Citation: Tsai AC (2017) Lay worker-administered behavioral treatments for psychological distress in resource-limited settings: Time to move from evidence to practice? PLoS Med 14(8): e1002372. https://doi.org/10.1371/journal.pmed.1002372
Published: August 15, 2017
Copyright: © 2017 Alexander C. Tsai. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No specific funding was received to support the writing of this Perspective. ACT acknowledges salary support through US National Institutes of Health K23MH096620. The funder had no role in the decision to publish or the preparation of the manuscript.
Competing interests: ACT receives a stipend as a specialty consulting editor for PLOS Medicine and serves on the journal's editorial board.
Abbreviations: EUC, enhanced usual care; PM+, Problem Management Plus
Provenance: Commissioned; not externally peer reviewed
Exposure to nonlethal violence is, apart from its resulting physical injury or other adverse health sequelae, one of the most consistently estimated causal risk factors for psychological distress, mental and substance use disorders, suicidal behaviors, and completed suicide [1–7]. Throughout sub-Saharan Africa, a strong gendered patterning in these exposures has been observed, and the rates of intimate partner and nonpartner violence against women in this region are among the highest in the world [8–11]. Even were health systems in sub-Saharan Africa equipped, contrary to fact [12, 13], to handle the additional burden of mental health service delivery for affected populations, most survivors of violence never seek or obtain proper treatment . In many settings, care-seeking behaviors are severely compromised by stigma, gender-inequitable norms, and inadequate legal protections . Further, screening of asymptomatic women has not been shown to be a useful approach for improving health outcomes [15, 16].
In the face of these significant structural challenges, considerable progress has been made in the past 2 decades on the development, implementation, and evaluation of behavioral interventions in resource-limited settings. Recently published studies have convincingly demonstrated that lay health workers can be trained and supervised to deliver low-intensity behavioral interventions (“task shifting”) of adequate dose and timing to improve health outcomes in a variety of vulnerable populations, including pregnant women [17–21]; adults with common mental disorders [22–25], schizophrenia , and alcohol use disorders ; and survivors of torture and other forms of interpersonal violence [28–30]. Thus, task shifting should be viewed as a valid and effective approach for expanding access to evidence-based psychological interventions in settings where underfunded mental health systems lack the capacity to address unmet population mental health needs.
It is in this context that we celebrate the publication, in this issue of PLOS Medicine, of the findings from a randomized controlled trial by Bryant and colleagues  designed to estimate the efficacy of a brief, manualized, lay worker-administered, behavioral intervention (“Problem Management Plus,” or PM+) on reducing psychological distress among women survivors of interpersonal violence living in periurban settlements near Nairobi, Kenya. Of note, the PM+ intervention tested in this study—and in a companion study conducted in Pakistan, the findings of which were recently published by Rahman and colleagues —is of lower intensity compared with most of the interventions tested in the studies cited above. Bolton and colleagues , for example, tested the efficacy of a 16-session group interpersonal therapy intervention, while Bass and colleagues  tested the efficacy of a 12-session individual and group cognitive processing therapy intervention. PM+ adopts a “transdiagnostic” approach, which presses treatment elements commonly employed in evidence-based psychological interventions (e.g., psychoeducation, behavioral activation, and cognitive restructuring) into the service of addressing symptoms characteristic of a broad range of distress states . These distress states are referred to as “common mental disorders” because they are often encountered in the community or at the level of primary care, frequently manifesting with a mixed picture of anxiety, depressive, and unexplained somatic symptoms. Transdiagnostic interventions are particularly amenable to task shifting to meet the mental health burden occasioned by such presentations, because they skirt the need for lay health workers to formulate a definitive or even working diagnosis and select from a portfolio a theory-driven intervention to address the hypothesized basis for the observed signs and reported symptoms—tasks that may be especially challenging for already overburdened lay health workers when a patient presents with potentially comorbid mental disorders and overlapping symptoms. Thus, while the findings of this study’s predecessors [17–30] all support the feasibility of the task-shifting approach, PM+ may have even greater appeal in settings where implementation and supervisory capacity are particularly limited.
Bryant and colleagues  enrolled 421 women with a history of exposure to interpersonal violence and who were impaired by psychological distress. Three-quarters reported a lifetime history of physical violence, and one-half a history of sexual violence; one-fifth reported suicidal ideation in the month prior to enrollment. Remarkably, the study also included, but did not emphasize the data from, 97 women who met the inclusion criteria for impairment and distress but who did not report a history of exposure to interpersonal violence. This design choice permitted the investigators to minimize any potential stigma  attached to participation in a study that otherwise would have been framed as targeting survivors of interpersonal violence. After 3 months of follow-up, with a 24% attrition rate, study participants allocated to PM+ had a 3.3 lower mean score on the General Health Questionnaire compared with participants assigned to enhanced usual care (EUC, or nurse-provided, nonspecific counseling). Expressed in terms of its effect size, the magnitude of this observed treatment effect is comparable to what has been observed in short-term randomized trials of antidepressant medication [34, 35] and collaborative care [36, 37] treatment of depressive disorders. Smaller differences were observed on the secondary outcomes of functional impairment and symptoms of post-traumatic stress, perhaps suggesting broad-spectrum, transdiagnostic utility.
Bolstered by the findings of 2 positive studies conducted in very different cultural contexts [31, 32], is PM+ ready for widespread implementation? Our collective interpretation of the estimates presented by Bryant and colleagues  is subject to 3 important limitations, 2 of which were touched upon by the authors.
First, while allocation to the PM+ intervention arm appears to have reduced symptom severity across several domains, because of the study design, we lack certainty about whether the observed treatment effects resulted from PM+ itself or from other potentially confounding influences linked to treatment allocation. Uptake of the intervention was relatively high, with more than one-half of women allocated to the PM+ arm ultimately completing all 5 sessions (compared with a much smaller proportion of women allocated to the EUC arm), and the number of sessions attended was correlated with greater symptom reduction. Further, as the authors note, the home visit itself could have acted as a salubrious active ingredient independent of any effects of the PM+ components, given that the EUC sessions took place at primary health care centers and also given that systematic differences in contact time—which was uncontrolled—could have emerged. Neither is there evidence of mechanistic specificity, which could have been provided (e.g., by collecting data on potentially mediating variables such as the Behavioral Activation for Depression-Short Form ) had concerns about respondent burden not required the authors to minimize the length of the survey. Therefore, it is possible that the observed treatment effects represent, at least in part, nontrivial biases away from the null.
A second important limitation of the study is the short duration of follow-up. Certainly, the common mental disorders targeted by PM+ and the other brief interventions tested in this literature are characterized by symptoms and impairment of relatively low severity. On the other hand, effective treatment of syndromal illnesses prone to relapse or recurrence, such as major depressive disorder or post-traumatic stress disorder, would require the mobilization of considerably more resources for continuation and maintenance treatment. For example, up to one-half of patients with major depressive disorder experience recurrent episodes in a given year [39–42], and the median duration of episodes is 3–5 months [39, 43, 44]. Presumably, if resources were so limited in a particular setting that a brief behavioral intervention such as PM+ was being considered for widespread implementation, then its use for longer-term maintenance treatment would be out of the question. To demonstrate efficacy in preventing recurrence of future illness episodes, a study would need to show benefit for at least 6 months after remission of symptoms [45, 46]. Alternatively, PM+ could potentially be embedded within a larger collaborative care treatment apparatus, its role limited to episodic, short-term treatment of psychological distress associated with significant impairment (with tailored alternatives such as medication management to be made available for nonresponders or treatment-refractory cases); evidence to support efficacy in this context could be derived from a sequential multiple assignment randomized trial to estimate an optimal dynamic treatment regime.
Third, while Bryant and colleagues  elicited women’s histories of exposure to interpersonal violence upon entry into the study, they did not assess re-exposure to interpersonal violence during the study as a secondary outcome. Their failure to do so represents somewhat of a missed opportunity. (It should be noted that statistically significant improvements were not observed on the Life Events Checklist, which includes exposure to physical and sexual violence among the 16 events assessed, but these were not analyzed separately.) In general, there has been little discussion about the potential role for individual-level behavioral interventions in the secondary and tertiary prevention of violence against women . Concerns about victim blaming have hampered empirical research into understanding how individual-level characteristics of survivors may be predictive of subsequent re-exposure to interpersonal violence [5, 48]. Acknowledging the need for this sensitivity, it should be noted that a key role has been proposed for individual-level variables such as psychological distress, relational disruption, self-blame, emotional numbing, impaired risk perception, and affect dysregulation in conceptual models linking exposure and re-exposure to interpersonal violence [49–54]. Consistent with these models, longitudinal studies in multiple contexts have demonstrated a potentially bidirectional relationship between exposure to interpersonal violence and elevated psychological distress [5, 54–58]. Similarly, the United States–based randomized controlled trial by Iverson and colleagues  found that a cognitive processing therapy intervention to treat symptoms of depression and post-traumatic stress among women survivors of interpersonal violence successfully reduced the probability of re-exposure to violence at 6-month follow-up. Given these disparate strands of research, it is possible that brief interventions like PM+ might exert similar beneficial preventive impacts on interrupting the vicious cycle between interpersonal violence and psychological distress—perhaps either only in settings where a broad array of related services are available (e.g., case management, safety planning, crisis services, legal advocacy, emergency shelters, transitional housing, and/or parenting and childcare support ) or through combination interventions in which some of these elements are packaged together with PM+. At this time, the field will have to wait until the next study before these hypotheses are adequately tested.
Despite these limitations, PM+ has considerable appeal. The nature of the intervention content augurs well for the possibility of finding evidence of longer-term benefit, given that the skills learned during treatment sessions can be practiced long after treatment is discontinued. This feature would give PM+ and related behavioral interventions an advantage over medication-driven treatment strategies  in settings where the rare prescriber is available yet pharmacies are beleaguered by frequent stock outs. Even if PM+ turns out not to be cost saving, it may still be cost-effective in providing value for money. One might reasonably expect the costs (i.e., of training, of visits occurring with greater frequency during acute-phase treatment, etc.) to be front-loaded and for any incremental cost-effectiveness ratios to be more favorably estimated in studies of longer duration. Further evidence to support the cost-effectiveness of PM+ might be gained by directly measuring collateral outcomes related to functional impairment of index participants, including improved economic productivity [22, 62–65] or parenting behaviors (and attendant child outcomes) [66, 67], or reduced need for informal support from family caregivers .
The potential widespread deployment of PM+ stands at the intersection of 2 vital issues relevant to women’s health: mental health and interpersonal violence. Until the large-scale structural forces that give rise to health disparities affecting vulnerable populations can be eliminated—poverty, gender-inequitable norms, differences in social and economic power, and so forth [60, 69, 70]—the health system will continue to play a key role in the multisectoral response to violence against women in resource-limited settings. Bryant and colleagues  appropriately recognize the need for long-term implementation trials to establish the feasibility and sustainability of PM+ when deployed at scale. Their study is a welcome step toward forming an evidence-based foundation for an effective health sector response in this regard. More work is urgently needed.
- 1. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry. 1999;156(6):837–41. pmid:10360120.
- 2. Hearst N, Newman TB, Hulley SB. Delayed effects of the military draft on mortality. A randomized natural experiment. N Engl J Med. 1986;314(10):620–4. pmid:3945247.
- 3. Lee J. Wounded: life after the shooting. Ann Am Acad Pol Soc Sci. 2012;642(1):244–57.
- 4. Cesur R, Sabia JJ, Tekin E. The psychological costs of war: military combat and mental health. J Health Econ. 2013;32(1):51–65. pmid:23220456.
- 5. Tsai AC, Tomlinson M, Comulada WS, Rotheram-Borus MJ. Intimate partner violence and depression symptom severity among South African women during pregnancy and postpartum: population-based prospective cohort study. PLoS Med. 2016;13(1):e1001943. pmid:26784110; PMCID: PMC4718639.
- 6. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–49. pmid:19654388.
- 7. Devries KM, Seguin M. Violence against women and suicidality: does violence cause suicidal behavior? In: García-Moreno C, Riecher-Rössler A, editors. Violence against women and mental health. Basel: Karger; 2013. p. 148–58.
- 8. Garcia-Moreno C, Jansen HA, Ellsberg M, Watts C. WHO multi-country study on women's health and domestic violence against women: initial results on prevalence, health outcomes, and women's response. Geneva: World Health Organization; 2005.
- 9. Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med. 2002;55(7):1231–44. pmid:12365533.
- 10. Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, et al. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet. 2014;383(9929):1648–54. pmid:24529867.
- 11. Stockl H, Devries K, Rotstein A, Abrahams N, Campbell J, Watts C, et al. The global prevalence of intimate partner homicide: a systematic review. Lancet. 2013;382(9895):859–65. pmid:23791474.
- 12. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378(9802):1592–603. pmid:22008429.
- 13. Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: current situation and strategies for action. Lancet. 2011;378(9803):1654–63. pmid:22008420.
- 14. Bartels SA, Scott JA, Leaning J, Kelly JT, Joyce NR, Mukwege D, et al. Demographics and care-seeking behaviors of sexual violence survivors in South Kivu Province, Democratic Republic of Congo. Disaster Med Public Health Preparedness. 2012;6(4):393–401.
- 15. MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, Ford-Gilboe M, et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2009;302(5):493–501. pmid:19654384.
- 16. Hegarty K, O'Doherty L, Taft A, Chondros P, Brown S, Valpied J, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet. 2013;382(9888):249–58. pmid:23598181.
- 17. Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry. 2002;180:76–81. pmid:11772856.
- 18. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008;372(9642):902–9. pmid:18790313; PMCID: PMC2603063.
- 19. Maselko J, Sikander S, Bhalotra S, Bangash O, Ganga N, Mukherjee S, et al. Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial. Lancet Psychiatry. 2015;2(7):609–17. pmid:26303558.
- 20. Rotheram-Borus MJ, Tomlinson M, Roux IL, Stein JA. Alcohol use, partner violence, and depression: a cluster randomized controlled trial among urban South African mothers over 3 years. Am J Prev Med. 2015;49(5):715–25. pmid:26231855.
- 21. Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A, et al. Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ. 2009;338:b974. pmid:19366752; PMCID: PMC2669116.
- 22. Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P, et al. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003;289(23):3117–24. pmid:12813117.
- 23. Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, et al. Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. Br J Psychiatry. 2011;199(6):459–66. pmid:22130747; PMCID: PMC3227809.
- 24. Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 2010;376(9758):2086–95. pmid:21159375; PMCID: PMCPMC4964905.
- 25. Patel V, Weobong B, Weiss HA, Anand A, Bhat B, Katti B, et al. The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial. Lancet. 2017;389(10065):176–85. pmid:27988143; PMCID: PMCPMC5236064.
- 26. Chatterjee S, Naik S, John S, Dabholkar H, Balaji M, Koschorke M, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet. 2014;383(9926):1385–94. pmid:24612754; PMCID: PMC4255067.
- 27. Nadkarni A, Weobong B, Weiss HA, McCambridge J, Bhat B, Katti B, et al. Counselling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial. Lancet. 2017;389(10065):186–95. pmid:27988144; PMCID: PMCPMC5236065.
- 28. Bass JK, Annan J, McIvor Murray S, Kaysen D, Griffiths S, Cetinoglu T, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368(23):2182–91. pmid:23738545.
- 29. Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, et al. A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Med. 2014;11(11):e1001757. pmid:25386945; PMCID: PMCPMC4227644.
- 30. Bolton P, Bass J, Betancourt T, Speelman L, Onyango G, Clougherty KF, et al. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. JAMA. 2007;298(5):519–27. pmid:17666672.
- 31. Bryant RA, Schafer A, Dawson KS, Anjuri d, Mulili C, Ngodoni L, et al. Effectiveness of a brief behavioural intervention on psychological distress among women with a history of gender-based violence in urban Kenya: A randomised clinical trial. PLoS Med. 2017;14(8):e1002371.
- 32. Rahman A, Hamdani SU, Awan NR, Bryant RA, Dawson KS, Khan MF, et al. Effect of a multicomponent behavioral intervention in adults impaired by psychological distress in a conflict-affected area of Pakistan: a randomized clinical trial. JAMA. 2016;316(24):2609–17. pmid:27837602.
- 33. Harvey A, Watkins E, Mansell W, Shafran R. Cognitive behavioural processes across psychological disorders: a transdiagnostic approach to research and treatment. Oxford: Oxford University Press; 2004.
- 34. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358(3):252–60. pmid:18199864.
- 35. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5(2):e45. pmid:18303940; PMCID: PMC2253608.
- 36. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–21. pmid:17130383.
- 37. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11(8):478–88. pmid:16095434.
- 38. Manos RC, Kanter JW, Luo W. The behavioral activation for depression scale-short form: development and validation. Behav Ther. 2011;42(4):726–39. pmid:22036000.
- 39. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–105. pmid:12813115.
- 40. Eaton WW, Anthony JC, Gallo J, Cai G, Tien A, Romanoski A, et al. Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up. Arch Gen Psychiatry. 1997;54(11):993–9. pmid:9366655.
- 41. Mattisson C, Bogren M, Horstmann V, Munk-Jorgensen P, Nettelbladt P. The long-term course of depressive disorders in the Lundby Study. Psychol Med. 2007;37(6):883–91. pmid:17306047.
- 42. Colman I, Naicker K, Zeng Y, Ataullahjan A, Senthilselvan A, Patten SB. Predictors of long-term prognosis of depression. CMAJ. 2011;183(17):1969–76. pmid:22025655; PMCID: PMCPMC3225418.
- 43. Solomon DA, Keller MB, Leon AC, Mueller TI, Shea MT, Warshaw M, et al. Recovery from major depression. A 10-year prospective follow-up across multiple episodes. Arch Gen Psychiatry. 1997;54(11):1001–6. pmid:9366656.
- 44. Spijker J, de Graaf R, Bijl RV, Beekman AT, Ormel J, Nolen WA. Duration of major depressive episodes in the general population: results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS). Br J Psychiatry. 2002;181:208–13. pmid:12204924.
- 45. Goodwin FK, Whitham EA, Ghaemi SN. Maintenance treatment study designs in bipolar disorder: do they demonstrate that atypical neuroleptics (antipsychotics) are mood stabilizers? CNS Drugs. 2011;25(10):819–27. pmid:21936585
- 46. Tsai AC, Rosenlicht NZ, Jureidini JN, Parry PI, Spielmans GI, Healy D. Aripiprazole in the maintenance treatment of bipolar disorder: a critical review of the evidence and its dissemination into the scientific literature. PLoS Med. 2011;8(5):e1000434. pmid:21559324
- 47. Oram S, Khalifeh H, Howard LM. Violence against women and mental health. Lancet Psychiatry. 2017;4(2):159–70. pmid:27856393.
- 48. Cattaneo LB, Goodman LA. Risk factors for reabuse in intimate partner violence: a cross-disciplinary critical review. Trauma, Violence & Abuse. 2005;6(2):141–75. pmid:15753198.
- 49. Chu JA. The revictimization of adult women with histories of childhood abuse. J Psychother Pract Res. 1992;1(3):259–69. pmid:22700102; PMCID: PMCPMC3330300.
- 50. Messman-Moore TL, Brown AL, Koelsch LE. Posttraumatic symptoms and self-dysfunction as consequences and predictors of sexual revictimization. J Trauma Stress. 2005;18(3):253–61. pmid:16281220
- 51. Miller AK, Markman KD, Handley IM. Self-blame among sexual assault victims prospectively predicts revictimization: a perceived sociolegal context model of risk. Basic Appl Soc Psych. 2007;29(2):129–36.
- 52. Classen CC, Palesh OG, Aggarwal R. Sexual revictimization: a review of the empirical literature. Trauma, Violence & Abuse. 2005;6(2):103–29. pmid:15753196.
- 53. Foa EB, Cascardi M, Zoellner LA, Feeny NC. Psychological and environmental factors associated with partner violence. Trauma, Violence & Abuse. 2000;1(1):67–91.
- 54. Krause ED, Kaltman S, Goodman L, Dutton MA. Role of distinct PTSD symptoms in intimate partner reabuse: a prospective study. J Trauma Stress. 2006;19(4):507–16. pmid:16929505.
- 55. Exner-Cortens D, Eckenrode J, Rothman E. Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics. 2013;131(1):71–8. pmid:23230075; PMCID: PMC3529947.
- 56. Roberts TA, Klein JD, Fisher S. Longitudinal effect of intimate partner abuse on high-risk behavior among adolescents. Arch Pediatr Adolesc Med. 2003;157(9):875–81. pmid:12963592.
- 57. Lehrer JA, Buka S, Gortmaker S, Shrier LA. Depressive symptomatology as a predictor of exposure to intimate partner violence among US female adolescents and young adults. Arch Pediatr Adolesc Med. 2006;160(3):270–6. pmid:16520446.
- 58. Perez S, Johnson DM. PTSD compromises battered women's future safety. Journal of interpersonal violence. 2008;23(5):635–51. pmid:18272729
- 59. Iverson KM, Gradus JL, Resick PA, Suvak MK, Smith KF, Monson CM. Cognitive-behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors. J Consult Clin Psychol. 2011;79(2):193–202. pmid:21341889; PMCID: PMC3071252.
- 60. Tsai AC. Intimate partner violence and population mental health: why poverty and gender inequities matter. PLoS Med. 2013;10(5):e1001440. pmid:23667344
- 61. Cuijpers P, Hollon SD, van Straten A, Bockting C, Berking M, Andersson G. Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open. 2013;3(4). pmid:23624992; PMCID: PMCPMC3641456.
- 62. Rost K, Smith JL, Dickinson M. The effect of improving primary care depression management on employee absenteeism and productivity. A randomized trial. Med Care. 2004;42(12):1202–10. pmid:15550800; PMCID: PMCPMC1350979.
- 63. Wang PS, Simon GE, Avorn J, Azocar F, Ludman EJ, McCulloch J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial. JAMA. 2007;298(12):1401–11. pmid:17895456; PMCID: PMCPMC2859667.
- 64. Levinson D, Lakoma MD, Petukhova M, Schoenbaum M, Zaslavsky AM, Angermeyer M, et al. Associations of serious mental illness with earnings: results from the WHO World Mental Health surveys. Br J Psychiatry. 2010;197(2):114–21. pmid:20679263; PMCID: PMC2913273.
- 65. Lewandowski RE, Bolton PA, Feighery A, Bass J, Hamba C, Haroz E, et al. Local perceptions of the impact of group interpersonal psychotherapy in rural Uganda. Global Mental Health. 2016;3:e23. pmid:28596891; PMCID: PMCPMC5454764.
- 66. Rouhani SA, Scott J, Greiner A, Albutt K, Hacker MR, Kuwert P, et al. Stigma and parenting children conceived from sexual violence. Pediatrics. 2015;136(5):e1195–203. pmid:26438704; PMCID: PMCPMC4890150.
- 67. Tsai AC, Tomlinson M. Mental health spillovers and the Millennium Development Goals: The case of perinatal depression in Khayelitsha, South Africa. Journal of Global Health. 2012;2(1):010302. pmid:23198127
- 68. Lund C, De Silva M, Plagerson S, Cooper S, Chisholm D, Das J, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet. 2011;378(9801):1502–14. pmid:22008425.
- 69. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med. 2010;71(3):517–28. pmid:20621748.
- 70. Jewkes R. HIV/AIDS. Gender inequities must be addressed in HIV prevention. Science. 2010;329(5988):145–7. pmid:20616253.