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.

Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion.

This editorial proposes a shift in emphasis in the field of mental health epidemiology in conflict-affected settings. After a brief summary of the nature of contemporary armed conflicts, we consider the current and potential roles that epidemiology can play with regard to: (1) establishing the burden of mental disorders; (2) identifying risk and protective factors; and (3) intervention research. We advocate for improved methodological rigor; more attention to mixed methods approaches and multi-level longitudinal research; inclusion of the determinants of mental health beyond conflict-related violence; and consideration of a wider array of mental health outcomes. We particularly highlight the importance of expanding interest to epidemiological research that advances prevention and promotion interventions (e.g., in the early childhood period), in order to fill the gap between epidemiology and mental health practice in conflict-affected settings.

Glucocorticosteroid interactions with natural toxins: a mini review.

A growing area of research in pharmacology and toxicology is concerned with the role of adrenal glucocorticosteroids (predominantly corticosterone in rats and mice, and cortisol in humans) in modulating toxicological responses. These steroids are secreted from the adrenal cortex, and in laboratory rodents secretion occurs particularly in response to stressful environmental change or noxious challenge, which can include a toxic insult. Glucocorticoids have profound biochemical effects in diverse tissues (e.g., inhibition of DNA and RNA synthesis; effects on carbohydrate metabolism, protein catabolism, and immunosuppression, and anti-inflammatory effects). Given this range of pharmacological actions of glucocorticoids, effects on the response and tolerance to a toxic insult can be hypothesised. Indeed, it is now becoming clear that the toxicological response to a toxin can be modulated by pretreatment with, or coadministration of, natural glucocorticosteroids or their synthetic analogues. As achieving the maximum tolerated dose (MTD) in an experimental animal, whether via a natural toxin or a synthetic chemical, can be stressful, the implications of these findings are far reaching. This review is intended to illustrate the principle that the toxicological responses to natural toxins (e.g., kainic acid, aflatoxin B1, trichothecenes) can be modulated by corticosterone and other natural and synthetic glucocorticosteroids. Particular emphasis is given to neurotoxicity and hepatotoxicity in laboratory rodent models, but nephrotoxicity and cardiotoxicity, of which there are fewer studies, are also covered. Glucocorticoids can both enhance toxicity or protect against toxicity, and the direction of the effect depends on the target organ, the particular steroid, the properties of the toxin, and the temporal relationship of the coadministration regime.