The relationship between adolescent depression and a history of sexual abuse.

Buzi, Ruth S. ; Weinman, Maxine L. ; Smith, Peggy B. 等

INTRODUCTION

Depression among adolescents in general, and female adolescents in particular, has been identified as a major mental health diagnosable disorder (Lahey et al., 1996). It is estimated that 28% of adolescents will have experienced an episode of major depression by age 19 (Lewinsohn, Rohde, & Seeley, 1998). Data from community-based, epidemiological surveys also suggested that nearly 30% of a sample of adolescents aged 14 to 18 had at least one current symptom of major depression (Roberts, Lewinsohn, & Seeley, 1995). Depression rates are steadily increasing among adolescents, with symptoms beginning at earlier ages (Son & Kirchner, 2000). Major depression is also the most prevalent mental disorder affecting young adults. Data from a longitudinal community study showed that overall, 23.7% of the sample met diagnostic criteria for major depression between ages 18 and 26 (Paradis, Reinherz, Giaconia, & Fitzmaurice, 2006). There are marked gender differences in major depression prevalence with females being twice as likely as males to develop depression during adolescence (Hazler & Mellin, 2004).

Depressed adolescents may experience more extreme consequences than depressed adults (Schraedley, Gotlib, & Hayward, 1999). They are more susceptible to later traumatic life events and are more likely to experience depressive occurrences in adulthood (Son & Kirchner, 2000; Stannard, 2000). Depression during adolescence is also of utmost concern as it increases the risk for suicide (Stanard, 2000; Capelli et al., 1995).

The most frequently studied risk factors for depression during adolescence include poor attachments with parents, poor relationships with friends, poor school performance, feelings of hopelessness and/or loneliness, substance abuse, and depression or psychiatric illness in the family (Stanard, 2000; Diego, Sanders, & Field, 2001; Son & Kirchner, 2000). Some studies also identified sexual abuse as a major risk factor for depression. For example, a study of 171 women with major depression found that 40 (23.3%) of them reported childhood sexual abuse. A comparison between abused and non-abused women found that women who were sexually abused did not differ on psychiatrist-rated mood severity estimates, but they did have higher self-report depression scores. They also exhibited more self-destructive behavior and personality dysfunction (Gladstone, Parker, Wilhelm, Mitchell, & Austin, 1999). Another study among 125 women with depressive disorders examined the impact of childhood sexual abuse on severity of depression (Gladstone et al., 2004). Although women who reported childhood sexual abuse did not differ from women without such an experience in severity of depression, they became depressed at an earlier age and were also more likely to have attempted suicide and/or engaged in deliberate self-harm.

Relationship Between Depression and Sexual Abuse

Depression is frequently examined in studies focusing on the consequences of sexual abuse. However, a history of sexual abuse is rarely examined in studies that focus on depression. For example, a recent literature review identified changes in social development, social role expectations, and/or biology as important risk factors that explain depression among adolescents (Hazler & Mellin, 2004). However, the contribution of sexual abuse to adolescent depression was only briefly mentioned. Another study examined depression correlates among 413 adolescent primary care attendees who presented with multiple health issues. Although a variety of demographic and contextual factors such as drug use and exposure to drugs were examined, the impact of sexual abuse was not included. Lastly, an analysis of data from Wave I of the National Longitudinal Study of Adolescent Health examined the associations of depression and suicide with patterns of sex and drug use behaviors. However, the possible impact of sexual abuse on these behaviors was not examined (Hallfors et al., 2004).

It is known that approximately one-third of the female population experience depression (Lewinsohn, Rohde, & Seeley, 1998). Studies have also shown that approximately one-third of females have been sexually victimized before age 18 (Finkelhor, 1979; Finkelhor, Hoataling, Lewis, & Smith, 1989; Wyatt, 1985). As depression and sexual abuse are prevalent among females, their interrelationship should be further examined. In addition, since psychiatric symptoms and particularly depression are present among adolescents attending healthcare settings (Yates, Kramer, & Garralda, 2004), it is important to determine the risk factors for depression in these settings. Studies in family planning clinics also found a high prevalence of mental health issues including depression among adolescents who attend these clinics. For example, Capelli et al. (1995) found that 41% of adolescents receiving services at a teen clinic scored from moderate to severe on depression, and half of them were suicidal. They concluded that the prevalence of depression among these teens overwhelmingly exceeds national statistics of depression among adolescents, suggesting that youth experiencing mental health disorders are more likely to seek care in clinics. Since depression is prevalent among adolescents attending healthcare settings, it would be important to examine the risk factors for depression in these settings. Therefore, the purpose of this study is to examine the occurrence of depression among adolescents attending family planning clinics and examine the relationships of depression, a history of sexual abuse, and other risk behaviors. Knowledge about pertinent risk factors for depression would help identify those youths most in need of intensive preventive interventions.

METHOD

Participants

Adolescents were sequentially recruited for the study from June 2002 through August 2002. The study was conducted in Teen Health Clinics located in the southwest part of the United States. These clinics provide free comprehensive family planning and reproductive health services to indigent adolescents who reside in the inner city. Parental consent for clinical services is solicited but not required because under state statutes, minors who receive Title X funding are not required to have parental consent. The study protocol was approved by the Institutional Review Board of the affiliated medical school.

Measures

The questionnaire for this study utilized several measures from existing adolescent risk-behavior surveys such as the original Safer Choices survey (Coyle et al., 1999), the National Youth Risk Behavior Survey (Center of Disease Control and Prevention, 2000), and the National Longitudional Study of Adolescent Health (Udry, 1997). In addition to collecting sociodemographic and background information, participants were asked about their sexual behaviors, use of drugs and alcohol, depression symptoms, and history of sexual abuse.

Depression

The Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1986) was used to measure depression symptoms. This is a brief self-report measure designed to assess depressive symptomatology within the past two weeks. The scale is comprised of 30 items rated on a 4-point Likert-type format with anchors 1: almost never, to 4: most of the time. A total score is then computed. The scale is designed as a screening measure for identification of depression in school-based and clinic populations. An adolescent who scores at or above a raw score of 77 should be identified for further evaluation. Cronbach's alpha as reported by the authors is .92. Cronbach's alpha for the data in this study was .91.

History of sexual abuse. A history of sexual abuse was ascertained by the question, "Have you ever been forced to have sex against your will?" Participants were considered as having a history of sexual abuse if they answered yes to this question. This question was also used in the 1997 Massachusetts Youth Risk Behavior Surveillance Survey (Rajh, Silverman, & Amaro, 2000).

Sexual risk behaviors. Risky sexual behaviors were measured in seven domains: age of sex initiation, number of sexual partners in the last 3 months, use of alcohol and drugs before last sexual intercourse, number of times of having sex without using condoms, a history of pregnancy, exchanging of sex for drugs or money, and a history of sexually transmitted infections (STIs).

Other risk behaviors. Other risk behaviors included use of alcohol in the past 30 days and lifetime and recent drug use. Questions also covered specific drug use such as marijuana, cocaine, codeine, fry, LSD, speed, and heroin. Contextual factors such as lifetime and recent mobility were also examined.

Procedure

Clinic staff trained by the lead author recruited the participants. A clinic staff member distributed the questionnaires consecutively among participants during the course of their visits. Participants completed the questionnaires in a private room adjacent to the waiting room while waiting for clinical services. The purpose of the study was explained and informed consent was obtained before data were collected. A clinic staff member was available to clarify any questions. A few adolescents required some assistance in completing the survey. Adolescents were excluded from the study if they did not speak English.

RESULTS

Sociodemographic profile. Two hundred seventy-nine females participated in the study. The majority, 185 (66.3%), were African American, and 94 (33.7%) were Hispanic. The mean age of the participants was 18.59 (range = 13-23, SD = 1.97). The number of participants and their reasons for visiting the clinic were: 149 (53.4%) for contraception, 81 (29.0%) for a pregnancy test, 75 (26.9%) for an STI check-up, and 19 (6.8%) for STI treatment. Some participants came for multiple reasons.

Depression. Forty (14.3%) adolescents scored at or above a raw score of 77. This score indicates that these adolescents should be identified for further evaluation.

History of sexual abuse. A history of sexual abuse was reported by 40 (4.3%) of the participants.

Sexual risk behaviors. The mean age for initiation for sexual intercourse was 15.07 (range = 7-20, SD = 1.86) and the mean number of lifetime partners was 4.58 (range = 1-70, SD = 6.54). The majority, 140 (50.2%), reported not using a condom at their last sexual encounter. The mean number of times participants had sex without using a condom in the last three months was 6.28 (range = 1-270, SD = 21.57). Although the majority, 159 (57.0%), reported that they intend to use a condom at their next sexual encounter, 49 (17.6%) did not intend to use a condom. One hundred twenty-four (44.4%) participants reported having a history of an STI. The majority, 229 (82.1%), reported that they have had an HIV test at least once.

Other risk behaviors. Many of these adolescents also reported engaging in other risky health behaviors. For example, 96 (34.4%), reported having at least one drink of alcohol in the past 30 days and 124 (44.4%) reported having used drugs in their lifetime. Many, 117 (41.9%), reported lifetime marijuana use and 44 (15.8%) reported using cocaine, codeine, fry, LSD, speed, or heroin.

Relationships among Depression and Sexual Abuse History and Other Risk Behaviors

Stepwise Linear Regression was used to evaluate which risk factors predict depression. Depression was entered as the dependent variable and a history of sexual abuse and other risk behaviors were entered as independent variables. The variables that predicted depression in linear order included: a sexual abuse experience, number of times the teens moved in the last year, use of marijuana in the last 30 days, and number of days teens had at least one drink of alcohol in the last 30 days. The final model predicted 16.9% of the variance. The best explanatory variable was a history of sexual abuse, predicting 7.8% of the variance. This suggests that it was the most potent predictor for depression. Thus, females with high scores on depression as compared to those with low scores were more likely to report a history of sexual abuse, move more frequently in the last year, use marijuana in the last 30 days, and drink alcohol in the last 30 days. (see Table 1).

DISCUSSION

The purpose of this study was to examine the occurrence of depression among adolescents attending family planning clinics and determine the relationships among depression, a history of sexual abuse, and other risk behaviors. Forty (14.3%) adolescents scored at or above a raw score of 77 for depression. This score indicates that these adolescents should be referred for further evaluation. The findings of the study suggest that sexual abuse was the most potent factor in predicting depression while other risk factors contributed only a small amount of variance to the overall model.

The results of this study are consistent with previous studies that identify a history of sexual abuse as a key risk factor for depression among women and that depression develops at a young age (Gladstone, Parker, Mitchell, Malhi, Wilhelm, & Austin, 2004; Gladstone, Parker, Wilhelm, Mitchell, & Austin, 1999). It is important to note that although 57 teens reported the age of sexual onset as 13 and under, an age where sexual consent cannot legally be given, only 15 (26%) reported it as sexual abuse. This raises some concerns that early sexual debut is not perceived as abuse or inappropriate by the teens but might lead to psychological distress. Data from the National Longitudinal Study of Adolescent Health showed that engaging in sex and drug behaviors places female adolescents at risk for future depression (Hallfors, Waller, Bauer, & Ford, 2005). Therefore, it is crucial to initiate a discussion about age of sexual onset and their feelings at that time with teens. These findings highlight the importance of screening concurrently for depression and a history of abuse in family planning and other healthcare settings. Since research on the physiological effects of childhood sexual abuse has found biochemical abnormalities among victims, such as long-term disregulation of physiological stress response systems (DeBellis, Burke, Trickett, & Puttnam, 1996), early intervention is crucial.

In terms of other risk behaviors that contributed to depression, recent mobility emerged as a significant factor. Geographic relocation has been implicated as an important correlate of psychopathology and behavioral problems such as suicide attempts among child and adolescent populations (Potter et al., 2001). This suggests that it would be important when screening for sexual abuse and depression to also examine other risk behaviors and contextual factors. Although this study has some limitations related to its cross-sectional design and a sexual abuse experience that was broadly defined, it clearly highlights the impact of a history of sexual abuse on depression.

Clinical Implications

The findings of this study have several implications for family planning and other healthcare settings that serve adolescents. First, clinical programs that assess the health of adolescents need to be aware that both sexual abuse and depression coexist and therefore require attention. Second, it is important to assess the age of sexual debut along with subsequent behaviors and feelings. Although teens do not always perceive early sexual debut as abuse, this experience may have the same characteristics as abuse and therefore can lead to the onset of a series of issues that may compromise healthy development. Third, known risk behaviors such as substance abuse and geographic mobility are life stressors that can compromise mental health and therefore have to be assessed. Last, further research that examines additional factors which can predict depression among adolescents is crucial.

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This project was partially supported by a grant from the John P. McGovern Foundation.

Maxine L. Weinman, Graduate College of Social Work, University of Houston, Texas.

Peggy B. Smith, Teen Health Clinic, Baylor College of Medicine, Houston, Texas.

Requests for reprints should be sent to Ruth S. Buzi, Teen Health Clinic, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030. E-mail:rbuzi@bcm.edu

Table 1

Stepwise Multiple Regression

Model R R Square Adjusted F
 R Square

1 .278 .078 .072 13.7 *

2 .349 .122 .111 11.2 *

3 .381 .145 .129 9.1 *

4 .412 .169 .149 8.1 *

Note. Predictors: a sexual abuse experience, moving in the
last 30 days, marijuana use in the last 30 days, alcohol
use in the last 30 days; dependent variable; depression.

* p<.05.