The associations among childhood maltreatment, “male depression” and suicide risk in psychiatric patients
Introduction
Childhood maltreatment, which includes abuse (physical, sexual, and emotional) and neglect (physical and emotional), is highly prevalent and a major public health concern (Gilbert et al., 2009), which often leads to deleterious effects on physical and mental health well-being (Draper et al., 2008). Official reports indicate that the overall prevalence of lifetime childhood maltreatment has been estimated to approach 30% in population-based samples (Hussey et al., 2006, Finkelhor et al., 2009). Researchers have consistently shown that childhood maltreatment is associated with a range of mental disorders, including depression (see Alloy et al. (2006) for a review). For example, Widom, DuMont, and Czaja (2007) found that individuals who experienced childhood abuse or neglect were 1.51 times more likely to be diagnosed with major depressive disorder (MDD) as adults. Thus, it is important for clinicians to identify individuals who have been victims of childhood maltreatment and intervene before this negative experience may contribute to the development of a mood disorder.
Rutz (1995, 1999) has suggested that “male depression” is a distinct construct and differs from common depressive symptoms often found among females. It includes abrupt lowered stress tolerance, irritability, impulsive, aggressive, and/or psychopathic behavior, such as alcohol and/or drug abuse or abusive equivalents (e.g., work alcholism and excessive exercise), which often go unnoticed when trying to detect depression in men. Specifically, the Gotland Male Depression Scale (GMDS) not only focuses on overconsumption of alcohol/excessive activity, but also on positive family history of abuse/depression/suicide unlike major depressive syndrome. Rutz (1999) suggested that due to the alexithymic inability to ask for help together with atypical depressive symptoms (e.g., aggressive or abusive behaviors), depressed males experienced rejection or are misdiagnosed in the health care system.
Accordingly, the Gotland studies have resulted in a screening instrument for assessing depression in men, “GMDS”, which has recently been validated (Stromberg et al., 2010, Innamorati et al., 2011b). Moreover, Möller-Leimkühler and Yücel (2010) found that “male depression” might also be prevalent in females and suggested that the association between "male depression" and gender be further explored. The GMDS consists of typical depressive symptoms as well as emotional distress symptoms that are more commonly found in males than in females according to Walinder and Rutz (2001). However, the diagnostic criteria have focused on typical depressive symptoms, which may have resulted in “male” symptoms being overlooked. Previous studies examining gender differences in depressive symptoms have consistently found that men report fewer depressive symptoms than women (Parker and Brotchie, 2010). However, a gender bias in the assessment of depression could contribute to lower rates of depression in men.
Several lines of evidence have suggested the association between a history of child sexual abuse and both psychological and social adverse outcomes in adulthood. In particular, a consistent link has been found between childhood maltreatment and “male depression”. Rihmer et al. (2009) investigated the influence of childhood maltreatment on GMDS scores in 150 nonviolent suicide attempters suggesting a significant association among unfavorable psychosocial situations, negative life events, “male depression”, and suicidal behavior. Specifically, the authors reported that independent of gender, the “male” depressive syndrome was significantly more severe among those who had experienced either physical or sexual abuse during childhood. Traumatic early experiences may predispose individuals, in the authors׳ opinion, to suicidal behavior. Similarly, Brodsky et al. (2001) reported that adult inpatients with a childhood abuse history were more likely to report attempted suicide and have significantly higher impulsivity and aggression scores compared to those who did not report child maltreatment.
A significant association was also found between child sexual abuse and subsequent treatment for mental disorders using a prospective cohort design in a sample of 1612 children (Spataro et al., 2004). Interestingly, male victims had higher rates of childhood mental disorders such as personality, anxiety, and major affective disorders and were significantly more likely to have had treatment when compared to females. Studies have reported that higher levels of behavioral problems were present in adult males who were sexually abused during childhood as compared to their female counterparts (Darves-Bornoz et al., 1998, Horwitz et al., 2001).
Childhood maltreatment has also been found to be a significant risk factor for suicidal ideation and behaviors (Pompili et al., 2011, Rhodes et al., 2012, Bryan et al., 2013, Fergusson et al., 2013). Research (Mann et al., 2005, Zouk et al., 2006) has demonstrated a strong association between a past experience of childhood abuse and impulsive/aggressive behaviors, which may contribute to suicidality. Impulsivity and aggressiveness may predispose individuals to suicidal behavior regardless of psychiatric conditions, as they are associated with structural and functional dysfunctions in key brain regions implicated in the regulation of mood, impulse, and behavior. However, a complex and multifaceted interaction among crucial risk factors may be evoked to explain the association between childhood abuse, impulsive/aggressive behaviors, and suicidality. To this end, Wanklyn et al. (2012) suggested that in a sample of 110 incarcerated youths, impulsivity and hopelessness were important factors to consider when examining the relationship between childhood maltreatment and depression. Screening for impulsivity as well as hopelessness may increase clinicians׳ ability to identify those at greatest risk of self-harm and suicidal behavior. In a longitudinal study (Enns et al., 2006), childhood neglect, psychological abuse, and physical abuse were all strongly associated with new onset ideation and suicide attempts, even after controlling for the effects of mental disorders. Moreover, Andover et al. (2007) found that individuals with a history of suicide attempts were more likely to report histories of childhood physical and sexual abuse compared to those without a suicide attempt history. Similarly, Brezo et al. (2008) demonstrated that young adults who reported childhood abuse histories had up to a 14 times greater risk of attempting suicide. Furthermore, Joiner et al. (2007) observed a significant relationship between childhood physical and sexual abuse and lifetime suicide attempts, after accounting for several important covariates (demographic variables such as age, gender, and family of origin together with clinical variables such as individual and family psychiatric histories as well as childhood abuse), each of which was considered to be strongly associated with suicide- and abuse-related variables. In sum, the above studies highlight the strong association between childhood maltreatment and negative mental health outcomes, including depression and suicidality.
Thus, the aim of the current study was to evaluate the possible association between “male” depressive symptoms (Rutz et al., 1995, Rutz, 1999) and suicidal behaviors in psychiatric patients who reported a history of child abuse and neglect on the CTQ (Bernstein et al., 1994, Bernstein et al., 1997, Bernstein and Fink, 1998). We hypothesized that individuals who experienced a more severe history of child abuse and neglect would report more “male depression” symptoms, which include not only prototypical symptoms of major depression (e.g., depressed mood or diminished interest or pleasure in activities, sleep disturbances), but also externalizing symptoms such as irritability, aggressiveness, and abusive and risky behavior.
Section snippets
Participants
This cross-sectional study consisted of adult patients consecutively admitted to the Department of Psychiatry of the Sant’Andrea University Hospital in Rome, Italy, between January 2012 and December 2012. Inclusion criteria were admission in the time period indicated and any psychiatric diagnosis according to the DSM-IV-TR criteria. Exclusion criteria were the presence of any condition that may affect the ability to complete the assessment, including delirium, dementia or denial of informed
Characteristics of the sample
Descriptive statistics are listed in Table 1. Eighty-one patients received a diagnosis of bipolar disorder (either type 1 or 2; 49.7%), 32 a diagnosis of major depressive disorder (19.6%), 20 a diagnosis of psychosis or schizophrenia (12.3%), and 30 were diagnosed with another specified Axis I or Axis II disorder (mostly personality disorders or schizoaffective disorder; 18.4%). Around 30% of the sample reported moderate to severe history of emotional abuse in the childhood, 14.7% and 22.2%,
Discussion
In the current study, we examined the associations among childhood maltreatment, “male depression”, and suicidality in a sample of adult inpatients. Specifically, we first compared a group of patients who had experienced moderate to severe childhood abuse and/or neglect with patients who had no or minimal history of maltreatment on minimization/denial of child abuse, “male depression”, and suicidal ideation, planning, and attempts. A GLM was then constructed to determine which variables were
Conclusion
In spite of these limitations, the results from the current study along with previous work (Widom et al., 2007, Bryan et al., 2013) may have several practical implications and contribute to our understanding of “male depression” and suicidal behavior among psychiatric inpatients with maltreatment histories. The findings suggest that exposure to abuse and neglect as a child may increase the risk of subsequent symptoms of “male depression”, which have been associated with higher suicidal risk.
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