Archive for June, 2009

Delayed Onset of Depression

June 15, 2009

Teicher MH, Samson JA, Polcari A. Andersen SL. Length of time between onset of childhood sexual abuse and emergence of depression in a young adult sample. Journal of Clinical Psychiatry 2009; 70(5): 684-691


Depression is the most extensively documented outcome of exposure to CSA in adults (1), but in children the most discernible manifestations are sexualized behaviors rather than depression or PTSD (1). Despite the numerous studies demonstrating an association between exposure to CSA and emergence of depression, we are not aware of any studies that have specifically reported on the length of time between exposure to CSA and development of major depression. There are several possibilities. One is that depression follows rapidly on the heels of exposure to CSA. Another possibility is that depression emerges after exposure or risk of exposure to CSA has abated. A third possibility is that CSA does not directly lead to depression, but that it sensitizes the individual, enhancing their risk of developing depression as they pass through adolescents into adulthood as part of a neuromaturational process (2). A fourth possibility is that CSA could both sensitize and accelerate the process leading to an earlier age of onset, as has been reported to occur in patients with bipolar (3) or substance abuse disorders (4). Finally, episodes of major depression may emerge in sensitized individuals only if they are exposed to new losses or traumas, resulting in a variable onset times.

Determining the temporal relationship between CSA and onset of depression is difficult, as CSA usually occurs in individuals who have been, or will be, exposed to multiple other forms of trauma5, 6. However, delineating the time course is a fundamental prerequisite for designing intervention strategies to prevent or minimize the long-term sequelae of abuse and for interrupting the cycle of violence. To begin to address this issue we retrospectively examined the temporal relationship between CSA and depression in this group of 29 women who were exposed to CSA but to no other forms of trauma or severe early stress. These subjects were 20 ± 1.3 years old. All were in college, and 90% came from a middle class or higher socioeconomic status family (SES 2.3 ± 1.0). Reported perpetrators were part of the extended family and/or members of the community, with only three perpetrators being step-parents. None of the subjects in this sample reported experiencing CSA by their biological parents.

Psychiatric history was assessed by certified mental health clinicians using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID), the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (7) and the Diagnostic Interview for Borderline Patients (DIB) (8). Age of onset was assessed as a part of this interview, which can be reliably determined through this form of assessment (9, 10). Kaplan-Meier analysis (SPSS version 11.0) provided mean survival time (±95% confidence interval [CI]) for onset of CSA, and from onset of CSA to emergence of depression.

Subjects who developed major depression (n=18) had the onset occur between 10–20 years of age (mean survival 15.0 years; 95% CI: 13.6–16.4 years). The average time from onset of CSA to onset of major depression, in those who developed depression, was 9.2 ± 3.6 years. Mean survival time from onset of CSA to onset of depression for the entire sample was 11.47 years (95% CI: 9.80–13.13 years). Mean survival from offset of CSA (first episode if there were multiple perpetrators) was 9.55 years (95% CI: 7.45–11.65 years). Figure 1 illustrates the number of cases with a history of depression who experienced CSA in a given year, and the cumulative prevalence of depression. Note that many of the subjects who went on to develop major depression experienced CSA at ages 5 and 6, and that 56% of depressive episodes began between 12–15 years of age.


Figure 1. Age of abuse and cumulative incidence of depression for 18 CSA subjects developing depression. Red line and left axis indicate number of subjects exposed to CSA at each age. Blue shaded area and right axis indicate the percentage of subjects who had an episode of major depression prior to or during each year of age (11).

The key finding of this formative study is that episodes of major depression did not immediately occur following exposure to CSA, but took several years to emerge. Further, the onset of depression did not directly coincide with the abatement of CSA. Rather, there was typically a long delay between exposure to CSA and onset of depression, with a surge in new cases occurring between 12–15 years of age. This is somewhat earlier than the peak surge of newly emergent cases reported to occur in a prospective longitudinal study of a contemporary birth cohort (12). Overall, these findings are compatible with the hypothesis that CSA sensitizes the individual to later emergence of depression during adolescence, and that it shifts the peak period of risk from mid-adolescence to early adolescence. This finding is consistent with a previous report of earlier age of onset of depression in women with histories of childhood abuse (13). Clinically, this is important information as it shows that there may be substantial time available in which to potentially intervene to minimize or preempt the most common major psychiatric consequences of CSA.

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11. Teicher MH, Samson JA, Polcari A, Andersen SL. Length of time between onset of childhood sexual abuse and emergence of depression in a young adult sample: a retrospective clinical report. J Clin Psychiatry 2009
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