The role of social support in the association between childhood trauma and depression among HIV-infected and HIV-uninfected individuals

Abstract

Childhood trauma (CT) – emotional, physical or sexual abuse, or emotional or physical neglect – has been associated with HIV infection and can lead to poor health outcomes and depression in adulthood. Though the impact of CT on depression may be decreased by social support, this may not be true of individuals living with HIV, due to the additive traumatic effects of both CT and acquisition of HIV. This study examined social support, depression, and CT among HIV-infected (n = 134) and HIV-uninfected (n = 306) men and women. Participants (N = 440) were assessed regarding sociodemographic characteristics, CT, depression, and social support. Participants were racially and ethnically diverse, 36 ± 9 years of age on average, and 44% had an income of less than USD$500 a month. Among HIV-uninfected individuals, social support explained the association between depression in persons with CT (b = 0.082, bCI [0.044, 0.130]). Among HIV-infected individuals, after accounting for sociodemographic characteristics, social support did not explain the association between depression and CT due to lower levels of social support among HIV-infected individuals [95% CI: −0.006, 0.265]. The quality of social support may differ among HIV-infected persons due to decreased social support and smaller social networks among those living with HIV. Depressive symptoms among those living with HIV appear to be less influenced by social support, likely due to the additive effects of HIV infection combined with CT.

Keywords

Childhood trauma neglect depression social support HIV

Introduction

Childhood trauma (CT) – defined as emotional, physical or sexual abuse, or emotional or physical neglect – has been associated with poor health outcomes, psychological distress, and social maladjustment.^1,2 CT has been implicated in the development and maintenance of mental health disorders and symptom clusters of psychopathology, as well as in increased engagement in high-risk behaviors in the United States, sub-Saharan Africa, Asia, and Latin America.^3–5 Emotion dysregulation, a core feature of several diagnostic classes, including depression, has a well-established association with CT.^6,7 Numerous factors, including disruption of affective and psychosocial development, contribute to the association between CT and psychopathology.⁸ In particular, CT is associated with depression in adulthood⁹ and is linked to greater risk for HIV acquisition through increased engagement in high-risk behavior.^10,11 It has been estimated that > 50% of HIV-infected individuals have experienced CT, in comparison with 20–33% of HIV-uninfected individuals.^12–15 Long-term studies have suggested that certain symptoms of depression associated with CT may be linked to interpersonal dysfunction as well as to decreased peer acceptance.¹⁶ Interpersonal models of depression suggest that interpersonal dysfunction has a bidirectional association with depression, such that interpersonal conflict may both cause and arise from depressive symptomatology.¹⁷

HIV infection, like CT, is also associated with depression; depression prevalence among HIV-infected people ranges from 18 to 81% – much higher than that of the general population.¹⁸ Among individuals living with HIV, rates of depression are higher in groups that have experienced a greater number of factors contributing to depressive symptomatology, such as women in rural, low-income settings¹⁹ and men who have sex with men with a history of drug use.²⁰ Different etiological mechanisms of depression between HIV-infected and HIV-uninfected people have been found, including lack of social support and hopelessness.^18,21 Depression has also been linked to accelerated HIV progression, with physiological, psychological, social, and behavioral mechanisms theorized to contribute to this association.^22,23 In fact, treatment of depression is a priority in the context of HIV care due to its detrimental effect across the HIV care continuum, as illustrated in the United States, Europe, Latin America, Africa, and Asia.²⁴

Social support – comfort, assistance, and/or information received from individuals or groups²⁵ – has been shown to reduce long-term psychological impairment from trauma and adversity. Individuals appear to cope better with traumatic events when they perceive others to be available to provide support in managing the event.^26,27 As such, social support may account for the association between CT and depression, with CT being associated with decreased social support, which in turn may be associated with increased depressive symptomatology. In fact, social support has been found to mitigate the association between CT and psychological disorders.²⁶ Social support also acts as a protective factor against depression in HIV-infected individuals.^21,28,29 However, negative HIV-related social interactions, particularly those which may be stigmatizing, may reduce the quality of social support and increase depressed mood.^30,31 For instance, decreased social support among individuals with HIV may result from both perceived stigma and nondisclosure of HIV status,^32,33 which may be exacerbated by limitations to illness-associated social support,³⁴ increasing depressive symptoms.³⁵ Given that CT has been linked to reduced levels of social support, smaller social networks, and interpersonal dysfunction,¹⁶ the combination of CT and HIV may result in significantly greater levels of depression that are not mitigated by social support, as this additive or synergistic effect may require greater levels of support in order to be protective. Therefore, it is possible that even among HIV-infected individuals with higher levels of social support, the synergy of CT, HIV infection, and depression may thwart the protective benefit of social support.

Given the unique challenges to support networks among HIV-infected individuals and the potential additive effect of CT and HIV infection, this study sought to explore the influence of social support on the relationship between CT and depression in those with and without HIV infection. It was hypothesized that social support would explain the association between CT and depression among HIV-uninfected individuals, but not among HIV-infected individuals due to the additive effects of CT and HIV acquisition among people living with HIV. Findings from this study were anticipated to guide etiological research in depression among those living with HIV and ultimately inform interventions to treat depression in this population.

Methods

Participants, recruitment, and procedures

Prior to any study-related activities, approval from the University of Miami Miller School of Medicine Institutional Review Board was obtained. Study candidates were HIV-infected and HIV-uninfected men and women aged 18–50 years recruited from December 2014 to September 2016 in Miami, Florida who were conveniently sampled from various outpatient infectious disease clinics, community clinics and hospitals, as well as advertisements in street press and peer referral. Candidates were excluded if they had a history of hepatitis C, diabetes mellitus, hypertension, myocardial infarction, transient ischemic attack, bypass surgery, angioplasty, or lipid-lowering agents or statin use. Recruitment and data collection procedures for the present study have been previously described.³⁶ A total of N = 440 participants were included in this study (n = 229 men, n = 206 women, n = 5 transgender women). Participants completed a one-time study visit at the University of Miami, Miller School of Medicine; participants were administered a battery of self-report study measures, along with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), non-patient version (SCID-IV-NP), Substance Use Disorders Module. After completion of the study visit, all participants were compensated USD$50 for their time and transportation expenses.

Measures

Demographics

Participants completed a demographic questionnaire, which included age, gender, current employment status, and monthly personal income.

Depressive symptoms

Depressive symptoms were measured using the Center for Epidemiological Studies-Depression Scale (CES-D).³⁷ Respondents provided the frequency of depressive symptoms in the past week on a scale from 0 (Rarely) to 3 (Most or all of the time), which are then summed after reverse coding four items. For the present study, however, the somatic subscale of the CES-D was subtracted from the total score in order to compare HIV-infected and HIV-uninfected individuals due to the overlap of HIV symptoms and somatic symptoms of depression. CES-D scores range from 0 to 39; higher scores indicate more severe depressive symptomatology. In this sample, internal consistency was adequate (α = 0.87).

Childhood abuse and neglect

The Childhood Trauma Questionnaire is a 28-item Likert scale (1 = never true, 2 = rarely true, 3 = sometimes true, 4 = often true, 5 = very often) used to measure emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect in childhood. Scores for this scale range from 28 to 140, where greater scores indicate increased CT. Respondents provided scale scores to scenarios in the context of ‘when I was growing up’.³⁸ Internal reliability in this sample was excellent (α = 0.91).

Social support

Perceived availability and adequacy of social support from family, friends, and significant others was measured using the Multidimensional Scale of Perceived Social Support (MSPSS).³⁹ The MSPSS is a 12-item Likert scale of 1–7 (1 = very strongly disagree to 7 = very strongly agree), with a possible total 84, which is then divided by 12; higher scores indicate a higher perceived sense of social support. Internal reliability for this scale in this sample was also excellent (α = 0.91).

Substance dependence

The DSM-IV, (SCID-IV-NP)⁴⁰ was used to evaluate substance dependence. The assessment includes the duration and frequency of substance use, as well as remission from substance dependence. An indicator variable was created such that if the participant met criteria for dependence or abuse to any substance, a one (1) was assigned; a zero (0) was assigned otherwise, including recreational use, and remission from substances.

Statistical analyses

Descriptive statistics were used to analyze demographic and psychosocial variables. Based on associations from previous research, correlations, t-tests, and analyses of variance were used to assess bivariate associations between demographic and psychosocial variables with depression; comparisons by HIV status were also conducted. When distributional assumptions were violated, nonparametric alternatives were used, such as Spearman’s rank correlation coefficient, Mann–Whitney Z test, and Kruskal–Wallis H test. Given the exploratory nature of this study, variables found to be associated with depression at p < 0.15 on bivariate analyses were included in the subsequent tests of mediation, if significant at p < 0.05 in multivariate linear regression analyses. Then, a moderated mediation model⁴¹ was developed, using depression as the dependent variable, CT as the independent variable, and social support as a mediator; HIV status was included as a moderator, while controlling for the variables retained in the reduced multivariable model. Moderated mediation analyses were conducted using the PROCESS macro developed by Hayes for SPSS (model 5), specifying 5000 bootstrap samples as recommended by Hayes.^41,42 A cutoff of p < 0.05 level was used as the threshold for significance.

Results from the mediation analysis are reported using Baron and Kenny’s⁴³ four-step approach. The significance of the indirect effect was assessed using bootstrapped bias-corrected 95% confidence interval (bCI).⁴² Statistical Package for the Social Sciences v22 for Windows⁴⁴ was used for all analyses.

Results

Participants were HIV-infected (n = 134, 30.5%) and HIV-uninfected (n = 306, 69.5%) men and women with an average age of 35.97 (SD = 9.10) years. The majority of participants (82.4%) were heterosexual. Nearly two-thirds (63.2%) of participants were African American, and the majority (77.7%) were unmarried/single. Two-thirds (65.1%) of participants were unemployed and half (56.4%) had a monthly personal income of at least $500. Further demographic details and comparisons by HIV status are presented in Table 1.

Table 1.

Demographic characteristics of participants (N = 440).

	AllMean (SD) N (%)	HIV− (n = 306) Mean (SD) N (%)	HIV+ (n = 134) Mean (SD) N (%)	Χ²/t, p
Age (years)	35.97 (9.10)	35.14 (8.91)	41.38 (8.33)	1.45, 0.148
Gender
Male	229 (52.0%)	179 (58.5%)	50 (37.3%)
Female	206 (46.8%)	125 (40.8%)	81 (60.4%)
Transgender	5 (1.1%)	2 (0.7%)	3 (2.2%)	17.74, < 0.001
Race
White/Caucasian	50 (11.4%)	40 (13.2%)	10 (7.5%)
Black-American	278 (63.2%)	176 (57.5%)	102 (76.1%)
Hispanic	99 (22.5%)	77 (25.2%)	22 (16.4%)
Other	13 (3.0%)	13 (4.2%)	0 (0.0%)	16.55, 0.001
Sexual orientation
Heterosexual	361 (82.4%)	263 (89.2%)	98 (68.5%)
Homosexual	51 (11.6%)	21 (7.1%)	30 (21.0%)
Lesbian	5 (1.1%)	4 (1.4%)	1 (0.70%)
Bisexual	21 (4.8%)	7 (2.4%)	14 (9.8%)	32.28, < 0.001
Relationship status
Single	342 (77.7%)	240 (78.4%)	102 (76.1%)
In a relationship	84 (19.1%)	56 (18.3%)	28 (20.9%)
Separated	14 (3.2%)	10 (3.3%)	4 (3.0%)	0.42, 0.812^a
Employment
Not working	286 (65.1%)	183 (59.8%)	103 (77.4%)
Working	153 (34.9%)	123 (40.2%)	30 (22.6%)	12.71, < 0.001
Monthly personal income
$0–$500	192 (43.6%)	141 (46.1%)	51 (38.1%)
$500–$1000+	248 (56.4%)	165 (53.9%)	83 (61.9%)	2.44, 0.119
Substance dependence
No	327 (73.3%)	235 (77.6%)	92 (64.3%)
Yes	119 (26.7%)	68 (22.4%)	51 (35.7%)	8.68, 0.003
Depression (CES-D)	8.84 (8.56)	7.67 (8.18)	10.87 (8.84)	5.31, < 0.001
CES-D cutoffs^b
None or minimal depression	200 (45.6%)	157 (53.0%)	43 (30.1%)
Mild depression	93 (21.2%)	57 (19.3%)	36 (25.2%)
Moderate depression	63 (14.4%)	37 (12.5%)	26 (18.2%)
Moderate to severe depression	83 (28.9%)	45 (15.2%)	38 (26.6%)	21.52, < 0.001
Adverse childhood events (CTQ)	53.12 (17.95)	51.71 (16.10)	67.43 (22.93)	4.53, < 0.001
Social support (MSPSS)	5.16 (1.28)	5.24 (1.27)	4.64 (1.27)	3.05, 0.002

CES-D: Center for Epidemiological Studies-Depression Scale; CTQ: Childhood Trauma Questionnaire; MSPSS: Multidimensional Scale of Perceived Social Support.

^aFisher’s exact test was used.

^bIncluded somatic symptoms subscale, as cutoffs are based on the full scale.Bold values denote statistical significance at p < 0.05.

Bivariate and multivariable linear regression models predicting depression

Based on past research and theory, bivariate associations between depression and age,⁴⁵ race,⁴⁶ relationship status,⁴⁷ employment status,⁴⁸ income,⁴⁸ HIV status,²⁴ substance dependence,⁴⁹ CT,¹⁶ and social support¹⁶ were assessed. Bivariate associations emerged with age, employment status, income, HIV status, CT, and social support. In multiple linear regression, associations with employment status, HIV status, substance dependence, CT, and social support remained, and these variables were used as covariates in subsequent analyses.

Moderated mediation model: Indirect effect of trauma on depression through social support moderated by HIV status

Only variables retained in the reduced multivariable model were used in the following analyses testing the potential indirect effect of CT on depression through social support moderated by HIV status, after controlling for substance dependence and work status. In the first model, excluding the proposed mediator and after adjusting for substance dependence, employment status, and HIV status, CT was associated with depression, b = 0.251, p < 0.001. In the second model, CT was associated with decreased social support (b = −0.398, p = 0.001), accounting for the aforementioned covariates (substance dependence, employment status, and HIV status). In the third model, decreased social support was associated with depression (b = −0.205, p < 0.001) after controlling for CT and other identified covariates (substance dependence, employment status, and HIV status).

After controlling for social support and the covariates previously described (employment status, HIV status, substance dependence), the effect of CT on depression decreased, b =0.189, p < 0.001, and the indirect effect of CT on depression was statistically significant according to a 95% confidence interval for 5000 bootstrap samples, b = 0.082, bCI [0.044, 0.130]. That is, social support partially mediated the relationship between CT and depression. However, the indirect effect of CT on depression through social support was only significant for HIV-uninfected persons [0.110, 0.268], but not among HIV-infected persons [−0.022, 0.231], indicating an absence of full or partial mediation in this group related to reduced levels of social support among HIV-infected people, as illustrated in Figure 1.

Figure 1.

Moderated mediation model: moderated indirect effect of CT and neglect on depression through social support.

Discussion

This study assessed the indirect effect of CT on depression through social support and whether this relationship varied as a function of HIV status. As in previous research in the United States, sub-Saharan Africa, Asia, and Latin America,^3–5 CT was associated with decreased levels of social support, which in turn was associated with depression. As such, the effect of CT on depression was reduced, and significantly accounted for, by social support. However, as hypothesized, the mediational effect of social support on the association between CT and depression was not present among those living with HIV, due to decreased social support in this group.

Depression among those HIV infected was significantly higher than that of their HIV-uninfected counterparts, as found in previous studies.⁵⁰ Social support was also significantly lower among those with HIV, as in previous research.³⁴ Social support did not influence the association between CT and depression among those living with HIV, likely due to decreased levels of social support in this group. In contrast, social support partially explained the relationship between CT and depression among those HIV uninfected, as in previous studies of social support, CT, and post-traumatic stress disorder.²⁶ The unaffected association between depression and CT, even in the presence of social support, may have been related to the experience of multiple traumatic life events among individuals living with HIV, such as the experience of traumatic events in childhood in combination with an HIV diagnosis, a traumatic experience that has been associated with additional stressors following diagnosis, e.g. medication side effects, disclosure of HIV status.⁵¹ Given that social support did not account for the association between CT and depression among those living with HIV, further research may be needed to identify potential mediators of this association between CT and depression in this group. In fact, results suggest that depressive symptoms were greater among those living with HIV, even after removing the effect of somatic symptoms, which may overlap with symptoms of HIV and medication side effects.⁵²

Social support has been shown to improve both depression and physical health,⁵³ but in this study, it was not associated with decreased depression among those living with HIV, likely due to decreased levels of social support in this group. This may have been due, in part, to the negative interpersonal relationships and decreased social support that individuals with HIV experience.^54,55 These levels of decreased social support may arise from real or perceived negative reactions to disclosure of one’s HIV status,³⁰ which may cause HIV-infected persons to anticipate negative reactions from others and choose not to disclose their HIV status to family, friends, or significant others.⁵⁶ As a result of nondisclosure, HIV-infected individuals may feel less support or the need to hide this significant area of their lives, thereby diminishing the quality of support, and increasing their vulnerability to depression.³⁵ Future research should evaluate concerns regarding disclosure and/or reactions to disclosure and its association with perceived social support, and promote targeted interventions to treat depression that focus on enhancing communication and disclosure to stimulate social support. Interpersonal therapy, for instance, is aimed at targeting interpersonal conflict or situations as well as at increasing individuals’ social networks, thereby improving the quality of interpersonal relationships or circumstances, specifically, those linked to current depressive symptoms.¹⁷ Therefore, interpersonal therapy may be an avenue by which the social networks of individuals with HIV who also have experienced CT may be improved, which may provide the benefit of increased social networks as well as lessen symptoms of depression. Interpersonal therapy is an intervention for depression currently classified as having strong research support,⁵⁷ including preventing the onset of major depressive disorder among those with subclinical levels of depression. Interpersonal psychotherapy has been found to have a medium-sized effect for a number of different disorders and conditions, including depression, in the United States, Europe, Africa, and Asia.⁵⁸ As such, interpersonal therapy in this context may not only treat depression potentially arising from repeated exposures to traumatic events among those with decreased levels of social support, but also prevent subclinical symptom clusters of depression from reaching diagnostic criteria, which may be more difficult to treat and may take longer to remit.⁵⁸

In interpreting these findings, some limitations should be noted. The cross-sectional design of this study limits causal interpretation of the results, and longitudinal studies are needed to confirm or disprove temporality. Further, CT and depression may be underreported by participants and are subject to recall bias and as such, may have been inaccurate.⁵⁹ In addition, participants were limited to those without a history of metabolic syndrome who were predominantly African American and unemployed, and findings may not generalize to other samples. African Americans were not intentionally oversampled in the current study. Rather, the racial composition of the sample was representative of the racial composition of the community in which participants were recruited.⁶⁰

CT has consequences which include psychological, immunological, and metabolic pathologies,⁶¹ effects which previous research has shown to be improved by social support.^26,53 This study highlights the need for further etiological research to examine the mechanisms underlying the effect of social support and its applicability to HIV. Depression has been shown to have negative consequences across the HIV continuum of care in the United States, Europe, Latin America, Africa, and Asia,²⁴ and understanding pathways to ameliorating depression may help to inform interventions for this population, which could have an important impact on HIV health outcomes.⁶²

Footnotes

Acknowledgments

All authors have seen and approved the content of this manuscript and have contributed significantly to the work. All authors drafted the paper and revised it critically for important intellectual content. We thank all those in our research team at the University of Miami, community sites providing referrals, and the men and women participating in this study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by grant number R01DA034589, from the National Institute on Drug Abuse (NIDA), with support from the Miami Center for AIDS Research (CFAR) at the University of Miami, Miller School of Medicine (NIH grant no. P30AI073961). The contents of this publication are solely the responsibility of the authors and do not represent the official views of NIDA or NIH. Part of the manuscript was carried out under a Ford Foundation Fellowship to Violeta Rodriguez.

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