Introduction
For more than a decade, researchers have investigated the impacts of adverse childhood experiences (ACEs) and their significance on public health and global health burden surveillance [1]. ACEs are defined as emotional, physical, or sexual abuse; neglect; substance misuse; and other traumatic events that occur to a child before the age of 18 [2]. Annually, nearly 600,000 documented cases of child abuse and neglect are reported [3, 4].
Additionally, 60% of American adults report experiencing at least one ACE, with 17% reporting four or more [3, 4]. ACEs have been linked to an increased risk of morbidity and mortality, contributing to conditions such as coronary ischemic heart disease, cancer, chronic lung disease, skeletal fractures, disability, and liver disease during adulthood [2, 5]. Additionally, ACEs are associated with mental health concerns, including depression, illicit drug use, and alcohol consumption [6–8].
Certain minority groups face a significantly higher risk of experiencing ACEs, which may be partly driven by discrimination [9, 10]. This discrimination can lead to economic disadvantages, which in turn increase the likelihood of encountering ACEs [11]. Minority communities also experience lower quality healthcare and inferior access to mental health resources compared to their white counterparts [12].
ACEs also vary in prevalence across different racial groups [13]. Among non-Hispanic Black children, 61% have experienced at least one ACE, compared to 51% of Hispanic children [13]. The prevalence is 40% for non-Hispanic White children and significantly lower at 23% for non-Hispanic Asian children [13].
Given that minority groups often face more severe and prolonged mental health challenges, it is crucial to identify risk factors to proactively address and mitigate their effects [14, 15].
Cancer survivors are at higher risk of developing mental health conditions, specifically depression, which is three times more likely to manifest in cancer survivors compared to the general population [16]. A robust association exists between the mortality rate in cancer survivors and the presence of minor or major depression, which can increase the mortality rate by 39% [17]. In the USA, 25% of cancer survivors experience depression [18], and there are racial disparities in how ACEs contribute to the development of depression in this population [14, 15].
In addition, existing literature has demonstrated increased risk of cancer in adults with certain types of ACEs such as physical and psychological abuse [19, 20]. While prior studies have explored the association between ACEs and depression within the general population, research focusing on cancer survivors stratified by racial differences is lacking. Our study addresses this gap by quantifying the risk of depression in cancer survivors across different racial groups based on the number of ACEs they experienced.
Specifically, we evaluated the association between the number of ACEs experienced and a history of self-reported depression among cancer survivors from different racial/ethnic groups (non-Hispanic White, non-Hispanic Black, non-Hispanic Other, and Hispanic). This data may provide the empirical data necessary for developing race-specific, risk stratified screening methods for patients diagnosed with cancer who have experienced ACEs.
Methods
Data source and study sample
This was a cross-sectional analysis of data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is the largest continuously conducted health survey in the world, administered by state health departments with oversight from the Centers for Disease Control and Prevention (CDC), and reaches over 500,000 respondents. It is a state-based telephone survey of noninstitutionalized adults administered annually in the USA and associated territories.
The BRFSS has three overall components: core modules (sets of questions consistently administered to all states and territories to establish national estimates), optional modules (CDC–developed questions that states can include in their BRFSS survey depending on their priorities), and state-added questions (state-customized items). Details of the survey methods have been published elsewhere [21]. This study utilized open-access de-identified data and was exempt from institutional review board approval.
In 2020, 28 states (AL, AZ, CA, DC, FL, GA, HI, ID, IA, KS, KY, MD, MA, MS, MO, MT, NV, NJ, ND, OK, RI, SC, SD, TX, UT, VA, WI, WY) included state-added adverse childhood experience questions. For this study, we included 22,292 cancer survivors aged 18 and above. Respondents with missing ACE or depression data were excluded.
Cancer survivors were identified with a yes response to the following question: “(Ever told) you had skin cancer or any other types of cancer?”
Measures
Adverse childhood experiences
The primary exposure variable in this study was the number of ACEs. ACE was determined by responses to 11 questions that assessed exposure to eight types of adverse childhood experiences. These childhood experiences included three types of abuse and five types of household challenges before age 18.
The three types of abuse considered included physical, emotional, and sexual. The five types of household challenges assessed included household member(s) of the respondent’s families with substance misuse, incarceration or mental illness, parental divorce, or witnessing intimate partner violence. Answers were coded as “one” if the ACE was present and “zero” if absent.
The responses were summed to produce an ACE score, with cumulative scores ranging from zero to 11. We created categories of ACE scores as follows: zero; one; two-three; and ≥ four based on prior literature [22–25].
Depression
The outcome variable was a self-reported history of depression, assessed by response to the BRFSS question, “Has a doctor, nurse, or other health professionals ever told you that you had a depressive disorder (including depression, major depression, dysthymia, or minor depression)?” Response options were yes or no, and those who answered yes were classified as having a history of depression.
Race/ethnicity
Three race/ethnicity groups were selected a priori for this analysis: non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Others.
Covariates
The following covariates, selected based on prior literature [26–32] were included in the study: age (18–39, 40–64, and ≥ 65), sex (female, male), marital status (married/partnered, divorced/separated/widowed, or never married), education level (college graduate, some college, or < high school (HS)/HS graduate), income level (≥ $50,000, $25,000 to 49,999, < $25,000, or missing), body mass index (BMI) (normal, overweight, or obese; BMI was defined as normal if 18.5 to < 25 kg/m2, overweight if 25.0 to < 30 kg/m2, and obese if 30.0 kg/m2 or higher), and smoking status (never, former, or current).
Statistical analysis
Descriptive statistics were used to describe the characteristics of respondents overall and stratified by the number of ACEs experienced. Chi-square tests were used to compare the differences in covariates across the number of ACEs (zero, one, two–three, or ≥ four ACEs). Second, four weighted multivariable logistic regression models were used to examine the association between the number of ACEs and self-reported depression, one for each race/ethnicity, adjusting for age, sex, marital status, education level, income level, body mass index, smoking status, and health status.
All analyses were weighted to account for the complex survey design of BRFSS and were performed using SAS version 9.4 (Cary, NC). P-values were two-sided, and P < 0.05 was considered statistically significant.
Results
A total of 22,292 cancer survivors were included in the study, of whom 4338 (21.2%) reported a history of depression. Approximately 41%, 22%, 21%, and 16% reported having zero, one, two–three, or ≥ four ACEs, respectively. Table 1 summarizes the study sample’s characteristics, overall and stratified by number of ACEs.
Overall, most respondents were 65 years or older (59.4%), female (56.0%), non-Hispanic whites (83.7%), married (61.4%), half were never smokers (49.9%), and there was equal distribution for BMI. In the bivariate analyses, respondents with depression were 18–39 years, female, non-Hispanic Blacks, never married, obese, current smokers, earned < $ 25 K, or reported fair/poor health.
Table 1Sample characteristics, overall and stratified by history of depression, 2020 Behavioral Risk Factor Surveillance System (n = 22,292)Overall (n = 22,292)DepressionP-valueYes (n = 4338)No (n = 17,870)Depression diagnosis Yes4338 (21.2%)–-–- No17,870 (78.8%)–-–-Number of ACEs < 0.0001 Zero9773 (41.1%)1081 (11.7%)8664 (88.3%) One5088 (22.1%)868 (18.4%)4197 (81.6%) Two–Three4375 (20.9%)1059 (22.6%)3296 (77.4%) > Four3056 (15.9%)1330 (47.8%)1713 (52.2%)Age at time of survey < 0.0001 18–39675 (5.3%)296 (45.3%)374 (54.7%) 40–646149 (32.3%)1677 (28.1%)4458 (71.9%) ≥6515,179 (59.4%)2330 (15.2%)12,787 (84.8%)Sex < 0.0001 Female12,690 (56.0%)3038 (26.3%)9612 (73.7%) Male9602 (44.0%)1300 (14.7%)8258 (85.3%)Race/ethnicity0.0021 Non-Hispanic White19,427 (83.7%)3681 (20.9%)15,681 (79.1%) Non-Hispanic Black914 (5.6%)195 (30.1%)714 (69.9%) Hispanic576 (5.9%)149 (15.7%)424 (84.3%) Non-Hispanic Other1375 (4.7%)313 (24.1%)1051 (75.9%)Marital status < 0.0001 Married12,759 (61.4%)2130 (18.3%)10,598 (81.7%) Divorced/separated/widowed8004 (32.6%)1825 (24.7%)6137 (75.3%) Never married1422 (6.0%)370 (33.4%)1048 (66.6)Education level0.0005 College graduate8992 (29.9%)1530 (17.8%)7437 (82.2%) Some college6605 (33.3%)1436 (22.0%)5144 (78.0%) ≤ High school graduate6647 (36.8%)1364 (23.3%)5249 (76.7%)Income level < 0.0001 ≥ 50K9326 (41.7%)1444 (17.3%)7862 (82.7%) 25–50K4858 (20.6%)976 (23.1%)3867 (76.9%) < 25K4070 (20.2%)1290 (33.1%)2751 (66.9%) Refused or missing4038 (17.6%)628 (14.6%)3390 (85.6%)BMI category < 0.0001 Normal6888 (31.3%)1171 (19.0%)5691 (81.0%) Overweight7863 (36.1%)1349 (18.1%)6483 (81.9%) Obese6383 (32.6%)1581 (27.0%)4782 (73.0%)Smoking status < 0.0001 Never11,797 (49.9%)1906 (17.7%)9849 (82.3%) Former7986 (37.0%)1542 (19.8%)6418 (80.2%) Current2364 (13.1%)875 (39.0%)1474 (61.0%)Health status < 0.0001 Excellent/very good9565 (40.8%)1181 (12.3%)8365 (87.7%) Good7197 (32.2%)1357 (22.1%)5794 (77.9%) Fair/poor5530 (27.0%)1780 (33.7)3711 (66.3%)ACE, adverse childhood experienceP-value based on the chi-square test
Table 2 summarizes multivariable logistic regression models for the association between the number of ACEs and history of depression stratified by race/ethnicity. Respondents who experienced ≥ four ACEs had a higher likelihood of reporting depression for all racial/ethnicity groups: non-Hispanic Whites (aOR = 4.20; 95% CI 3.32, 5.32), non-Hispanic Blacks (aOR = 2.98; 95% CI 1.45, 6.14), Hispanics (aOR = 10.74; 95% CI 5.01, 23.00), or non-Hispanic Others (aOR = 4.29; 95% CI 2.31, 7.98) compared to those who experienced zero ACEs. Respondents who experienced 2–3 ACEs had a higher likelihood of reporting depression for non-Hispanic Whites (aOR = 1.98; 95% CI 1.58, 2.48) compared to those who experienced zero ACEs.
There was no statistically significance between experiencing 2–3 ACEs and depression for non-Hispanic Blacks, non-Hispanic Others, and Hispanics. Respondents who experienced one ACE had a higher likelihood of reporting depression for non-Hispanic Whites (aOR = 1.71; 95% CI 1.37, 2.14) compared to those who experienced zero ACEs, but no statistically significant difference was observed for non-Hispanic Blacks, non-Hispanic Others, and Hispanics. Table 2Four multivariable logistic models (one for each race/ethnicity) estimating associations between number of ACEs and history of depression, 2020 Behavioral Risk Factor Surveillance System (n = 22,292)Adjusted odds ratios (95% confidence interval)Non-Hispanic WhiteNon-Hispanic BlackHispanicNon-Hispanic OthersNumber of ACEs ZeroRefRefRefRef One1.71 (1.37, 2.14)0.94 (0.43, 2.04)1.42 (0.53, 3.85)1.44 (0.85, 2.46) Two–Three1.98 (1.58, 2.48)0.98 (0.48, 2.03)1.29 (0.48, 3.41)1.02 (0.50, 2.08) > Four4.20 (3.32, 5.32)2.98 (1.45, 6.14)10.74 (5.01, 23.00)4.29 (2.31, 7.98)Age at time of survey ≥65 RefRefRefRef 18–393.59 (2.46, 5.22)3.40 (0.99, 11.65)0.67 (0.21, 2.11)3.58 (1.65, 7.75) 40–641.51 (1.25, 1.82)1.55 (0.91, 2.62)2.76 (1.33, 5.73)1.77 (1.06, 2.94)Sex Female2.17 (1.82, 2.58)1.41 (0.66, 3.02)3.44 (1.74, 6.77)1.38 (0.91, 2.10) MaleRefRefRefRefMarital status MarriedRefRefRefRef Divorced/separated/widowed1.18 (0.98, 1.41)0.52 (0.24, 1.10)2.04 (1.03, 4.13)0.96 (0.61, 1.51) Never married1.49 (1.02, 2.18)1.51 (0.49, 4.66)1.66 (0.48, 5.77)0.61 (0.22, 1.69)Education level College graduateRefRefRefRef Some college0.87 (0.71, 1.05)0.76 (0.35, 1.66)2.20 (0.99, 4.92)0.76 (0.42, 1.37) ≤ High school graduate0.91 (0.72, 1.13)0.69 (0.33, 1.44)0.88 (0.34, 2.26)0.88 (0.53, 1.45)Income level ≥ 50KRefRefRefRef 25–50K1.20 (0.96, 1.49)0.53 (0.26, 1.08)0.58 (0.18, 1.91)4.95 (2.56, 9.56) < 25K1.35 (1.07, 1.71)1.13 (0.51, 2.51)0.86 (0.28, 2.71)2.32 (1.19, 4.52) Refused/missing0.73 (0.58, 0.93)0.43 (0.17, 1.12)0.82 (0.29, 2.38)2.88 (1.38, 6.04)BMI category NormalRefRefRefRef Overweight1.20 (1.00, 1.44)0.77 (0.33, 1.82)1.09 (0.46, 2.56)1.47 (0.90, 2.38) Obese1.57 (1.29, 1.90)0.59 (0.24, 1.46)0.92 (0.36, 2.34)3.95 (2.35, 6.64)Smoking status NeverRefRefRefRef Former1.11 (0.92, 1.34)0.91 (0.51, 1.66)0.70 (0.30, 1.61)0.60 (0.36, 1.00) Current1.47 (1.15, 1.87)1.63 (0.77, 3.49)2.04 (0.93, 4.49)1.99 (1.19, 3.33)Health status Excellent/very goodRefRefRefRef Good1.83 (1.49, 2.25)4.33 (2.05, 9.14)1.42 (0.58, 3.52)1.29 (0.74, 2.26) Fair/poor2.99 (2.46, 3.65)7.16 (3.12, 16.45)1.78 (0.79, 4.15)2.97 (1.79, 4.91)ACE Adverse childhood experience
Non-Hispanic Whites (aOR = 1.51; 95% CI 1.25, 1.82), Hispanics (aOR = 2.75; 95% CI 1.33, 5.73), and non-Hispanic Others (aOR = 1.77; 95% CI 1.06, 2.94) aged 40–64 had a higher likelihood of reporting depression compared to their ≥ 65 counterparts. Additionally, non-Hispanic Whites (aOR = 3.59; 95% CI 2.46, 5.22) and non-Hispanic Others (aOR = 3.58; 95% CI 1.65, 7.75) aged 18–39 had a higher likelihood of reporting depression compared to their ≥ 65 counterparts. Non-Hispanic White females (aOR = 2.17; 95% CI 1.82, 2.58) and Hispanic females (aOR = 3.44; 95% CI 1.74, 6.77) had a higher likelihood of reporting depression compared to their male counterparts.
Among non-Hispanic Whites who were never married (aOR = 1.49; 95% CI 1.02, 2.18) vs. married; earned < $ 25 K (aOR = 1.35; 95% CI 1.07, 1.71) vs. > $ 50 K; were obese (aOR = 1.57; 95% CI 1.29, 1.90) vs. normal; were current smokers (aOR = 1.47; 95% CI 1.15, 1.87) vs. never smokers; and had good (aOR = 1.83; 95% CI 1.49, 2.25) or fair/poor (aOR = 2.99; 95% CI 2.46, 3.65) vs. very good/excellent self-reported health status had a higher likelihood of reporting depression. Among non-Hispanic Blacks who had good (aOR = 4.33; 95% CI 2.05, 9.14) or fair/poor (aOR = 7.16; 95% CI 3.12, 14.4) vs. very good/excellent self-reported health status had a higher likelihood of reporting depression.
Discussion
Recognition of causes of depression in patients diagnosed with cancer is important because depression in this population affects both the individual as well as the health care system. Individuals with depression have a higher risk of suicide [33], lower adherence to treatment [34], and increased mortality rates of up to 39% [17]. Depression in cancer survivors results in more frequent healthcare visits, increased emergency department visits, higher rates of hospital readmissions, longer hospital stays, and greater healthcare costs [35–37].
In this paper, we explored the impact of ACEs experienced during childhood on depression diagnosis in adult cancer survivors across different racial/ethnic groups. We found that overall, 21% of cancer survivors reported a history of depression, which is higher than the 18.5% of self-reported depression observed in the general US adult population [38]. However, it falls within the range of self-reported depression rates typically seen in the cancer population [39].
We found that irrespective of respondents’ race/ethnicity, experiencing a higher number of ACEs, specifically four or more, was associated with increased odds of reporting depression in adulthood among cancer survivors compared to those who did not experience any ACE. There were no significant differences in depression for non-Hispanic Blacks, non-Hispanic Others, and Hispanics with less than three ACEs. A previous meta-analysis of ACEs and risk of depression has found that this relationship is non-linear and there is a more pronounced increase in the risk of depression with subsequent numbers of ACES [40].
This in addition to healthy coping mechanisms and resilience may have led to no significant differences in depression at lower levels of ACEs among minoritized groups.
Understanding the full psychosocial history of cancer survivors allows providers to tailor care in a way that mitigates long-term mental health consequences and reduces costs. For instance, the National Comprehensive Cancer Network (NCCN) currently recommends distress screenings at every visit if possible, but that can be difficult, and there are no other recommended specific intervals [41]. Incorporating an ACE assessment into this workflow could identify patients who warrant prioritized attention regarding mood disorders.
While our analysis established a significant association between a history of ACEs and depression among cancer survivors, it is important to acknowledge that this relationship is likely multifaceted. Several other factors that are often interrelated to mental health outcomes, such as socioeconomic factors, cancer-related stress, and access to quality care, could act as confounding variables. Future research should isolate these factors and their impact on ACEs and depression.
This study found that individuals from different racial/ethnic groups exhibited increased odds of depression with an increased number of ACEs. A previous longitudinal study of adolescents of African or European ancestry followed these participants into early adulthood (upper age of 42) and found no statistically significant association between a higher number of ACEs and depression [42]. The increased risk of developing depression in cancer survivors who experienced a higher number of ACEs may be due to biological.
Previous studies have found that stressful events in childhood may lead to an overactivation of the hypothalamic-pituitary-adrenal (HPA) axis, which can persist into adulthood [43]. Changes in the HPA axis play a large role in the development of depression and are a key contributor to decreased cognitive function in depressed patients [44, 45]. Additionally, higher levels of stress have been associated with depression [46], and ACEs have a dose-dependent relationship with frequency of stress, severity of stress, and negative affect that persists in adulthood [47].
Age and sex were associated with depression among some respondents in this study. Non-Hispanic Whites ages 18–39 had a higher odds of reporting depression compared to their ≥ 65 counterparts; respondents of non-Hispanic Whites and Hispanics ages 40–64 had a higher odds of reporting depression compared to their ≥ 65 counterparts. This is not entirely surprising, given that the prevalence of depression is highest in young adulthood and lowest in individuals aged 65 and older [48].
This may be due to the way depression manifests in elderly patients. Older individuals are more likely to experience depression without the affective component, meaning they may have depression without the typical feelings of sadness [49]. Consequently, self-reported depression may be underreported in the older adult population [50].
Younger adults may be at a greater risk of depression due to poor coping strategies, which may elevate their risk of experiencing self-reported depression [51]. In this study, there was no difference in the rates of depression between different age groups of non-Hispanic Blacks. This may be due to younger non-Hispanic Blacks being more likely to utilize a variety of coping strategies such as psychological openness, informational support, religious coping, and seeking professional help compared to older non-Hispanic Black people [52], which may provide a protective role in this age group leading to no significant difference in depression between the different ages of non-Hispanic Black people.
In our study, both non-Hispanic white and Hispanic females had higher odds of reporting depression than males. The difference between men and women developing depression after facing ACEs is inconsistent in the current literature. Some studies have shown that there is no difference in the rate of depression between men and women later in life after experiencing ACES [53, 54].
However, other studies have found that females have higher rates of depression compared to males [55, 56]. In the general population, female sex hormones can increase the risk of depression due to higher levels of neuro-immune response [57]. While depression is diagnosed twice as frequently in females compared to males [58], males have a higher rate of undiagnosed depression [58, 59] and are less likely to seek medical help compared to women [60].
Additionally, a previous study has found that ACEs affect men and women differently later in life [61, 62]. Women more frequently develop psychological disorders, while men develop substance use disorders [62] which may be a confounding variable for the diagnosis of mood disorders [63]. However, one study has found that non-Hispanic Black women are more open to receiving professional help and are more psychologically open in terms of mental health disorders compared to men [52].
Additionally, non-Hispanic Black women have greater economic advantages and higher education compared to non-Hispanic Black men [64, 65], both of which may be protective factors for depression [66]. These protective factors in non-Hispanic Black women may have led to lower levels of depression in our study, which could cause no significant difference between the depression of non-Hispanic Black women compared to non-Hispanic Black men.
Limitations and strengths
This study has limitations. First, BRFSS did not have information on the severity of cancer, and thus, we could not adjust for it in the analyses, which could influence findings on depression. Second, ACEs and depression were self-reported; relying on self-reported data introduces potential biases, such as misclassification or recall bias.
This method leaves room for both overestimation or underestimation of ACE exposure or depression. Third, the depression variable used in this study is a single-item measure, although it has been used in several published studies. Moreover, the dataset does not contain information on the onset or severity of the depression among respondents or treatment received by respondents.
Future research should use validated screening tools (e.g., Patient Health Questionnaire-9 (PHQ-9), the Beck Depression Inventory (BDI), and the Center for Epidemiologic Studies Depression Scale (CES-D)) to provide a more nuanced understanding of depression in this population. Fourth, the dataset does not contain information on the age at which ACEs occurred, which could have affected the findings. Future research should evaluate if ACEs experienced in childhood had different psychological impacts than experiences during adolescence.
Fifth, our analysis was cross-sectional, meaning that while associations were drawn, we cannot establish temporal significance or causality for outcomes. Despite these limitations, one main strength is that our study is one of the first to explore the association between ACEs and self-reported depression among different racial/ethnic cancer survivors. Secondly, this study had a large sample size, which reduces the risk of a statistical difference being due to sampling error.
Our findings fill gaps in existing literature and offer insights that could guide the development of targeted prevention interventions for populations who experienced ACEs, potentially reducing the risk of depression in adult cancer patients.
Conclusion
An increased number of ACEs were associated with a higher likelihood of self-reporting depression diagnoses across all race/ethnicity groups in our study. Cancer survivors are deemed vulnerable in terms of health, given the adverse impact of cancer on both physical and mental well-being. Additional studies are warranted to explore potential social factors contributing to this heightened risk and to develop intervention strategies aimed at mitigating this risk.