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Perspective Intimate Partner Violence and Population Mental Health: Why Poverty and Gender Inequities Matter Alexander C. Tsai1,2,3* 1Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 2Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 3Harvard Medical School, Boston, Massachusetts, United States of America Steven Pinker  suggests that the world is becoming less violent. Yet, although it has been nearly two decades since the United Nations issued its Decla- ration on the Elimination of Violence against Women, the global burden of violence against women still remains alarmingly high . Violence commonly results in physical injury, and other serious physical or psychological sequelae may also result, compounding its contribution to the overall global burden of disease . The systematic review and meta-analysis by Karen Devries and colleagues  in this week’s PLOS Medicine brings us one step closer toward understanding the mental health liabilities associated with violence against women. The public health impact of their contribution is substantial, given the lack of resources devoted to the prevention and treatment of mental disor- ders worldwide [5,6,7]. Their article is not the first to summa- rize the impacts of various forms of violence and abuse against women on mental health [8,9,10] (Table 1). Karen Devries and colleagues  contribute to this body of literature reviews by restrict- ing their focus to longitudinal studies, thereby examining the temporal relation- ship between intimate partner violence and depression. Although the literature contained few studies examining the impacts of violence on incident depressive disorders, the authors identified enough studies to support a conclusion that violence was associated with incident symptoms of depression. They had intend- ed to also examine the association between victimization and depression among men, but lack of data limited their ability to draw firm conclusions. Notably, Karen Devries and colleagues  also found that, among women, symp- toms of depression were associated with incident experiences of violence. Whether the relationship between violence and depression is truly causal in both directions is unknown. For example, in examining the association between exposure to intimate partner violence during adulthood and incident symptoms of depression, an un- measured confounder preceding both var- iables such as childhood abuse—not mea- sured in most of the studies—could be causally related to both irrespective of their temporal relationship with each other, inducing a spurious association that could be mistakenly interpreted as bidirectional. Statistical adjustment for baseline depres- sion symptom severity, which was done in most of the studies, could potentially help with this problem if it is a key pathway through which the confounding effects of childhood abuse are transmitted. So what do these findings suggest for clinical practice, programming, or policies to prevent violence against women? If depression is causally related to violence, one might consider evidence-based collab- orative care management of depression [11,12] in order to prevent subsequent experiences of violence. If violence is causally related to depression, one might suggest counseling interventions for wom- en with histories of partner abuse in order to prevent subsequent episodes of depres- sion, but high-quality randomized con- trolled trials have shown mixed results [13,14,15,16]. The only randomized trial of universal screening for intimate partner violence yielded null findings . It is possible that screening may exert substan- tive benefits only in settings where provid- ers also have the ability to refer their clients to a broad array of services (e.g., case management, crisis services, legal advocacy, emergency shelters, transitional housing, and/or parenting and childcare support) , but the effectiveness of such a multipronged approach is as of yet unknown. This particular gap in the literature redirects our attention to more systemic determinants of the excess burden of violence and depression among women. The simplified conceptual model depicted in Figure 1, informed in part by previously published work [19,20], suggests not only that violence against women is a conse- quence of gendered norms about the use violence against intimate partners and power relations [21,22], but also that its Citation: Tsai AC (2013) Intimate Partner Violence and Population Mental Health: Why Poverty and Gender Inequities Matter. PLoS Med 10(5): e1001440. doi:10.1371/journal.pmed.1001440 Published May 7, 2013 Copyright: 2013 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 write this article. Competing Interests: AT acknowledges salary support from U.S. National Institutes of Health K23 MH- 096620. * E-mail: email@example.com Provenance: Commissioned; not externally peer reviewed. Linked Research Article This Perspective discusses the following new study published in PLOS Medicine: Devries KM, Mak J, Bacchus L, Child J, Falder G, et al. (2013) Intimate Partner Violence and Incident De- pressive Symptoms and Suicide At- tempts: A Systematic Review of Longitudinal Studies. PLoS Med 10(5): e1001439. doi:10.1371/journal. pmed.1001439 Karen Devries and colleagues con- duct a systematic review of longi- tudinal studies to evaluate the direction of association between symptoms of depression and inti- mate partner violence. PLOS Medicine | www.plosmedicine.org 1 May 2013 | Volume 10 | Issue 5 | e1001440 direct and indirect effects serve to repro- duce these norms and power relations [23,24,25]. The extent to which exposure to violence results in poor mental health outcomes is modified by gendered norms governing how men and women safely negotiate situations of potential danger [26,27] as well as by biological differences in physical strength. And finally, poverty offers a hospitable environment for gen- der-unequal norms , violence against women [22,29,30], and psychological dis- tress [31,32] to thrive. A reduced form of this model might not be obtainable, but at the very least this model suggests that: (a) violence against women may have direct adverse effects on mental health, as suggested by Karen Devries and colleagues ; and, simultaneously, (b) both violence and depression are partly rooted in gender- unequal relations and the unremitting strain of poverty. Meeting this formidable challenge will require complex interven- tions operating at multiple levels [33,34]. As the epidemiologist Geoffrey Rose succinctly stated in his now-classic work, ‘‘Mass diseases and mass exposures re- quire mass remedies’’  (p.129). Rose argued that interventions aimed at shift- ing the entire distribution of disease (rather than interventions aimed at pre- venting disease in ‘‘high-risk’’ individuals) would yield substantive benefits for pop- ulation health even if they carry little benefit for a given individual [36,37]. This approach emphasizes the societal changes needed to curtail the production and unequal distribution of violence against women. With regard to the conceptual model depicted in Figure 1, effective structural interventions would target the conditions that shape women’s risks for these co- occurring problems. For example, in one randomized controlled trial conducted in rural South Africa, partnered women who took part in a microfinance intervention experienced a statistically significant de- cline in intimate partner violence . While the intervention might be consid- ered an ‘‘agentic’’ type of structural intervention that targets individual behav- ior change [39,40], it is plausible that participation led to environmental changes on a micro scale, such as improvements in women’s bargaining power vis-a`-vis their intimate partners. Thus the findings of that study  hint at the possibilities for change on a macro scale. Consistent with their findings, an analysis of macroeco- nomic data from the US showed that changes in labor market conditions favor- ing women led to reductions in domestic violence . Related work in India showed that a policy change increasing the number of women in political leader- ship positions had the effect of weakening stereotypes about gender roles  and raising parental aspirations for their daughters’ educational attainment . It would be imprudent to suggest that Rose’s ‘‘high-risk’’ strategy  has no place in violence prevention. The review by Karen Devries and colleagues  reveals major gaps in research on intimate Table 1. Peer-reviewed journal articles summarizing the literature on intimate partner violence and mental health. Author Sample Design Exposure Outcome Findings Golding  Womena 36 cross-sectional studies Physical violence by men against women Depressionb, suicidality, post-traumatic stress, substance use Greater prevalence of outcomes among victims of violence Beydoun and colleagues  Women 32 cross-sectional and 5 longitudinal studies IPVc Any author definition of depression Pooled RRs of outcomes ranged from 1.43–1.81, depending on study design and outcome; pooled RR for major depressive disorder was 2.70 Trevillion and colleagues  Womena or mend 38 cross-sectional and 3 longitudinal studiese Lifetime or past-year violence or abuse by any intimate contactc Mental disorders as assessed with diagnostic instruments Pooled ORs for depressive, anxiety, and post- traumatic stress disorders among women ranged from 2.29 to 7.34; insufficient data to estimate pooled ORs for longitudinal studies Devries and colleagues  Womena or mend 16 longitudinal studies IPVc Any author definition of depression or suicide attempts Pooled OR for incident depression among women was 1.97 (six studies), while pooled OR for incident IPV among women was 1.93 (four studies) aExcluded studies that assessed outcomes among women solely during the perinatal period. bTerm used (both here and throughout the article) to refer broadly to either formal diagnoses of depressive disorders or elevated symptoms of depression. cIncluded psychological abuse or emotional violence. dInsufficient data to calculate pooled estimates among men. eExplicitly specified absence of a language restriction. IPV, intimate partner violence; OR, odds ratio; RR, relative risk. doi:10.1371/journal.pmed.1001440.t001 Figure 1. Conceptual framework depicting connections between intimate partner violence and mental health, in the context of poverty, gender relations, and biological differences between men and women. doi:10.1371/journal.pmed.1001440.g001 PLOS Medicine | www.plosmedicine.org 2 May 2013 | Volume 10 | Issue 5 | e1001440 partner violence and depression, including lack of adjustment for childhood sexual abuse or other trauma. A life course perspective, which is missing from much of the research on determinants of vio- lence in general [44,45], would greatly enrich the field by helping intervention programs better address histories of child abuse and/or family violence in identify- ing targets for secondary prevention. As we continue to advance the science of developing and testing structural interven- tions, we should remain vigilant for potential synergies to emerge. Quite likely, the most effective approaches will involve interventions targeting high-risk individu- als, complemented with population-based approaches focused on shifting the entire frequency distribution. At this time, the effectiveness of such a combination ap- proach may be speculative. What is clear is that we cannot sit idly by while awaiting Pinker ’s long arc of history to avert the persistent psychological scars of violence. Acknowledgments I thank Kristin Hung, Ingrid Katz, Mark Siedner, and Sheri Wieser for helpful comments on an earlier draft of this manuscript. Author Contributions Contributed to the writing of the manuscript: AT. ICMJE criteria for authorship read and met: AT. Agree with manuscript results and conclusions: AT. Wrote the first draft of the manuscript: AT. References 1. Pinker S (2011) The better angels of our nature: why violence has declined. New York: Viking Penguin. 2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, et al. 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