Journal of Affective Disorders 331 (2023) 167–174

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Journal of Affective Disorders

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

Research paper

Mediating role of personality traits in the association between

multi-dimensional adverse childhood experiences and depressive symptoms
among older adults: A 9-year prospective cohort study
Yanzhi Li a, b, 1, Lu Cheng c, 1, Lan Guo a, b, Liwan Zhu a, b, Hao Zhao a, b, Caiyun Zhang a, b,
Manjun Shen c, Yifeng Liu c, Muhammad Youshay Jawad d, e, Lingjiang Li f, Wanxin Wang a, b, *,
Ciyong Lu a, b, Roger S. McIntyre d, e, g, h
a
Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
b
Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
c
Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
d
Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
e
Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
f
Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China
g
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
h
Brain and Cognition Discovery Foundation, Toronto, ON, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Background: To explore the mediating role of personality traits in the correlation between multi-dimensional
Depressive symptoms adverse childhood experiences (ACEs) and depressive symptoms in older adults.
Adverse childhood experiences Methods: This cohort study used data from the English Longitudinal Study of Ageing, and included 4050 older
Personality traits
adults without depressive symptoms in 2010–2011. Multi-dimensional ACEs were evaluated in 2006–2007.
Mediation
Older adults
Personality traits were assessed using the Midlife Development Inventory in 2010–2011. Depressive symptoms
were measured using the 8-item version of the Center for Epidemiologic Studies Depression Scale during
2012–2019. Cox proportional hazard model was used to explore the associations between ACEs and depressive
symptoms. The package named “mediation” in R was used to test mediating role of personality traits.
Results: ACEs in each dimension significantly increased the risk of depressive symptoms (all P-values < 0.05). The
association of maltreatment (18.18 %) and household dysfunction (19.69 %) with depressive symptoms was
significantly mediated by neuroticism. The correlation between poor parent-child bonding and depressive
symptoms was significantly mediated by neuroticism (19.43 %), conscientiousness (4.84 %), and extroversion
(8.02 %).
Limitations: ACEs were retrospectively assessed based on participants' memories, which may induce recall bias.
Conclusions: Maltreatment and household dysfunction may induce depressive symptoms by increasing neuroti­
cism. Poor parent-child bonding may induce depressive symptoms by increasing neuroticism and reducing
conscientiousness and extraversion. In addition to reducing the occurrence of ACEs, reducing neuroticism of
individuals with maltreatment and household dysfunction in childhood, and reducing neuroticism, and
increasing conscientiousness and extraversion of individuals with poor parent-child bonding in childhood might
help to decrease their risk of depressive symptoms.

Abbreviations: ACEs, Adverse childhood experiences; ELSA, English Longitudinal Study of Ageing; CES-D, Epidemiologic Studies Depression Scale; HR, Hazard
ratio; CI, Confidence interval.
* Corresponding author at: Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Rd 2,
Guangzhou 510080, China.
E-mail address: wangwx65@mail.sysu.edu.cn (W. Wang).
1
Yanzhi Li and Lu Cheng contributed equally to this work.

https://doi.org/10.1016/j.jad.2023.03.067
Received 26 October 2022; Received in revised form 17 March 2023; Accepted 20 March 2023
Available online 22 March 2023
0165-0327/© 2023 Elsevier B.V. All rights reserved.
Y. Li et al.
Fig. 1. The timeline and procedures of this study.
Abbreviations: ACEs, adverse childhood experiences.
1. Introduction
Depression is a serious and debilitating mental disorder affecting
approximately 256 million adults globally, with a prevalence of 5.02 %
(Institute of Health Metrics and Evaluation, 2021). Depression is asso­
ciated with considerable morbidity and mortality (Cuijpers et al., 2014),
and leads to high economic costs (JamaBloom et al., 2011). Addition­
ally, the World Health Organization has ranked depression as the third
cause of burden of disease worldwide, and has predicted that depression
will rank first by 2030 (World Health Organization, 2008). Thus, it is of
great significance to clarify the potential risk factors and relevant
mechanisms of depression. At present, compelling evidence has
confirmed that adverse childhood experiences (ACEs) increase the risk
of depressive symptoms in adulthood (Iob et al., 2020a; Kim et al., 2022;
Yazawa et al., 2022). Overall, individuals with at least one ACE have a
>2-fold increased risk of developing depression in adulthood (Li et al.,
2016). Nevertheless, the underlying mechanisms by which ACEs induce
depressive symptoms in adulthood have not been fully elucidated.
Personality traits (i.e., neuroticism, conscientiousness, extraversion,
openness, and agreeableness) are usually formed in childhood under the
influence of various social and environmental factors (Clark and Wat­
son, 2008; Shiner, 2006), and continue to develop throughout adult­
hood, albeit at a slow rate (Damian et al., 2019). Several studies have
reported that individuals with ACEs are more likely to develop unfa­
vorable personality traits, increasing their likelihood of depressive
symptoms in turn (Dagnino et al., 2020; Hovens et al., 2016; Lee and
Song, 2017; Okubo et al., 2017; Spinhoven et al., 2016; Zhang et al.,
2018). However, the results on the mediating effects of specific per­
sonality traits on the association between ACEs and depressive symp­
toms are inconsistent. For example, Lee et al. found that only
neuroticism could mediate the effects of ACEs on depressive symptoms
(Lee and Song, 2017). In contrast, Zhang et al. uncovered that
168
Journal of Affective Disorders 331 (2023) 167–174
extraversion could also mediate the correlation between ACEs and
depressive symptoms in addition to neuroticism (Zhang et al., 2018).
Furthermore, the samples of previous longitudinal studies were from
patients with depressive or anxiety disorders (Hovens et al., 2016;
Spinhoven et al., 2016), which might reduce the generalizability of the
results due to selection bias. Studies in non-clinical adults were limited
to the cross-sectional design (Lee and Song, 2017), so they could not
determine the temporality between personality traits and depressive
symptoms. Although it is reasonable to assume that personality traits
precede depressive symptoms in adulthood given that personality traits
usually form early in life and remain generally stable throughout life
(Clark and Watson, 2008), this does not mean that personality traits
cannot change a bit in adulthood (Damian et al., 2019; Roberts et al.,
2008). Another limitation is that ACEs in previous studies only included
abuse (emotional, physical, and sexual) and neglect (emotional and
physical) (Dagnino et al., 2020; Hovens et al., 2016; Lee and Song, 2017;
Okubo et al., 2017; Spinhoven et al., 2016; Zhang et al., 2018). Recent
studies have incorporated additional adversities to represent other
important dimensions of ACEs, such as household dysfunction, loss ex­
periences, and poor parent-child bonding (Iob et al., 2020a, 2020b). It is
uncertain whether ACEs in other dimensions can increase the risk of
depressive symptoms via unfavorable personality traits.
Therefore, this study aimed to use a 9-year nationally representative
cohort study to explore the mediating role of personality traits in the
association between multi-dimensional ACEs (i.e., maltreatment,
household dysfunction, poor parent-child bonding, and loss experi­
ences) and depressive symptoms in non-clinical older adults. This study
might clarify some mechanisms by which ACEs induce depressive
symptoms, and provide a theoretical basis for effectively preventing and
improving depressive symptoms.
Y. Li et al. Journal of Affective Disorders 331 (2023) 167–174

Table 1 scored in reverse. The total scores were calculated separately for each
Different types of adverse childhood experiences before the age of 16 in the Life parental-child bonding, ranging from 0 to 7. Higher scores indicate
History Interview in wave 3 (2006–2007). poorer father/mother-child bonding. According to the previous studies
Dimensions Adverse childhood experiences Exposure (Iob et al., 2020a, 2020b), individuals with the total scores ≥ 3 were
rates (%) considered to have poor father/mother-child bonding. ACEs were
Maltreatment 7.26 divided into four dimensions: maltreatment, household dysfunction,
Serious physical attack or assault 3.84 poor parent-child bonding, and loss experiences, which has been
Sexual assault (including rape or 1.34 confirmed by factor analysis and been widely used in previous studies
harassment)
(Iob et al., 2020a, 2020b). In each dimension, individuals with at least
Physical abuse from parents 3.25
Household 24.43 one ACE were considered to have ACEs (Iob et al., 2020a, 2020b). In
dysfunction Parents drank excessively, took drugs, or 6.08 addition, this study generated a dichotomy indicator of whether ACEs
had mental health problems had been experienced (any ACEs vs. no ACEs).
Parents argued or fought very often 19.70
Parents permanently separated or 6.98
divorced
2.3. Assessment of depressive symptoms
Poor parent-child 24.41
bonding Poor father-child bonding 16.16 In waves 6–9, depressive symptoms were assessed using the 8-item
Poor mother-child bonding 15.84 version of the Center for Epidemiologic Studies Depression Scale (CES-
Loss experiences 19.28
D) (Radloff, 1977). The scale has good internal consistency in each wave
Parent death 6.38
Separation from mother for more than 15.50 (Cronbach α ≥ 0.95) (Di Gessa and Price, 2022). Participants responded
six months whether they felt depressed, felt that everything was an effort, slept
Foster care or adoption 1.31 restlessly, were happy, felt lonely, enjoyed life, felt sad, and could not
Living in a children's home 1.73 get going in the past week. Each item was rated as 0 (yes) or 1 (no), and
Adverse childhood 49.51
experiences
two items (i.e., “were happy” and “enjoyed life”) were scored in reverse.
The total scores range from 0 to 8, with higher scores suggesting greater
severity of depressive symptoms. A cut-off value of ≥4 was adopted to
2. Methods indicate significant depressive symptoms (Zaninotto et al., 2022), which
is equivalent to the conventional cut-off value of ≥16 on the full 20-item
2.1. Study design and participants CES-D scale (Steffick, 2000).

This study used data from the English Longitudinal Study of Ageing
(ELSA) (www.elsa-project.ac.uk), which has been reported previously in
detail (Steptoe et al., 2013). Briefly, the ELSA is an ongoing, prospective,
and nationally representative cohort of community-dwelling adults ≥
50 years in the UK. This sample represents the general population of
older adults in the UK, and was not selected based on exposure to ACEs
or the presence of depressive symptoms (Iob et al., 2020a). The ELSA
was initiated in 2002–2003 (wave 1). Participants were biennially fol­
lowed up until 2018–2019 (wave 9). The ELSA datasets can be down­
loaded from the UK Data Service (https://ukdataservice.ac.uk/). Ethical
approval for ELSA was obtained from the London Multicenter Research
Ethics Committee (MREC/01/2/91). All participants provided informed
consent.
Data on ACEs were collected during the Life History Interview in
wave 3 (2006–2007). Data on personality traits were collected in wave 5
(2010–2011). Thus, wave 5 was used as the baseline for this prospective
cohort study, and new-onset depressive symptoms were assessed from
wave 6 (2012–2013) to wave 9 (2018–2019). Fig. 1 shows the timeline
and procedures. This study merged data on the Life History Interview in
wave 3 (7855 participants) and data in wave 5 (10,274 participants). A
total of 6446 individuals participated in the two surveys. The following
participants were excluded: those younger than 50 years at baseline (n
= 91), those with missing data on ACEs (n = 845), personality traits (n
= 471) or depressive symptoms (n = 26) at baseline, those with
depressive symptoms (n = 650) at baseline, and those lost to follow-up
(n = 313). Ultimately, this study included 4050 participants. Supple­
mentary Fig. S1 presents the inclusion process of participants.
2.2. Assessment of ACEs
As shown in Table 1, different types of ACEs before the age of 16
were investigated during the Life History Interview in wave 3. Except for
father-child bonding and mother-child bonding, participants responded
whether they had experienced the events in Table 1. Father-child
bonding and mother-child bonding were evaluated using the 7-item
Parental Bonding Instrument (Parker et al., 1979). All responses were
divided into “agree (=1)” and “disagree (=0)”, and positive items were
2.4. Assessment of personality traits
In wave 5, personality traits were assessed using the Midlife Devel­
opment Inventory. Personality traits included neuroticism, conscien­
tiousness, extraversion, openness, and agreeableness, assessed by four
items (i.e., “worrying”, “nervous”, “moody”, and “calm”), five items (i.
e., “responsible”, “hardworking”, “thorough”, “organized”, and “care­
less”), five items (i.e., “outgoing”, “lively”, “friendly”, “active”, and
“talkative”), seven items (i.e., “intelligent”, “creative”, “imaginative”,
“broad-minded”, “sophisticated”, “curious”, and “adventurous”), and
five items (i.e., “warm”, “helpful”, “softhearted”, “caring”, and “sym­
pathetic”), respectively (Lachman and Weaver, 1997). Participants used
a Likert scale (1 = not at all; 4 = a lot) to rate how much each adjective
described themselves. Some items were reversely scored when neces­
sary. The average value of each subscale was regarded as the score for
each personality trait. Higher scores represent higher levels of person­
ality traits (Strickhouser and Sutin, 2021). Cronbach α ranged from 0.67
to 0.80, suggesting at least adequate internal consistency (Gale et al.,
2015).
2.5. Assessment of potential covariates
Potential covariates included age (continuous), sex (male and fe­
male), race (White race and others), childhood socioeconomic status,
education level, marital status (married, divorced/separated/widowed,
and never married), adult wealth, employment status (retired,
employed, and unemployed), smoking status (never, former, and current
smokers), drinking status, and physical activity. All potential covariates
were assessed in wave 5 (baseline) except for childhood socioeconomic
position. During the Life History Interview in wave 3, information on
childhood socioeconomic status was collected, including overcrowding
(1 = number of people/number of bedrooms > 2; 0 = number of people/
number of bedrooms ≤ 2), number of books in the home (1 = 0–10
books; 0 = >10 books), father's occupation (1 = manual; 0 = other),
financial hardship (1 = yes; 0 = no), and father unemployment for >6
months (1 = yes; 0 = no). The total scores of the above items were
calculated to represent childhood socioeconomic status. Higher scores

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Y. Li et al. Journal of Affective Disorders 331 (2023) 167–174

suggest lower childhood socioeconomic status (Iob et al., 2020a, Table 2

2020b). Education level was classified into three groups: university Baseline characteristics by exposure status of ACEs (wave 5, 2010–2011).
degree or equivalent, advanced level (A-level)/higher education below Characteristics Overall (n No ACEs Any ACEs P-value
degree, and no qualifications/ordinary level (O-level) or equivalent = 4050) (n = 2045) (n = 2005)
(Ronaldson et al., 2022). O-level is the first half part of the General Age (years), mean (SD) 67.34 67.28 67.40 0.670
Certificate of Education (GCE). O-level is usually taken up either in the (8.98) (9.03) (8.93)
11th year or between the age group of 14–16. It is the final certification Female, n (%) 2249 1069 1180 <0.001
for secondary school and once a student has completed it, they are (55.53) (52.27) (58.85)
White race, n (%) 3985 2016 1969 0.339
considered to have completed formal education. A-level is the second (98.40) (98.58) (98.20)
part of the GCE. Students between the ages of 16–18 or the 12th or 13th Education level, n (%) 0.175
year of schooling take up this programme. It is a two-year course and is University degree or 1415 738 677 (33.77)
considered as a standard assessment of students in order to determine equivalent (34.94) (36.09)
A-level/higher 325 (8.02) 170 (8.31) 155 (7.73)
their candidacy for college and university applications. Adult wealth
education below degree
was derived from a comprehensive assessment of the economic re­ No qualifications/O- 2310 1137 1173
sources (e.g., financial, housing, and physical wealth) excluding pension level or equivalent (57.04) (55.60) (58.50)
wealth, and was categorized into quintiles (1 = poorest; 5 = richest) Marital status, n (%) 0.008
(Steptoe and Di Gessa, 2021). According to the frequency of drinking in Married 2925 1520 1405
(72.22) (74.33) (70.07)
the past 12 months, drinking status was categorized into three groups: Divorced/separated/ 928 438 490 (24.44)
less than weekly, 1–4 days a week, and 5–7 days a week (Iob et al., widowed (22.02) (21.42)
2020a). Physical activity was assessed by the frequency of participation Never married 173 (4.66) 87 (4.45) 110 (5.49)
in vigorous, moderate, and light physical activities, and was categorized Employment status, n (%) 0.290
Retired 2485 1243 1242
into three groups: vigorous (vigorous activity on a weekly basis), mod­
(61.36) (60.78) (61.95)
erate (moderate activity on a weekly basis), and light (no vigorous or Employed 1213 633 580 (28.93)
moderate activity on a weekly basis) (Iob et al., 2020b). (22.91) (30.95)
Unemployed 197 (4.86) 169 (8.26) 183 (9.13)
Wealth quintiles, n (%)
1 (poorest) 462 187 (9.14) 275 (13.72) <0.001
2.6. Statistical analyses (11.41)
2 677 331 346 (17.26)
The baseline characteristics of participants were presented as mean (16.72) (16.19)
(standard deviation) or number (percentage), as appropriate. Student's t- 3 778 384 394 (19.65)
(19.21) (18.78)
tests were used to compare the mean levels of continuous variables
4 847 442 405 (20.20)
between participants with and without ACEs. Pearson chi-squared tests (20.91) (21.61)
were performed to compare the distribution of categorical variables. 5 (richest) 1286 701 585 (29.18)
Cox proportional hazard model was used to estimate the hazard ratio (31.75) (34.28)
(HR) and 95 % confidence interval (CI) to explore the associations be­ Smoking status, n (%) 0.003
Never smokers 399 (9.85) 185 (9.05) 214 (10.67)
tween ACEs and depressive symptoms. Person-years were measured in Former smokers 2071 1011 1060
months, from the date of interview in wave 5 to the date of new-onset (51.14) (49.44) (52.87)
depressive symptoms, loss to follow-up, or end of follow-up, which­ Current smokers 1580 849 731 (36.46)
ever came first. The proportional hazards assumption was examined by (39.01) (41.52)
Drinking status, n (%)
Schoenfeld tests. No violation of the assumption was identified. To
<0.001
Less than weekly 1509 700 809 (40.35)
assess the effects of potential covariates on the association of ACEs with (37.26) (34.23)
depressive symptoms, we incorporated potential covariates into the 1–4 days a week 1629 875 754 (37.61)
models in turn. Model 1 was unadjusted for any potential covariates. (40.22) (42.79)
Model 2 was adjusted for age, sex, and race at baseline. Model 3 was 5–7 days a week 912 470 442 (22.04)
(22.52) (22.98)
further adjusted for childhood socioeconomic position. Model 4 was Physical activity, n (%) 0.254
additionally adjusted for education level, marital status, employment Light 869 449 420 (20.95)
status, adult wealth, smoking status, drinking status, and physical ac­ (21.46) (21.96)
tivity at baseline. Moderate 1855 951 904 (45.09)
(45.80) (46.50)
The package named “mediation (4.5.0)” in R version 4.0.3 was used
Vigorous 1326 645 681 (33.97)
to perform mediation analyses with each personality trait as a separate (32.74) (31.54)
mediator. According to the procedure described by Tingley (Tingley Childhood socioeconomic 0.55 (0.78) 0.48 (0.73) 0.63 (0.82) <0.001
et al., 2014), we established two models: an exposure-mediator-outcome score, mean (SD)
model (survival regression) and an exposure-mediator model (linear Neuroticism, mean (SD) 2.01 (0.55) 1.97 (0.53) 2.06 (0.57) <0.001
Conscientiousness, mean 3.32 (0.47) 3.34 (0.45) 3.30 (0.48) 0.005
regression). Firstly, depressive symptoms were regressed by ACEs, per­ (SD)
sonality traits, and potential covariates. Secondly, personality traits Extraversion, mean (SD) 3.19 (0.53) 3.20 (0.52) 3.18 (0.54) 0.286
were regressed by ACEs and potential covariates. The scores of person­ Openness, mean (SD) 2.90 (0.53) 2.90 (0.53) 2.90 (0.53) 0.828
ality traits were standardized before being entered into the above two Agreeableness, mean (SD) 3.51 (0.46) 3.51 (0.47) 3.52 (0.46) 0.654
models. Personality traits reaching statistical significance (α = 0.05) in Student's t-tests were used to compare the means of continuous variables.
both models were further investigated. Finally, the results of the Pearson chi-squared tests were performed to compare the distribution of cate­
exposure-mediator-outcome and exposure-mediator models were com­ gorical variables.
bined to calculate the proportion of mediation. Quasi-Bayesian estima­ Abbreviations: ACEs, adverse childhood experiences; SD, standard deviation.
tion with 1000 iterations was used to estimate the P-values of the
mediating effect (Ho et al., 2020).
All statistical analyses were conducted using Stata version 17.0
(StataCorp LLC) and R version 4.0.3 (R Core Team, Vienna, Austria).
Statistical significance was defined as a two-tailed P-value < 0.05.

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Y. Li et al. Journal of Affective Disorders 331 (2023) 167–174

Table 3
The association of ACEs at baseline (wave 5, 2010–2011) with depressive symptoms during follow up (waves 6–9, 2012–2019).
Model 1 Model 2 Model 3 Model 4

HR (95 % CI) P-value HR (95 % CI) P-value HR (95 % CI) P-value HR (95 % CI) P-value

ACEs
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes 1.64 (1.40, 1.91) <0.001 1.56 (1.24, 1.82) <0.001 1.52 (1.30, 1.77) <0.001 1.44 (1.24, 1.69) <0.001
Maltreatment
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes 1.32 (1.02, 1.73) 0.036 1.45 (1.11, 1.89) 0.007 1.43 (1.10, 1.87) 0.008 1.39 (1.06, 1.82) 0.017
Household dysfunction
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes 1.53 (1.30, 1.79) <0.001 1.60 (1.37, 1.89) <0.001 1.54 (1.30, 1.81) <0.001 1.48 (1.26, 1.75) <0.001
Low parental bonding
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes 1.53 (1.30, 1.81) <0.001 1.52 (1.29, 1.80) <0.001 1.49 (1.26, 1.76) <0.001 1.43 (1.20, 1.69) <0.001
Loss experiences
No 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Yes 1.50 (1.26, 1.79) <0.001 1.33 (1.12, 1.59) 0.001 1.31 (1.10, 1.56) 0.003 1.25 (1.05, 1.50) 0.012

Model 1: unadjusted for any potential covariates.

Model 2: adjusted for age, sex, and race at baseline.
Model 3: model 2 plus childhood socioeconomic status.
Model 2: model 3 plus education level, marital status, employment status, adult wealth, smoking status, drinking status, and physical activity at baseline.
Abbreviations: ACEs, adverse childhood experiences; HRs, hazard ratios; CIs, confidence intervals.

3. Results extraversion, openness, and agreeableness scores, respectively. ACEs

3.1. Characteristics of participants
As shown in Table 1, 49.51 % of participants had at least one ACE.
The percentages of participants with at least one ACE related to
maltreatment, household dysfunction, poor parent-child bonding, and
loss experiences were 7.26 %, 24.43 %, 24.41 %, and 19.28 %, respec­
tively. Table 2 summarizes the baseline characteristics of participants by
exposure status of ACEs. The mean age of participants was 67.34 years
(standard deviation: 8.98 years), and females accounted for 55.53 %.
Compared with participants without ACEs, those with at least one ACE
were more likely to be females, unmarried, and never smokers, had
lower socioeconomic status both in childhood and adulthood, drank less
than once a week, and had higher neuroticism, and lower conscien­
tiousness scores. However, there existed no statistically significant dif­
ferences in the distributions of age, race, education level, employment
status, physical activity, extraversion, openness, and agreeableness be­
tween the two groups.
3.2. Association of ACEs with depressive symptoms
During the median follow-up of 7.92 years (interquartile range:
4.17–8.08 years), 675 participants developed depressive symptoms,
with an incidence density of 25.98 per 1000 person-years. Table 3 shows
the association of ACEs with depressive symptoms in adulthood. After
adjusting for childhood socioeconomic status, baseline age, sex, race,
education level, marital status, employment status, adult wealth,
smoking status, drinking status, and physical activity, compared with
participants without any ACEs, the HR (95 % CI) of those with at least
one ACEs was 1.44 (1.24, 1.69). Moreover, compared with participants
without ACEs, the full-adjusted HRs (95 % CIs) of those with at least one
ACE related to maltreatment, household dysfunction, poor parent-child
bonding, and loss experiences were 1.39 (1.06, 1.82), 1.48 (1.26, 1.75),
1.43 (1.20, 1.69), and 1.25 (1.05, 1.50), respectively.
3.3. Mediating role of personality traits
As shown in supplementary Table S1, the full-adjusted HRs (95 %
CIs) of depressive symptoms were 1.58 (1.46, 1.71), 0.85 (0.78, 0.91),
0.79 (0.73, 0.85), 0.90 (0.83, 0.97), and 0.99 (0.91, 1.07) for each
standard deviation increase in neuroticism, conscientiousness,
was positively correlated with neuroticism (β = 0.127, 95 % CI: 0.065,
0.188), and negatively correlated with conscientiousness (β = − 0.076,
95 % CI: − 0.137, − 0.020) and agreeableness (β = − 0.068, 95 % CI:
− 0.128, − 0.008), but not correlated with other personality traits. Both
maltreatment (supplementary Table S2, β = 0.128, 95 % CI: 0.008,
0.248) and household dysfunction (supplementary Table S3, β = 0.168,
95 % CI: 0.096, 0.240) were only positively related to neuroticism. Poor
parent-child bonding was positively associated with neuroticism (β =
0.153, 95 % CI: 0.081, 0.226), and negatively associated with consci­
entiousness (β = − 0.102, 95 % CI: − 0.173, − 0.030), extraversion (β =
− 0.122, 95 % CI: − 0.195, − 0.050), and agreeability (β = − 0.118, 95 %
CI: − 0.190, − 0.046), but not associated with openness (supplementary
Table S4). Loss experiences were not correlated with any personality
traits (supplementary Table S5).
Fig. 2 displays the standardized path coefficient and mediation
proportion of personality traits with a statistically significant mediation
effect (all P-values < 0.05). The association of ACEs with depressive
symptoms was mediated by neuroticism and conscientiousness in 15.68
% and 3.24 %, respectively. In each dimension analysis, the correlation
of maltreatment and household dysfunction with depressive symptoms
was mediated by neuroticism in 18.18 % and 19.69 %, respectively. The
relationship between poor parent-child bonding and depressive symp­
toms was mediated by neuroticism, conscientiousness, and extroversion
in 19.43 %, 4.84 %, and 8.02 %, respectively.
4. Discussion
Using nationally representative data from the ELSA, this 9-year
prospective cohort study explored the mediating role of personality
traits in the effects of multi-dimensional ACEs (i.e., maltreatment,
household dysfunction, poor parent-child bonding, and loss experi­
ences) on the risk of depressive symptoms in non-clinical older adults.
Our results indicate that ACEs in each dimension significantly increase
the risk of depressive symptoms in adulthood, and the mediating role of
personality traits might vary with the dimensions of ACEs. The associ­
ation of maltreatment (18.18 %) and household dysfunction (19.69 %)
with depressive symptoms might be mediated by neuroticism. The as­
sociation between poor parent-child bonding and depressive symptoms
might be mediated by neuroticism (19.43 %), conscientiousness (4.84
%), and extraversion (8.02 %). In contrast, the relationship between loss
experiences and depressive symptoms might not be mediated by any

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Y. Li et al. Journal of Affective Disorders 331 (2023) 167–174

Fig. 2. The standardized path coefficient and mediation proportion of personality traits with statistically significant mediation effect.
Adjusted confounders included ACEs (only for personality traits), age, sex, race, childhood socioeconomic status, education level, marital status, employment status,
adult wealth, smoking status, drinking status, and physical activity.
*P-value < 0.05; **P-value < 0.01; ***P-value < 0.001.
Abbreviations: ACEs, adverse childhood experiences.

personality traits. This study clarifies some mechanisms by which ACEs
lead to depressive symptoms in adulthood, and provides a theoretical
basis for effectively preventing and improving depressive symptoms.
Previous studies have consistently reported that neuroticism medi­
ates the association of maltreatment with depressive symptoms, and
openness and agreeableness do not play a mediating role. However, in
previous studies, the mediating roles of extraversion and conscien­
tiousness remain controversial (Hovens et al., 2016; Lee and Song, 2017;
Zhang et al., 2018). This disagreement might be attributed to differences
in instruments for evaluating maltreatment, study design (longitudinal
studies vs. cross-sectional studies), age (adolescents vs. adults), and
source of sample (clinical population vs. non-clinical population). This
9-year prospective cohort study further provides solid evidence that in
the non-clinical adults, only neuroticism at baseline significantly me­
diates the correlation between maltreatment with depressive symptoms
during follow-up, but other personality traits might not be significant
mediating factors. Besides, this study extends previous findings by
exploring the mediating role of personality traits in the correlation be­
tween ACEs in other dimensions and depressive symptoms. The rela­
tionship between poor parent-child bonding and depressive symptoms
was mediated by the most personality traits (i.e., neuroticism, consci­
entiousness, and extraversion). The association of household

172
Y. Li et al.
dysfunction with depressive symptoms was only mediated by neuroti­
cism. We speculate that compared with ACEs in other dimensions, the
poor parent-child relationship might be a more important factor
affecting the formation of personality traits. Our findings also suggest
that when exploring the other mechanism by which ACEs induce
depressive symptoms, the dimensions of ACEs should be considered.
Furthermore, Stieger et al. found that personality traits can be changed
through intervention in a randomized controlled trial of non-clinical
adults, and pointed out that some intervention measures of personality
traits are low-cost and low-threshold (Stieger et al., 2021). Our findings
suggest that neuroticism mediates the effects of ACEs in three di­
mensions on depressive symptoms, and has the highest mediation pro­
portion (approximately 20 %) among personality traits. Thus,
neuroticism might be an important intervention factor when formu­
lating measures to prevent depressive symptoms in individuals with
ACEs.
It is biologically plausible that personality traits mediate the asso­
ciation of ACEs with depressive symptoms in adulthood. First, person­
ality traits usually develop during childhood under the influence of
multiple social and environmental factors (Clark and Watson, 2008;
Shiner, 2006). Individuals with ACEs are likely to develop maladaptive
personality traits, and individuals often rely on personality traits to cope
with stressful events in later life (Zhang et al., 2018). Thus, maladaptive
personality traits might induce depressive symptoms through unrea­
sonable coping styles. For instance, compared with individuals with low
extraversion, those with high extraversion usually engage in more social
activities, and seek more comfort and help from others, so extraversion
can protect individuals from stress events to a certain extent, and then
reduce their depressive symptoms (Yu and Hu, 2022). On the contrary,
neuroticism is characterized by low self-esteem, shyness, anxiety, guilt,
tension, emotional, irrational, and moody, so individuals with high
neuroticism might have more negative emotions under stressors, which
can induce depressive symptoms (Malouff et al., 2005). Second, per­
sonality traits can predict life outcomes, such as success in love and work
and well-being, which are closely related to depressive symptoms
(Borghans et al., 2008; Soto, 2019). For example, individuals with high
conscientiousness tend to exhibit better academic achievement, job
performance, relationship quality, and physical health, which might
reduce the incidence of their depressive symptoms in turn (Dudley et al.,
2006; Dumfart and Neubauer, 2016; Hampson et al., 2013; Hill et al.,
2014; Kern and Friedman, 2008). Finally, high neuroticism, low
conscientiousness, and low extraversion can reduce resilience, and then
lead to depressive symptoms (Gong et al., 2020). It is worth noting that
the mediation proportion of all personality traits is <20 %, indicating
that there are other important mediators between ACEs and depressive
symptoms. Previous studies have reported that self-esteem (Kim et al.,
2022), emotion regulation (Hopfinger et al., 2016), C-reactive protein
(Iob et al., 2020a), and cortisol (Iob et al., 2021) can mediate the as­
sociation of ACEs with depressive symptoms. Therefore, a study
covering multi-dimensional mediators is needed to comprehensively
clarify the mechanism by which ACEs lead to depressive symptoms.
This study has several important strengths. First, the ELSA is a large-
scale and nationally representative study in older adults, and the study
population was not selected based on exposure to ACEs or the presence
of depressive symptoms, so the sample of this study is representative of
the general elderly population. Second, a 9-year prospective cohort
study design can identify the temporality between personality traits and
depressive symptoms, overcoming the shortcomings of previous non-
clinical sample studies to some extent. Finally, this study included
multi-dimensional ACEs, enabling us to assess the mediating role of
personality traits in the effects of ACEs in different dimensions on
depressive symptoms.
However, this study still has some limitations. First, ACEs were
retrospectively assessed based on participants' memories of childhood
experiences. Such assessments might be prone to induce recall bias due
to participants' motivation, cognitive function, and memory bias,
173
Journal of Affective Disorders 331 (2023) 167–174
especially in older adults (Hardt and Rutter, 2004). Second, since our
sample is restricted to the general elderly population in the UK, the re­
sults might not be generalized to other ethnic and age groups. Our
findings need to be validated in different populations in the future.
Finally, despite controlling for a large number of potential confounders,
we could not exclude residual confounding from unmeasured and un­
recognized confounders.
In conclusion, maltreatment and household dysfunction in childhood
might increase the risk of depressive symptoms in the elderly by
increasing neuroticism. Poor parent-child bonding in childhood might
induce depressive symptoms in the elderly through increasing neuroti­
cism, and reducing conscientiousness and extraversion. Although loss
experiences in childhood might elevate the risk of depressive symptoms
in the elderly, personality traits might not play a mediating role. Our
findings provide preliminary evidence that in addition to interventions
to reducing the occurrence of ACEs, reducing neuroticism of individuals
with maltreatment and household dysfunction in childhood, and
reducing neuroticism, and increasing conscientiousness and extraver­
sion of individuals with poor parent-child bonding in childhood might
help to decrease their risk of depressive symptoms.
Role of the funding source
This work was supported by Sanming Project of Medicine in Shenz­
hen Nanshan (No. 11).
CRediT authorship contribution statement
Yanzhi Li and Wanxin Wang designed this study. Lu Cheng, Lan Guo,
Liwan Zhu, Hao Zhao, Caiyun Zhang, and Xiuwen Li managed the
literature searches and summaries of previous related work. Yanzhi Li,
Lu Cheng, and Lan Guo did the statistical analysis. Yanzhi Li wrote the
first draft of the manuscript. Wanxin Wang, Ciyong Lu, Muhammad
Youshay Jawad, Roger S. McIntyre, Manjun Shen, Yifeng Liu, and
Lingjiang Li reviewed the manuscript.
Conflict of interest
None.
Acknowledgments
The authors gratefully acknowledge the research team and partici­
pants from the English Longitudinal Study of Ageing (ELSA), and
gratefully acknowledge technical support from the School of Public
Health, Sun Yat-sen University.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jad.2023.03.067.
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