Adverse Childhood Events and the Risk for New-Onset Depression and Post-Traumatic Stress Disorder Among U.S. National Guard Soldiers

Transcription

1 MILITARY MEDICINE, 180, 9:972, 2015 Adverse Childhood Events and the Risk for New-Onset Depression and Post-Traumatic Stress Disorder Among U.S. National Guard Soldiers Sasha Rudenstine, PhD*; Greg Cohen, MSW*; Marta Prescott, PhD*; Laura Sampson, AB*; Israel Liberzon, MD ; Marijo Tamburrino, MD ; Joseph Calabrese, MD ; Sandro Galea, MD, DrPH* ABSTRACT This article examines the relationship between childhood adversity and postdeployment new-onset psychopathology among a sample of U.S. National Guard personnel deployed during Operation Iraqi Freedom and Operation Enduring Freedom with no history of post-traumatic stress disorder (PTSD) or depression. We recruited a sample of 991 Ohio Army National Guard soldiers and conducted structured interviews to assess traumatic event exposure, a history of childhood adversity, and postdeployment depression, and PTSD, consistent with the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. We assessed childhood adversity by using questions from the Childhood Adverse Events Survey. In multivariable logistic models, a history of any childhood adversity was significantly associated with new-onset depression, but not PTSD, postdeployment. This finding suggests that a history of childhood adversity is predisposing for new-onset depression, among U.S. National Guard soldiers who were deployed with no prior history of PTSD or depression. This highlights the centrality of childhood experience for the production of mental health among soldiers. INTRODUCTION Soldiers have a substantial burden of psychopathology, including post-traumatic stress disorder (PTSD), depression, and substance use disorders. 1 5 Deployment-related factors, particularly combat, are clearly linked to soldiers risk of mental illness. 6 9 However, a variety of other experiences and exposures shape soldiers vulnerability to mental illness. 10 These risk factors can be considered in three groups defined by their temporal relationship to a soldier s military service, i.e., factors that occur before, during, or after an individual s military involvement. 10 Adverse childhood experiences, such as physical, sexual, and emotional child maltreatment, predispose individuals to the development of adult psychopathology, in particular for mood and anxiety disorders. 11 Nonetheless, few studies have specifically assessed the role of childhood abuse on mental health functioning in combat-exposed military samples Studies of veterans of the Vietnam and Gulf Wars suggest that while combat exposure is the strongest predictor of PTSD, a soldier s risk of PTSD is significantly increased by a history of childhood physical abuse. 13,16,17 More recent studies with Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) troops have replicated these findings. For *Department of Epidemiology, Columbia University, 722 West 168th Street, Room 1505, New York, NY Department of Psychiatry, University of Michigan, 2215 Fuller Road, Ann Arbor, MI Department of Psychiatry, University of Toledo, 3120 Glendale Avenue Toledo, OH Department of Psychiatry, University Hospitals Case Medical Center, Case Western Reserve University, Euclid Avenue No. 526, Cleveland, OH doi: /MILMED-D example, OIF and OEF soldiers with a history of at least two types of childhood abuse (e.g., physical and sexual) are more vulnerable to depression and PTSD than those military personnel without such histories. 12 Moreover, childhood physical abuse and combat exposure were independently associated with postdeployment PTSD, anxiety, and depression. 18 Additionally, there is increasing evidence of a relationship between a history of childhood abuse and difficulty developing and maintaining a network of social support over the life course. 15 Consequently, it is plausible that National Guard soldiers and reservists, who partake only in a limited way in military culture between deployments, may be at particular risk of the consequences of early childhood experiences if their civilian social support is limited. Further, the life circumstances and postdeployment affiliation with the military among National Guard soldiers are substantially different than those of active duty soldiers. For example, National Guard soldiers typically train only one weekend per month in addition to 2 weeks every summer, and unlike active military personnel, many National Guard soldiers have civilian employment that they leave when deployed and which may not be available to them on their return. These factors, among others, may contribute to the differences in the psychological consequences of deployment on National Guard soldiers compared to regular duty soldiers, irrespective of their deployment responsibilities and/or combat exposure. 19,20 Despite the evidence that a history of childhood adversity heightens a soldier s risk for developing psychopathology, to our knowledge, no study has examined the relationship between childhood maltreatment and postdeployment pathology among soldiers with no prior history of depression and/ or PTSD. Therefore, it remains unclear if prior history of adversity is linked to postdeployment mental illness only 972

2 through the mediating influence of antecedent predeployment illness. Clarifying the effect that a history of childhood maltreatment may have on (i) how National Guard soldiers endure the experiences associated with deployment and (ii) their subsequent susceptibility to new-onset depression and/or PTSD following deployment, therefore, has potential to focus etiologic understanding and to guide potential intervention. Informed by the import of childhood events on one s vulnerability to adult stressors, this article addresses how having a history of childhood maltreatment serves as a risk factor for mental illness among deployed National Guard soldiers with no history of depression or PTSD. Specifically, using data from a longitudinal prospective cohort study of a representative sample of Ohio Army National Guard (OHARNG), we aimed to examine the effect of childhood abuse on incident depression and incident PTSD after deployment. METHODS AND MATERIALS OHARNG MHI and Study Population Data were drawn from the Ohio Army National Guard Mental Health Initiative (OHARNG MHI). The OHARNG MHI is a longitudinal cohort of OHARNG soldiers who are interviewed annually to assess mental health, substance use, and life experiences. The study contacted all soldiers who were enlisted between June 2008 and February 2009 through a letter, which notified them of the study. Of these, 11,212 soldiers did not return an opt-out card and allowed the OHARNG to release their contact information. Among these released telephone numbers, 58.1% were working and accurate (n = 6,514). Of the 6,514 who were potential participants, 20.9% (n =1,364)didnotwanttoparticipate,2.9%(n =187) were ineligible (e.g., retired or too young), 0.5% (n =31) were ineligible (e.g., hard of hearing), and 35.6% (n = 2316) were not contacted before the cohort closed. The final sample had 2,616 with a survey response rate of 43.2%. Participants were contacted for follow-up interviews in November of 2009, within 12 months of their original interview and given 12 months to respond. Of the original 2,616 soldiers 67.7% responded to follow-up surveys (n = 1,770). Forboth survey waves, after providing informed consent, soldiers participated in an hour-long computer-administered telephone interview (conducted by highly trained lay interviewers at Abt SRBI) that obtained information on mental health, substance use, military experiences, and life events history. The main health indicator of interest in this investigation was the risk of new-onset PTSD or new-onset depression first developed during or after the respondents most-recent deployment. Using the Posttraumatic Stress Disorder Checklist-17 (civilian version), 21 we obtained the report of 17 PTSD symptoms in relation to a specific event, as well as feelings of fear or hopelessness at the time of the event, duration of symptoms, and the presence of any impairment linked to symptoms. Nondeployment-related traumatic events were assessed using a list compiled from the Life Events Checklist, 22 and events from Breslau et al 23 ; the deploymentrelated traumatic events were assessed using that same list, asked in reference to their most recent deployment, and also added items from the Deployment Risk and Resilience Inventory. 24 Participants were asked to relate PTSD symptoms to their worst deployment-related traumatic event, as well as to their worst nondeployment-related event (if this event occurred after their most-recent deployment). Thus, we included in our case definition of PTSD: (a) cases linked to a most-recent-deployment event, that onset during or after their most recent deployment, and (b) cases that linked to a nondeployment event, that onset following participants most recent deployment. The probable diagnosis of PTSD was then assessed using Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria. 25 Participants who reported a traumatic event (A1), fear or helplessness (A2), were bothered at least moderately (3) by at least one symptom of intrusion (criterion B), at least three symptoms of avoidance and numbing (criterion C), and at least two symptoms of hyperarousal (criterion D), had symptoms lasting for at least a month (criterion E) and reported as very difficult (3) or extremely difficult (4) either social or function impairment (criterion F) were categorized as having PTSD. To categorize depression, we used the Patient Health Questionnaire Participants were categorized with depression if they had either five out of nine possible symptoms (major depressive disorder) or between two and five symptoms (other depressive disorder). 26 Additionally, the symptoms had to occur together within a 2-week period, had to occur at least more than half the days, and at least one of the symptoms had to be depressed mood or anhedonia. In a clinical reappraisal of 500 participants of the telephone survey, the PTSD categorization we describe above had excellent specificity at 92% and moderate sensitivity at 54%, as compared to the Clinician-Administered PTSD Scale Similarly, the depression categorization had good specificity at 83% and moderate sensitivity at 51%, as compared to the gold-standard Structured Clinical Interview for DSM. 30 The validity of the telephone survey categorization suggests that it functions well as a research tool with its high specificity, but should not be used to diagnose individual participants due to its lower sensitivity. 27 Our main exposures of interest were whether participants experienced several categories of child maltreatment. We assessed these experiences using questions from the Childhood Adverse Events Survey. 31 To assess emotional abuse, participants were asked (yes vs. no) did a parent or other adult in the household you grew up in often or very often insult you, put you down, or act in a way that made you afraid you would be physically hurt? To assess physical abuse, participants were asked (yes vs. no) did a parent or other adult in the household you grew up in often or very often grab, shove, or slap you, or hit you so hard you had marks or were injured? To assess sexual abuse, participants were asked (yes vs. no) Did a parent or other adult in the 973

3 household you grew up in touch you or have you touch them in a sexual way, or attempt to or actually have oral, anal, or vaginal intercourse with you? These exposures to childhood maltreatment were not mutually exclusive; those who were physically abused may also have been sexually abused. These three questions were also combined to assess if the soldier had experienced any childhood maltreatment. Statistical Analysis The study sample for this work was the 1,770 soldiers who participated in both the baseline and the first follow-up survey to allow us the assessment of child abuse at baseline and the assessment of incident PTSD or depression at follow-up. Therefore, we limited the sample to those who had some form of deployment experience (N = 1143, 64.8%) and then further limited it to those who did not have symptoms of PTSD or depression before their most recent deployment to examine incident, or new-onset, cases (N = 991, 87%). First we examined the distribution of new-onset PTSD or depression that developed during or after the soldiers most recent deployment. We then examined the distribution of selected characteristics of the sample, and in bivariable logistic regression, examined the association between these selected characteristics and new-onset PTSD or depression among those who had been deployed. We examined the association of childhood maltreatment with new-onset PTSD or depression using multivariable logistic regression. These models were adjusted for age (17 24 as reference, 25 34, 35 44, 45+), gender, and whether this most recent deployment was combat related. Prior deployments were classified as conflict or nonconflict, based on service dates and location. In particular, conflict deployments included deployments that took place in Afghanistan between 2001 and 2011, and in Iraq between 2003 and 2011; all other deployments were classified as nonconflict. We ran these multivariable models twice, once among all deployed participants, and then once among those who experienced at least one traumatic event while deployed. We explored the use of Firth s penalized likelihood function in our multivariable logistic models to account for potential bias induced by small sample size and found that the estimates were comparable to those in our standard logistic models; accordingly we present the standard models for simplicity. 32 The OHARNG MHI has been approved by the Institutional Review Boards of Columbia University, Case Western Reserve, University of Toledo, University of Michigan, and the Department of Defense and is supported by a grant from the Congressional Department of Defense Appropriation, the Combat Mental Health Initiative. RESULTS The distribution of selected characteristics in the study sample is presented in Table I. The most commonly reported form of reported child maltreatment was emotional abuse (10.6%), followed by physical abuse (9.7%); 1.2% of soldiers reported experiencing sexual abuse as a child. Of all soldiers, 13.8% reported some form of child abuse, with 6.7% overall reporting one type and 7.2% overall reporting two or more types. Regarding demographic characteristics, 8.8% of the sample were female, and most were between the ages of 25 and 44 (70.7%). Close to half (46.5%) of soldiers had been deployed to conflict settings. Overall, 6.6% of soldiers developed new-onset PTSD during or after deployment and 10.5% of soldiers developed new-onset depression either during or after deployment. Bivariable results are listed in Table I. Experiencing sexual abuse as a child was associated with new-onset PTSD (odds ratio [OR]: 8.5; 95% confidence interval [CI]: ). Experiencing any child abuse (OR: 1.9; 95% CI: ) or 2 or more types of child abuse was associated with newonset depression (OR: 2.5; 95% CI: ), as was emotional abuse (OR: 2.4; 95% CI: ) and physical abuse (OR: 1.9; 95% CI: ). Female gender was associated with new-onset PTSD (OR: 3.4; 95% CI: ) and newonset depression (OR: 2.0; 95% CI: ). Multivariable logistic regression results examining the association between experiencing any childhood maltreatment and new-onset PTSD or depression are listed in Table II. Models were first fit among the entire sample (Models 1, 2), and then among the subsample who experienced at least 1 traumatic event in their most recent deployment (Models 3, 4). In final adjusted Models 3 and 4, we found that experiencing any form of child abuse was significantly associated with new-onset depression (adjusted odds ratio [AOR]: 1.8; 95% CI: ), but not with PTSD (AOR: 1.7; 95% CI: ). Gender was associated with incident PTSD and depression, whereas age and conflict setting were related to neither. DISCUSSION Taking advantage of a longitudinal study of U.S. National Guard soldiers, we sought to understand the role that adverse childhood events (physical, sexual, and/or emotional abuse) can have on new-onset adult depression or PTSD following deployment. We found, first, that a history of childhood maltreatment is predisposing to new-onset depression among National Guard soldiers who have been deployed and who do not report a lifetime history of PTSD or depression. Second, we did not find a significant association between having a history of adverse childhood events and developing PTSD during or after deployment. This suggests that there may be different mechanisms contributing to the role that childhood maltreatment has on new-onset adult depression and PTSD. The present analysis suggests that among soldiers with no lifetime PTSD or depression, a history of childhood abuse is a contributor to a soldier s risk of developing depression during or following deployment, independent of the soldier s traumatic event exposure history. These findings are consistent with the existing literature on the role of childhood maltreatment on adult psychopathology more generally and 974

4 TABLE I. Distribution (Number [%]) of Individuals With Selected Characteristic and the Distribution (Number [%]) of Individuals Who Developed Psychopathology Symptoms During or After Deployment by Each Selected Characteristic Characteristic TABLE II. Total Sample Number (%) illustrate the importance of childhood experiences on lifetime mental health, even in the face of other, marked adversity. 11,15,18,33 38 There are a number of potential explanations for why a history of childhood maltreatment might be a risk factor for depression among deployed National Guard soldiers. Prolonged or recurring adverse childhood experiences may permanently alter how the body s hypothalamic pituitary adrenal axis responds to stress Consistent with the accumulation of stress model, exposure to exorbitant or ongoing stress during core developmental years (i.e., sensitive periods) may alter underlying biological and/or psychological processes that dayto-day are undetectable, but which challenge the individual s Adjusted Association (OR, 95% CI) Between Incident Psychopathology Development and History of Any Type of Child Abuse Model 1 PTSD (N = 908) Number (%) Who Develop PTSD Everyone With All the Values for the Model Model 2 Depression (N = 983) Limiting to Those Who Experienced At least 1 Traumatic Event Model 3 PTSD (N = 697) Model 4 Depression (N = 748) Characteristics AOR, 95% CI AOR, 95% CI AOR, 95% CI AOR, 95% CI Any Abuse (Yes vs. No) 1.6 ( ) 1.9 ( ) 1.7 ( ) 1.8 ( ) Gender (Female vs. Male) 3.3 ( ) 1.6 ( ) 3.6 ( ) 1.9 ( ) Age (Reference, Years) ( ) 1.6 ( ) 0.5 ( ) 1.5 ( ) ( ) 1.5 ( ) 0.7 ( ) 1.2 ( ) ( ) 1.7 ( ) 0.8 ( ) 1.4 (0.6, 3.2) Most Recent Deployment 2.6 ( ) 1.3 ( ) 1.6 ( ) 1.0 ( ) Setting to Conflict Setting (Yes vs. No) 2 log Likelihood OR Number (%) Who Develop Depression Any Child Abuse No 854 (86.2) 47 (6.0) 1 80 (9.4) 1 Yes 137 (13.8) 13 (10.2) 1.7 ( ) 23 (16.9) 1.9 ( ) Emotional Abuse No 886 (89.4) 50 (6.2) 1 82 (9.3) 1 Yes 105 (10.6) 10 (10.3) 1.7 ( ) 21 (20.2) 2.4 ( ) Physical Abuse No 895 (90.3) 50 (6.1) 1 85 (9.6) 1 Yes 96 (9.7) 10 (11.2) 1.7 ( ) 18 (19.0) 1.9 ( ) Sexual Abuse No 979 (98.8) 57 (6.3) (10.4) 1 Yes 12 (1.2) 3 (30.0) 8.5 ( ) 2 (16.7) 2.0 ( ) Dose of Child Abuse No Child Abuse 854 (86.2) 47 (6.0) 1 80 (9.4) 1 Reported 1 Type 66 (6.7) 5 (8.1) 1.4 ( ) 7 (10.6) 1.2 ( ) Reported 2 or More Types 71 (7.2) 8 (12.3) 2.0 ( ) 16 (22.9) 2.5 ( ) Gender Male 904 (91.22) 48 (5.8) 1 90 (10.0) 1 Female 87 (8.8) 12 (15.3) 3.4 ( ) 13 (14.9) 2.0 ( ) Age (Years) (20.8) 14 (9.9) 1 12 (7.4) (39.4) 18 (5.1) 0.5 ( ) 44 (11.3) 1.5 ( ) (31.3) 18 (6.2) 0.6 ( ) 32 (10.4) 1.2 ( ) (12.7) 10 (8.3) 0.7 ( ) 15 (12.2) 1.4 ( ) Most Recent Deployment Setting Nonconflict 530 (53.5) 20 (4.1) 1 49 (9.3) 1 Conflict 461 (46.5) 40 (9.4) 1.5 ( ) 54 (11.8) 1.0 ( ) Total (6.6) 103 (10.5) OR 975

5 ability to tolerate and cope effectively with stressors encounteredinlaterlife. 15,18,35,36,44 47 Similarly, the trauma sensitization model suggests that previous exposure to trauma reduces an individual s resilience to new traumas. 48 Hence, among deployed National Guard soldiers with no previous depression those who report a history of childhood abuse are more susceptible to developing incident depression than their peers who do not report childhood maltreatment. The question remains, however, how adverse early life events, which had not triggered mental illness in youth and/or young adulthood, can weaken one s resilience during or after deployment. One possible explanation is that the psychological sequelae of child abuse may be suppressed and that the experience of being deployed a potentially significant stressor in essence triggers a phenotype that had been unexpressed. In this case, and similar to the accumulation of stress and trauma sensitization models, exposure to excessive stress during deployment may trigger physiological and psychological vulnerabilities that make one more susceptible to depression. For example, an analysis from the National Comorbidity Survey-Replication data found that childhood adversity has a direct effect on functional impairment in every stage of the adult life course. 36 This finding is further evidence that having a history of childhood maltreatment leaves one susceptible to adult psychopathology irrespective of the time period since maltreatment and/or having a history of prior psychopathology. Our second key finding is the lack of a significant association between childhood maltreatment and PTSD among National Guard personnel. Although previous studies have found an association between adverse childhood events and PTSD among soldiers, these studies examined all soldiers regardless of their mental health history, which may have exacerbated the relation between childhood trauma and the risk of PTSD. 12 To focus only on new-onset PTSD as related to deployment, we excluded those who had a history of PTSD before deployment. Therefore, our work demonstrates that the association between childhood trauma and incident PTSD among deployed National Guard may be weaker than prior research indicates. Our findings are inconsistent with the trauma sensitization model and thus suggest that a different mechanism may contribute to the relationship between a history of childhood trauma and new-onset adult PTSD. This conclusion is consistent with prior research related to the postdisaster context that found PTSD onset to be driven primarily by an individual s experience of the traumatic event vis-à-vis other variables. 49 To our knowledge, aside from this current study, there is little data assessing how a history of childhood maltreatment is associated with incident depression and incident PTSD. Consequently, we apply a broader literature to help understand our findings. Unlike depression, which has been shown to develop spontaneously in the context of stress, PTSD by definition necessitates an identifiable trauma. 50 Therefore, the predominant predictors of an individual s vulnerability to a trauma may be demographics and variables related to current functioning or context as opposed to childhood experiences. 49 In this vein, one study found that current mental health functioning before deployment was strongly associated with incident PTSD among combat soldiers of OIF and OEF. 6 Additionally, it is suspected that due to developmental maturity, traumatic experiences in childhood will be processed differently than traumatic experiences in adolescence or adulthood, and consequently may result in a greater vulnerability for depression than for PTSD. 51 This study benefited from its population-based longitudinal design, allowing us to understand relations between a history of child abuse and incident depression and PTSD within a U.S. National Guard sample who had been deployed. Elements of our study, however, introduce limitations to the study findings. First, since reports of childhood adversity are retrospective there may be reporting bias. However, there is compelling literature suggesting that (i) current mental health does not affect retrospective reporting of child abuse, and (ii) retrospective reporting is more often associated with underreporting of child abuse than with overreporting. 52,53 Additionally, the consistency of association across psychopathology and type of abuse found in this study mitigates this concern. Second, because of the minimal reporting of childhood sexual abuse we could not explore the relationship between sexual abuse and incident depression or PTSD while we were able to control for lifetime depression or PTSD. Third, we did not account for other types of mental illness, such as generalized anxiety disorder or substance use, which are also correlated with child maltreatment. 11,35 37,43,54 Fourth, our decision to categorically define PTSD and depression in accordance with the DSM-IV, as our research question was focused on the risk of PTSD or depression and not necessarily PTSD or depression symptoms, may have excluded individuals with subthreshold PTSD and/or depression. Fifth, the moderate sensitivity of both our PTSD and depression instruments may have led to an underestimation of the magnitude of the relationship between adverse childhood events and new-onset adult depression or PTSD. Sixth, the operationalization of child abuse for this analysis was limited to perpetration by parents and/or adults living in the home, which may underestimate the prevalence of abuse. However, since no research participant reported that he/she experienced another form of child abuse when asked if he/she experienced any traumatic experience not specifically asked about in the survey we believe we have captured experiences of child abuse as comprehensively as possible within the confines of this particular study s parameters. Seventh, as with all population-based samples, and specifically with military samples, there remains a concern that our sample is not representative of all U.S. National Guard. However, we took careful measure to obtain a representative sample of Ohio National Guard and analyses show that there are no significant differences between our sample 976

6 and characteristics of the Ohio National Guard. 55 Hence, we believe these findings can inform our understanding of the vulnerability for PTSD and depression among National Guard soldiers with a history of child abuse. Lastly, our analyses did not control for a number of variables, such as preparedness and social support during and after deployment, which may also contribute to the mental health functioning of soldiers. 19,20,56 Notwithstanding these limitations, this article documents that a history of childhood maltreatment is significantly associated with incident depression among a sample of U.S. National Guard soldiers. There are two implications of our work. First, although PTSD is the disorder most often associated with military personnel, this article highlights the significant role that premilitary experiences may have on a soldier s susceptibility for incident depression postdeployment. Second, raising awareness of the role that childhood experiences can have on adult vulnerability to mental illness, especially in contexts that are characterized by stressors, is a critical step in helping prevent and treat the psychological ramifications of deployment. ACKNOWLEDGMENT This work was funded by the Congressional Department of Defense Appropriation W81XWH /W81XWH , the Combat Mental Health Initiative. REFERENCES 1. Brown T, Hull L, Horn O, et al: Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. Br J Psychiatry 2007; 190: Kline A, Falca-Dodson M, Sussner B, et al: Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: implications for military readiness. 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