israel group.

All the analyses were conducted using SPSS (SPSS, version 16, Chicago, IL).



The results revealed that the population in Northern Israel exhibited higher comorbidity rate of PTSD symptoms and depressive symptoms (χ2= 2.365; p = 0.018). See Table 1 for more details. The comorbidity prevalence in Northern Israel (17.6%) was about twice than in Central Israel (8.9%). See Tables 2 and 3 for more details. Surprisingly, no significant differences were found between the groups on the separate scales of PCL-C and SCES-D. The results of the multiple regression revealed that having higher levels of depressive symptoms (S-CESD; b = 0.200; t = 2.051; p = 0.041), and psychosomatic symptoms (PSP; β = 0.200; t = 2.270; p = 0.024) were associated with higher levels of PTSD symptoms. Furthermore, the results of the logistic regression showed the participants from Northern Israel who had elevated level of depressive symptoms (S-CESD > 10) were 8.5 times more likely to have elevated risk of PTSD symptoms (HR = 8.500; 95% C.I = 3.340-21.635; p < 0.001). However, these results were found to be non-significant among the Central Israel group (HR = 1.350; 95% C.I = 0.689-2.644; p = 0.381).



The results indicated that level of exposure to war-related stress was associated with different comorbidity rates of PTSD symptoms and depressive symptoms. The results revealed that civilians from Northern Israel had a higher rate of comorbidity in comparison to civilians from Central Israel. It is interesting to see that on the other hand the prolonged effect of war on PTSD symptoms and depressive symptoms separately was not significant. It is to say that war has a unique long-term effect on comorbidity that is different from its effect on PTSD and depression alone. In line with the dose-response model18,19, it can be assumed that the combination of PTSD and depression might be a more sensitive indicator to assess long lasting vulnerability to war-related stress. Another possible explanation that is concurrent with the second hypothesis and the results is the integration of vulnerability and resilience. While most people cope with the aftermath of psychological trauma in various levels, there is a group of people who present vulnerability. Since the vulnerability is specific, it is to say that this specific vulnerability and a more general resiliency is predicted by the integrated model21. The number of studies regarding comorbidity as a result of war-related stress are few17,30,31. One lesson from this study can be applied to prospective studies in the case of large-scale disasters whether originated by man or attributed to the forces of nature. This is the measurement of level of exposure between exposed and non-exposed areas.

The main limitation of our study is the sampling method we used - a convenience sample. Although there were demographic differences between our groups, these are well-documented differences that represent the true nature of these regions, as seen in central bureau of statistics reports22. In light of our study, it is recommended to examine differential exposure on comorbidity rates of depressive symptoms and PTSD symptoms in other sources of trauma.



We thank Amana Bumash, Tsofia Bar-Shalom, Adi Balulu and Shachar Cohen for their assistance in gathering the data.



1. Perkonigg A, Kessler RC, Storz S, Wittchen HU. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatri Scand 2000; 101: 46-59.        [ Links ]

2. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry 1995; 52: 1048-1060.        [ Links ]

3. Yehuda R, McFarlane AC. Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. Am J Psychiatry 1995; 152: 1705-1713.        [ Links ]

4. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998; 55: 626-632.        [ Links ]

5. Kilpatrick DG, Ruggiero KJ, Acierno RE, Saunders BE, Resnick HS, Best CL. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. J Consult Clin Psychol 2003; 71: 692-700.        [ Links ]

6. O´Donnell ML, Creamer M, Pattison P, Atkin C. Psychiatric morbidity following injury. Am J Psychiatry 2004; 161: 507-514.        [ Links ]

7. Oquendo MA, Friend JM, Halberstam B, Brodsky BS, Burke AK, Grunebaum MF, et al. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. Am J Psychiatry 2003; 160: 580-582.        [ Links ]

8. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SP, et al. Prospective study of posttraumatic stress disorder and depression following trauma. Am J Psychiatry 1998; 155: 630-637.        [ Links ]

9. Creamer M, Burgess PM, McFarlane AC. Posttraumatic stress disorder: Findings from the Australian National Survey of Mental Health and Well-Being. Psychol Med 2001; 31: 1237-1247.        [ Links ]

10. Grieger TA, Fullerton CS, Ursano RJ. Posttraumatic stress disorder, alcohol use, and perceived safety after the terrorist attack on the Pentagon. Psychiatr Serv 2003; 54: 1380-1382.        [ Links ]

11. Roberts K, Robbins S. The relationship between post-traumatic stress disorder and affective disorder. EMJ 2006; 23: 935-936.        [ Links ]

12. Deering CG, Glover SG, Ready D, Eddleman HC, Alarcon RD. Unique patterns of comorbidity in posttraumatic stress disorder from different sources of trauma. Compr Psychiatry 1996; 37: 336-346.        [ Links ]

13. Koren D, Norman D, Cohen A, Berman J, Klein EM. Increased PTSD risk with combat-related injury: A matched comparison study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry 2005; 162: 276-282.        [ Links ]

14. Kozaric-Kovacic D, Hercigonja KD, Grubisic-Ilic M. Posttraumatic stress disorder and depression in soldiers with combat experiences. CMJ 2001; 42: 165-170.        [ Links ]

15. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007; 298: 2141-2148.        [ Links ]

16. Zoricic Z, Karlovic D, Buljan D, Marusic S. Comorbid alcohol addiction increases aggression level in soldiers with combat-related post-traumatic stress disorder. Nord J Psychiatry 2003; 57: 199-202.        [ Links ]

17. Palgi Y, Ben-Ezra M, Essar N, Langer S. The effect of prolonged exposure to war stress on the comorbidity of PTSD and depression among hospital personnel. Psychiatry Res 2009; 168: 262-264.        [ Links ]

18. Kaysen D, Rosen G, Bowman M, Resick PA. Duration of trauma exposure and the dose-response model of PTSD. J Interpers Violence 2010; 25: 63-74.        [ Links ]

19. March JS. What constitutes a stressor? the "Criterion A" issue. In: Davidson JRT, Foa EB, eds. Posttraumatic stress disorder, DSM-IV and beyond. Washington, DC: American Psychiatric Association; 1993. p. 37-54.        [ Links ]

20. Yehuda R, Flory JD. Differentiating biological correlates of risk, PTSD, and resilience following trauma exposure. J Trauma Stress 2007; 20: 435-447.        [ Links ]

21. Shmotkin D. Vulnerability and resilience intertwined: A review of research on Holocaust survivors. In: Jacoby R, Keinan G, eds. Between stress and hope: From a disease-centered to a health-centered perspective. Westport, CT: Praeger; 2003. p. 213-233.        [ Links ]

22. Central Bureau of Statistics. Statistical yearbook 2008. Retrieved September 11, 2009, from Central Bureau of Statistics Web site:        [ Links ]

23. Benyamini Y, Blumstein T, Lusky A, Modan B. Gender differences in the self-rated health-mortality association: is it poor self-rated health that predicts mortality or excellent self-rated health that predicts survival? Gerontologist 2003; 43: 396-405.        [ Links ]

24. Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. Psychometric Properties of the PTSD Checklist-Civilian Version. J Trauma Stress 2003; 16: 495-502.        [ Links ]

25. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1: 385-401.        [ Links ]

26. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults - Evaluation of a short-form of the CES-D. Am J Prev Med 1994; 10: 77-84.        [ Links ]

27. Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997; 27: 191-197.        [ Links ]

28. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess 1985; 49: 71-75.        [ Links ]

29. Hagquist C. Psychometric properties of the psychosomatic problems scale - a Rasch analysis on adolescent data. Soc Indic Res 2008; 86: 511-523.        [ Links ]

30. Kimhi S, Eshel Y, Zysberg L, Hantman S, Enosh G. Sense of coherence and socio-demographic characteristics predicting posttraumatic stress symptoms and recovery in the aftermath of the Second Lebanon War. Anxiety Stress Coping 2010; 23(2): 139-152.        [ Links ]

31. Somasundaram DJ, Sivayokan S. War trauma in a civilian population. Br J Psychiatry 1994; 165: 524-527.        [ Links ]



Dr. Menachem Ben-Ezra
School of Social Work
Ariel University Center of Samaria
Ariel 40700, Israel
Tel: +97236760285

Received: 12 September 2009
Revised: 15 June 2010
Accepted: 28 June 2010

Creative Commons License Todo el contenido de esta revista, excepto dónde está identificado, está bajo una Licencia Creative Commons