The impact of maternal depressive symptoms and traumatic events on early childhood mental health in conflict-affected Timor-Leste.

BACKGROUND: Longitudinal studies are needed to examine the association between maternal depression, trauma and childhood mental health in conflict-affected settings. AIMS: To examine maternal depressive symptoms, trauma-related adversities and child mental health by using a longitudinal path model in conflict-affected Timor-Leste. METHOD: Women were recruited in pregnancy. At wave 1, 1672 of 1740 eligible women were interviewed (96% response rate). The final sample comprised 1118 women with complete data at all three time points. Women were followed up when the index child was aged 18 months (wave 2) and 36 months (wave 3). Measures included the Edinburgh Postnatal Depression Scale, lifetime traumatic events and the Child Behaviour Checklist. A longitudinal path analysis examined associations cross-sectionally and in a cross-lagged manner across time. RESULTS: Maternal depressive symptom score was associated with child mental health (cross-sectional association at wave 2, ß = 0.35, P < 0.001; cross-sectional association at wave 3, ß = 0.33, P < 0.001). The maternal depressive symptom score at wave 1 was associated with child mental health at wave 2 (ß = 0.12, P < 0.001), and the maternal depressive symptom score at wave 2 showed an indirect association with child mental health at wave 3 (indirect standardised coefficient 0.23, P < 0.001). There was a time-lagged relationship between child mental health at wave 2 and maternal depression at wave 3 (ß = 0.08, P = 0.02). CONCLUSIONS: Maternal depressive symptoms are longitudinally associated with child mental health, and traumatic events play a role. Maternal depression symptoms are also affected by child mental health. Findings suggest the need for skilled assessment for depression, trauma-informed maternity care and parenting support in a post-conflict country such as Timor-Leste.

Longitudinal path analysis of depressive symptoms and functioning among women of child-rearing age in postconflict Timor-Leste.

This longitudinal study indicates that exposure to the traumas of mass conflict and subsequent depressive symptoms play an important role in pathways leading to functional impairment in the postconflict period among women of child-rearing age. Our study, conducted in Timor-Leste, involved an analytic sample of 1292 women recruited at antenatal clinics in the capital and its surrounding districts. Women were re-interviewed at home 2 years later (77.3% retention). We applied the Edinburgh Postnatal Depression Scale, the Harvard Trauma Questionnaire for conflict-related traumatic events, the WHO Violence Against Women Instrument covering the past year for intimate partner violence and the WHO Disability Assessment Schedule (WHODAS V.2.0) to assess functional impairment. A longitudinal path analysis tested direct and indirect relationships involving past conflict-related trauma exposure, depressive symptoms measured over the two time points and functional impairment at follow-up. The prevalence of predefined clinically significant depressive symptoms diminished from 19.3% to 12.8%. Nevertheless, there was a tendency for depressive symptoms to persist over time (ß=0.20; p<0.001). Follow-up depressive symptoms were associated with functional impairment (ß=0.35; p<0.001). Reported conflict-related trauma occurring a minimum of 6 years earlier (ß=0.23; p<0.001) and past-year physical intimate partner violence (ß=0.26; p<0.001) were each associated with depressive symptoms at baseline and at follow-up. A measure of poverty specific to the context and reported health problems in the mother and infant also contributed to depressive symptoms. The findings highlight the association between ongoing trauma-related depressive symptoms and the capacity of women in the childbearing age to function in multiple areas of their lives in a postconflict country. Recognition of these relationships is important in the formulation and implementation of contemporary international recovery and development policies applied to postconflict countries.

Erratum: Risk of perpetrating intimate partner violence amongst men exposed to torture in conflict-affected Timor-Leste - CORRIGENDUM.

[This corrects the article DOI: 10.1017/gmh.2018.16.].

Risk of perpetrating intimate partner violence amongst men exposed to torture in conflict-affected Timor-Leste.

BACKGROUND: A key issue in need of empirical exploration in the post-conflict and refugee mental health field is whether exposure to torture plays a role in generating risk of intimate partner violence (IPV), and whether this pathway is mediated by the mental health effects of torture-related trauma. In examining this question, it is important to assess the impact of socio-economic hardship which may be greater amongst survivors of torture in low-income countries. METHODS: The study data were obtained from a cohort of 870 women (recruited from antenatal clinics) and their male partners in Dili district, Timor-Leste. We conducted bivariate and path analysis to test for associations of men's age, socioeconomic status, torture exposure, and mental disturbance, with IPV (the latter reported by women). RESULTS: The path analysis indicated positive paths from a younger age, torture exposure, and lower socio-economic status amongst men leading to mental disturbance. Mental disturbance, in turn, led to IPV. In addition, younger age, lower socio-economic status, torture exposure, and mental disturbance were directly associated with IPV. CONCLUSIONS: Our data provide the first systematic evidence of an association between torture and IPV in a low-income, post-conflict country, confirming that low socio-economic status, partly related to being a torture survivor, adds to the risk. The high prevalence of IPV in this context suggests that other structural factors, such as persisting patriarchal attitudes, contribute to the risk of IPV. Early detection and prevention programs may assist in reducing the risk of IPV in families in which men have experienced torture.

Associations between bride price stress and intimate partner violence amongst pregnant women in Timor-Leste.

BACKGROUND: Reducing violence against women is a global public health priority, particularly in low-income and conflict-affected societies. However, more needs to be known about the causes of intimate partner violence (IPV) in these settings, including the stress of bride price obligations. METHODS: The representative study of women attending ante-natal clinics in Dili, Timor-Leste was conducted between June, 2013 and September, 2014 with 1672 pregnant women, a response rate of 96%. We applied contextually developed measures for the stress of bride price and poverty, and the World Health Organisation measure for intimate partner violence. RESULTS: Compared to those with no problems with bride price, women with moderate or serious problems with that custom reported higher rates of IPV (18.0% vs. 43.6%). Adjusting for socio-demographic factors, multivariate analysis revealed that ongoing poverty (OR = 1.75, 95% CI: 1.20-2.56) was significantly associated with IPV. Importantly, the strongest association with IPV was problems with bride price (OR = 2.73, 95% CI: 1.86-4.01). CONCLUSIONS: This is the first large consecutively sampled study to demonstrate a strong association between the stressors of bride price and poverty with IPV. Notably, bride price stress had the strongest association with IPV. Revealing this hitherto unrecognized factor of bride price stress may prove pivotal in guiding policy and interventions aimed at reducing IPV, and thereby improve the health and psychosocial status of women in low income and conflict-affected settings.

Six-year longitudinal study of pathways leading to explosive anger involving the traumas of recurrent conflict and the cumulative sense of injustice in Timor-Leste.

PURPOSE: Cumulative evidence suggests that explosive anger may be a common reaction among survivors of mass conflict. However, little is known about the course of explosive anger in the years following mass conflict, or the psychosocial factors that influence the trajectory of that reaction pattern. We examined these issues in a 6-year longitudinal study (2004-2010) conducted among adult residents of a rural and an urban village in Timor-Leste (n = 1022). METHODS: We derived a brief, context-specific index of explosive anger using qualitative methods. Widely used measures of post-traumatic stress disorder (PTSD) and severe psychological distress were calibrated to the Timor context. We developed an index of the cumulative sense of injustice related to consecutive historical periods associated with conflict in Timor-Leste. We applied partial structural equation modeling (SEM) to examine pathways from baseline explosive anger, socio-demographic factors, recurrent trauma, mental health indices (PTSD, severe psychological distress) and the sense of injustice, to explosive anger. RESULTS: Half of the sample with explosive anger at baseline continued to report that reaction pattern after 6 years; and a third of those who did not report explosive anger at baseline developed the response by follow-up. A symmetrical pattern of younger age, female gender and the trauma count for the preceding historical period predicted explosive anger at each assessment point. The sense of injustice was related to explosive anger at follow-up. Explosive anger was associated with impairment in functioning and conflict with the intimate partner and wider family. CONCLUSIONS: Sampling constraints caution against generalizing our findings to other populations. Nevertheless, our data suggest that explosive anger may persist for a prolonged period of time following mass conflict and that the response pattern is initiated and maintained by recurrent trauma exposure associated with a sense of injustice. Averting recurrence of mass violence and addressing persisting feelings of injustice may assist in reducing anger in conflict-affected societies. Whether explosive anger at the individual level increases risk of collective violence under conditions of social and political instability requires further inquiry.

Identifying a combined construct of grief and explosive anger as a response to injustice amongst survivors of mass conflict: A latent class analysis of data from Timor-Leste.

Previous studies have identified high rates of explosive anger amongst post-conflict populations including Timor-Leste. We sought to test whether explosive anger was integrally associated with symptoms of grief amongst the Timorese, a society that has experienced extensive conflict-related losses. In 2010 and 2011 we recruited adults (n = 2964), 18-years and older, living in an urban and a rural village in Timor-Leste. We applied latent class analysis to identify subpopulations based on symptoms of explosive anger and grief. The best fitting model comprised three classes: grief (24%), grief-anger (25%), and a low symptom group (51%). There were more women and urban dwellers in the grief and grief-anger classes compared to the reference class. Persons in the grief and grief-anger classes experienced higher rates of witnessing murder and atrocities and traumatic losses, ongoing poverty, and preoccupations with injustice for the two historical periods of conflict (the Indonesian occupation and the later internal conflict). Compared to the reference class, only the grief-anger class reported greater exposure to extreme deprivations during the conflict, ongoing family conflict, and preoccupations with injustice for contemporary times; and compared to the grief class, greater exposure to traumatic losses, poverty, family conflict and preoccupations with injustice for both the internal conflict and contemporary times. A substantial number of adults in this post-conflict country experienced a combined constellation of grief and explosive anger associated with extensive traumatic losses, deprivations, and preoccupations with injustice. Importantly, grief-anger may be linked to family conflict in this post-conflict environment.

Pathways to perinatal depressive symptoms after mass conflict in Timor-Leste: a modelling analysis using cross-sectional data.

BACKGROUND: The contributions of potentially traumatic events (PTEs) of mass conflict and post-traumatic stress disorder (PTSD) symptoms to perinatal depression in women living in low-income, post-conflict countries are unclear. We tested a model including these factors, intimate partner violence (IPV), and continuing adversity in women in Timor-Leste. METHODS: Our modelling study used cross-sectional data from a sample of women living in two districts in Timor-Leste, identified through service registers, clinic records, village chiefs, and a door-to-door survey between June, 2012, and June, 2013. Eligible women were 3-6 months pregnant or 3-6 months postpartum. We assessed conflict-related PTEs, IPV, continuing adversity (poverty and insecurity), PTSD symptoms (the Harvard Trauma Questionnaire), and maternal depressive symptoms (the Edinburgh Postnatal Depression Scale [EPDS]) to develop a theoretical model to examine pathways leading directly and indirectly to depressive symptoms. FINDINGS: We assessed 427 eligible women, of whom 258 (60%) were pregnant and 169 (40%) were postnatal. 87 (22%) of 387 women who were given the EPDS to complete were above the threshold used to define depression, and 40 (9%) of 427 were regarded as having PTSD. Our most comprehensive model showed that IPV and conflict-related deprivations led directly to depressive symptoms as well as to continuing adversity. Human rights-related trauma, witnessing murder, and a further path from IPV led to PTSD symptoms. Human rights-related trauma also led to continuing adversity. Paths from continuing adversity led to depressive symptoms, and PTSD symptoms, which was the predominant path. We noted a strong and unidirectional path from PTSD symptoms to depressive symptoms. INTERPRETATION: Protection of women from human rights abuses, prevention of IPV, reduction in insecurity and poverty in the post-conflict period, and identification of and treatment for PTSD symptoms might reduce the risk of perinatal depression in post-conflict, low-income countries. Longitudinal studies are needed to confirm these findings. FUNDING: Australian National Health and Medical Research Council.