Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review

Linnemayr, Sebastian PhD; Barreras, Joanna L. PhD; Izenberg, Max MSc; Brooks, Ronald A. PhD; Gonzalez, Ana BA; MacCarthy, Sarah DSc Author Information

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

It is estimated that one in 10 children (approximately 230 million children) currently live in a war or conflict-affected society and will be exposed to daily violence in their communities (UNICEF, 2016). Some may be forced into violent combat, and many more will experience familial, social and cultural losses (Betancourt, McBain, Newnham & Brennan, 2013; Betancourt, Meyers-Ohki, Charrow & Tol, 2013; IASC, 2014; Santa Barbara, 2006). It is generally accepted that children and young people exposed to violence in areas of conflict are at an increased risk of harmful effects, including injury, sexual abuse, disability, illness and long-term mental health issues or psychological problems. The harmful psychological effects of living through war or conflict include depression and anxiety disorders and post-traumatic stress symptoms (PTSS) such as flashbacks, nightmares or intrusive thoughts about the trauma, avoidance of people, places or activities related to the trauma, disturbed sleep, disturbed play in young children and somatic symptoms (Attanayake et al., 2009; Dimitry, 2012; Fasfous, Peralta-Ramírez & Pérez-García, 2013; Jordans, Tol, Komproe & de Jong, 2009; Slone & Mann, 2016; Yule et al., 2000). While most people will experience some post-traumatic stress symptoms following trauma, those whose symptoms persist and interfere with daily life may be diagnosed with post-traumatic stress disorder (PTSD). A meta-analysis of child and adolescent mental health in conflict affected settings estimated that prevalence rates were elevated for PTSD (47%, 17 studies, 95% CI: 35–60%), depression (43%, four studies, 95% CI: 31–55%) and anxiety (27% three studies, 95% CI: 21–33%) (Attanayake et al., 2009). This is compared to much lower lifetime prevalence estimates in the general population of, for example, American adolescents of 5% PTSD, 12% depressive disorder, 2.2% generalized anxiety disorder (Merikangas et al., 2010). A systematic review of the effect of war or conflict related violence on young children (age 0–6) found that prevalence of either PTSD or PTSS ranged from 8% to 45% (Slone & Mann, 2016). PTSD is the most common mental-health condition associated with exposure to war, conflict or political violence (Attanayake et al., 2009; Betancourt, Borisova, et al., 2013; Dimitry, 2012; McDermott, Duffy, Percy, Fitzgerald & Cole, 2013; Slone & Mann, 2016). As with adults, children suffering PTSD present with broad categories of post-traumatic stress symptoms (re-experiencing, avoidance/numbing and increased arousal). Younger children may display more overt aggression and destructiveness and re-experiencing symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams. Subjective experience of the event and peri-trauma factors, such as perceived severity and proximity, have been identified as possible risk factors for developing PTSD after trauma (Trickey, Siddaway, Meiser-Stedman, Serpell & Field, 2012). Post-trauma risk factors include low social support, poor family functioning (Trickey et al., 2012) and higher negative posttraumatic cognitions (Punamäki, Palosaari, Diab, Peltonen & Qouta, 2014). Finally, pre-trauma factors, such as a non-related mental health disorder, age and gender have also been linked to development of PTSD following war and conflict related violence. The exact nature of the relationship between age, gender and PTSD is unclear. There is some evidence suggesting that girls are at greater risk than boys because they may have higher levels of rumination or pre-trauma anxiety (McDermott et al., 2013), girls may be more likely to experience greater subjective exposure than boys, but boys may exhibit more externalizing problems in response to trauma such as increased aggression (Dimitry, 2012). It may be that this different pattern of response in boys and girls reflects socially constructed gendered norms of appropriate behaviour and inequitable distribution of power and agency between boys and girls, but gender inequalities are understudied in the context of war and conflict and trauma more generally (Gilfus, 1999). Concerning age, older children are more likely to have direct exposure to conflict related violence (Dimitry, 2012) but younger children may be more vulnerable to developing PTSD as they lack the cognitive capability to process trauma that older children have developed. Others have argued that younger children may actually be protected by their less developed cognitive capacity as they cannot fully comprehend the meaning and implications of war and conflict (Barenbaum, Ruchkin & Schwab-Stone, 2004). In recent years there has been a noticeable shift in attention to the influence of mediating variables (e.g., cultural context, family/community support and personal capacity) and the importance of these influences in reducing the impact of war or conflict (Tol, Reis, Susanty & de Jong, 2010; Tol, Song & Jordans, 2013). This understanding has informed preventative psychosocial interventions, which aim to strengthen and improve protective factors for children living in war affected societies in order to inoculate children against the harmful effects of exposure to war, conflict or political violence. Having fundamental (although possibly relative) elements included in a intervention such as promoting community, self-efficacy, a sense of hope, and feeling connected to a place may help reduce the negative effects of war (Betancourt, Borisova, et al., 2013; IASC, 2007). While PTSD is common in children exposed to war and conflict related violence, it is important to note that not all children exposed to trauma will go on to develop PTSD. Severe distress and fear is a normal reaction to trauma and there is substantial natural recovery in the initial months and years after a traumatic event (Bisson et al., 2010). For example Punamäki et al. (2014) showed that 12% of children aged 10–12 exposed to war in Gaza suffered relatively low amount of post-traumatic stress symptoms in the following year. A further 76% of children had initial high levels of symptoms but recovered within 11 months. A sizeable minority of 12% experienced initial severe levels of post-traumatic stress symptoms which increased over a year. It is important to recognise that immediate intervention may not be necessary, and in the case of critical incident stress debriefing (CISD) may in fact be harmful (NICE, 2013; Rose, Bisson, Churchill & Wessely, 2002). Providing an intervention too early may interfere with the natural recovery process. A Cochrane Review of 11 trials involving adults indicated that CISD should not be routinely implemented with victims of trauma (Rose et al., 2002). The current evidence base for the use of debriefing with children is low quality (Pfefferbaum, Jacobs, Nitiéma & Everly, 2015; Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015) and while there is no current evidence of harm there is little empirical support for its use (Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015). This raises important questions; when, if at all, should intervention be offered after a potentially traumatising event? How can we decide who does and does not need intervention to reduce the risk that PTSD will develop? Can at-risk children be identified, screened and offered appropriate interventions? This review focuses on psychosocial interventions that can be implemented with children following exposure to war and conflict-related violence and will only include early interventions that aim to prevent childhood PTSD. We define psychosocial intervention as any intervention that offers psychological or social support (or both) with a goal of helping to prevent mental disorders developing (in particular PTSD) and improve long-term mental health. Universal interventions are offered to everyone in a population, regardless of the level of their exposure to war or conflict related violence. Selective interventions are targeted at subpopulations who may be at a higher risk of developing mental disorders, for example, only those directly exposed to war and conflict related violence. Indicated interventions are aimed at those already displaying some symptoms of disorder and who may benefit from intervention to prevent PTSD developing. We intend to include all three levels of intervention in this review. The range of approaches that may be included in this review is broad. To illustrate the kinds of interventions that may be included we describe examples of potentially relevant interventions at each level. Psychological First Aid (PFA), currently recommended by humanitarian guidelines (Sphere Project, 2004) to reduce distress after a humanitarian disaster through providing practical help, linking to services to meet basic needs for food, shelter and safety, along with listening and providing care and comfort. A school based intervention that used mind-body techniques to reduce PTSS among children in Gaza (Staples, Gordon & Abdel Atti, 2011). A classroom-based intervention in Indonesia that focused on trauma processing and co-operative play to reduce post-traumatic stress symptoms and anxiety for children aged 8–12 affected by political violence (Tol, Komproe, Susanty, Jordans & De Jong, 2008). The interventions described above are not an exhaustive list and we will include any interventions that provide psychological and/or social support to children affected by war and conflict that aims to prevent PTSD developing. Interventions may be delivered as a one-off session, or over a number of weeks and they may be delivered by a trained professional or by a school-teacher. Interventions to prevent the development of PTSD may work on a number of levels, from directly addressing and processing trauma through to improving individual, family or community resiliency and reducing distress for example, Jordans et al. (2010) and Khamis, Macy, and Coignez (2004). We do not yet claim to know the full universe of interventions that have been tested in this area and so, what follows, is a summary of the known mechanisms through which these interventions typically aim to bring about positive change. One goal of this review will be to examine intervention components to try to identify which components relate to greater effects. By providing safe spaces for children to reduce the risk of further traumatisation and facilitate access to psychosocial support can reduce the risk of post-traumatic symptoms developing into PTSD. For example.'Child Friendly Spaces' (CFS), primary goal is to protect children from further harm and traumatisation by reducing their exposure to potentially traumatic events, including the victimisation and abuse that children are at high risk of in emergency humanitarian settings. Child Friendly Spaces gives children spaces where they can play safely, whilst also creating opportunities to access psychosocial support and screening (Ager, Metzler, Vojta & Savage, 2013). This focus on building community capacity through improved child protection to reduce risk of further trauma, and community level psycho-educational/awareness raising activities and events to help communities support traumatised children through greater understanding of normal reactions to trauma. Community level psychosocial interventions can encourage groups of participants to reflect on difficult times and aim to develop coping skills to allow them to face trauma-related experiences in a supportive social environment for example, Kumakech, Cantor-Graae, Maling, and Bajunirwe (2009). Peltonen and Palosaari (2013) connect the benefits of resiliency interventions on short-term impacts (e.g., reducing the likelihood of trauma-related symptoms) and long-term impacts (i.e., the child has a resource to draw upon for life), with improved relationships with their family and connectedness to their community. Community level interventions can also help to reduce stigma (Betancourt, Agnew-Blais, Gilman, Williams & Ellis, 2010). Many psychosocial support programmes include a community component in which children's engagement in their local community is thought to increase hope, social connectedness and prosocial behaviour, and to reduce externalising symptoms such as aggression by increasing awareness of, and attachment to, the wider social environment. Activities may include community events, volunteer work or public theatre (Constandinides, Kamens, Marshoud & Flefel, 2011). The literature suggests that, in order to be able to withstand the harmful effects of living in a conflict-affected society, it is vital for children to have loving, secure and consistent relationships with their caregivers (Betancourt, Borisova, et al., 2013; Qouta, Punamäki & El Sarraj, 2008; Thabet, Ibraheem, Shivram, Winter & Vostanis, 2009). Caregiver-focused support interventions aim to protect dependents from the adverse consequences of experiencing conflict-related harm by improving family structures, for example, improving the relationship between parent and child, increasing parental involvement and reducing the risk of parental stress (see Dybdahl, 2001). This may include improved parenting skills, improved attachment behaviours or parental psycho-education, all of which aim to assist parents in meeting the needs of their children and promoting their well-being. Psycho-education for example may work by helping parents to understand the symptoms of PTSD, how this may manifest in a child and how parents can best support their child after exposure to a traumatic event. Therapies based in groups, often within a psycho-educational or skills based therapeutic model, draw on an added mechanism of change by drawing on peer influence and support. Group settings are used to normalise experiences, to alleviate shame, to build cooperative behaviours and provide a forum to practice skills (Bolton et al., 2007). Classroom based interventions use much the same rationale, but with the addition of a real world setting to further normalise and integrate learning (Constandinides et al., 2011). These formats are also used given the larger number of beneficiaries that can be reached with few resources (O'Callaghan, McMullen, Shannon, Rafferty & Black, 2013). Interventions that use psycho-educational techniques endeavour to use education, information and insight to protect and promote well-being and to challenge misperceptions and taboos. Providing evidence-based information on traumatic reactions and living through the daily stressors of war is thought to help normalise experiences, to screen for more serious reactive disorders and encourage healthy and adaptive coping responses (Betancourt, Meyers-Ohki, et al., 2013). For example, Individual Psychological First Aid aims to strengthen mental health outcomes immediately after conflict by providing psycho-education on posttraumatic reactions and encouraging positive coping strategies in the immediate aftermath of the potentially traumatic events(s) (Betancourt, Meyers-Ohki, et al., 2013). Many psychosocial preventative interventions include teaching the ability to self-regulate emotions during or after a traumatic event occurring using, for example, breathing exercises, help seeking, social connectedness or positive self-talk. For example, Punamäki et al. (2014) evaluated the effectiveness of the psychosocial intervention 'Teaching Recovery Techniques' which is based on cognitive behavioural therapy (CBT) principles and provides several ways of increasing emotion regulation, expression and recognition. This in turn can help children to develop effective coping skills, to feel empowered and be able to regulate their emotions using narrative, imagery and psychoeducational techniques. Psychosocial preventative interventions that incorporate trauma processing techniques aim to facilitate the integration of traumatic memories into autobiographical memory in order to reduce PTSS and the risk of PTSD. Trauma processing is most commonly used to treat PTSD through narrative storytelling, such as in KidNET (Neuner et al., 2008) or imaginal and in vivo exposure to specific distressing, and often intrusive, memories, such as in Trauma-Focused CBT (TF-CBT; Brown et al., 2017). Some interventions have incorporated these techniques for children with PTSS as part of a wider aim of healing, through play and guided imagery (Peltonen & Punamäki, 2010), to help to integrate and assign meaning to traumatic experiences (Apfel & Simon, 1996) and for indicated secondary prevention interventions for children already displaying symptoms of PTSD (Tol et al., 2008). Some trauma focused interventions, usually derived from CBT, include the identification and evaluation of unhelpful thoughts and appraisals of traumatic experiences (such as self-blame) in order to help integrate fragmented and intrusive thoughts about traumatic experiences (Peltonen & Punamäki, 2010). Children living in areas of conflict are at elevated risk of negative mental, emotional and behavioural outcomes, including high rates of PTSS, PTSD and depression and anxiety problems (Attanayake et al., 2009; Dimitry, 2012). There are multiple studies on the immediate impact or war and conflict-related violence on children but few studies on the long-term impacts (Attanayake et al., 2009; Shaw, 2003), or on the impact psychosocial preventative interventions can have. Few reviews explicitly address the mechanisms of change (Betancourt, Borisova, et al., 2013; Brown et al., 2017; Peltonen & Punamäki, 2010). There is professional debate around which approach is most effective and least harmful to children living in war or conflict-affected societies, and whether only children with a diagnosed condition should be treated (Apfel & Simon, 1996; Betancourt, Borisova, et al., 2013). The inevitable fact of limited resources in these contexts may mean resources are directed to those who are perceived to be in most immediate need, at the expense of 'inoculating' all children from potential future problems. What is vital, as we have learned from the debriefing trials in adults, is that interventions should not be harmful or inadvertently disable adaptive responses to trauma. It is currently recommended that children exposed to war or conflict-related violence should not be given pharmacological intervention (IASC, 2007, 2014), so psychosocial interventions provide an important alternative response to try to prevent mental health problems developing. Not all children exposed to trauma will go on to develop PTSD but it is assumed what works for adults will work for children as well. However, there is no evidence to support this assumption and less still is known in what is effective to prevent PTSD for children aged under 11. Adults and adolescents can have broadly the same techniques applied in interventions but this does not apply so readily to children where there is a much larger gap and less clear guidance around what works. There is the potential for vast clinical relevance if we can understand more in this area, especially in the context of childhood PTSD and exposure to war and conflict-related violence. We don't yet know which children are most at risk of developing PTSD following trauma and which children are likely to recover without intervention. Nor do we know how best to screen for potential problems and who to offer intervention too as a result. One aim of this review will be to examine which children are most likely to benefit from intervention. There are a number of relevant existing reviews detailed below. Our review and existing/ongoing reviews differ in three ways. First we will not be limiting our inclusion criteria to studies conducted in low income countries. Second, we will not be limiting our review to randomised controlled trials. Finally, our review will focus on prevention of PTSD rather than treatment. Reviews which focus only on LMIC's (e.g., Purgato et al., 2014, 2015, 2016; Morina, Malek, Nickerson & Bryant, 2017; Brown et al, 2017) overlook interventions for trauma-exposed youth in high income countries (HIC), such as Northern Ireland, Cyprus and Israel. Reviews that only include RCTs (e.g., Purgato et al., 2014, 2015, 2016; Morina et al., 2017; O'Sullivan, Bosqui & Shannon, 2016; Brown et al., 2017) risk missing interventions developed and evaluated within the LMIC context. The well conducted trials tend to be based on interventions developed in the west and so by including only RCTs 'home grown' interventions may be excluded. This means they may not capture the interventions being delivered in the challenging context of ongoing conflict and violence with limited resources which precludes the use of RCT designs, for example studies like (Ager et al. (2011), Jordans, Tol, Ndayisaba, and Komproe (2013), Loughry et al. (2006); Thabet, Vostanis, and As our review is focused on prevention of PTSD rather than have been evaluated by existing reviews et al., 2015; Morina et al., 2017). reviews have narrative of existing interventions but have been limited in their & 2013; Betancourt, Borisova, et al., 2013; et al., 2013; Jordans et al., 2009; Jordans, & Tol, 2016; Peltonen & Punamäki, 2010), not focus on children in or conflict-affected settings et al., 2013; & 2010; & & or were not systematic reviews & 2010; & 2006). affected by war and may not have the resources or be in the to offer the and secure environment to the level of in an For these we intend to include controlled studies and studies to allow for the of including more and context specific interventions developed within whilst not from our review. the number and of ongoing and the of children affected by war and conflict related violence, this review is likely to be to and around the world and in conflict affected countries. To the effectiveness of psychosocial interventions for PTSD in young children aged years living in war and conflict-affected controlled trials and participants are to groups using a such as of or controlled studies with that studies in which have participants (or to intervention or we be We will not include studies with case studies, studies or case Children aged from to 11 years who have been exposed to war and conflict-related violence. including children older than 11 years can be included providing that the mean age of participants is under In the case of studies where the mean age of participants is older than will be to summary to effect for children under We are in that population which does not have a of PTSD. As PTSD is the most commonly diagnosed mental health condition we are in interventions which aim to protect and support young people from developing this disorder, rather than those which are as to those with a of PTSD. we will studies children who have a of PTSD. In studies with a population with and without or where PTSD not as we will include studies where the of participants have not been identified as meeting the criteria for PTSD and where it is clear that the intervention is aimed at PTSD developing into a We will also children who are or they are or to that affected by war and conflict-related violence. This is because we feel children and will have issues to stressors and we to focus on interventions for children who are still living in conflict settings or living with the aftermath of psychosocial intervention that has an of PTSD or reducing PTSS and is delivered in any conflict-affected setting (e.g., or to children or their compared with no as or any We define psychosocial interventions in this as any intervention that offers psychological or social support (or both) with a goal of helping to prevent mental disorders developing (in particular PTSD) and improve long-term mental health. Interventions aimed at children affected by one-off of (e.g., or a natural disaster will be as this population in not living under of violence, war or We will studies that include children with a of PTSD. We will also interventions whose focus is to treat PTSD rather than prevent Interventions which were to treat (e.g., may be included so as the intervention is being used to prevent PTSD and/or reduce We will only their specific or stress reactions and post-traumatic stress of include the Child & the Child Trauma and the for Children 2006). for example to future of for example or of include the et al., the or the for Children & 2012). relationships for example family peer relationships and attachment of include the & Cole, 1996) which children's attachment to symptoms as a potential traumatic reaction for example depression and specific example is the for Child et al., 1999). symptoms as a potential traumatic reaction for example behaviour and specific include the Child and the and and the Psychological Betancourt, and 2014). will use those outcomes with an to the of are we will provide a narrative of the We will include all in included For will be into categories of immediate and than months We will include any psychosocial intervention that has an of reducing PTSS or PTSD and is delivered in any setting (e.g., or to children or their The developed by the from relevant reviews and the from a of relevant trials. The were into those to the setting and intervention. for in the in and a list of potentially relevant Review each list and added any missing and The tested to that studies already identified were The for participants setting political and intervention We will use the in A to and for the below. possible specific will be applied (e.g., the use of age to the number of We will the following and we will not apply any or Cochrane of part of The Cochrane which the of the Cochrane Psychosocial and on all to to to including and to to of

Background Post Traumatic Stress Disorder (PTSD) is a psychiatric debilitating condition that can occur in individuals who experience extremely stressful or traumatic life events. Sexual assault is considered as one of the most traumatic stressor in life. Although few studies investigated the association between history of sexual assault and PTSD, no studies have examined the impact of age at sexual assault on PTSD.Method A cross-sectional telephone survey was conducted among adult female residents of Virginia from November 2002 to February 2003. A total of 1,769 women aged 18 and older were interviewed using a random digit dialing method. Detailed screening questionnaire was utilized to ascertain the occurrence of sexual assault, age at sexual assault and PTSD. The DSM-IV diagnostic criteria were used to define PTSD.Result The prevalence of PTSD among women with no history of sexual assault, those victimized before the age of 18 and 18 and above was 8.1%, 35.3%, and 30.2% respectively. Multivariate logistic regression model showed an increase risk of PTSD among women assaulted at a younger age. Compared to women with no history of sexual assault, women who were victimized before their 18th birthday were 2.8 times more likely to suffer from PTSD [OR=2.78 (95% C1=1.87- 4.23)]. The risk of PTSD among women victimized as adults was 2.6 times higher compared to women with no history of sexual assault [OR=2.59 (95%CI =1.43-4.70)].Conclusion This study provided important information on the association between PTSD and age at sexual assault. The risk of PTSD is relatively higher among those assaulted before the age of 18. The adverse effect of sexual assault as a risk for PTSD in addition to other negative health problems is a major public health concern. Primary prevention strategies should be in place to detect sexual assault victims and prevent the occurrence of PTSD.

Exposure to potentially traumatic events (PTE) is associated with a range of negative mental health outcomes, including post-traumatic stress disorder (PTSD) and complex PTSD (cPTSD). Although exposure to PTEs is highly prevalent, and their impact on mental health is pervasive, research is mostly limited to diagnosed populations or specific trauma cohorts in the post-pandemic era. We conducted an online survey of 1,000 Seoul residents from October 6-12, 2023, using a stratified sampling method. Participants were asked about their traumatic experiences, mental health outcomes, and experiences with mental health services. Most participants (98.8%) reported that they had experienced at least one PTE. The average number of PTEs reported was 9.19 (SD=7.908). Ninety participants (9%) were categorized as having probable PTSD (2.8% with PTSD only, and 6.2% with cPTSD). The sum of direct and indirect exposures to PTEs of individuals was associated with mental health outcomes, including PTSD symptom severity. Only 34.4% of patients with probable PTSD reported that they had received appropriate mental health services. Our results suggest that PTE exposures are highly prevalent, and self-awareness of mental health conditions and utilization of mental health services are low in South Korea. Given the lasting effects of traumatic events and the large number of untreated cases, this study highlights the need for proactive responses to traumatic events and better access to short- and long-term services for traumatized individuals.

Intimate partner violence (IPV) is a significant public health threat that contributes to a wide range of mental and physical health problems for victims. The purpose of this study was to examine IPV-related experiences and mental health outcomes among college students in Japan, Singapore, South Korea and Taiwan. The data were obtained from the Inter-University Consortium for Political and Social Research (ICPSR), the International Dating Violence Study (IDVS) 2001-2006 (ICPSR 29583; N = 981; Japan n = 207; Singapore n = 260; South Korea n = 256; Taiwan n = 258). Co-experience of physical IPV victimization and perpetration was associated with borderline personality traits and posttraumatic stress disorder (PTSD), but not with depression. Childhood sexual abuse, gender hostility and violence socialization were significant predictors of borderline personality traits, depression and PTSD. While country and gender variations in mental health are noted, there are two specific populations that may need special attention for mental health interventions: Taiwanese women especially for borderline personality traits and PTSD, and Japanese men especially for depression. IPV victimization and perpetration, childhood sexual abuse, gender hostility and violence socialization have a significant impact on the mental health of college students in Japan, Singapore, South Korea and Taiwan. Since IPV and mental health are significant public health issues, research on IPV and mental health consequences of IPV victimization and perpetration in these countries should be further expanded in order to better understand the interventions that will be effective in treating victims, perpetrators and victim/perpetrators of IPV.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Update on Posttraumatic Stress Disorder and Implications for Acute and Critical Care APRNs.

British Journal of Healthcare AssistantsVol. 15, No. 8 ProfessionalNavigating work and post-traumatic stress disorderDominic KenyonDominic KenyonRegistered Nursing AssociateSearch for more papers by this authorDominic KenyonPublished Online:11 Sep 2021https://doi.org/10.12968/bjha.2021.15.8.398AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bowirrat A, Chen TJH, Blum K et al. Neuro-psychopharmacogenetics and neurological antecedents of posttraumatic stress disorder: unlocking the mysteries of resilience and vulnerability. Curr Neuropharmacol. 2010 Dec;8(4):335–358. doi: https://doi.org/10.2174/157015910793358123 Crossref, Google ScholarBrewin CR. Re-experiencing traumatic events in PTSD: new avenues in research on intrusive memories and flashbacks. Eur J Psychotraumatol. 2015 May 19;6:27180. doi: https://doi.org/10.3402/ejpt.v6.27180. eCollection 2015 Crossref, Google ScholarCloitre M, Garvert DW, Weiss B, Carlson EB and Bryant RA. Distinguishing PTSD, complex PTSD and borderline personality disorder: a latent class analysis. Eur J Psychotraumatol. 2014 Sep 15;5. doi: https://doi.org/10.3402/ejpt.v5.25097. eCollection 2014. Google ScholarGold JA. COVID-19: adverse mental health outcomes for healthcare workers. BMJ. 2020 May 5;369:m1815. doi: https://doi.org/10.1136/bmj.m1815 Crossref, Google ScholarHabukawa M, Uchimura N, Maeda M et al. Differences in rapid eye movement (REM) sleep abnormalities between posttraumatic stress disorder (PTSD) and major depressive disorder patients: REM interruption correlated with nightmare complaints in PTSD. Sleep Med. 2018 Mar;43:34–39. doi: https://doi.org/10.1016/j.sleep.2017.10.012. Epub 2017 Nov 23 Crossref, Google ScholarLai J, Ma S, Wang Y et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020 Mar 2;3(3):e203976. doi: https://doi.org/10.1001/jamanetworkopen.2020.3976 Crossref, Google ScholarLee D. The hidden cost or workplace trauma: human nature at work. 1996. https://humannatureatwork.com/article/the-hidden-cost-of-workplace-trauma (accessed 20 August 2021) Google ScholarMalcolm-Smith S, Koopowitz S, Pantelis E, Solms M. Approach/avoidance in dreams. Consciousness and cognition. Conscious Cogn. 2012 Mar;21(1):408–412 Google ScholarMIND. Mental health facts and statistics. 2020. https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/ (accessed 20 August 2021) Google ScholarNHS. Overview—post-traumatic stress disorder (PTSD). 2018. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/ (accessed 20 August 2021) Google ScholarNewman C, Roche M, Elliott D. Exposure to workplace trauma for forensic mental health nurses: a scoping review. Int J Nurs Stud. 2021 May;117:103897. doi: https://doi.org/10.1016/j.ijnurstu.2021.103897. Epub 2021 Feb 4 Crossref, Google ScholarPTSDUK. Post-traumatic stress disorder explained. 2021. https://www.ptsduk.org/what-is-ptsd/ptsd-explained/ (accessed 20 August 2021) Google ScholarRibeiro-Nelson C. Managing traumatic events in the workplace. 2018. UK-EAPA-Factsheet-Managing-traumatic-events-in-the-workplace-January-2018.pdf9 (accessed 20 August 2021) Google ScholarRitchie H, Roser M. Mental health. 2018. https://ourworldindata.org/mental-health (accessed 20 August 2021) Google ScholarRossi R, Socci V, Pacitti F et al. Mental health outcomes among healthcare workers and the general population during the COVID-19 in Italy. Front Psychol. 2020 Dec 8;11:608986. doi: https://doi.org/10.3389/fpsyg.2020.608986. eCollection 2020 Crossref, Google ScholarSellbom M, Bagby RM. Identifying PTSD personality subtypes in a workplace trauma sample. J Trauma Stress. 2009 Oct;22(5):471–475. doi: https://doi.org/10.1002/jts.20452 Crossref, Google ScholarSleep Foundation. How trauma can affect dreams: how to cope. 2020. https://www.sleepfoundation.org/dreams/how-trauma-can-affect-dreams (accessed 20 August 2021) Google ScholarTull M. Recognising hyperarousal symptoms in PTSD—a heightened state of anxiety after extreme trauma. 2020. https://www.verywellmind.com/hyperarousal-2797362 (accessed 20 August 2021) Google ScholarWorld Health Organization. Depression. 2020. https://www.who.int/news-room/fact-sheets/detail/depression (accessed 20 August 2021) Google Scholar FiguresReferencesRelatedDetails 2 September 2021Volume 15Issue 8ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 11 September 2021 Published in print 2 September 2021 Information© MA Healthcare LimitedPDF download

Global mental health and HIV care: gaps and research priorities.

LettersJuly 2023Mental Health and Health-Related Quality of Life After Firearm Injury: A Preliminary Descriptive StudyFREESydney C. Timmer-Murillo, PhD, Sarah J.H. Melin, MPH, Carissa W. Tomas, PhD, Timothy J. Geier, PhD, Amber Brandolino, MS, Andrew T. Schramm, PhD, Christine L. Larson, PhD, Terri A. deRoon-Cassini, PhDSydney C. Timmer-Murillo, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Sarah J.H. Melin, MPHMedical College of Wisconsin, Milwaukee, Wisconsin, Carissa W. Tomas, PhDDivision of Epidemiology & Social Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, Timothy J. Geier, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Amber Brandolino, MSDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, and Division of Data Surveillance & Informatics, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, Wisconsin, Andrew T. Schramm, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Christine L. Larson, PhDDepartment of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, Terri A. deRoon-Cassini, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, and Division of Data Surveillance & Informatics, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WisconsinAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0309 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Firearm injury is a public health crisis in the United States (1). Organizations have called for the consideration of long-term consequences of firearm violence, particularly for those directly impacted. Interpersonal firearm violence survivors report significantly worse physical health and functioning compared with the general population and other mechanisms of traumatic injury (1). Furthermore, firearm violence impacts the mental health of survivors and communities. Yet, there is limited work examining self-reported mental and physical health consequences of firearm violence for survivors acutely after injury, thwarting health care systems' ability to comprehensively intervene.Objective: To describe the mental health symptoms and health-related quality of life of firearm injury survivors 6 months after injury.Methods: A convenience sample of 87 adults was recruited from the trauma service of a level 1 trauma center in a midwestern, mid-sized city. Data were pooled from 2 studies occurring at the same center between the years of 2014 to 2016 and 2017 to 2021; both studies examined psychological and biological outcomes of traumatic injury (2). Participants were recruited in the emergency department or during hospitalization. Inclusion criteria were: 1) being 18 years of age or older, 2) having a Glasgow Coma Scale score of at least 13 on arrival, 3) having an unintentional suicidal self-injury, and 4) communicating in English. Exclusion criteria were: 1) experiencing loss of consciousness greater than 30 minutes, 2) experiencing posttraumatic amnesia for more than 24 hours, or 3) being in police custody. Although both studies recruited participants with all mechanisms of injury, the current investigation presents data on patients with interpersonal firearm-related injuries. Baseline sessions occurred up to 1 month postinjury and follow-up approximately 6 months after injury. After consent, participants completed measures on posttraumatic stress disorder (PTSD; PTSD Symptom Checklist for DSM-5); depression, anxiety, and stress (Depression, Anxiety, and Stress Scale [DASS-21]); and physical health-related quality of life (Short Form 12). Studies were approved by the Medical College of Wisconsin institutional review board and were funded by the National Institute of Mental Health. The funding organization was not involved in study design, data collection, or analyses.Findings: The Table provides demographic characteristics and outcome variables at baseline and 6 months. At baseline, patients exhibited symptoms of PTSD with a mean score of 27.15 (SD, 19.19), but symptoms were more severe at 6 months at a mean score of 38.66 (SD, 19.91). The PTSD mean score was above the recommended diagnostic cutoff of 34 for PTSD after interpersonal trauma and was higher than previous injury samples (3). Using interpretation guidelines from DASS-21, anxiety was "mild" at baseline with a mean score of 9.28 (SD, 9.23) and "moderate" at 6 months with a mean score of 11.20 (SD, 11.17). Depressive symptoms were in the "normal" range at baseline with a mean score of 7.25 (SD, 8.91), and higher at 6 months, nearing the cutoff to mild range at a mean score of 9.56 (SD, 10.87). Patients reported normal stress levels at a mean score of 9.52 (SD, 9.31) at baseline. Although reported stress was higher at 6 months with a mean score of 12.93 (SD, 11.29), it was still within the normal range. Patients' health-related quality of life was poor at baseline at a mean score of 30.48 (SD, 13.94), remained poor at 6 months with a mean score of 30.45 (SD, 19.22), and was well below scores reported in previous studies of both injury populations and the general population (4). The Figure shows changes in outcome measures from baseline to 6 months.Table. Sample Demographics, and Mental Health and Health-Related Quality-of-Life Descriptive StatisticsCharacteristicDescriptive StatisticRangeSex, n (%) Female77 (88.5)– Male10 (11.5)–Race, n (%) Asian1 (1.1)– Black/African American69 (79.3)– Hispanic/Latinx11 (12.6)– White/European American6 (6.9)–Psychiatric history,* n (%) Yes36 (41.4)– No50 (57.5)–Mean age (SD), y32.96 (10.06)18–57Mean Injury Severity Score (SD)13.12 (8.49)1–43Mean PCL-5–PTSD score† (SD) Baseline (n = 87)27.15 (19.19)1–72 6 mo (n = 41)38.66 (19.91)2–73Mean DASS-21–Anxiety score† (SD) Baseline (n = 87)9.29 (9.23)0–42 6 mo (n = 41)11.20 (11.17)0–42Mean DASS-21–Depression score† (SD) Baseline (n = 87)7.25 (8.91)0–42 6 mo (n = 41)9.56 (10.87)0–42Mean DASS-21–Stress score† (SD) Baseline (n = 87)9.52 (9.31)0–38 6 mo (n = 41)12.93 (11.29)0–42Mean SF-12 Physical Health score‡ (SD) Baseline (n = 87)30.48 (13.94)5.17–55.48 6 mo (n = 41)30.45 (19.22)0–60.73DASS-21 = Depression, Anxiety, Stress Scale; PCL-5 = PTSD Checklist for DSM-5, measure of PTSD symptom severity; PTSD = posttraumatic stress disorder; SF-12 = Short Form 12, for physical health.* One participant declined to answer.† Higher scores are indicative of worse symptoms for PTSD, Depression, Anxiety, and Stress.‡ Lower scores are indicative of poorer health for Physical Health. Download table Table. Sample Demographics, and Mental Health and Health-Related Quality-of-Life Descriptive StatisticsFigure. Mental and physical health outcome variables across time.Error bars depict SE. DASS-21 = Depression, Anxiety, and Stress Scale; PCL-5 = PTSD Checklist for DSM-5, measure of PTSD symptom severity; PTSD = posttraumatic stress disorder; SF-12 = Short Form 12, for physical health.* Lower SF-12 scores correspond to poorer health. General population average from Haider et al (4). Download figure Download PowerPoint Discussion: The need to understand the physical and mental health consequences of firearm injury in the United States is vital. In this preliminary descriptive study, firearm injury survivors reported poor PTSD acutely after the injury that persisted at 6 months. Furthermore, these patients endorse poor physical health–related quality of life across time, with values worse than previously studied injury samples (4). Medical advancements have increased the survivability of firearm injury, though survivors still carry the burden of injury as the mental and physical health outcomes seem poorer relative to the general population and those who have sustained other traumatic injuries (1, 4). These findings must be considered within the context of limitations including the small convenience sample, relatively short follow-up, and lack of data on preinjury mental health comorbidity. However, this preliminary study highlights the needs to better understand and manage the mental health consequences of firearm injury. Early screening and comprehensive care may improve outcomes in this at-risk population.

Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care

BackgroundChildhood maltreatment and HIV are both associated with a greater risk for adverse mental health, including posttraumatic stress disorder (PTSD), depression, and increased systemic inflammation. However, it remains unknown whether childhood maltreatment and HIV interact to exacerbate PTSD, depression, and inflammation in a manner that may further increase the risk of adverse health outcomes in people living with HIV. This study investigated the interaction between childhood maltreatment and HIV status on PTSD and depression symptom severity, and on peripheral concentrations of lipopolysaccharide (LPS) and high sensitivity C-reactive protein (hsCRP) in women. We hypothesized that women living with HIV (WLWH) who report high levels of childhood maltreatment exposure would show the greatest PTSD and depressive symptoms, as well as the highest concentrations of LPS and hsCRP.MethodsWe conducted a cross-sectional study of 116 women (73 WLWH and 43 women without HIV). Participants completed interviews to measure trauma exposure, including childhood maltreatment, and PTSD and depression symptoms. They also provided blood samples that were analyzed for LPS and hsCRP concentrations.ResultsBoth women living with and without HIV reported high rates of trauma exposure and showed no statistically significant differences in overall rates of childhood maltreatment. Moderate to severe childhood maltreatment was associated with higher PTSD symptom severity (p =.005), greater depression severity (p =.005), and elevated plasma LPS concentrations (p =.045), regardless of HIV status. There were no effects of childhood maltreatment on hsCRP concentrations. There were no detectable significant effects of HIV status, or interactions between HIV status and childhood maltreatment, on PTSD and depression symptoms, or LPS and hsCRP concentrations (all p’s > 0.05).ConclusionsOur findings highlight the impact of childhood maltreatment on depression and PTSD symptoms and LPS concentrations in women. These results underscore the importance of trauma-informed health care in addressing childhood maltreatment to potentially improve both mental and physical health outcomes of adult women.

Bill, a 35-year-old journalist working for a local radio station, was sent to report from the scene of a bomb attack that resulted in several fatalities. What he witnessed
\nat the scene distressed him greatly. Immediately afterward, he began repeatedly to re-experience what had happened, leading him to avoid either discussing or thinking about it. He continued to work, but he lost interest in things
\naround him. He became withdrawn, irritable, and hypervigilant. These symptoms rapidly diminished over the first few weeks, but then 1 month after the attack they began to increase again for no apparent reason. What is the differential diagnosis? How should Bill’s symptoms
\nbe managed?

The mental and maternal health of women in flood-affected areas in Pakistan: a call for action