Can adoption at an early age protect children at risk from depression in adulthood? A Swedish national cohort study

1 Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access Can adop ion a an ea ly age p o ec child en a isk om dep ession in adul hood? A Swedish na ional coho s udy Ande s Hje n,1,2 Jesus Palacios,3 Bo Vinne ljung2,4 To ci e: Hje nA, PalaciosJ, Vinne ljungB. Can adop ion a an ea ly age p o ec child en a isk om dep ession in adul hood? A Swedish na ional coho s udy. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/ bmjpo-2018-000353 Recei ed 1 Augus 2018 Re ised 2 No embe 2018 Accep ed 12 No embe 2018 1Cen e o Heal h Equi y S udies (CHESS), Ka olinska Ins i u e , S ockholm Uni e si y, S ockholm, Sweden 2Clinical Epidemiology/ Depa men o Medicine, Ka olinska Ins i u e , S ockholm, Sweden 3Depa men o De elopmen al Psychology, Uni e si y o Se ille, Se illa, Spain 4Depa men o Social Wo k, S ockholm Uni e si y, S ockholm, Sweden Co espondence o D Ande s Hje n; ande s. hje n@ chess. su. se O iginal a icle © Au ho (s) (o hei employe (s)) 2018. Re-use pe mi ed unde CC BY. Published by BMJ. Abs AC Objec i e Ou aim was o in es iga e whe he he isk o dep ession in adul hood in child en aised by subs i u e pa en s om an ea ly age di e by ca e a angemen s. Me hods Regis e s udy in Swedish na ional coho s bo n 1972–1981, wi h h ee s udy g oups o child en aised in adop i e o os e homes wi h ca e s a ing be o e he age o 2 yea s and a compa ison majo i y popula ion g oup. Cox eg ession es ima ed HRs o p esc ibed an idep essi e medica ion and specialised psychia ic ca e wi h a diagnosis o dep ession in adul hood du ing 2006–2012. esul s Compa ed wi h he gene al popula ion, long- e m os e ca e ca ied he highes age-adjus ed and sex-adjus ed HR o bo h an idep essi e medica ion, 2.07 (95% CI 1.87 o 2.28), and psychia ic ca e o dep ession, 2.85 (95% CI 2.42 o 3.35), in adul hood. Adul s aised by adop i e pa en s we e a mo e simila o he gene al popula ion wi h HR o 1.19 (95% CI 1.00 o 1.43) o domes ic and 1.13 (95% CI 1.08 o 1.18) o in e na ional adop ion o an idep essi e medica ion. Adjus ing he analysis o school ma ks and income a enua ed hese isks mo e in he long- e m os e ca e g oup. Conclusion The s udy demons a es he bene i s o ea ly adop ion when subs i u e pa en s a e p o ided o young child en, and unde lines he impo ance o imp o ed educa ional suppo o child en in os e ca e. In OduC IOn Ea ly ad e se expe iences, pa icula ly child abuse and neglec , ha e been linked o a numbe o nega i e ou comes, wi h longi u- dinal e idence showing he impac on phys- ical1 as well as on men al heal h.2 Resea ch on s ess neu obiology is helping o gain a be e unde s anding o he connec ions be ween ea ly ad e si y (in he o m o abuse and neglec , auma ic expe iences and ch onic exposu e o oxic s ess), i s ‘deep-sea ed’ neu obiological al e a ions3 and la e men al heal h dis u bances. Li e a u e e iews and me a-analy ic e idence highligh he connec ion be ween ea ly ad e si y and poo psychia ic ou comes, including dep ession. Be ween a qua e and a hi d o mal ea ed child en mee c i e ia o majo dep ession by hei la e 20s.4 Compa ed wi h non-mal ea ed indi iduals, hose wi h a his o y o abuse and neglec a e wice as likely o de elop bo h ecu en and pe sis en dep essi e episodes.5 In wel a e socie ies, one common conse- quence o mal ea men in ea ly childhood is placemen in o subs i u e amilies. Main- aining hese child en wi h hei pa en s, o placing hem in esiden ial ca e, has been associa ed wi h a highe incidence o men al heal h p oblems, including anxie y, dep es- sion and conduc diso de s.6 A he same ime, s udies om many coun ies ha e consis en ly shown ha g owing up in subs i u e amilies does no elimina e he ill consequences o ea ly ad e si y. Bo h adop ed and os e ed child en exhibi mo e men al heal h p ob- lems—including dep ession— han hose in he gene al popula ion.7 Swedish popula ion Wha is al eady known on his opic? ►The isk o dep ession in adul hood is much in- c eased in mal ea ed child en. ►Fos e ca e and adop ion a e he main ypes o ca e p o ided o child en mal ea ed a an ea ly age. ►Compa ed wi h hose placed in os e ca e, adop ed child en ha e been shown o ha e be e educa ion- al and employmen ou comes in he adul Swedish popula ion. Wha his s udy hopes o add? ►Adul s wi h a his o y o long- e m os e ca e had wo old a es o dep ession indica o s compa ed wi h he gene al popula ion. ►Adop ion du ing in ancy is associa ed wi h a isk o adul dep ession lowe han long- e m os e ca e. ►Poo e educa ional and employmen ou comes may con ibu e o he highe isk o dep ession in o me os e child en. BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by copy igh . 2Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access s udies ha e shown ha , compa ed wi h majo i y popula- ion pee s, young adul s wi h a his o y o long- e m os e ca e, as well as o domes ic and in e coun y adop ion, p esen highe isk o a ious psychological and psychi- a ic diso de s.8–10 Conside able di e ences in educa- ional achie emen and labou ma ke pa icipa ion ha e also been epo ed.11 The highe le els o psychological and psychia ic mo bidi y in adul hood, as well as o poo educa ional pe o mance indica o s, ha e ypically been assumed o be ela ed p ima ily o exposu e o amilial isk ac o s be o e placemen .12 Fo he in e na ional adop ees, speci ic ad e se consequences ela ed o ea ly neglec ul ins i u ional ca e ha e been epo ed.13 Age a placemen has been demons a ed o be an impo an isk ac o o nega i e ou comes la e in li e such as lowe IQ, p oblem beha iou and emo ional dis u bances.14 15 Type and quali y o ca e also seem o play a ole. Adop ion p o ides mo e s abili y han os e ca e, wi h equen changes o os e amilies and o he ou -o -home ca e a angemen s being inhe en o long- e m os e ca e.16 17 This ins abili y causes os e ed child en o de elop beha iou al and men al heal h p ob- lems. Fos e ca e ins abili y is also p esen in Sweden, he se ing o his s udy. E en o long- e m placemen s ha las om ea ly yea s un il he beginning o adolescence, e e y ou h b eaks down du ing he i s eenage yea s.18 Adop ed child en in Sweden may also expe ience place- men ins abili y a some ime be o e age o majo i y, bu he p e alence (3%) is minuscule compa ed wi h long- e m os e ca e.19 In hei analysis o he impac o place- men s abili y on he well-being o os e child en, Rubin e al20 concluded ha os e child en expe ience place- men ins abili y un ela ed o hei baseline p oblems, and ha his ins abili y has pe se a signi ican impac on hei beha iou and well-being. In Sweden, domes ic adop ion was common in he mid-1900s, including a ound 1% o bi h coho s, o en child en bo n ou o wedlock by young mo he s. Du ing he 1960s, new wel a e policies ha p o ided economic suppo o single mo he s and a mo e libe al abo - ion policy g adually dec eased he numbe o child en a ailable o adop ion. Since he mid-1970s, domes ic adop ions ha e been a e in Sweden and os e ca e has become he main o m o long- e m subs i u e ca e o young child en who canno be euni ed wi h hei bi h pa en s.21 22 In e na ional adop ion in Sweden was ini i- a ed in he 1960s and peaked in he 1970s when bi h coho s in Sweden included 1.5%–2.0% in e na ionally adop ed child en, a ha ime he highes pe capi a p opo ion in he wo ld.8 The aim o his s udy was o exploi his pe iod o d as ic changes in Swedish adop ion p ac ices o in es i- ga e whe he he isk o dep ession in adul hood di e s be ween di e en o ms o subs i u e ca e o child en placed in ca e in in ancy, and whe he isk pa e ns di e be ween he ligh e o ms o dep ession, ea ed ou side o hospi als (ie, an idep essi e medica ion) and mo e se e e o ms, ea ed in hospi al ca e (ie, specialised psychia ic ca e wi h a diagnosis o dep ession). Taking in o accoun he well documen ed di e ences in school pe o mance and labou ma ke pa icipa ion be ween adop ed and long- e m os e child en in Sweden,11 we also wan ed o explo e i hese ac o s in luence hei isk o dep ession. Me hOds This s udy is based on in o ma ion om Swedish na ional egis e s, con aining da a wi h high alidi y and low a i- ion a es.23 24 These egis e s a e based on he unique pe sonal iden i y numbe assigned a bi h (o ime o immig a ion) o all Swedish esiden s. Da a om di e en egis e s can be linked using hese iden i y numbe s. The s udy popula ion comp ises indi iduals bo n 1972–1981 who, acco ding o he Regis e o he To al Popula ion (RTP), we e ali e and esiden in Sweden on 31 Decembe 2005. This popula ion was ollowed up om 1 Janua y 2006 o 31 Decembe 2012, a age 25–41 yea s. Biological and/o adop i e pa en s o hese indi- iduals we e iden i ied in he mul igene a ion egis e . In o ma ion abou egion o bi h, yea o adop ion, sex and yea o bi h in RTP was linked o he s udy subjec s and hei pa en s. Da a on age a i s placemen in ou -o -home ca e (OHC) and ime spen in OHC be o e age 18 yea s was e ie ed om he Na ional Child Wel a e Regis e . Based on his in o ma ion, we c ea ed h ee s udy g oups o child en who had en e ed OHC o been adop ed be o e he age o 2 yea s: domes ic adop ees (n=618) we e Swedish-bo n and had wo egis e ed Swedish-bo n adop i e pa en s. In e na ional adop ees (n=8878) ul illed he c i e ia o being bo n ou side o wes e n Eu ope, ha ing a leas one Swedish-bo n adop i e pa en bu no bi h pa en in he mul igene a ion egis e , and ha ing en e ed Sweden be o e hei second bi hday; long- e m os e ca e subjec s (n=1 115) had no eco d o adop ion and a o al ime in OHC o a leas 10 yea s (median o 15.2 yea s) in ca e be o e age 18 yea s. A compa ison popula ion labelled majo i y popula ion (n=930 944), all Swedish-bo n indi iduals wi h a leas one Swedish-bo n bi h pa en and no adop i e pa en s in he mul igene - a ion egis e , and wi h no eco d o placemen in OHC be o e he age o 18 yea s. dep ession Two indica o s o dep ession we e c ea ed o he ollow-up 2006–20121: i s indica ion o dispensed an i- dep essi e medica ion (AC-code N06A) was ob ained om he Swedish P esc ibed D ug Regis e ,2 i s en y in ou pa ien specialised ca e o a hospi al discha ge wi h a diagnosis o dep essi e diso de (F32-F39 in 10 h e i- sion o he In e na ional Classi ica ion o Disease) in o he Na ional Pa ien Discha ge Regis e . BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by copy igh . 3 Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access sociodemog aphic end educa ional co a ia es Da a on age, gende , disposable income, domicile and indica o s o labou ma ke pa icipa ion we e e ie ed om he 2005 Longi udinal In eg a ion Da abase o Heal h Insu ance and Labou Ma ke S udies. Disposable income was di ided in o quin- iles, and included all egis e ed sou ces o income deduc ed by axes, and he ea e di ided by consume uni s in he household acco ding o a o mula de el- oped by S a is ics Sweden. Domicile was spli in o h ee ca ego ies and de ined by he place o esidence in 2008: ‘ci y’ e e ed o he me opoli an a eas o Sweden’s h ee la ges ci ies, S ockholm, Go hen- bu g and Malmo, ‘ own’ co e ed o he p edomi- na ely u ban communi ies, and ‘ u al’ co e ed he emainde . Labou ma ke pa icipa ion was de ined as ha ing an income om employmen /sel -employ- men in No embe 2005 o ha ing ecei ed socie al bene i s as an ac i e s uden ha yea . School ma ks in g ade 9 ( inal yea o compulso y school, 15–16 yea s) we e e ie ed om he Na ional School Regis e , which is adminis e ed join ly by he Swedish School Au ho i y and S a is ics Sweden. The g ading sys em du ing 1987–1996 na ionally ollowed a Gaussian dis ibu ion and consis ed o a scale om 1 (poo ) o 5 (excellen ). s a is ical analyses Cox p opo ional haza ds models we e used o es ima e HRs and co esponding 95% CI o dispense o an ide- p essi e medica ion and hospi al specialised ca e wi h a diagnosis o dep ession as de ined abo e. Pe son ime o ollow-up was accumula ed om Janua y 2006 un il he da e o he i s dispense/da e o i s admission/ isi , da e o dea h om he Na ional Cause o Dea h Regis e o end o ollow-up in Decembe 2013. Table 1 Cha ac e is ics o he s udy popula ion Domes ic adop ees In e na ional adop ees Fos e ca e Gene al popula ion n=618 n=8778 n=1115 930 944 Sex Men 56.1 38.5 49.4 51.4 Women 43.9 61.5 50.6 48.6 Age a adop ion/en y in o os e ca e 0–12 mon hs 90.3 42.5 45.5 – 13–24 mon hs 9.7 57.5 54.5 – Yea o bi h 1972–1974 50.3 23.1 30.2 32.6 1975–1977 27.7 32.8 26.0 29.4 1978–1981 22.0 44.1 43.8 38.0 Ma ks in nin h g ade Mean a e age 2.99 3.08 2.55 3.21 Educa ion in 2005 ≤9 yea s 10.0 10.2 35.2 9.3 10–12 yea s 55.2 50.6 54.9 49.1 13+ yea s 34.8 39.2 9.9 41.5 Income in quin iles in 2005 Fi s 11.8 14.6 26.1 13.2 Second 17.3 17.8 24.2 18.3 Thi d 19.4 20.5 23.1 20.2 Fou h 23.6 24.4 16.2 22.7 Fi h 27.8 22.6 10.5 25.6 Employed No embe 2005 79.0 69.7 53.3 73.4 S uden in 2005 13.0 24.8 12.3 20.1 Geog aphic esidency Ci y 42.9 52.8 37.7 42.9 Town 43.9 39.1 44.6 43.9 Ru al 13.3 8.1 8.5 13.3 BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by copy igh . 4Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access The modelling o ea ly childhood de e minan s o adul men al heal h is complex, since ajec o ies po en ially in ol e in e media e ac o s ha a e p od- uc s o he ea ly childhood en i onmen and de e - minan s o adul men al heal h. In a p e ious s udy,11 we ha e shown ha he educa ional achie emen and income o young adul men aised in os e ca e in Sweden is conside ably lowe han ha o men in he gene al popula ion wi h he same es sco es on IQ es s, sugges ing ha educa ional achie emen and income a e impo an componen s in ajec o ies om os e ca e o adul hood. In his s udy, we he e- o e conside ed model 1, adjus ed only o gende , and u ban/ u al esidency as ca ego y a iables and yea o bi h as a con inuous a iable, as he main analysis o he e ec s o ca e in ea ly childhood. To s udy he e ec o ca e, a e adjus men o po en ial consequences o ype o ca e, we also c ea ed a model 2 adjus ed o g ade poin a e ages a age 15–16 yea s and a model 3 u he adjus ed o employmen / income in adul age. All analyses we e conduc ed using SPSS V.24.0. esul s Table 1 shows he cha ac e is ics o he s udy g oups. In e na ional adop ees we e mo e o en emales in compa ison wi h he o he s udy g oups. The domes ic adop ees we e he younges when en e ing ca e (90% du ing hei i s yea o li e), wi h in e na ional adop ees mo e o en being adop ed be ween hei i s and second bi hday (46%). As expec ed om he policy change desc ibed abo e, he domes ic adop ees we e mo e o en han he o he s udy g oups bo n in 1972–1974 and he os e child en mo e o en du ing 1975–1981. The domes ic adop ees had he highes income and employ- men a es o he s udy g oups. Fos e child en had he lowes school ma ks in g ade 9, he lowes educa ional achie emen and he lowes income. Domes ic and in e - na ional adop ees had mean g ade poin a e ages and Table 2 Dep ession indica o s by sociodemog aphic a iables (pe cen ages) Medica ion Hospi al ca e Men Women Men Women S udy g oups Gene al popula ion 12.3 21.6 3.4 5.8 Domes ic adop ees 12.1 29.2 3.2 5.2 In e na ional adop ees 14.1 24.0 5.5 8.1 Fos e ca e 26.8 39.1 11.8 13.5 Yea o bi h 1972–1974 12.2 22.5 3.1 5.3 1975–1977 12.4 21.7 3.4 5.7 1978–1981 12.4 21.0 3.7 6.3 Highes educa ion in 2005 ≤9 yea s 19.0 29.4 7.6 12.8 10–12 yea s 12.2 23.1 3.4 6.2 13+ yea s 9.1 16.8 2.1 4.3 S uden and/o employed in 2005 No 24.7 35.2 9.3 12.7 Income in quin iles in 2005 Fi s 17.1 22.5 5.9 8.7 Second 15.1 25.1 4.5 7.2 Thi d 13.9 22.3 4.0 5.9 Fou h 11.7 18.5 3.1 4.6 Fi h 8.8 14.7 1.9 3.5 Geog aphic esidency Ci y 12.2 21.1 3.4 5.8 Town 12.4 22.2 3.4 5.9 Ru al 12.3 22.4 3.4 5.7 To al 12.3 21.7 3.4 5.8 BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by copy igh . 5 Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access educa ional achie emen in be ween he compa ison popula ion and he os e child en. As able 2 demons a es, he accumula ed incidence o an idep essi e medica ion was 12% in men and 21% in women in he gene al popula ion. The highes incidences we e ound among he o me os e child en, wi h 27% o men and 39% o women. Fo hospi al psychia ic ca e wi h a diagnosis o dep ession, he accumula ed incidence was 3% in men and 6% in women in he gene al popula ion. Fo me os e child en had he highes incidences also o his ou come; 13% o women and 12% o men. Cox eg ession models o he e ec s o ype o ca e on dep ession ou comes a e p esen ed in able 3. In he main analysis, p esen ed in model 1, we adjus ed o yea o bi h, gende and u al/u ban esidency only. Compa ed wi h he gene al popula ion, indi iduals in he os e ca e g oup had he highes HRs o bo h ou comes, 2.07 (95% CI 1.87 o 2.28) o an idep essi e medica ion, and 2.85 (95% CI 2.42 o 3.35) o hospi al psychia ic ca e wi h a diagnosis o dep ession. In e na ional and domes ic adop ees had simila isks o an idep essi e medica ion, HRs 1.13 (95% CI 1.08 o 1.18) and 1.19 (955 CI 1.00 o 1.43), espec i ely, while he HR o psychia ic ca e o dep ession was highe in in e na ional adop ees, 1.45 (95% CI 1.34 o 1.57) compa ed wi h 0.93 (95% CI 0.63 o 1.38) in he domes ic adop ees. In e ac ion analyses could no de ec any signi ican gende di e ences o any o hese wo ou comes. Adjus ing he analysis o ac o s on he ajec o y om childhood o adul hood, school ma ks in model 2 and income and employmen in model 3, a enua ed hese isks mo e in he os e ca e g oup, sugges ing ha some o he excess isks o dep ession in he o me os e child en was indeed associa ed wi h hese in e media e ac o s. HRs, howe e , emained mo e ele a ed o o me os e child en han o he adop ion g oups and he gene al popula ion. dIsCussIOn This na ional coho s udy o adul s aised by adop i e o os e pa en s demons a es ha , compa ed wi h os e ca e, adop ion du ing he in ancy yea s is associa ed wi h a lowe isk o an idep essi e medica ion and psychia ic ca e wi h a diagnosis o dep ession in adul hood. Educa- ion, employmen and income, as possible consequences o ype o ca e, a enua ed hese isks mo e in he os e ca e g oup. P e ious esea ch on Swedish adul s aised in subs i u e amilies ha e shown ha os e child en consis en ly ha e a highe consump ion o psychia ic ca e and psycho- opic d ugs, and a highe isk o suicidali y han adop- ees.25–27 The pa e n demons a ed in his s udy sugges s ha a highe incidence o dep essi e diso de s may be an impo an ac o behind he excess isk o suicide p e i- ously ound in o me os e child en compa ed wi h in e na ional adop ees in Sweden.25 In he os e ca e g oup, he HRs we e s ongly a en- ua ed by school ma ks and income le els, al hough he pe cen age o hose wi h highe academic quali ica ions and be e income is signi ican ly lowe o he os e ca e g oup. P e ious Swedish s udies ha e shown ha , despi e a simila cogni i e compe ence,9 adop ees pe o m be e in school, each highe educa ional le els and ha e highe labou ma ke pa icipa ion han adul s aised in os e ca e, wi h he in e na ional adop ees doing pa icula ly well.11 Thus, amily ela ed en i onmen al di e ences in cogni i e and educa ional suppo be o e and du ing he school yea s, and he consequences on labou ma ke pa icipa ion o his ‘s un ed’ educa ional achie emen o he o me os e child en may be one mechanism ha can explain hei highe a e o dep ession.28 The isk es ima es o he os e child en and he in e - na ional adop ees we e pa icula ly high o he mo e se e e ou come o hospi al psychia ic ca e, compa ed wi h an idep essi e medica ion. This is in line wi h Table 3 Cox eg ession models o indica o s o dep ession and di e en o ms o subs i u e ca e Model 1 Model 2 Model 3 HR (95% CI) HR (95% CI) HR (95% CI) An idep essi e medica ion Gene al popula ion 111 Domes ic adop ees 1.19 (1.00 o 1.43) 1.12 (0.93 o 1.34) 1.13 (0.94 o 1.35) In e na ional adop ees 1.13 (1.08 o 1.18) 1.06 (1.01 o 1.11) 1.05 (1.00 o 1.10) Fos e child en 2.07 (1.87 o 2.28) 1.64 (1.47 o 1.83) 1.44 (1.29 o 1.61) Hospi al ca e Gene al popula ion 111 Domes ic adop ees 0.93 (0.63 o 1.38) 0.85 (0.57 o 1.27) 0.86 (0.58 o 1.29) In e na ional adop ees 1.45 (1.34 o 1.57) 1.32 (1.22 o 1.44) 1.30 (1.19 o 1.41) Fo me os e child en 2.85 (2.42 o 3.35) 2.01 (1.68 o 2.41) 1.62 (1.35 o 1.94) Model 1 is adjus ed o gende , yea o bi h and u ban/ u al esidency. Model 2 is also adjus ed o mean g ade poin a e ages in nin h g ade. Model 3 is also adjus ed o income in quin iles and employmen /being a s uden in young adul hood. BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by copy igh . 6Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353 Open access p e ious s udies, whe e dep ession associa ed wi h child- hood ad e si y has been linked o a g ea e isk o ecu - en and pe sis en dep essi e episodes, and also o less bene i s om ea men .5 The esul s o his s udy sugges s ha ea ly adop ion can limi he isk o dep ession associa ed wi h ea ly childhood ad e si y. Lacking de ailed indi idual da a, we hypo hesise ha an impo an mechanism is ha adop- ion p o ides be e s abili y and a mo e p edic able childhood home base—bo h o child en and subs i u e pa en s.29 F om a de elopmen al pe spec i e, sa e y, secu- i y, s abili y and nu u ance in ou -o -home placemen s a e key equisi es o he eco e y om pas ad e si ies and he well-being o looked a e child en.30 The impo - ance o s abili y is highligh ed by s udies showing ha an inc ease in he numbe o OHC placemen expe iences p edic s a g ea e a e o men al heal h di icul ies.31 32 The well-known di icul ies o you h ansi ioning om OHC o independen li ing also seem o include subs an- ial p oblems wi h access o adul men al heal h se ices.33 Ou indings can be pu a i ely linked o neu obio- logical s udies showing he connec ion be ween ea ly ad e si y and he HPA sys em, wi h pe sis en high le els o co isol ha ing been linked o adul dep ession in animal models.34 Lau en e al35 ha e demons a ed ha a high-quali y ca ing en i onmen has he po en ial o no malise and s abilise he daily pa e n o co isol le els in ea ly childhood. s eng hs and limi a ions The main s eng h o his s udy is he use o he Swedish na ional egis e s ha allows o long- e m ollow-up wi h minimal a i ion and high-quali y da a. The main limi a ion is he lack o in o ma ion abou amilial isk ac o s, ha is, he edi a y, e al and ea ly childhood exposu es in he s udy g oups and he eason o why he child en we e aken in o os e ca e o we e adop ed. In a p e ious s udy, whe e we had access o mo e in o ma- ion abou he bi h pa en s, we showed ha he bi h pa en s o na ional adop ees as well as child en in long- e m os e ca e ha e much highe cumula ed incidences o psychia ic diso de s and subs ance abuse han he gene al popula ion, wi h he long- e m os e child en ha ing he highes incidences. Thus, i seems p ob- able ha e al exposu es o subs ances and gene ic isk ac o s o dep ession explain some o he di e ences be ween he s udy g oups.11 The use o a unique window in Swedish child wel a e his o y, howe e , when domes ic adop ions we e eplaced wi h os e ca e as he de aul choice o placemen s in mal ea ed young child en can be expec ed o limi he in luence o such con ounding. Ano he ype o po en ial con ounding would ha e o ha e been conside ed i adop ed child en and/o os e child en we e o e ed a ge ed psychia ic se ices ha would inc ease he chance o ecei ing psychia ic ca e and ha ing been being p esc ibed an idep essi e medi- ca ion in adul hood. Such a ge ed se ices, howe e , a e no in place in Sweden oday and we e no in place when he s udied popula ions we e child en. This and o he s udies indica e ha such se ices should be conside ed.36 COnClusIOns This s udy sugges s ha ea ly adop ion can p o ec chil- d en om some o e en all o he isk o dep ession associa ed wi h ea ly childhood ad e si y. Fu he s udies wi hin he os e ca e g oup a e needed o elucida e he p o ec i e e ec o placemen s abili y. Con ibu o s AH came up wi h he idea o his manusc ip , made he egis e linkages, c ea ed he da a se o he analyses, made all s a is ical analyses and w o e he i s d a o he manusc ip . JP and BV bo h con ibu ed o he heo e ical amewo k o he s udy, he in e p e a ion o he esul s and he w i ing o he manusc ip . All h ee au ho s ha e ead and app o ed he inal manusc ip . Funding This s udy was suppo ed by a g an om he Bank o Sweden Te cen ena y Founda ion P10-0514:1. Compe ing in e es s None decla ed. Pa ien consen o publica ion No equi ed. e hics app o al This s udy was app o ed by he e hics commi ee in he S ockholm egion (No. 2014/415-31/5). P o enance and pee e iew No commissioned; ex e nally pee e iewed. da a sha ing s a emen The egis e da a used in his s udy is p o ec ed by Swedish legisla ion and canno be sha ed by esea che s no in ol ed in he s udy. Open access This is an open access a icle dis ibu ed in acco dance wi h he C ea i e Commons A ibu ion 4.0 Unpo ed (CC BY 4.0) license, which pe mi s o he s o copy, edis ibu e, emix, ans o m and build upon his wo k o any pu pose, p o ided he o iginal wo k is p ope ly ci ed, a link o he licence is gi en, and indica ion o whe he changes we e made. See: h ps:// c ea i ecommons. o g/ licenses/ by/ 4. 0/. eFe enCes 1 Flahe y EG, Thompson R, Li ownik AJ, e al. E ec o ea ly childhood ad e si y on child heal h. A ch Pedia Adolesc Med 2006;160:1232–8. 2 E hie LS, Lemelin JP, Lacha i é C. A longi udinal s udy o he e ec s o ch onic mal ea men on child en's beha io al and emo ional p oblems. Child Abuse Negl 2004;28:1265–78. 3 Sonuga-Ba ke EJS, Kennedy M, Kums a R, e al. Child- o-adul neu ode elopmen al and men al heal h ajec o ies a e ea ly li e dep i a ion: he young adul ollow-up o he longi udinal English and Romanian Adop ees s udy. Lance 2017;389:1539–48. 4 Gilbe R, Widom CS, B owne K, e al. 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