Prescription rates for antidepressant and anxiolytic drugs increased in a dose–response fashion as the ACE Score increased for young, middle-aged, and older adults. This finding suggests that the cost of prescription psychotropics extends throughout adulthood. Such relationships were also found among younger and middle-aged adults for antipsychotic and lithium-based drugs. The lack of a relationship between the score and antipsychotics in older adults is likely explained by the use of these medications to treat agitation and other severe symptoms in older persons with dementia.30
These rates reinforce the notion that ACEs frequently have a lifetime effect on the emotional and mental health of millions of Americans.3,6,11,19
Despite intensive and increasingly sophisticated research using animal models, genetic studies, neuro-imaging, neurotransmitter, and other biologic assessments, the causes of anxiety and mood disorders remain unclear.31
Family history is a predictor of depression,32
and heritability of affective disorders is estimated to be approximately 40%.33
Regardless, the biology of psychiatric disorders likely involves the interaction of polygenic factors, epigenetics, and early-life experiences.34
Notably, the exclusion of a history of mental illness in the home from the ACE Score as a way of controlling for potential genetic influences had little effect on the strength of the ACE Score–prescription rate relationship. A recent discovery that a polymorphism in the serotonin transporter allele is associated with increased risk of depression in persons exposed to ACEs such as physical or sexual abuse34
is consistent with this view of the multiple factors contributing to the occurrence of these disorders.35
However, advances in genomic technology have not similarly advanced understanding of the etiology of psychiatric disorders.31
The data presented herein and elsewhere6,11,19
provide evidence for a role of early-life adversity in the manifestation and treatment of common psychiatric symptoms and disorders.
The strengths of this study are its prospective design and the use of prescription data, which reflect physician practices rather than patient self-reports. Use of prospectively collected data reduces the risk that the results were influenced by reporting or recall bias. Between 1997 and 2004, rates of psychotropic medication use increased in the study cohort. This finding is consistent with recent increases in prescriptions for drugs treating mental illness among older adults in a population-based study in Ontario.36
In addition, the relationship between the ACE Score and individual types of psychotropic drugs is strong and graded.
The relevance of ACEs to the treatment of mental illness is emerging. Childhood adversity may lead to psychiatric disorders that are neurobiologically distinct, require unique treatment approaches, have different treatment responses, or necessitate clinical trials that incorporate childhood adversity and understanding of the neurobiologic changes that accompany them into their design.33
A 1992 survey of primary care providers indicated their reluctance to inquire about issues such as domestic violence for fear of opening a “Pandora’s Box” of their own issues including lack of comfort, fear of offending, powerlessness, loss of control, and time constraints.37
More than a decade later, discussion of barriers to screening and need for training for clinicians in the areas of child maltreatment, intimate partner violence, and related issues continues.38,39
These issues are “… a significant health problem in the United States requiring support for the education and training of medical professionals.”39,40
Research is needed to help clinicians in understanding how to prevent ACEs and intervene early with persons exposed to them (primary and secondary intervention) to impact the need for psychotropics later in life. In addition, many clinicians may not yet be aware that high levels of childhood adversity are associated with high risk of a wide variety of comorbid health and social problems37
that may affect treatment outcomes when prescribing psychotropic medication.
The strong, graded relationship of ACEs to prescription rates for psychotropic medications in adults has implications for understanding the early life origins of the mental illness and human suffering for which they are prescribed. Moreover, the huge economic costs1,2,36
and potential risks41– 47
associated with the use of psychotropic medications provide additional incentive to reduce the high prevalence and consequences of exposure to childhood traumatic stressors.