Almost one in two depressed adult patients report maltreatment in childhood and are at increased risk of early onset, chronic or treatment-resistant depression, a meta-analysis has found.¹

A total of 184 studies met the inclusion criteria. Most studies were cross-sectional in design and used a retrospective self-report measure of maltreatment such as the 28-item Childhood Trauma Questionnaire (CTQ). Maltreatment was categorised as sexual, physical or emotional abuse,  or emotional or physical neglect. Depression was diagnosed either by standardised diagnostic interview e.g. CDI² or self-administered questionnaire e.g. PHQ-9.³

Almost half (46%) of depressed patients reported some form of childhood maltreatment. Maltreated individuals were between 2.45 times (childhood physical neglect) and 3.73 times (childhood emotional abuse) more likely than those who had not been maltreated to become depressed as adults. Childhood emotional abuse and neglect were most strongly associated with both risk of depression and depression severity.

Compared with those who did not report maltreatment, individuals who had suffered any form of maltreatment were twice as likely to develop chronic or treatment-resistant depression.

However, as the authors acknowledge, the strength of the association is likely to have been affected by confounding. Although individual studies made some attempt to adjust for potential confounders e.g. age, gender and education,² this was not possible in the meta-analysis. The effect of the use of retrospective questionnaires to identify maltreatment is unclear: this may have resulted in under-reporting due to impaired recall of childhood events or reluctance to disclose painful memories, or overreporting due to negative recall bias in depressed patients.²

A significant limitation of the CTQ is that it does not ask about witnessing domestic violence, or bullying by peers.⁴ A recent study found that, compared with controls, depressed patients were 2.5 times more likely to report that they had been bullied.⁵ A UK prospective cohort study found that children who were frequently bullied during adolescence were more than twice as likely to experience depression as young adults.⁶

The meta-analysis only included a small number of studies that reported on treatment resistance. However, a study of 1,008 depressed participants and 336 matched healthy controls, found that those who reported abuse between the ages of four and seven were 1.6 times less likely to respond to antidepressant treatment.⁵

Emotional abuse may involve conveying to a child that they are worthless or unloved or any humiliating, demeaning or threatening behaviour. Emotional neglect is the failure to provide basic psychological and emotional needs including love, affection and encouragement.⁷ According to CBT theory, negative core beliefs associated with helplessness or unlovability develop as a consequence of childhood trauma and predispose the individual to depression.⁸

Child maltreatment may provide one explanation for why depression runs in families. A recent study found that the adult offspring of mothers with antenatal depression were 3.4 times more likely to have major depression, and that this association was mediated by the offsprings’ experience of maltreatment in childhood.⁹

In conclusion, I think that we should consider the possibility of childhood maltreatment in patients with early onset, chronic or treatment-resistant depression.

I have found that constructing a family tree with the patient can provide a historical and family context and facilitate disclosure of childhood abuse. If patients report a history of childhood maltreatment we should consider referral for high intensity psychological therapy.⁵