The objectives of the present study were the relations between experienced potential traumatic events (PTE) and further factors with PTSD or depression and comorbid PTSD in Yazidi women, after the ISIS attacks in 2014. In the present study, the numbers for prevalence and comorbidity were in the very high range. Women with comorbid PTSD and depression had been held in captivity more frequently and for a longer time and had experienced a higher number of PTEs than women with PTSD. The number of PTEs predicted the double diagnosis of PTSD and depression. The prevalence rates of 97.9% for PTSD and 88.1% for depression are higher than the numbers reported in the relevant literature8,9,10. In a previous study on the Yazidis who fled, 42.9% were reported to have a diagnosis of PTSD and 39.5% were reported to have depression10. The reason for the differences could be that the participants in the study of Tekin and colleagues10 had not been held in captivity for more than three months. Furthermore, this study only examines women, who have a higher risk of PTSD7 and depression36.
In the present study, both the frequency and the duration of captivity showed a correlation in the existence of both disorders. In a random sample of women from Croatia and Bosnia and Herzegovina who had been subjected to sexual violence and some of whom had been held captive, 14.0% had PTSD and 76.0% depression9. One explanation for the higher incidence of the double diagnosis PTSD and depression in the case of the Yazidi could be the influence of the collective, historical traumatic events entrenched in their society. Compared to individuals with no historical trauma who have had the same experiences, the descendants of individuals who have been subjected to collective traumata show more PTSD symptoms and a generally higher risk of PTSD37. They identify emotionally with the traumatic events of their ancestors and report symptoms of depression such as sadness, shame, anger, shyness in taking any action, stress and low self-confidence38. For example, the significance which is attributed to the traumatic events plays an important role7. In the case of the Yazidi, identity means living together in a community with traditions and passing on their religion orally. At present this is not possible and this represents a lasting change to their society. They do not know if it will be possible to return to their area in the near future and whether the perpetrators will be legally held accountable1.
The number of PTEs experienced proofed to be a predictor for the combined presences of PTSD and depressions. Individuals with both disorders had experienced significantly more PTEs than individuals with only PTSD. The results of the present study are consistent with results obtained from various countries and cultures8,18.
Individuals with both disorders had been held captive more frequently than individuals with PTSD. In a study of victims of kidnapping in Italy, dejectedness and hopelessness were recorded as psychological reactions to the situation of captivity39. This could explain the link to depression. Rather than viewing captivity per se as a PTE, the individual PTEs experienced in captivity or the accumulation of the PTEs experienced in captivity seem to have an influence. In the current study, the number of PTEs is a predictor of the comorbid presence of PTSD and depression. For this reason, the difference between both disorder groups concerning captivity could also be the result of having experienced many PTEs in the captivity situation. Another indication for this is that individuals with comorbid PTSD and depression in this study had spent a longer period in captivity that individuals with only PTSD. This explanation is also given in a study on those affected by sexual exploitation27. The authors of that study also point out that a longer period of captivity can go hand in hand with severe alienation, humiliation, hopelessness, and loss of control and this, in turn, could explain the link to depression. However, with regards to the length of captivity, in many studies there was no link between the length of captivity and depression9,23,39.
Individuals with both disorders had experienced the death of a significant other, a sexual attack, or being sold more frequently. With regards to the death of an attachment Fig. 10 and sexual attack27, this is consistent with previous studies. The experience of being sold was examined in this study for the first time and, therefore, presents the starting point for further research.
The first limitation of this study is, that study sample consists of a very specific group of women only without randomization. Thus, the results cannot be generalized to other populations like other minority groups or even Yazidi women living under different circumstances. Moreover, the current sample showed a high level of homogeneity. Consequently, the PTEs related to living in a war zone and violent attack could not be compared, as they were experienced by all the women participating. Owing to the unequal distribution of the subsamples women with PTSD (n = 22) and women with comorbid PTSD and depression (n = 168) there were, in parts, only very few participants for each set of conditions.
The interviews took place in a war zone and at the time of collecting the information, the participants were living in refugee accommodations. Some of the participants were questioned immediately after release from captivity. These circumstances might been seen as another limitation and could explain parts of the missing data. Moreover, even though all interviews were carried out by a psychotherapist with experience in dealing with traumatized individuals and with knowledge of the Yazidi culture, misunderstandings or mistranslations could have occurred when filling in the questionnaires. Some of the symptoms could have been unknown or unfamiliar to the Yazidi women and other symptoms relating to suffering may have been neglected. Lastly, on the evaluation of the ETI, two aspects were especially noticeable. First, the participants had difficulties choosing “the worst event”. Apart from a few exceptions, more than one event was named as the most traumatic event. Secondly, the list of PTEs given was not sufficient to cover the things experienced by the women involved in the study.
The clinical pictures of PTSD and depression can differ significantly between cultures with regards to avoidance behaviour, deafness, nightmares and somatic symptoms7. To obtain a more exact picture of the specific cultural expressions of the psychological suffering of the Yazidi, a follow-up study with a more sophisticated analytical approach that allows for causal conclusions about universal and culture-specific contributions should be done. Particularly with traditional societies, it seems to make sense to include a society-internal view of the expression of suffering to obtain a holistic picture of the psychological consequences of traumatic events40. In the case of the Yazidi, it might make sense for further research to specify the events in captivity. In that case, it could be ascertained more closely whether there is a link between captivity and symptoms of depression due to individual events or due to the number of events.