Childhood trauma predicts onset and recurrence of depression, and comorbid anxiety and depressive disorders

ABSTRACT FROM: Hovens JG, Giltay EJ, Spinhoven P, et al. Impact of childhood life-events and childhood trauma on the onset and recurrence of depressive and anxiety disorders. J Clin Psychiatry 2015;76:931–8.

What is already known on this topic?

In the general population, prevalence rates of childhood trauma range from 8.4% for physical abuse, to 17.5% for psychological abuse, with much higher rates in patient samples.¹ Trauma in childhood is a developmental risk factor with a negative impact across adulthood and substantially contributes to the burden of disease worldwide.² Childhood trauma is not only associated with presence of affective disorders.³ One meta-analysis showed that childhood maltreatment predicted persistence of depression, recurrence of depression and worse treatment outcomes (OR 2.34, 2.24 and 1.40, respectively).⁴

Hovens and colleagues have attempted to unravel the detrimental effects of childhood trauma. They have shown that it is associated with a chronic course of depression, and comorbid depression and anxiety, and that this association is mediated by the severity of depressive symptoms at baseline.¹ In their present study, they expand their research by examining the association between childhood life-events and childhood trauma, with first-ever and recurrent incident anxiety, depressive and comorbid anxiety and depressive disorders.

Methods of the study

Using the data of the Netherlands Study of Depression and Anxiety (NESDA), the authors selected 1167 adults without baseline anxiety or depressive disorder (n=569 with a lifetime history and n=598 without a lifetime history of anxiety and/or depressive disorder). Adults were recruited from the general population and primary care settings between 2004 and 2007. At baseline, childhood life-events and childhood trauma were thoroughly assessed by the NEMESIS childhood trauma interview. In addition to childhood life-events, this interview covers areas of interpersonal trauma, all prior to 16 years. Occurrence of anxiety disorders, depressive disorders, and comorbid anxiety and depressive disorders (including both first incidence and recurrent incidence) were assessed after a 2-year follow-up period. Additionally, the authors examined whether the severity of baseline symptoms and a lifetime history of anxiety and/or depressive disorders mediated the relationship between childhood trauma and the occurrence of anxiety, depressive and comorbid anxiety and depressive disorders.

What does this paper add?

• Whereas most papers are based on cross-sectional data, the present study is based on longitudinal data, which allows for a more reliable assessment of onset and recurrence of psychopathology.

• Contrasting many previous studies that focus on sexual or physical abuse, this paper includes emotional neglect as a type of childhood trauma. Results showed the importance of emotional neglect as predictor of onset and recurrence of any disorder that is independent of psychological, physical and sexual abuse (emotional neglect once or sometimes: OR 2.71, 95% CI 1.75 to 4.21; emotional neglect regularly or very often: OR 2.06, 95% CI 1.23 to 3.44).

• By examining mediating factors, this paper provides more insight in the developmental process linking childhood trauma to the occurrence of psychopathology (for instance, subclinical depressive symptoms and a previous disorder mediate the association between childhood trauma, and onset/recurrence of depression and/or anxiety disorders).

Limitations

• Associations between childhood trauma and occurrence of post-traumatic stress disorder (PTSD) could not be examined as PTSD has not been assessed in NESDA.

• NESDA includes adults. As a result, developmental processes occurring in childhood and adolescence are largely not considered.

What next in research?

• Given the substantial impact on course trajectories, further research examining the association between childhood trauma and depressive and comorbid episodes is warranted. The underlying processes of this association are far from understood so it is difficult to target these processes—this research area should be stimulated.

Do these results change your practices and why?

Yes and no. The long-term course of depressive, and comorbid depressive and anxiety disorders, is heterogeneous. Hence, predictors that identify patients at a high risk for unfavourable course trajectories are important. The present study underlines childhood trauma but not childhood life-events, as predictors of recurrence of depressive, and comorbid anxiety and depressive disorders. Clinicians should be aware of this vulnerability. Likewise, clinicians frequently apply a wait-and-see policy in cases of subclinical depressive symptoms. However, the present study implicates that treatment should be considered sooner in a patient with subclinical depressive symptoms and a history of childhood trauma. In addition, it shows that emotional neglect is especially linked to the occurrence of depressive and comorbid episodes. This finding should prompt clinicians to specifically inquire about emotional neglect in childhood.