The links between early childhood trauma and major mental illness: Psychiatry’s response?

Approximately two-thirds of both inpatients and outpatients in the mental health system report a history of childhood sexual and/or physical abuse. Middleton et al. (2014) cite in their most timely and important paper the Adverse Childhood Experiences (ACEs) Studies of 1998 and 2010, which demonstrate links between childhood trauma and mental illness, and call for more research in this area. Numerous studies since the early 1990s, including those in Australia (Mullen et al., 1993), have highlighted these links and also the effect on response to pharmacotherapy of early childhood trauma. These findings unfortunately have not been translated to any meaningful research.

Childhood adversities (CAs) are common. In a national survey among 13 to 17-year-old US adolescents with anxiety, mood, behavioural and substance-use disorders, CAs were found to be highly co-occurring and strongly associated with the onset of psychiatric disorders. Though the data cannot distinguish between the possibilities that CAs are causal risk factors rather than risk markers, the implications for mitigating the harmful effects of childhood adversity and for improving mental health outcome cannot be overstated (McLaughlin et al., 2012). Sexual abuse during childhood is surprisingly common, with estimates in the general population ranging from 15% to 38% (Bachmann et al., 1988). Some responses, such as suicidal behaviour, are not only life-threatening but have multigenerational repercussions (i.e. the transmission of mood disorders and suicidal behaviour to their offspring) (Brent et al., 2004). Childhood adversities are among the most consistently documented risk factors for psychiatric disorders and an association between child sexual abuse (CSA) and increased rates of mental health problems in adulthood is now well established on the basis of a range of methodologically robust studies (Mullen et al., 1993).

Child sexual abuse involving penetration is a risk factor for developing psychotic and schizophrenic syndromes; irrespective of whether this statistical association reflects any causal link, it does identify an at-risk population in need of ongoing support and treatment (Cutajar et al., 2010). Epidemiological studies indicate that children exposed to early adverse experiences are at increased risk for depression, anxiety disorders or both (Heim and Nemeroff, 2001) and that depressed people respond differently to pharmacotherapy, whether they have experienced childhood trauma or not (Nemeroff et al., 2003). Despite this, only a few randomized controlled trials have examined the effect of childhood trauma on response to treatment for depression.

The current state of knowledge about the consequences for mental health of early trauma (i.e. sexual, physical, emotional abuse and neglect) is too compelling for psychiatry to ignore. The high degree of heterogeneity in the therapeutic response to antidepressant medications among patients with major depression is an important problem that has implications both for research and for treatment. Is it possible that in the mentally ill with early abuse histories we are dealing with the effects of serious neurobiological and psychological sequelae in genetically susceptible persons, rather than a disease entity? Institutions have been held accountable by the Royal Commission for their silence and their failure to protect the very vulnerable young. Psychiatry is entrusted with the mental health and well-being of its patients and must rise to the challenge, or seen to be part of that societal silence that Middleton and colleagues refer to.

Psychiatry can address this by introducing the concepts of trauma-informed assessment and care in psychiatry training; by encouraging research in the area of early trauma and mental illness; by recognizing that early life trauma causes brain changes with resultant changes in neurophysiology and behaviour as demonstrated by a burgeoning literature. Structural and functional neuroimaging provide powerful tools to explore the long-term effects of life experiences on neurodevelopment. Most, but not all, structural magnetic resonance imaging studies examining neuroanatomical correlates of childhood sexual abuse thus far describe volume reductions in a variety of structures. Decreased volumes of the corpus callosum, the left hippocampus, the anterior cingulate, the caudate nucleus, the amygdala, and the visual cortex, as well as more general decreased cerebral volume, have all been reported in survivors of sexual abuse (Oquendo et al., 2013). Perhaps psychiatry needs to be open to the possibility, among other things, that ‘treatment resistance’ may, among other factors, be a result of the effects of unaddressed early trauma, and reduce its excessive reliance on psychotropic medication alone. This can be done in the first instance by looking at two subsets of patients: those who have suffered serious early adversity and those who have not. Therefore, combining psychotherapy with pharmacotherapy at the outset, particularly in those with poor or partial response, will give the mentally ill an opportunity to have their traumatic experiences validated, rather than for evermore to continue to endure the ‘shame’ of being unresponsive to all treatments and to continue to suffer in silence.

See Viewpoint by Middleton et al., 2014, 48(1): 22–25.