Adverse Childhood Experiences and Their Relationship with Depression Among Adults in a Low-Income Uninsured Population

Background and Purpose: Adverse Childhood Experiences (ACEs) have been linked to poor mental health outcomes among adults, yet prior research on clinical depression has generally relied on Electronic Health Records (EHRs), which limits understanding of this relationship to a relatively advantaged group of individuals with established access to health care. Adults in poverty may have been exposed to greater adversity in childhood, which could be compounded by poorer access to health and mental health care. The objective of this study was to estimate the association between ACEs and a measure of current clinical depression in a community-sample of (mostly) uninsured low-income adults. We also evaluate if the association persists after adjusting for access indicators, such as health insurance and having physical and behavioral health care needs met.

Methods: This study leverages the Oregon Health Insurance Experiment’s (OHIE) study population, who were randomly selected to apply for Medicaid, and key data, collected through in-person health screenings, including clinical measures of depression using the Patient Health Questionnaire depression module (PHQ-8). Data on ACEs were collected via a follow-up mail survey with OHIE study health screening participants, 12,054 individuals were sent the Oregon ACE survey with a response rate of 48%, n = 5,900. Ordinary least squares regression and logistic regression models were used to analyze the association between ACEs and the probability of depression, including subgroup analyses by depression severity and each of the ACE domains. We adjusted for socio-demographic characteristics as well as multiple comparisons.

Results: This study found a notably high prevalence of ACES; 36% reported high ACEs (defined as 4+ ACEs), 46% reported abuse, 35% reported neglect, and 72% reported household dysfunction. Among the sample, 29% were depressed (PHQ-8 score ≥10), 13% were severely depressed (PHQ-8 score ≥15), and 4% were very severely depressed (PHQ-8 score ≥20). Similarly, subgroup analyses on depression, severe depression, and very severe depression showed consistent and robust associations with ACEs in hierarchical logistic regression models. A high ACE score (4+) was generally associated with being depressed (145 percentage points, p<.0001), being severely depressed (176 percentage points, p<.0001), and being very severely depressed (271 percentage points, p<.0001). These strong associations persisted when adjusting for sociodemographic variables, including insurance status. Surprisingly, when respondents also reported their healthcare needs and alcohol and drug treatment needs had been met, the relationships between ACEs and clinical depression were no longer statistically significant.

Conclusions and Implications: This study design allowed us to understand the relationship between ACEs and clinical depression in an uninsured low-income adult population. In all analyses, ACEs were associated with increased prevalence of depression; however, when respondents indicated that their healthcare needs and alcohol and drug treatment needs were met, this association went away. These findings suggest that access to necessary medical and behavioral health care can alter the otherwise persistent relationship between ACEs and clinical depression among low-income adults.