Improved methods of assessment and research design have established a robust and causal association between stressful life events and major depressive episodes. The chapter reviews these developments briefly and attempts to identify gaps in the field and new directions in recent research. There are notable shortcomings in several important topics: measurement and evaluation of chronic stress and depression; exploration of potentially different processes of stress and depression associated with first-onset versus recurrent episodes; possible gender differences in exposure and reactivity to stressors; testing kindling/sensitization processes; longitudinal tests of diathesis-stress models; and understanding biological stress processes associated with naturally occurring stress and depressive outcomes. There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time-including effects of childhood and lifetime stress exposure on later reactivity to stress.

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Stress and Depression

Although the association between maternal depression and adverse child outcomes is well established, the strength of the association, the breadth or specificity of the outcomes, and the role of moderators are not known This information is essential to inform not only models of risk but also the design of preventive interventions by helping to identify subgroups at greater risk than others and to elucidate potential mechanisms as targets of interventions A meta-analysis of 193 studies was conducted to examine the strength of the association between mothers’ depression and children’s behavioral problems or emotional functioning Maternal depression was significantly related to higher levels of internalizing, externalizing, and general psychopathology and negative affect/behavior and to lower levels of positive affect/behavior, with all associations small in magnitude These associations were significantly moderated by theoretically and methodologically relevant variables, with patterns of moderation found to vary somewhat with each child outcome Results are interpreted in terms of implications for theoretical models that move beyond main effects models in order to more accurately identify which children of depressed mothers are more or less at risk for specific outcomes

/pdf/maternal-depression-and-child-psychopathology-a-meta-2mbyrrledi.pdf

Maternal Depression and Child Psychopathology: A Meta-Analytic Review

▪ Abstract This chapter reviews recent research on the relationship between stressful life experiences and depression. A distinction is made between aggregate studies of overall stress effects and focused studies of particular events and difficulties. A distinction is also made between effects of life stress on first onset of depression and on the subsequent course of depression. Although the available evidence suggests that acute stressful life events can lead to the recurrence of episodes of major depression, a series of methodological problems compromise our ability to make clear causal inferences about the effects of life events on first onset of major depression or about the effects of chronic stress on either onset or recurrence of depression. The main problems of this sort are discussed, and recommendations made for ways of addressing these problems in future studies.

The effects of stressful life events on depression.

Context Although significant associations of childhood adversities (CAs) with adult mental disorders have been documented consistently in epidemiological surveys, these studies generally have examined only 1 CA per study. Because CAs are highly clustered, this approach results in overestimating the importance of individual CAs. Multivariate CA studies have been based on insufficiently complex models. Objective To examine the joint associations of 12 retrospectively reported CAs with the first onset of DSM-IV disorders in the National Comorbidity Survey Replication using substantively complex multivariate models. Design Cross-sectional community survey with retrospective reports of CAs and lifetime DSM-IV disorders. Setting Household population in the United States. Participants Nationally representative sample of 9282 adults. Main Outcome Measures Lifetime prevalences of 20 DSM-IV anxiety, mood, disruptive behavior, and substance use disorders assessed using the Composite International Diagnostic Interview. Results The CAs studied were highly prevalent and intercorrelated. The CAs in a maladaptive family functioning (MFF) cluster (parental mental illness, substance abuse disorder, and criminality; family violence; physical abuse; sexual abuse; and neglect) were the strongest correlates of disorder onset. The best-fitting model included terms for each type of CA, number of MFF CAs, and number of other CAs. Multiple MFF CAs had significant subadditive associations with disorder onset. Little specificity was found for particular CAs with particular disorders. Associations declined in magnitude with life course stage and number of previous lifetime disorders but increased with length of recall. Simulations suggest that CAs are associated with 44.6% of all childhood-onset disorders and with 25.9% to 32.0% of later-onset disorders. Conclusions The fact that associations increased with length of recall raises the possibility of recall bias inflating estimates. Even considering this, the results suggest that CAs have powerful and often subadditive associations with the onset of many types of largely primary mental disorders throughout the life course.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/210584/yoa90080_113_123.pdf

Childhood Adversities and Adult Psychiatric Disorders in the National Comorbidity Survey Replication I: Associations With First Onset of DSM-IV Disorders

http://www.aipro.info/drive/File/The%20link%20between%20childhood%20trauma%20and%20depression.%20Insights%20drom%20HPA%20axis%20studies%20on%20humans.%20C.%20Heim%20et%20al.,%2001%2002%2014.pdf

The link between childhood trauma and depression: insights from HPA axis studies in humans.

The present study set out to examine the relationship between marital status, poverty and depression in a sample of inner-city women. Single and married mothers were followed up over a 2-year period during which time rates of psychosocial risk factors, onset of depression and experience of chronic episodes were measured. Risk of onset was double among single mothers. Single mothers were twice as likely as their married counterparts to be in financial hardship, despite being twice as likely to be in full-time employment. Both of these factors were independently associated with onset in single mothers. The link between them and onset was via their association with humiliating or entrapping severe life events. Single parents were at a much raised risk of experiencing these events. Onset was also more likely to follow such an event when women had poor self-esteem and lack of support, both of which were more common among single mothers. These risk factors were more frequently found among those in financial hardship. Financial hardship was also related to risk of having a chronic episode (lasting at least a year), of which single parents were also at greater risk. The majority of chronic episodes among single mothers had their origins in prior marital difficulties or widowhood and rates of chronicity reduced with length of time spent in single parenthood. Results are discussed in terms of an aetiological model of onset in which financial hardship probably influences outcome at a wide variety of points.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291796004060

Single mothers, poverty and depression.

Background Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002). Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into “Angry-dismissive” and “Withdrawn”. The degree to which attitudes and behaviour within such styles were dysfunctional (“non-standard”) was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder. Results The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the “non-standard” levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder. Conclusion The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance.

Adult attachment style. I: Its relationship to clinical depression.

BACKGROUND:
Childhood neglect and abuse, as measured by retrospective interview, is highly predictive of psychiatric disorder in adult life and has an important role in aetiological models. However, such measures are labour-intensive, costly, and thus restricted to relatively modest sample sizes. A compact self-report assessment of childhood experience is invaluable for research screening purposes and large-scale survey investigation.

METHOD:
A self-report questionnaire (CECA.Q) was developed to mirror an existing validated interview measure: the childhood experience of care and abuse (CECA). The questionnaire assessed lack of parental care (neglect and antipathy), parental physical abuse, and sexual abuse from any adult before age 17. A high-risk series of 179 London women were interviewed using the CECA together with the PSE psychiatric assessment, and completed the CECA.Q at later follow-up. Repeat CECA.Qs were returned for 111 women and 99 women additionally completed the parental bonding instrument (PBI; Parker, Tupling, & Brown, 1979).

RESULTS:
Satisfactory internal scale consistency was achieved on the CECA.Q for antipathy (alpha = .81) and neglect (alpha = .80) scales. There was satisfactory test-retest for both care and abuse scales. Significant associations were found between CECA.Q scales and the parallel interview scales with cut-offs determined for high sensitivity and specificity. CECA.Q neglect and antipathy scales were also significantly related to PBI parental care. CECA.Q scales were significantly related to lifetime history of depression. Optimal cut-off scores revealed significant odds ratios (average of 2) for individual scales and depression. When indices were compiled to reflect peak severity of each type of adversity across perpetrator, odds-ratios increased (average 3). A dose-response effect was evident with the number of types of neglect/abuse and rate of lifetime depression.

CONCLUSION:
The CECA.Q shows satisfactory reliability and validity as a self-report measure for adverse childhood experience. The merits of having parallel questionnaire and interview instruments for both research and clinical work are discussed.

The childhood experience of care and abuse questionnaire (CECA.Q): Validation in a community series

There has been little prospective investigation of the relationship between adult attachment style and clinical levels of anxiety and major depression. This paper seeks to address this, as well as examining the potentially mediating role of adult insecure attachment styles in the relationship between childhood adverse experience and adult disorder. 154 high-risk community women studied in 1990–1995, were followed-up in 1995–1999 to test the role of insecure attachment style in predicting new episodes of anxiety and/or major depressive disorder. The Childhood Experience of Care and Abuse (CECA) and the Attachment Style Interview (ASI) were administered at first interview and the Structured Clinical Interview for DSM-IV (SCID) administered at first and follow-up interview. Major depression and clinical level anxiety disorders (GAD, Social Phobia or Panic and/or Agoraphobia) were assessed at first contact and for the intervening follow-up period. 55% (85/154) of the women had at least one case level disorder in the follow-up period. Only markedly or moderately (but not mildly) insecure attachment styles predicted both major depression and case anxiety in follow-up. Some specificity was determined with Fearful style significantly associated both with depression and Social Phobia, and Angry-Dismissive style only with GAD. Attachment style was unrelated to Panic Disorder and/or Agoraphobia. In addition, Fearful and Angry-dismissive styles were shown to partially mediate the relationship between childhood adversity and depression or anxiety. In order to correctly interpret lifespan models of adult psychiatric disorder, it is necessary to test for mediating factors. Attachment theory provides a framework for explaining how dysfunctional interpersonal style arising from early childhood perpetuates vulnerability to affective disorders. This has implications for intervention and treatment to break cycles of risk.

Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety

BACKGROUND We consider how far it is possible to predict a chronic course of a depressive disorder from psychosocial and clinical material available at the point of onset.

METHOD A population survey found 404 working-class mothers living in an inner-city area of London. The majority were interviewed three times over a 3-year period.

RESULTS Chronicity (more than 12 months' duration) was strongly related to both childhood adversity (parental indifference, family violence or any sexual abuse) and current adult interpersonal difficulties. The lack of positive events during the course of the episode was also independently related to chronicity, but to a lesser degree. Clinical characteristics were relatively unimportant compared with psychosocial factors.

CONCLUSIONS The childhood risk factors were particularly important (judged by a path analysis), and a challenge for future research will be to establish the intervening processes involved with this distal link.

Patricia Moran

Papers

Single mothers, poverty and depression.

Adult attachment style. I: Its relationship to clinical depression.

The childhood experience of care and abuse questionnaire (CECA.Q): Validation in a community series

Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety

Clinical and psychosocial origins of chronic depressive episodes. I: A community survey.