Journal of Affective Disorders 228 (2018) 41–48

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Prevalence of childhood trauma and correlations between childhood T

trauma, suicidal ideation, and social support in patients with depression,
bipolar disorder, and schizophrenia in southern China
Peng Xiea,1, Kai Wub,1, Yingjun Zhengc, Yangbo Guoa, Yuling Yanga, Jianfei Hea, Yi Dingc,
⁎
Hongjun Penga,
a
Department of Clinical Psychology, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou 510370, China
b
Department of Biomedical Engineering, School of Materials Science and Engineering, South China University of Technology, Guangzhou, China
c
Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou 510370, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Childhood trauma has long-term adverse effects on physical and psychological health. Previous
Childhood trauma studies demonstrated that suicide and mental disorders were related to childhood trauma. In China, there is
Suicidal ideation insufficient research available on childhood trauma in patients with mental disorders.
Social support Methods: Outpatients were recruited from a psychiatric hospital in southern China, and controls were recruited
Depression
from local communities. The demographic questionnaire, the Childhood Trauma Questionnaire–Short Form
Bipolar disorder
Schizophrenia
(CTQ-SF), and the Social Support Rating Scale (SSRS) were completed by all participants, and the Self-rating Idea
of Suicide Scale (SIOSS) were completed only by patients. Prevalence rates of childhood trauma were calculated.
Kruskal-Wallis test and Dunnett test were used to compare CTQ-SF and SSRS scores between groups. Logistic
regression was used to control demographic characteristics and examine relationships between diagnosis and
CTQ-SF and SSRS scores. Spearman's rank correlation test was conducted to analyze relationships between
suicidal ideation and childhood trauma and suicidal ideation and social support.
Results: The final sample comprised 229 patients with depression, 102 patients with bipolar, 216 patient with
schizophrenia, and 132 healthy controls. In our sample, 55.5% of the patients with depression, 61.8% of the
patients with bipolar disorder, 47.2% of the patients with schizophrenia, and 20.5% of the healthy people
reported at least one type of trauma. In patient groups, physical neglect (PN) and emotional neglect (EN) were
most reported, and sexual abuse (SA) and physical abuse (PA) were least reported. CTQ-SF and SSRS total scores,
and most of their subscale scores in patient groups were significantly different from the control group. After
controlling demographic characteristics, mental disorders were associated with higher CTQ-SF scores and lower
SSRS scores. CTQ-SF scores and number of trauma types were positively correlated with the SIOSS score.
Negative correlations existed between SSRS scores and the SIOSS score.
Limitations: Our sample may not be sufficiently representative. Some results might have been interfered by
demographic characteristics. The SIOSS was not completed by controls. Data from self-report scales were not
sufficiently objective.
Conclusions: In southern China, childhood trauma is more severe and more prevalent in patients with mental
disorders (depression, bipolar disorder and schizophrenia) than healthy people. Among patients with mental
disorders in southern China, suicidal ideation is associated with childhood trauma and poor social support.

Abbreviations: CTQ-SF, Childhood Trauma Questionnaire–Short Form; EA, emotional abuse; PA, physical abuse; SA, sexual abuse; EN, emotional neglect; PN, physical neglect; SSRS,
Social Support Rating Scale; OS, objective support; SS, Subjective support; UOS, use of support; SIOSS, Self-rating Idea of Suicide Scale; ICD-10, the International Statistical Classification
of Diseases and Related Health Problems, Tenth Revision; SD, standard deviation; aOR, adjusted odds ratio; CI, confidence interval
⁎
Correspondence to: No. 36 Mingxin Road, Guangzhou 510370, Guangdong, China.
E-mail address: penghjgz@163.com (H. Peng).
1
Authors Peng Xie and Kai Wu contributed equally to this work.

https://doi.org/10.1016/j.jad.2017.11.011
Received 19 May 2017; Received in revised form 20 September 2017; Accepted 4 November 2017
Available online 06 November 2017
0165-0327/ © 2017 Elsevier B.V. All rights reserved.
P. Xie et al.
1. Introduction
Childhood trauma is a global problem that has immediate negative
impacts and long-term adverse effects on physical and psychological
health (Brennenstuhl and Fuller-Thomson, 2015; Buhlmann et al.,
2012; Chapman et al., 2013; Dong et al., 2004; Dube et al., 2001, 2003;
Edwards et al., 2003; James et al., 2016; Kessler et al., 2010; Su et al.,
2015). World Health Organization (WHO) surveys indicate that more
than one-third of the population has experienced childhood adversity
(Kessler et al., 2010). Further analyses suggest that childhood adversity
may be responsible for the incidence of mental disorders in 28.9% of
patients, and harmful effects of childhood adversity may last
throughout the whole life course (Kessler et al., 2010). Lansford et al.
(2007) conducted a prospective study with 574 children, and found that
maltreated children were more likely to break the law by violence and
be involved in other problems (e.g., school dropout, unemployment,
and teen or pre-marriage pregnancy) compared with children without
physical abuse. Strong positive correlations between childhood mal-
treatment and psychotic symptoms were reported by DeRosse et al.
(2014). Kelleher et al. (2013) observed a dose-response relationship
between the severity of childhood trauma and incidence of psychotic
experiences, and reported that cessation of childhood trauma decreased
the chance of an episode of psychosis. Childhood trauma also con-
tributes to morbidity and severity of bipolar disorder (Daruy-Filho
et al., 2011; Erten et al., 2014; Etain et al., 2013, 2010).
Suicide is a leading cause of death worldwide. More than 800,000
people die by suicide every year (World Health Organization, 2014).
Childhood trauma may be a risk factor for suicide. Some studies in-
volving patients with bipolar disorder found that patients were more
likely to attempt suicide if they had experienced childhood trauma
(Erten et al., 2014; Etain et al., 2013). Several studies reported sig-
nificant associations between childhood trauma and risk for suicide
among teenagers and adults (Barbosa et al., 2014; Hadland et al., 2015;
Saracli et al., 2016). Roy (2011) indicated that childhood trauma was
related to higher risk for a suicide attempt, earlier age of emergence,
and repeated attempts. At the same time, mental disorder (which has
been associated with childhood trauma) is another risk factor for sui-
cidal ideation and behavior. Gates et al. (2017) analyzed statistics from
a state prison system, and found that prisoners with mental disorders
were more likely to attempt suicide compared with those without
mental disorders. The association between mental disorders and high
suicide intent was also observed in a paired case-control study by Liu
et al. (2017).
Social support can be helpful in maintaining mental wellbeing. A
study by Spino et al. (2016) social support and low levels of depression
were correlated among people who lost people close to them by suicide.
As a form of social support, problematic friendships are related to more
severe depressive symptoms and higher risk for suicide attempts
(Marver et al., 2017). An association between suicide and low social
support among Asian female patients with depression has been noted by
Park et al. (2015). Liu et al. (2017) found low-level social support may
be a risk factor for suicide among rural Chinese people. Many studies
have demonstrated that social support is a protective factor against
suicide (Kleiman and Liu, 2013; Poudel-Tandukar et al., 2011; Rushing
et al., 2013).
In China, there is insufficient research available on the prevalence of
childhood trauma or correlations between childhood trauma, suicide
and social support in patients with mental disorders. Therefore, we
designed this study to investigate the prevalence of childhood trauma in
a sample of patients with mental disorders in southern China. We
compared severity of childhood trauma between patients with mental
disorders and healthy people, and aimed to identify correlations be-
tween childhood trauma, suicidal ideation, and social support. Our
hypotheses were: 1) childhood trauma is more severe and more pre-
valent among patients with mental disorders than healthy people; 2)
childhood trauma is positively correlated with suicidal ideation; and 3)
42
Journal of Affective Disorders 228 (2018) 41–48
suicidal ideation is negatively correlated with social support. In this
study, childhood trauma is defined as adversities that occurred in
childhood, including physical, sexual, or emotional abuse, and physical
or emotional neglect.
2. Methods
2.1. Participants
Our sample comprised three patient groups and one healthy control
group. Participating patients were outpatients recruited by simple
random sampling from the Department of Clinical Psychology at the
Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou,
Guangdong, China. These patients were interviewed by two psychia-
trists, and were diagnosed with depression, bipolar disorder, or schi-
zophrenia according to the International Statistical Classification of
Diseases and Related Health Problems, Tenth Revision (ICD-10).
Patients were divided into three groups by diagnoses. Healthy controls
were recruited from communities in Guangzhou, Guangdong, China.
Posters were put up in local communities to promote our study.
Volunteers from communities were selected by simple random sam-
pling and interviewed by two psychiatrists. Volunteers with a psy-
chiatric history and substance abuse were excluded. All participants
were considered eligible for our study only if they were able to read and
write in simplified Chinese, and were willing to join our study after
providing informed consent. For patients with mental disorders, con-
sent from their guardians was also obtained. From October 2014 to
August 2015, 562 patients and 137 controls were recruited. Of these
participants, 553 patients and 132 controls were eligible for our study.
After entering our study, participants were asked to complete several
self-report forms. Two (0.9%) cases in the depression group and six
(2.6%) in the schizophrenia group were excluded from the analysis
because of missing values in the CTQ-SF. Of the 679 people in the final
sample, 229 were patients with depression, 102 were patients with
bipolar disorder, 216 were patients with schizophrenia, and 132 were
healthy people. The present study was performed according to the
Declaration of Helsinki and approved by the Ethics Committee of the
Affiliated Brain Hospital of Guangzhou Medical University.
2.2. Instruments
2.2.1. Demographic questionnaire
A questionnaire was designed to collect demographic characteristics
including sex, age, ethnic group, years of education, marital status,
diagnosis, and family medical history.
2.2.2. Childhood Trauma Questionnaire–Short Form (CTQ-SF)
The CTQ-SF is a 28-item self-report questionnaire, designed to
measure childhood adversity. For each item, there are five response
options, ranging from 1 (never true) to 5 (very often true). The CTQ-SF
includes five subscales: physical abuse (PA), emotional abuse (EA),
sexual abuse (SA), physical neglect (PN), and emotional neglect (EN)
(Bernstein et al., 2003). According to previous studies (Jansen et al.,
2016; Kim et al., 2011; Peng, 2013), cutoff points for CTQ-SF subscales
are: EA score ≥ 13, PA score ≥ 10, SA score ≥ 8, EN score ≥ 15, and
PN score ≥ 10. The CTQ-SF was originally developed in English and
has been translated into many languages. Although some researchers in
China (Fu et al., 2005; Zhang, 2011; Zhao et al., 2005) and other
countries (Gerdner and Allgulander, 2009; Karos et al., 2014) found the
validity of the PN subscale was unsatisfactory, many other studies
concluded the CTQ-SF had acceptable psychometric properties overall
and recommended it as a valid and reliable tool for assessing childhood
adversity (Fu et al., 2005; Garrusi and Nakhaee, 2009; Gerdner and
Allgulander, 2009; Karos et al., 2014; Kim et al., 2013; Zhang, 2011;
Zhao et al., 2005).
P. Xie et al.
2.2.3. Social Support Rating Scale (SSRS)
The SSRS is a self-report inventory in Chinese. It has 10 items on
three subscales: objective support (OS), subjective support (SS), and use
of support (UOS). Objective support refers to objective, visible, or
practical support (e.g., direct material support, and the existence of and
participation in group relationships and social networks). Subjective
support refers to the individual emotional experience of being re-
spected, supported, and understood in the community. Use of support
reflects the degree social support was used (Xiao, 1994). The SSRS has
been shown to have good reliability and validity in various studies in
different communities, and is considered to be an eligible and easily
understandable instrument to assess social support in Chinese popula-
tions (Liu et al., 2008; Su et al., 2009; Yang et al., 2006).
2.2.4. Self-rating Idea of Suicide Scale (SIOSS)
The SIOSS is a 26-item self-report questionnaire in Chinese (Xia
et al., 2002). Each question is answered “yes” or “no.” In our study, we
used the sum of three subscales (sleep, desperation, and optimism) to
assess suicidal ideation. Previous research demonstrated the SIOSS had
good reliability and validity (Chen et al., 2013; Xia et al., 2012). In the
present study, the SIOSS was not completed by the control group.
2.2.5. ICD-10
The ICD is a unified classification and coding system of diseases,
developed and updated by the WHO. The ICD-10 is the latest version.
Clinical descriptions and diagnostic guidelines for mental disorders
based on Chapter V of the ICD-10 have been published (World Health
Organization, 1992), and are a recognized diagnostic system for mental
disorders worldwide.
2.3. Statistical analysis
Statistical analysis was performed with SPSS version 19 (IBM Corp.,
Armonk, NY, USA). Categorical variables were compared using Chi-
square test. Numerical variables were ranked and compared using
Kruskal-Wallis test for overall comparisons and Dunnett test for post
hoc comparisons. Binary logistic regression was used to examine whe-
ther CTQ-SF and SSRS scores were different between groups when de-
mographic characteristics were controlled. In each patient group,
Spearman's rank correlation test was conducted between suicidal
ideation and childhood trauma and suicidal ideation and social support.
3. Results
3.1. Demographic characteristics
The final sample comprised 229 patients diagnosed with depression,
102 patients with bipolar disorder, 216 with schizophrenia, and 132
healthy people (control group). The demographic characteristics of
participants by group are presented in Table 1. Kruskal-Wallis test and
Chi-square test showed that age, years of education, family history, and
marital status were statistically different between four groups (Table 1).
3.2. CTQ-SF, SSRS and SIOSS Scores and prevalence of childhood trauma
CTQ-SF and SSRS scores for each group are presented in Table 1.
Suicidal ideation scores (SIOSS) were 11.86 ± 5.717 for the depression
group, 8.29 ± 5.185 for the bipolar disorder group, and 7.47 ± 4.975
for the schizophrenia group. The SIOSS was not completed by the
control group.
Numbers and percentages of cases whose CTQ-SF scores were higher
than cutoff points were shown in Table 2. The cutoff point for CTQ-SF
total score were set at 50, which was approximately the sum of mean
and standard deviation (SD) calculated from all participants’ CTQ-SF
total score (41.06 ± 12.40). Cutoff points for CTQ-SF subscales were:
EA score ≥ 13, PA score ≥ 10, SA score ≥ 8, EN score ≥ 15, and PN
43
Journal of Affective Disorders 228 (2018) 41–48
score ≥ 10 (Jansen et al., 2016; Kim et al., 2011; Peng, 2013).
In the depression group, the two most reported trauma types were
emotional neglect (n = 97, 42.4%) and physical neglect (n = 88,
38.4%). Physical neglect was the most reported trauma type in the
bipolar disorder (n = 45, 44.1%) and schizophrenia (n = 84, 38.9%)
groups. In the control group, physical abuse was the most reported
trauma type (n = 15, 11.4%) (Table 2 and Fig. 1).
When a subscale score was higher than the cut-off point, we as-
sumed that type of trauma existed. For each case, numbers of existing
trauma types were also calculated: 127 (55.5%) patients with depres-
sion, 63 (61.8%) with bipolar disorder, 102 (47.2%) with schizo-
phrenia, and 27 (20.5%) healthy controls reported at least one type of
trauma. Among those people, 85 (37.1%) patients with depression, 39
(38.2%) with bipolar disorder, 66 (30.6%) with schizophrenia, and 3
(2.3%) healthy controls reported more than one type of trauma. No case
reported all five types of trauma in any group (Table 2).
3.3. Comparisons of CTQ-SF scores and SSRS scores between groups
Comparisons of CTQ-SF and SSRS scores between groups are pre-
sented in Table 1 and Table 3. There were significant differences be-
tween EA, SA, EN, PN and CTQ-SF total scores of each patient group
and control group. SSRS scores were also significantly different be-
tween each patient group and healthy control group, except for OS
scores between bipolar and control group.
Furthermore, binary logistic regression was used to control demo-
graphic characteristics and examine impacts of mental disorders on
CTQ-SF and SSRS scores. Cutoff points of CTQ-SF and medians of SSRS
scores were used to transform the scores into categorical variables
(level of scores). In the logistic regression models, dependent variables
were level of CTQ-SF and SSRS scores, and independent variables were
age, years of education, marital status, family history and diagnosis.
The enter method was chosen to include all the independent variables
into regression models. A patient group and the control group were
analyzed together in a logistic regression model. Results of binary lo-
gistic regression are shown in Table 4. Depression was related to higher
EA, EN, PN and CTQ-SF total scores (adjusted odds ratio [aOR] =
3.614–5.614, lower bound of confidence interval [CI] > 1), and lower
SSRS subscale and total scores (aOR = 0.097–0.226, upper bound of
CI < 1). Bipolar disorder was related to higher EN, PN and CTQ-SF total
scores (aOR = 9.386–14.485, lower bound of CI > 1), and the lower OS
score (aOR = 0.291, upper bound of CI > 1). Schizophrenia was re-
lated to higher EN and PN scores (aOR = 14.635–16.153, lower bound
of CI > 1), and lower PA, SS and UOS scores (aOR = 0.168–0.464,
upper bound of CI < 1).
3.4. Correlations between suicidal ideation and childhood trauma
Spearman's rank correlation tests showed that suicidal ideation
score was positively correlated with CTQ-SF total score (rho = 0.200,
p < 0.01) and EA, PA, and EN scores (rho = 0.168–0.229,
p < 0.01–0.05) in the depression group. In the bipolar disorder group,
there were significant positive correlations between suicidal ideation
score and CTQ-SF total and all subscale scores (rho = 0.195–0.536,
p < 0.01–0.05), as well as number of trauma types (rho = 0.416,
p < 0.01). In the schizophrenia group, suicidal ideation score was po-
sitively correlated with CTQ-SF total score, and EN and EA scores (rho
= 0.234–0.493, p < 0.01). Complete results of the correlation analysis
between childhood trauma and suicidal ideation are shown in Table 5.
3.5. Correlations between suicidal ideation and social support
We analyzed correlations between social support and suicidal
ideation. In the depression group, SSRS total score and SS and UOS
scores were negatively correlated with suicidal ideation (rho = −0.259
to −0.158, p < 0.01–0.05). In the bipolar disorder group, suicidal
P. Xie et al. Journal of Affective Disorders 228 (2018) 41–48

Table 1
Demographic characteristics, and CTQ-SF and SSRS scores.

Variables Depression Bipolar Schizophrenia Control Comparisons

(n = 229) (n = 102) (n = 216) (n = 132) χ2 df p

Sex, N (%)
Male 127 (55.5) 54 (52.9) 108 (50.0) 54 (40.9) 7.374 3 0.061
Female 102 (44.5) 48 (47.1) 108 (50.0) 78 (59.1)
Age, mean ± SD
27.78 ± 8.126 25.50 ± 9.358 27.91 ± 8.325 27.86 ± 4.831 15.971 3 0.001
Ethnic group, N (%)
Han 217 (94.8) 93 (91.2) 210 (97.2) 123 (93.2) 3.888 3 0.274
Minority 12 (5.2) 3 (2.9) 6 (2.8) 9 (6.8)
Marital status, N (%)
Unmarried 132 (57.6) 72 (70.6) 156 (72.2) 78 (59.1) 44.579 6 < 0.001
Married 88 (38.4) 21 (20.6) 36 (16.7) 52 (39.4)
Divorced 9 (3.9) 9 (8.8) 18 (8.3) 0 (0.0)
Years of education, mean ± SD
12.32 ± 3.248 12.73 ± 3.588 11.80 ± 3.213 16.70 ± 3.104 167.083 3 < 0.001
Family History, N (%)
Yes 44 (19.2) 24 (23.5) 36 (16.7) 0 (0.0) 35.580 3 < 0.001
No 181 (79.0) 66 (64.7) 150 (69.4) 132 (100.0)
CTQ-SF scores, mean ± SD
EA 9.06 ± 4.093 9.24 ± 4.408 8.94 ± 4.064 6.97 ± 2.255 15.971 3 0.001
PA 6.64 ± 2.396 6.53 ± 2.170 6.47 ± 2.356 6.18 ± 1.832 4.344 3 0.227
SA 5.77 ± 1.931 5.97 ± 1.697 6.56 ± 2.917 5.25 ± 0.886 52.600 3 < 0.001
EN 12.95 ± 5.019 12.97 ± 5.309 10.67 ± 4.058 9.27 ± 3.130 61.560 3 < 0.001
PN 9.09 ± 3.541 9.29 ± 3.676 8.64 ± 3.417 6.93 ± 1.640 36.632 3 < 0.001
CTQ-SF total 43.27 ± 13.120 44.00 ± 12.994 41.28 ± 12.431 34.60 ± 7.374 47.973 3 < 0.001
SSRS scores, mean ± SD
OS 6.53 ± 2.019 7.97 ± 2.521 7.81 ± 2.968 8.23 ± 2.281 56.478 3 < 0.001
SS 18.28 ± 4.594 18.33 ± 4.522 18.78 ± 6.038 20.78 ± 3.469 31.909 3 < 0.001
UOS 6.51 ± 2.012 7.37 ± 2.146 7.31 ± 1.931 8.80 ± 1.727 96.961 3 < 0.001
SSRS total 30.73 ± 6.471 33.56 ± 7.180 33.83 ± 9.510 37.82 ± 5.270 81.346 3 < 0.001

Sex, ethnic group, marital status, and family history were compared by Chi-square test.
Other variables were compared by Kruskal-Wallis test.
CTQ-SF: Childhood Trauma Questionnaire–Short Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect, PN: physical neglect, SSRS: Social Support
Rating Scale, OS: objective support, SS: Subjective support, UOS: use of support, SD: standard deviation.

ideation score was negatively correlated with SSRS total score, and OS
and UOS scores (rho = −0.299 to −0.255, p < 0.01–0.05). In the
schizophrenia group, negative correlations were also found between
SSRS total score, and OS and UOS scores (rho = −0.321 to −0.403,
p < 0.01), and suicidal ideation score (Table 5).
4. Discussion
In the present study, we calculated prevalence rates, and found rates
for EA, SA, EN, PN, and CTQ-SF total scores over the cutoffs were
higher in the patient groups than in the control group, indicating that
childhood trauma was more prevalent among patients with mental
disorders than healthy people. Previous studies that used the CTQ-SF to
assess childhood trauma among patients reported prevalence rates
dissimilar to our study. In some Chinese (Li et al., 2015) and foreign
(Duhig et al., 2015; Kim et al., 2011; Negele et al., 2015) studies,
prevalence rates of childhood trauma were higher than in this study.
One study involving Brazilian people diagnosed with mood disorders
reported lower prevalence of PN, EN, SA and higher prevalence of EA
and PA (Jansen et al., 2016).
In all three patient groups, PN and EN were the two most reported
types of trauma, and EA and SA were least reported. This is consistent

Table 2
Prevalence of childhood trauma and number of trauma types.

Variables Depression (n = 229) Bipolar disorder (n = 102) Schizophrenia (n = 216) Control (n = 132)

N % 95% CI N % 95% CI N % 95% CI N % 95% CI

CTQ-SF scores
EA ≥ 13 39 17.0 (12.0–22.0) 24 23.5 (15.0–32.0) 42 19.4 (14.0–25.0) 3 2.3 (0.0–5.0)
PA ≥ 10 27 11.8 (8.0–16.0) 15 14.7 (8.0–22.0) 24 11.1 (7.0–15.0) 15 11.4 (6.0–17.0)
SA ≥ 8 24 10.5 (6.0–14.0) 15 14.7 (8.0–22.0) 30 13.9 (9.0–19.0) 6 4.5 (1.0–8.0)
EN ≥ 15 97 42.4 (36.0–49.0) 36 35.3 (26.0–45.0) 42 19.4 (14.0–25.0) 3 2.3 (0.0–5.0)
PN ≥ 10 88 38.4 (32.0–45.0) 45 44.1 (34.0–54.0) 84 38.9 (32.0–45.0) 9 6.8 (2.0–11.0)
CTQ-SF total ≥ 50 60 26.2 (20.0–32.0) 33 32.4 (23.0–42.0) 48 22.2 (17.0–28.0) 3 2.3 (0.0–5.0)
Number of trauma types
No trauma 102 44.5 (38.0–51.0) 39 38.2 (29.0–48.0) 114 52.8 (46.0–59.0) 105 79.5 (73.0–87.0)
1 type of trauma 42 18.3 (13.0–23.0) 24 23.5 (15.0–32.0) 36 16.7 (12.0–22.0) 24 18.2 (12.0–25.0)
2 types of traumas 46 20.1 (15.0–25.0) 15 14.7 (8.0–22.0) 30 13.9 (9.0–19.0) 3 2.3 (0.0–5.0)
3 types of traumas 15 6.6 (3.0–10.0) 15 14.7 (8.0–22.0) 18 8.3 (5.0–12.0) 0 0.0 –
4 types of traumas 24 10.5 (6.0–14.0) 9 8.8 (3.0–14.0) 18 8.3 (5.0–12.0) 0 0.0 –
5 types of traumas 0 0.0 – 0 0.0 – 0 0.0 – 0 0.0 –

CTQ-SF: Childhood Trauma Questionnaire–Short Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect, PN: physical neglect, CI: confidence interval.

44
P. Xie et al. Journal of Affective Disorders 228 (2018) 41–48

50.0
study. This suggests that cultural differences may be another important
45.0
factor that affects the incidence of childhood trauma. In addition,
40.0 considering that our sample was not large, sampling error might have
Prevalence rates (%)

35.0 contributed to the variation in prevalence rates among studies.

30.0
25.0
20.0
15.0
10.0
5.0
.0
EA PA SA EN PN
Fig. 1. Prevalence of childhood trauma. CTQ-SF: Childhood Trauma Questionnaire–Short
Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect,
PN: physical neglect.
with some previous studies in China and South Korea (Kim et al., 2011;
Li et al., 2015). The order of trauma types in German and Australian
studies was similar to that found in our study, but EA was most reported
rather than PN and EN (Duhig et al., 2015; Negele et al., 2015). Around
47–61% of patients in our study reported at least one type of childhood
trauma, which was higher than in the control group, indicating that
many patients in our sample had suffered childhood trauma. In some
other studies, patients reporting childhood trauma reached higher
proportions (Duhig et al., 2015).
Moreover, it is possible for one individual to experience different
types of childhood trauma. We counted the number of trauma types
reported in each case. Rates of cases with multiple traumas were higher
among the three patient groups than controls, suggesting that multiple
traumas were more common among patients than controls. In Negele
et al.’s (2015) study, proportions of patients with depression who ex-
perienced one or two types of trauma were close to our results, but
many more patients in their sample reported three or more types of
trauma. Etain et al. (2010) also reported higher prevalence of multiple
traumas among patients with bipolar disorder.
Overall, our results calculated from CTQ-SF scores were partly
consistent with previous research. An important reason for the differ-
ences between our results and those of previous studies is that cutoff
points might vary across different countries or studies. For example,
cutoffs used by Li et al. (2015) were thresholds of low trauma, and
those used by Negele et al. (2015) were adjusted by other researchers
(Walker et al., 1999). The cutoff points of CTQ-SF subscales in the
present study were used in previous research by Kim et al. (2011), Peng
(2013), and Jansen et al. (2016). However, rates of prevalence reported
in Korean patients with mental disorders were still higher than in our
Depression
In our study, PA was the only type of trauma that was not reported
Bipolar disorder less by controls than by patient groups. In the control group, PA was the
Schizophrenia most reported type of trauma, with a prevalence of 11.4%, which was
Control
close to that in the depression (11.8%) and schizophrenia (11.1%)
groups. In addition, Kruskal-Wallis tests and Dunnett tests did not show
a significant difference in PA score between groups. In a logistic re-
gression model, the schizophrenia group had significantly lower PA
CTQ-SF total
score than the control group (aOR = 0.168, upper bound of CI =
0.614). This may reflect errors related to the sampling method and the
limited sample size, but cultural and social factors may also need to be
considered. In traditional Chinese culture, parents have absolute au-
thority over their children, and physical abuse was considered to be a
legitimate way of discipline. Such beliefs may remain in some con-
servative families. In addition, compared with some other countries, it
seems that protection against domestic violence provided by law and
governmental organizations still needs improvement in China.
We compared CTQ-SF and SSRS scores between three patient groups
and a control group. The majority of CTQ-SF scores for the patient
groups were significantly higher than the control group, except for the
PA score in the bipolar disorder and schizophrenia groups. Most SSRS
scores in the patient groups were significantly lower than the control
group. In logistic regression models, we controlled demographic char-
acteristics and observed that having mental disorders was associated
with higher CTQ-SF scores and lower SSRS scores. These results suggest
that patients with mental disorders in our sample experienced more
severe childhood trauma and poorer social support compared with
healthy controls. These findings are consistent with previous studies in
which mental disorders were associated with childhood trauma (Daruy-
Filho et al., 2011; DeRosse et al., 2014; Duhig et al., 2015; Etain et al.,
2013; Kelleher et al., 2013; Kessler et al., 2010) and low-level social
support was related to poor mental health (Hou et al., 2015; Pjescic
et al., 2014; Poudel-Tandukar et al., 2011).
A positive correlation was observed between suicidal ideation and
severity of childhood trauma. Furthermore, the number of trauma types
and suicidal ideation were also positively correlated. Many earlier
studies concluded that childhood trauma was a risk factor for suicide
among patients with mental disorders (Erten et al., 2014; Etain et al.,
2013). In addition, a positive correlation between mental disorders and
suicide has been observed by previous researchers (Gates et al., 2017;
Liu et al., 2017). Considering that the present study and many other
studies indicated childhood trauma could be a risk factor for mental

Table 3
Post hoc comparisons of CTQ-SF and SSRS scores.

Variables Depression and control Bipolar disorder and control Schizophrenia and control

MD of ranks (95% CI) p MD of ranks (95% CI) p MD of ranks (95% CI) p

CTQ-SF scores
EA 106.200 (57.613–154.788) < 0.001 105.629 (47.016–164.243) < 0.001 89.831 (40.711–138.950) < 0.001
PA 39.606 (−6.102–85.314) 0.105 32.993 (−22.147–88.133) 0.348 22.662 (−23.547–68.870) 0.505
SA 48.936 (10.198–87.674) 0.009 89.247 (42.515–135.978) < 0.001 118.984 (79.821–158.146) < 0.001
EN 146.546 (98.748–194.343) < 0.001 148.031 (90.371–205.692) < 0.001 59.040 (10.720–107.361) 0.012
PN 117.050 (68.546–165.555) < 0.001 128.506 (69.993–187.019) < 0.001 91.316 (42.280–140.351) < 0.001
CTQ-SF total 136.844 (88.390–185.298) < 0.001 145.587 (87.135–204.039) < 0.001 99.593 (50.609–148.578) < 0.001
SRSS scores
OS −146.751 (−194.173 to −99.329) < 0.001 −32.496 (−90.190–25.198) 0.396 −69.069 (−117.010 to −21.129) 0.002
SS −110.655 (−159.441 to −61.869) < 0.001 −115.951 (−175.305 to −56.597) < 0.001 −92.655 (−141.975 to −43.335) < 0.001
UOS −207.364 (−253.113 to −161.616) < 0.001 −126.338 (−181.862 to −70.815) < 0.001 −127.769 (−173.906 to −81.632) < 0.001
SSRS total −191.265 (−238.094 to −144.437) < 0.001 −120.226 (−177.060 to −63.392) < 0.001 −108.952 (−156.178 to −61.726) < 0.001

Dunnett test.
CTQ-SF: Childhood Trauma Questionnaire–Short Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect, PN: physical neglect, SSRS: Social Support
Rating Scale, OS: objective support, SS: Subjective support, UOS: use of support, MD: mean difference, CI: confidence interval.

45
P. Xie et al. Journal of Affective Disorders 228 (2018) 41–48

Table 4
Relationships between diagnosis and CTQ-SF and SSRS scores.

Dependent variables Depression and control Bipolar disorder and control Schizophrenia and control

aOR (95% CI) aOR (95% CI) aOR (95% CI)

CTQ-SF scores
EA 6.741 (1.803–25.199) 4.268 (0.535–34.015) 2.855 (0.634–12.852)
PA 0.803 (0.320–2.016) 0.827 (0.252–2.714) 0.168 (0.046–0.614)
SA 2.214 (0.750–6.534) 0.633 (0.095–4.209) 0.984 (0.245–3.951)
EN 16.541 (4.852–56.394) 14.485 (3.782–55.485) 16.153 (3.102–84.121)
PN 3.614 (1.602–8.152) 9.386 (3.367–26.167) 14.635 (4.377–48.933)
CTQ-SF total 8.697 (2.471–30.610) 9.863 (2.275–42.767) 3.079 (0.572–16.572)
SSRS scores
SS 0.097 (0.050–0.188) 0.511 (0.218–1.194) 0.296 (0.143–0.613)
OS 0.226 (0.125–0.407) 0.291 (0.130–0.649) 0.760 (0.387–1.493)
UOS 0.226 (0.125–0.407) 0.489 (0.230–1.040) 0.464 (0.236–0.914)
SSRS total 0.145 (0.074–0.281) 0.432 (0.178–1.049) 0.468 (0.206–1.065)

Binary logistic regression analysis.

Adjusted for demographic characteristics (age, years of education, marital status, and family history).
CTQ-SF: Childhood Trauma Questionnaire–Short Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect, PN: physical neglect, SSRS: Social Support
Rating Scale, OS: objective support, SS: Subjective support, UOS: use of support, aOR: adjusted odds ratio, CI: confidence interval.

Table 5 in southern China. There are some limitations in this study. First, our
Correlations between the SIOSS score and results from other scales. sample may not be sufficiently representative. Although the patients
were recruited from a large psychiatric hospital in China, the limited
Variables Depression Bipolar disorder Schizophrenia
(n = 229) (n = 102) (n = 216)
sample size might have increased the chance of sampling error in our
study. This may explain why some of our results differed from previous
CTQ-SF scores reports. Second, demographic characteristics including age, marital
EA 0.204** 0.536** 0.493** status, family history, and years of education were significantly dif-
PA 0.229** 0.262** 0.007
ferent between groups, indicating that our results (especially the results
SA 0.122 0.372** −0.003
EN 0.168* 0.345** 0.234** of comparisons between patients and controls) might reflect inter-
PN 0.102 0.195* −0.035 ference from these factors. Third, as a secondary outcome, the SIOSS
CTQ-SF total 0.200** 0.407** 0.278** was not completed by controls, which limited further exploration of
Number of trauma types
suicidal ideation. Fourth, all scales in our study were self-reported,
0.125 0.416** 0.040
SSRS scores
which might mean our data were not sufficiently objective. In Chinese
SS −0.158 *
−0.017 −0.006 society, people tend to avoid talking about their connection with
OS −0.098 −0.297** −0.357** mental illness or traumatic experiences (especially a history of sexual
UOS −0.259** −0.299** −0.403** abuse) because of stigma and prejudice. In addition, patients with im-
SSRS total −0.182** −0.255* −0.321**
paired insight are likely to conceal information that they think may
Spearman's rank correlation test. prove they are still in a state of mental illness and prolong the duration
SIOSS: Self-rating Idea of Suicide Scale, CTQ-SF: Childhood Trauma Questionnaire–Short of their medication. Future studies are needed to verify and explain the
Form, EA: emotional abuse, PA: physical abuse, SA: sexual abuse, EN: emotional neglect, relationship of childhood trauma and mental disorders. Such studies
PN: physical neglect, SSRS: Social Support Rating Scale, OS: objective support, SS: should use larger samples, control for more demographic features, and
Subjective support, UOS: use of support. use instruments other than self-rating scales.
* p < 0.05.
** p < 0.01.
5. Conclusion
disorders (Daruy-Filho et al., 2011; DeRosse et al., 2014; Duhig et al.,
Our study investigated the prevalence of childhood trauma in a
2015; Etain et al., 2013; Kelleher et al., 2013; Kessler et al., 2010), the
sample of outpatients with mental disorders (depression, bipolar dis-
association between trauma and suicide among patients with mental
order, and schizophrenia) in southern China. Many patients with
disorders may be partially mediated by the incidence of mental dis-
mental disorders had experienced childhood trauma, and childhood
orders.
trauma is more severe in patients with mental disorders compared with
We also found that social support was negatively related to suicidal
healthy people. Among patients with mental disorders in southern
ideation. Previous studies on social support mostly used general po-
China, childhood trauma and poor social support are associated with
pulations as their experimental groups. It was suggested that low-level
suicidal ideation.
social support was a risk factor for suicide in both the general popu-
Our study suggests that childhood trauma needs more attention in
lation (Liu et al., 2017; Marver et al., 2017) and patients with mental
psychiatric clinical practice and scientific research. Suicide risk in pa-
disorders (Park et al., 2015; Pjescic et al., 2014). Conversely, protective
tients with mental disorders who have experienced childhood trauma
effects of social support against suicide have been demonstrated in
should be assessed. Providing social support may be a helpful way of
previous research conducted in the general population (Kleiman and
preventing suicide among patients who have experienced childhood
Liu, 2013; Poudel-Tandukar et al., 2011) and in patients with mental
trauma. It is necessary to educate the public about the definition and
disorders (Rushing et al., 2013).
harm of childhood abuse and neglect, as well as the importance of so-
cial support for patients with mental disorders.
4.1. Limitations
Acknowledgment
The present study is a preliminary investigation of the prevalence
and severity of childhood trauma in outpatients with mental disorders We thank our subjects for their readiness to engage in this study. We

46
P. Xie et al.
thank Audrey Holmes, MA, from Liwen Bianji, Edanz Group China
(www.liwenbianji.cn/ac), for editing the English text of a draft of this
manuscript.
Conflicts of Interest
All authors declare that they have no conflict of interest.
Contributors
Peng Xie and Hongjun Peng designed the study and drafted the
primary manuscript. Kai Wu, Yingjun Zheng and Yangbo Guo su-
pervised the recruitment and made statistical analyses. Yuling Yang and
Jianfei He and Yi Ding took part in recruitment and data management.
Hongjun Peng made further revisions of the manuscript. All the authors
had read and approved the final manuscript.
Role of Founding Resource
This study was supported by the Guangdong Natural Science
Foundation, China (2015A030313800 to Hongjun Peng); the Science
and Technology Program of Guangzhou, China (2013J4100096 to
Hongjun Peng); the National Clinical Key Special Program, China
(201201003 to Hongjun Peng); the Fundamental Research Funds of
Central Universities under the South China University of Technology,
China (2013ZM046 to Kai Wu); the National Natural Science
Foundation of China (31400845 to Kai Wu); the Guangzhou municipal
key discipline in medicine for Guangzhou Brain Hospital (GBH2014-
ZD04 to Hongjun Peng).
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