Abstract
This study offers a rare opportunity to evaluate life-course differences in the likelihood of developing major depressive disorder (MDD) after exposure to georeferenced neighborhood-level violence during an armed conflict. To examine age cohort (age <11 vs ≥11 years) differences in associations of neighborhood-level violence with subsequent depression onset, independently of individual exposure and other key characteristics. The Chitwan Valley Family Study is a population-representative panel study (1995 to present) conducted in Western Chitwan in Nepal, a low-income country that experienced a medium-intensity armed conflict from 2000 to 2006. Data for violent events were collected during the armed conflict and were linked to lifetime histories of MDD (collected in 2016-2018). The present cohort study analyzes 10 623 participants within 151 neighborhoods, systematically selected and representative of Western Chitwan. All residents aged 15 to 59 years at MDD assessment were eligible (response rate, 93%). Data analysis was performed from May 2019 to July 2020. Georeferenced number of armed conflict-related physical beatings within 1 km of residential neighborhood. The main outcome was onset of MDD, as defined by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), during or after the conflict, stratified by children (aged <11 years) and older individuals (aged ≥11 years), assessed by the Nepal-specific World Mental Health-Composite International Diagnostic Instrument 3.0 with a life history calendar. In total, 10 623 participants (5745 female [54.08%]; 4074 [38.35%] aged <11 years at the conflict start) contributed 171 899 person-years of exposure to the risk of MDD. Two or more beatings occurred within 1 km of 15 neighborhoods (9.9%). Discrete-time survival models showed that children (but not older individuals) living in neighborhoods with 2 or more beatings had a higher likelihood of developing MDD than those who lived in a community with no beatings (odds ratio, 1.82; 95% CI, 1.17-2.84; P = .008); there was also a significant interaction between age group and neighborhood beatings (odds ratio, 1.85; 95% CI, 1.27-2.70; P = .001). A confirmatory, multivariable, multilevel matching analysis showed a neighborhood association for children (z = -2.66; P = .008), but not older individuals (z = -0.454; P = .65). The mean (SE) incidence of MDD among children living in neighborhoods with 2 or more beatings nearby was 12.69% (2.37%) vs 5.08% (1.56%) in the matched unexposed sample. The youngest individuals may be the most at risk during times of violence, with mental health consequences lasting long after conflicts have subsided and should be a priority for population-level interventions. Future research should consider other disorders, other types of violence, and elderly individuals.
Highlights
Discrete-time survival models showed that children living in neighborhoods with 2 or more beatings had a higher likelihood of developing major depressive disorder (MDD) than those who lived in a community with no beatings; there was a significant interaction between age group and neighborhood beatings
Important advances have been made in our understanding of the underpinnings of major depressive disorder (MDD) at the individual level, less is understood about wider contextual risk factors, such as those at the neighborhood level.[1]
This study found that living in a neighborhood with 2 or more beatings nearby as a young child during an armed conflict was associated with subsequent development of MDD, even after controlling for individual and neighborhood characteristics
Summary
Important advances have been made in our understanding of the underpinnings of major depressive disorder (MDD) at the individual level (eg, genes, temperament, and direct experiences of traumatic events), less is understood about wider contextual risk factors, such as those at the neighborhood level.[1] A large body of research has demonstrated that direct exposure to community violence (as either a victim or a witness) is associated with depressive symptoms and MDD,[2,3] but fewer studies have evaluated the potential risks of living in a more violent neighborhood, independently of personal exposure to violence.[4,5] Living in a neighborhood with greater levels of violence may be associated with the development of depression through Beck’s proposed triad of cognitions,[6] perceiving the world as dangerous or without meaning, the self as worthless, and the future as hopeless. A handful of studies have used objective measures, such as official government crime statistics,[5,15,16,17] and none of those is able to estimate subsequent MDD over the life course
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