Resumen de Correlatos del maltrato físico en la infancia en mujeres adultas con trastorno distímico o depresión mayor

María Concepción Ibarra Alcantar, José Antonio Ortiz Guzmán, Francisco Javier Alvarado Cruz, Hermelinda Graciano Morales, Alejandro Jiménez-Genchi

• español

  De acuerdo con estudios epidemiológicos en México, 18% de los adultos y de 14 a 21% de los adolescentes afirman haber recibido golpes durante su niñez por parte de alguno de sus padres.

  Las experiencias de maltrato en la infancia se han asociado con el desarrollo de psicopatología en la edad adulta. Sin embargo, en el caso particular de la depresión mayor, el interés se ha concentrado en la relación existente con la historia de abuso sexual. Uno de los argumentos que se han planteado es que ambas condiciones son más frecuentes en la mujer, mientras que el maltrato físico lo es en hombres.

  No obstante, el abuso físico tiene más consecuencias negativas en la salud de las mujeres. Se ha identificado que no existen diferencias significativas entre las mujeres adultas con historia de abuso sexual y aquéllas con antecedente de abuso físico, con respecto a los síntomas físicos y psicológicos que experimentan. Además, la historia de maltrato físico se asocia significativamente con la presencia de depresión sólo en las mujeres. En conjunto, esta información sugiere que el maltrato físico puede cumplir un papel más importante del que se ha pensado en el desarrollo de la depresión.

  La experiencia de eventos adversos en la infancia también parece asociarse con el curso y pronóstico del trastorno distímico, aunque la información con respecto a este trastorno es escasa.

  Por lo anterior, en el presente trabajo nos propusimos: a) determinar y comparar la frecuencia del maltrato físico en la infancia en mujeres con trastorno depresivo mayor y trastorno distímico en un centro comunitario de salud mental; b) determinar la comorbilidad psiquiátrica asociada con la historia de maltrato físico; y c) comparar la gravedad de la sintomatología depresiva y del riesgo suicida en función de la historia de maltrato físico y el diagnóstico.

  Se estudiaron mujeres, de 18 a 65 años de edad, alfabetas, con diagnóstico de trastorno depresivo mayor o trastorno distímico (DSM–IV) y que aceptaran participar otorgando su consentimiento informado por escrito. Las participantes fueron evaluadas con la Mini Entrevista Neuropsiquiátrica y respondieron el Inventario de Depresión de Beck (IDB) y el Índice de Maltrato Físico Infantil (IMFI).

  El IMFI es un instrumento autoaplicable que se desarrolló como parte de la investigación. Inicialmente se elaboraron 59 reactivos sobre experiencias de maltrato en la infancia, los cuales fueron clasificados por cuatro jueces clínicos. Cinco reactivos se clasificaron como maltrato físico por tres de los cuatro jueces, por lo que éstos se emplearon para conformar el IMFI. El instrumento mostró propiedades psicométricas satisfactorias: coeficientes de correlación elevados entre los reactivos y la suma total, un alto coeficiente de confiabilidad, y en el análisis factorial produjo un solo componente que explicaba casi 70% de la varianza.

  Participaron en la investigación ochenta mujeres, 42 con trastorno depresivo mayor (TDM) y 38 con trastorno distímico (TD). El 75 y 72%, respectivamente, reportaron una historia positiva de maltrato físico. La intensidad del maltrato experimentado mostró una tendencia a ser significativamente mayor entre las mujeres con TDM (4.88 [DE 4.81] vs. 3.18 [DE 3.10]; t=1.8, gl 78, p=.07).

  Las mujeres con historia de maltrato físico obtuvieron calificaciones significativamente más elevadas en el IDB en comparación con las que no lo habían sufrido. Este resultado fue independiente del diagnóstico. En contraste, el riesgo suicida no varió significativamente en función de la historia de maltrato físico.

  Las pacientes con historia de maltrato físico tendieron a presentar un mayor número de trastornos psiquiátricos comórbidos. En este mismo grupo, la gravedad de la sintomatología depresiva se relacionó significativamente con la gravedad del maltrato (r=0.27, p=.03).

  Los resultados muestran que aproximadamente tres de cada cuatro mujeres con TDM o TD experimentaron maltrato físico en la infancia. Éste se asocia, además, con una mayor gravedad de los síntomas depresivos y posiblemente con una mayor comorbilidad psiquiátrica.

  La elevada proporción de mujeres con TDM o TD con una historia de maltrato contrasta con los datos obtenidos en estudios previos. El origen de la discrepancia puede estar, al menos en parte, en la definición empleada, ya que en este estudio se usó una definición más estricta que incluye el maltrato considerado "leve".

  Estos resultados sugieren que se debe investigar sistemáticamente el maltrato físico infantil en las mujeres con TDM o TD y tomarse en cuenta en el plan terapéutico.

• English

  Epidemiologic studies have found that childhood physical maltreatment affects 31% and 21% of males and females, respectively, and almost one half of cases correspond to severe physical abuse.

  A recent study carried out in population from four representative regions of our country found that 14% to 21% of adolescents reported a history of physical abuse during childhood.

  Childhood maltreatment experiences have been found to be associated to development of psychopathology during childhood. In regard to mood disorders, interest has been focused on the relationship between depression and sexual abuse. An explanation to this situation is that both conditions predominantly affect women while physical abuse is more frequent among men. However, physical abuse produces more negative consequences on women's health; severe physical abuse equally affects men and women; moreover, child physical abuse has been significantly associated with depression only in women.

  The experiences of adverse events during childhood also seem to be associated with dysthymic disorder, a depressive condition of lower symptomatic severity but longer duration than major depression. Nevertheless, data about childhood physical abuse among patients with dysthymic disorder are scarce. One study found that physical and sexual abuses were significantly more frequent among dysthymic and depressed patients in comparison with control subjects. This finding suggests an association between physical abuse and both acute and chronic forms of depression.

  On the basis of this knowledge, the aims of this study were: a) to determine and compare the frequency of childhood physical abuse among women with major depression or dysthymic disorder in a community mental health centre; b) to determine psychiatric comorbidity in relation to the history of physical abuse; and c) to compare the severity of depressive symptoms and suicide risk between depressed patients (major depression or dysthymic disorder) with or without a history of childhood physical maltreatment.

  Subjects were recruited from the population seeking psychiatric attention in a community mental health centre. To be included, patients were required to be females, 18–65 years old, literate, meet DSM IV criteria for major depressive disorder or dysthymic disorder, and give their written informed consent.

  All patients were assessed with the Mini International Neuropsychiatric Interview, the Beck Depression Inventory and the Childhood Physical Maltreatment Index. This self–report instrument was developed as part of the study. It consists of five questions and it showed satisfactory psychometric properties (e. g., inter–item score correlations .54–.67, item–total score correlations .78–.85 and Cronbach's alpha = .88).

  Eighty patients were studied: 42 with major depression (MD) and 38 with dysthymic disorder (DD). Patients with MD were not significantly different from DD subjects in age (38.0±11.3 vs. 39.8±12.9, respectively; t = –.64, gl 78, p = .52), civil status (64.2% vs 55.2% living with a partner; x2 = .67, gl 1, p = .49), education years (9.5±3.2 vs. 10.3±3.1, respectively; t = –1.1, gl 78, p = .25) and occupation (50% vs. 60% dedicated to housework; x2 = .89, gl 1, p = .37).

  Seventy six percent of patients reported a history of childhood physical abuse; there were no significant differences between MD and DD patients (75% vs. 72%, respectively). However, severity of maltreatment showed a tendency to be significantly higher among MD patients (4.88 [DE 4.81] vs. 3.18 [DE 3.10]; t = 1.8, gl 78, p= 07). Women with a history of physical abuse obtained significantly higher scores on depression than patients without it. This association was not dependent on diagnosis. In contrast, suicide risk was not significantly different between patients with or without child physical abuse.

  The number of comorbid psychiatric disorders showed a marginal association with the history of physical abuse (1.2 —DE 1.0] vs. 0.78 —DE 0.91], t= –1.6, gl 78, p=.09).

  According to these results, three out of four women with major depression or dysthymic disorder suffered from physical abuse during childhood. This proportion is notably higher than the one found in general population, and it also differs from the prevalence rate reported in previous studies with depressed patients. In one study where authors examined 1019 patients admitted in a psychiatric hospital, they identified a history of child physical abuse in 12.3% and 8.3% of MD and DD patients, respectively. Later, a rate of 16% and 29% among MD and DD patients was reported. More recently, an epidemiologic study found a rate of 40.3% among women with major depression.

  The disparity in the reported prevalence rates might have several explanations. Some studies have used definitions of childhood physical maltreatment which seem to correspond to a severe form. For example, in one study it was defined as the experience of being hit hard or often enough to leave bruises, draw blood, or require medical attention. Another one included some other aggressive behaviors (being pushed, grabbed or shoved), but they were not considered as maltreatment if they had had a low frequency. The inclusion of these behaviors, which could be classified as "mild violence" has yielded figures up to 72% in adolescents.

  Then we decided to restrict our definition in such a way it was equivalent to the one used in one of the previous studies. However, the rate remained high (65%), although it was similar to the rate obtained in major depressed women with suicide ideation.

  A prospective follow–up study of physically abused children referred to protection agencies found they were more likely to develop major depression during adulthood in comparison with children without exposure to physical abuse. However, as the authors of this report point out, their findings might not be generalized to maltreatment that is not referred to protection agencies, which probably includes "mild" abuse. The exclusion of this kind of physical abuse has lead to a lack of data about its effects, and therefore, it might be wrongly understood as innocuous.

  Our findings might also be influenced by a selection bias, since subjects with childhood physical abuse might be more likely to seek psychiatric attention. In fact, some of our results support this view because we found that depressed or dysthymic women who suffered from childhood physical abuse showed more severe depressive symptoms and a higher number of comorbid psychiatric disorders. Even so, these findings highlight the relevance of investigating the experiences of physical abuse during clinical assessment of depressed patients.

  This is still more important if the significant positive relation between severity of depression and child physical abuse is taken into account. Although the relation was weak (r=.27, p=.03), it should not be dismissed because it suggests that childhood adverse events have an influence on current patient's clinical status; therefore, the combination of psychotherapeutic approaches with the pharmacological treatment should be considered.

  As it was expected, suicide risk was significantly associated with a major depression diagnosis but not with the history of child physical abuse. This is not consistent with a previous study which found a significant relation with suicide ideation. Suicide risk is a wide dimension and, possibly, the relation to physical abuse is more specific (suicide ideation or suicidal intent). This topic warrants future research.

  This study has some limitations such as the memory bias, use of self–report instruments, and transversal diagnostic assessments.