Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A cross-sectional, population-based study

Abstract

Background

Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda.

Methods and findings

Between 2016 and 2018, research assistants visited the homes of 1,626 adult residents of Nyakabare Parish, a rural area in southwestern Uganda. ACEs were assessed using a modified version of the Adverse Childhood Experiences-International Questionnaire, and depression symptom severity and suicidal ideation were assessed using the Hopkins Symptom Checklist for Depression (HSCL-D). We applied a validated algorithm to determine major depressive disorder diagnoses. Overall, 1,458 participants (90%) had experienced at least one ACE, 159 participants (10%) met criteria for major depressive disorder, and 28 participants (1.7%) reported suicidal ideation. We fitted regression models to estimate the associations between cumulative number of ACEs and depression symptom severity (linear regression model) and major depressive disorder and suicidal ideation (Poisson regression models). In multivariable regression models adjusted for age, sex, primary school completion, marital status, self-reported HIV status, and household asset wealth, the cumulative number of ACEs was associated with greater depression symptom severity (b = 0.050; 95% confidence interval [CI], 0.039–0.061, p < 0.001) and increased risk for major depressive disorder (adjusted relative risk [ARR] = 1.190; 95% CI, 1.109–1.276; p < 0.001) and suicidal ideation (ARR = 1.146; 95% CI, 1.001–1.311; p = 0.048). We assessed the robustness of our findings by probing for nonlinearities and conducting analyses stratified by age. The limitations of the study include the reliance on retrospective self-report as well as the focus on ACEs that occurred within the household.

Conclusions

In this whole-population, cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had statistically significant associations with depression symptom severity, major depressive disorder, and suicidal ideation. These findings highlight the importance of developing and implementing policies and programs that safeguard children, promote mental health, and prevent trajectories toward psychosocial disability.

Abstract

In a cross-sectional, population based study of adults in rural Uganda, Emily Satinsky and colleagues investigate adverse childhood experiences and associations with depression and suicidal ideation.

Author summary

Why was this study done?

• Depression is recognized globally as a leading cause of disability. Studies from high-income countries have shown robust associations between adverse childhood experiences (ACEs) and depression during adulthood.

• While studies from sub-Saharan Africa have demonstrated associations between ACEs and depression and suicidality among children, adolescents, and young adults, no study from this region has yet estimated the associations between ACEs and major depressive disorder and suicidal ideation within a whole-population sample of adults.

What did the researchers do and find?

• We conducted a cross-sectional, population-based study of 1,626 adults in rural Uganda, eliciting ACEs, current depression, and suicidal ideation through face-to-face interviews.

• The cumulative number of ACEs that occurred before age 18 had statistically significant associations with adult depression symptom severity, major depressive disorder, and suicidal ideation.

• Depression symptom severity and major depressive disorder had statistically significant associations with each of the 9 types of ACEs. Suicidal ideation also had statistically significant associations with living with an adult who was sent to jail or prison during childhood and experiencing food and/or water insecurity during childhood.

What do these findings mean?

• Our interpretation of these findings raises implications for the development of policies and programs that support children, adolescents, and their families, and promote mental health.

• We are not able to determine the extent to which these associations are causal, and our analysis is susceptible to potential bias from the use of retrospective self-report of ACEs.