Epidemiologic research on interpersonal violence and common psychiatric disorders: where do we go from here?

Interpersonal violent injury and subsequent risk of suicide and deliberate self-harm: a register-based national cohort study from Norway, 2010-2018

Background

Interpersonal violence is a leading cause of morbidity, with potentially severe adverse consequences for the mental health of the injured persons. The extent to which violent injury is associated with subsequent suicidal behavior, however, remains unclear. This study aimed to examine how violent injury was associated with subsequent deliberate self-harm and death by suicide.

Methods

This retrospective cohort study used nationwide longitudinal registry data from Norway to identify all individuals presenting to emergency services in 2010-2018 with a violence-related injury, along with sex- and age-matched control individuals from the general population. The primary outcomes were any emergency visit for deliberate self-harm (DSH) and suicide death, observed through 31 December 2018. Rates of each outcome were compared between violence-injured patients and comparison individuals using stratified multivariable Cox regression models, controlling for sociodemographic characteristics as well as history of psychiatric treatment and DSH. Secondary analyses tested for moderation by sex, age, and prior psychiatric treatment.

Findings

Violence-injured patients (n = 28,276) had substantially higher rates of DSH (946.7 per 100,000 person-years) and suicide death (74.5 per 100,000) when compared to controls (n = 282,760; 90.0 and 15.2 per 100,000, respectively). The hazard ratios (HRs) remained significantly higher even after accounting for covariates (HRadj for DSH: 5.11; 95% CI: 4.62, 5.66; HRadj for suicide: 2.40; 95% CI: 1.78, 3.24). Sex differences in this association were negligible, but the association between violence injury and DSH increased with age. Violence-injured patients with prior psychiatric treatment had the highest risk of suicidal behavior.

Interpretation

Violence-injured patients experience significantly excess rates of suicidal behavior, a finding with potential to inform both clinical intervention and population-level suicide prevention strategies.

Funding

Fulbright Norway Scholarship.

Exploring the relationship between intimate partner violence during pregnancy and stillbirths

INTRODUCTION

The relationship between intimate partner violence (IPV) in pregnancy and stillbirths is poorly understood. We aimed to determine if there was any association between stillbirths and IPV during pregnancy.

METHODS

A community-based, matched, case-control study was conducted in 2014, nested within the Maternal and Newborn Health Registry of the Global Network for Women's and Children's Health Research in Pakistan. Using a WHO questionnaire, IPV in pregnancy was ascertained from 256 cases (women with stillbirths) and 539 controls (women with live births), individually matched on parity. Multivariable conditional logistic regression analysis assessed the association of IPV in pregnancy ending in stillbirths compared to those with live births.

RESULTS

The effect of physical and psychological IPV was modified by maternal age. Among women 25-34 years old with stillbirths, the odds of experiencing physical IPV in pregnancy were four times greater than those with live births, after controlling for confounders [odds ratio 4.1 (95% CI: 1.5, 11.2)]. A negative association was observed between psychological IPV in pregnancy and stillbirths among women younger than 25 years, and no association was observed between sexual IPV during pregnancy and stillbirths.

CONCLUSION

Study results show that women 25-34 years of age with stillbirths were four times more likely to experience physical IPV during pregnancy. Further studies replicating the effect modification of IPV by maternal age are warranted.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project

BACKGROUND

The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence.

METHOD

Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process.

RESULTS

The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant.

CONCLUSIONS

This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

Cultural adaptation of the guidelines for offering mental health first aid to a person after a potentially traumatic event: a delphi expert consensus study in Brazil

BACKGROUND

Traumatic events increase the risk of mental disorders. In a country with relatively under-developed mental health support systems, services to assist people who have experienced potentially traumatic events may be unavailable. In such situations, people in the community become key sources of support. However, they do not always have the knowledge and skills to offer effective help. This study reports on the cultural adaptation for Brazil of the English-language mental health first aid guidelines for helping someone who has experienced a potentially traumatic event.

METHODS

A Delphi expert consensus study with two expert panels, one comprising health professionals with experience in the treatment of trauma (n = 33) and the other comprising people with lived experience, (n = 29) was conducted. A questionnaire containing 131 statements from the English language guidelines was translated into Brazilian Portuguese. Participants were asked to rate the importance of actions to be taken to help a person who has experienced a potentially traumatic event and to suggest new items where appropriate.

RESULTS

Data were collected over two survey rounds. A total of 149 items were included in the final guidelines (110 items from the English-language guidelines and 39 new items created from expert panel comments, in the second round). Immediate action items were endorsed by both panels, while items related to encouraging victims were rejected by the professional panel. The suggested statements mostly related to providing psychological support and attending to the person's subjective experience rather than providing material or structural support.

CONCLUSION

While there were many similarities with the English-language guidelines for high-income countries, the guidelines also incorporate actions of importance for Brazil, including the emphasis on the first aider's management of the person's subjective experiences. These guidelines may inform Mental Health First Aid training for Brazil and may also be used as standalone resources.

The association between adverse childhood experiences and common mental disorders and suicidality: an umbrella review of systematic reviews and meta-analyses

Adverse childhood experiences (ACEs) are related to increased risk of common mental disorders. This umbrella review of systematic reviews and meta-analyses aimed to identify the key ACEs that are consistently associated with increased risk of mental disorders and suicidality. We searched PsycINFO, PubMed, and Google Scholar for systematic reviews and meta-analyses on the association between ACEs and common mental disorders or suicidality published from January 1, 2009 until July 11, 2019. The methodological quality of included reviews was evaluated using the AMSTAR2 checklist. The effect sizes reported in each meta-analysis were combined using a random-effects model. Meta-regressions were conducted to investigate whether associations vary by gender or age of exposure to ACEs. This review is registered with PROSPERO (CRD42019146431). We included 68 reviews with moderate (55%), low (28%) or critically low (17%) methodological quality. The median number of included studies in these reviews was 14 (2-277). Across identified reviews, 24 ACEs were associated with increased risk of common mental disorders or suicidality. ACEs were associated with a two-fold higher odds of anxiety disorders (pooled odds ratios (ORs): 1.94; 95% CI 1.82, 2.22), internalizing disorders (OR 1.76; 1.59, 1.87), depression (OR 2.01; 1.86, 2.32) and suicidality (OR 2.33; 2.11, 2.56). These associations did not significantly (P > 0.05) vary by gender or the age of exposure. ACEs are consistently associated with increased risk of common mental disorders and suicidality. Well-designed cohort studies to track the impact of ACEs, and trials of interventions to prevent them or reduce their impact should be global research priorities.

Organization-Based Factors Bearing on Provider Screening and Referral Practices for Women Exposed to Intimate Partner Violence

Essential steps in the provision of health care for women exposed to intimate partner violence (IPV) are screening and referral for specialized services, as might occur in primary care settings. Prior to participating in a cross-disciplinary IPV training program, medical care (N = 223) and social/behavioral practitioners (N = 197) completed a survey that ascertained current practices, provisions, and perceived barriers related to IPV screening and referral. Roughly half of the study participants did not routinely screen their patients/clients for IPV, with no differences for the professional groupings. Utilization of referral resources was significantly lower for medical care providers, 78.5% of whom did not use any. Perceived barriers to screening and referral were examined as practitioner-based and organization-based, and we identified tangible provisions (protocols and practice materials) as a relevant variable. As we conjectured, organization-based barriers were more strongly associated with lower rates of screening and referral than were practitioner-based barriers, regardless of professional grouping. Moreover, tangible provisions, controlling for perceived barriers, significantly added to routine screening and frequency of referral resources usage, particularly for medical care providers. Results are discussed in the context of a systems-level approach to improving IPV services in health care with organizational practice enhancements.

Lifetime exposure to violence and other life stressors and hair cortisol concentration in women

Women are exposed to a variety of life stressors, particularly violence, during their lifetime which increases the risk of developing various psychiatric and somatic diseases, with the dysregulated secretion of cortisol as one potential biological mechanism. We examined the association between violence and other life stressors and hair cortisol concentration (HCC) in a population of urban women. We included 470 adult women (age = 21-86 years) attending the Cancer Detection Clinic in Iceland. The Life Stressor Checklist-Revised (LSC-R; 30-items) was used to assess exposure. HCC was measured with liquid chromatography coupled with tandem mass spectrometry. We used linear regression models to assess the association between life stressors and log-transformed HCC. The median HCC (pg/mg) in the study population was 4.9 (range 0.6-616.6). HCC was not associated with background covariates, including age (p = 0.868), education level (p = 0.824), marital status (p = 0.545), income (p = 0.363), occupation (p = 0.192), but associated with current smoking (p = 0.013). We noted a 3.3% (95% CI: 0.17-6.6%) associated increase in HCC per endorsed life stressor after adjusting for age and smoking, while non-violent life stressors were not associated with HCC. Per endorsed violence item, we observed a 10.2% (95% CI: 1.4-19.7%) associated increase in HCC after age and smoking adjustment. Women with lifetime exposure to both physical and sexual violence presented with higher HCC than unexposed women (p = 0.010), after age and smoking adjustment. Lifetime exposure to violence was associated with higher levels of HCC in a community sample of women. These findings need confirmation with prospective studies.

Using Social Media to Explore the Consequences of Domestic Violence on Mental Health

A great deal of research has focused on the negative consequences of domestic violence (DV) on mental health. However, current studies cannot provide direct and reliable evidence on the impacts of DV on mental health in a short term as it is not feasible to measure mental health shortly before and after an unpredictable event like DV. This study aims to explore the short-term outcomes of DV on individuals' mental health. We collected a sample of 232 victims (77% female) and 232 nonvictims (gender and location matched with 232 victims) on Sina Weibo. In both the victim and nonvictim groups, we measured their mental health status during the 4 weeks before the first DV incident and during the 4 weeks after the DV incident. We used our proposed Online Ecological Recognition (OER) system, which is based on several predictive models to identify individuals' mental health statuses. Mental health statuses were measured based on individuals' Weibo profiles and messages, which included "Depression," "Suicide Probability," and "Satisfaction With Life." The results showed that mental health in the victim group was impacted by DV while individuals in the nonvictim group were not. Furthermore, the victim group demonstrated an increase in depression symptoms, higher suicide risks, and decreased life satisfaction after their DV experience. In addition, the effect of DV on individuals' mental health could appear in the conditions of child abuse, intimate partner violence, and exposure to DV. These findings inform that DV significantly impacts individuals' mental health over the short term, as in 4 weeks. Our proposed new data collection and analyses approach, OER, has implications for employing "big data" from social networks to identify individuals' mental health.

Effect of Caffeine Consumption on the Risk for Neurological and Psychiatric Disorders: Sex Differences in Human

Caffeine occurs naturally in various foods, such as coffee, tea, and cocoa, and it has been used safely as a mild stimulant for a long time. However, excessive caffeine consumption (1~1.5 g/day) can cause caffeine poisoning (caffeinism), which includes symptoms such as anxiety, agitation, insomnia, and gastrointestinal disorders. Recently, there has been increasing interest in the effect of caffeine consumption as a protective factor or risk factor for neurological and psychiatric disorders. Currently, the importance of personalized medicine is being emphasized, and research on sex/gender differences needs to be conducted. Our review focuses on the effect of caffeine consumption on several neurological and psychiatric disorders with respect to sex differences to provide a better understanding of caffeine use as a risk or protective factor for those disorders. The findings may help establish new strategies for developing sex-specific caffeine therapies.

Interpersonal violence and mental health: a social justice framework to advance research and practice

This editorial paper accompanies a special series in the journal Global Mental Health focused on the topic of interpersonal violence and mental health. This series included 24 papers reporting on data from 31 countries, published between 2017 and 2019. This accompanying paper provides a short summary of findings in the special series and reflects on next steps in research and practice. Collectively, the series' 24 papers suggest intricate bi-directional relationships between interpersonal violence and mental health, situated in particular contexts and varying across the life course. In order to study this complexity, an overarching theoretical framework is critical. This paper takes the social justice theory developed by Powers and Faden (2006, 2019) as a starting point. It is argued that application of this social justice framework will be helpful to: strengthen conceptual clarity; provide a sense of direction for research and practice in the area of interpersonal violence and mental health; assist in conducting more fine grained analyses of contextually determined processes of disadvantage; and help situate disciplinary specific research and practice questions in their broader context, thereby strengthening multi-disciplinary research and multi-sectoral policy and programming efforts.

Use of mental health services by community-resident adults with DSM-IV anxiety and mood disorders in a violence-prone area: São Paulo, Brazil

BACKGROUND

While under-use of mental health services by adults with anxiety and/or depression is well established, use in a violence-prone area, and as a function of diagnosis and personality characteristics such resilience, is little known. We examine the sociodemographic and personality characteristics (specifically resilience), associated with use of mental health services in a violence-prone city by those with anxiety, depression, and their comorbidity.

METHODS

The structured Composite International Diagnostic Interview was used to identify 12-month DSM-IV- and ICD-10-defined anxiety and depression in a cross-sectional, representative, community-resident sample age 15-75y (N = 2536) in São Paulo, Brazil, and their use of mental health services. Resilience was determined by the Wagnild and Young scale. Analyses, using weighted, design-corrected statistical tests, included frequency measures and multivariable logistic regression.

RESULTS

Mental health services were used by 10% with only anxiety, 22% with only depression, and 34% with comorbidity, with odds of use in controlled analyses doubling from anxiety to depression to comorbidity. Use was significantly higher among those who were white, older (age >30 years, with substantial social support, low resilience, living in low homicide rate areas; use was not affected by experience of traumatic events. Psychiatrists, general practitioners, and psychologists were the primary providers.

LIMITATIONS

Cross-sectional design CONCLUSIONS: Contrary to expectation, use was greater among residents of lower homicide areas, and was not associated with personal traumatic experience. This may reflect increased immunity to violence in higher homicidal rate areas, lower resilience, and poorer access to services. Increased access to mental health services is needed.

Child maltreatment, psychopathological symptoms, and onset of diabetes mellitus, hypothyroidism and COPD in adulthood

BACKGROUND

The aim of this study was to assess the associations between child maltreatment (CM), psychopathological symptoms, and onset of diabetes mellitus, hypothyroidism (i.e., low metabolism), and chronic bronchitis/emphysema/COPD in adulthood.

METHODS

The present analysis used cross-sectional data collected in 2007-2008 within the Tromsø Study, Norway (N = 12,981). CM was measured with a single item, and self-reported information on psychopathological symptoms and physical health outcomes was used. The associations between CM, psychopathological symptoms, and physical health outcomes were assessed with linear and Poisson regression models. Mediation was assessed with difference-in-coefficients method.

RESULTS

In the fully-adjusted models, CM was associated with higher levels of anxiety and depression, psychological distress, difficulty in sleeping, insomnia, and use of sleeping pills and antidepressants in adulthood (p < 0.05). Moreover, CM was associated with a more than two-folds increased risk of consultation with psychiatrist (p < 0.001), a 26% increased risk of forgetfulness (p < 0.001), a 15% increased risk of decline in memory (p < 0.001), and a 96% increased risk of psychiatric problems (p < 0.001) over the course of life. In the fully-adjusted models, CM was associated with a 27-82% increased risk of physical health outcomes in adulthood (p < 0.05). Indicators of psychopathological symptoms significantly (p < 0.05) mediate the associations between CM and physical health outcomes.

LIMITATIONS

The design of this study is cross-sectional, and all measures are self-reported.

CONCLUSION

The associations between retrospectively-reported CM and physical health outcomes in adulthood are partially driven by psychopathological symptoms in adulthood.

The Co-Occurrence and Unique Mental Health Effects of Political Violence and Intimate Partner Violence

The global mental health ramifications of political violence and intimate partner violence (IPV) are well established. There also exists a growing body of evidence about the increased risks for IPV within situations of political violence. Yet, except for a few studies, there is little literature that simultaneously examines how political violence and IPV might result in unique risks for particular types of mental health sequela. Delineating possible divergent patterns between specific mental health conditions resulting from political violence and IPV takes on an increased urgency given that, although they are related, the two most commonly reported outcomes of these two types of violence-post-traumatic stress disorder (PTSD) and depression-not only require different types of treatment, but may in fact be generated or maintained by disparate paths. Using survey data from adult women in Palestine ( n = 122), this study explores the relationships between IPV and political violence (both lifetime and past-month exposure) and tests their independent relationships to PTSD and depressive symptomology. After controlling for the other form of violence exposure, political violence was correlated with PTSD and not with depressive symptomology, while IPV was correlated with depressive symptomology and not with PTSD. Findings demonstrate that distinct forms of violence exposure might indeed be associated with specific mental health outcomes. Results illustrate the need to assess for both political violence and IPV when researching and designing interventions related to violence.

Pathways from assaultive violence to post-traumatic stress, depression, and generalized anxiety symptoms through stressful life events: longitudinal mediation models

BACKGROUND

Assaultive violence events are associated with increased risk for adverse psychiatric outcomes, including post-traumatic stress (PTS), depression, and generalized anxiety. Prior research has indicated that economic, legal, and social stressors that could follow assaultive events may explain the increased risk for adverse psychiatric outcomes, yet longitudinal studies have not adequately examined this pathway. In the current study, we aimed to address this limitation.

METHODS

Participants (N = 1360) were part of a longitudinal population-based study of adults living in Detroit. At three waves, participants indicated their exposure to assaultive violence and economic, legal, and social stressors, and completed inventories of PTS, depression, and generalized anxiety. Longitudinal mediation models were used to test the hypothesized pathway from assaultive violence to each psychiatric outcome.

RESULTS

The hypothesized models evidenced good fit with the data and, in each, the paths from Wave 1 (W1) assaultive violence to W2 stressors, and from W2 stressors to W3 symptoms were significant (range of Standardized Estimates: 0.09-0.15, all p < 0.01). Additionally, the indirect paths from W1 assaultive violence to W3 symptoms were significant (range of Standardized Estimates: 0.01-0.02, all p < 0.05).

CONCLUSIONS

The findings illustrate that the economic, legal, and social stressors that could follow assaultive violence increase risk for a range of psychiatric symptoms. Although future research is needed, the results suggest that investment in interventions that prevent and mitigate assaultive violence survivors' exposure to such stressors may be an effective way to prevent mental illness in the aftermath of violent assaults.

Intimate Partner Violence Victims Seeking a Temporary Restraining Order: Social Support and Resilience Attenuating Psychological Distress

Social support has been found in many studies to be a protective factor for those exposed to intimate partner violence (IPV), but personal resilience has received far less attention. The present study concerns 136 female IPV victims seeking a temporary restraining order (TRO) from a Family Justice Center (FJC). The relationships between IPV victimization, social support, resilience, and psychological distress were examined. Hierarchical regressions found that both perceived social support and self-reported resilience were inversely associated with distress symptoms. Higher social support was associated with lower trauma symptoms, controlling for abuse history, demographics, and resilience. Higher resilience was associated with lower mood symptoms and lower perceived stress, controlling for abuse history, demographics, and social support. No significant associations were recorded for anger symptoms. These findings suggest that fostering resilience can have important health benefits for IPV victims, above and beyond the well-known benefits of social support. Ways that resilience might be cultivated in this population and other implications for practice are discussed.

Prospective Study of the Mental Health Consequences of Sexual Violence Among Women Living With HIV in Rural Uganda

The association between sexual violence and depression is well known, but the temporal aspects of the association have not been well established. We analyzed data from a cohort of 173 HIV-positive women in rural Uganda who were interviewed every 3 months for a median of 1.8 years of follow-up. The method of generalized estimating equations (GEE) was used to model the marginal expectation of depression symptom severity (Hopkins Symptom Checklist for Depression), mental health-related quality of life (MOS-HIV Mental Health Summary), and heavy drinking (Alcohol Use Disorders Identification Test) as a function of self-reported forced-sex victimization in the 3 months prior to interview. Estimates were adjusted for variables known to confound the association between victimization and mental health status. To assess any potential reciprocal relationships, we reversed the temporal ordering of the exposures and outcomes and refitted similar GEE models. In multivariable analyses, victimization was associated with greater depression symptom severity (b = 0.17; 95% CI = [0.02, 0.33]) and lower mental health-related quality of life (b = -5.65; 95% CI = [-9.34, -1.96]), as well as increased risks for probable depression (adjusted relative risk [ARR] = 1.58; 95% CI = [1.01, 2.49) and heavy drinking (ARR = 3.99; 95% CI = [1.84, 8.63]). We did not find strong evidence of a reciprocal relationship. Our findings suggest that forced sex is associated with adverse mental health outcomes among HIV-positive women in rural Uganda. Given the substantial mental health-related impacts of victimization, effective health sector responses are needed.

Potentially Traumatic Events, Posttraumatic Stress Disorder, and Depression among Adults in Puerto Rico

The aims of the current study were to examine the prevalence of potentially traumatic events (PTEs), posttraumatic stress disorder (PTSD; data available in males only), and depressive symptoms in a Puerto Rican sample of 678 adult caretakers (50% female) of twins participating in the Puerto Rican Infant Twin Study. The World Health Organization Composite International Diagnostic Interview version 3.0 (CIDI 3.0) was utilized to assess rates of PTEs, PTSD, and depression among male participants while an abbreviated version of the CIDI 3.0 and the Mood and Feelings Questionnaire were administered to females to assess PTEs and depressive symptoms. Significantly more males than females reported exposure to a PTE (76.6% vs. 44.2%, χ(2) = 64.44, p < 0.001). In males, endorsement of multiple PTEs was associated with increased level of PTSD symptomatology (β = 0.33, p < 0.001). With regard to depression, a similar dose-response relationship was found in both males and females, with depressive symptoms increasing as number of PTEs increased (βs = 0.15, 0.16, ps < 0.05). Exposure to an attack with a weapon was significantly associated with increased depression symptoms in both males and females (βs = 0.24, 0.20, ps < 0.01, respectively). These findings highlight the need for identification of putative risk and resilience factors among PTE-exposed individuals in Puerto Rico.

Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population

INTRODUCTION

Conditional risk for PTSD is the risk of developing PTSD after exposure to traumatic events. This epidemiological study of the general urban population from the two largest cities in Brazil reports exposure to traumatic events; conditional risk for PTSD; and proportion/estimated number of PTSD cases secondary to each type of traumatic event.

METHOD

Cross-sectional study of general population (15-75 y.o.) from Rio de Janeiro and São Paulo. PTSD was assessed through Composite International Diagnostic Interview 2.1.

RESULTS

Our main findings, from 3744 participants, were: 1) high prevalence of traumatic events (86%), urban violence being the most common; 2) conditional risk for PTSD was 11.1%; 3) women (15.9%) have overall conditional risk 3 times higher than men (5.1%); 4) war-related trauma (67.8%), childhood sexual abuse (49.1%) and adult sexual violence (44.1%) had the highest conditional risks; 5) 35% of PTSD cases (estimated 435,970 individuals) were secondary to sudden/unexpected death of a close person, and 40% secondary to interpersonal violence.

CONCLUSIONS

Brazilian urban population is highly exposed to urban violence, and overall conditional risk for PTSD was 11.1%. Violence prevention and enhancement of resilience should be part of public policies, and mental health sequelae of trauma should be better recognized and treated.

Understanding how domestic abuse is associated with greater depressive symptoms in a community sample of female primary care patients: does loss of belongingness matter?

This study examined the relationship between domestic abuse, belongingness, and depressive symptoms in a community sample of 71 female primary care patients. As expected, domestic abuse was associated with greater depressive symptoms. Results from conducting mediation analyses, including bootstrapping techniques, provided strong convergent support for a model in which the hypothesized effect of domestic abuse on depressive symptoms in women is mediated by a loss of belongingness. Noteworthy, even after controlling for content overlap between measures of belongingness and depressive symptoms, the mediation model remained significant. Some implications of the present findings are discussed.

Understanding the relationship between domestic abuse and suicide behavior in adults receiving primary care: does forgiveness matter?

This study examined the interrelation of domestic abuse, forgiveness of self, forgiveness of others, and suicide behavior in a community sample of 101 patients receiving primary care from a clinic in the southeastern United States. As expected, it was found that more frequent experience of domestic abuse was associated with more frequent suicide behavior. Results from conducting mediation analyses and using bootstrapping techniques provided support for a model in which the relationship between domestic abuse and suicide behavior was accounted for by forgiveness of self, but not by forgiveness of others. The article concludes with a discussion of some of the implications of the present findings for practice and the study's limitations.