Delayed Onset of Depression

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.

1. Putnam FW. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-278
2. Andersen SL, Teicher MH. Stress, sensitive periods and maturational events in adolescent depression. Trends Neurosci 2008;31:183-191
3. Post RM, Leverich GS, Xing G, Weiss RB. Developmental vulnerabilities to the onset and course of bipolar disorder. Dev Psychopathol 2001;13:581-598.
4. Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics 2003;111:564-572
5. Felitti VJ, Anda RF, Nordenberg D, 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;14:245-258
6. Teicher MH, Samson JA, Polcari A, McGreenery CE. Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. Am J Psychiatry 2006;163:993-1000
7. Bremner JD, Steinberg M, Southwick SM, et al. Use of the Structured Clinical Interview for DSM-IV Dissociative Disorders for systematic assessment of dissociative symptoms in posttraumatic stress disorder. Am J Psychiatry 1993;150:1011-1014
8. Gunderson JG, Kolb JE, Austin V. The diagnostic interview for borderline patients. Am J Psychiatry 1981;138:896-903
9. Farrer LA, Florio LP, Bruce ML, et al. Reliability of self-reported age at onset of major depression. J Psychiatr Res 1989;23:35-47
10. Prusoff BA, Merikangas KR, Weissman MM. Lifetime prevalence and age of onset of psychiatric disorders: recall 4 years later. J Psychiatr Res 1988;22:107-117
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
12. Hankin BL, Abramson LY, Moffitt TE, et al. Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol 1998;107:128-140
13. Gladstone GL, Parker GB, Mitchell PB, et al. Implications of childhood trauma for depressed women: an analysis of pathways from childhood sexual abuse to deliberate self-harm and revictimization. Am J Psychiatry 2004;161:1417-1425


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One Response to “Delayed Onset of Depression”

  1. Gretchen Paules Says:

    The Let Go…Let Peace Come In Foundation is a newly formed nonprofit with a mission to help heal and support adult survivors of childhood sexual abuse worldwide. We are actively seeking adult survivors who would be willing to post a childhood photo and caption, their story, or their creative expressions to our website By uniting survivors from across the globe we can help provide a stronger and more powerful voice to those survivors who have not yet found the courage to speak out. Together we can; together we should; together we NEED to stand up and be counted. Please visit our site for more details on how you can send us your submissions.

    Thank you for everything you do!

    Gretchen Paules
    Administrative Director
    Let Go…Let Peace Come In Foundation
    111 Presidential Blvd., Suite 212
    Bala Cynwyd, PA 19004

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