Suicidal ideation among Nepali widows: an exploratory study of risk factors and comorbid psychosocial problems.

PURPOSE: Suicide is a leading cause of death among Nepali women of reproductive age. Suicidal ideation has known associations with stressful life events, which Nepali widows disproportionately experience. We aimed to identify risk and protective factors that could lead to effective interventions for this population. METHODS: To study suicidal ideation in Nepali widows, we collected data from 204 women in urban, semi-urban, and rural areas whose husbands died at least one year prior. The questionnaire included sociodemographic information, the Hopkins Symptom Checklist-25, PTSD Checklist-Civilian Version, Somatic Symptom Scale-8, and the Multidimensional Scale of Perceived Social Support. Overall severity of prolonged grief was assessed by a counselor after completing a structured clinical interview. Using multivariate regression models, we assessed associations of sociodemographic and psychosocial indicators with past-year suicidal ideation. Latent profile analysis was also performed to estimate profiles of comorbidities. RESULTS: Past-year suicidality was high, with 16.2% (N = 33). Each year increase since husband's death was protective and reduced odds of ideation 8% (95% CI 0.85-0.98) and being educated and of older age also reduced the odds of ideation by 0.21 (95% CI 0.06-0.70), and 0.09 (95% CI 0.01-0.64), respectively. Depression (OR = 6.37, 95% CI 2.78-14.59), PTSD (OR = 3.84, 95% CI 2.15-6.86), prolonged grief (OR = 6.04, 95% CI 3.04-12.00) and anxiety (OR = 6.52, 95% CI 2.96-14.38) were highly associated with suicidality, and mapped onto the three profiles of increasing mental distress severity. CONCLUSION: Suicide remains a major issue among Nepali widows, showing high comorbidity with other mental disorders. Screening for depression, anxiety, and prolonged grief, may aid in identifying widows at increased risk of suicidal ideation.

Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review.

BACKGROUND: Epidemiological research suggests an interrelationship between mental health problems and the (re)occurrence of intimate partner violence (IPV). However, little is known about the impact of mental health treatments on IPV victimization or perpetration, especially in low- and middle-income countries (LMIC). METHODS: We conducted a systematic review to identify prospective, controlled studies of mental health treatments in LMIC. We defined 'mental health treatment' as an intervention for individuals experiencing mental ill health (including substance misuse) including a substantial psychosocial or pharmacological component. Studies had to measure a mental health and IPV outcome. We searched across multi-disciplinary databases using a structured search strategy. Screening of title/abstracts and full-text eligibility assessments were conducted by two researchers independently, data were extracted using a piloted spreadsheet, and a narrative synthesis was generated. RESULTS: We identified seven studies reported in 11 papers conducted in five middle-income countries. With the exception of blinding, studies overall showed acceptable levels of risk of bias. Four of the seven studies focused on dedicated mental health treatments in various populations, including: common mental disorders in earthquake survivors; depression in primary care; alcohol misuse in men; and alcohol misuse in female adult sex workers. The dedicated mental health treatments targeting depression or alcohol misuse consistently reduced levels of these outcomes. The two studies targeting depression also reduced short-term IPV, but no IPV benefits were identified in the two alcohol-focused studies. The other three studies evaluated integrated interventions, in which a focus on substance misuse was part of efforts to reduce HIV/AIDS and violence against particularly vulnerable women. In contrast to the dedicated mental health interventions, the integrated interventions did not consistently reduce mental ill health or alcohol misuse compared to control conditions. CONCLUSIONS: Too few studies have been conducted to judge whether mental health treatments may provide a beneficial strategy to prevent or reduce IPV in LMIC. Key future research questions include: whether promising initial evidence on the effects of depression interventions on reducing IPV hold more broadly, the required intensity of mental health components in integrated interventions, and the identification of mechanisms of IPV that are amenable to mental health intervention.

Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda.

BACKGROUND: Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done. RESULTS: The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences. CONCLUSIONS: In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

A controlled evaluation of a brief parenting psychoeducation intervention in Burundi.

PURPOSE: Conduct problems and emotional distress have been identified as key problems among children and adolescents in post-war Burundi. This pilot study aims to evaluate the impact of a brief parenting psychoeducation intervention on children's mental health. METHODS: This study employs a controlled pre and post evaluation design. The two-session psychoeducation intervention was offered to groups of parents of children (mean age 12.3 years, 60.8 % female) who had been screened for elevated psychosocial distress. Children in the intervention group (n = 58) were compared to a waitlist control group (n = 62). Outcome indicators included child-reported levels of aggression (using the Aggression Questionnaire), depression symptoms (using the Depression Self Rating Scale) and perceived family social support. RESULTS: The intervention had a beneficial effect on reducing conduct problems compared to the control condition (Cohen d = 0.60), especially among boys, while not showing impact on depression symptoms or family social support. Parents evaluated the intervention positively, with increased awareness of positive parenting strategies and appropriate disciplinary techniques reported as the most common learning points. CONCLUSION: A brief parenting psychoeducation intervention conducted by lay community counselors is a promising public health strategy in dealing with widespread conduct problems in boys living in violence-affected settings and not so for social and emotional indicators and for girls. An efficacy study is warranted to confirm these preliminary findings.

Treatment processes of counseling for children in South Sudan: a multiple n=1 design.

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n=1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client's problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

Practice-driven evaluation of a multi-layered psychosocial care package for children in areas of armed conflict.

Psychosocial and mental health service delivery frameworks for children in low-income countries are scarce. This paper presents a practice-driven evaluation of a multi-layered community-based care package in Burundi, Indonesia, Sri Lanka and Sudan, through a set of indicators; (a) perceived treatment gains; (b) treatment satisfaction; (c) therapist burden; (d) access to care; (e) care package costs. Across four settings (n = 29,292 children), beneficiaries reported high levels of client satisfaction and moderate post-treatment problem reductions. Service providers reported significant levels of distress related to service delivery. Cost analyses demonstrated mean cost per service user to vary from 3.46 to 17.32 depending on country and specification of costs. The results suggest a multi-layered psychosocial care package appears feasible and satisfactory in reaching out to substantial populations of distressed children through different levels of care. Future replication should address therapist burden, cost reductions to increase sustainability and increase evidence for treatment efficacy.

A call for greater conceptual clarity in the field of mental health and psychosocial support in humanitarian settings.

AIMS: When the Interagency Standing Committee (IASC) adopted the composite term mental health and psychosocial support (MHPSS) and published its guidelines for MHPSS in emergency settings in 2007, it aimed to build consensus and strengthen coordination among relevant humanitarian actors. The term MHPSS offered an inclusive tent by welcoming the different terminologies, explanatory models and intervention methods of diverse actors across several humanitarian sectors (e.g., health, protection, education, nutrition). Since its introduction, the term has become well-established within the global humanitarian system. However, it has also been critiqued for papering over substantive differences in the intervention priorities and conceptual frameworks that inform the wide range of interventions described as MHPSS. Our aims are to clarify those conceptual frameworks, to argue for their essential complementarity and to illustrate the perils of failing to adequately consider the causal models and theories of change that underlie our interventions. METHODS: We describe the historical backdrop against which the term MHPSS and the IASC guidelines were developed, as well as their impact on improving relations and coordination among different aid sectors. We consider the conceptual fuzziness in the field of MHPSS and the lack of clear articulation of the different conceptual frameworks that guide interventions. We describe the explanatory models and intervention approaches of two primary frameworks within MHPSS, which we label clinical and social-environmental. Using the examples of intimate partner violence and compromised parenting in humanitarian settings, we illustrate the complementarity of these two frameworks, as well as the challenges that can arise when either framework is inappropriately applied. RESULTS: Clinical interventions prioritise the role of intrapersonal variables, biological and/or psychological, as mediators of change in the treatment of distress. Social-environmental interventions emphasise the role of social determinants of distress and target factors in the social and material environments in order to lower distress and increase resilience in the face of adversity. Both approaches play a critical role in humanitarian settings; however, the rationale for adopting one or the other approach is commonly insufficiently articulated and should be based on a thorough assessment of causal processes at multiple levels of the social ecology. CONCLUSIONS: Greater attention to the 'why' of our intervention choices and more explicit articulation of the causal models and theories of change that underlie those decisions (i.e., the 'how'), may strengthen intervention effects and minimise the risk of applying the inappropriate framework and actions to a particular problem.

Interpersonal violence and mental health: a social justice framework to advance research and practice.

This editorial paper accompanies a special series in the journal Global Mental Health focused on the topic of interpersonal violence and mental health. This series included 24 papers reporting on data from 31 countries, published between 2017 and 2019. This accompanying paper provides a short summary of findings in the special series and reflects on next steps in research and practice. Collectively, the series' 24 papers suggest intricate bi-directional relationships between interpersonal violence and mental health, situated in particular contexts and varying across the life course. In order to study this complexity, an overarching theoretical framework is critical. This paper takes the social justice theory developed by Powers and Faden (2006, 2019) as a starting point. It is argued that application of this social justice framework will be helpful to: strengthen conceptual clarity; provide a sense of direction for research and practice in the area of interpersonal violence and mental health; assist in conducting more fine grained analyses of contextually determined processes of disadvantage; and help situate disciplinary specific research and practice questions in their broader context, thereby strengthening multi-disciplinary research and multi-sectoral policy and programming efforts.

Impact of maternal mental health interventions on child-related outcomes in low- and middle-income countries: a systematic review and meta-analysis.

AIMS: Observational studies have shown a relationship between maternal mental health (MMH) and child development, but few studies have evaluated whether MMH interventions improve child-related outcomes, particularly in low- and middle-income countries. The objective of this review is to synthesise findings on the effectiveness of MMH interventions to improve child-related outcomes in low- and middle-income countries (LMICs). METHODS: We searched for randomised controlled trials conducted in LMICs evaluating interventions with a MMH component and reporting children's outcomes. Meta-analysis was performed on outcomes included in at least two trials. RESULTS: We identified 21 trials with 28 284 mother-child dyads. Most trials were conducted in middle-income countries, evaluating home visiting interventions delivered by general health workers, starting in the third trimester of pregnancy. Only ten trials described acceptable methods for blinding outcome assessors. Four trials showed high risk of bias in at least two of the seven domains assessed in this review. Narrative synthesis showed promising but inconclusive findings for child-related outcomes. Meta-analysis identified a sizeable impact of interventions on exclusive breastfeeding (risk ratio = 1.39, 95% confidence interval (CI): 1.13-1.71, ten trials, N = 4749 mother-child dyads, I2 = 61%) and a small effect on child height-for-age at 6-months (std. mean difference = 0.13, 95% CI: 0.02-0.24, three trials, N = 1388, I2 = 0%). Meta-analyses did not identify intervention benefits for child cognitive and other growth outcomes; however, few trials measured these outcomes. CONCLUSIONS: These findings support the importance of MMH to improve child-related outcomes in LMICs, particularly exclusive breastfeeding. Given, the small number of trials and methodological limitations, more rigorous trials should be conducted.

Screening for psychosocial distress amongst war-affected children: cross-cultural construct validity of the CPDS.

BACKGROUND: Large-scale psychosocial interventions in complex emergencies call for a screening procedure to identify individuals at risk. To date there are no screening instruments that are developed within low- and middle-income countries and validated for that purpose. The present study assesses the cross-cultural validity of the brief, multi-informant and multi-indicator Child Psychosocial Distress Screener (CPDS). METHODS: The CPDS data of total samples in targeted catchment areas of a psychosocial care program in four conflict-affected countries (Burundi n = 4193; Sri Lanka n = 2573; Indonesia n = 1624; Sudan n = 1629) were studied to examine the cross-cultural construct validity of the CPDS across settings. First, confirmatory factor analyses were done to determine the likelihood of pre-determined theory-based factor structures in each country sample. Second, multi-sample confirmatory factor analyses were done within each country sample to test measurement equivalence of the factor structure as a measure of construct validity. RESULTS: A 3-factor structure reflecting the theoretical premises of the instrument (e.g., child distress, child resilience and contextual factors) was found in the samples from Burundi, Sri Lanka and Indonesia, albeit with context specific deviations. The robustness of the 3-factor structure as an indicator of construct validity was confirmed within these three samples by means of multi-sample confirmatory factor-analyses. A 3-factor structure was not found in the Sudan sample. CONCLUSIONS: This study demonstrates the comparability of the assessment by the CPDS of the construct 'non-specific psychosocial distress' across three out of four countries. Robustness of the factor structure of the CPDS within different samples refers to the construct validity of the instrument. However, owing to context-specific deviations of inter-item relationships, the CPDS scores cannot be compared cross-culturally, a finding that confirms the need for attention to contextual factors when screening for non-specific psychosocial distress.

Identifying research priorities for psychosocial support programs in humanitarian settings.

BACKGROUND: Given the range and reach of psychosocial support (PSS) interventions in humanitarian settings, within the continuum of mental health and psychosocial support services, evaluation of their impact is critical. Understanding stakeholders' perspectives on which PSS interventions of unknown effectiveness warrant rigorous evaluation is essential to identify research priorities. This project aimed to facilitate a process with stakeholders to reach consensus on PSS interventions that are of high priority for further research based on existing evidence and stakeholders' opinions. METHODS: Interviews with 109 stakeholders working on PSS programming in humanitarian settings served as the foundation for two in-person regional meetings and four webinars. Nominal Group Technique (NGT) was used to develop a priority PSS program list. The top five priorities from each meeting were combined for a final online survey distributed globally. RESULTS: Seventy participants across six meetings contributed to the prioritization process. Eighty-seven individuals completed the final online survey. 'Community based PSS' was the top-ranked research priority, followed by PSS integrated into basic services, providing PSS to caregivers to improve child wellbeing, PSS-focused gender-based violence programming, and classroom-based PSS interventions. CONCLUSIONS: NGT and online surveys were effective methods to engage stakeholders in a priority setting exercise to development a research agenda. Information from this stage of the project will be combined with findings from a concurrent systematic review to form the base of a second phase of work, which will include the development and implementation of a research strategy to strengthen the evidence base for those prioritized interventions.

Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: findings from a representative cluster sample survey.

AIMS: Two large earthquakes in 2015 caused widespread destruction in Nepal. This study aimed to examine frequency of common mental health and psychosocial problems and their correlates following the earthquakes. METHODS: A stratified multi-stage cluster sampling design was employed to randomly select 513 participants (aged 16 and above) from three earthquake-affected districts in Nepal: Kathmandu, Gorkha and Sindhupalchowk, 4 months after the second earthquake. Outcomes were selected based on qualitative preparatory research and included symptoms of depression and anxiety (Hopkins Symptom Checklist-25); post-traumatic stress disorder (PTSD Checklist-Civilian); hazardous alcohol use (AUDIT-C); symptoms indicating severe psychological distress (WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS)); suicidal ideation (Composite International Diagnostic Interview); perceived needs (Humanitarian Emergency Settings Perceived Needs Scale (HESPER)); and functional impairment (locally developed scale). RESULTS: A substantial percentage of participants scored above validated cut-off scores for depression (34.3%, 95% CI 28.4-40.4) and anxiety (33.8%, 95% CI 27.6-40.6). Hazardous alcohol use was reported by 20.4% (95% CI 17.1-24.3) and 10.9% (95% CI 8.8-13.5) reported suicidal ideation. Forty-two percent reported that 'distress' was a serious problem in their community. Anger that was out of control (symptom from the WASSS) was reported by 33.7% (95% CI 29.5-38.2). Fewer people had elevated rates of PTSD symptoms above a validated cut-off score (5.2%, 95% CI 3.9-6.8), and levels of functional impairment were also relatively low. Correlates of elevated symptom scores were female gender, lower caste and greater number of perceived needs. Residing in Gorkha and Sindhupalchowk districts and lower caste were also associated with greater perceived needs. Higher levels of impaired functioning were associated with greater odds of depression and anxiety symptoms; impaired functioning was less strongly associated with PTSD symptoms. CONCLUSIONS: Four months after the earthquakes in Nepal, one out of three adults experienced symptoms of depression and distressing levels of anger, one out of five engaged in hazardous drinking, and one out of ten had suicidal thoughts. However, posttraumatic stress symptoms and functional impairment were comparatively less frequent. Taken together, the findings suggest that there were significant levels of psychological distress but likely low levels of disorder. The findings highlight the importance of indicated prevention strategies to reduce the risk of distress progressing to disorder within post-disaster mental health systems of care.

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda.

BACKGROUND: In this period of unprecedented levels of displacement, scalable interventions are needed to address mental health concerns of forced migrants in low-resource settings. This paper describes the adaptation and piloting of a guided, multi-media, self-help intervention, Self-Help Plus (SH+), which was developed to reduce psychological distress in large groups of people affected by adversity. METHODS: Using a phased approach that included community consultations, cognitive interviewing, facilitator training, pilot implementation, and a qualitative process evaluation, we adapted SH+ for use among South Sudanese refugees in a refugee settlement in northern Uganda. RESULTS: The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Juba Arabic. Cognitive interviewing primarily resulted in adaptations to language with some minor adaptations to content. Facilitator training and supervision led to further suggested changes to delivery methods. An uncontrolled pilot study (n = 65) identified changes in the expected direction on measures of psychological distress, functional impairment, depression, wellbeing, and psychological flexibility. The process evaluation resulted in further adaptations to intervention materials and the decision to focus future effectiveness evaluations of the intervention in its current form on South Sudanese female refugees. CONCLUSIONS: We found that this potentially scalable, guided self-help intervention could be adapted for and feasibly implemented among female South Sudanese refugees in northern Uganda. These findings lay the groundwork for a future rigorous evaluation of SH+ in this context.

Self Help Plus: study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda.

BACKGROUND: Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women. METHODS: A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators. DISCUSSION: This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity. TRIAL REGISTRATION: ISRCTN50148022; registered 13/03/2017.

Alcohol use and intimate partner violence among women and their partners in sub-Saharan Africa.

BACKGROUND: Alcohol use is a well-documented risk factor for intimate partner violence (IPV); however, the majority of research comes from high-income countries. METHODS: Using nationally representative data from 86 024 women that participated in the Demographic and Health Surveys, we evaluated the relationship between male partner alcohol use and experiencing IPV in 14 countries in sub-Saharan Africa (SSA). Using multilevel mixed-effects models, we calculated the within-country, between-country, and contextual effects of alcohol use on IPV. RESULTS: Prevalence of partner alcohol use and IPV ranged substantially across countries (3-62 and 11-60%, respectively). Partner alcohol use was associated with a significant increase in the odds of reporting IPV for all 14 countries included in this analysis. Furthermore, the relationship between alcohol use and IPV, although largely explained by partner alcohol use, was also attributable to overall prevalence of alcohol use in a given country. The partner alcohol use-IPV relationship was moderated by socioeconomic status (SES): among women with a partner who used alcohol those with lower SES had higher odds of experiencing IPV than women with higher SES. CONCLUSIONS: Results of this study suggest that partner alcohol use is a robust correlate of IPV in SSA; however, drinking norms may independently relate to IPV and confound the relationship between partner alcohol use and IPV. These findings motivate future research employing experimental and longitudinal designs to examine alcohol use as a modifiable risk factor of IPV and as a novel target for treatment and prevention research to reduce IPV in SSA.

A homozygous DPM3 mutation in a patient with alpha-dystroglycan-related limb girdle muscular dystrophy.

Defects of O-linked glycosylation of alpha-dystroglycan cause a wide spectrum of muscular dystrophies ranging from severe congenital muscular dystrophy associated with abnormal brain and eye development to mild limb girdle muscular dystrophy. We report a female patient who developed isolated pelvic girdle muscle weakness and wasting, which became symptomatic at age 42. Exome sequencing uncovered a homozygous c.131T > G (p.Leu44Pro) substitution in DPM3, encoding dolichol-P-mannose (DPM) synthase subunit 3, leading to a 50% reduction of enzymatic activity. Decreased availability of DPM as an essential donor substrate for protein O-mannosyltransferase (POMT) 1 and 2 explains defective skeletal muscle alpha-dystroglycan O-glycosylation. Our findings show that DPM3 mutations may lead to an isolated and mild limb girdle muscular dystrophy phenotype without cardiomyopathy.

A high-risk group of pregnant women with elevated levels of conflict-related trauma, intimate partner violence, symptoms of depression and other forms of mental distress in post-conflict Timor-Leste.

Women in low-income, post-conflict (LI-PC) [Corrected] countries are at risk of exposure to the traumatic events (TEs) of war and intimate partner violence (IPV), forms of stress that are known to lead to depression and other adverse mental health outcomes. We aimed to assess an index of exposure to these two forms of trauma to identify pregnant women attending antenatal clinics in conflict-affected Timor-Leste at high risk of depression and other forms of stress. A large, cross-sectional study of women in the second trimester of pregnancy was conducted in the four main government antenatal clinics in Dili district of Timor-Leste, between May 2014, and January 2015. The sample consisted of 1672 consecutive women, 3 to 6 months pregnant, with a response rate of 96%. We applied the Edinburgh Postnatal Depression Scale, the Kessler-10 psychological distress scale and the Harvard Trauma Questionnaire. IPV was assessed by the World Health Organisation measure. Composite categories of conflict-related TEs and severity of IPV showed a dose-response relationship with depressive symptoms: for exposure to four or more conflict-related TEs and severe psychological IPV, the adjusted odds ratio (AOR) was 3.95 (95% confidence interval (CI) 2.10-7.40); for four or more TEs and physical abuse, AOR 8.16 (95% CI 3.53-18.85); and for four or more TEs and severe psychological and physical abuse, AOR 9.78 (95% CI 5.31-18.02). For any mental distress, the AOR for four or more TEs and severe psychological abuse was 3.60 (95% CI 2.08-6.23); for four or more TEs and physical abuse 7.03 (95% CI 3.23-15.29); and for four or more TEs and severe psychological and physical abuse the AOR was 10.45 (95% CI 6.06-18.01). Of 184 women (11% of the sample) who reported ⩾ 4 TEs and either physical abuse alone or in combination with severe psychological abuse, 78 (42%) reached threshold for depressive symptoms and 93 (51%) for any mental distress, a 10-fold increase in depressive and other mental health symptoms. Priority should be directed to providing urgent mental health and social interventions for this group of women. Our findings offer a framework for a tiered approach to detection, guiding prevention and intervention strategies for IPV and associated mental health problems in low-income post-conflict countries.

Patterns of separation anxiety symptoms amongst pregnant women in conflict-affected Timor-Leste: Associations with traumatic loss, family conflict, and intimate partner violence.

BACKGROUND: Adult separation anxiety (ASA) symptoms are prevalent amongst young women in low and middle-income countries and symptoms may be common in pregnancy. No studies have focused on defining distinctive patterns of ASA symptoms amongst pregnant women in these settings or possible associations with trauma exposure and ongoing stressors. METHODS: In a consecutive sample of 1672 women attending antenatal clinics in Dili, Timor-Leste (96% response), we assessed traumatic events of conflict, ongoing adversity, intimate partner violence (IPV), ASA, post-traumatic stress disorder (PTSD) and severe psychological distress. Latent Class Analysis was used to identify classes of women based on their distinctive profiles of ASA symptoms, comparisons then being made with key covariates including trauma domains of conflict, intimate partner violence (IPV) and ongoing stressors. RESULTS: LCA yielded three classes, comprising a core ASA (4%), a limited ASA (25%) and a low symptom class (61%). The core ASA class reported exposure to multiple traumatic losses and IPV and showed a pattern of comorbidity with PTSD; the limited ASA class predominantly reported exposure to ongoing stressors and was comorbid with severe psychological distress; the low symptom class reported relatively low levels of exposure to trauma and stressors. LIMITATIONS: The study is cross-sectional, cautioning against inferring causal inferences. CONCLUSIONS: The core ASA group may be in need of immediate intervention given the high rate of exposure to IPV amongst this class. A larger number of women experiencing a limited array of non-specific ASA symptoms may need assistance to address the immediate stressors of pregnancy.

Stemming the tide: promoting mental health and preventing mental disorders in low- and middle-income countries.

The first World Health Organization's global action plan for mental health recognizes the importance of mental health promotion and prevention of mental disorders, through the inclusion of one of four objectives focused on this crucial area of research and practice. This paper aims to provide an 'aerial view' of the field of mental health promotion and prevention of mental disorders with a focus on low- and middle-income countries. Starting with reasons why promotion and prevention need to take center stage in global mental health efforts, the paper provides a framework and four general principles to guide such efforts: a socio-ecological perspective (place); an inter-sectoral and interdisciplinary approach (collaboration), a developmental perspective (timing), and a participatory and empowerment approach (strengths), or PaCTS. Evidence-based examples of mental health promotion, universal, selective, and indicated prevention are described.

Mental health and psychosocial support for children in areas of armed conflict: call for a systems approach.

This paper focuses on the question of whether separate attention to children who have faced specific conflict-related events is justified, or whether the scarce resources for mental health should be spent on the development of services for children more broadly in low- and middle-income countries (where most contemporary armed conflicts are taking place). It is argued that a systems approach to mental health and psychosocial support for children is warranted.