title: Pathways to perinatal depressive symptoms after mass conflict in Timor-Leste: a modelling analysis using cross-sectional data.
abstract: BACKGROUND
  The contributions of potentially traumatic events (PTEs) of mass conflict and post-traumatic stress disorder (PTSD) symptoms to perinatal depression in women living in low-income, post-conflict countries are unclear. We tested a model including these factors, intimate partner violence (IPV), and continuing adversity in women in Timor-Leste.
  
  
  METHODS
  Our modelling study used cross-sectional data from a sample of women living in two districts in Timor-Leste, identified through service registers, clinic records, village chiefs, and a door-to-door survey between June, 2012, and June, 2013. Eligible women were 3-6 months pregnant or 3-6 months postpartum. We assessed conflict-related PTEs, IPV, continuing adversity (poverty and insecurity), PTSD symptoms (the Harvard Trauma Questionnaire), and maternal depressive symptoms (the Edinburgh Postnatal Depression Scale [EPDS]) to develop a theoretical model to examine pathways leading directly and indirectly to depressive symptoms.
  
  
  RESULTS
  We assessed 427 eligible women, of whom 258 (60%) were pregnant and 169 (40%) were postnatal. 87 (22%) of 387 women who were given the EPDS to complete were above the threshold used to define depression, and 40 (9%) of 427 were regarded as having PTSD. Our most comprehensive model showed that IPV and conflict-related deprivations led directly to depressive symptoms as well as to continuing adversity. Human rights-related trauma, witnessing murder, and a further path from IPV led to PTSD symptoms. Human rights-related trauma also led to continuing adversity. Paths from continuing adversity led to depressive symptoms, and PTSD symptoms, which was the predominant path. We noted a strong and unidirectional path from PTSD symptoms to depressive symptoms.
  
  
  CONCLUSIONS
  Protection of women from human rights abuses, prevention of IPV, reduction in insecurity and poverty in the post-conflict period, and identification of and treatment for PTSD symptoms might reduce the risk of perinatal depression in post-conflict, low-income countries. Longitudinal studies are needed to confirm these findings.
  
  
  BACKGROUND
  Australian National Health and Medical Research Council.
authors.affiliation: Psychiatry Research and Teaching Unit, School of Psychiatry and Ingham Institute, University of New South Wales, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: Derrick
authors.initials: D
authors.lastname: Silove
authors.affiliation: Psychiatry Research and Teaching Unit, School of Psychiatry and Ingham Institute, University of New South Wales, Liverpool Hospital, Sydney, NSW, Australia. Electronic address: s.j.rees@unsw.edu.au.
authors.forename: Susan
authors.initials: S
authors.lastname: Rees
authors.affiliation: Psychiatry Research and Teaching Unit, Southwest Sydney Local Health District, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: Alvin Kuowei
authors.initials: AK
authors.lastname: Tay
authors.affiliation: Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: Zelia Maria
authors.initials: ZM
authors.lastname: da Costa
authors.affiliation: Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: Elisa Soares
authors.initials: ES
authors.lastname: Savio
authors.affiliation: Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: Cesarina
authors.initials: C
authors.lastname: Soares
authors.affiliation: Johns Hopkins University, Hampton House, Baltimore, MD, USA.
authors.forename: Wietse
authors.initials: W
authors.lastname: Tol
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology*; D019052:Depression, Postpartum / Q000453:epidemiology*; D005260:Female; D045809:Human Rights Abuses / Q000523:psychology*; D006801:Humans; D008962:Models, Theoretical; D011247:Pregnancy; D037841:Pregnant People / Q000523:psychology*; D013179:Spouse Abuse / Q000523:psychology*; D013313:Stress Disorders, Post-Traumatic / Q000523:psychology*; D049648:Timor-Leste / Q000453:epidemiology; D014857:Warfare; D055815:Young Adult