The relationship between subjective experience of childhood abuse and neglect and depressive symptoms during pregnancy

Accepted Manuscript The relationship between subjective experience of childhood abuse and neglect and depressive symptoms during pregnancy Sinem Yildiz Inanici, Mehmet Akif Inanici, A. Tevfik Yoldemir PII:

S1752-928X(17)30067-7

DOI:

10.1016/j.jflm.2017.05.016

Reference:

YJFLM 1502

To appear in:

Journal of Forensic and Legal Medicine

Received Date: 5 September 2016 Revised Date:

20 December 2016

Accepted Date: 24 May 2017

Please cite this article as: Yildiz Inanici S, Inanici MA, Yoldemir AT, The relationship between subjective experience of childhood abuse and neglect and depressive symptoms during pregnancy, Journal of Forensic and Legal Medicine (2017), doi: 10.1016/j.jflm.2017.05.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT “The relationship between subjective experience of childhood abuse and neglect and depressive symptoms during pregnancy”

Sinem YILDIZ İNANICI

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Marmara University School of Medicine, Department of Medical Education, İstanbul, Turkey [email protected]

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Mehmet Akif INANICI

Marmara University School of Medicine, Department of Forensic Medicine, İstanbul, Turkey

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[email protected]

A. Tevfik YOLDEMİR

Marmara University School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey

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[email protected]

Corresponding Author name mailing address:

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Sinem YILDIZ İNANICI

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Marmara University School of Medicine, Department of Medical Education, Başıbüyük Mah. Maltepe Başıbüyük Yolu Sok. No: 9/1 Maltepe, İstanbul, 34854, Turkey Contact phone number: + 90 216 421 2222-2003; + 90 535 815 61 52 Fax number: + 90 216 625 4728 E-mail: [email protected]

ACCEPTED MANUSCRIPT “The relationship between subjective experience of childhood abuse and neglect and depressive symptoms during pregnancy” Abstract

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Introduction: Childhood abuse and neglect have devastating effects in adulthood such as depression. During pregnancy, depression’s effects in women have great importance

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due to its serious consequences for both children and families.

It is aimed to find out a relationship between childhood abuse/neglect and depression

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among pregnant women.

Methodology: 144 married and healthy volunteer pregnant women were recruited between February-May 2015 during their regular hospital visit. Beck Depression Inventory and Childhood Trauma Questionnaire were used to evaluate depression and

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childhood abuse experiences.

Results: The participants’ mean age was 29.37 years (SD ±4.71) and the average

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duration gestation was 28.81 weeks (SD = 5.05). Depressed women tended to get marry earlier (M = 21.07, SD = 3.47) than the non-

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depressed group (M = 22.55, SD = 3.36) (p = .012) and they had higher number of lifetime gestations (M = 3.31, SD = 2.06) than their non-depressed counterparts (M = 2.33, SD = 1.26) (p = .001). Each abuse and neglect score helped to predict the participants’ depression scores. Conclusions: Scanning of pregnant women for both depression and childhood trauma will give change to health providers to support this vulnerable group and their prospective children.

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ACCEPTED MANUSCRIPT Introduction Childhood abuse and neglect have devastating effects not only during childhood but also in adulthood. Increased risk for suicide attempt, problems in the marriage (1),

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enhanced anxiety, anger, physical symptoms, and depression (2) are among these longterm consequences. As one of these long-term consequences, depression is a common disorder that causes role impairment (3).

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During pregnancy, depression’s effects in women have great importance due to its

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serious and long-lasting consequences for both children and families (4). Evidence suggests that maternal distress is associated with prematurity and low birth weight (5), poor health, and limitation in moderate activities in infants (6). Besides, becoming a mother psychologically requires the working of mental schemas that were mutually shaped by expectant mothers and their own parents (7). This process might be difficult

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and disrupted in women with childhood abuse and neglect experiences. Therefore, depression during pregnancy might damage mother-child relationship (8) and

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depression in adulthood may be one of the predictors of passing abusive behaviour from generation to generation (9). Therefore, it is important to understand related risk factors

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to provide help for the well-being of women and foetus.

Strictly speaking, scientific research has focused primarily on postpartum depression and less attention has been paid to the possible association between a history of abuse and maternal depression during pregnancy and the postpartum period (10). It is now recognized that antenatal depression is just as problematic as postpartum depression (4). Actually, depression during pregnancy also has a correlation with postpartum

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ACCEPTED MANUSCRIPT depression (11). Women with antepartum depressive symptomatology may show earlier obstetric complications (12) and pregnant women with a history of abuse may experience severe depression symptoms (13). Therefore, early identification and

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treatment of it will decrease morbidity and mortality for the woman, the child, and the family (14) and let the clinicians understand specific needs of abused expectant mothers (15). Due to aforementioned detrimental effects, it is suggested to study the relationship

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between abuse and depression with larger samples and include pregnant women (16).

This study aims to reveal the differences in childhood abuse and neglect experiences

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between depressed and non-depressed pregnant women as classified by Beck Depression Inventory (BDI) scores and investigate the predictive role of abuse among other factors for depression during pregnancy.

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Method

X University Ethical Committee approved the study and a hundred and forty-four volunteer pregnant women were recruited between February-May 2015 during a

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prenatal visit to the Department of Obstetrics and Gynaecology of X University

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Hospital. The inclusion criteria were being healthy physically and having no complications related to pregnancy at the time of the study. Participants’ doctors verified these requirements before their admission to the study and after that, participants were introduced to the study subject and asked for filling the questionnaires by themselves upon their informed consent. Approximately forty-four percent of the participants (n = 63) were classified depressed according to BDI scores. Depressed and non-depressed groups were similar in their mean age (F = 1.40, t = -.75, df = 142, p = .451), mean week of gestation (F = .136, t = .552, df = 142, p = .582), previously having

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ACCEPTED MANUSCRIPT an abortion or not (X2 (1) = 3.27, p = .080), the rates of having treatment for their current pregnancy or not (X2 (1) = .158, p = .726).

Depression was assessed by Turkish version of BDI (17). This 21-item inventory

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evaluates affective, cognitive, and motivational dimensions of depression by responses from 0-3. The higher the score the more severe the depressive symptoms and its cut-off

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score is 17 (18).

The Turkish version of the Childhood Trauma Questionnaire (CTQ) was used to

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evaluate childhood abuse experiences of the participants (19). It is a self-report inventory that has five different subscales (each with five items and responses ranging from 1 to 5) emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect. For each scale, total scores can range from five to 25 and the higher the score

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the higher the frequency of childhood abuse and neglect.

Descriptive and frequency analyses, Chi-square Test, Independent Samples T-test and Binary Logistic Regression analyses were used to compare groups’ scores and make

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predictions. All analyses were done by using SPSS 14.0. The significance level was

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determined as 0.05.

Results

Demographics and pregnancy related factors

Participants’ mean age was 29.37 (SD = 4.71) and average duration gestation was 28.81 weeks (SD = 5.05). Table 1 indicates the participants’ general background information.

[Insert Table 1 here]

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ACCEPTED MANUSCRIPT Participants were either in 2nd or 3rd trimester and there was no difference between depression condition and trimester distribution (X2 (1)= .158, p = .726). Table 2 shows the Chi-square analysis results between depressed and non-depressed groups.

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[Insert Table 2 here]

Also, women in the depressed group tended to get marry earlier (mean age = 21.07, SD

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= 3.47) than the women in the non-depressed group (mean age 22.55, SD = 3.36) (F = .284, t = 2.558, df = 141, p = .012). Number of lifetime gestations in depressed

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participants were 3.31 (SD = 2.06) and 2.33 (SD = 1.26) in non-depressed ones (F = 10.451, t = -3.32, df = 96.90, p = .001).

Variables that showed a significant difference between depressed and non-depressed

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groups were used to create models for regression analysis of abuse and neglect types.

Relationship between childhood abuse and adult depression

[Insert Table 3 here]

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Participants’ general childhood abuse and neglect score are presented in Table 3.

All types of childhood abuse and neglect scores were both positively correlated with depression scores and they were differentiated significantly between depressed and nondepressed groups (Table 4, 5).

[Insert Table 4 here]

[Insert Table 5 here]

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ACCEPTED MANUSCRIPT Childhood abuse as a predictor of depression during pregnancy

Five different models were created by using bivariate logistic regression analyses to predict BDI scores. The following independent variables were stable in each model.

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Education level (code 1 for less than high school, code 2 for high school, code 3 for university) ,monthly income (code 1 for less than 2000 TL, code 2 for 2000 TL and

above), current planned pregnancy (code 1 for yes, code 2 for no), number of lifetime

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gestations and age at the marriage. Each abuse and neglect score was added to these one

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at a time to create a model.

Emotional Abuse. The overall chi-square for the model was found to be significant (X2 (7) = 63.70, p = .000) for emotional abuse. Residuals and goodness-of-fit were checked in the model (Hosmer and Lemeshow test chi-square p-value .284) and there was no

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lack of fit in the final model. The model explained 48.2% (Nagelkerke R2) of the variance in depression and correctly classified 81.1% of the cases (Table 6).

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[Insert Table 6 here]

Physical Abuse. For physical abuse the overall chi-square for the model was X2 (7) =

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29.40, p = .000 with Hosmer and Lemeshow test chi-square p-value .566. The model explained 24.9% (Nagelkerke R2) of the variance in depression and correctly classified 74.1% of cases (Table 7).

[Insert Table 7 here]

Sexual Abuse. For sexual abuse, the overall chi-square for the model was found to be significant (X2 (7) = 31.45, p = .000). Residuals and goodness-of-fit were checked in the

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ACCEPTED MANUSCRIPT model (Hosmer and Lemeshow test chi-square p-value .204) and there was no evidence of lack of fit in the final model. The model explained 26.5% (Nagelkerke R2) of the variance in depression and correctly classified 72% of cases (Table 8).

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[Insert Table 8 here]

Physical Neglect. Model for physical neglect was also significant (X2 (7) = 32,25, p = .000) and there was no evidence of lack of fit in the final model (Hosmer and Leme

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show test chi-square p value .877). The model explained 27.1% (Nagelkerke R2) of the

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variance in depression and correctly classified 69.2% of the cases (Table 9).

[Insert Table 9 here]

Emotional Neglect. The overall chi-square for the model was found to be significant (X2

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(7) = 33.28, p = .000) for emotional neglect (Hosmer and Lemehow test chi-square pvalue .847) and there was no evidence of lack of fit in the final model. The model explained 27,8% (Nagelkerke R2) of the variance in depression and correctly classified

[Insert Table 10 here]

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69.9% of the cases (Table 10).

Discussion

Our data indicated that in depressed expectant mothers, age at the marriage was earlier, income levels, education levels and the rates of having planned pregnancy currently were lower, and lifetime gestation number was higher than the non-depressed group. These socio-demographic and obstetric variables were widely investigated in the literature to both understand and predict prenatal depression. Our results were supported

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ACCEPTED MANUSCRIPT by the relevant Turkish literature: Şahin (2010) found a negative correlation between monthly income and depression scores. Expectant mothers’ planned pregnancy and their pleasure when heard the pregnancy were the predictors of depression (20). In other

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studies, pregnant women’s education level and income level were negatively and stillbirth number was positively correlated with depression scores (21). Erbil’s (2009)

study verified the data about education and income above and indicated high depression

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scores if women had abortion previously. However, it indicated no effects of trimester sequence; the number of lifetime gestation and having an abortion on depression scores

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(22). Çakır (2012) showed that in more than half of the unplanned pregnancy conditions, women experienced depression and the more lifetime gestations the higher the depression scores (23). Not only the Turkish literature but also studies from different countries agreed on the effects of demographic and obstetric factors on

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depression during pregnancy. Lower educational attainment (24, 25, 26, and 27) and perceived lower income (24, 25, 26) were significantly and negatively associated with the depression in pregnancy. Single status and negative experience of previous birth

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were identified as risk factors (24, 26, and 28). Years of education, income, marital status, employment, and the number of miscarriages and stillbirths were significant

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predictors of total BDI score (29). Moderating and mediating analysis, which are out of the scope of this research, are required to understand the nature of socio-demographics and obstetric variables. One study indicated that income and marriage status significantly moderated the relationship for depressive symptoms at late pregnancy. Besides, smoking and drug use mediated young maternal age, single marital status, low education, and low income in predicting late pregnancy depressive symptoms (30).

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ACCEPTED MANUSCRIPT In addition to demographic and pregnancy-related factors, childhood traumatic experiences may have an effect on depression in adulthood, especially in a critical lifeperiod such as pregnancy. Actually, studies indicated that childhood abuse and neglect

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were among the risk factors for depression in adulthood (31). However, there were not so many studies about prenatal depression’s predictors and most of the studies

concentrated on postpartum depression (32). So many the perinatal depression studies

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lacked different types of abuse and neglect as possible predictors of depression during pregnancy (33, 34).

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It is important to understand the effects of abusive behaviours on mothers’ mental health. These abusive behaviours might be incorporated into their own parenting when they became adults by direct modelling effect (35, 36). Long-term effects of those kinds of adverse experiences might come together with other difficulties such as mental

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illness and take part in the transmission of abusive behaviours from generation to generation. Pears (2001) found out that parent’s own abuse experiences in their childhood, as well as consistent discipline and post-traumatic stress disorder, were

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predictive of parental abuse of the child (9). Besides, mothers’ performance of their own abusive behaviours onto their children may increase the probability of the adult

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offspring has a mental illness such as depression (37).

In this study, depressed group had higher childhood abuse and neglect scores than the non-depressed group in accordance with the literature above. Besides, each abuse and neglect type were the unique predictors of the perinatal depression score. Lang (2006) found that individual subscales of CTQ were related to different aspects of women mental health symptoms and behaviour (38). Among those subscales, sexual abuse was associated with enhanced depression scores during pregnancy. Leigh (2008) also

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ACCEPTED MANUSCRIPT indicated childhood sexual abuse as a risk factor for antenatal depression (39). Pregnant women who had multiple childhood abuse history showed higher levels of severity and had more residual symptoms of depression in the postpartum period at 6-month even

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though they got brief interpersonal psychotherapy (40). Parent’s witnessing or experiencing violence in their childhood was a risk factor for adverse family outcomes in the postpartum period (41). Being emotionally abused as a child was the predictor of

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postpartum depression in Edwards, Galletlt and Semmler-Booth’s (2008) study (42).

This study contributed to the literature by adding different types of childhood abuse and

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neglect as risk factors for prenatal depression specifically. Literature indicated that perinatal depression is a predictor of postpartum depression and rate of not receiving any form of treatment is high in pregnant women (43). To be aware of pregnant women’s past abuse experiences and other risk factors and to screen them for prenatal

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depression might tailor the prenatal care appropriately and enhance the chance for treating prenatal depression and preventing postnatal depression.

Lack of the investigation of some possible risk factors such as pregnancy and

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marriage/relationship related worries in the expectant mothers were the shortcoming of this study. Besides, the cross-sectional design of the research prevented us from coming

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to a conclusion about the direct relationship between depression and abuse. And some of the participants might show recall bias about their childhood experiences. Future studies may search for the interactive effects of childhood abuse and neglect, current worries about pregnancy, relationship/marriage, attachment type and child rearing practices in the transmission of abuse from generation to generation. Acknowledgments

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ACCEPTED MANUSCRIPT The authors would like to thank Burak Kaner, İlayda Sarar, İrem Şeker, Burak Ahmet Gürel and Cihan Uykun for their contributions during data collection. References

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22. Erbil N, Oruç H, Karabulut A. [Determination of depression and affecting factors in pregnancy]. Turkish Clinics J Gynecol Obst. 2009;19:67-74.

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27. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among

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28. Rubertsson C, Waldenstrom U. Depressive mood in early pregnancy: Prevalence and women at risk in a national Swedish sample. J Reprod Infant Psychol. 2003;21:13 - 121.

29. Koleva H, Stuart S, O’Hara MW, Bowman-Reif J. Risk factors for depressive

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33. Pottinger AM, Trotman-Edwards H, Younger N. Detecting depression during pregnancy and associated lifestyle practices and concerns among women in a 14

ACCEPTED MANUSCRIPT hospital-based obstetric clinic in Jamaica. Gen Hosp Psychiatry. 2009;31:254261. 34. Flynn HA, Walton MA, Chermack ST, Cunningham RM, Marcus SM. Brief

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detection and co-occurrence of violence, depression, and alcohol risk in prenatal care settings. Arch Womens Ment Health 2007:10;155-161.

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Abuse Negl. 1995;19:1323-1335.

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maltreatment and psychopathology and aggression during pregnancy and postpartum. Child Abuse Negl. 2006;30:17-25.

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ACCEPTED MANUSCRIPT 41. Wilson LM, Reid AJ, Midmer DK, Biringer A, Carroll JC, Stewart DE. Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. CMAJ. 1996;154:785.

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42. Edwards B, Galletly C, Semmler-Booth T, Dekker G. Antenatal psychosocial risk factors and depression among women living in socioeconomically disadvantaged suburbs in Adelaide, South Australia. Aust N Z J

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Psychiatry. 2008;42:45-50.

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among pregnant women in hospital-affiliated obstetrics practices. Gen Hosp

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Psychiatry. 2006;28:289-295.

Table 1.

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ACCEPTED MANUSCRIPT General background information about the participants %

Elementary

71

49.3

High School

42

29.2

University

31

N

144

Less than 2000 TL

103

2000 TL and above

41

28.4

N

144

100.0

Education Level

65.3

144

100.0

109

75.7

No

35

24.3

N

144

100.0

Yes

19

13,2

No

125

86,8

N

144

100.0

1st

0

0

2nd

50

34.7

3rd

94

65.3

N

144

100.0

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Yes

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current pregnancy

Trimesters

71.6

94

N

Treatment for

100.0

34.7

No

pregnancy

21.5

50

Miscarriage

Planned current

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Yes

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Monthly Income

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n

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ACCEPTED MANUSCRIPT Table 2. Chi-square analysis of participants’ background information as a function of depression Depressed

depressed

all, N = 63

all, N = 81

Planned

Yes

n

%

n

%

70

86,4

39

61,9

No

11

13,6

52

64.2

24

Less than 2000 TL

38,1

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pregnancy

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X2 (1) = 11.57, p = .001

current

Monthly

X2

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Non-

51

81.0

X2 (1) = 4.88, p = .040

Income

2000 Tl 29

Elementary Education

School

39,5

39

61,9

26

32,1

16

25,4

28,4

8

12,7

23

X2 (2) = 8.20, p = .017

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University

19.0

32

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Level

High

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and above

35.8

Table 3.

The participants’ CTQ mean scores all, N=144 M

SD

Emotional Abuse

8,07

3,55

Physical Abuse

6,47

2,58

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3,44

Physical Neglect

8,20

3,31

Emotional Neglect

10,27

4,75

Table 4. Pearson correlation between BDI and CTQ scores

abuse

abuse

--

.624**

--

--

--

neglect

.470**

.546**

.178*

.575**

.460**

.286**

--

--

.329**

.378**

.350**

--

--

--

.726**

.385**

--

--

--

.339**

abuse

abuse Physical --

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Sexual

--

--

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neglect

neglect

Depression

.523**

Physical

Emotional

Emotional

.339**

abuse

neglect

abuse

Physical

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Emotional

Sexual

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Physical

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Emotional

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Sexual Abuse

** Correlation is significant at the 0.01 level * Correlation is significant at the 0.05 level

Table 5. Comparison of Childhood Trauma Questionnaire sub scores

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ACCEPTED MANUSCRIPT Non-depressed

Depressed

all, N = 81

all, N = 63 T-test

CTQ M

SD

M

SD

Emotional Abuse

6.40

1.82

10.22

4.07

t(81.23) = 6.90, p = .000

Physical Abuse

5.74

1.92

7.41

3.00

t(99.81) = 3.84, p = .000

Sexual Abuse

6.23

2.11

7.79

4.49

t(83.29) = 2.54, p = 0.013

Physical Neglect

7.09

2.49

9.61

3.68

t(103.90) = 4.65, p = .000

Emotional Neglect

8.81

4.09

12.14

4.91

t(119.89) = 4.33, p = .000

M AN U

SC

RI PT

Scores

Table 6.

Summary of Logistic Regression Analysis for Variables Predicting Depression B

TE D

Predictors

Education level

EP

Planned current pregnancy (1)

-1.05

SE B

.57

eB

p

.34

.068

.483 .78

.74

2.18

.292

Education level (2)

.21

.68

1.24

.751

Age at the marriage

.048

.075

1.04

.528

Number of lifetime gestation

.067

.192

1.06

.727

AC C

Education level (1)

20

ACCEPTED MANUSCRIPT Monthly Income (1)

.367

.584

1.44

.530

Emotional abuse

.535

.10

1.70

.000

-5.53

RI PT

Constant

Note: eB = exponentiated B.

SC

Table 7.

Summary of Logistic Regression Analysis for Variables Predicting Depression B

Planned current pregnancy (1)

Education level (1)

-.849

TE D

Education level

SE B

M AN U

Predictors

.48

eB

p

.42

.078

.576

.67

.66

1.95

.308

.34

.61

1.41

.572

-.016

.067

.985

.816

Number of lifetime gestation

.163

.143

1.17

.253

Monthly Income (1)

.367

.584

1.44

.530

Physical abuse

.168

.51

1.18

.746

EP

Education level (2)

AC C

Age at the marriage

Constant

-1.75

21

ACCEPTED MANUSCRIPT

Table 8. Summary of Logistic Regression Analysis for Variables Predicting Depression

Planned current pregnancy (1)

-.902

Education level .68

.48

p

.40

.062

.363

.64

1.98

.285

.02

.62

1.02

.967

-.014

.067

.986

.830

Number of lifetime gestation

.245

.146

1.27

.093

Monthly Income (1)

.312

.528

1.36

.555

.197

.068

1.21

.004

M AN U

Education level (1)

eB

SE B

RI PT

B

SC

Predictors

Education level (2)

EP

AC C

Sexual abuse

TE D

Age at the marriage

Table 9.

Summary of Logistic Regression Analysis for Variables Predicting Depression Predictors

B

22

SE B

eB

p

ACCEPTED MANUSCRIPT Planned current pregnancy (1)

-.79

.49

.45

Education level

.108

.468 .65

Education level (2)

.33

.60

Age at the marriage

.007

.069

Number of lifetime gestation

.15

TE D

Physical neglect

.245

1.39

.586

1.00

.923

1.16

.304

.106

.521

1.11

.839

.215

.067

1.2

.001

-2.51

EP

Table 10.

.15

M AN U

Monthly Income (1)

Constant

2.13

RI PT

.75

SC

Education level (1)

Summary of Logistic Regression Analysis for Variables Predicting Depression B

AC C

Predictors

Planned current pregnancy (1)

-.87

SE B

.49

eB

p

.41

Education level

.073

.470

Education level (1)

.70

23

.65

2.02

.281

ACCEPTED MANUSCRIPT .21

.61

1.23

.731

Age at the marriage

.008

.068

1.00

.912

Number of lifetime gestation

.14

.15

Monthly Income (1)

.408

.528

Emotional neglect

.149

RI PT

Education level (2)

EP AC C 24

.338

1.50

.440

SC .044

M AN U -2.39

TE D

Constant

1.16

1.16

.001

ACCEPTED MANUSCRIPT

RI PT

SC M AN U TE D

•

EP

• •

Five different models were created by using bivariate logistic regression analyses to predict BDI scores. Only abuse and neglect scores predicted depression scores. Emotionally abused participants were 1.7, physically abused participants were 1.2 times and sexually abused participants were 1.2 times more likely to exhibit depression than non-neglected participants Physically neglected participants were 1.2 times and emotionally neglected participants were 1.15 times more likely to exhibit depression than non-neglected participants

AC C

•

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

There is no conflict of interest for this study