Psychiatry Research 220 (2014) 571–578

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The associations among childhood maltreatment, “male depression” and suicide risk in psychiatric patients Maurizio Pompili a,n, Marco Innamorati a, Dorian A. Lamis b, Denise Erbuto a, Paola Venturini a, Federica Ricci a, Gianluca Serafini c, Mario Amore c, Paolo Girardi a a Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, 1035-1039, Via di Grottarossa, 00189 Rome, Italy b Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA c Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genova, Italy

art ic l e i nf o

a b s t r a c t

Article history: Received 21 December 2013 Received in revised form 19 June 2014 Accepted 24 July 2014 Available online 13 August 2014

In the current cross-sectional study, we aimed to investigate the presence and severity of “male” depressive symptoms and suicidal behaviors in psychiatric patients with and without a history of child abuse and neglect, as measured by the Childhood Trauma Questionnaire (CTQ), as well as to explore the associations among childhood maltreatment, “male depression” and suicide risk. The sample consisted of 163 consecutively admitted adult inpatients (80 men; 83 women). The patients were administered the CTQ, Gotland Male Depression Scale (GMDS), and Suicidal History Self-Rating Screening Scale (SHSS). Those with a moderate-severe childhood maltreatment history were more likely to be female (po 0.05) and reported more “male depression” (po 0.001) and suicidal behaviors (p o0.01) as compared to those not having or having a minimal history of child abuse and neglect. In the multivariate analysis, only the minimization/denial scale of the CTQ (odds ratio¼ 0.31; p o0.001) and “male depression” (odds ratio¼ 1.83; po0.05) were independently associated with moderate/severe history of child maltreatment. The findings suggest that exposure to abuse and neglect as a child may increase the risk of subsequent symptoms of “male depression”, which has been associated with higher suicidal risk. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Male depression Child abuse Suicide

1. Introduction Childhood maltreatment, which includes abuse (physical, sexual, and emotional) and neglect (physical and emotional), is highly prevalent and a major public health concern (Gilbert et al., 2009), which often leads to deleterious effects on physical and mental health well-being (Draper et al., 2008). Official reports indicate that the overall prevalence of lifetime childhood maltreatment has been estimated to approach 30% in population-based samples (Hussey et al., 2006; Finkelhor et al., 2009). Researchers have consistently shown that childhood maltreatment is associated with a range of mental disorders, including depression (see Alloy et al. (2006) for a review). For example, Widom, DuMont, and Czaja (2007) found that individuals who experienced childhood abuse or neglect were 1.51 times more likely to be diagnosed with major depressive disorder (MDD) as adults. Thus, it is important for clinicians to identify individuals who have been victims of childhood maltreatment and intervene before this negative experience may contribute to the development of a mood disorder.

n

Corresponding author. Tel.: þ 39 0633775675; fax: þ 39 0633775342. E-mail address: [email protected] (M. Pompili).

http://dx.doi.org/10.1016/j.psychres.2014.07.056 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

Rutz (1995, 1999) has suggested that “male depression” is a distinct construct and differs from common depressive symptoms often found among females. It includes abrupt lowered stress tolerance, irritability, impulsive, aggressive, and/or psychopathic behavior, such as alcohol and/or drug abuse or abusive equivalents (e.g., work alcholism and excessive exercise), which often go unnoticed when trying to detect depression in men. Specifically, the Gotland Male Depression Scale (GMDS) not only focuses on overconsumption of alcohol/excessive activity, but also on positive family history of abuse/depression/suicide unlike major depressive syndrome. Rutz (1999) suggested that due to the alexithymic inability to ask for help together with atypical depressive symptoms (e.g., aggressive or abusive behaviors), depressed males experienced rejection or are misdiagnosed in the health care system. Accordingly, the Gotland studies have resulted in a screening instrument for assessing depression in men, “GMDS”, which has recently been validated (Stromberg et al., 2010; Innamorati et al., 2011b). Moreover, Möller-Leimkühler and Yücel (2010) found that “male depression” might also be prevalent in females and suggested that the association between "male depression" and gender be further explored. The GMDS consists of typical depressive symptoms as well as emotional distress symptoms that are more

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commonly found in males than in females according to Walinder and Rutz (2001). However, the diagnostic criteria have focused on typical depressive symptoms, which may have resulted in “male” symptoms being overlooked. Previous studies examining gender differences in depressive symptoms have consistently found that men report fewer depressive symptoms than women (Parker and Brotchie, 2010). However, a gender bias in the assessment of depression could contribute to lower rates of depression in men. Several lines of evidence have suggested the association between a history of child sexual abuse and both psychological and social adverse outcomes in adulthood. In particular, a consistent link has been found between childhood maltreatment and “male depression”. Rihmer et al. (2009) investigated the influence of childhood maltreatment on GMDS scores in 150 nonviolent suicide attempters suggesting a significant association among unfavorable psychosocial situations, negative life events, “male depression”, and suicidal behavior. Specifically, the authors reported that independent of gender, the “male” depressive syndrome was significantly more severe among those who had experienced either physical or sexual abuse during childhood. Traumatic early experiences may predispose individuals, in the authors' opinion, to suicidal behavior. Similarly, Brodsky et al. (2001) reported that adult inpatients with a childhood abuse history were more likely to report attempted suicide and have significantly higher impulsivity and aggression scores compared to those who did not report child maltreatment. A significant association was also found between child sexual abuse and subsequent treatment for mental disorders using a prospective cohort design in a sample of 1612 children (Spataro et al., 2004). Interestingly, male victims had higher rates of childhood mental disorders such as personality, anxiety, and major affective disorders and were significantly more likely to have had treatment when compared to females. Studies have reported that higher levels of behavioral problems were present in adult males who were sexually abused during childhood as compared to their female counterparts (Darves-Bornoz et al., 1998; Horwitz et al., 2001). Childhood maltreatment has also been found to be a significant risk factor for suicidal ideation and behaviors (Pompili et al., 2011; Rhodes et al., 2012; Bryan et al., 2013; Fergusson et al., 2013). Research (Mann et al., 2005; Zouk et al., 2006) has demonstrated a strong association between a past experience of childhood abuse and impulsive/aggressive behaviors, which may contribute to suicidality. Impulsivity and aggressiveness may predispose individuals to suicidal behavior regardless of psychiatric conditions, as they are associated with structural and functional dysfunctions in key brain regions implicated in the regulation of mood, impulse, and behavior. However, a complex and multifaceted interaction among crucial risk factors may be evoked to explain the association between childhood abuse, impulsive/aggressive behaviors, and suicidality. To this end, Wanklyn et al. (2012) suggested that in a sample of 110 incarcerated youths, impulsivity and hopelessness were important factors to consider when examining the relationship between childhood maltreatment and depression. Screening for impulsivity as well as hopelessness may increase clinicians' ability to identify those at greatest risk of self-harm and suicidal behavior. In a longitudinal study (Enns et al., 2006), childhood neglect, psychological abuse, and physical abuse were all strongly associated with new onset ideation and suicide attempts, even after controlling for the effects of mental disorders. Moreover, Andover et al. (2007) found that individuals with a history of suicide attempts were more likely to report histories of childhood physical and sexual abuse compared to those without a suicide attempt history. Similarly, Brezo et al. (2008) demonstrated that young adults who reported childhood abuse histories had up to a 14 times greater risk of attempting suicide. Furthermore, Joiner et al. (2007) observed a significant relationship between

childhood physical and sexual abuse and lifetime suicide attempts, after accounting for several important covariates (demographic variables such as age, gender, and family of origin together with clinical variables such as individual and family psychiatric histories as well as childhood abuse), each of which was considered to be strongly associated with suicide- and abuse-related variables. In sum, the above studies highlight the strong association between childhood maltreatment and negative mental health outcomes, including depression and suicidality. Thus, the aim of the current study was to evaluate the possible association between “male” depressive symptoms (Rutz et al., 1995; Rutz, 1999) and suicidal behaviors in psychiatric patients who reported a history of child abuse and neglect on the CTQ (Bernstein et al., 1994; Bernstein et al., 1997; Bernstein and Fink, 1998). We hypothesized that individuals who experienced a more severe history of child abuse and neglect would report more “male depression” symptoms, which include not only prototypical symptoms of major depression (e.g., depressed mood or diminished interest or pleasure in activities, sleep disturbances), but also externalizing symptoms such as irritability, aggressiveness, and abusive and risky behavior.

2. Method 2.1. Participants This cross-sectional study consisted of adult patients consecutively admitted to the Department of Psychiatry of the Sant’Andrea University Hospital in Rome, Italy, between January 2012 and December 2012. Inclusion criteria were admission in the time period indicated and any psychiatric diagnosis according to the DSM-IV-TR criteria. Exclusion criteria were the presence of any condition that may affect the ability to complete the assessment, including delirium, dementia or denial of informed consent. All the patients were assessed in the first 72 h after hospital admission by clinical psychiatrists who are experts in psychopathological assessment. Subjects voluntarily participated in the study, and each provided written informed consent. The study protocol was approved by the local research ethics review board. The sample consisted of 163 adult patients (80 men and 83 women), with a mean age of 42.1 years (S.D. ¼14.2; Range: 18–77 years). Male and female patients did not differ in age (42.33714.41 vs. 41.81 7 14.01; t161 ¼ 0.23; p ¼ 0.82), or diagnosis (χ23 ¼4.35; p¼ 0.23). The response rate was 86%. Twenty-seven patients who were eligible to be included in the study refused their consent to take part in the study. No patients returned incomplete or not analyzable questionnaires.

2.2. Measures All the patients were administered the Italian versions of the below measures. The Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) is a brief, fully structured diagnostic interview that assesses 17 Axis I disorders, antisocial personality, and suicidality according to DSM-IV criteria. Interviews typically were 15–20 min per person. One section of this instrument is dedicated to the assessment of suicidal risk, with questions about past and current suicidality. The suicidality section of the MINI classifies subjects into four groups: no suicidal risk, low suicidal risk, medium suicidal risk, and high suicidal risk. The MINI has demonstrated good validity, with median kappa coefficients greater than 0.63 against other interviews and interrater reliabilities ranging from kappas of 0.79 to 1.00 (Sheehan et al., 1998). The Gotland Male Depression Scale (Rutz et al., 1995; Rutz, 1999; Walinder and Rutz, 2001) is a screening instrument for “male depression”, consisting of 13 items which are rated on a 4-point Likert scale from 0 (not present) to 3 (present to a high degree) with a range from 0 to 39. Items of the GMDS assess symptoms such as lower stress threshold, aggressiveness, feeling of being burned out, tiredness, irritability and restlessness, difficulty in decision making, sleep problems, anxiety and uneasiness especially in the morning, alcohol and substance misuse, hopelessness, tendency to complain, and hereditary loading. In addition to typical depressive symptoms (e.g., depressed or irritable mood, decreased interest or pleasure in most activities, significant weight change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, and suicidality), the GMDS also includes questions regarding characteristics commonly found in depressed men (e.g., irritability, aggression, and alcohol use). In Italian samples, the GMDS has been shown to be a valid instrument for measuring non-typical (“suicidality-related”) symptoms of depression in both

M. Pompili et al. / Psychiatry Research 220 (2014) 571–578 male and female patients (Innamorati et al., 2011b). Moller Leimkuhler et al. (2007) reported an internal consistency (Cronbach's alpha) of 0.81 for the GMDS total score. In the present sample, the Cronbach alpha for the GMDS was 0.87. The Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1994; Bernstein et al., 1997; Bernstein and Fink, 1998) is a 28-item self-report questionnaire that assessed five types of child maltreatment: physical abuse, emotional abuse, sexual abuse, emotional neglect, and physical neglect. Each item begins with the anchor, “When I was growing up” and respondents indicate on a 5-point Likert scale the frequency of a particular incident (1¼never true; 5¼ very often true). Each 5-item subscale ranges from 5 (no history of abuse) to 25 (very extreme history of abuse), with three items assessing the tendency to minimize or deny abuse, neglect, or trauma. Any score greater than 0 on the minimization/denial scale may suggest under-reporting of maltreatment during childhood. For each abuse dimension, the CTQ produces dimensional scales to which cutoff scores, supplied by the authors, are used to classify individuals as abused or not abused (DiLillo et al., 2006). The CTQ has been shown to have solid psychometric properties (Bernstein et al., 1997; Bernstein and Fink, 1998; Bernstein et al., 2003; DiLillo et al., 2006). In the present sample, all the dimensions had satisfactory homogeneity of content (Cronbach alphas from 0.79 for physical abuse to 0.91 for sexual abuse), with the exception of the physical neglect subscale, which had a Cronbach alpha of 0.50. The Suicidal History Self-Rating Screening Scale (SHSS) is a 16-item measure assessing death thoughts, suicidal ideation and behavior in the last 12 months and lifetime except in the last 12 months. It is a valid and reliable instrument able to identify individuals at higher risk for suicidal behavior and is characterized by cut-off scores with high sensitivity. Moreover, the SHSS scale demonstrated good convergent validity with commonly used measures in the field of suicide assessment (Innamorati et al., 2011a). In the present sample, the Cronbach alpha for the SHSS was 0.90.

2.3. Statistics All the analyses were performed with the Statistical Package for the Social Sciences (SPSS 19.0 for Windows). For grouping patients with respect to their history of child abuse and neglect, z-scores were calculated for each dimension of the CTQ and then they were subjected to maximum likelihood factoring analysis to obtain latent common factors (factors with eigenvalue 41) and to calculate factor scores. Then, in order to reveal groupings (or clusters) of participants with different histories of child abuse and neglect, we used a Two Step Cluster Analysis procedure. This procedure can handle categorical and continuous variables, using a likelihood distance measure which assumes that variables in the cluster model are independent. To determine which number of clusters is “best”, each of the cluster solutions is compared using Schwarz's Bayesian Criterion (BIC) or the Akaike Information Criterion (AIC) as the clustering criterion. For the analysis, we let the procedure automatically determine the number of clusters, and selected log-likelihood distance measure and Schwarz's Bayesian Criterion (BIC) as clustering criterion. We did not categorize patients according to CTQ cutoffs suggested in the manual of the original version of the test because they were never validated in Italian samples. However, we also described the sample and subgroups according to the categorization suggested by the use of these cutoffs. One-way Fisher exact tests, chi-squared tests (χ2), and t-tests were used for bivariate analyses. All of the variables that were significantly different between the two abuse/neglect groups at the bivariate level (except for the dimensions of the CTQ which were used to create clusters) or between sex groups were entered as independent variables in two generalized linear model with a robust estimator, and the two abuse groups (or sex groups) served as dependent variables. Odds Ratios (OR) and their 95% confidence interval (95% CI) were calculated and used as measures of association. If not otherwise indicated, statistical tests are two-tailed with pr0.05.

3. Results 3.1. Characteristics of the sample Descriptive statistics are listed in Table 1. Eighty-one patients received a diagnosis of bipolar disorder (either type 1 or 2; 49.7%), 32 a diagnosis of major depressive disorder (19.6%), 20 a diagnosis of psychosis or schizophrenia (12.3%), and 30 were diagnosed with another specified Axis I or Axis II disorder (mostly personality disorders or schizoaffective disorder; 18.4%). Around 30% of the sample reported moderate to severe history of emotional abuse in the childhood, 14.7% and 22.2%, respectively reported physical and sexual abuse, and more than 30% of the patients reported emotional or physical neglect. Lastly, almost 21% of the patients reported moderate to severe “male depression.”

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3.2. Differences between sex Although male and female patients did not differ for age and diagnoses, they differed for their mean score on the CTQ emotional abuse, and on the SHSS (Table 1). Specifically, women had higher mean scores on the CTQ emotional abuse and on the SHSS. Above 37% of female patients reported emotional abuse vs. 20% of their male peers (po0.05). Regarding suicide behavior and ideation, female patients (compared to male patients) more frequently had attempted suicide more than once in the last 12 months (21.6% vs. 5.6%; po0.01), and more often had attempted suicide during their lifetime with the exclusion of the last 12 months (49.3% vs. 33.8%; po0.05). Sex groups did not differ for other dimensions of the CTQ and for “male depression.” At the multivariate analyses (not reported in the tables), both the CTQ emotional abuse (OR¼ 1.06; 95% CI¼ 0.97/ 1.13; p¼0.07) and the SHSS (OR¼1.07; 95% CI¼ 1.00/ 1.15; p¼0.07) failed to reach statistical significance. 3.3. Characteristics associated with moderate to severe history of childhood abuse The z-scores for the Childhood Trauma Questionnaire (CTQ) were subjected to maximum likelihood factoring analysis, resulting in only one single factor with eigenvalue greater than 1 (2.59; variance explained¼ 51.75%). All the dimensions of the CTQ saturated on this factor with loadings ranging between 0.54 for sexual and 0.78 for emotional abuse. A two-step cluster analysis with factor scores on the common factor indicated the presence of two groups of patients. The first group (with no or minimal history of child abuse and neglect; N¼98) was characterized by lower scores on all the dimensions of the CTQ and higher scores on minimization/denial than the second group (with moderate to severe history of child abuse and neglect; N¼ 64; Table 2). Specifically, compared to the patients included in the first cluster with no or minimal history of child abuse and neglect, the patients included in the second cluster reported significantly more emotional (68.8% vs. 3.1%), physical (37.5% vs. 0.0%), and sexual (43.8% vs. 8.2%) abuse. Similarly, 62.5% (vs. 14.3%) and 65.6% (vs. 14.3%) of the patients included in the cluster with a moderate to severe history of child abuse and neglect reported moderate to severe emotional neglect and physical neglect, respectively. Groups differed for gender, GMDS scores, and the SHSS, but not for age or diagnosis (Table 3). The patients with a moderate to severe history of child abuse and neglect were more often females, reported more severe “male” depressive symptoms, and higher SHSS scores than patients with no or minimal history of child abuse and neglect. More than 30% of the patients included in the cluster with moderate to severe history of child abuse and neglect reported moderate to severe “male depression”, vs. 13.5% of the patients with no or minimal history of child abuse and neglect (po0.01). On the SHSS, one out of five patients with moderate to severe history of child abuse and neglect reported having attempted suicide more than once in the last 12 months vs. 7.9% of the patients included in the cluster with no or minimal history of child abuse and neglect (po0.05). Furthermore, on the SHSS, more patients with moderate to severe history of child abuse and neglect (compared to patients with no or minimal history of child abuse and neglect) reported suicide ideation and planning. A generalized linear model (GLM) fit the data well (Likelihood Ratio χ24 ¼ 35.62; po0.001; Table 3), indicating that the patients who were victims of moderate to severe child abuse and/or neglect (compared to patients with no or minimal history of child abuse and neglect) were: 1) more likely to have lower scores on the CTQ minimization/denial dimension (OR¼0.31; 95% CI¼0.18 / 0.54; po0.001); and 2) 1.83 times more likely to have more severe “male depression” (OR¼1.83; 95% CI¼ 1.05 / 3.17; po0.05). The multivariate model indicated that higher SHSS scores were not independently

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Table 1 Characteristics of the sample.

Men – percentage Age – M 7S.D. Diagnosis – percentage BD MDD Psychosis Other specified diagnosis CTQ minimization denial – M 7 S.D. Emotional abuse – M 7 S.D. Emotional abuse Z 13 – percentage Physical abuse – M7 S.D. Physical abuseZ 10 – percentage Sexual abuse – M 7S.D. Sexual abuseZ 8 – percentage Emotional neglect – M 7 S.D. Emotional neglect Z 15 – percentage Physical neglect – M 7S.D. Physical neglectZ 10 – percentage GMDS – M 7S.D. GMDS 4 26 – percentage SHSS – M 7 S.D. Last 12 months – percentage Suicide ideation Suicidal planning Suicide attempt More than one suicide attempts

Whole sample N ¼163

Men N¼ 80

Women N ¼ 83

Test

po

49.1% 42.07714.16

– 42.337 14.41

– 41.81 714.01

49.7% 19.6% 12.3% 18.4% 0.59 7 0.90 10.53 75.34 28.8% 6.92 7 3.43 14.7% 7.02 7 4.10 22.2% 12.69 7 5.70 33.1% 8.53 7 3.20 34.4% 17.357 9.79 20.8% 5.747 4.60

56.3% 15.0% 13.8% 15.0% 0.65 7 0.95 9.53 7 4.90 20.0% 6.81 7 3.06 12.5% 6.59 7 3.74 16.5% 12.95 7 5.76 32.5% 8.65 7 3.53 37.5% 17.047 9.26 19.2% 4.92 7 4.41

43.4% 24.1% 10.8% 21.7% 0.53 70.85 11.497 5.59 37.3% 7.02 7 3.76 16.9% 7.43 7 4.40 27.7% 12.43 75.67 33.7% 8.417 2.87 31.3% 17.65 7 10.33 22.2% 6.54 74.67

– t161 ¼ 0.23 χ23 ¼ 4.35 – – – – t161 ¼ 0.82 t161 ¼  2.39 – t161 ¼  0.39 – t161 ¼  1.31 – t161 ¼ 0.58 – t161 ¼ 0.48 – t161 ¼  0.24 – t161 ¼  2.24

– 0.82 0.23 – – – – 0.41 0.05 0.05a 0.70 0.29a 0.19 0.06a 0.57 0.50a 0.63 0.25 a 0.81 0.39a 0.05

56.1% 43.5% 36.2% 13.8%

52.6% 43.6% 32.4% 5.6%

59.7% 43.4 39.7% 21.6%

– – – –

0.23a 0.56a 0.23a 0.01a

48.6% 36.5% 33.8% 15.7%

61.8% 45.3% 49.3% 21.1%

– – – –

0.07a 0.18a 0.05a 0.27a

During your lifetime, excluding the last 12 months – percentage Suicide ideation 55.3% Suicidal planning 40.9% Suicide attempt 41.4% More than one suicide attempt 18.4%

Legend. M ¼mean; S.D.¼ standard deviation; MDD¼ major depressive disorder; BD¼ bipolar disorders; CTQ ¼ Childhood Trauma Questionnaire; GMDS ¼Gotland Male Depression Scale; SHSS¼ Suicidal History Self-Rating Screening Scale. a

One-way Fisher exact tests.

Table 2 Characteristics of the clusters according to the Childhood Trauma Questionnaire (CTQ) dimensions. po

Variables

No or minimal history of child abuse and neglect N¼ 98

More severe history of child abuse and neglect N¼ 64

Test

Emotional abuse – M 7 S.D. Emotional abuse Z 13 – percentage Physical abuse – M7 S.D. Physical abuseZ 10 – percentage Sexual abuse – M 7S.D. Sexual abuseZ 8 – percentage Emotional neglect – M 7 S.D. Emotional neglect Z 15 – percentage Physical neglect – M 7S.D. Physical neglectZ 10 – percentage

7.22 7 2.34 3.1%

15.64 74.59 68.8%

t160 ¼  13.56 o 0.001 o 0.001a

5.32 70.90 0.0% 5.55 71.51 8.2% 10.11 74.39 14.3%

9.39 74.32 37.5% 9.28 75.56 43.8% 16.777 5.06 62.5%

t160 ¼  7.44

7.177 2.22 14.3%

10.63 7 3.38 65.6%

t160 ¼  7.21

t160 ¼  5.25 t160 ¼  8.61

o 0.001 o 0.001a o 0.001 o 0.001a o 0.001 o 0.001a o 0.001 o 0.001a

Legend. M ¼mean; S.D.¼ standard deviation. a

One-way Fisher exact tests.

associated with more severe history of child abuse and neglect (OR¼1.01; 95% CI¼0.92 / 1.12; p¼0.78).

4. Discussion In the current study, we examined the associations among childhood maltreatment, “male depression”, and suicidality in a sample of adult inpatients. Specifically, we first compared a group of patients who had experienced moderate to severe childhood abuse and/or neglect with patients who had no or minimal history of maltreatment

on minimization/denial of child abuse, “male depression”, and suicidal ideation, planning, and attempts. A GLM was then constructed to determine which variables were independently associated with patients who reported a moderate to severe childhood maltreatment history. Regarding the group comparisons, at the bivariate analyses, the patients in the group with a moderate to severe childhood maltreatment history were more likely to be female. This may be explained by a combination of both biological and psychological factors. Females may exhibit a greater vulnerability to chronic stressors and more maladaptive stress responses, feelings of guilt

M. Pompili et al. / Psychiatry Research 220 (2014) 571–578

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Table 3 Differences between groups. Variables

No or minimal history of child abuse and neglect N ¼98

More severe history of child abuse Test and neglect N ¼ 64

po

Multivariate analysis Odds ratio

95% confidence p o interval

51.6% 14.1% 14.1% 20.3%

– t160 ¼1.69 χ23 ¼2.27 – – – –

0.05a 0.09 0.52 – – – –

2.11 – – – – – –

0.98 / 4.54 – – – – – –

0.06 – – – – – –

0.84 7 1.03

0.20 70.44

t160 ¼5.35

o 0.001 0.31

0.18 / 0.54

o 0.001

15.177 8.99 13.5%

20.82 710.12 32.3%

t160 ¼  3.68 o 0.001 1.83 – 0.01a –

1.05 / 3.17 –

0.05 –

4.93 7 4.51

6.90 74.49

t160 ¼  2.68 0.01

1.01

0.92/1.12

0.78

66.1% 55.9% 34.5% 21.8%

– – – –

0.05a 0.05a 0.48a 0.05a

– – – –

– – – –

– – – –

During your lifetime, excluding the last 12 months – percentage Suicide ideation 47.3% 67.2% Suicidal planning 30.4% 57.1% Suicide attempt 35.3% 50.0% More than one suicide 17.0% 19.2% attempt

– – – –

0.05a 0.001a 0.06a 0.46a

– – – –

– – – –

– – – –

Women – percentage Age – M 7 S.D. Diagnosis – percentage BD MDD Psychosis Other specified diagnosis CTQ Minimization denial – M7 S.D. GMDS – M 7 S.D. GMDS 426 – percentage SHSS – M 7 S.D.

43.9% 43.72 714.88

62.5% 39.84 712.60

48.0% 23.5% 11.2% 17.3%

Last 12 months – percentage Suicide ideation 49.5% Suicidal planning 36.2% Suicide attempt 36.5% More than one suicide 7.9% attempts

Note: Multivariate model fit: Akaike's Information Criterion (AIC) ¼ 140.96; Pearson χ296 ¼89.69; χ2/d.f. ¼ 0.93; Likelihood Ratio χ24 ¼35.62; p o 0.001. Legend. M ¼ mean; S.D.¼ standard deviation; MDD¼ major depressive disorder; BD¼ bipolar disorders; CTQ ¼ Childhood Trauma Questionnaire; GMDS ¼ Gotland Male Depression Scale; SHSS¼ Suicidal History Self-Rating Screening Scale. a

One-way Fisher exact tests.

and worries about the future because they may perceive a higher sense of social responsibility or higher scores of neuroticism. Males may socially exhibit more directly their anger, impulsivity and aggression as signs of dominance conversely to females who often inhibit their aggressive tendencies or tend to be more passive fearing to be stigmatized as losing self-control (Thomas, 2005; Brescoll and Uhlmann, 2008). However, there are also many biological differences (e.g., dysfunctions of hormonal imbalance) which may explain why “male depression” may be more pronounced in females than in males. Susceptibility to depression may vary significantly based on gender. Gender-related differences may be explained by differential psychoneuroendocrine and psychobiochemical responses (Maes et al., 1988). Biological gender-related characteristics reflecting clinical differences in types, rates, comorbidities, antecedents, correlates, and trajectories of psychiatric diseases may also precede the expression of clinical syndromes as reported by Zahn-Waxler et al. (2008). Of note is the fact that depression and suicidal behaviors have been largely ignored in women as suggested by Möller-Leimkühler and Yücel (2010). In fact, when exploring the issue, these authors found that females had a significantly greater risk of “male depression” than their male counterparts, pointing to similar symptom structure for males and females although prototypic depressive symptoms and externalizing symptoms were predominant among females. Also, the GMDS has been shown to be a valid instrument for measuring non-typical (“suicidality-related”) symptoms of

depression in both male and female patients according to our previous studies (Innamorati et al., 2011b). The “male depressive syndrome” construct seems to be useful in the prediction of negative outcomes such as suicidal behavior and not limited by the sex of the respondents. This is consistent with previous research (Maikovich-Fong and Jaffee, 2010) and suggests that females may be more likely to experience child abuse and neglect. The child maltreatment group also reported more “male depression,” which is in line with prior studies demonstrating the link between child abuse and later adult depression (Schneider et al., 2007; Maniglio, 2010). This finding suggests that individuals who were abused as children have an increased risk of experiencing negative adult mental health outcomes (Herrenkohl et al., 2013). Spataro et al. (2004) reported that, although subtle differences may exist in the responses to child sexual abuse between the genders, male survivors demonstrated the more adverse mental health outcomes as compared to females. Moreover, in their sample, the authors revealed approximately 4 times as many contacts with mental health services relative to the general population. To further highlight the importance of the association between child sexual abuse and mental disorders as well as their consequences in adult life, Spataro et al. (2004) concluded that individuals in the child sexual abuse cohort had twice the rate of major affective disorders and were more than 3 times as likely to be diagnosed with an anxiety disorder or an acute stress reaction. However, it is important to note that the consequences related to

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child sexual abuse are often derived by a complex interaction among a series of adversities mediated by familial, social, psychological and biological variables. The present study suggests that exposure to abuse and neglect as a child may increase the risk of subsequent symptoms of “male depression,” which has been associated with higher suicidal risk. Our results are consistent with other studies which have demonstrated direct correlation between child maltreatment and suicidal behavior (Thornberry et al., 2010; Dunn et al., 2013). Attention has traditionally focused on the negative consequences related to the exposure to child maltreatment that has been shown to be a major risk factor in terms of patients' negative outcomes. However, the extent to which maltreatment contributed to such negative outcomes is, even currently, poorly understood. This is largely due to the fact that child maltreatment, being a risk factor associated with negative outcomes, is nothing other than an antecedent characteristic associated with an increase in the likelihood through which these outcomes may occur. We proposed that “male depression” may be a valid moderator between child maltreatment and suicidal behaviour. This has also been confirmed in the Gotland Study (Walinder and Rutz, 2001), suggesting the existence of the “male” depressive syndrome, including a low stress tolerance, an acting-out behavior, a low impulse control, substance abuse, a hereditary loading of depressive illness, and suicide, which has been further developed in our recent investigations (Innamorati et al., 2011b; Pompili et al., 2012; Pompili et al., 2013). In line with this result and consistent with past research (Gal et al., 2012; Easton et al., 2013), the patients with moderate to severe child abuse and neglect reported more total suicidal behavior, which included more 12 month and lifetime suicide ideation and planning, and more suicide attempts within the past 12 months. These findings suggest that patients who experienced childhood maltreatment reported higher levels of lifetime and relatively current suicidality as compared to those who were not abused as children. One explanation for the child maltreatmentsuicidality relation may be explained within the context of the interpersonal theory of suicidal behavior (Joiner, 2005; Van Orden et al., 2010). Specifically, adverse events such as childhood maltreatment may reduce the fear of self-harm and increase the likelihood of suicidal behavior. Furthermore, factors such as mental health problems (e.g., depressive symptoms) may further contribute to the risk of suicidality. In the multivariate analysis, only the minimization/denial scale of the CTQ and “male depression” were independently associated with moderate/severe history of child abuse and neglect. With regards to minimizing childhood abuse and in accordance with the current findings, previous research (Pipe et al., 2007) has demonstrated that children and adolescents frequently remain silent about their abuse, deny it, or disclose it incompletely, often recanting their allegations over time. Our findings suggest that patients who reported not being exposed to child abuse and/or neglect, may be minimizing or denying their childhood maltreatment experiences. As anticipated, the patients who reported a moderate to severe abuse and/or neglect history were almost twice as likely than those with no history of child maltreatment to be experiencing symptoms of “male depression.” This result suggests that individuals who are abused or neglected as children have an increased risk of developing “male depression,” which includes impulsive and aggressive behaviors. Given that previous research has demonstrated a link between child maltreatment and adult impulsivity and aggression (Mann et al., 2005; Zouk et al., 2006; Chen et al., 2012), it should be expected that previous abuse and/ or neglect contributes to the development of “male depression.” One interpretation for this result can be explained within the context of the self-trauma model (Briere, 1992), which posits that a

sustained sense of external security is essential for children to establish internal methods to cope with uncomfortable affect states and stressful experiences. Children who are abused or neglected are often exposed to long-term emotional pain, which prevents the development of a sense of security. Thus, maltreated children are less likely to maintain regulation skills to cope with negative thoughts or emotions and may respond to unpleasant cognitions or negative emotional arousal with aggression (Briere, 1992). Although suicidal behavior, as measured by the total SHSS score, was not independently associated with a history of child maltreatment over and above “male depression” in the multivariate analysis, it is important to note that several indicators of suicidality were more frequently reported in patients with maltreatment histories as compared to those who did not experience maltreatment as a child. Taken as a whole, our results suggest that being abused and/or neglected as a child increases the risk of “male depression” and suicidality; however, more research is warranted to replicate these findings. 4.1. Limitations of the study The findings should be considered within the context of the study's limitations. First, some of our measures were self-report questionnaires, which raise the potential problem of response bias as participants may underreport past abuse or the extent to which they feel depressed or suicidal. Similarly, there are problems associated with the retrospective reports assessing childhood abuse, including accuracy of recall and fallibility of memory, with some researchers (Henry et al., 1994; Hardt and Rutter, 2004) suggesting that recall bias may contribute to underreporting. Future studies should include multiple methods of assessment, including self-report, collateral informant reports, and clinical interviews to ensure reliability in measurement and corroborate information across time. Second, given the relatively small sample size of this study, it will be important to develop studies in the future that investigate these research questions with larger samples. Third, the sample consisted entirely of Italian psychiatric inpatients, which limits the generalizability of these results to other populations, such as those individuals residing outside of Italy (i.e., non-Italians) and Italians who are not involved in the mental health system. Fourth, there may have been problems with multicollinearity among the predictor variables in the sample, and future researches should consider including variables that assess diverse constructs. Also, this study used a cross sectional design, which precludes finding causal associations among variables. Therefore, longitudinal designs and more sophisticated methodologies should be employed before causal inferences can be made regarding the directional and developmental pathways that connect these variables in psychiatric inpatients. Moreover, future research, using both cross-sectional and longitudinal designs, that replicates our findings in more diverse samples would allow for cross-validation of the current results. Finally, as only the minimization/denial scale of the CTQ and “male depression” was independently associated with moderate/severe history of child abuse and neglect, patients who reported not being exposed to child abuse and/or neglect, may be minimizing or denying their childhood maltreatment experiences.

5. Conclusion In spite of these limitations, the results from the current study along with previous work (Widom et al., 2007; Bryan et al., 2013) may have several practical implications and contribute to our understanding of “male depression” and suicidal behavior among psychiatric inpatients with maltreatment histories. The findings

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suggest that exposure to abuse and neglect as a child may increase the risk of subsequent symptoms of “male depression”, which have been associated with higher suicidal risk. Additionally, our study adds to the research base demonstrating that child maltreatment is associated with depression in both men and women. The assessment of childhood abuse and neglect could potentially aid in the identification of individuals at risk for depression and suicidality. The results provide mental health professionals with insights into factors that can heighten the risk for depression and subsequently suicide in this vulnerable population. Accordingly, individuals who have experienced childhood maltreatment may need to be assessed for “male depression” and suicidality on a regular basis and/or be referred to treatment. In sum, this research adds to a growing body of evidence that highlights the importance of improving public health policies and mental health services for individuals who were abused and/or neglected in childhood.

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The associations among childhood maltreatment, "male depression" and suicide risk in psychiatric patients.

In the current cross-sectional study, we aimed to investigate the presence and severity of "male" depressive symptoms and suicidal behaviors in psychi...
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