case study on depression ppt

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Case Report

When a patient with depression is feeling sleepy, be aware of sleep apnoea, carlijn wiersema.

University Center for Psychiatry, University Medical Center Groningen, Groningen, The Netherlands

Willeke Van Zelst

Richard oude voshaar.

A 67-year-old man was referred to an outpatient clinic of geriatric psychiatry because of persistent symptoms of depression and anxiety, accompanied by sleepiness. The latter had been evaluated multiple times in the general practice over several years; each time it was considered to be a symptom of depression. After referral, the patient was diagnosed with severe obstructive sleep apnoea (OSA), comorbid to a depressive and anxiety disorder. Retrospectively, we conclude that affective symptoms accompanying OSA and sleepiness were wrongfully interpreted as depression, but after having led to problems at work, they have triggered psychiatric comorbidity. Treatment of OSA in addition to the psychiatric disorders resulted in a full recovery over time. The delayed diagnosis of OSA has certainly diminished the patient’s quality of life and might have precipitated the depressive disorder. Moreover, OSA poses patients at an increased risk of cardiovascular disease, hypertension, stroke and traffic accidents.

Obstructive sleep apnoea (OSA) is the most common sleep disorder worldwide, affecting 2%–6% of the adult population, increasing up to 15%–26% in those aged 70–100 years old. 1 OSA is characterised by repetitive complete (apnoea) and partial (hypopnoea) obstruction of the upper airway during sleep, which decreases arterial oxygen saturation. 2 Daytime functioning may be impaired due to loss of energy, depressed mood, irritability and concentration difficulties, which are core symptoms of affective disorders. Therefore, the diagnosis of OSA may easily be missed in patients with depression. Moreover, sleepiness itself is one of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria of depressive disorder and also overlaps with the criterion of fatigue or loss of energy. 1 These diagnostic complexities may delay proper diagnosis of OSA in patients with depression. The aim of this case report is to increase awareness of the possibility of OSA in patients with depression.

Case presentation

A 67-year-old man was referred to our outpatient clinic of geriatric psychiatry because of persistent affective symptoms for years. The onset of symptoms coincided with an unpleasant work situation that, after a year of sick leave, had led to demotion at 49 years of age. From that moment on, he suffered from depressed mood, anhedonia, loss of initiative, increased appetite, worrying, catastrophising, feelings of anxiety with excessive sweating, difficulties staying asleep, nightmares, increased need of sleep, loss of energy and tiredness. Symptoms fluctuated over the years but increased during autumn/winter, after life events and during vacation periods. Over the years, he had gradually withdrawn from social activities.

His general practitioner (GP) had prescribed benzodiazepine hypnotics, but without any improvement of symptoms. Six weeks prior to his referral, he was started on citalopram 20 mg one time a day, a first-line serotonergic antidepressant. He had lost 7 kg bodyweight due to nausea. This weight loss increased his physical fitness, which made him feel slightly better.

His medical history did not reveal other mental or physical symptoms.

The patient was monitored, but not treated, for mild hypertension by his GP. He had no other previous medical or psychiatric history. His family history revealed no psychiatric problems or neurodegenerative diseases like M. Parkinson, M. Alzheimer or M. Huntington. The patient did not smoke or drink alcohol. Besides citalopram, the patient used simvastatin 40 mg one time a day.

Heteroanamnestic information of his wife and son revealed a change in character since the onset of his symptoms; he became more emotional and insecure about himself. Since his retirement, he tended to lose his temper over seemingly insignificant events. His wife explained that they slept apart for years because of his snoring. She nevertheless confirmed that his breathing paused regularly during sleep. Although they consulted their GP several times for his conspicuous sleepiness, they accepted the explanation that it was an inevitable part of his depression.

At psychiatric examination, we saw a tired man with bags under his eyes and reduced facial expression. Higher cognitive functions were intact. He had a depressed mood and flat affect, but denied suicidal ideation. Evaluation of his sleep pattern revealed a rapid sleep onset, but strikingly, he never woke up well rested, regularly dozed off during the day and he was often at risk of falling asleep while driving his car.

A full physical and neurological examination was remarkable only for an overweight body mass index (28.9 kg/m 2 ) and hypertension (130/100 mm Hg). Routine blood chemistry did not reveal any abnormalities.

Investigations

In his next visits to our clinic, the patient repeatedly brought forward his work situation as being a traumatic event. This made him anxious in situations where he did not feel in control, like during his children’s holiday. He did not meet DSM-5 criteria of post-traumatic stress disorder, but he met the criteria for a depressive disorder, partly seasonal, with a superimposed generalised anxiety disorder.

The patient scored 38 points on the 30-item Inventory of Depressive Symptomatology (IDS), which is indicative of a severe depression. The scores on the Mini-Mental State Exam (MMSE) and the Cambridge Examination for Mental Disorders of the Elderly/Cambridge Cognition test (CAMDEX/CAMCOG) were not indicative of cognitive problems (MMSE: 30/30, CAMDEX/CAMCOG 90/120). Based on his wife’s information, he was additionally referred to a sleep clinic at our hospital. The score on the Epworth Sleepiness Scale was 16/24, which is indicative of excessive daytime sleepiness. Polysomnography showed 356 apnoeas in 6 hours of sleep and an Apnoea–Hypopnoea Index (AHI) of 57. The arterial oxygen saturation varied between 76% and 95%. The sleep architecture was distorted, as no slow wave sleep was present. No significant periodic leg movements or other unusual movements were observed. The patient was diagnosed with severe OSA.

Differential diagnosis

Depressive disorder.

Depressed mood, anhedonia, increased appetite, constant worrying, loss of initiative, withdrawal of social activities, sleeping problems, loss of energy, increasing symptoms during autumn/wintertime and lesser facial expression.

Anxiety disorder

Feelings of anxiety with excessive sweating, catastrophising, nightmares, withdrawal of social situations and constant worrying.

Post-traumatic stress disorder

As a result of the unpleasant work situation, social withdrawal, nightmares and feelings of anxiety with excessive sweating.

Neurodegenerative disease

Change in character, mood disruptions and temper issues.

Obstructive sleep apnoea

Severe loss of energy/tiredness, falling asleep while driving, dozing off during daytime, wake up not fully rested, snoring, breathing pauses during sleep, irritability, change of character, obesity and hypertension.

Citalopram, indicated for depressive as well as anxiety disorders, slightly improved his depressed mood and reduced anxiety symptoms over the course of 8 weeks. The patient accepted cognitive–behavioural therapy (CBT), to improve coping with his work situation and to increase his self-esteem. Four weeks after starting CBT, the patient started with continuous positive airway pressure (CPAP) at night to treat his OSA.

Outcome and follow-up

Since starting citalopram, the patient experienced a small improvement of his affective symptoms. With CBT, his self-image became more positive. Over the course of 3 months, prior to the start of CPAP, his affective symptoms further improved, without any effect on his sleep (related) problems and fatigue. After four nights of CPAP treatment, the patient felt more energetic and started rebuilding his life. Full recovery was achieved after 4 months of treatment. His IDS score decreased from 38 to 8 (no depression present).

Although (hetero)anamnestic information may point to OSA, assessing the AHI by polysomnography is the gold standard for proper diagnosis. The AHI is the number of apnoeas or hypopnoeas recorded per hour of sleep. An AHI of 5–14 per hour indicates a mild, 15–30 a moderate and ≥30 a severe OSA. Hypopnoeas and apnoeas interrupt deep sleep and Rapid Eye Movement (REM) sleep and cause a fragmented sleeping pattern. 2  Patients wake up feeling unrefreshed and they stay tired during the day. Night-time symptoms include snoring, breathing pauses, a feeling of choking, excessive salivation, excessive sweating, gastro-oesophageal reflux, nocturia, waking up with a dry mouth and/or a headache. 1 3 During the day, the patient experiences excessive sleepiness, loss of energy, irritability, 4 withdrawal of social activities, difficulties with concentrating, 5 cognitive dysfunction, 6 7 loss of interest in daily activities, 8 temper issues, 5 psychomotor changes 4–8 and anxiousness and depressed mood. 9 These symptoms bear a striking resemblance to symptoms of depression. 3 10 11 Indeed, up to 63% of patients with OSA report depressive symptoms. 9 11 12 Most sleep clinics therefore regularly evaluate depressive symptoms of their patients with screening questionnaires. 3 The similarity in phenotypic expression of OSA and depressive disorders might be enough to misdiagnose sleep apnoea for a depressive disorder and wrongfully start antidepressant treatment. 13 14 In our case, the affective symptoms accompanying OSA have been wrongfully attributed to a depression by his GP and even temporarily treated with benzodiazepines. When his work problems due to OSA triggered a full-blown depressive disorder, he was referred for specialised mental healthcare.

Of particular interest for this case is that depressive disorders and sleep disorders co-occur more often than can be expected by chance. 15 16 This association is considered to be bidirectional as depression can evoke sleep disturbances and vice versa. Overall, 90% of patients with depression experience sleep disturbances. Also, sleep apnoea is found more often in patients primarily diagnosed with depressive disorders compared with the general population. 3 4 17–22 Because sleep disturbances are common in mood disorders, further examination is rarely employed. 3 17 Several authors have advocated screening for OSA in psychiatric patients, as this will hasten appropriate diagnosis. 5 17 19 22–26 Treatment of OSA will alleviate hypopnoeas and apnoeas and may improve affective symptoms. 18 23 27–32 Especially in patients with therapy-resistant depression and/or patients with risk factors for OSA like male sex, obesity and older age, OSA must be considered. 17 19 23 Our patient noticed some improvement after starting on citalopram, losing 7 kg of bodyweight and starting CBT, but the most significant improvement was following start of CPAP therapy.

Aside from improving psychiatric symptoms, the treatment of OSA offers other health benefits by reducing the risk of cardiovascular disease 33–35 and neurological damage. 36 37 The hypertension our patient presented with might be related to his OSA. Untreated OSA is associated with a twofold to threefold increased risk of traffic accidents because of daytime sleepiness. 38 39 Our patient also described almost falling asleep while driving his car. Ascribing symptoms of OSA to a psychiatric disorder may result in inappropriate prescriptions of benzodiazepines, as was the case in our patient. Whereas benzodiazepines are regularly used for treatment of anxiety and sleep(related) problems, benzodiazepines worsen hypopnoeas and apnoeas, 24 which can be life threatening for a patient with OSA. Apart from depression, our patient also suffered from an anxiety disorder. For this patient, it is quite possible that the anxiety was exacerbated by the OSA, as anxiety disorders are also associated with OSA. 30 40 Moreover, daytime tiredness and anxiety are positively correlated in patients with OSA. 41 CPAP treatment also has a positive effect on anxiety, 32 as our patient experienced.

With this case report, we underline the importance of diagnosing and treating OSA in patients with a depressive disorder, even when the depression is preceded by psychosocial stressors. As illustrated by our patient, proper diagnostics may improve quality of life and prevent misdiagnosing affective symptoms as a treatment-resistant depression.

Patient’s perspective

“The whole thing has actually been a positive experience for me, the discovery of the sleep apnoea has changed my life for the better. In hindsight I already had sleep problems and loss of energy for years, before the start of my depressive symptoms. I did not want to complain so I tried to live with it. I am very happy the doctors discovered my sleep apnoea, although it wasn’t what I expected when my general practitioner referred me to the psychiatric clinic! The medication and CBT really helped me, but the CPAP completed it. I am well now. I have my moments of feeling a little bit low, but that’s only around the fall/wintertime and is always of short duration. I think that’s just part of who I am. It has been never as bad as at that time. I realise how important it is to be healthy; the impact of the sleep apnoea, my depression and anxiety has been immense. But now I have my life back. I hope that physicians will learn from my case and will think of sleep apnoea as a cause of depression at an earlier stage.”

Learning points

• The similarity between daytime symptoms of obstructive sleep apnoea and depressive disorders presents a diagnostic challenge.
• It is important to be vigilant regarding symptoms of excessive daytime sleepiness and risk factors of obstructive sleep apnoea in patients with depressive disorder.
• Good history taking of snoring, breathing pauses during sleep, waking up unrefreshed (sometimes with dry mouth and headaches) as well as a thorough physical examination (obesity, hypertension and crowded oropharynx) can point in the direction of obstructive sleep apnoea.
• Treatment of obstructive sleep apnoea should complement psychiatric or psychological treatment of depression to optimise quality of life, as well as physical health.

Contributors: The manuscript was written by CW and supervised by WVZ and ROV.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Medical Depression Case Report

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There's still some reticence to speak about mental health, despite the fact that there's more people with depression than ever, and statistics don't look very promising either. Depression is a complex and pervasive condition that can deeply impact one's emotional well-being, relationships, and overall quality of life. There are a lot of misconcepts and counter-productive measures, so what we really need is information and awareness. As for you, you can help other professionals by sharing a case report. Explain how you fared, how you diagnosed depression and what you did to treat the patient. It doesn't look like much, but every single bit helps, and this editable template can be your way of showing all the information in an organized way.

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• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

This guideline has been stood down. All of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
• Depression in adults with a chronic physical health problem
• Depression in children and young people
• Generalised anxiety disorder and panic disorder in adults
• Obsessive-compulsive disorder and body dysmorphic disorder
• Social anxiety disorder

Case Presentation: A 23-Year-Old With Bipolar Disorder

Gus Alva, MD, DFAPA, presents the case of a 23-year-old female diagnosed with bipolar 1 disorder.

EP: 1 . Case Presentation: A 23-Year-Old With Bipolar Disorder

Ep: 2 . clinical impressions from the patient case, ep: 3 . clinical insights regarding the management of bipolar disorder.

Gus Alva, MD, DFAPA: Psychiatric Times presents this roundtable on the management of bipolar disorder, a phenomenal dialogue allowing clinicals a perspective regarding current trends and where we may be headed in the future.

This is an interesting case, as we take a look at this 23-year-old female who first comes in to see her psychiatrist with moderate depressive symptoms. At the time of the interview, her chief complaint included feeling like she’s lacking energy, she’s feeling depressed. She’s also reporting difficulty in paying attention, organizing her day, and accomplishing her tasks at work. Notably these symptoms started abruptly. Three weeks early, prior to that, she had been functioning better than usual, requiring very little sleep and getting more accomplished. Of significance, she reported two brief episodes of depression over the past 2 years. Each lasting about 2 months. And although the patient reported these depressive episodes as coming out of the blue, she learned after consulting with her therapist that they were related to significant psychosocial stress, stemming from the loss of her job and the deaths of 2 uncles, both of which were related to the COVID-19 pandemic. The patient reported that she still finds enjoyment talking to friends and socializing and she has hope of finding a new job and she’s constantly looking.

It’s noteworthy to bear in mind that in her first depressive episode she was treated with methylphenidate 25mg titrated up to 50 m and she stated feeling improved on this does with psychotherapy. Her second depressive episode, her does was bumped up to 100 mg which we saw improvement in depression, but she noted she felt a little activated and had trouble sleeping. With her third depressive episode, the therapist and PCP referred the patient over to a psychiatrist. Of great note should be her past psychological history: she was diagnosed with ADHD in middle school, during which time she responded well to methylphenidate. She continued to do well until her college years at which time she began experiencing difficulty falling asleep as well as irritability. At that time, she discontinued methylphenidate and was psychiatric drug free. She found that practicing mindfulness and yoga on a daily basis helped her residual ADHD symptoms. Of note, she had no history of suicidal thoughts or behavior, self-injurious behaviors, psychiatric hospitalization, or problems with substance abuse. Of note, regarding medical comorbidities, she was diagnosed a year earlier with type 2 diabetes, which was managed with metformin 1000 mg twice daily and her hemoglobin A1C was not poorly controlled. She was also diagnosed with high blood pressure 2 years earlier, that is managed by lisinopril 20 mg once daily. We noted that her BMI is 31, which is indicative of obesity. All other lab values were within normal limit. Significantly, her TSH was in the normal range and her urine toxicology screening was negative. Upon further querying of her family history, her maternal grandmother was diagnosed with a nervous breakdown and spent 2 months in a psychiatric hospital in her 30s. Her mother required little sleep, had a history of impulsive spending, and had a history of starting projects that she didn’t finish. The patient’s paternal uncles had a history of depression as well as alcohol abuse. Upon doing assessments, her PHQ9 is indicative of 18 points and her mood questionnaire she scored an 8.

Transcript Edited for Clarity

The Week in Review: May 6-10

Blue Light Blockers: A Behavior Therapy for Mania

Suicide and Other Deaths From Unnatural Causes in Bipolar Disorder

Blue Light, Depression, and Bipolar Disorder

FDA Approves Fanapt for Mixed, Manic Episodes Associated With Bipolar I Disorder

An Update on Bipolar I Disorder

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Pathophysiology Description

In a normal brain, the brain cells communicate with each other using chemicals, called neurotransmitters. These signals can cause emotions, can cause physical movement, and they help us perceive what is going on around us. In a person who is not affected by depression, there are enough neurotransmitters to ensure a stable mood and emotional state. Specifically, serotonin, dopamine and norepinephrine are able to be synthesized, released and degraded in the proper amounts. Someone who does not suffer from mood disorder has a mood that is stable over an extended period of time. Depression is described further here:

Depression is a heterogeneous disease process that mainly stems from neurotransmitter abnormalities. But, pathology may be more strongly influenced by genetics than previously thought, up to 40%. Environmental effects are accountable for the remaining susceptibility (Hasler,2010). These adverse effects are most influential when they occur in childhood, and when they are prolonged stressors such as being out of a job for months.

Depression is considered a stress disorder, but suprisingly most patients do not have HPA axis abnormalities.

Monoamines are neurotransmitters involved in regulation of mood, attention, reward processing, sleep, appetite, and cognition (Hasler, 2010). A deficiency in monoamine neurotransmitters is the main suspected pathophysiologic cause of MDD. In drug trials, monoamine reuptake inhibitors have been shown to improve depression in individuals. Thus the link between these neurotransmitters, including serotonin, and the cause of depression is strong.

Diagnostic criteria must include at least 5 of 9 features, but must include either #1 or #2, for two or more consecutive weeks. *1. Depressed mood or irritable *2. Decreased interest or pleasure in activities 3. Significant weight change (5%) or change in appetite 4. Change in sleep 5. Change in activity level of the brain; retardation or agitation 6. Fatigue 7. Feelings of guilt or worthlessness 8. Difficulty concentrating 9. Suicidal Ideation

IRIS MABRY-HERNANDEZ, MD, MPH, Medical Officer, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality

SUSAN J. CHING, DO, Preventive Medicine Resident, Uniformed Services University of the Health Sciences

Am Fam Physician. 2024;109(5):457-458

Related editorial:   Anxiety Screening Is Unlikely to Improve Mental Health Outcomes

Related USPSTF Clinical Summary:   Screening for Anxiety Disorders in Adults

Author disclosure: No relevant financial relationships.

A 34-year-old patient (gravida 2, para 2) presents for a well-woman examination and Papanicolaou smear. She feels healthy and has no significant medical history, aside from her uncomplicated pregnancies, which did not include postpartum depression or anxiety. She reports increased stress at home due to an upcoming move and some difficulty sleeping.

Case Study Questions

1 . According to the U.S. Preventive Services Task Force (USPSTF) recommendation, which one of the following is advised for this patient?

A. Screen for anxiety disorder.

B. Assess her anxiety in 6 months.

C. Refer her to an obstetrician-gynecologist for postpartum anxiety screening.

D. Recommend melatonin.

E. Refer her to a behavioral health professional for sleep management.

2 . According to the Diagnostic and Statistical Manual of Mental Disorders , 5th ed. (DSM-5), which of the following can be categorized as anxiety disorders?

A. Generalized anxiety disorder.

B. Obsessive-compulsive disorder.

C. Separation anxiety disorder.

D. Social anxiety disorder.

3 . Which one of the following populations should be screened for anxiety disorders, according to the USPSTF recommendation?

A. People already diagnosed with anxiety or another mental health disorder.

B. People younger than 18 years.

C. People older than 65 years.

D. People with no recognized signs or symptoms of anxiety disorders.

The correct answer is A . The USPSTF recommends screening all adults 19 to 64 years of age for anxiety disorder, including those who are pregnant and postpartum. The USPSTF notes there is little evidence for the ideal timing and frequency of anxiety screening for perinatal and general adult populations. 1 However, clinical judgment, particularly considering risk factors, comorbid conditions, and life events, can determine whether additional screening of high-risk patients is warranted. There is a lack of evidence on screening rates for anxiety disorders. Underdetection appears to be common. Patients with anxiety disorders may present with other concerns, such as sleep disturbances or somatic issues.

The correct answers are A, C, and D . The DSM-5 recognizes the following types of anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance or medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified. 2 Obsessive-compulsive disorder is not considered an anxiety disorder.

The correct answer is D . The USPSTF recommendation statement applies to adults (defined as those 19 to 64 years of age), including people who are pregnant or postpartum, who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders. 2 For people 65 years or older, the USPSTF concludes that the evidence is insufficient to recommend for or against screening for anxiety disorders.

The views expressed in this work are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. government.

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statement and supporting documents on the USPSTF website ( https://www.uspreventiveservicestaskforce.org ). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening .

O’Connor EA, Henninger ML, Perdue LA, et al. Anxiety screening: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2023;329(24):2171-2184.

Barry MJ, Nicholson WK, Silverstein M, et al. Screening for anxiety disorders in adults: US Preventive Services Task Force recommendation statement. JAMA. 2023;329(24):2163-2170.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of Putting Prevention Into Practice published in AFP is available at https://www.aafp.org/afp/ppip.

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Up to 40pc of mental health conditions are linked to child abuse and neglect, study finds

In 1996, Ange McAuley was just 11 years old when ABC's Four Corners profiled her family living on Brisbane's outskirts.

At the time her mother was pregnant with her sixth child and her father had long ago moved back to Perth.

WARNING: This story contains details that may be distressing to some readers.

It was a story about child protection and the program was profiling the role of community volunteers helping her mother, who had been in and out of mental health wards.

Ange was the eldest and it fell to her to get her younger siblings ready for school.

By the time the new baby arrived, she would stay home and change nappies.

"It was pretty crazy back then — I wasn't going to school a lot," she said.

By that age she was already holding a secret — she'd been sexually abused at age six by her stepfather, who would later be convicted of the crime.

"Back in the nineties, a lot of people kept stuff hidden and it wasn't spoken about outside of the family," she said.

"I've carried all these big burdens that weren't even mine. Sexual abuse happened to me. I didn't ask for it."

She says the trauma triggered a lifetime of mental health problems from substance abuse and self-harm as a teen, right through to post-natal depression.

Hidden source of our mental health crisis

A new study from the University of Sydney's Matilda Centre has established just how much Australia's mental health crisis can be traced back to this kind of childhood abuse and neglect.

The research has found that childhood maltreatment is responsible for up to 41 per cent of common mental health conditions including anxiety, depression, substance abuse, self-harm and suicide attempts.

The research, which draws on a 2023 meta-analysis of 34 research studies covering 54,000 people, found maltreatment accounted for 41 per cent of suicide attempts in Australia, 35 per cent of self-harm cases and 21 per cent of depression episodes.

It defined childhood maltreatment as physical, sexual, emotional abuse, emotional or physical neglect and domestic violence before the age of 18.

Lead researcher Lucy Grummitt said it is the first piece of work to quantify the direct impact of child abuse on long-term mental health. 

It found if childhood maltreatment was eradicated it would avert more than 1.8 million cases of depression, anxiety and substance use disorders.

"It shows just how many people in Australia are suffering from mental health conditions that are potentially preventable," she said.

Dr Grummitt said they found in the year 2023 child maltreatment in Australia accounted for 66,143 years of life lost and 118,493 years lived with disability because of the associated mental health conditions.

"We know that when a child is exposed to this level of stress or trauma, it does trigger a lot of changes in the brain and body," Dr Grummitt said.

"Things like altering the body's stress response will make a child hyper-vigilant to threat. It can lead to difficulties with emotion regulation, being able to cope with difficult emotions."

While some areas of maltreatment are trending down, figures from the landmark Australian child maltreatment study last year show rising rates of sexual abuse by adolescents and emotional abuse.

That study found more than one in three females and one in seven males aged 16 to 24 had experienced childhood sexual abuse.

Dr Grummit says childhood trauma can affect how the brain processes emotions once children become teens.

"It could be teenagers struggling to really cope with difficult emotions and certainly trauma can play a huge role in causing those difficult emotions," she said.

Mental health scars emerge early

For Ange, the trauma of her early years first showed itself in adolescence when she started acting out — she remembers punching walls and cars, binge drinking and using drugs.

"I would get angry and just scream," she said.

"I used to talk back to the teachers. I didn't finish school. Mum kicked me out a lot as a teenager. I was back and forth between mum and dad's."

By the time she disclosed her abuse, she was self-harming and at one point tried to take her own life.

"I was just done," she said.

"I was sick of having to get up every day. I didn't want to do it anymore."

Later on, she would have inappropriate relationships with much older men and suffered from depression, including post-natal depression.

"It's definitely affected relationships, it's affected my friendships, it's affected my intimate relationships," she said.

"Flashbacks can come in at the most inappropriate times — you're back in that moment and you feel guilt and shame.

"I feel like it's held me back a lot."

Calls for mental health 'immunisation'

Dr Grummitt said childhood abuse and neglect should be treated as a national public health priority.

In Australia, suicide is the leading cause of death for young people. 

"It's critical that we are investing in prevention rather than putting all our investments into treatment of mental health problems," she said.

Her team has suggested child development and mental health check-ins become a regular feature across a person's lifetime and have proposed a mental health "immunisation schedule".

Chief executive of mental health charity Prevention United, Stephen Carbone, said they estimate that less than 1 per cent of mental health funding goes toward prevention.

"There's been a big steady increase in per capita funding for mental health over the last 30 years but that hasn't translated into reductions," Dr Carbone, a GP, said. 

"You're not going to be able to prevent mental health conditions unless you start to tackle some of these big causes, in particular child maltreatment."

He said most of Australia's child protection system was about reacting to problems rather than trying to prevent them.

"If you're not tackling the upstream risk factors or putting in place protective factors you just keep getting more and more young people experiencing problems and services being overwhelmed," he said.

Now a mother of two teens herself, Ange says she wants to break the cycle and has been going to therapy regularly to help identify and avoid destructive patterns that she's seen herself fall into.

"I love my girls so much and I want better for them."

• X (formerly Twitter)

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• Child Abuse
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