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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 169-172

Childhood adversity in patients suffering from depression with a focus on differences across gender

Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Submission10-Mar-2021
Date of Decision25-Mar-2021
Date of Acceptance14-Apr-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Bhumika Shah
Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr. A L Nair Road, Mumbai Central, Mumbai - 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_28_21

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Context: Childhood adversity is highly prevalent and is associated with depression. Aims: The aim of the study is to assess the occurrence of adverse childhood experiences (ACEs) in male and female patients suffering from depression, measure its relationship with the severity of depression, and evaluate the association of factors across gender. Settings and Design: A cross-sectional study was conducted. Subjects and Methods: A total of 100 adult depressed patients were evaluated to calculate the severity of depression and the ACE score. Statistical Analysis Used: Statistical analysis was performed using Chi-square test and binary logistic regression. Results: One or more categories of ACEs were reported in 70% of male and 68% of female patients. The most common was violence between adults in the household and physical abuse. In male patients, there was a significant association between severity of depression and experiencing three or more categories of childhood adversity (P = 0.01). Conclusions: Childhood adversity occurs frequently and is associated with severity of depression in the male cohort.

Keywords: Adverse childhood experiences, depression, gender

How to cite this article:
Shah B, Kedare J, Mehta F. Childhood adversity in patients suffering from depression with a focus on differences across gender. Ann Indian Psychiatry 2021;5:169-72

How to cite this URL:
Shah B, Kedare J, Mehta F. Childhood adversity in patients suffering from depression with a focus on differences across gender. Ann Indian Psychiatry [serial online] 2021 [cited 2023 Jan 31];5:169-72. Available from: https://www.anip.co.in/text.asp?2021/5/2/169/329431

  Introduction Top

Adverse childhood experiences (ACEs) are traumatic events that occur before the age of 18 years and cause social, emotional, and cognitive impairment, leading to high-risk behaviors, disease, and early death. The first ACE study revealed that two-third of American adults have experienced at least one ACE.[1],[2],[3] These include multiple types of abuse, neglect, witnessing parental violence, and peer, community, and collective violence. Literature reports that six in ten people have experienced at least one ACE.[4] A survey indicates that a similar proportion of respondents reported ACEs from various countries across all income groups.[5]

A person who has experienced three or more categories of ACEs is six times more likely to suffer from depression.[6] Literature reports that 75% of depressed patients have experienced at least one category of ACE.[7],[8] In this population, the disease is found to be less responsive to treatment, with fewer chances of achieving remission, higher chances of relapse and recurrence, and poorer prognosis.[9] Higher the number of categories of ACEs experienced, more severe is the depression.[7],[10] Understanding this association is essential in the prevention and early intervention. It is reported that decreasing childhood adversities would lead to a 22.9% decrease in mood disorders.[11]

The aim was to study the occurrence of ACEs in male and female patients diagnosed with depression, explore the relationship between depression and ACEs in these patients, and assess the association of factors across gender.

  Subjects and Methods Top


A cross-sectional study of adult depressed outpatients was carried out for 3 months. Participants included acute, chronic, or remitted patients of either major depressive disorder (MDD) or persistent depressive disorder (PDD), diagnosed as per the Diagnostic and Statistical Manual of Mental Disorders 5. The sample size was calculated based on a pilot study where the frequency of ACEs was 60% among female patients and to 90% among male patients diagnosed with depression. Based on this, the sample size calculated was 28.747 of female and male cases each. However, since resources existed in sufficient quantity, we planned on enrolling a minimum of 50 depressed individuals of each gender.

The patients were between 19 and 60 years of age, without any comorbid mental illness and substance use disorder (except nicotine use disorder). Approval of the institutional ethics committee and individual consent of each patient were obtained before the study.


An intake sheet including sociodemographic details, diagnosis, “Severity Measure for Depression-Adult” to measure the severity of depression,[12] and “Behavioral Risk Factor Surveillance System Adverse Childhood Experience Module”[13] was administered.

Statistical analysis

Qualitative data were represented in the form of frequency and percentage. The tests used were Chi-square, with continuity correction for all 2×2 tables, and Fisher's exact test for all 2×2 tables where Chi-square test was invalid due to small counts. Pairwise Chi-square tests were used to ascertain the association between frequencies of ACEs with the severity of depression after stratifying by gender. Multiple hypothesis testing corrections were performed using the Bonferroni method. A P ≤ 0.05 was considered statistically significant. To determine risks associated with gender, we conducted binary logistic regression with gender (male = 1, female = 0) as the dependent variable and various independent variables. To do this, we used the glm function with family = binomial (link = “logit”) in R (Ver. 3.6) (R core team of the R project for statistical computing).

  Results Top

A total of 100 patients were assessed. The mean age was 41.1±10.6 years (39.2±11.1 years in males and 43±9.8 years in females), with the mean duration of illness being 59.4±61.5 months (59.8±61.5 in males and 59±62.1 in females). MDD was present in 79% of the patients, whereas the rest had PDD. Family history of mental illness was reported in 26% and medical comorbidity in 37% of patients, with the most common being hypertension, hypothyroidism, and diabetes mellitus.

The mean score for depression in male patients was 8.1±5 and 8±5.8 in female patients. Based on the total score in PHQ9, the patients were grouped as either none–minimum depression or mild–severe depression, with no statistical difference in the severity of depression in male and female patients across these two groups (P = 0.83).

One or more categories of childhood adversity were reported in 70% of the male and 68% of female patients. No significant differences were observed in frequency of ACEs when compared across gender (P = 0.89). [Table 1] depicts the frequency and type of ACEs across gender [Table 1].
Table 1: Comparison of adverse childhood experiences and depression based on gender

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In male patients, there was a significant difference in the number of categories of ACEs experienced by patients having minimal–no depression versus those with mild–severe depression (P = 0.01). Post hoc analyses using pairwise Chi-square tests followed by Bonferroni correction showed significance in the group experiencing three or more categories of childhood adversity. There is no such relationship observed in female patients.

Logistic regression analysis was used to examine gender-associated risks in our dataset. We found that ACE categories of physical abuse (P = 0.03), emotional abuse (P = 0.03), household violence (P = 0.03), and living with a mentally ill household member (P = 0.04) were risks associated with females and total ACE score (P = 0.03) and having no comorbidities (P < 0.00) were risks associated with males.

  Discussion Top

The current study evaluates the occurrence of childhood adversity in male and female patients diagnosed with depression and its relationship to the severity of depression. Consistent with our hypothesis and literature, the majority of male (70%) and female (68%) patients have experienced ACEs. Literature reports that 77.2%–84.61% of depressed patients have experienced at least one category of childhood adversity.[7],[8] There have been reports of the cumulative effect of the adverse experiences impacting future depression. Vitriol et al. reported that 43% and Poole et al. reported 58% of the patients with MDD experience three or more categories of childhood adversity which is higher compared to our results.[14],[15] Three or more categories of childhood adversity were present in 24% of our patients. Our sample has fewer patients reporting multiple categories of ACEs, which may indicate that either fewer occurrence of ACEs or less disclosure. Differences may be attributable to cultural and regional variations. Unfortunately, there are scant data on the occurrence of ACEs in the Indian population, which prevents forming conclusions. A study on the Indian youth has shown physical abuse being the most common childhood adversity in both genders and males experienced higher childhood adversity in all domains.[16] Physical abuse was least common in another study on Indian youth.[17] Frequency or a cumulative effect has also been associated with severity of depression.[7],[9],[10] We found this to be true only for male patients in our cohort, where a higher frequency of adverse events was associated with more severe depression. This may be mitigated by the beneficial role of other factors such as social support, effective coping mechanisms, and resilience in patients which may decrease the severity of depression. Further research needs to shed light on this finding.

Besides studying the frequency of ACEs, the type of adversity has also been investigated and literature shows conflicting reports. While some studies have reported neglect and emotional abuse linked to depression, another study has said that any form of adversity can cause depression.[18],[19] Physical abuse and violence in families were part of the top categories of childhood adversity experienced by both male and female patients in our study. Male patients also reported a high occurrence of household substance abuse, whereas female patients reported emotional abuse. Many studies have reported substance abuse, household dysfunction, verbal and physical abuse as the frequent categories of ACEs in women suffering from depression.[4],[14],[18],[19] Sexual abuse is not as prevalent in our study, and this may be an artifact of self-reporting. Logistic regression revealed that the ACE categories of physical abuse, emotional abuse, household violence, and living with a mentally ill household member were risks associated with depression in females. At the same time, in males, it was the total ACE score. This differential association may imply that specific types of adversity rather than the overall score may be consequential in females. Researchers explain that women are more inclined to blame themselves or be blamed following victimization and manifest internalizing behaviors. It is also speculated that the tendency to internalize stress symptoms and dwell on negative emotions is more pronounced among women due to sociocultural factors.[20]

While our study confirms the role of ACE, its frequency, and its type implicated in depression, it has also revealed some differences across gender. This should be interpreted by keeping the limitation that this was a hospital-based cross-sectional study using a convenience sample and self-reported scales. Future research including prospective studies in the Indian context with a larger sample would provide more clarity.

In conclusion, our research reveals that more than two-thirds of depressed male and female patients have experienced childhood adversities. In male patients, there was a correlation between the severity of depression and having more than three adversities. This highlights the need to inquire and treat ACEs in patients suffering from depression. Multisectoral efforts to reduce or eliminate the occurrence of ACEs and its impact are required.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Springs FE, Friedrich WN. Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clin Proc 1992;67:527-32.  Back to cited text no. 1
Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-31.  Back to cited text no. 2
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245-58.  Back to cited text no. 3
Raheel H. Depression and associated factors among adolescent females in Riyadh, Kingdom of Saudi Arabia, A cross-sectional study. Int J Prev Med 2015;6:90.  Back to cited text no. 4
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Patient Health Questionnaire (PHQ) Screeners. PHQ-9. Available from: https://www.phqscreeners.com/. [Last accessed on 2021 Apr 27].  Back to cited text no. 12
Center for Disease Control and Prevention. Atlanta: Behavioral Risk Factor Surveillance System Adverse Childhood Experience (ACE) Module. Available from: https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-brfss.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Face_brfss.html. [Last accessed on 2021 Apr 27]; Last updated on 2020 Apr 03].  Back to cited text no. 13
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