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

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Derrick Silove, Mohammed Mohsin, Louis Klein, Natalino De Jesus Tam, Mark Dadds, Valsamma Eapen, Wietse A Tol, Zelia da Costa, Elisa Savio, Rina Soares, Zachary Steel, Susan J Rees


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 (β=0.20; p<0.001). Follow-up depressive symptoms were associated with functional impairment (β=0.35; p<0.001). Reported conflict-related trauma occurring a minimum of 6 years earlier (β=0.23; p<0.001) and past-year physical intimate partner violence (β=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.

Summary box

What is already known?

  • Exposure to violence has been established as a major contributor to symptoms of common mental disorders in general populations.

  • Women have been shown to suffer higher risk of depressive symptoms than their male counterparts, particularly women raising children.

  • Depressive symptoms can be associated with high levels of functional impairment.

What are the new findings?

  • Women in the childbearing age exposed to past mass conflict are at risk of ongoing depressive symptoms in the postconflict period.

  • Recent exposure to intimate partner violence adds to the burden of depressive symptoms among these women, as does poverty and ill health in the mother and infant.

  • Women with persisting depressive symptoms are more functionally impaired in multiple areas of their lives.

What do the new findings imply?

  • By detecting and intervening early, agencies involved in providing mental health services in lowresource conflict-affected settings may be able to avert risk of functional impairment among women in the childbearing period.

  • Identifying families in which intimate partner violence is ongoing and implementing strategies to overcome the problem may contribute to reducing depressive symptoms and increase functioning among women in the childbearing age in conflict affected countries