Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
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