title: domestic violence, mental illness and suicidal ideation-a study from lahore, pakistan...

For Peer Review O

nly

Domestic Violence, Mental Illness and Suicidal Ideation- A

study from Lahore, Pakistan

Journal: Journal of Mental Health

Manuscript ID: Draft

Manuscript Type: Original Article

Subject Area: Suicide

Further Detail: Pakistan, Women, Path analysis, Predictors

E-mail: [email protected] URL: http://mc.manuscriptcentral.com/cjmh

Journal of Mental Health

For Peer Review O

nly

Page 1 of 12

TITLE: Domestic Violence, Mental Illness and Suicidal Ideation- A study from

Lahore, Pakistan

Background

Suicidal ideation is an indicator of psychological distress and a proportion of people

reporting suicidal ideation attempt or commits suicide. Mental illness of any type is

strongly associated with suicidal ideation. Furthermore, the links between exposure

to domestic violence and mental health problems are well established. Furthermore,

a number of studies have reported an association between domestic violence and

suicidal ideation.

Aims

To study the link between domestic violence, mental health and suicidal ideation.

Method

Using data from a group of 650 Pakistani women we explored the putative predictors

of suicidal ideation using univariate and multiple logistic regression. Significant

predictors were then entered into a path analysis in order to evaluate both the direct

and indirect effects of domestic violence on the odds of a study participant reporting

suicidal ideation.

Results

Mental disorders were observed to significantly predict suicidal ideation. Ability to

negotiate conflict between couples appeared to both directly and indirectly, via

mitigation against mental disorder, protect against suicidal ideation.

Conclusions

The effect of verbal aggression on suicidal ideation appeared to be mostly mediated

via its impact on mental health.

Conflict of interest none

Page 1 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 2 of 12

BACKGROUND:

Suicide is one of the leading causes of mortality in the world claiming one million

lives a year (Bertolote and Fleischmann 2002). Suicidal ideation and suicide

attempts are highly prevalent in the community (11%-14% and 2.8%-4.6%,

respectively) (Kessler, Borges et al. 1999; Neeleman, de Graaf et al. 2004) and

strongly predict completed suicide (Suominen, Isometsa et al. 2004; Kuo and Gallo

2005). Suicidal behavior in itself is an important indicator of psychological distress.

Existing literature on the correlates of suicide suggests that mental illness has a

strong association with suicidal behaviour but additional socioeconomic factors are

independent predictors of it. In women domestic violence is an important predictor of

suicidal behaviour. Worldwide data suggests that one out of every four women who

are the victims of domestic violence attempt suicide (Ellsberg, Jansen et al. 2008).

Current and past exposure to domestic violence predispose to attempted suicide but

the effect of current exposure is stronger of the two (Mccauley, Kern et al. 1995).

Some evidence suggests domestic violence as a major determinant of female suicide

attempts (Stark & Flitcraft, 1996). A study in Bangladesh reported a high prevalence

of lifetime suicidal ideation among married woman. This study observed that the

victims of domestic violence were up to four times more likely to report suicidal

ideation (Naved and Akhtar 2008). Domestic violence has also been reported as an

independent predictor of attempted suicide in India (Maselko and Patel 2008).

Domestic violence has also been suggested as a risk factor for completed suicide

(Ali, Rahbar et al. 2002). A study among pregnant woman in Pakistan showed 16%

woman considered suicide as a response to domestic abuse (Karmaliani, Irfan et al.

2008).

Page 2 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 3 of 12

Some of the risk factors for suicide, such as low socio-economic status, lack of

education and unemployment have also been associated with domestic violence.

A trend toward increased suicide rates have been seen in Pakistan in recent years

(Khan and Prince 2003). A psychological autopsy study in Karachi reported a high

prevalence of mental illness and psychosocial distress among the people who

committed suicide (Khan, Mahmud et al. 2008). Another study carried out in primary

care in Pakistan, including mothers from an Afghan refugee camp showed 36%

women suffering from common mental disorder, out of which 91% expressed having

suicidal thoughts (Rahman and Hafeez 2003).

In order to better understand the risk, protective and mediating factors for suicidal

behaviour in woman of Pakistani origin conducted a survey in women presenting to

primary care health facilities in Lahore, Pakistan and a modelling approach was

taken to data analysis. In addition to socioeconomic status and education we looked

at domestic violence and mental health problems as possible predictors. We have

previously reported the correlates of mental illness in this sample (Ayub, Irfan et al.

2009). In this article we report the results of a path analysis which looked at effects of

domestic violence on suicide ideation directly and mediated through symptoms of

mental illness.

METHODS:

Six hundred and fifty women from primary care facilities in Lahore participated in the

present study ranging in age between 17 and 65 years (mean age 34.5 years). We

collected demographic details including age, education, and family structure (nuclear

or extended), employment status (house wives / unemployed / employed / self-

employed), monthly income of the family and marital status. Women with ill infants or

Page 3 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 4 of 12

with severe physical illnesses presenting to the doctors, were excluded from the

study.

Interviews took place in a primary care setting and we interviewed the first eligible

and consenting woman and every 5th women after that. The interviews were

conducted by psychology graduates who held Masters level degrees in psychology

and had a minimum of 2 yrs of clinical experience. They underwent training before

they started to collect the data. Data were collected between February and

September 2005. Details regarding setting, data collection and measurements have

been described in detail elsewhere (Ayub, Irfan et al. 2009).

Measurements:

The mini-International Neuropsychiatric Interview (MINI), Women Experience with

Battering (WEB), The Relationship Assessment Scale, Life Events Checklist (LEC),

The Oslo Social Support Scale, and Conflict Tactics Scale were translated into Urdu

(Ayub, Irfan et al. 2009).

The MINI was used for assessment of psychiatric disorders. This generated the

following ICD 10 diagnoses: Generalized Anxiety Disorder; Depressive Episode;

Dysthymia; Panic Disorder; Agoraphobia; Social Phobia; Obsessive-Compulsive

Disorder, and; Post-traumatic stress disorder (PTSD). For the purposes of analysis

the disorders were grouped together whilst PTSD was used as a separate category.

The MINI suicidality module was used to determine the suicidal risk (Sheehan,

Lecrubier et al. 1997; Amorim, Lecrubier et al. 1998). The suicidality module contains

six items relating to suicidal risk. These questions enquire about the previous months

thinking and ideation in terms of contemplating or planning a suicide attempt, suicidal

wishes or fantasies and any previous suicidal attempts over the lifetime. A score of 1-

Page 4 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 5 of 12

5 points is categorised as a low suicide risk, 6-9 points moderate risk and a score of

10 points is designated as consistent with a high risk of eventual suicide.

Women’s Experience with Battering (WEB)

To assess exposure to domestic violence we used Women’s Experience with

Battering (Smith, Earp et al. 1995; Smith, Tessaro et al. 1995; Smith, Smith et al.

1999) a modified version of this scale was used in which women responded in ‘Yes’

or ‘No’ instead of showing agreements on a Likert scale. The internal reliability

consistency for this as indexed by Cronbach’s alpha in our sample was 0.87.

The perceived quality of the marital relationship was measured using Relationship

Assessment Scale (RAS) (Hendrick 1988; Hendrick, Dicke et al. 1998) which rates

satisfaction with intimate relationships. It consists of 7 items that enquire about

satisfaction with relationship with the partner. Each item is rated on a Likert scale of

1-5. The RAS is an appropriate, useful and brief measure for partnered love

relationships in a wide variety of research settings. The Cronbach’s alpha in our

sample was 0.94.

The Life Events Checklist (LEC) for Pakistan(Rahman, Iqbal et al. 2003) discusses

the life events and difficulties in the previous years and specially looks at the areas

relevant in Pakistani context. Items relating to life events and difficulties were derived

from the Life Events and Difficulties Schedule (LEDS)(Brown and Birley 1968; Brown,

Harris et al. 1973).

The Oslo Social Support Scale (Dowrick, Casey et al. 1998) is a three-item rating

scale used for reported the level of social support experienced by the respondent.

These 3 items were selected from community mental health studies among a number

of variables measuring social support on the basis of a factor analysis

(neighbourhood support and support from family/friends), and the individual effect of

each item on mental health. The items enquire about the respondents’ perception of

Page 5 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 6 of 12

the number of people one can count on in case of a serious problem, concern shown

by others, and how easily the respondent can get help from neighbours. It was

translated into Urdu.

The Conflict Tactics Scale (CTS) (Gelles and Straus 1979) is a 15-item measure,

which reports the tactics used by couples to resolve their conflicts including

reasoning, verbal aggression and physical violence. Higher scores for a tactic

indicate greater reliance on that approach. Responses for each sub-scale were

added. The Cronbach’s alpha for reasoning sub-scale was 0.6 and .87 for the other

two subscales.

Statistical analysis

Univariate comparison of proportions of binary variables was performed using chi-

squared testing. For the purposes of performing a logistic regression MINI suicidal

scores were dichotomised into ‘suicidal’ versus ‘non-suicidal’. The suicidal group

included all the levels of risks from ideation to past attempts. Variables that were

significant predictors at the p<.05 level were entered into a step-wise multiple logistic

regression.

In the first part of this model mental illness was endogenous variable and social

support, education, reasoning, life events and women’s reported experience of

partner aggression were treated as exogenous variables. In the second part suicidal

ideation was endogenous variable and mental illness, reasoning, life events, verbal

aggression, relationship with partner and income were exogenous variable. The

model was assessed for goodness of fit via a number of accepted indices. In addition

both direct and indirect effects of life events, reasoning and verbal aggression on

suicidal ideation were evaluated. The model was estimated utilising robust weighted

least squares to accommodate the binary nature of the dependent variable. The

Page 6 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 7 of 12

software package Mplus version 6.1 (Muthén and Muthén 1998-2011) was used for

the path analysis whilst SPSS version 18 was utilised for other analyses.

RESULTS:

Table 1 here

The participants women in our final sample ranged from 17 to 65 years of age (mean

34.5 years). Data relating to suicidal ideation were available for 636 women (97.8 %

of the total sample), with 201 of them reporting significant problems in this area.

In the suicidal group 186 (93%) had a psychiatric diagnosis and constituted 45% of

women who were likely to have met the criteria for a mental health diagnosis.

Seventy-six (11.9%) women met the criteria for PTSD and 40 (52.6%) of them were

in suicidal group. In the suicidal group only eleven women were without a psychiatric

diagnosis or diagnosis of PTSD.

Logistic regression Analyses

Page 7 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 8 of 12

Table 2 shows results of logistic regression. The variables which were significant

predictors at the p<0.05 level in the univariate analysis were included in the multiple

regression model. Positively perceived intimate partner relationships, negotiations to

resolve conflicts were related to reduced odds of reported suicidality whilst adverse

life events, verbal violence, lower income, psychiatric disorders and PTSD increased

the risk of suicidal behaviour.

Table 2 logistic regression

Path analysis

Missing data were treated by list wise deletion with 573 participants included in the

modelling process. According to testing our model was not statistically different from

a saturated model (χ2=3.5, degrees of freedom 5, p=0.62). The other parameters of

goodness of fit were:

Root Mean Square Error of Approximation (RMSEA) 0.000; Comparative Fit Index

(CFI), 1.00; Tucker-Lewis Index (TLI), 1.03.

Figure 1 and table 3 here

DISCUSSION:

In our sample about one third of women reported suicidal thoughts or more serious

suicidal behaviour. This is comparable to previously published studies from Pakistan.

In a sample of Pakistani young people attending college the rate of suicidal ideation

was 31.4%(Khokher and Khan 2005).In a group of women living in refugee camps in

Peshawar, Pakistan 36% screened positive for common psychiatric disorders and

91% of them had suicidal ideation in the previous month.

As expected, Mental Disorder, including Post-Traumatic Stress Disorder were the

best predictors of suicidal ideation. Only 11 women with suicidal ideation did not have

Page 8 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 9 of 12

a probable diagnosis of mental illness. We conceptualised suicidal behaviour as a

two stage process with mental illness as the first step and suicidal ideation as the

final outcome based on previous research evidence. The findings from the logistic

regression analyses were then used to develop the path model. Variables like

education and social support are protective against the risk of mental disorder whilst

good quality intimate relationships and better income appeared to protect against

suicidal ideation. Adverse life events and verbal aggression increased vulnerability to

mental illness and, indirectly, to suicidal ideation. Use of reasoning to resolve conflict

is protective both against the mental illness and suicidal ideation. The clinical

relevance of these findings is that to address the risk of suicide in victims of domestic

violence we need to address violence but also mental health problems.

Potential limitations of the study:

Women at low, moderate and high suicidal risk were grouped together into suicidal

versus non-suicidal groups. Whereas this strategy increases the power of study,

important information regarding the difference between such groups would have

been lost. We grouped together psychiatric disorders which meant that we could not

draw conclusions about the relationship with individual disorders. However there is

an overlap between these disorders in the primary care samples and this is a

commonly use strategy. Because of missing data we were only able to include 573

women in the path analysis. This could have been a potential source of bias. A

qualitative component would have enhanced the ability to understand in depth the

inter relationship between domestic violence mental disorder and suicidal ideation.

Page 9 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 10 of 12

Conclusions

In this sample, the effects of exposure to aggression in the home on suicidality were

mainly mediated by mental health the relationship is complex, with protective factors

perhaps having more direct effects. This suggests that social and healthcare policy

should be directed at addressing both mental health and domestic violence in these

vulnerable women. Strengthening protective factors such as education may be

effective even in the presence of mental disorder and other direct risk factors. Future

research should focus on testing putative interventions to reduce the risk of suicide in

this vulnerable population.

Page 10 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 11 of 12

REFERENCES:

Ali, B. S., M. H. Rahbar, et al. (2002). "Prevalence of and factors associated with anxiety and depression among women in a lower middle class semi-urban community of Karachi, Pakistan." J Pak Med Assoc 52(11): 513-517.

Amorim, P., Y. Lecrubier, et al. (1998). "DSM-IH-R Psychotic Disorders: procedural validity of the Mini International Neuropsychiatric Interview (MINI). Concordance and causes for discordance with the CIDI." Eur Psychiatry 13(1): 26-34.

Ayub, M., M. Irfan, et al. (2009). "Psychiatric morbidity and domestic violence: a survey of married women in Lahore." Soc Psychiatry Psychiatr Epidemiol 44(11): 953-960.

Bertolote, J. M. and A. Fleischmann (2002). "Suicide and psychiatric diagnosis: a worldwide perspective." World Psychiatry 1(3): 181-185.

Brown, G. W. and J. L. Birley (1968). "Crises and life changes and the onset of schizophrenia." Journal of Health & Social Behavior 9(3): 203-214.

Brown, G. W., T. O. Harris, et al. (1973). "Life Events and Psychiatric-Disorders .2. Nature of Causal Link." Psychol Med 3(2): 159-176.

Dowrick, C., P. Casey, et al. (1998). "Outcomes of Depression International Network (ODIN). Background, methods and field trials. ODIN Group." Br J Psychiatry 172: 359-363.

Page 11 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Page 12 of 12

Ellsberg, M., H. A. F. M. Jansen, et al. (2008). "Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study." Lancet 371(9619): 1165-1172.

Gelles, R. J. and M. A. Straus (1979). "Violence in the American-Family." Journal of Social Issues 35(2): 15-39.

Hendrick, S. S. (1988). "A Generic Measure of Relationship Satisfaction." Journal of Marriage and the Family 50(1): 93-98.

Hendrick, S. S., A. Dicke, et al. (1998). "The Relationship Assessment Scale." Journal of Social and Personal Relationships 15(1): 137-142.

Karmaliani, R., F. Irfan, et al. (2008). "Domestic violence prior to and during pregnancy among Pakistani women." Acta Obstetricia Et Gynecologica Scandinavica 87(11): 1194-1201.

Kessler, R. C., G. Borges, et al. (1999). "Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey." Archives of General Psychiatry 56(7): 617-626.

Khan, M. M., S. Mahmud, et al. (2008). "Case-control study of suicide in Karachi, Pakistan." Br J Psychiatry 193(5): 402-405.

Khan, M. M. and M. Prince (2003). "Beyond rates: the tragedy of suicide in Pakistan." Tropical Doctor 33(2): 67-69.

Khokher, S. and M. M. Khan (2005). "Suicidal ideation in Pakistani college students." Crisis 26(3): 125-127.

Kuo, W. H. and J. J. Gallo (2005). "Completed suicide after a suicide attempt." Am J Psychiatry 162(3): 633.

Maselko, J. and V. Patel (2008). "Why women attempt suicide: the role of mental illness and social disadvantage in a community cohort study in India." J Epidemiol Community Health 62(9): 817-822.

Mccauley, J., D. E. Kern, et al. (1995). "The Battering Syndrome - Prevalence and Clinical Characteristics of Domestic Violence in Primary-Care Internal-Medicine Practices." Annals of Internal Medicine 123(10): 737-&.

Muthén, L. K. and B. O. Muthén (1998-2011). Mplus User's Guide. Sixth Edition. Los Angeles, CA, Muthén & Muthén.

Naved, R. T. and N. Akhtar (2008). "Spousal Violence against Women and Suicidal Ideation in Bangladesh." Womens Health Issues 18(6): 442-452.

Neeleman, J., R. de Graaf, et al. (2004). "The suicidal process; prospective comparison between early and later stages." Journal of Affective Disorders 82(1): 43-52.

Rahman, A. and A. Hafeez (2003). "Suicidal feelings run high among mothers in refugee camps: a cross-sectional survey." Acta Psychiatrica Scandinavica 108(5): 392-393.

Rahman, A., Z. Iqbal, et al. (2003). "Life events, social support and depression in childbirth: perspectives from a rural community in the developing world." Psychol Med 33(7): 1161-1167.

Sheehan, D. V., Y. Lecrubier, et al. (1997). "The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability." European Psychiatry 12(5): 232-241.

Smith, P. H., J. A. Earp, et al. (1995). "Measuring battering: development of the Women's Experience with Battering (WEB) Scale." Womens Health 1(4): 273-288.

Smith, P. H., J. B. Smith, et al. (1999). "Beyond the measurement trap - A reconstructed conceptualization and measurement of woman battering." Psychology of Women Quarterly 23(1): 177-193.

Smith, P. H., I. Tessaro, et al. (1995). "Women's experiences with battering: a conceptualization from qualitative research." Womens Health Issues 5(4): 173-182.

Suominen, K., E. Isometsa, et al. (2004). "Completed suicide after a suicide attempt: A 37-year follow-up study." American Journal of Psychiatry 161(3): 562-563.

Page 12 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

TABLE-1 Table1. Socio-demographic characteristics for suicidal’ and ‘non-suicidal’ women,

as defined by the MINI . All figures number (%) except where otherwise stated. [as footnote]*

P values relate to difference according to χ2 test, except in the case of age which relates to a

t-test.

Non-suicidal

N (% of total

sample)

Suicidal

N (% of total

sample)

p*

Education in years

< 5

5-10

> 10

156(58.2%)

169(71.6%)

110(83.3%)

112(41.8%)

67(28.4%)

22(16.7%)

0.000

Family structure

Nuclear

Extended or joint

335(76.7%)

102(23.3%)

148(73.6%)

53(26.4%)

0.408

Employment status

Housewife/unemployed

Employed

Self employed

431(98.9%)

4(0.9%)

1(0.2%)

198(98.5%)

3(1.5%)

0(0%)

0.645

Income in Rupees

<5000

5000-10000

>10000

202(49%)

146(35.4%)

64(15.5%)

141(74.6%)

40(21.2%)

8(4.2%)

0.000

Mean age in years (SD) 33.9 (10.5) 35.4(9.9) 0.091

Marital status

Married

Widowed/divorced

421(96.3%)

16(3.7%)

196(97.5%)

5(2.5%)

0.440

Page 13 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Table-2 Results of logistic regression.

NS means not significant

Independent Variables Univariate

Coefficient and

CI

p

value

Multiple

regression

Coefficients

p value

Education -.36 (-0.51- -0.22) 0.000 NS

Life events .21 (0.15- 0.26) .000 0.09 0.02

Relationships -.11(-.14- -0.08) .000 -0.08 7.53e-05

Reasoning to resolve conflict -.11(-.14- -.07) .000 -0.12 2.62e-06

Verbal violence on CTS .12(0.09-.15) .000 0.06 0.06

Physical violence .12(.07-.16) .000 NS

Battering .19(.12-.15) 0.000 NS

Social support -.1(-.14- -.04) .001 NS

Income -.62(-.84- -.4) 0.000 -0.45 0.002

PTSD 1.118 .002 1.23 0.0002

Psychiatric Disorders 2.813 .000 2.58 5.86e-12

Page 14 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Table 3 Predictors of suicide

Predictor Estimate Standard Error Estimate/SE p value

Psychiatric diagnosis 0.684 0.059 11.61 0.000

Reasoning -0.043 0.014 -2.98 0.003

Verbal aggression 0.012 0.018 0.642 0.52

Relationships -0.041 0.012 -3.389 0.001

Income -0.182 0.084 -2.169 0.03

Life events 0.034 0.022 1.57 0.11

Specific indirect effects mediated via Mental Disorder

Reasoning -0.021 0.009 -2.473 0.013

Verbal violence 0.021 0.012 1.696 0.090

Life events 0.047 0.012 3.777 0.000

Page 15 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Peer Review O

nly

Path analysis model

210x297mm (200 x 200 DPI)

Page 16 of 16



123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

title: domestic violence, mental illness and suicidal ideation-a study from lahore, pakistan...

Documents