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Abuse and mental disorders among women at walk-in clinics in Trinidad: A cross-sectional study

  • Rohan G Maharaj1Email author,
  • Colanne Alexander2,
  • Candace H Bridglal2,
  • Aysha Edwards2,
  • Hassina Mohammed2,
  • Teri-Ann Rampaul2,
  • Sharlene Sanchez2,
  • Gina P Tanwing2 and
  • Kristy Thomas2
BMC Family Practice201011:26

https://doi.org/10.1186/1471-2296-11-26

Received: 11 November 2009

Accepted: 30 March 2010

Published: 30 March 2010

Abstract

Background

To determine the prevalence of abuse by their partners and its association with mental disorders among female patients at walk-in clinics in Trinidad.

Methods

Female participants from 16 randomly selected walk-in clinics, previously stratified to represent all administrative regions and urban and rural settings, who were 18 years or older, were surveyed during May to August 2007 using the WAST-Short and PRIME-MD questionnaires.

Results

432 women participated (a 92% response rate), Of these 16% were aged 20-29, 11.8% 30-39 and 19% 40-49; 37% were married, 25% single; 44.7% were Indo- and 35% Afro-Trinidadian; 67.8% had achieved education up to age 14 only. 30.3% were employed and 3.0% reported incomes more than $5,001 TTD (Trinidad and Tobago Dollars) per month. Forty percent (173) of all respondents were positive for abuse as scored by the WAST-Short scale. Chi-square analysis suggested associations (p < 0.05) between abuse and age, employment status, being in a current relationship, and having the desire to cut down on alcohol intake. Further there were associations between abuse and the presence of depression, suicidal ideation, post-traumatic stress disorder and somatization as determined by the PRIME-MD scale. Logistic regression showed that the statistically significant (p < 0.05) predictors of woman abuse were age less than 49, wanting to cut down on alcohol use and currently being in a relationship.

Conclusion

Among women of primarily lower socioeconomic status who attend walk-in clinics in Trinidad abuse as measured by the WAST-Short scale is high and there are statistically significant associations with mental disorders as determined by the PRIME-MD scale.

Background

In Trinidad prevalence studies of domestic violence have been conducted in a variety of settings. Point prevalence rates in the general female population have been reported as16% [1, 2], among currently pregnant, 9.2% [3], in the emergency room, 8% [4], and at the fee-for-service family practices, 27% [5]. Additionally, up to 40% of women at emergency rooms report a past experience of domestic violence. However we know little about the mental disorders or the long term consequences that may be associated with this abuse in Trinidad. Recently international studies have focused on the mental disorders associated with such abuse and reports suggest that there is a greater likelihood of depression [6], multiple somatic complaints [7] and post-traumatic stress disorder symptomatology [8].

Our objective was to determine the prevalence of woman abuse and the mental disorders associated with this experience, and further to explore which demographic factors may predict the likelihood of such abuse at walk-in clinics in Trinidad.

Methods

In Trinidad there are seventy nine (79) health centres, most of which have walk-in clinics (where patients can present without an appointment for any medical problem). These clinics were stratified to represent all regional health authorities (administrative regions) and to capture rural and urban populations. Clinics were then selected using a table of random numbers; given the timeframe to conduct the interviews and the knowledge of attendance rates, 16 clinics were chosen according to the proportion of clinics per administrative region. Consecutive females attending these clinics were invited to participate if they were 18 years and older, willing to take part and had signed the consent form. Persons who presented with an emergency were excluded.

The WAST-Short (Woman Abuse Screening Tool-Short Form) was used to determine the presence of abuse among women. This tool has been shown to accurately detect 100% of non-abused women and 91.7% of abused women [9]. Only the 2 questions of the Short Form were used in an attempt control the number of questions in the survey instrument and to reduce respondent fatigue. The WAST-Short was used because a locally developed and validated scale was longer and had been found to have a low positive predictive value [5]. Additionally, the other major instrument in the questionnaire (see below) had a component for studying physical and sexual abuse.

The PRIME-MD PHQ (Primary Care Evaluation of Mental Disorders-Patient Health Questionnaire) has a specificity of 90%, a sensitivity of 75% and is used for the screening of minor psychiatric disorders and illnesses [10, 11]. This questionnaire is based on the DSM-IV and has been used in many populations [1215] and medical settings [1619] and collects mental health, social and medical information and as noted above assisted in collecting information on physical and sexual abuse.

The WAST-Short scored as positive if a woman gave a response of 'a lot of tension', or 'some tension' to the question: 'In general, how would you describe your present intimate relationship?' Or if the woman completes the phrase: 'Do you and your partner work out arguments with... with 'great difficulty' or 'some difficulty'. The combined questionnaire was piloted and found to be easily understood; inter-rater reliability was not tested. Responses to the PRIME-MD questionnaire were scored based on the "Reference Guideline for Interpreting the Patient Health Questionnaire and Brief PHQ" and the scores were used to determine the possibility of being at risk for having a mental disorder [20]. Demographic characteristics were also collected. Questionnaires were applied by trained interviewers. All authors except RGM carried out the interviews. Data were analysed using SPSS v.12. Associations between independent variables and the presence of woman abuse were analyzed using the chi-square test with a statistical significance of 5%. Regression analysis was carried out to determine which independent variables predicted the presence of woman abuse as defined by the WAST-Short.

This study was approved by the Ethics Committee of the Faculty of the Medical Sciences, The University of the West Indies (St. Augustine campus) and the relevant regional health authorities (RHAs) and was coordinated and supervised by the first author and conducted by medical students as part of their compulsory year-2 undergraduate research project. Patients were informed that the study was to understand common psychological and social problems among patients at the walk-in clinics and consent was obtained from all participants. Privacy was maintained by conducting the interviews on a one-to-one basis in a quiet part of the waiting room. However total seclusion was not possible because of the limited space and large volumes of patients at these clinics.

Results

Four hundred and thirty two women responded (a 92% response rate), 49.5% were between 18 and 49 years; 37% were married. Indo-Trinidadians made up 44.7% and 35% were Afro-Trinidadian. Those who had achieved education up to age 14 only represented 67.8%, 30.3% were employed and 3.0% received more than TTD $5,001 per month ($1 USD = $6.3 TTD). Table 1 gives further details of the participants' demographic characteristics.
Table 1

Demographic description of 432 female participants in a survey of abuse and mental disorders in Trinidad.

Variable

 

N (%)

Age Group (years)

18-19

12 (2.8)

 

20-29

69 (16.0)

 

30-39

51 (11.8)

 

40-49

82 (19.0)

 

50-59

91 (21.1)

 

60-69

87 (20.1)

 

≥ 70

40 (9.3)

Marital Status

Married

160 (37.0)

 

Single

108 (25.0)

 

Divorced

21 (4.9)

 

Separated

20 (4.6)

 

Common law

57 (13.2)

 

Visiting §

64 (14.8)

 

Widowed

1 (0.2)

 

Others

1 (0.2)

Ethnicity

Indo-Trinidadian*

193 (44.7)

 

Afro-Trinidadian**

151 (35.0)

 

Mixed

87 (20.1)

 

Others

1 (0.2)

Monthly Income

<$1,000

100 (23.1)

 

$1,001-$2,500

149 (34.5)

 

$2,501-$5,000

52 (12.0)

 

>/= $5001

13 (3.0)

 

Does Not Know

85 (19.7)

 

No Response

33 (7.6)

Education

Primary school (approximately Grade 5)

55 (12.7)

 

School Leaving (Approximately Grades 5-6)

52 (12.0)

 

Secondary School (approximately Grades 6 and above)

83 (19.2)

 

Higher Education (Certificate/Diploma, Degree)

41 (9.5)

 

Others

15 (3.5)

 

None

186 (43.1)

Employment

Yes

131 (30.3)

 

No

301 (69.7)

• * or ** Trinidadians of South Asian or African descent

• §A long-term relationship where a common home is not shared, participants may live at their family of origin or independent premises

Forty percent (173) of all respondents were positive for abuse as scored by the WAST-Short scale. Younger women were more likely to report abuse with those between the ages 20 - 49 reporting an average of 54.1% versus those between the ages 50 - 61 who reported an average of 31.4%. Women who were married (55.6%), in common-law relationships (40.7%) or single (66.7%) were more likely to report abuse versus 2% of all other groups. All major ethnic groups Indo- (37.8%), Afro-Trinidadians (44.4%) and mixed (37.9%) reported abuse. Higher proportions of women with lower educational achievements reported abuse (40.7%) versus 34.8% of women with higher achievements. However women with employment were more likely to report abuse (50.4%) versus 35.6% of unemployed. Similarly, among women who were in the higher income bracket, 53.9% reported abuse versus 39.6% of women in the lower income bracket. See Table 2.
Table 2

The association between demographic variables and the presence of a positive response on the Woman Abuse Screening Tool-Short form (WAST-Short).

 

Positive response on WAST-Short

Positive response on WAST-Short

p-value*

 

Yes N (%)

No (%)

 

Education

  

NS

Lower achievement

157 (40.7)

229 (59.3)

 

Higher achievement

16 (34.8)

30 (65.2)

 

Age

  

< 0.001

49 years and less

115 (53.7)

99 (46.4)

 

50 years and more

58 (26.6)

160 (72.4)

 

Employment

  

0.003

Employed

66 (50.4)

65 (49.6)

 

Un-employed

107 (35.6)

194 (64.4)

 

Income

  

NS

< $4, 999 TTD

166 (39.6)

253 (60.4)

 

$5, 000 TTD and more

7 (53.9)

6 (46.1)

 

Relationship

  

0.002

Current (e.g. married, common-law)

127 (70.2)

154 (29.8)

 

None (e.g. widowed, divorced)

46 (30.5)

105 (69.5)

 

*Fisher's exact test

Abuse and mental disorders

Violence and PTSD

Eight percent of all women reported physical violence being 'hit, slapped, kicked, or otherwise physical hurt or being forced into an unwanted sexual act' in the past 12 months. Additionally, 10.4% of all women reported symptoms suggestive of post-traumatic stress disorder (PTSD), being 'bothered a lot' and 15.2% 'bothered a little' by 'thinking or dreaming about something terrible that happened to them in the past'. There was a statistically significant association between reports of abuse and PTSD with 48.9% of the women who were 'bothered a lot' and 58.5% of the women who were bothered a little' reporting abuse, compared with 35.1% of respondents who were 'not bothered'.

Alcohol abuse

There was a statistically significant association between reports of abuse and women's report that they would like to 'cut down on their alcohol intake'. Sixteen (64%) of the 25 women having this wish reported that they had experienced abuse in the past year.

Depression

There was a statistically significant association between reports of abuse and both suicidal thinking and the scoring of major depression. See Table 3.
Table 3

The association between mental health symptoms and the presence of a positive response on the Woman Abuse Screening Tool-Short form (WAST-Short).

 

Positive response on WAST-Short

Positive response on WAST-Short

p-value*

 

Yes

N (%)

No

N (%)

 

Would like to cut down on alcohol use

  

0.011

Yes

16 (64.0)

9 (36.0)

 

No

157 (38.6)

250 (61.4)

 

Possible depression

  

0.001**

Major depression

23 (69.7)

10 (30.3)

 

No depression

117 (31.3)

206 (68.7)

 

Other depressive disorder

33 (44.0)

42 (58.0)

 

Suicidal ideation

  

0.018

Yes

12 (66.7)

6 (33.3)

 

No

161 (38.9)

253 (61.1)

 

Possible somatization

  

0.014

Yes

59 (48.8)

62 (51.2)

 

No

114 (36.7)

197 (63.3)

 

Possible anxiety disorder

  

0.072

Yes

14 (56.0)

11 (44.0)

 

No

159 (39.1)

248 (60.9)

 

Possible Post Traumatic Stress Disorder

  

0.001**

Not Bothered***

113 (35.1)

209 (64.9)

 

Bothered a little

38 (58.5)

27 (41.5)

 

Bothered a lot

22 (48.9)

23 (51.1)

 

Reported physical or sexual abuse in the past year

  

< 0.001

 

25 (71.4)

10 (28.6)

 

Yes

148 (37.3)

249 (62.7)

 

No

   

*Fisher's exact test

** Pearson Chi-square

*** About something terrible that has happened in the past.

Somatization

There was a statistically significant association between reports of abuse among women with multiple somatic complaints when compared to those who did not have multiple somatic complaints, with 48.8% versus 36.7% respectively reporting abuse. Further analysis was carried out to describe which somatic complaints were more common among women who reported abuse, it was found that women who complained of being 'bothered a lot' in the past 4 weeks with either menstrual cramps, pain or problem with sexual intercourse, headaches, feeling the heart pounding or racing, shortness of breath or nausea, gas and indigestion were more likely to report abuse.

Anxiety and Panic

There was a statistically significant association between reports of abuse and anxiety where of the 25 women (5.8%) reporting symptoms suggestive of anxiety 56% reported abuse versus the 39.7% who reported abuse but had no anxiety symptoms. Of the 21 women with panic symptoms 52.4% had abuse versus 39.4% with no panic disorder. This was not statistically significant.

Additional analysis

Chi-square analysis suggested association (p < 0.05) between history of abuse and age, employment status, current relationship, the desire to cut down on alcohol intake, and the presence of symptoms of depression, PTSD and somatization. Tables 2 and 3 provide more details of the chi-square analysis. Logistic regression showed that statistically significant (p < 0.05) predictors of woman abuse were age less than 50, wanting to cut down on alcohol use and being in a relationship. See Table 4.
Table 4

Results of Binary Logistic Regression analysis to determine the independent variables associated with the presence of a positive response to the Woman Abuse Screening Tool-Short form (WAST-Short) among female attendees at walk-in clinics in Trinidad.

Independent Variable

Odds Ratio

(95% CI)

pvalue

Education

  

Lower vs. Higher achievement

1.57 (0.75-3.26)

NS

Age

 

< 0.001

>/= 50 vs. </= 49 y

3.42 (2.18-5.34)

 

Employment

 

NS

Unemployed vs. Employed

1.48 (0.91-2.39)

 

Income

 

NS

> $5000 vs. <$4 999 TTD/mo

0.69 (0.195-2.46)

 

Presently in a relationship

 

< 0.001

No vs. Yes

2.63 (1.62-4.25)

 

Would like to cut down on alcohol

 

0.045

No vs. Yes

2.48 (1.02-6.02)

 

Discussion

This study shows that abuse was common and was reported by 40% of female respondents at walk-in clinics in Trinidad and further 8% of all participants reported physical and sexual abuse in the last year. There were associations between abuse and age, employment status, current relationship, and the desire to cut down on alcohol intake. Further analysis suggested that at these primary care walk-in clinics, statistically significant predictors of woman abuse were being of an age less than 50, wanting to cut down on alcohol use and being in a relationship.

This paper supports previous studies that show that abuse is as common in this population as in primary care populations worldwide. Its results add to the Caribbean literature by exploring the association between abuse experienced by women in their relationships and mental disorders in the primary care setting. It further shows that among women who report abuse, depression, somatization and PTSD are common. Suicidal ideation also occurs more commonly among the women who report abuse than those who do not.

These findings are consistent with the recent medical literature [68, 21].

Another potentially important finding is the relationship between the symptoms which 'bothered the participants 'a lot' during the past 4 weeks and the reporting of abuse, these symptoms included menstrual cramps, pain or problem with sexual intercourse, headaches, feeling the heart pounding or racing, shortness of breath or nausea, gas and indigestion. These are all common primary care symptoms. The lesson to take away is that if these symptoms are present and somatisation is considered then the physician should explore the possibility of abuse.

This paper has several strengths including the large sample of participants, the good response rate, and the random selection of clinics to represent the various administrative centres and urban and rural centres. The good response rate was thought to be due to 3 factors, the long waiting times at the clinics before patients saw the physician which meant that patients were not rushed and could easily complete the questionnaire before their consultation, the interviewers were all females and so participants may have been more comfortable talking about sensitive topics, and these clinics have been poorly studied in the local medical literature.

The participants are not representative of the entire population since the middle and upper income groups are under-represented. These are free health centers which have large patient populations and long waiting times and attract those of a lower socio-economic status. We also know nothing of the non-responders; their non-participation might have possibly skewed the results. A major weakness is that the instruments employed are screening and not confirmatory tests. Also because this was a cross-sectional study we can draw no conclusion on the causality of violence and mental illness so these results set the scene for further investigation using prospective studies. Future research should focus on refining the prevalence of the mental disorders found and confirming the findings using validated diagnostic tests. Additionally we need to document if the patient's quality of life is presently severely enough affected such that treatment was required and subsequently if this treatment was successful over time.

These results have a myriad of implications for primary care first contact clinics in Trinidad. Firstly these clinics and similar ones in Trinidad have a history of very large numbers of patients, and very short consultation times [22]. Yet results from studies such as this and those reported above [15] support the international findings [10, 12, 13, 23] of a high level of mental health morbidity among primary care patients of woman abuse and other conditions including depression, anxiety, and posttraumatic stress disorder. Such conditions require a much longer consultation to recognize and initiate treatment plus sizable resources to support the primary care worker. It has been well documented that mental health continues to be under-funded, under-researched and poorly resourced in the developing world [24]. Papers such as this one continue to provide advocates with the evidence to entreat the political powers to provide the financial and human resources required to address these issues and educators with the conviction to train their students with these curricula.

Conclusions

This cross-sectional survey of 432 women of primarily lower socioeconomic status who attend walk-in clinics in Trinidad revealed that abuse as measured by the Woman Abuse Screening Test (WAST)-Short scale is high. There were statistically significant associations between abuse and mental disorders such as depression, suicidal ideation, post-traumatic stress disorder and somatization, as determined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) scale.

Declarations

Authors’ Affiliations

(1)
The Unit of Public Health and Primary Care, Faculty of Medical Sciences, The University of the West Indies
(2)
Faculty of Medical Sciences, The University of the West Indies

References

  1. Rawlins J: A family and public health problem. Caribbean Journal of Criminology and Social Psychology. 2000, 5 (1&2): 165-180.Google Scholar
  2. Zackerali J, Chankadyal K, Nagessar R, Sampson N, Ramasir C, Boodram R, Rawlins JM: The prevalence of domestic violence within different socio-economic classes in Trinidad [abstract]. West Indian Medical Journal. 2002, 51 (Suppl 2): 32-Google Scholar
  3. Patel S, Lee Pow N, Kawal R, Khan S, Mohess D, Sankar S, McDougall L: Prevalence and factors associated with physical and emotional abuse against pregnant women in central Trinidad [abstract]. West Indian Medical Journal. 1999, 48 (Suppl 2): 34-Google Scholar
  4. Bissoon A, Anmolsingh R, Judhan R, Jurawan T, Bridgelal R, Maccum A, Bhimull V, Ramroop S, McDougall L: Incidence and factors associated with domestic violence among women presenting to an Accident and Emergency Department, Trinidad and Tobago [abstract]. West Indian Medical Journal. 2003, 52 (Suppl 3): 37-Google Scholar
  5. Maharaj RG, Daniel M, Dookeeram D, Lee-Chong M, Mohammed-Hosein M, Roopchand B, Sookdar A, Sookram A: Validation of the Intimate Partner Abuse Screening Test (IPAST) for use in Trinidadian Family Practice. Caribbean Med J. 2006, 68 (1): 28-34.Google Scholar
  6. Hegarty K, Gunn J, Chondros P, Small R: Association between depression and abuse by partners of women attending general practice: descriptive, cross sectional survey. BMJ. 2004, 328: 621-624. 10.1136/bmj.328.7440.621.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Eberhard-Gran M, Schei B, Eskild A: Somatic Symptoms and Diseases are more Common in Women Exposed to Violence. J Gen Intern Med. 2007, 22 (12): 1668-1673. 10.1007/s11606-007-0389-8.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Woods SJ, Hall RJ, Campbell JC, Angott DM: Physical Health and Posttraumatic Stress Disorder Symptoms in Women Experiencing Intimate Partner Violence. Journal of Midwifery & Women's Health. 2008, 53 (6): 538-546.View ArticleGoogle Scholar
  9. Brown JB, Lent B, Brett PJ, Sas G, Pederson L: Development of the Woman Abuse Screening Tool (WAST) for Use in Family Practice. Fam Med. 1996, 28 (6): 422-8.PubMedGoogle Scholar
  10. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV, Hahn SR, Brody D, Johnson JG: Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994, 272 (22): 1749-56. 10.1001/jama.272.22.1749.View ArticlePubMedGoogle Scholar
  11. Spitzer RL, Kroenke K, Williams JB: Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999, 282 (18): 1737-44. 10.1001/jama.282.18.1737.View ArticlePubMedGoogle Scholar
  12. Norton J, De Roquefeuil G, Boulenger JP, Ritchie K, Mann A, Tylee A: Use of the PRIME-MD Patient Health Questionnaire for estimating the prevalence of psychiatric disorders in French primary care: comparison with family practitioner estimates and relationship to psychotropic medication use. Gen Hosp Psychiatry. 2007, 29 (4): 285-93. 10.1016/j.genhosppsych.2007.02.005.View ArticlePubMedGoogle Scholar
  13. Ansseau M, Dierick M, Buntinkx F, Cnockaert P, De Smedt J, Haute Van Den M, Mijnsbrugge Vander D: High prevalence of mental disorders in primary care. J Affect Disord. 2004, 78 (1): 49-55. 10.1016/S0165-0327(02)00219-7.View ArticlePubMedGoogle Scholar
  14. Baca E, Saiz J, Agüera L, Caballero L, Fernández-Liria A, Ramos J, Gil A, Madrigal M, Porras A: [Validation of the Spanish version of PRIME-MD: a procedure for diagnosing mental disorders in primary care]. Actas Esp Psiquiatr. 1999, 27 (6): 375-83.PubMedGoogle Scholar
  15. Loerch B, Szegedi A, Kohnen R, Benkert O: The primary care evaluation of mental disorders (PRIME-MD), German version: a comparison with the CIDI. J Psychiatr Res. 2000, 34 (3): 211-20. 10.1016/S0022-3956(00)00005-4.View ArticlePubMedGoogle Scholar
  16. Avasthi A, Varma SC, Kulhara P, Nehra R, Grover S, Sharma S: Diagnosis of common mental disorders by using PRIME-MD Patient Health Questionnaire. Indian J Med Res. 2008, 127 (2): 159-64.PubMedGoogle Scholar
  17. Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL: Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Ann Emerg Med. 2001, 37 (2): 132-40. 10.1067/mem.2001.112255.View ArticlePubMedGoogle Scholar
  18. Malmenström M, Bixo M, Björn I: Patients with psychiatric disorders in gynecologic practice--a three year follow-up. J Psychosom Obstet Gynaecol. 2006, 27 (1): 17-22. 10.1080/01674820500165968.View ArticlePubMedGoogle Scholar
  19. Russell AS, Hui BK: The use of PRIME-MD questionnaire in a rheumatology clinic. Rheumatol Int. 2005, 25 (4): 292-5. 10.1007/s00296-004-0548-8.View ArticlePubMedGoogle Scholar
  20. Spitzer RL, Williams JB, Kroenke K: Prime MD Today: Evaluation of mental disorders. 1999, USA: PfizerGoogle Scholar
  21. Bradley F, Smith M, Long J, O'Dowd T: Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ. 2002, 324: 271-5. 10.1136/bmj.324.7332.271.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete-Brown L, Hernandez O: The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ. 1998, 32 (2): 181-9. 10.1046/j.1365-2923.1998.00196.x.View ArticlePubMedGoogle Scholar
  23. Simsek Z, Ak D, Altindag A: Prevalence and predictors of mental disorders among women in Sanliurfa, Southeastern Turkey. Journal of Public Health. 2008, 30 (4): 487-493. 10.1093/pubmed/fdn025.View ArticlePubMedGoogle Scholar
  24. Patel V, Garrison P, Mari J, Minase H, Prince M, Saxena S, on behalf of the advisory group of the Movement for Global Mental Health: The Lancet's Series on Global Mental Health: 1 year on. Lancet. 2008, 372: 1354-1357. 10.1016/S0140-6736(08)61556-1.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/26/prepub

Copyright

© Maharaj et al; licensee BioMed Central Ltd. 2010

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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