Childhood abuse, encompassing various forms such as sexual, physical, emotional, and psychological abuse, is a prevalent experience with well-documented consequences for adult health. While there is a growing body of literature exploring the relationship between adverse childhood events (ACEs) and defecation problems such as fecal incontinence (FI) and constipation, research specifically investigating depressive symptoms as a mediator in this relationship remains limited. A recent study, provided valuable insights into the potential mediating role of depression symptoms in linking ACEs to somatic symptoms (1). Mechanisms proposed in existing literature include alterations in stress response systems, neurotransmitter levels, gut-brain communication pathways, and gut microbiota composition. Our aim was to describe the associations between ACEs and FI and constipation among community-dwelling men and women, and whether depressive symptoms mediated these associations.

For this study a secondary analysis was performed utilizing baseline data collected from the Coevorden observational population-based cohort study, spanning two years. Initially, 11,724 individuals were invited, of whom 694 men and 997 women provided informed consent. The primary objective of this cohort was to evaluate pelvic floor symptoms (PFS) over a 2-year follow-up period using self-administered questionnaires. Eligible participants, aged 16 years or older and residing in a Dutch municipality, were recruited through invitations from their general practitioners. Exclusion criteria included individuals with cognitive impairment (e.g., dementia), terminal illness, or those considered too unwell to participate.
Participants completed a survey including questions related to PFS, demographic characteristics, and lifestyle behaviors. Assessment of FI and constipation was conducted using the validated Wexner incontinence and constipation scale, which ranges from 0 to 20 for incontinence and 0 to 30 for constipation. Higher scores on the scale indicate a greater severity of defecation symptoms. ACEs were evaluated using a subset of questions from the NEMESIS questionnaire, specifically addressing emotional, psychological, physical, and sexual abuse experienced before the age of 16. Each item was scored on a scale from 0 (never) to 3 (regularly). A composite childhood adversity score (ranging from 0 to 12) was computed by summing the scores of the four questions, with higher scores indicating greater exposure to adverse events. The internal consistency of this score was assessed using Cronbach's Alpha, yielding a value of 0.783. Depressive symptoms were screened using the Patient Health Questionnaire (PHQ-9), with total scores ranging from 0 to 27 and higher scores indicating a greater severity of symptoms.

In total, 401 men and 525 women completed all items of the Wexner incontinence and constipation scale, PHQ-9, and childhood adversity questionnaire. Mediation analysis was performed through a series of linear regression analyses (2). Initially, FI was regressed on ACE, followed by regressing depression on ACE, and subsequently, regressing FI on both ACE and depression. Adjustments were made for covariates including age, sex, BMI, and current smoking. These steps were repeated for constipation.  
The results revealed that the total direct effect (path C) of ACE on FI was significant (p= 0.013). The coefficient of path A (B = 0.571, p<0.001) and path B (B = 0.067, p<0.001) indicated positive associations of ACE on depression, and depression on FI. Additionally, the point estimate of the indirect effect (path A * B) between ACE and FI through depression, assessed using the Sobel test was 0.208, p<0.001, indicating that depression mediated the relation between ACE and FI (3) (figure 1) in both men and women. 
For constipation, the results showed that the total direct effect (path C) of ACE on constipation was significant (p =0.001). The coefficient of path A (B = 0.571, p<0.001) and path B (B = 0.127, p<0.001) indicated positive associations of ACE on depression, and depression on constipation. The point estimate of the indirect effect (path A * B) between ACE and constipation through depression, determined using the Sobel test, was 0.073 at a p-value of <0.001. This result suggests that depression served as a mediator (3) (figure 2).

Our findings highlight the possible enduring impact of ACEs on FI and constipation during adulthood and underscore the importance of addressing early-life trauma in healthcare settings. Furthermore, our study extends previous research by investigating the mediating role of depressive symptoms in the relationship between ACEs and defecation problems. We found that depressive symptoms mediate the association between ACEs and both FI and constipation. This suggests that individuals who have experienced ACEs may be at increased risk of developing depressive symptoms, which in turn, heighten their susceptibility to gastrointestinal issues. These findings emphasize the complex interplay between mental health and gastrointestinal health and underscore the importance of addressing both aspects in clinical practice.

Our study has several implications for healthcare practice and research. First, our findings highlight the importance of early intervention and support for individuals who have experienced ACEs to decrease the risk of developing mental health problems and defecation problems later in life. Second, our results emphasize the need for integrated healthcare approaches that consider the bidirectional relationship between mental health and gastrointestinal health. Clinicians should be alert to the mental health needs of patients presenting with defecation problems, particularly those with a history of childhood abuse.

Lee RY, Oxford ML, Sonney J, Enquobahrie DA, Cato KD. The mediating role of anxiety/depression symptoms between adverse childhood experiences (ACEs) and somatic symptoms in adolescents. J Adolesc. 2022 Feb;94(2):133–47.
Collins LM, Graham JW, Flaherty BP. An alternative framework for defining mediation. Multivar Behav Res. 1998;33:295–312.
Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986 Dec;51(6):1173–82.

Continence 12S (2024) 101675
DOI: 10.1016/j.cont.2024.101675