Adverse Childhood Experiences, Traumatic Events, and Mental Health Among Adults at Two Outpatient Psychiatric Facilities in Johannesburg, South Africa: A Sex-Disaggregated Cross-Sectional Analysis

Background:

While current literature shows a strong association between adverse childhood experiences and traumatic experiences on adverse mental health outcomes, few studies have explored how gender impacts this relationship. Gender is a critical factor that influences mental health outcomes. Globally, females are more likely to report mental health challenges than their male counterparts. For instance, a global study across 31 countries found that compared to males, females reported higher levels of overall emotional distress and more depressive symptoms. Therefore, this study examines the gender-based impact of traumatic events and ACEs on depression and anxiety scores among men and women receiving outpatient psychiatric care at two public mental health treatment facilities in Johannesburg, South Africa.

Methods:

A sample of 309 participants was recruited between January and June 2022 at Helen Joseph Hospital and Alexandra 18th Avenue Clinic. Participants completed screening measures for mental health outcomes, including the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder Scale (GAD-7). Linear regression models stratified by sex were fitted to estimate the impact of ACEs and adult experiences of trauma on depression and anxiety scores. Results were disaggregated by sex due to the sex-specific nature of exposure to ACEs, adult trauma, and mental health outcomes for psychiatric patients included in this analysis. We fitted separate models to estimate the association between ACEs and mental health outcomes and the association between traumatic events and mental health outcomes.

Findings:

47.57% (n=147) of participants screened positive for anxiety, and 44.66% (n=138) for depression. More women (65%) than men (35%) screened positive for anxiety (c²=10.56, p=001). Similarly, more women (66%) compared to men (34%) screened positive for depression (c²=10.68, p=001). Findings further indicated that depressive symptom severity was associated with ACEs (unstandardized coefficient [b]=0.60; per ACE, 95% confidence interval [CI], 0.18-1.03; P =0.006) for men and not women. However, depressive symptom severity was associated with traumatic events for both men (b= 0.75, per traumatic event, 95% CI = 0.24, 1.27, P =.005) and women (b = 0.82, per traumatic event, 95% CI = 0.34, 1.31, P=.001). Additionally, anxiety symptom severity was associated with ACEs for both men (b = 0.55, per ACE, 95% CI = 0.20, 0.90, P=.002) and women (b = 0.45, per ACE, 95% CI = 0.15, 0.75, P=.003). Anxiety symptom severity was associated with traumatic events for both men (b= 0.47, per traumatic event, 95% CI = 0.03, 0.91, P =.04) and women (b = 0.67, per traumatic event, 95% CI = 0.31, 1.03, P<.001).

Conclusion:

Study findings advance our understanding of the prevalence of ACEs and traumatic events and its influence on mental health symptoms of both men and women psychiatric patients. Results highlight the urgent need for future research and behavioral mental health interventions targeting the interplay between ACEs, traumatic events, and mental health outcomes in sub-Saharan Africa.