Veena A. Satyanarayana

Women reporting intimate partner violence in India: Associations with PTSD and depressive symptoms

Intimate Partner Violence (IPV) is prevalent worldwide and often has mental health sequelae. The aims of this study were (a) to describe the prevalence and the nature of PTSD symptoms among Indian women reporting IPV, (b) to study the relationship between symptoms of PTSD and depression, and (c) to examine the relationship between sexual coercion and PTSD symptoms. Consecutive women (n = 105) presenting to an adult psychiatry outpatient unit of National Institute of Mental Health and Neuro Sciences in South India were recruited. These women were assessed for IPV, sexual coercion, PTSD symptoms, and depression. Fifty-nine women (56%) reported a history of IPV, of whom 41 (70%) also reported sexual coercion. Among women reporting IPV, seven (14%) exceeded cut-off scores for PTSD and twelve (20%) exceeded cut-off scores for sub-threshold PTSD. The majority of those reporting IPV exceeded cut-off scores for a depressive disorder. Compared to women without a history of IPV, women reporting IPV had higher scores on PTSD and depression. Severity of violence and sexual coercion correlated positively (r = 0.39) with PTSD severity. The findings highlight the importance of screening women for IPV and its sequelae, in mental health settings.

Maternal mental health in pregnancy and child behavior.

Maternal mental health research is a public health priority due to its impact on both maternal and child health. Despite the growing number of empirical studies in this area, particularly from developing countries, there is a paucity of synthetic review articles. Therefore, attempting to synthesize the existing literature in this area seems relevant to appraise the readers of the fields progress and to infer directions for future research. The present review aims to provide an overview of the literature on maternal mental health and its association with birth outcomes and child behavior. Specifically, the literature on mental health during pregnancy and in the postpartum period and its influence on birth outcomes and child behavior have been reviewed. Further, a conceptual and methodological evaluation of the existing literature has been provided to identify gaps in the literature and to suggest directions for future research.

Gender disadvantage and common mental disorders in women

Research in the area of gender and mental health indicates that women are disproportionately affected by common mental disorders (CMDs) as well as co-morbid mental disorders. However, the concept of gender disadvantage, its correlates, and mental health outcomes has received relatively less research attention. In addition, there are no known systematic reviews in the area of gender disadvantage and common mental disorders in recent years. In this review we have therefore attempted to deconstruct the concept of gender disadvantage, identify important correlates of gender disadvantage and illustrate their influence on common mental disorders. Since gender is a social construct and is greatly influenced by ones culture and ethnicity, we have made an attempt to integrate international literature on the subject and highlight cultural and ethnic relevance of topics as they emerge. Finally, we have provided take home messages from existing literature, identified gaps in literature, and formulated directions for future research in this area.

Mental health consequences of violence against women and girls

Purpose of review Recent studies on mental health consequences of violence against women and girls were reviewed in a range of situations. Recent findings Although several studies continued to show cross-sectional associations between child sexual abuse (CSA) and mental health outcomes, a few prospective studies showed a robust association between CSA and depression. Studies on the impact of dating violence are still at a nascent stage and focus on antecedents of violence rather than its consequences. Women at higher risk, such as adolescents, migrants, the homeless, and women in the perinatal period have been studied and specific vulnerabilities identified. Women reporting bidirectional violence had higher rates of depression and post-traumatic stress disorder (PTSD). Cumulative violence, severity of violence, and recent violence are associated with higher morbidity. Studies among women in conflict zones have emphasized the role of different forms of sexual and physical violence on mental health. Summary Newer emerging areas that need more research include mental health consequences of women in conflict zones and among same sex relationships. There are also few studies on the violence experience of both older women and adolescents. The need to better delineate the psychopathology of complex manifestations of PTSD is underscored.

Factors influencing consent to HIV testing among wives of heavy drinkers in an urban slum in India.

Abstract The study examined the influence of socio cultural factors, perception of risk and exposure to violence on consent to HIV testing among at risk women in an urban slum. Married women chosen via a multistage probability sampling in a section of Bangalore, India, between 18 and 44 years, sexually active and considered to be at risk because of their husbands hazardous drinking were recruited for the study. Written informed consent was obtained and measures of risk behavior and violence were administered. Pretest HIV counseling was then conducted and consent for HIV testing was sought. Factors influencing refusal of and consent to HIV testing were documented. Data collected on 100 participants indicated that over half the sample (58%) refused consent for HIV testing. There were no significant differences between the groups who consented and those who refused on perception of risk and exposure to violence. Reasons women refused testing include the following: spouse/family would not allow it (40%), believed that they were not at risk or would test negative (29%) and underwent HIV testing during an earlier pregnancy (21%). Among those who consented for HIV testing, 79% did so because the testing site was easily accessible, 67% consented because testing was free and because the importance of HIV testing was understood. The findings highlight the role of social, logistic and awareness related factors in utilizing voluntary counseling and testing services by women in the slum community. They have important implications for HIV testing, particularly among at risk monogamous women.

Problem drinking among married men in India: comparison between husband's and wife's reports.

INTRODUCTION AND AIMS This study compared the husbands report and wifes report of her husbands problem drinking, among residents of an urban slum in Bangalore, India. DESIGN AND METHODS The data come from a feasibility study to prevent HIV infection among at-risk women in Bangalore. Household enumeration was carried out (n = 509) to choose 100 married men between 18 and 50 years who reported problem drinking (scores 8 and above) on the Alcohol Use Disorder Identification Test (AUDIT). Wives of these married men, considered to be at risk for HIV because of their husbands hazardous drinking, were subsequently recruited for the study (n = 100). Written informed consent was obtained; wives were asked about the drinking history of their husbands through the AUDIT-WR (Wifes Report) developed for the present study. RESULTS Prevalence of problem drinking in the enumerated sample (n = 509) was high (n = 186; 37%). The husbands report and his wifes report of his problem drinking was concordant (r = 0.57-0.75) on eight out of 10 items, and the total AUDIT score. DISCUSSION AND CONCLUSIONS The AUDIT-WR is a reliable and culturally relevant measure of husbands problem drinking. In India, men with problem drinking are hard to reach. Therefore, proxy report of the wife may be useful when the husband is either unavailable or uncooperative for assessment.

Should mental health assessments be integral to domestic violence research

Research on sensitive issues such as abuse and violence in vulnerable populations poses several ethical dilemmas. An important aspect is the impact of such enquiries on ones mental health. This paper discusses specific ethical issues related to mental health based on violence research conducted and reviewed by the authors. Research on violence among women includes the possibility that some revelations are occurring for the first time and are likely to be emotionally charged. Further, the very act of disclosure may involve emotional risks for the respondent. Psychological distress may be present prior to, during, or following the study. Hence assessing mental health parameters becomes essential and integral to research of this nature. Several issues in methodology are also important in mitigating the level of distress. Research on sensitive issues should either use measures developed in the same culture or those with adequate adaptation. The order of questions, language and method of termination of the interview may often make a difference to its psychological impact. While focus group discussions and semi structured interview schedules are most suited, questionnaires with a less structured and rigid approach may also be used. Preludes may be introduced to facilitate transition between different sections of an interview schedule and to provide a rationale for further enquiry. Obtaining informed consent in violence research should be a process rather than a one-time formality. Reports of adverse events are likely in violence research and hence such studies must include mental health intervention, ongoing follow up, documentation and appropriate referral services. Finally, since the researcher and the subject of the research are both affected in a study of this nature, adequate sensitisation, ongoing training and supervision of research staff are essential. Based on findings from ongoing research on violence and from review of other studies done in India, the paper will focus on best practices in addressing mental health issues in domestic violence research.

Suicidality in early pregnancy among antepartum mothers in urban India

This study assessed the prevalence and predictors of suicidality among 462 pregnant women in South India. Women in early pregnancy (<20 weeks) attending an urban public hospital antenatal center were assessed for suicidality using a modified version of the Suicide Behaviors Questionnaire–Revised (SBQR) and a single-item (item 10) from the Edinburgh Postnatal Depression Scale (EPDS). Severity of depressive symptoms, family violence, and perceived social support were also measured. The prevalence of suicidality in pregnancy was 7.6 % (35/462). Eleven women (2.4 %) reported having had suicidal plans, and 8 (1.7 %) had made a suicidal attempt during the current pregnancy. Younger age, belonging to a middle socioeconomic status, poor perceived support, domestic violence, depressive symptoms, and having a past history of suicidality predicted suicidal ideation during the current pregnancy. Multivariate analysis revealed depression severity and a life time history of suicidal ideation as being the strongest predictors. The findings underscore the need for assessment of psychiatric and psychosocial factors that confer risk among women in this vulnerable period. The results of the study however may be specific to low-income urban women from this geographical location limiting the external validity of our findings.

Mental health consequences of cannabis use.

I read with great interest the recent article by Pedersen (1). Cannabis is a widely used illegal drug worldwide. Very few studies have examined the impact of cannabis use on depression and suicidal behaviours (2) and hence the research question pursued in this study seems relevant. Strengths of the article also include a longitudinal design and control for a host of potentially confounding factors and reverse causality. A careful review of the article, however, reveals methodological limitations, which can be, overcome in future research in this area. Depression, an important outcome variable was measured by Kandel and Davies six item scale. None of these six items tap anhedonia, a cardinal symptom of depression. The measures also do not provide information about the presence of ICD-10 or DSM-IV lifetime and current depression and abuse and dependence to different substances. Future studies may therefore benefit from using structured diagnostic interview schedules which provide the above information. The authors have also not reported whether a proportion of the sample had received or were receiving treatment for depression. Further, the assessment of suicidal behaviours warrants a more comprehensive approach which elicits information about intentionality, lethality, inimicality and whether suicide attempts were made under the influence of a substance. Considering the above limitations in measurement, the conviction with which we can claim that early cannabis use predicted later suicidal behaviours but not depression is limited. Suicidal behaviours occurring in the absence of depression has been attributed to personality traits such as impulsivity (3) and hopelessness (4). Although the author attributed the above to impulsivity, this unfortunately was not supported by data. The number of respondents who met criteria for impulsivity and whether these respondents also endorsed suicidal behaviours was not reported. Both the neurophysiological and social process arguments provided by the author are not convincing enough. Future research therefore ought to replicate these findings and offer a better understanding of suicidal behaviours occurring in the absence of depression. Nevertheless, exploring mental health consequences of cannabis use has important implications for public health. Studies have demonstrated the effectiveness of cannabis derived substances in the treatment of medical illnesses, such as cancer and AIDS, resulting in demands to legalize the drug (5). Recent studies have also demonstrated the role of cannabis in psychotic and affective mental health outcomes (6). Riskbenefit assessment and policy decisions can only be made when adequate numbers of studies employing sound methodologies substantiate the above.

I have no peace of mind —psychosocial distress expressed by rural women living with HIV in India as part of a mobile health intervention—a qualitative study

This qualitative study assessed psychosocial concerns that rural women with HIV who had multiple psychosocial vulnerabilities were able to express and communicate during a mobile phone intervention delivered by nurses. The study is part of a pilot randomised controlled trial of an mHealth self-care intervention by nurses for women living with HIV in rural India. For the trial, 60 women were randomised to receive the mHealth intervention. All calls were recorded and call logs were maintained. Call logs of 59 women based on 1186 calls were scanned for psychosocial themes. Audio recordings of 400 calls rich in content were then transcribed and translated for analysis. Themes and subthemes were identified by two independent raters. Majority of the women had low literacy and more than half were widowed. Clinical depression was found in 18.6%. Of the 1186 call logs analysed, 932 calls had a record of at least one psychosocial concern and 493 calls recorded two psychosocial concerns. Some of the major themes that women discussed with nurses included worries about their own and their children’s future; loneliness; stigma; inadvertent disclosure; death and dying; abandonment by partner; financial difficulties; body image; poor social support; emotions such as sadness, guilt, and anger; and need for social services. Almost all expressed appreciation for the intervention. Findings indicate the usefulness of mHealth-based self-care interventions delivered by nurses in hard to reach women in low- and middle-income countries, especially those with multiple psychosocial vulnerabilities.