Abstract
Introduction
Adverse childhood experiences (ACEs), including physical, sexual, and emotional abuse, have been shown to result in a variety of poor outcomes including depression. The majority of research has examined the impact of such events on adolescents and young adults leaving a dearth of information regarding how these events may affect depressive symptom point prevalence later in life.
Methods
Data from the CDC’s 2010 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to estimate the point prevalence of depression in individuals sixty years of age and greater based on presence or absence of certain ACEs. Depressive symptoms were assessed using eight items from the Patient Health Questionnaire (PHQ). Subjects with a PHQ score of 10 or greater were categorized as depressed. Six different types of ACE were included in the study: parents being physically abusive to each other, being physically harmed by a parent, being sworn at by the parent, being touched sexually by an adult, being forced to sexually touch an adult, and being forced into a sexual encounter. ACEs were categorized as never, single if subject reported it occurring once, or repeated if subject reported multiple episodes.
Results
The study sample consisted of 8,051 adults aged 60 years and greater who responded to questions about adverse childhood experiences. The study sample was comprised of 53% females, 83% Caucasians, and had a mean age of 70.4 years. After controlling for age, gender, and race, depression was significantly correlated with repeated ACEs of all types (adjusted odds ratio [AOR] ranging from 2.41 to 9.78, all statistically significant). The only ACE where a single occurrence was significantly associated with late life depression was forced sexual intercourse (AOR 2.92, 95% C.I. 1.06-8.02). After controlling for all types of abuse in a single model, repeated physical abuse and repeated forced sexual intercourse remained significant (AOR 2.94, 95% C.I. 1.68-5.13, and AOR 3.66, 95% C.I. 1.01-13.2, respectively).
Discussion
These results indicate a significant association between repeated ACE and depression in older adults. When controlling for all forms of abuse, the repeated physical abuse and forced sexual intercourse are significantly correlated with late life depression. It emphasizes the need to continue developing techniques to help individuals with a history of ACE in order to decrease their negative effects, not only immediately, but also later in life.
Introduction
Adverse childhood experiences (ACEs) have been associated with many negative outcomes throughout life, both physical and mental. Physically, early stress has been associated with increased fatigue in middle age and obesity in adulthood 1. Psychiatrically, ACEs have been associated with an increase of nicotine and alcohol dependence, personality disorders, and anxiety disorders in adults as well as suicidal ideation and behaviors in adolescence 2,3. ACEs have been categorized into three forms: emotional, physical, and sexual. Each has been the focus of multiple studies and linked to some degree with the subsequent development of depression among teens and young adults 4.
These findings are not universal throughout the literature. For instance, one study has found that while emotional abuse was associated with adult depression, neither sexual nor physical abuse was 4. Additionally, some adversity may be helpful for people; compared to either no adversity or high levels of adversity, a low to moderate level was associated with better mental health, possibly due resilience 5.
There remains limited research on the effects ACEs in older adults. One study found increased risk of suicidal ideation in older women admitted to a psychiatric unit if they had a history of childhood sexual abuse 6. Individuals who have had adversities in childhood tend to have less adaptive functioning when they age compared to their peers 7. Several studies show that emotional abuse in childhood is associated, in those aged 60 years and greater, with difficulty developing social support, increased emotional distress, and poor sleep quality. These findings suggest that various types of abuse may impact mental health in older adults; however, it does not directly answer the question of the effects ACEs may have on geriatric depression prevalence. It is this question we seek to answer.
We hypothesized that emotional abuse would be more likely to impact depression and that repetitive abuse of either type would have higher impact. We hypothesized that any level of sexual abuse would be associated with increased levels of depression with chronic sexual abuse having the highest association.
Methods
Sample
This study utilizes data from the 2010 Behavioral Risk Factor Surveillance System (BRFSS), available at the Centers for Disease Control and Prevention (CDC) website. The BRFSS consists of a randomly selected, nationally representative group of participants interviewed via telephone. The surveys consist of three main types: a fixed core of questions asked of all participants, optional modules states may add if desired, and state-added questions. Complete information about the survey may be found at the CDC’s website at www.cdc.gov/brfss. In 2010, 4 states (Hawaii, Nevada, Vermont, and Wisconsin) asked both the depression screening and the ACE questions, such as physical and sexual abuse in childhood, and were included in analysis.
Questions
The depression screening questions were drawn from the Patient Health Questionnaire eight-item scale (PHQ-8). The PHQ-8 assesses symptoms of depression as well as level of impairment from the perspective of the participant. The items are rated on a scale from 0 (not at all) to 3 (nearly every day) for a total of 24 possible points with higher scores indicating more severe symptoms. The PHQ-8 has been studied in the context of the BRFSS and found to have a sensitivity and specificity for major depressive disorder of 100% and 95% respectively 8. For the purposes of this study, a cut-off score of 10 or greater was utilized to categorize participants as depressed versus non-depressed, which has good sensitivity, 88%, and specificity, 88%, and a positive likelihood ratio of 7.1 8 on the PHQ-9 (includes a question regarding suicidal ideation). The exclusion of the suicidal ideation question (PHQ-8) does not significantly impact the prevalence of depressive symptoms found.
ACEs were assessed with several questions. Episodes of abuse were categorized as never, once, or more than once. Six different types of ACEs were examined which are as follows: parents being physically abusive to each other, being physically harmed by a parent, being sworn at by the parent, being touched sexually by an adult, being forced to sexually touch an adult, and being forced into intercourse. The questions asked are as follows: “How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up,” “Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking,” “How often did a parent or adult in your home ever swear at you, insult you, or put you down,” “How often did anyone at least 5 years older than you or an adult, ever touch you sexually,” “How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually,” and “How often did anyone at least 5 years older than you or an adult, force you to have sex.”
Analyses
Analyses were performed using STATA 11. Data was weighted with the provided population weights, and sampling units, using Taylor approximation; and represent a best estimate of point prevalence and associations in the population.
Results
Our sample was comprised of 8,051 individuals aged 60 years and greater who completed questions regarding depression and ACEs. Their demographics are represented in Table 1. As noted in the table, there are significant differences between the depressed and non-depressed groups in terms of race and number of ACEs, with no differences on gender or age.
Table 1.
Sample description for 2010 BRFSS participants over age 60 included in the analysis (N=8051)
| Non Depressed N=7617 | Depressed N=434 | Total N=8051 | Test statistics and p value * | |
|---|---|---|---|---|
| % Female | 53% (51-55) | 58% (49-67) | 53% (51-55) | Design-based F (1,8008)=0.96, p<0.33 |
| Race | Design-based F (2.8, 21753)=2.7 p=0.047 ** | |||
| Caucasian | 84% (82-85) | 74% (64-82) | 83% (82-84) | |
| African-American | 2% (1-2) | 2% (0-5) | 2% (1-2) | |
| Hispanic | 2% (2-3) | 6% (2-14) | 3% (2-3) | |
| Other | 12% (12-13) | 18% (11-28) | 13% (12-14) | |
| Age | Design-based F (3.9, 31246) = 1.8, p=0.12 | |||
| 60-64 | 31% (29-33) | 40% (31-49) | 31% (30-33) | |
| 65-69 | 22% (20-23) | 23% (17-31) | 22% (20-23) | |
| 70-74 | 17% (15-18) | 16% (11-23) | 17% (15-18) | |
| 75-79 | 15% (14-17) | 10% (6-1) | 15% (14-17) | |
| 80+ | 16% (14-17) | 12% (7-18) | 15% (14-17) | |
| Number of Adverse Childhood Experiences | Design-based F (1.99, 15963)=27.4, p<0.001 *** | |||
| zero | 76% (74-78) | 54% (45-63) | 75% (73-76) | |
| 1 | 14% (13-16) | 16% (11-23) | 14% (13-16) | |
| More than 1 | 10% (9-11) | 30% (23-38) | 11% (10-12) |
Design-based F is a corrected, weighted, Pearson chi square statistic; in order to get a valid p-value, the chi square statistic is converted to an F statistic accounting for the complex sampling design.
On post hoc logic regression race categories African American, Hispanic, and Other had a statistically significant higher prevalence of depression compared to Caucasian.
On post hoc logistic regression having “more than 1 ACE” had a statistically significant higher depression prevalence compared to having zero ACE – while reporting one ACE was not.
Table 2 notes the point prevalence of depression, the crude odds ratio, and the odds ratio adjusted for gender, age, and race. Both prior to and after controlling for age, gender, and race, only one ACE scenario (forced sex) resulted in a statistically significant change in point prevalence of depression after a single episode. The greatest increase from the baseline depression occurred in the group endorsing multiple episodes of forced sexual intercourse. When any ACE occurred on a repeated basis, however, significant changes were seen in depression point prevalence across all types of abuse. Once all ACEs are included in a single model, significance remains only for repetitive physical abuse and repeated forced intercourse (see Table 2 for statistics).
Table 2.
Association between type and frequency of ACEs and Geriatric Depression
| Total (N) | % Depressed (95% C.I.) | Crude Odds Ratio (95% C.I.) | Adjusted Odds Ratio* (95% C.I.) | Full Model** | ||
|---|---|---|---|---|---|---|
| Parents beat each other | Never | 7202 | 4.7% (3.9-5.7) | – | – | |
| Once | 319 | 9.3% (4.2-19.1) | 2.05 (0.86-4.87) | 1.95 (0.9-4.21) | 1.47 (0.6-3.57) | |
| More than once | 724 | 12.5% (8.7-17.7) | 2.89 (1.83-4.54) | 2.69 (1.7-4.8) | 1.32 (0.65-2.69) | |
| Parents physically hurt you | Never | 7209 | 4.3% (3.5-5.3) | - | - | |
| Once | 307 | 7.7% (3.5-16) | 1.85 (0.78-4.37) | 1.98 (0.83-4.73) | 1.58 (0.58-4.27) | |
| More than once | 790 | 17.1% (12.8-22.6) | 4.59 (3.06-6.87) | 4.55 (3.05-6.77) | 2.94 (1.68-5.13) | |
| Parents swore at you | Never | 6182 | 4.4% (3.5-5.5) | - | - | |
| Once | 446 | 5.5% (2.2-12.8) | 1.26 (0.48-3.31) | 1.26 (0.51-3.08) | 1.11 (0.45-2.73) | |
| More than once | 1646 | 10.2% (8-13.1) | 2.49 (1.74-3.58) | 2.41 (1.68-3.45) | 1.11 (0.69-1.76) | |
| Someone touched you sexually | Never | 7575 | 4.9% (4-5.8) | - | - | |
| Once | 287 | 9.4% (5-17.1) | 2.04 (1-4.17) | 1.63 (0.77-3.44) | 1.17 (0.54-2.5) | |
| More than once | 418 | 18.2% (11.8-27) | 4.36 (2.53-7.52) | 3.93 (2.27-6.8) | 0.9 (0.38-2.1) | |
| Someone made you touch them sexually | Never | 7869 | 5% (4.2-6) | - | - | |
| Once | 166 | 9.5% (3.5-23.4) | 1.97 (0.65-5.84) | 1.86 (0.61-5.69) | 1.33 (0.44-3.97) | |
| More than once | 256 | 23% (14.1-35.4) | 5.63 (2.99-10.6) | 5.18 (2.91-9.22) | 1.87 (0.5-7.02) | |
| Forced to have sex | Never | 8067 | 5.1% (4.3-6.1) | - | - | |
| Once | 84 | 13.7% (5.7-29.5) | 2.96 (1.11-7.89) | 2.92 (1.06-8.02) | 1.68 (0.49-5.8) | |
| More than once | 150 | 35.2% (22.4-50.6) | 10.12 (5.22-19.62) | 9.78 (4.58-20.9) | 3.66 (1.01-13.2) | |
Adjusted for age, gender, and race using logistic regression.
Adjusted for age, gender, race, and other ACEs using logistic regression.
Discussion
In a large community sample of subjects 60 years or older, we found that depression point prevalence is significantly higher among those reporting repeated ACEs of any type. Overall, a onetime ACE is not significantly related to an increased point prevalence of depression in older adults, the one exception being forced sex, where one occurrence is enough to increase the point prevalence of depression. When all ACEs are included in one single model, significance is noted only for repeated acts of physical abuse and forced sexual intercourse.
This study has limitations. First, the history of ACE is based on self-report, which may lead to recall bias, particularly when the events happened many years previously. It is possible that those with depression may recall these negative events more than those without. Second, depression categorization was made on current symptom report rather than a clinical diagnosis.
In terms of study limitations, a review on recall bias effects concludes that in retrospective studies the occurrence of ACE are likely to be underreported. They also add that should there be a bias, it does not appear to be secondary to the effects of mood 9. Second, if a person were being adequately treated for depression with resultant symptom control, it is possible that a person with depression would not meet our cut-off; if this is the case, it could strengthen our findings.
Our finding, that repeated ACEs are associated with a higher point prevalence of depression later in life, most notably with physical abuse and forced sexual intercourse, is in line with other studies. A 2008 study found that individuals subjected to childhood physical or sexual abuse had a greater risk for poor mental and physical health in older age though unlike our study the participants were not a community sample 10. Our study largely supported these findings, particularly prior to controlling for all forms of abuse. The BRFSS questions did not specifically assess for number of perpetrators.
With its focus on the geriatric population of the United States, this study enriches the current knowledge of the effects of ACEs on geriatric depression and examines each of the three forms of abuse identified in the ACE literature. The results of this study emphasize the importance that remote events may have in the development or persistence of depression and the need for screening of both ACEs and depression across the lifespan due to their high prevalence and high correlation, hopefully leading to the development of early intervention to minimize their morbidity and mortality effects.
Footnotes
No Disclosures to Report
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