Julia L. Sheffler

In my end is my beginning: developmental trajectories of adverse childhood experiences to late-life suicide.

Objectives: Converging evidence suggests that the sequelae of adverse childhood experiences (ACEs) including childhood abuse (e.g., sexual, physical, emotional/verbal abuse, neglect) and other ACE (e.g., family dysfunction, parental loss, parental psychopathology, substance abuse, incarceration, and domestic violence) have pronounced effects on suicidal behaviors (suicidal ideation, attempts, and death by suicide) in older age. There are fundamental changes in the developmental trajectory of biological, psychological and behavioral processes that result from ACE and that exert influence throughout the life span. Different moderators and mediators may affect the extent and nature of the relationship. However, the literature on the specific mechanisms whereby ACE affects suicidality in later life has not been well identified. Method: We review and draw from extant multidisciplinary evidence to develop a heuristic framework through which to understand how ACE may lead to suicide in later life. Results: Proposed mechanisms span biological factors (neurological, gene-environment), psychiatric and health functioning, and psychosocial development (cognitive biases, coping resources, interpersonal deficits). Evidence suggests that ACEs affect each of these constructs, and it is likely in the interaction of these constructs with late-life stressors that suicidality in older adulthood emerges. Conclusion: ACEs have persistent and multifaceted effects on suicidality in late life. This association is due to multi-varied pathways. It is believed that the explanatory framework developed herein – in which biological, psychological and behavioral factors are organized, and the role of late-life stressors is highlighted – will spark further scientific inquiry into this important area.

Melancholia in later life: late and early onset differences in presentation, course, and dementia risk.

Depression is a risk factor for cognitive decline and dementia. This risk may vary with age of onset and depression subtype. Late onset depression (LOD, 60 years and older) is associated with more cognitive decline, whereas early onset depression (EOD, before 60 years) is associated with more residual depressive symptoms. Potential differences may reflect divergent etiologies. These onset differences, however, have not been examined in the melancholic subtype of depression in older adults.

Stress, race, and APOE: understanding the interplay of risk factors for changes in cognitive functioning

Objectives: Biological and environmental factors are thought to contribute to the development of cognitive decline (CD). The Apolipoprotein E (APOE) ϵ4 allele is the greatest known genetic risk factor. The current study focused on the extent to which environmental factors, specifically stress, influence the relationship between the APOE allele and cognitive functioning and whether this relationship is stronger for African-Americans compared to Caucasians.Methods: Participants consisted of community-dwelling older adults from the Duke Established Populations for Epidemiologic Studies of the Elderly (N = 4,162). Data were drawn from two waves, which were three years apart. Cognitive functioning was assessed at both waves using the Short Portable Mental Status (SPMSQ).Results: Whereas there was no main effect of stress, there was a significant interaction between APOE status and stressful life events, such that increased stress in individuals with an ϵ4 allele lead to more errors on the SPMSQ than individuals with no allele. Inconsistent with predictions, there was a significant interaction between stress and race such that increased stressful events predicted CD in Caucasians but not African-Americans.Conclusions: Recent stressful late-life events have a greater impact on the cognitive status of individuals with an ϵ4 allele. While Caucasians appear to be less vulnerable to cognitive losses at lower levels of stress, as the number of stressful life events increases that advantage disappears for Caucasians.

Racial Differences in the Effect of Stress on Health and the Moderating Role of Perceived Social Support

Objective: The current study examined racial differences in the relationship between late-life stress and health functioning and the moderating role of perceived social support (PSS) in older adults. Method: A biracial sample of community-dwelling older adults (65+) from the first two waves of the Duke University’s Established Populations for Epidemiologic Studies of the Elderly (EPESE; N = 2,952) was analyzed. Baseline levels of PSS and stress were obtained. Health status was assessed at baseline and follow-up. Results: Analyses revealed a positive effect of PSS on health functioning. There was a three-way interaction among race, stress, and PSS on health functioning. Probing the interaction, for Caucasians, PSS was beneficial at low stress, but not high stress. For African Americans, PSS had a positive effect regardless of stress level. Discussion: PSS is an important protective factor for preserving positive health in late-life; however, benefits may differ by race and intensity of stressor.

The influence of prior rape on the psychological and physical health functioning of older adults

Objectives: Older adults who have experienced traumatic events earlier in life may be especially vulnerable to additional challenges associated with aging. In a cross-sectional study of older females, the present study examines whether a history of rape is associated with current psychological and health problems. Method: This study used existing data from the female respondents (N = 1228) in the National Social Life, Health, and Aging Project (NSHAP), a national probability sample of adults between the ages of 57 and 85 interviewed in their homes. It was determined whether or not the participant experienced forced sexual contact since the age of 18. Measures of psychological health (e.g., scales of depression, anxiety, and loneliness), the presence or absence of a number of serious health problems, and a one-item measure of self-esteem were obtained. Results: Adult rape occurred in 7% of the sample. On average, 36 years had elapsed since the rape had occurred. Using structural equation modeling (SEM), rape was associated with lower self-esteem, psychological, and physical health functioning. Self-esteem partially mediated the association between rape and psychological functioning, but not health functioning. These associations were significant even after controlling for participant characteristics and risky health behaviors. Conclusions: Mechanisms linking prior rape to psychological and health problems in older age are discussed, as well as treatment recommendations for symptomatic older adults.

Early childhood abuse and late-life suicidal ideation.

Objectives: In younger populations childhood sexual and physical abuse have been found to be associated with suicidal ideation. Such associations have not been examined among older adults. Setting: Data from the National Comorbidity Study-Replication (NCS-R). Participants: Older adults (60+, N = 1610) from the NCS-R sample. Measurements: Suicidal ideation occurring after the age of 60 was assessed. Early-life factors were assessed including childhood physical and sexual abuse and parents internalizing and externalizing symptoms. Participants’ internalizing and externalizing symptoms were also assessed. Results: Logistic regression analysis showed that male gender, mothers internalizing symptoms and childhood physical and sexual abuse were associated with suicidal ideation. The association between child abuse and suicidal ideation was mediated by participants’ externalizing symptoms. Conclusions: Health care workers should screen for suicidal ideation among older adults. In particular, older males with externalizing disorders and a history of child abuse may be at a heightened risk for suicidal ideation.

When Emotional Pain Becomes Physical: Adverse Childhood Experiences, Pain, and the Role of Mood and Anxiety Disorders

OBJECTIVE We examined the association between retrospective reports of adverse childhood experiences (ACEs) and painful medical conditions. We also examined the mediating and moderating roles of mood and anxiety disorders in the ACEs-painful medical conditions relationship. METHOD Ten-year longitudinal data were obtained from the National Comorbidity Surveys (NCS-1, NCS-2; N = 5001). The NCS-1 obtained reports of ACEs, current health conditions, current pain severity, and mood and anxiety disorders. The NCS-2 assessed for painful medical conditions (e.g., arthritis/rheumatism, chronic back/neck problems, severe headaches, other chronic pain). RESULTS Specific ACEs (e.g., verbal and sexual abuse, parental psychopathology, and early parental loss) were associated with the painful medical conditions. Baseline measures of depression, bipolar disorder, and posttraumatic stress disorder were also associated with the number of painful medical conditions. Anxiety and mood disorders were found to partially mediate the ACEs-painful medical conditions relationship. We determined through mediation analyses that ACEs were linked to an increase in anxiety and mood disorders, which, in turn, were associated with an increase in the number of painful medical conditions. We determined through moderation analyses that ACEs had an effect on increasing the painful medical conditions at both high and low levels of anxiety and mood disorders; though, surprisingly, the effect was greater among participants at lower levels of mood and anxiety disorders. CONCLUSION There are pernicious effects of ACEs across mental and physical domains. Dysregulation of the hypothalamic-pituitary-adrenal stress response and the theory of reserve capacity are reviewed to integrate our findings of the complex relationships.

Non-violent and violent forms of childhood abuse in the prediction of suicide attempts: Direct or indirect effects through psychiatric disorders?

BACKGROUND Childhood abuse is linked to suicide. Potential pathways include the increased risk for the development of psychiatric disorders and the contribution of abuse to suicide capability. The current study compared the effects of childhood non-violent and violent abuse in the prediction of suicide attempts, and examined the potential mediated effects of psychiatric disorders. METHODS Data from the National Comorbidity Surveys were obtained. At baseline, assessments of childhood non-violent abuse (e.g., parental verbal abuse) and violent abuse (e.g., parental physical abuse, relative rape) were obtained. We also assessed for other adverse childhood experiences, baseline suicidal behaviors, and psychiatric disorders. At the ten-year follow-up, we assessed for psychiatric disorders and suicide attempts that had occurred over time. RESULTS Both non-violent and violent abuse predicted attempts, though participants experiencing violent abuse had significantly higher rates. Bootstrapped mediation analyses determined that the influence of non-violent abuse on suicide attempts was indirect, and exerted its influence through the psychiatric disorders that occurred during the ten-year follow-up. LIMITATIONS The study relied on retrospective reports of childhood abuse. Further, we could not clearly determine the temporal order of the psychiatric disorders and suicide attempts occurring over follow-up. CONCLUSION Different mechanisms may underlie the pathway between violent and non-violent abuse and suicide attempts. Verbal abuse may lead to negative cognitive styles and psychiatric disorders associated with suicidality; violent abuse may contribute to the capacity for suicide. Interventions may need to be specifically tailored to meet the distinct needs of individuals who have experienced past childhood abuse.

The long-term impact of combat exposure on health, interpersonal, and economic domains of functioning

Purpose: Wartime combat exposure is linked to a broad array of negative outcomes. The current study identified potential differences between middle-to-older aged men exposed to combat and those not exposed for physical health, interpersonal, and economic functioning over 10 years. Post-traumatic stress disorder (PTSD) and social support were examined as moderators between combat exposure and outcomes. Methods: Data from the National Comorbidity Survey, baseline and 10-year follow-up, were utilized. Only men aged 50–65 at follow-up (N = 727) were included. Group differences between combat and non-combat men were examined. Regression analyses were performed to examine relationships between earlier combat and health, interpersonal, and economic outcomes over time, while controlling for important covariates. Results: Combat-exposed men were at increased risk for asthma, arthritis/rheumatism, lung diseases, headaches, and pain; they also had greater marital instability. However, combat-exposed men reported economic advantages, including higher personal earnings at follow-up. For combat-exposed men, PTSD did not increase risk for headaches; however, PTSD in non-combat men was associated with increased risk for headaches at follow-up. Whereas combat-exposed men with higher levels of social support were less likely to report chronic pain at follow-up, there were no group differences in pain at lower levels of social support. Implications: Individuals who experience combat may be susceptible to later health and marital problems; however, as combat-exposed men age, they demonstrate some resilience, including in economic domains of life. Given that consequences of combat may manifest years after initial exposure, knowledge of combat exposure is necessary to inform treatments and the delivery of disability benefits.

Putamen Volume Differences Among Older Adults: Depression Status, Melancholia, and Age:

Background: Individuals with major depressive disorder (MDD) may exhibit smaller striatal volumes reflecting deficits in the reward circuit. Deficits may change with age and be more pronounced among the melancholic subtype. Limited research has investigated striatal volume differences in older adults and by depression subtypes. Method: We used baseline data from the Neurocognitive Outcomes of Depression in the Elderly study. We examined volumetric differences in the putamen and caudate nucleus among older adults (60 years and older), comparing healthy control participants (n = 134) to depressed participants (n = 226), and comparing nonmelancholic depressed participants (n = 93) to melancholic depressed participants (n = 133). Group-by-age interactions were examined. Results: There were no significant group differences for the caudate nucleus. For the left putamen, investigation of the significant group-by-age interaction revealed that volume size was greater for the healthy controls compared to the depressed participants but only at younger ages (60-65 years); group differences diminished with increasing age. Examining volume by depression subtype revealed that the melancholic depressed participants had a smaller left putamen compared to the nonmelancholic depressed participants. Anhedonia symptoms were related to both smaller left and right putamen. Conclusion: Structural abnormalities in reward regions may underlie the anhedonic phenotype. Volume loss associated with MDD may attenuate in older age.