Influence of childhood maltreatment on major depressive disorder in adulthood: mediating role of social support

Influence of childhood maltreatment on major depressive disorder in adulthood: mediating role of social support | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 19 April 2025 V1 Latest version Share on Influence of childhood maltreatment on major depressive disorder in adulthood: mediating role of social support Authors : Zhi Zeng , Xiaozhen Lv , Shuzhe Zhou , Qi Liu , Tian-Mei Si 0000-0001-9823-2720 , Gang Zhu , Qiaoling Chen , … Show All … , Hongjun Tian , Nan Zhang , Kerrang Zhang , Xueyi Wang , Jing Wei , Gang Wang , and Xin Yu 0000-0003-3983-4937 [email protected] Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.174507678.83294076/v1 194 views 114 downloads Contents Abstract Introduction Methods Results Discussion Conclusions Abbreviations Supplementary Material References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background and objectives: Childhood maltreatment is strongly associated with major depressive disorder (MDD) in adulthood, social support may mediate the effect of childhood maltreatment on MDD, but there were few studies exploring the mediating role of different types of social support between childhood maltreatment and MDD, and whether sex difference existing in the mediating models was also unclear. Methods: The study included 965 MDD patients and 443 healthy participants from nine centers in China. MDD patients are diagnosed using the DSM-IV. The Childhood Trauma Questionnaire-Short Form, Social Support Rate Scale, and 17-item Hamilton Depression Rating Scale, were used to assess the status of childhood maltreatment, social support and MDD, respectively. Multivariable mediation analyses were used to examine the mediating role of different types of social support between childhood maltreatment and MDD after controlling for sex, age, ethnicity, educational level, family history, work status and marriage. Results: The childhood maltreatment increased the risk of MDD. All types of social support significantly reduced the risk of MDD. Total social support (β = -0.37, 95%CI: -0.43, -0.30, p <0.001), perceived support (β = 0.05, 95%CI: 0.03, 0.07) and support utilization (β = 0.01, 95%CI: 0.01, 0.12) played a mediating role in childhood maltreatment and MDD, respectively,but not tangible support. For males, only perceived support mediated the relationship between childhood maltreatment and MDD, while for females, both perceived support and support utilization mediated the relationship. Introduction Major depressive disorder (MDD) is a common and highly disabling mental illness(GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018). According to the latest national survey in China, the lifetime prevalence of depressive disorder in the Chinese population reached 6.8%(Huang et al., 2019). In recent years, the incidence of MDD has been increasing year by year, further increasing the global burden( Proudman, D., Greenberg, P., & Nellesen, D., 2021). As for the causes of major depressive disorder (MDD), in addition to genetic factors, environmental factors also play an important role, such as childhood maltreatment(Otte et al., 2016). Childhood maltreatment refers to physical and emotional abuse, sexual abuse, neglect, and commercial or other forms of exploitation of children, often occurring in a variety of settings. Studies showed that the incidence of child maltreatment in China is generally higher than the global epidemiological data (Stoltenborgh, M., Bakermans-Kranenburg, M. J., Alink, L. R. A., & van Ijzendoorn, M. H., 2015; Ta, X., 2014). Previous studies suggested that child maltreatment is associated with an increased risk of MDD in adulthood, regardless of the type of abuse experienced (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010; Widom, C. S., DuMont, K., & Czaja, S. J., 2007; Fergusson, Boden, & Horwood, 2008; Liu, R. T., Alloy, L. B., Abramson, L. Y., Iacoviello, B. M., & Whitehouse, W. G., 2009). As early as the 1980s, researchers (Cohen & Wills, 1985)had found that adequate social support was helpful for maintaining mental health in both main effect and buffering models, while the definition of social support was inconsistent worldwide. Taylor divides social support into explicit social support and implicit social support(Taylor, S. E., Welch, W. T., Kim, H. S., & Sherman., 2007). There are also scholars who divide social support into two components:emotional support and instrumental support(Park, S. M., Cho, S. I., & Moon, S. S., 2010).According to Chinese cultural characteristics, Xiao SY proposed that social support could be divided into three categories( SY, X. 1994): tangible support, perceived support, and support utilization. Tangible support refers to objective, visible or practical support, including direct material assistance and the presence and participation of social networks and group relationships. Perceived support refers to individuals’ subjective, experienced, and perceived support from family, friends and colleagues, care, and help, including the emotional experience and satisfaction of being respected, supported, and understood in the society. Support utilization refers to the extent to which we use support resources, such as some people who are available for some social support but refuse or ignore it. Which type of social support was most protective against MDD hadn’t reached agreement. For example, one study showed that inpatients with low perceived support had a higher risk of depression (Yan et al., 2013). Other studies found that the perception and use of social support were more beneficial to health(Moak, Z. B., & Agrawal, A., 2010), and less perceived social support was strongly associated with higher levels of depression(Eagle, Hybels, & Proeschold-Bell, 2018). A study of 907 graduate students (Wang et al., 2015)found that childhood maltreatment affects depressive symptoms not only directly, but also through social support, which suggested that social support probably played a mediating role between childhood maltreatment and depressive symptoms among students. On the other hand, different cultural characteristics may influence the mediating role of social support between child maltreatment and MDD. Asians who with more collective cultural influence often seek less social support, whereas Europeans and Americans with more individualistic cultural influence always seek more social support( Kim, H. S., Sherman, D. K., Ko, D., & Taylor, S. E., 2006). Some scholars found that in Asian cultures, seeking social support was considered as undermining collective harmony and leading to criticism or loss of face(S. E. Taylor et al., 2004), which may therefore affect Asians’ initiative to seek social support. To our knowledge, there were few studies exploring the mediating role of different types of social support between childhood maltreatment and MDD in China. We noticed that the relationship between social support and depression is different between male and female. One Study on college students found that the support utilization in females is higher than that in males, thus helping to reduce the degree of depression in females(WANG Ling & hua, 2001). Another study found that social support reduced the risk of depression for women more than that for men(Schraedley, P. K., Gotlib, I. H., & Hayward, C., 1999). The relationship between emotional perceived support and depression was different between men and women, for example, it was found that emotional perceived support was more effective in preventing depression in women than in men Kenneth S. Kendler, M. D., John Myers, M. S., & Carol A. Prescott, P. D., 2005). A study found that childhood maltreatment in women, but not in men, can reduce the attachment to mothers and affect social support, and thus social support mediated the onset of depressive symptoms(Alto, Handley, Rogosch, Cicchetti, & Toth, 2018). At present, we have not seen studies based on Chinese population to analyze whether the mediating effect of social support was different between male and female. In this study, we aimed to investigate the mediating role of different types of social support in childhood maltreatment and MDD among Chinese adults. We hypothesized that different types of social support have different mediating effects between childhood maltreatment and adult MDD. Moreover, there were sex differences in these mediating roles. Methods Participants The participants were recruited between December 2013 and December 2016 from nine tertiary hospitals in six provinces in China. The details of the project can be found elsewhere(Lv et al., 2016). The study was approved by the research ethics committee of the institutions where it was performed. All subjects participating in the project had signed informed consent. The researchers were all strictly trained according to the work manual. Clinical data were acquired by psychiatrists. The inclusion criteria for the MDD patients in this study were: (1) aged between 18 and 55 years; (2) an MDD diagnosis made by psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) criteria and then confirmed by a structured clinical interview using the Chinese version of the Mini-International Neuropsychiatric Interview (MINI); (3) a total score on the 17-Item Hamilton Rating Scale for Depression (HRSD 17 )≥14; (4) the ability to complete the questionnaire and assessment; (5) written confirmation of informed consent. The exclusion criteria for MDD participants were: (1) a lifetime or current diagnosis of other psychotic disorders or alcohol/substance dependence; (2) serious physical diseases, such as serious cardiovascular and cerebrovascular diseases, serious respiratory diseases, serious liver and kidney diseases, malignant tumors; (3) informed consent was not signed; (4) was participating in other studies; (5) pregnant or breast-feeding. The inclusion criteria for healthy participants in this study were: (1) aged between 18 and 55 years; (2) the ability to read and write to complete the assessment on social support and childhood maltreatment; (3) written confirmation of informed consent. The exclusion criteria for healthy participants were: (1) According to Chinese version of the Mini-International Neuropsychiatric Interview (MINI) interview assessment, a lifetime or current diagnosis of any mental disorders, serious physical diseases, such as serious cardiovascular and cerebrovascular diseases, serious respiratory diseases, serious liver and kidney diseases, malignant tumors; (2) informed consent was not signed; (3) was participating in other studies; (4) pregnant or breast-feeding. The inclusion criteria for this present analysis were as follows: (1) the criteria above; (2) Complete the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Social Support Rating Scale (SSRS) and HRSD 17 . Demographic and clinical characteristics assessment The demographic and clinical characteristics, including age, sex, ethnicity, educational level, family history of psychiatric disorder, work status, marital status, and history of MDD episode were collected using a set of questionnaires designed for this study. HRSD 17 (Hamilton, 1960)was used to assess depressive symptoms. Assessment of childhood maltreatment Childhood maltreatment was assessed with CTQ-SF, which is a 28-item self-report inventory that provides brief and relatively noninvasive screening of maltreatment experiences before the age of 18 years. Studies found that CTQ-SF had good reliability and validity(Min, 2011; Zhao, X. F., Zhang, Y. L., Li, L. F., & Zhou, Y. F., 2005). The CTQ-SF is designed to assess five types of negative childhood experiences, including emotional neglect, emotional abuse, physical neglect, physical abuse, and sexual abuse. Each of the five types of abuse experiences was assessed by five items. Each item scores ranged from 1 to 5, 1= never; 2=occasionally; 3=sometimes; 4=five points; 5=always. The total score was between 25 and 125 points. Higher scores indicated more severe maltreatment. Assessment of social support Considering cultural differences, the social support system of the Chinese may be different from that of the European and American( Schaefer, M. 2009; YAN XU & BURLESON, 2001). Therefore, we used the Social Support Rating Scale (SSRS) compiled by Xiao SY in 1994 according to Chinese cultural characteristics( SY, X., 1994), to assess the level of an individual’s social support over the past year. The scale was composed of 10 questions in 3 dimensions, including tangible support, perceived support, and support utilization. Each question was rated on a scale of 1-4, and the overall score was used to assess an individual’s current social support status, with a higher score indicating a higher level of social support. The sum of the scores of the 10 questions is the score of total social support, the sum of the scores of the 2nd, 6th and 7th questions is the score of tangible support, the sum of the scores of the 1st, 3rd, 4th, and 5th questions is the score of perceived support, and the sum of the scores of the 8, 9 and 10 questions is the score of support utilization. The scale has high reliability and validity and is widely used in China(LIU Ji-wen, LI Fu-ye, & Yu-long, L., 2008; Sufei,X., Yangming,Y., Ziqiang,X., & Chongde,L., 2018; Xiao SY, & DS, Y., 1987). Statistical Package of the IBM SPSS Statistics 23.0 was used to conduct all statistical analyses. Kolmogorov-Smirnov test was used to test the normal distribution of continuous variables. Data were expressed as mean ± standard deviations for continuous variables and frequency and percentage for categorical variables. Chi-square tests, independent t-tests and Mann‒Whitney U tests were used to compare the demographic and clinical data between the MDD patients and healthy participants. The mediation model was conducted using the Process V3.3 plug-in for mediation variable calculation. The mediation analysis used a three-step linear regression. According to previous studies (Feng et al., 2007; Fergusson et al., 2008; Kenneth S. Kendler, M. D., John Myers, M. S., & Carol A. Prescott, P. D., 2005; Kessler et al., 2003), age, sex, ethnicity, educational level, family history, work status, and marital status were considered as covariates. The first step is to analyze the relationship between childhood maltreatment and social support. The second step is to analyze the influence of social support on MDD. The third step is to include both childhood maltreatment and social support into the model to examine the direct and indirect effects. The Hayes PROCESS macro was used to analyze the mediating effect of social support between child maltreatment and MDD. The mediation effect was tested with the Bootstrap method(Hayes, 2013). A total of 5000 samples were taken and 95% confidence intervals were estimated, and the mediating effect was statistically significant if the confidence intervals not including 0. Total and different types of social support were substituted into the model for mediation analysis, respectively. Similar mediation analysis was done in male and female, respectively. Results Demographic and clinical characteristics of the participants There were 1408 participants, 965 MDD patients and 443 healthy participants, included into the final analysis. The average age of the MDD group was 38.23±10.50 years, and 32.29±9.01 for the healthy group. A total of 70.3% of MDD patients and 59.1% of healthy participants were female. MDD group had more positive family history, less work, more physical labor, lower educational level, and were more likely to be married than the healthy group. MDD group experienced more childhood maltreatment and received less social support than healthy group (Table 1). The mediating effect of social support on childhood maltreatment and MDD The mediating effects of total social support and different types of social support on childhood maltreatment and depressive symptoms were shown in Table 2 and Figure. After controlling for sex, age, ethnicity, educational level, family history, work status, marriage and other variables, there was a negative association between childhood maltreatment and total social support (β = -0.21, 95%CI: -0.34, -0.25, p<0.001). Total social support was negatively associated with MDD (β = -0.37, 95%CI: -0.43, -0.30, p <0.001). The indirect effect of total social support (β = 0.12, 95%CI: 0.08, 0.14), perceived support (β = 0.05, 95%CI: 0.03, 0.07) and support utilization (β = 0.01, 95%CI: 0.01, 0.12) were statistically significant, but not tangible support (β = 0.01, 95%CI: -0.01, 0.01). The results showed that all types of social support reduced the degree of MDD. Both perceived support and support utilization mediated the relationship between childhood maltreatment and MDD. In the tangible support model, the mediating effect was not significant. Mediating effects of social support on childhood maltreatment and MDD in different sex The mediating effects of social support on the association between childhood maltreatment and MDD in male and female were shown in Table 3. For male, total social support (β = 0.12, 95%CI: 0.07, 0.18) and perceived support (β = 0.05, 95%CI: 0.02, 0.09) mediated the mediating relationship between childhood maltreatment and MDD, while the mediating effect of tangible support (β = 0.01, 95%CI: -0.01, 0.02) and support utilization (β = 0.01, 95%CI: -0.01, 0.02) were not significant. For female, total social support (β = 0.1, 95%CI: 0.08, 0.13), perceived support (β = 0.05, 95%CI: -0.03, 0.07) and support utilization (β = 0.01, 95%CI: 0.01, 0.03) mediated the relationship between childhood maltreatment and MDD, but not tangible support (β = 0.01, 95%CI: -0.01, 0.01). Discussion In this study of 1,408 adult participants, we found that individuals who experienced more childhood maltreatment had less social support in adulthood, and that more social support was associated with lower risk of MDD. Total social support, perceived support and support utilization mediated the relationship between childhood maltreatment and MDD. We also found only perceived support mediated the relationship between childhood maltreatment and MDD in male, while both perceived support and support utilization mediated the relationship between childhood maltreatment and MDD in female. Our study supports that childhood maltreatment can increase the risk of MDD. Previous studies have suggested that the mechanism of action includes the influence of childhood abuse experience on psychological cognition, attachment relationship, emotional regulation, personality characteristics, and neurobiological changes, so as to promote the onset of MDD(Jin & Wang, 2017). Moreover, we found that total social support, perceived support, tangible support, and support availability, both significantly reduced the risk of MDD, which is different from previous studies( Powers, A., Ressler, K. J., & Bradley, R. G., 2009). We found that social support mediated the relationship between childhood maltreatment and adult MDD. This is consistent with previous research( Sperry, D. M., & Widom, C. S. 2013; Wang Min, Guo Fei, & Yan, 2015). Our study found that only perceived suppor mediated the relationship between childhood maltreatment and MDD for both male and female, which highlighted the effect of perceived support. Previous studies suggested that perceived support is more correlated with MDD than tangible support and support utilization(Feng et al., 2007; YANG Chun-Xiao, 2016), which was basically consistent with our findings. Previous studies found that perceived support can maintain family stability(Wang et al., 2015), and poor family relationships are more likely to cause MDD(Kendler, K. S., Gardner, C. O., & Prescott, C. A., 2002). Perceived support characteristics mainly reflected in the closely related to the individual subjective feeling, and subjective feeling in many studies, negatively correlated with depression (Chen, Siu, Lu, Cooper, & Phillips, 2009; Powers, A., Ressler, K. J., & Bradley, R. G., 2009), even the most strongly associated of any type of social support(YANG Chun-Xiao, 2016). We only found sex differences in the mediating effect of support utilization on childhood maltreatment and MDD. In female, support utilization was an intermediary between childhood maltreatment and adult MDD, but not in male. ’After puberty, women have higher attachment needs and need more social activities to participate in with their peers. It was reported that female were more prone to have depressive symptoms than male when met poor utilization of social resources and decreased utilization of social support (Cyranowski, Frank, Young, & Shear, 2000). A meta-analysis from China showed that women had a significantly greater negative association between social support and depression than men, and that women were more likely to get help from social support(Chunxiao, Y., Dajun, Z., Yinghao, L., & Tianqiang, H.,2016). The sex differences in psychodynamics, social role and evolution, and social construction may be also the reasons for the difference in social support between male and female Pines, A. M., & Zaidman, N., 2003). We did not find the mediating effect of tangible support on childhood maltreatment and MDD. One study found that tangible support has no significant effect on depression(YL Zhang & Li, 2003). Another study showed that the protective advantage of tangible support on mental health was mainly reflected in special groups, such as empty-nesters( Liu, L. J., & Guo, Q., 2007). These findings may indicate that tangible support may have no mediating effect on childhood maltreatment and adult MDD. The strengths of this study were as follows. First, this study analyzed the mediating effect of total and different types of social support on childhood maltreatment and MDD in detail. Second, we analyzed the mediating effect of social support in male and female, respectively, which provided basis for further personalized intervention. Third, as a multi-center study, the subjects were continually recruited from outpatient clinics of 9 research centers in China, which represented the MDD patients to some extent. There was a limitation in this study: Child maltreatment were assessed by participants themselves, which may be influenced by recall bias and depressive status. However, previous researchers found that even in the serious maltreatment case, the risk of mental illness was lower in the absence of subjective reporting, while the risk of mental illness was higher in the subjective reporting of childhood abuse in adulthood(Danese & Widom, 2020). Therefore, recall bias of childhood maltreatment in our study may have a minor effect on the results. Conclusions Social support, especially perceived support, and support utilization, mediates the relationship between childhood maltreatment and adult MDD. For males, only perceived support mediated the relationship between childhood maltreatment and adult MDD, while for females, both perceived support and support utilization had mediating effects. For individuals who have experienced childhood maltreatment, further MDD prevention could focus on providing personalized social support. Abbreviations MDD:Major depressive disorder; DSM-IV:Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition; MINI:Mini-International Neuropsychiatric Interview;CTQ-SF: Childhood Trauma Questionnaire-Short Form; SSRS :Social Support Rate Scale; HRSD17:17-Item Hamilton Rating Scale for Depression. Table 1.Demographic and clinical characteristics of the participants. Table 2. The mediating effect of social support on childhood maltreatment and depressive symptoms (n=1408). 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Keywords child and family health major depressive disorder social support Authors Affiliations Zhi Zeng Peking University Sixth Hospital View all articles by this author Xiaozhen Lv Peking University Sixth Hospital View all articles by this author Shuzhe Zhou Peking University Sixth Hospital View all articles by this author Qi Liu Peking University Sixth Hospital View all articles by this author Tian-Mei Si 0000-0001-9823-2720 Peking University Sixth Hospital View all articles by this author Gang Zhu The First Hospital of China Medical University Department of Surgical Oncology View all articles by this author Qiaoling Chen Dalian Medical University View all articles by this author Hongjun Tian The Affiliated Hospital of Nankai University View all articles by this author Nan Zhang Tianjin Medical University General Hospital View all articles by this author Kerrang Zhang First Hospital of Shanxi Medical University View all articles by this author Xueyi Wang The First Hospital of Hebei Medical University View all articles by this author Jing Wei Peking Union Medical College Hospital View all articles by this author Gang Wang Capital Medical University View all articles by this author Xin Yu 0000-0003-3983-4937 [email protected] Peking University Sixth Hospital View all articles by this author Metrics & Citations Metrics Article Usage 194 views 114 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Zhi Zeng, Xiaozhen Lv, Shuzhe Zhou, et al. 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