Previous studies have reported that childhood maltreatment experiences could induce biological and psychological vulnerability in depressive disorders. However, it is still unclear that type-specific effects of childhood maltreatment on psychological resilience, depressive symptoms and interactions among childhood maltreatment experiences, resilience, and depressive symptoms.
A total of 438 medical students were included in the study. The Childhood Trauma Questionnaire-Short Form, the Conner-Davidson Resilience Scale, and the Beck Depression Inventory were used for measuring childhood maltreatment experiences, psychological resilience, and depressive symptoms, respectively. We investigated the effects of childhood maltreatment experiences on resilience and depressive symptoms using correlation analysis. In addition, we analyzed the mediating effect of resilience on the association between childhood maltreatment and symptoms of depression.
Among childhood maltreatment, emotional neglect was a significant predictor of the scores of low resilience and high depressive symptoms in both gender groups (all ps<0.05). Furthermore, resilience was found to be a mediator connecting emotional neglect experiences with depressive symptoms.
Our results suggest that emotional neglect has detrimental effects on mood and resilience, and clinicians need to focus on the recovery of resilience when they deal with depressive symptoms in victims of childhood maltreatment.
Experiences of childhood maltreatment (CM) are closely linked with various adult psychopathologies.
CM could induce biological and psychological vulnerability in depression. Even in preclinical samples, abusive experiences damage the brain structure and function related to emotion processing. The main fiber tracts linking prefrontal and subcortical regions are altered by experiences of emotional abuse.
Although a relationship between CM and depression has been established, the role of psychological resilience on the onset and course of depression is still unclear. The term “resilience” has begun to attract attention because recent studies reported protective effects of psychological resilience on aggravation of psychiatric symptoms in subjects with CM experiences including post-traumatic stress disorder, depression, and suicidal behaviors.
In this study, we aimed to clarify the effects of CM on resilience and depressive symptoms. In addition, we verified whether the CM type-specific effect exists. In addition, we analyzed the mediating effect of resilience on the association between CM and symptoms of depression. We assumed that the CM experiences, especially emotional type of CM, have negative effects on psychological resilience and depressive symptoms, and low resilience could lead the victims of CM to a depressive state.
All subjects were graduate medical students at the Kyungpook National University School of Medicine in South Korea. The Kyungpook National University School of Medicine conducted mental health assessment for students annually from 2009, and the data used in this study were drawn from first- and third-year students in 2012 and 2013. Among 440 students, 2 subjects were excluded from our analysis due to missing values. Therefore, in the final analysis, the data of 438 graduate students [265 male subjects and 173 female subjects; mean age (SD)=25.2 (2.5) years] were included. All subjects voluntarily participated and provided written consent, and this study was approved by the Ethics Committee of the Kyungpook National University School of Medicine (IRB No. 2013-05-026-001).
The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is a self-report questionnaire with 28-items developed to assess the severity of 5 types of maltreatment experiences, such as emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect during childhood and adolescence.
The Conner-Davidson Resilience Scale (CD-RISC) is a questionnaire to evaluate psychological resilience related to coping skills on stressful events.
Depressive symptoms in the subjects were measured using the Beck Depression Inventory (BDI). The cognitive, behavioral, affect, and somatic components of depressive symptoms are included in the BDI, a 21-item, self-report questionnaire.
To evaluate effect of CM on depressive symptoms, our subjects were divided into two groups based on median score of CTQ-SF (high CM and low CM). T-test was used to measure the differences in scores of BDI between high CM and low CM groups. Also, binary logistic regression analysis was conducted to assess the differences in risk of clinically significant depressive symptoms (the scores of BDI 16 or above) between two groups. Also, we checked normality of the data using skewness and kurtosis. To assess the relationships between current depressive symptoms, resilience, and childhood trauma experiences, partial correlation analysis was applied (covariate: gender). In addition, multiple regression analysis was used to investigate the effects of each maltreatment experience on depressive symptoms and psychological resilience because various maltreatment experiences could influence each other. We analyzed the whole group after controlling for gender as well as male and female groups to evaluate the gender effects in multiple regression analysis. SPSS software (version 18; SPSS Inc., Chicago, IL, USA) was used in these analyses.
In addition, mediation analysis using structural equation modeling (SEM) was performed to determine the associations between childhood trauma experiences, resilience, and depressive symptoms. Based on the results of multiple regression analysis, we selected the independent variable (childhood trauma experiences) that is a significant predictor of the dependent variable (depressive symptoms) and the mediator (resilience), respectively. The mediating effects of resilience on predicting depressive symptoms using traumatic childhood experiences were evaluated using SEM analysis. Furthermore, an additional analysis including gender effects as a covariate was conducted. The significances on SEM analysis were supported by 1,000 times bootstrapping. AMOS software (version 18; SPSS Inc.) was applied for mediation analysis.
High CM group showed high scores of BDI compared to low CM group (7.4 in high CM and 4.9 in low CM groups, p<0.001). Also, high CM group represented high chance to have clinically significant depressive symptoms (odds ratio=3.82, 95% CI=1.50–9.71, p=0.005). In normality test using skewness (S) and kurtosis (K), several data represented highly skewed results [Emotional abuse: 2.8 (S) and 12.2 (K); Emotional neglect: 1.3 (S) and 2.2 (K); Sexual abuse: 5.4 (S) and 35.0 (K); Physical abuse: 3.4 (S) and 15.1 (K); Physical neglect: 1.0 (S) and 0.1 (K); CD-RISC: -0.4 (S) and 1.6 (K); BDI: 1.7 (S) and 4.4 (K)]. Therefore, we conducted additional analyses using transformed data applying natural logarithm transformation, and transformed data showed better results in skewness and kurtosis (except CD-RISC) (
In correlation analysis, childhood maltreatment experiences, except sexual abuse, have significant positive relationships with depressive symptoms in both genders (all ps<0.05). Experiences of physical abuse experiences in men and emotional abuse in women showed significant relationship with low resilience and high depressive symptoms (all ps<0.05). Among childhood maltreatment experiences, emotional neglect represented high correlations with total scores, scores of subscales (except spiritual) of CD-RISC, and the scores of the BDI in both genders (all ps<0.01). Detailed results are described in
Emotional neglect was a significant predictor for low CD-RISC scores after adjusting for the effects of other types of maltreatment in male subjects, female subjects, and all groups (all ps<0.001). Furthermore, physical abuse was negatively associated with the scores of CD-RISC in the male group (p<0.05) (
In addition, we observed that the higher the scores for emotional neglect were, the greater were the depressive symptoms in both male and female groups (all ps<0.05). While physical abuse experiences were a significant predictor of depressive symptoms in the male group (p<0.01), the female group represented significant effects of emotional abuse, and not physical abuse, on depressive symptoms (p<0.001) (
To compensate distribution issues, we conducted additional multiple regression analysis using values that were transformed using natural logarithm, and the results were similar with analysis using raw data (
The scores of emotional neglect were selected as independent variables in mediating regression analyses because emotional neglect had a significant relationship with low resilience and high depressive symptoms both in male and female groups. The scores of emotional neglect significantly predicted the scores of depressive symptoms and those of resilience (all ps<0.001). However, a significant path connecting emotional neglect and depressive symptoms disappeared in the analysis with no covariate or decreased (p<0.05) in the analysis with gender covariate when the mediating effects of resilience were included in the SEM analysis (
We conducted additional SEM analysis using values that were transformed using natural logarithm, and the results were similar with analysis using raw data (
Our results showed that CM experiences are significantly related to psychological resilience and depressive symptoms. Among various CM experiences, emotional neglect is a consistent and significant factor for predicting low scores of resilience and high scores of depressive symptoms in both genders. In addition, we found that resilience could be a mediator in connecting emotional neglect experiences with depressive symptoms. These results suggest that emotional neglect, which is an easily neglected form of CM, has considerable effects on psychological resilience that can lead people to depression.
While child neglect is the most prevalent type of CM, its effects seem to be neglected in previous studies. Category of neglect had the highest percentage (about 60%) of CM experiences in the United States.
In our results, only emotional neglect was a consistent and significant factor showing relationships with low resilience scores and high depressive symptoms scores in both genders. There were two possible explanations for these results. First, the medical school is considered one of the most competitive departments for admission in South Korea. Previous studies reported CM experiences could lead to impaired school performance including low grade point average.
Furthermore, the results of mediation analysis showed resilience may have mediating effects on the association between CM and depressive symptoms. The meaning of resilience is rather vague and hard to define in a sentence. Resilience is a multidimensional construct containing the meaning of the capacity for, the process of, or the outcome of successful adaptation despite threatening circumstances.
There are several limitations of the study to be considered. First, our study is a cross-sectional design. Mediation analysis is more acceptable for prospective studies than cross-sectional studies, and our results could not determine a definite causal relationship among CM, resilience, and depressive symptoms. The results should be interpreted in a cautious manner. However, our results could inform future studies on the effects of CM on resilience and depressive symptoms. Second, only medical students were included in our study. High level of intellectual functioning may be related to high resilience,
Despite these limitations, our study showed the detrimental effects of emotional neglect on resilience and how resilience mediate the association between CM experiences and depressive symptoms. These results indicate the need for a careful consideration of emotional neglect experiences and providing increased attention to enhancing resilience for alleviating symptoms of depression.
This research was supported by Kyungpook National University Research Fund, 2015.
The online-only Data Supplement is available with this article at
The mediating effect of resilience on the relationship between previous abuse experiences and current depressive symptoms. (A) Natural logarithm transformed data were applied except CD-RISC. The changed values after controlling for gender were described within the bracket. Indirect effects of resilience on depressive symptoms were significant in both physical abuse in male (B) and emotional abuse in female (C). Total scores of CD-RISC and BDI are used for resilience and depressive symptoms, respectively. *p<0.05, **p<0.01, ***p<0.001. CD-RISC: Connor-Davidson Resilience Scale, BDI: Beck Depression Inventory.
Multiple regression analysis for explaining resilience scores (CD-RISC) and depression scores (BDI) using the quantity of abusive experiences
All correlation coefficients were transformed using Fisher r-to-z transformation. *p<0.05, **p<0.01, ***p<0.001. CD-RISC: Connor-Davidson Resilience Scale, BDI: Beck Depression Inventory
*p<0.05, ***p<0.001. CD-RISC: Connor-Davidson Resilience Scale
*p<0.05, **p<0.01, ***p<0.001. BDI: Beck Depression Inventory