Journal of Psychiatric Research 82 (2016) 80e90

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Journal of Psychiatric Research

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

Childhood adversity and depressive symptoms following retirement

in the Gazel cohort
Guillaume Airagnes a, b, *, Ce

dric Lemogne a, b, c, Nicolas Hoertel a, b, c, Marcel Goldberg d, e,

ric Limosin a, b, c, Marie Zins d, e

de
Fre
a ^pitaux Universitaires Paris Ouest, Department of Psychiatry, Paris, France
AP-HP, Ho
b
Universit

e Paris Descartes, Sorbonne Paris Cit

e, Facult

ede M
edecine, France
c
Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
d
Inserm, UMS 011, Population-based Epidemiological Cohorts, Villejuif, France
e
Inserm UMR 1168, VIMA, Villejuif, France

a r t i c l e i n f o a b s t r a c t

Article history: Background: Only a few studies have examined whether specific moderators may impact the magnitude
Received 15 January 2016 of the relationship between retirement and depression. The aim of this study was to examine the po-
Received in revised form tential moderating role of adverse childhood life events (ACLE) on changes in depressive symptoms
7 July 2016
following retirement in the GAZEL cohort.
Accepted 15 July 2016
Methods: 9242 participants, followed up since 1989, completed the Center of Epidemiologic Studies
Depression scale (CESD) every three years and were asked in 2004 to answer an ACLE questionnaire.
Keywords:
Subjects were classed according to 6 clusters by Two-Step Cluster Analysis (no ACLE: cluster 1; increasing
Depression
Depressive symptoms
material deprivation: clusters 2 to 4; history of early separation: cluster 5 and history of conflicts or
Retirement violence: cluster 6), and then stratified for sex. Analyses were based on general linear models with the
Elderly CESD variation between, before and after retirement as dependent variable. All results were adjusted
Childhood experience according to age, marital status, occupational status, alcohol consumption, self-rated health and CESD
score before retirement.
Results: The association between exposure to ACLE and changes in depressive symptoms following
retirement was significant in both men (F ¼ 6.929; p < 0.001; eta2 ¼ 0.005) and women (F ¼ 6.890;
p < 0.001; eta2 ¼ 0.016). Exposure to early separation or history of conflicts or violence during childhood
was associated with less improvement in both men and women, whereas early exposure to material
deprivation only affected results in men.
Conclusions: Programs aimed at facilitating retirement transition may focus on subjects at risk of not
experiencing the expected benefits of retirement, which is the case for those with a history of ACLE.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction 2015). Unfortunately, the treatment of late-life depression en-

Although the prevalence of depression is usually thought to
decrease with aging (Hoertel et al., 2013; Jorm, 2000), epidemio-
logical findings suggest that it may increase again in the very old
(e.g. from 6.6% for subjects after 50 y.o. (Mojtabai and Olfson, 2004)
to 11% after 71 y.o. (Steffens et al., 2009)). Furthermore, depression
in the elderly is more likely to induce suicide, cognitive changes,
somatic symptoms and functional impairment (An and Xiang,
* Corresponding author. Centre Ambulatoire d'Addictologie, Ho ^pital Europe

en
Georges Pompidou, 20 rue Leblanc, 75908, Paris Cedex 15, France.
E-mail address: guillaume.airagnes@aphp.fr (G. Airagnes).
counters several barriers such as the attribution of depression to
old age per se (Sarkisian et al., 2003). As a matter of fact, healthy
aging seems to be associated with maintained or even improved
emotional well-being thanks to better emotion regulation (Mather,
2012). Unfortunately, the likelihood of stressful life events that may
overwhelm these coping abilities (e.g. physical illness, bereave-
ment, social isolation) also increases in old age. Such disruptive
experiences are known to be risk factors for depression (Bruce,
2002), especially when they induce unwanted role changes (e.g.
role change associated with bereavement of the spouse) (Fiske
et al., 2009). Retirement is typically one of such major life events.
Among 1439 individuals from the English Longitudinal Study of

http://dx.doi.org/10.1016/j.jpsychires.2016.07.015
0022-3956/© 2016 Elsevier Ltd. All rights reserved.
 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
Ageing, 8% of the retirees were depressed and 9% of the employees
(Behncke, 2012). Beside decrease in income, cessation of employ-
ment is associated with role changes, with a potential loss of sense
of purpose in life, as well as with changes of social environment,
with a potential loss of social support (Kim and Moen, 2002;
Osborne, 2012; Zantinge et al., 2014). These changes may impact
the mental health (Eibich, 2015; Luhmann et al., 2012; Sjosten et al.,
2011; Zins et al., 2011). However, it remains open to debate whether
retirement is a period associated with an increased risk of
depression (Choi et al., 2013; Di Gessa and Grundy, 2014; Latif,
2013; Mojon-Azzi et al., 2007; Oliffe et al., 2013; Villamil et al.,
2006; Westerlund et al., 2009, 2010). Although several studies have
observed a substantial improvement in depressive symptoms
following retirement (Airagnes et al., 2014; Kendler et al., 2004;
Monroe et al., 2014; Morse and Robins, 2005; Segel-Karpas et al.,
2013; Weiss et al., 2009), particularly in older adults pursuing their
daily activities (Segel-Karpas et al., 2013), others suggest that
retirement may be associated with increased depression levels
(Latif, 2013; Oliffe et al., 2013). Understanding these discrepancies
is critical to better understand liability for depression in old age and
inform preventive strategies.
These discrepancies may be partly explained by the presence of
factors that may moderate the association between retirement and
depression, such as personality traits, attachment style, and family
history of depression (Kendler et al., 2004; Monroe et al., 2014;
Morse and Robins, 2005; Segel-Karpas et al., 2013; Weiss et al.,
2009). Only a few studies have examined whether specific factors
may impact the magnitude of this relationship (i.e., moderating
effect or effect modifier) (Airagnes et al., 2014; Segel-Karpas et al.,
2013). They suggest that aging is a developmental process involving
multiple time-dependent factors (Hoyer, 2002; Schafer and Ferraro,
2012), likely to interact with each other. Some of these factors such
as childhood adversities may reduce the likelihood of successful
aging by increasing the risk of depression following retirement,
which negatively impacts the well-being in the elderly (Waddell
and Jacobs-Lawson, 2010). The long-lasting impact of adverse
childhood life events (ACLE) on the risk of depression in adulthood
is well-established (Agorastos et al., 2014; Ege et al., 2015; Heim
et al., 2008; Hovens et al., 2010; Kajantie, 2008; Krsteska and
Pejoska, 2013; Kuhlman et al., 2013; Remigio-Baker et al., 2014;
Waite and Shewokis, 2012). Moreover, the risk of disability retire-
ment increases with a higher number of childhood adversities,
especially for disability retirement due to a mental disorder
(Harkonmaki et al., 2007). However, to our knowledge, no study has
examined whether ACLE have a moderating effect on the rela-
tionship between retirement and depression. Different subtypes of
ACLE may have distinct effects on the risk of depression, such as
material deprivation, early separation or child abuse (Ege et al.,
2015; Green et al., 2013; Hovens et al., 2010; Moskvina et al.,
2007). However, these ACLE are unlikely to have an impact on the
risk of depression to a similar extent. For instance, there is evidence
that early separation and child abuse might be associated with a
greater risk than material deprivation alone (Danese et al., 2009).
Because of these hierarchical relationships between ACLE, an
approach based on clustering individuals exposed to a homoge-
neous combination of ACLE may be particularly informative when
examining this issue (Carr et al., 2013; Kuhlman et al., 2015; Van
Veen et al., 2013), rather than a commonly used, approach based
on a cumulative risk, computed from a questionable sum of het-
erogeneous ACLE subtypes (Agorastos et al., 2014; Bjorkenstam
et al., 2013; Ege et al., 2015; Hovens et al., 2010).
Regarding sex differences, depressive mood is typically twice as
common in women as in men (Hoertel et al., 2015a; Manetti et al.,
2014). These differences may result from a more stable course of
depressive mood in women (Barry et al., 2008), greater emotional
81
awareness allowing them to recognize depressive symptoms more
easily once depressed (Barrett et al., 2000) or a higher tendency to
disclose these symptoms once recognized when seeking social
support (Angst and Dobler-Mikola, 1984). However these differ-
ences may also result from increased vulnerability for depression in
women (Accortt et al., 2008). Since it emerges during puberty, this
increased risk for depression in women is often attributed to bio-
logical differences between men and women. However, it remains
similar, or even increases in older adults, i.e. after the menopause
(Hoertel et al., 2015a; Manetti et al., 2014). Regardless of the nature
of this increased vulnerability, women may be more sensitive to the
impact of ACLE on depressive symptoms (Baker et al., 2009; Dunn
et al., 2011; Green et al., 2013; Heim et al., 2008; Kendler et al.,
2001). However, little is known about the differential impact of
ACLE on depressive symptoms in older men and women.
Since 1989, the Gazel cohort has followed up employees of the
French National Gas and Electricity Company who typically stayed
with this company until retirement. Therefore, the Gazel cohort
provides a unique opportunity to examine the consequences of
retirement on depressive symptoms across the entire cohort. In
particular, retirement was found to be associated with an
improvement in depressive symptoms in the Gazel cohort
(Westerlund et al., 2009). The present study aims to address the
potential moderating role of ACLE on changes in depressive
symptoms following retirement, in men and women. We hypoth-
esized that exposure to ACLE would be associated with less of an
improvement in depressive symptoms, ranging from isolated ma-
terial deprivation to early separation or child abuse. In order to
explore sex differences, individuals were first clustered according
to their ACLE exposure and then associations between this expo-
sure and depressive symptoms were explored separately in men
and women.
2. Material and methods
2.1. Participants
Details of the Gazel cohort study are available elsewhere
(Goldberg et al., 2007). Briefly, the target population consisted of
44,992 employees (31,411 men and 13,511 women) employed by
the French National Gas and Electricity Company “Electricite
de
France-Gaz de France” (EDF-GDF) (Goldberg et al., 2007). In 1989,
20,625 employees (45.8%) (15,011 men and 5614 women) agreed to
participate in the Gazel cohort study. Since 1989, participants have
been followed up by means of an annual mailed questionnaire and
via administrative databases. The study protocol was approved by
the French Data Confidentiality Authority (“Commission Nationale
Informatique et Liberte
”) and by the Ethics Evaluation Committee
of the National Health and Medical Research Institute “Institut
National de la Sante
et de la Recherche Me
dicale” (INSERM)
(IRB0000388, FWA00005831).
In 2004, the annual questionnaire mailed to the 19,658
remaining Gazel members included specific questions about
exposure to ACLE. Depressive symptoms were assessed in 1993,
1996, 1999, 2002, 2005, 2008 and 2012 according to the Center of
Epidemiologic Studies Depression Scale (CESD) (Fuhrer and
Rouillon, 1989).
2.2. Measures
2.2.1. The Center of Epidemiologic Studies Depression Scale (CESD)
This 20-item questionnaire has been designed for use in com-
munity studies and has a high internal consistency (a ¼ 0.8 to
a ¼ 0.9 across samples) (Fuhrer and Rouillon, 1989). The CESD asks
participants how often they have experienced specific depressive
82 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
symptoms during the previous week (e.g. ‘I felt depressed’, ‘I felt
everything I did was an effort’, ‘My sleep was restless’). Responses
range from 0 (‘hardly ever’) to 3 (‘most of the time’). Since reliance
on a binary cut-off may be statistically unsafe, the CESD score was
mainly considered as a continuous variable (MacCallum et al.,
2002).
2.2.2. Assessment of ACLE in the 2004 questionnaire
Participants were asked ten questions about exposure to ACLE
before the age of 17:
1. Were you separated from your mother for one year or longer
during childhood?
2. You spent 4 or more weeks in hospital
3. Your parents divorced
4. Your father and/or mother was/were (is/are) unemployed, so
they would have liked to work
5. You have been a victim of violence by a close relative
6. Your parents used to quarrel or fight
7. You lived in an orphanage or similar institution
8. Your family constantly had financial problems
9. In your home, the toilets were located outside
10. Your parents had no car
2.3. Covariates
Age, sex, marital status, and occupational status (i.e. blue-collar
workers or clerks, first-line supervisors or sales representatives,
management or training) were obtained from the employer's hu-
man resources files. Since retirement has been associated with
increased alcohol consumption in the Gazel cohort (Zins et al.,
2011), which could in turn promote depressive symptoms
(Fergusson et al., 2009), self-reported alcohol consumption was
also recorded when analyzing depressive symptoms before retire-
ment. Heavy alcohol consumers were defined as men (women)
reporting at least 28 (14) drinks per week, moderate consumers as
men (women) reporting between 14 and 27 (7e20) drinks and light
consumers as men (women) reporting between 1 and 13 (1e6)
drinks. Self-rated health was measured with a single question put
to participants every year: “How would you rate your overall
health?”. Participants responded on a 7-point Likert scale (i.e. from
1:“Very good” to 8: “Very poor”) and we took the last score avail-
able before retirement.
3. Procedure
3.1. Participants enrolled in the study
From the 20,625 Gazel volunteers in 1989, 828 died before
receiving the annual questionnaire in 2004 and 139 left the study.
Among the 19,658 participants still in the cohort in 2004, 11,976
responded to the ACLE questionnaire. Eligibility criterion includes
the ability to compute changes in CESD scores before and after
retirement. To estimate the baseline CESD score before retirement,
we used the closest available score prior to retirement. Likewise,
regarding the CESD score after retirement, if the closest CESD score
was missing, the next one was used if available. Therefore, the
participants who had no data for at least one of the two CESD scores
before retirement or no data for at least one of the two CESD scores
after retirement were not included in the present study. For 1860
responders, changes in the CESD score could not be computed
because of missing data. For 869 other responders, data were
missing because of premature death (n ¼ 28), retirement before the
first CESD measurement or retirement after the last CESD mea-
surement (n ¼ 841). Occupational status was missing for 5 subjects;
therefore 9242 participants were finally included. Since self-rated
health was missing for 1615 (17.5%) participants, we performed
stochastic regression imputation to adjust the results of the entire
sample for this covariate (Haukoos and Newgard, 2007). There
were no missing data for other covariates.
3.2. Statistical analysis
To obtain meaningful clusters of individuals exposed to a ho-
mogeneous combination of ACLE, we first performed a Two-Step
Cluster Analysis to compute clusters on receipt of answers to the
ACLE-questionnaire. The SPSS Two-Step Clustering Component
relies on a cluster analysis algorithm designed to handle large

datasets (Bacher et al., 2004; Rezankov
, 2014). The first step
a
consists of pre-clustering data into many small sub-clusters. The
second step yields the final solution by clustering these sub-
clusters into the optimal number of clusters based on clinical
interpretability (SPSSInc, 2001.). Since the impact of early separa-
tion rather than history of conflicts or violence on depressive
symptoms may be different (Ege et al., 2015; Hovens et al., 2010),
we aimed to use a cluster solution that distinguished exposure to
these two ACLE subtypes. Therefore, we systematically examined
all the solutions starting from a two-cluster solution until we found
such a solution. This goal was achieved with a 6-cluster solution
(Table 1). The previous solutions are displayed in Supplemental
Table 1. This two-step cluster analysis was performed in the
whole population in order to allow meaningful subsequent com-
parisons between men and women.
To examine the association between ACLE and changes in
depressive symptoms following retirement, we used general linear
models. Our dependent variable was the CESD variation following
retirement, computed as follows: (CESD score before retirement) e
(CESD score after retirement). To control for potential regression to
the mean effects, all the analyses were adjusted for the CESD score
before retirement (Airagnes et al., 2014). Firstly, the relations of all
variables with the changes in depressive symptoms were sepa-
rately examined. Subsequent multivariate analyses took into ac-
count all the covariates, including the time between retirement and
the CESD measurement after retirement. Statistical significance
was determined using a two-sided alpha a priori set at 0.05.
Since only 61% of the remaining Gazel participants in 2004
responded to the ACLE questionnaire, we used a weighted general
linear model in the sensitivity analysis in order to check for po-
tential selection biases. Firstly, all of the variables that significantly
discriminated responders from non-responders were entered in
multivariate logistic regression, in order to compute individual
propensity scores. Secondly, each subject was given a weight equal
to the multiplicative inverse of the propensity score in the subse-
quent general linear model (Thoemmes and Kim, 2011).
Quantitative variables are presented as means and standard
deviations, qualitative variables as percentages. Percentages were
compared using the Pearson Chi-squared test. Means were
compared with the Student t-test.
Analyses have been carried out with the IBM SPSS Statistics 22.0
software for Windows (SPSS Inc., Chicago).
4. Results
4.1. Participants’ characteristics
Compared to non-responders, responders were more likely to
be male, younger at the ACLE assessment, with a higher occupa-
tional status and better self-rated health before retirement
(Supplemental Table 2). Compared to non-included responders,
included participants were younger at the ACLE assessment, older
 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90 83

Table 1
Adverse childhood life events distribution following each cluster affiliation.

Total Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6

N (%) 9242 (100) 2099 (22.7) 1146 (12.4) 2111 (22.8) 1136 (12.3) 1217 (13.2) 1533 (16.6)

ACLEa N % N %b %c N %b %c N %b %c N %b %c N %b %c N %b %c

Were you separated from your 1068 11.6 0 0 0 0 0 0 0 0 0 0 0 0 819 76.7 67.3 249 23.3 16.2
mother for one year or
longer during childhood?
You spent 4 or more weeks in 612 6.6 0 0 0 0 0 0 0 0 0 0 0 0 476 77.8 39.1 136 22.2 8.9
hospital
Your parents divorced 424 4.6 0 0 0 0 0 0 0 0 0 0 0 0 65 15.3 5.3 359 84.7 23.4
Your father and/or mother 215 2.3 0 0 0 0 0 0 0 0 0 0 0 0 1 0.5 0.1 214 99.5 14.0
was/were (is/are)
unemployed, so they would
have liked to work
You have been a victim of 201 2.2 0 0 0 0 0 0 0 0 0 0 0 0 19 9.5 1.6 182 90.5 11.9
violence by a close relative
Your parents used to quarrel or 1194 12.9 0 0 0 0 0 0 0 0 0 0 0 0 9 0.8 0.7 1185 99.2 77.3
fight
You lived in an orphanage or 205 2.2 0 0 0 0 0 0 0 0 0 0 0 0 135 65.9 11.1 70 34.1 4.6
similar institution
Your family constantly had 2214 24.0 0 0 0 0 0 0 0 0 0 1136 51.3 100 309 14.0 25.4 769 34.7 50.2
continual financial
problems
In your home, the toilets were 4227 45.7 0 0 0 0 0 0 2111 50.0 100 729 17.2 64.2 561 13.3 46.1 826 19.5 53.9
located outside
Your parents had no car 4782 51.7 0 0 0 1146 24.0 100 1222 25.6 57.9 845 17.7 74.4 660 13.8 54.2 909 19.0 59.3

Participants numbered in the table are those who answered yes; ACLE: adverse childhood life events.
a
Self-reported in 2004 by answering yes or no to the following question: “Do one of the following event occurred in childhood (until 16 y.o)?”.
b
Distribution of each ACLE according to cluster affiliation.
c
Prevalence of each ACLE in a given cluster.

at retirement and more likely to be male, with a higher occupa- having been victims of violence by a close relative or having wit-
tional status and better self-rated health before retirement nessed parents quarreling or fighting were included in cluster 6,
(Supplemental Table 2). The characteristics of included participants regardless of whether they had encountered other ACLE. Moreover,
at baseline, duly stratified by sex are displayed in Table 2. A total of
1658 men (23.5% of the male cohort) and 540 women (24.7% of the Table 2
female cohort) were likely to present with clinical depression Participants’ characteristics.
before retirement, as indicated by meeting a threshold of 17 for
Sex Men Women
men and 23 for women on CESD (Fuhrer and Rouillon, 1989).
N (%) 7052 (76.3) 2190 (23.7)

Continuous variables Mean SD Mean SD

4.2. Cluster description
Age at history of ACLE assessment (years) 59.4 2.7 57.0 3.9
Age at retirement (years) 55.5 2.3 55.8 3.1
To distinguish early separation and history of conflicts or
CESD score before retirement 12.1 8.0 16.4 10.5
violence, as suggested by prior research (Ege et al., 2015; Hovens Self-rated health before retirement a 3.2 1.2 3.4 1.3
et al., 2010), we found that a 6-cluster model was the best solu-
Categorical variables N % N %
tion (Table 1). The 6 clusters were ranked according to our a priori
hypotheses regarding the hierarchical relationships between ACLE Occupational status
Blue-collar workers, clerks 645 9.1 416 19.0
and depressive symptoms (see above). However, cluster affiliation First-line supervisors, sales representatives 3594 51.0 1530 69.9
was subsequently used as a nominal variable. Subjects from cluster Management 2813 39.9 244 11.1
1 had no exposure to any ACLE. Subjects from clusters 2 to 4 had a Marital status
gradually increasing exposure to material deprivation during Single 145 2.1 126 5.8
Married or living with a partner 6265 88.8 1537 70.2
childhood, ranging from having no car (cluster 2), to a combination
Widower 215 3.0 117 5.3
of having no car and an outside toilet (cluster 3) and finally, having Separated or divorced 427 6.1 410 18.7
continual financial difficulties (cluster 4). However, subjects from Alcohol consumption
clusters 2 to 4 did not report other ACLE. Subjects from cluster 5 Heavy consumers b 1098 15.6 89 3.8
specifically reported a history of early separations, regardless of Moderate consumers c 1798 25.5 510 23.3
Light consumers d 3597 51.0 1034 47.2
financial deprivation during childhood. For instance, more than 75% Abstinent 559 7.9 563 25.7
of subjects who reported having been separated from his or her Clinical depression before retirement e
mother for one year or more or having spent 4 or more weeks in Yes 1658 23.5 540 24.7
hospital were included in cluster 5, regardless of whether they had No 5394 76.5 1650 75.3
encountered material deprivation. Moreover, all participants SD: Standard Deviation; ACLE: adverse childhood life events.
a
including in cluster 5 reported early separation. On the other hand, Results yielded similar results before imputation for missing data.
b
only 2.3% of these participants reported a history of conflicts or Defined as men (women) reporting at least 28 (14) drinks per week.
c
Defined as men (women) reporting between 14 and 27 (7e20) drinks per week.
violence (i.e., being abused by a close relative, being the witness of d
Defined as men (women) reporting between 1 and 13 (1e6) drinks per week.
parental conflicts), which indeed characterized subjects from e
Defined as men (women) reporting a score at the Center of Epidemiologic
cluster 6. For instance, more than 90% of participants who reported Depression Scale  17 (23).
84 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
more than 80% of cluster 6 participants reported a history of con-
flicts or violence.
There were significant differences across clusters regarding all
covariates at baseline (all p < 0.001, except for alcohol consump-
tion: p ¼ 0.011), warranting further adjustment for all these cova-
riates (Supplemental Table 3). In particular, participants from
cluster 5 and 6 displayed the highest levels of depressive symp-
toms, as well as the highest prevalence of clinically significant
depression.
4.3. Changes in depressive symptoms after retirement
As expected, we found a decrease in depressive symptoms after
retirement, from a mean CESD score of 12.1 (SD ¼ 8.0) to 10.0
(SD ¼ 7.1) in men and from 16.4 (SD ¼ 10.5) to 13.6 (SD ¼ 9.2) in
women.
In both men and women, univariate analyses revealed that the
improvement in depressive symptoms following retirement was
significantly greater amongst participants who were younger at
ACLE assessment, with better self-rated health at retirement and a
shorter time between the date of retirement and CESD measure-
ment following retirement. In men, improvement was also signif-
icantly greater amongst those with a low occupational status, light
or moderate alcohol consumption and marital status other than the
single category. In women, improvement was also significantly
stronger amongst those with a younger retirement age. These as-
sociations remain significant in multivariate analyses except for
alcohol consumption in men and age at retirement in women
(Tables 3a and 3b).
In univariate analysis, we found a significant association be-
tween cluster affiliation and changes in depressive symptoms
following retirement, with an improvement that gradually
decreased from 2.7 in the CESD for cluster 1 to 1.4 for cluster 6
among men, and from 3.7 to 1.1 among women. These associations
remained significant for both sex in multivariate analysis with a
greater size effect for women of 0.016 versus 0.005 for men
(Tables 3a and 3b). The interaction between cluster affiliation and
sex was significant (p ¼ 0.027; eta2 ¼ 0.001). In both men and
women, there was no significant interaction between cluster affil-
iation and occupational status (p > 0.10).
In men, compared to cluster 1 (no ACLE), differences in esti-
mated CESD changes were significant for cluster 4 (t ¼ 2.601;
p ¼ 0.009; eta2 ¼ 0.001), cluster 5 (t ¼ 2.702; p ¼ 0.007;
eta2 ¼ 0.001) and cluster 6 (t ¼ 5.236; p < 0.001; eta2 ¼ 0.004) in
multivariate analyses. For women, differences in estimated CESD
changes were significant for cluster 5 (t ¼ 2.402; p ¼ 0.016;
eta2 ¼ 0.003) and cluster 6 (t ¼ 4.691; p < 0.001; eta2 ¼ 0.010).
Fig. 1 shows the estimated means for CESD changes following
retirement according to cluster affiliation in men and women,
separately.
4.4. Sensitivity analyses
Individual propensity scores (i.e. the a priori likelihood of
responding) were computed based on multivariate logistic
regression including covariates that significantly discriminate re-
sponders from non-responders (i.e. sex, age at history of ACLE
assessment, occupational status, marital status and self-rated
health). Sensitivity analyses based on subsequently weighted
general linear models yielded similar results. Results indicate that
there was a significant association between cluster affiliation and
changes in depressive symptoms in both men and women, with a
greater size effect for women (F ¼ 6.990; p < 0.001; eta2 ¼ 0.005
versus F ¼ 7.057; p < 0.001; eta2 ¼ 0.016, respectively). The inter-
action between cluster affiliation and sex remained significant
(F ¼ 2.644; p ¼ 0.021; eta2 ¼ 0.001).
4.5. Post hoc analyses
In order to examine the clinical relevance of our results, we
computed post hoc analyses focusing on participants who were
likely to present clinical depression. After adjusting for all cova-
riates, the prevalence of clinically depressed men from cluster 6
whose symptoms remained clinically elevated after retirement was
higher than those from cluster 1 (Odds Ratio (OR): 0.61 [95% con-
fidence interval (CI): 0.44e0.86]). This result was similar in women,
with a higher prevalence of clinically depressed women from
clusters 6 and 5 whose symptoms remained clinically elevated after
retirement compared to that observed in cluster 1 (OR: 0.43 [95%
CI: 0.25e0.74] and OR: 0.46 [95% CI: 0.24e0.89], respectively). Fig. 2
displays the prevalence of clinically significant depression for both
men and women after retirement amongst participants who were
depressed prior to retirement by ACLE Cluster.
5. Discussion
5.1. Summary of results
The aim of this study was to examine the potential moderating
role of ACLE on changes in depressive symptoms following retire-
ment. Retirement was associated with a substantial decrease in
depressive symptoms. As expected, this improvement was
moderated by ACLE exposure, in both men and women. More
specifically, exposure to early separation or history of conflicts or
violence was associated with less improvement in depressive
symptoms following retirement compared to no exposure to ACLE,
with a greater impact in women than in men. Isolated financial
deprivation was associated with less of an improvement in
depressive symptoms among men only. Amongst men and women
likely to be clinically depressed before retirement, the benefits of
retirement on depressive symptoms were significantly reduced in
the presence of history of early separation or conflicts or violence
during childhood.
5.2. Strength and limitations
The strengths of this study include its innovative approach and
longitudinal design. It is noteworthy that the determination of
clusters was totally independent of the main outcome. Moreover,
all of the solutions were systematically examined to ensure the
relevant clustering of individuals according to ACLE exposure in
accordance with previous literature on this topic (Carr et al., 2013;
Ege et al., 2015; Hovens et al., 2010). We used a clustering proce-
dure especially designed for large samples that does not rely on a
priori assumptions regarding the relative weight of specific ACLE
(SPSSInc, 2001.).
Some limitations should nevertheless be considered. Firstly, the
list-wise deletion of individuals who did not answer the ACLE
questionnaire led to a decrease in statistical power and selection of
the most motivated participants. However, sensitivity analyses
using a weighting approach to take into account the likelihood of
responding to the ACLE questionnaire yielded similar results. This
suggests that our results were robust and not substantially biased
by the likelihood of response to the ACLE questionnaire. However,
exposure to ACLE per se may have reduced the likelihood of
response. In addition, the ACLE questionnaire did not include sex-
ual abuse despite its well-known impact on mental health in
adulthood (Carr et al., 2013). Therefore our results might have
underestimated the moderating effect of ACLE. Secondly, although
the Gazel cohort covers all regions of France, various areas ranging
Table 3a
Association between variables and the changes of depressive symptoms following retirement for men.

Univariate modela Multivariate model without ACLEb Multivariate model with ACLEc

Continuous variables B Estimated parameterd F p Eta2 B Estimated parameterd F p Eta2 B Estimated parameterd F p Eta2

Age at history of ACLE assessment 0.169 47.279 <0.001 0.007 0.164 42.409 <0.001 0.006 0.158 39.018 <0.001 0.006
Age at retirement 0.033 1.220 0.269 <0.001 0.035 1.206 0.272 <0.001 0.038 1.437 0.231 <0.001
Time between the date of retirement and CESD 0.214 10.410 0.001 0.001 0.182 7.650 0.006 0.001 0.183 7.823 0.005 0.001
measure after retirement
Self-rated health before retirement 0.550 92.517 <0.001 0.013 0.519 82.642 <0.001 0.012 0.514 81.181 <0.001 0.011

G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90

Categorical variables CESD score changee F p Eta2 CESD score changee F p Eta2 CESD score changee F p Eta2

Occupational status 8.624 <0.001 0.002 8.619 <0.001 0.002 8.425 <0.001 0.002
Blue-collar workers, clerks 1.395 0.915 0.876
First-line supervisors, sales representatives 2.031 1.502 1.462
Management 2.382 1.901 1.854
Marital status 5.923 <0.001 0.003 4.669 0.003 0.002 4.937 0.002 0.002
Single 0.146 0.166 0.058
Married or living with a partner 2.159 1.932 1.873
Widower 2.072 1.878 1.901
Separated or divorced 2.126 1.781 1.758
Alcohol consumption 3.047 0.028 0.001 1.583 0.191 0.001 1.643 0.177 0.001
Heavy consumersf 1.687 1.167 1.111
Moderate consumersg 2.183 1.564 1.517
Light consumersh 2.242 1.575 1.528
Abstinent 1.892 1.451 1.433
Cluster affiliation following history of ACLE 7.958 <0.001 0.006 6.929 <0.001 0.005
Cluster 1 2.694 1.866
Cluster 2 2.267 1.685
Cluster 3 2.265 1.676
Cluster 4 1.826 1.243
Cluster 5 1.815 1.234
Cluster 6 1.381 0.679

ACLE: adverse childhood life events.

a
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement only adjusting for CESD score before retirement.
b
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement adjusting for all covariates excluding cluster affiliation following ACLE history.
c
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement adjusting for all covariates including cluster affiliation following ACLE history.
d
Direction of the association is presented for continuous variables as B estimated parameter.
e
Estimated means of CESD changes following retirement are presented for each class of categorical variables.
f
Defined as men reporting at least 28 drinks per week.
g
Defined as men reporting 14 to 27 drinks per week.
h
Defined as men reporting 1 to 13 drinks per week.

85
 86
Table 3b
Association between variables and the changes of depressive symptoms following retirement for women.

Univariate modela Multivariate model without ACLEb Multivariate model with ACLEc
d 2 d 2
Continuous variables B Estimated parameter F p Eta B Estimated parameter F p Eta B Estimated parameterd F p Eta2

Age at history of ACLE assessment 0.172 17.717 <0.001 0.008 0.145 12.148 0.001 0.006 0.142 11.496 0.001 0.005
Age at retirement 0.106 4.219 0.040 0.002 0.054 0.998 0.318 <0.001 0.036 0.436 0.509 <0.001
Time between the date of retirement and CESD 0.493 11.152 <0.001 0.005 0.497 11.579 0.001 0.005 0.480 10.912 0.001 0.005
measure after retirement
Self-rated health before retirement 0.888 45.849 <0.001 0.021 0.846 41.405 <0.001 0.019 0.811 38.405 <0.001 0.017

G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90

Categorical variables CESD score changee F p Eta2 CESD score changee F p Eta2 CESD score changee F p Eta2

Occupational status 1.373 0.253 0.001 1.557 0.211 0001 1.470 0.230 0.001
Blue-collar workers, clerks 2.342 1.881 2.032
First-line supervisors, sales representatives 2.806 2.419 2.519
Management 3.321 2.900 3.034
Marital status 0.919 0.431 0.001 0.410 0.746 0.001 0.572 0.634 0.001
Single 1.906 1.816 1.865
Married or living with a partner 2.811 2.505 2.557
Widower 3.447 2.788 3.056
Separated or divorced 2.718 2.492 2.636
Alcohol consumption 1.511 0.210 0.002 1.500 0.213 0.002 1.168 0.320 0.002
Heavy consumersf 1.103 1.145 1.402
Moderate consumersg 2.937 2.810 2.866
Light consumersh 2.829 2.689 2.847
Abstinent 2.778 2.956 2.999
Cluster affiliation following history of ACLE 8.155 <0.001 0.018 6.890 <0.001 0.016
Cluster 1 3.656 3.113
Cluster 2 3.328 3.056
Cluster 3 3.628 3.373
Cluster 4 3.017 2.853
Cluster 5 1.967 1.812
Cluster 6 1.152 0.963

ACLE: adverse childhood life events.

a
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement only adjusting for CESD score before retirement.
b
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement adjusting for all covariates excluding cluster affiliation following ACLE history.
c
General Linear models testing the association between each variable and the changes of depressive symptoms after retirement adjusting for all covariates including cluster affiliation following ACLE history.
d
Direction of the association is presented for continuous variables as B estimated parameter.
e
Estimated means of CESD changes following retirement are presented for each class of categorical variables.
f
Defined as women reporting at least 14 drinks per week.
g
Defined as women reporting 7 to 20 drinks per week.
h
Defined as women reporting 1 to 6 drinks per week.
 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90 87

Fig. 1. Estimated CESD mean changes from pre- to post-retirement according to cluster affiliation. The figures above the bars display the estimated CESD mean changes for each
cluster, for men (left panel) and women (right panel), separately.

Fig. 2. Prevalence of non-depressed participants after retirement amongst those who were clinically depressed prior to retirement by ACLE Cluster. The figures above the bars
display the proportion (%) of non-depressed participants after retirement amongst those who were likely to be clinically depressed before retirement for each cluster, for men (left
panel) and women (right panel), separately. The likelihood of clinical depression was determined by a CESD score 17 or 23, for men or women, respectively.

from small villages to large cities and a wide range of socioeco-
nomic status and occupations, it is not representative of the general
population as it includes only middle-aged working individuals
with guaranteed post-retirement incomes with a rather young
retirement age. Thus, further studies are warranted to examine
whether our findings may apply to other settings. Thirdly, retro-
spective reporting of ACLE might be subject to recall bias. Fourthly,
besides ACLE, unmeasured factors may influence adjustment to
retirement (e.g. chronic diseases, socio-economic status, history of
depression) (Latham, 2015; Lei et al., 2014). However, we used
several proxies to adjust our results for these factors such as self-
rated health before retirement as well as occupational and
marital status. Nevertheless, we did not have reliable proxy for the
history of depression, whereas such history may mediate, at least
partially, the association between exposure to ACLE and changes in
depressive symptoms following retirement. Finally, we cannot rule
out that differences in depressive symptoms may only be transient,
reflecting a slower adjustment of subjects exposed to interpersonal
conflicts during childhood.
5.3. Explanatory hypotheses
The improvement in depressive symptoms following retirement
might result from several factors, such as a decrease in depresso-
genic factors associated with work (e.g. occupational stress), pro-
tective factors associated with retirement (e.g. new meaningful
activities), or even improved capacity to regulate emotion with
ageing (Mather, 2012). However, according to our main hypothesis,
we will focus here on explanatory hypotheses regarding the
moderating effect of ACLE.
Since the clustering analysis did not identify a cluster charac-
terized by participants who would have experienced either early
separation or conflicts or violence alone, the 6-cluster solution is
consistent with a cumulative model of adversity exposure. More
specifically, our results indicate that participants from clusters 1 to
5 may have been exposed to an increasing number of ACLE and that
a greater proportion of individuals from cluster 6 may have been
exposed to material deprivation than those from cluster 5. Never-
theless, material deprivation alone (i.e. clusters 1 to 4) was not a
significant moderator of changes in depressive symptoms following
88 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
retirement after adjusting for potential confounders, except for
cluster 4 in men. It suggests that material deprivation may not
independently increase the risk of depression unless it is associated
with early separation or child abuse (Dong et al., 2003; Dunn et al.,
2011; Spence et al., 2002). These results suggest that beyond a
certain level of global ACLE exposure, the moderating effect of this
exposure on changes in depressive symptoms following retirement
becomes substantial. However, because material deprivation was
less prevalent in participants belonging to clusters 5 and 6
compared to those in cluster 4 (Table 1), we cannot exclude that our
results might also be explained by specific effects of early separa-
tion or conflicts or violence, which characterized subjects from
clusters 5 and 6. We will henceforth refer to these ACLE as “severe
ACLE”.
Because of the observational nature of our findings, no causal
link could be drawn. Several mechanisms, either psychological,
biological or both, may nonetheless contribute to explain the as-
sociation of early adversity with subsequent vulnerability for
depression (Hoertel et al., 2015b; McMahon et al., 2015). Exposure
to severe ACLE exposure affects developmental processes related to
the strengthening of interpersonal and emotional regulation during
adulthood (Roy, 2001). An inability to regulate emotions effectively
during adulthood may eventually be captured by several constructs
linked to increased vulnerability for depression such as poor coping
capacities (Morris et al., 2014), neuroticism (Kendler et al., 2004),
hostility (Airagnes et al., 2014), insecure attachment (Segel-Karpas
et al., 2013; Tanaka et al., 2008) and long-lasting cognitive distor-
tions (Luhmann et al., 2012). Therefore severe ACLE might moder-
ate the impact of more proximal stressful life events through long-
lasting effects (Kamiya et al., 2013), possibly though epigenetic
modifications (Teicher and Samson, 2013). For instance, childhood
trauma was found to be associated with increased pro-
inflammatory gene expression levels (Levine et al., 2015) whereas
inflammatory pathways are associated with vulnerability to
depression (Haapakoski et al., 2015). Furthermore, severe ACLE has
been found to be associated with persistent anatomical and func-
tional changes in those regions of the brain involved in emotion
regulation (Heim et al., 2008). Pathways linking ACLE with such
brain changes, and eventually depressive states, involve the
deregulation of the hypothalamicepituitaryeadrenal axis (De Bellis
and Zisk, 2014). Finally, these findings may explain why treatment
responses in depressed individuals may differ depending on the
history of severe ACLE (Heim et al., 2008). Diminished social sup-
port associated with severe ACLE (Vranceanu et al., 2007) might
also contribute to this association.
Our findings extend the role of ACLE in vulnerability for
depression to the context of retirement. They are also consistent
with the fact that more severely depressed individuals are less
likely to improve over time. Since participants from clusters 5 and 6
displayed the highest levels of depressive symptoms before
retirement, this might partially explain why they were also less
likely to experience the benefits of retirement. Although our ana-
lyses were adjusted for depressive symptom levels before retire-
ment, it remains unclear whether our findings reflect general
effects of these severe ACLE or specific effects in this context. For
instance, retirement is characterized by a loss of professional
achievement and changes in life goals, thus challenging the sense of
purpose in life which could have been potentially weakened by
severe ACLE. Retirement is also specifically associated with the
simultaneous loss of several former interpersonal relationships,
thus challenging the ability to create new relationships. This ability
might have been impaired by adversity during childhood such as
early separation or abuse (Ford et al., 2011).
Regarding sex differences, greater effects amongst women are in
line with the literature, which consistently shows that stressful life
events impact more heavily on women's risk of depression (Kendler
et al., 2001). Although biological differences may have a smaller
role in this increased vulnerability for depression in menopausal
women, it is noteworthy that the above-mentioned biological
consequences of ACLE might persist after menopause. The fact that
continual financial difficulties without early separation or conflicts
or violence were associated with less of an improvement in
depressive symptoms in men only is also consistent with previous
data, highlighting the higher sensitivity of men to financial hard-
ship (Chazelle et al., 2011; Harley et al., 2014; Kendler et al., 2001). It
could be linked with gender role theories on emotion regulation
that could be tied to western gender role norms (Costa et al., 2001).
Indeed, such gender effects may be already present before the age
of 16, consistent with early exposure to gender stereotypes linking
male gender with a specific role in securing financial resources. This
is consistent with the fact that material deprivation alone may not
increase the risk of depression in men unless associated with
perceived financial difficulties (i.e. a gap between material needs
and financial resources).
6. Conclusion
The present study provides initial evidence that an improve-
ment in depressive symptoms following retirement could be
diminished by exposure to adverse childhood life events in both
men and women. Besides the specificity of retirement, these results
confirmed the long-lasting impact of ACLE on regulating emotions
over a period of at least 40 years.
Although ACLE are by definition remote events amongst older
adults, their impact should not be dismissed, especially in the
context of life-changing events such as retirement. Since exposure
to ACLE and in particular to interpersonal conflicts during child-
hood may be a risk factor for depressive symptoms after retirement,
such history should be investigated in order to increase medical
monitoring in these subjects who are prone to risk, and to propose
pre-retirement intervention. Indeed, pre-retirement training,
dealing more with psychological issues than with social life or
financial issues may promote future well-being (Rosenkoetter and
Garris, 2001; Yeung, 2013). In particular, interventions aiming at
promoting a new social role after retirement may be useful (Heaven
et al., 2013). These interventions challenge the ability to mobilize
new resources to achieve this goal (Heaven et al., 2015), which is
not far from interventions aiming at enhancing resilience in older
adults. They have been associated with successful aging and
depression improvement (MacLeod et al., 2016). Therefore, such
interventions aimed at facilitating retirement transition may be
encouraged in particular to counterbalance the negative long-term
outcomes of ACLE, in a society in which healthy aging is a growing
issue.
Conflicts of interest
Guillaume Airagnes has nothing to disclose.

dric Lemogne reports activities outside the submitted work:
Ce
grants, personal fees and non-financial support from Lundbeck,
personal fees from Servier, personal fees from Astra-Zeneca, per-
sonal fees from Daiichi-Sankyo.
Nicolas Hoertel has nothing to disclose.
Marcel Goldberg has nothing to disclose.

de
Fre
ric Limosin reports activities outside the submitted work:
personal fees from Astra Zeneca, personal fees from Eutherapie-
Servier, personal fees from Janssen, personal fees from Lundbeck,
personal fees from Otsuka Pharmaceuticals France, personal fees
from Roche.
Marie Zins has nothing to disclose.
 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
Role of funding source
No funding source.
Contributors
Guillaume Airagnes and Ce
dric Lemogne designed the study and
wrote the first draft of the manuscript. Marcel Goldberg and Marie
Zins collected the data. Guillaume Airagnes managed the literature
searches and undertook the statistical analysis. All authors partic-
ipated in the interpretation of results, revised the draft critically for
important intellectual content and have approved the final
manuscript.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.jpsychires.2016.07.015.
References
Accortt, E.E., Freeman, M.P., Allen, J.J., 2008. Women and major depressive disorder:
clinical perspectives on causal pathways. J. Womens Health (Larchmt) 17 (10),
1583e1590.
Agorastos, A., Pittman, J.O., Angkaw, A.C., Nievergelt, C.M., Hansen, C.J., Aversa, L.H.,
Parisi, S.A., Barkauskas, D.A., Baker, D.G., 2014. The cumulative effect of different
childhood trauma types on self-reported symptoms of adult male depression
and PTSD, substance abuse and health-related quality of life in a large active-
duty military cohort. J. Psychiatr. Res. 58, 46e54.
Airagnes, G., Lemogne, C., Consoli, S.M., Schuster, J.P., Zins, M., Limosin, F., 2014.
Personality moderates the improvement of depressive symptoms after retire-
ment: evidence from the GAZEL cohort. Am. J. Geriatr. Psychiatry 23 (9),
941e949.
An, R., Xiang, X., 2015. Smoking, heavy drinking, and depression among U.S. middle-
aged and older adults. Prev. Med. 81, 295e302.
Angst, J., Dobler-Mikola, A., 1984. Do the diagnostic criteria determine the sex ratio
in depression? J. Affect Disord. 7 (3e4), 189e198.
Bacher, J., Wenzig, K., Vogler, M., 2004. SPSS TwoStep Cluster e a First Evaluation,
Nürnberg.
Baker, C.K., Norris, F.H., Jones, E.C., Murphy, A.D., 2009. Childhood trauma and
adulthood physical health in Mexico. J. Behav. Med. 32 (3), 255e269.
Barrett, L.F., Lane, R.D., Sechrest, L., Schwartz, G.E., 2000. Sex differences in
emotional awareness. Personal. Soc. Psychol. Bull. 26 (9), 1027e1035.
Barry, L.C., Allore, H.G., Guo, Z., Bruce, M.L., Gill, T.M., 2008. Higher burden of
depression among older women: the effect of onset, persistence and mortality
over time. Archives general psychiatry 65 (2), 172e178.
Behncke, S., 2012 Mar. Does retirement trigger ill health? Health Econ. 21 (3),
282e300.
Bjorkenstam, E., Hjern, A., Mittendorfer-Rutz, E., Vinnerljung, B., Hallqvist, J.,
Ljung, R., 2013. Multi-exposure and clustering of adverse childhood experi-
ences, socioeconomic differences and psychotropic medication in young adults.
PLoS One 8 (1), e53551.
Bruce, M.L., 2002. Psychosocial risk factors for depressive disorders in late life. Biol.
Psychiatry 52 (3), 175e184.
Carr, C.P., Martins, C.M., Stingel, A.M., Lemgruber, V.B., Juruena, M.F., 2013. The role
of early life stress in adult psychiatric disorders: a systematic review according
to childhood trauma subtypes. J. Nerv. Ment. Dis. 201 (12), 1007e1020.
Chazelle, E., Lemogne, C., Morgan, K., Kelleher, C.C., Chastang, J.-F., Niedhammer, I.,
2011. Explanations of educational differences in major depression and gener-
alised anxiety disorder in the Irish population. J. Affect. Disord. 134 (1e3),
304e314.
Choi, K.S., Stewart, R., Dewey, M., 2013. Participation in productive activities and
depression among older Europeans: survey of health, ageing and retirement in
Europe (SHARE). Int. J. Geriatr. Psychiatry 28 (11), 1157e1165.
Costa Jr., P.T., Terracciano, A., McCrae, R.R., 2001. Gender differences in personality
traits across cultures: robust and surprising findings. J. Pers. Soc. Psychol. 81 (2),
322e331.
Danese, A., Moffitt, T.E., Harrington, H., Milne, B.J., Polanczyk, G., Pariante, C.M.,
Poulton, R., Caspi, A., 2009. Adverse childhood experiences and adult risk fac-
tors for age-related disease: depression, inflammation, and clustering of
metabolic risk markers. Archives Pediatr. Adolesc. Med. 163 (12), 1135e1143.
De Bellis, M.D., Zisk, A., 2014. The biological effects of childhood trauma. Child.
Adolesc. Psychiatr. Clin. N. Am. 23 (2), 185e222 vii.
Di Gessa, G., Grundy, E., 2014. The relationship between active ageing and health
using longitudinal data from Denmark, France, Italy and England. J. Epidemiol.
Community Health 68 (3), 261e267.
Dong, M., Anda, R.F., Dube, S.R., Giles, W.H., Felitti, V.J., 2003. The relationship of
exposure to childhood sexual abuse to other forms of abuse, neglect, and
89
household dysfunction during childhood. Child. Abuse Negl. 27 (6), 625e639.
Dunn, V.J., Abbott, R.A., Croudace, T.J., Wilkinson, P., Jones, P.B., Herbert, J.,
Goodyer, I.M., 2011. Profiles of family-focused adverse experiences through
childhood and early adolescence: the ROOTS project a community investigation
of adolescent mental health. BMC Psychiatry 11, 109.
Ege, M.A., Messias, E., Thapa, P.B., Krain, L.P., 2015. Adverse childhood experiences
and geriatric depression: results from the 2010 BRFSS. Am. J. Geriatr. Psychiatry
23 (1), 110e114.
Eibich, P., 2015. Understanding the effect of retirement on health: mechanisms and
heterogeneity. J. Health Econ. 43 (0), 1e12.
Fergusson, D.M., Boden, J.M., Horwood, L.J., 2009. Tests of causal links between
alcohol abuse or dependence and major depression. Arch. Gen. Psychiatry 66
(3), 260e266.
Fiske, A., Wetherell, J.L., Gatz, M., 2009. Depression in older adults. Annu. Rev. Clin.
Psychol. 5, 363e389.
Ford, E., Clark, C., Stansfeld, S.A., 2011. The influence of childhood adversity on social
relations and mental health at mid-life. J. Affect. Disord. 133 (1e2), 320e327.
Fuhrer, R., Rouillon, F., 1989. La version française de l'e
chelle CES-D (Center for
Epidemiologic Studies-Depression Scale). Description et traduction de l'e
chelle
d'autoe
valuation. Eur. Psychiatry 4 (3), 163e166.
Goldberg, M., Leclerc, A., Bonenfant, S., Chastang, J.F., Schmaus, A., Kaniewski, N.,
Zins, M., 2007. Cohort profile: the GAZEL cohort study. Int. J. Epidemiol. 36 (1),
32e39.
Green, K.M., Fothergill, K.E., Robertson, J.A., Zebrak, K.A., Banda, D.R.,
Ensminger, M.E., 2013. Early life predictors of adult depression in a community
cohort of urban African Americans. J. Urban Health 90 (1), 101e115.
Haapakoski, R., Ebmeier, K.P., Alenius, H., Kivimaki, M., 2015. Innate and adaptive
immunity in the development of depression: an update on current knowledge
and technological advances. Prog. Neuropsychopharmacol. Biol. Psychiatry 66,
63e72.
Harkonmaki, K., Korkeila, K., Vahtera, J., Kivimaki, M., Suominen, S., Sillanmaki, L.,
Koskenvuo, M., 2007. Childhood adversities as a predictor of disability retire-
ment. J. Epidemiol. Community Health 61 (6), 479e484.
Harley, A.E., Yang, M., Stoddard, A.M., Adamkiewicz, G., Walker, R., Tucker-
Seeley, R.D., Allen, J.D., Sorensen, G., 2014. Patterns and predictors of health
behaviors among racially/ethnically diverse residents of low-income housing
developments. Am. J. Health Promot 29 (1), 59e67.
Haukoos, J.S., Newgard, C.D., 2007. Advanced Statistics: missing data in clinical
researchdpart 1: an introduction and conceptual framework. Acad. Emerg.
Med. 14 (7), 662e668.
Heaven, B., Brown, L.J., White, M., Errington, L., Mathers, J.C., Moffatt, S., 2013.
Supporting well-being in retirement through meaningful social roles: system-
atic review of intervention studies. Milbank Q. 91 (2), 222e287.
Heaven, B., O'Brien, N., Evans, E.H., White, M., Meyer, T.D., Mathers, J.C., Moffatt, S.,
2015. Mobilizing resources for well-being: implications for developing in-
terventions in the retirement transition. Gerontologist. http://dx.doi.org/
10.1093/geront/gnu159.
Heim, C., Newport, D.J., Mletzko, T., Miller, A.H., Nemeroff, C.B., 2008. The link be-
tween childhood trauma and depression: insights from HPA axis studies in
humans. Psychoneuroendocrinology 33 (6), 693e710.
Hoertel, N., Le Strat, Y., Gorwood, P., Bera-Potelle, C., Schuster, J.P., Manetti, A.,
Dubertret, C., Limosin, F., 2013. Why does the lifetime prevalence of major
depressive disorder in the elderly appear to be lower than in younger adults?
Results from a national representative sample. J. Affect Disord. 149 (1e3),
160e165.
Hoertel, N., Franco, S., Wall, M.M., Oquendo, M.A., Kerridge, B.T., Limosin, F.,
Blanco, C., 2015a. Mental disorders and risk of suicide attempt: a national
prospective study. Mol. Psychiatry 20 (6), 718e726.
Hoertel, N., Franco, S., Wall, M.M., Oquendo, M.A., Wang, S., Limosin, F., Blanco, C.,
2015b. Childhood maltreatment and risk of suicide attempt: a nationally
representative study. J. Clin. Psychiatry 76 (7), 916e923.
Hovens, J.G., Wiersma, J.E., Giltay, E.J., van Oppen, P., Spinhoven, P., Penninx, B.W.,
Zitman, F.G., 2010. Childhood life events and childhood trauma in adult patients
with depressive, anxiety and comorbid disorders vs. controls. Acta Psychiatr.
Scand. 122 (1), 66e74.
Hoyer, W.J., 2002. Life-span development. In: Encyclopedia of Aging.
Jorm, A.F., 2000. Does old age reduce the risk of anxiety and depression? A review
of epidemiological studies across the adult life span. Psychol. Med. 30 (01),
11e22.
Kajantie, E., 2008. Early-life events. Effects on aging. Horm. (Athens) 7 (2), 101e113.
Kamiya, Y., Doyle, M., Henretta, J.C., Timonen, V., 2013. Depressive symptoms
among older adults: the impact of early and later life circumstances and marital
status. Aging Ment. Health 17 (3), 349e357.
Kendler, K.S., Thornton, L.M., Prescott, C.A., 2001. Gender differences in the rates of
exposure to stressful life events and sensitivity to their depressogenic effects.
Am. J. Psychiatry 158 (4), 587e593.
Kendler, K.S., Kuhn, J., Prescott, C.A., 2004. The interrelationship of neuroticism, sex,
and stressful life events in the prediction of episodes of major depression. Am. J.
Psychiatry 161 (4), 631e636.
Kim, J.E., Moen, P., 2002. Retirement transitions, gender, and psychological well-
being: a life-course, ecological model. J. Gerontol. B Psychol. Sci. Soc. Sci. 57
(3), P212eP222.
Krsteska, R., Pejoska, V.G., 2013. The association of poor economic condition and
family relations in childhood with late-life depression. Psychiatr. Danub 25 (3),
241e247.
90 G. Airagnes et al. / Journal of Psychiatric Research 82 (2016) 80e90
Kuhlman, K.R., Maercker, A., Bachem, R., Simmen, K., Burri, A., 2013. Developmental
and contextual factors in the role of severe childhood trauma in geriatric
depression: the sample case of former indentured child laborers. Child. Abuse
Negl. 37 (11), 969e978.
Kuhlman, K.R., Geiss, E.G., Vargas, I., Lopez-Duran, N.L., 2015. Differential associa-
tions between childhood trauma subtypes and adolescent HPA-axis func-
tioning. Psychoneuroendocrinology 54, 103e114.
Latham, K., 2015. The “long arm” of childhood health: linking childhood disability to
late midlife mental health. Res. Aging 37 (1), 82e102.
Latif, E., 2013. The impact of retirement on mental health in Canada. J. Ment. Health
Policy Econ. 16 (1), 35e46.
Lei, X., Sun, X., Strauss, J., Zhang, P., Zhao, Y., 2014. Depressive symptoms and SES
among the mid-aged and elderly in China: evidence from the China health and
retirement longitudinal study national baseline. Soc. Sci. Med. 120, 224e232.
Levine, M.E., Cole, S.W., Weir, D.R., Crimmins, E.M., 2015. Childhood and later life
stressors and increased inflammatory gene expression at older ages. Soc. Sci.
Med. 130, 16e22.
Luhmann, M., Hofmann, W., Eid, M., Lucas, R.E., 2012. Subjective well-being and
adaptation to life events: a meta-analysis. J. Pers. Soc. Psychol. 102 (3), 592e615.
MacCallum, R.C., Zhang, S., Preacher, K.J., Rucker, D.D., 2002. On the practice of
dichotomization of quantitative variables. Psychol. methods 7 (1), 19.
MacLeod, S., Musich, S., Hawkins, K., Alsgaard, K., Wicker, E.R., 2016. The impact
of resilience among older adults. Geriatr. Nurs. http://dx.doi.org/10.1016/
j.gerinurse.2016.02.014.
Manetti, A., Hoertel, N., Le Strat, Y., Schuster, J.P., Lemogne, C., Limosin, F., 2014.
Comorbidity of late-life depression in the United States: a population-based
study. Am. J. Geriatr. Psychiatry 22 (11), 1292e1306.
Mather, M., 2012. The emotion paradox in the aging brain. Ann. N. Y. Acad. Sci. 1251,
33e49.
McMahon, K., Hoertel, N., Wall, M.M., Okuda, M., Limosin, F., Blanco, C., 2015.
Childhood maltreatment and risk of intimate partner violence: a national study.
J. Psychiatric Res. 69, 42e49.
Mojon-Azzi, S., Sousa-Poza, A., Widmer, R., 2007. The effect of retirement on health:
a panel analysis using data from the Swiss Household Panel. Swiss Med. Wkly.
137 (41e42), 581e585.
Mojtabai, R., Olfson, M., 2004. Major depression in community-dwelling middle-
aged and older adults: prevalence and 2- and 4-year follow-up symptoms.
Psychol. Med. 34 (04), 623e634.
Monroe, S.M., Slavich, G.M., Gotlib, I.H., 2014. Life stress and family history for
depression: the moderating role of past depressive episodes. J. Psychiatr. Res.
49, 90e95.
Morris, M.C., Kouros, C.D., Fox, K.R., Rao, U., Garber, J., 2014. Interactive models of
depression vulnerability: the role of childhood trauma, dysfunctional attitudes,
and coping. Br. J. Clin. Psychol. 53 (2), 245e263.
Morse, J.Q., Robins, C.J., 2005. Personalityelife event congruence effects in late-life
depression. J. Affect Disord. 84 (1), 25e31.
Moskvina, V., Farmer, A., Swainson, V., O'Leary, J., Gunasinghe, C., Owen, M.,
Craddock, N., McGuffin, P., Korszun, A., 2007. Interrelationship of childhood
trauma, neuroticism, and depressive phenotype. Depress Anxiety 24 (3),
163e168.
Oliffe, J.L., Rasmussen, B., Bottorff, J.L., Kelly, M.T., Galdas, P.M., Phinney, A.,
Ogrodniczuk, J.S., 2013. Masculinities, work, and retirement among older men
who experience depression. Qual. Health Res. 23 (12), 1626e1637.
Osborne, J.W., 2012. Psychological effects of the transition to retirement. Can. J.
Couns. Psychotherapy 46 (1), 45e58.
Remigio-Baker, R.A., Hayes, D.K., Reyes-Salvail, F., 2014. Adverse childhood events
and current depressive symptoms among women in Hawaii: 2010 BRFSS.
Hawaii. Matern. Child. Health J. 18 (10), 2300e2308.

Rezankov
a, H., 2014. Cluster analysis of economic data. Statistika 94 (1), 73e86.
Rosenkoetter, M.M., Garris, J.M., 2001. Retirement planning, use of time, and psy-
chosocial adjustment. Issues Ment. Health Nurs. 22 (7), 703e722.
Roy, A., 2001. Childhood trauma and hostility as an adult: relevance to suicidal
behavior. Psychiatry Res. 102 (1), 97e101.
Sarkisian, C.A., Lee-Henderson, M.H., Mangione, C.M., 2003. Do depressed older
adults who attribute depression to “old age” believe it is important to seek
care? J. Gen. Intern Med. 18 (12), 1001e1005.
Schafer, M.H., Ferraro, K.F., 2012. Childhood misfortune as a threat to successful
aging: avoiding disease. Gerontologist 52 (1), 111e120.
Segel-Karpas, D., Bamberger, P.A., Bacharach, S.B., 2013. Income decline and retiree
well-being: the moderating role of attachment. Psychol. Aging 28 (4),
1098e1107.
Sjosten, N., Nabi, H., Westerlund, H., Singh-Manoux, A., Dartigues, J.F., Goldberg, M.,
Zins, M., Oksanen, T., Salo, P., Pentti, J., Kivimaki, M., Vahtera, J., 2011. Influence
of retirement and work stress on headache prevalence: a longitudinal model-
ling study from the GAZEL Cohort Study. Cephalalgia 31 (6), 696e705.
Spence, S.H., Najman, J.M., Bor, W., O'Callaghan, M.J., Williams, G.M., 2002. Maternal
anxiety and depression, poverty and marital relationship factors during early
childhood as predictors of anxiety and depressive symptoms in adolescence.
J. Child. Psychol. Psychiatry 43 (4), 457e469.
SPSSInc, 2001. The SPSS Twostep Cluster Component: a Scalable Component
Enabling More Efficient Customer Segmentation. Technical report No. TSCWP-
0101. SPSS, Chicago, IL.
Steffens, D.C., Fisher, G.G., Langa, K.M., Potter, G.G., Plassman, B.L., 2009. Prevalence
of depression among older Americans: the aging, demographics and memory
study. Int. psychogeriatrics/IPA 21 (5), 879e888.
Tanaka, N., Hasui, C., Uji, M., Hiramura, H., Chen, Z., Shikai, N., Kitamura, T., 2008.
Correlates of the categories of adolescent attachment styles: perceived rearing,
family function, early life events, and personality. Psychiatry Clin. Neurosci. 62
(1), 65e74.
Teicher, M.H., Samson, J.A., 2013. Childhood maltreatment and psychopathology: a
case for ecophenotypic variants as clinically and neurobiologically distinct
subtypes. Am. J. Psychiatry 170 (10), 1114e1133.
Thoemmes, F.J., Kim, E.S., 2011. A systematic review of propensity score methods in
the social sciences. Multivar. Behav. Res. 46 (1), 90e118.
Van Veen, T., Wardenaar, K., Carlier, I., Spinhoven, P., Penninx, B., Zitman, F., 2013.
Are childhood and adult life adversities differentially associated with specific
symptom dimensions of depression and anxiety? testing the tripartite model.
J. Affect. Disord. 146 (2), 238e245.
Villamil, E., Huppert, A.F., Melzer, D., 2006. Low prevalence of depression and
anxiety is linked to statutory retirement ages rather than personal work exit: a
national survey. Psychol. Med. 36 (07), 999e1009.
Vranceanu, A.M., Hobfoll, S.E., Johnson, R.J., 2007. Child multi-type maltreatment
and associated depression and PTSD symptoms: the role of social support and
stress. Child. Abuse Negl. 31 (1), 71e84.
Waddell, E.L., Jacobs-Lawson, J.M., 2010. Predicting positive well-being in older men
and women. Int. J. Aging Hum. Dev. 70 (3), 181e197.
Waite, R., Shewokis, P.A., 2012. Childhood trauma and adult self-reported depres-
sion. ABNF J. 23 (1), 8e13.
Weiss, A., Sutin, A.R., Duberstein, P.R., Friedman, B., Bagby, R.M., Costa Jr., P.T., 2009.
The personality domains and styles of the five-factor model are related to
incident depression in Medicare recipients aged 65 to 100. Am. J. Geriatr.
Psychiatry 17 (7), 591e601.
Westerlund, H., Kivimaki, M., Singh-Manoux, A., Melchior, M., Ferrie, J.E., Pentti, J.,
Jokela, M., Leineweber, C., Goldberg, M., Zins, M., Vahtera, J., 2009. Self-rated
health before and after retirement in France (GAZEL): a cohort study. Lancet 374
(9705), 1889e1896.
Westerlund, H., Vahtera, J., Ferrie, J.E., Singh-Manoux, A., Pentti, J., Melchior, M.,
Leineweber, C., Jokela, M., Siegrist, J., Goldberg, M., Zins, M., Kivimaki, M., 2010.
Effect of retirement on major chronic conditions and fatigue: French GAZEL
occupational cohort study. BMJ 341, c6149.
Yeung, D.Y., 2013. Is pre-retirement planning always good? An exploratory study
of retirement adjustment among Hong Kong Chinese retirees. Aging Ment.
Health 17 (3), 386e393.
Zantinge, E.M., van den Berg, M., Smit, H.A., Picavet, H.S.J., 2014. Retirement and a
healthy lifestyle: opportunity or pitfall? A narrative review of the literature. Eur.
J. Public Health 24 (3), 433e439.
Zins, M., Gueguen, A., Kivimaki, M., Singh-Manoux, A., Leclerc, A., Vahtera, J.,
Westerlund, H., Ferrie, J.E., Goldberg, M., 2011. Effect of retirement on alcohol
consumption: longitudinal evidence from the French Gazel cohort study. PLoS
One 6 (10), e26531.