Top

International Journal of Mental Health Systems

Published in:

Open Access 01-12-2023 | Research

Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study

Authors: Lauren C. Ng, Kimberly Hook, Maji Hailemariam, Medhin Selamu, Abebaw Fekadu, Charlotte Hanlon

Published in: International Journal of Mental Health Systems | Issue 1/2023

Abstract

Background

This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting.

Methods

A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers.

Results

Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure.

Conclusions

Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.CrossRef

Benjet C, Bromet E, Karam EG, Kessler RC, McLaughlin KA, Ruscio AM, et al. The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychol Med. 2015;46(2):327–43.PubMedPubMedCentralCrossRef

Seides R. Should the current DSM-IV-TR definition for PTSD be expanded to include serial and multiple microtraumas as aetiologies? J Psychiatr Ment Health Nurs. 2010;17(8):725–31.PubMedCrossRef

Cusack KJ, Grubaugh AL, Knapp RG, Frueh BC. Unrecognized trauma and PTSD among public mental health consumers with chronic and severe mental illness. Community Ment Health J. 2006;42(5):487–500.PubMedCrossRef

Mueser KT, Rosenberg SD, Goodman LA, Trumbetta SL. Trauma, PTSD, and the course of severe mental illness: an interactive model. Schizophr Res. 2002;53(1–2):123–43.PubMedCrossRef

Seedat S, Stein MB, Oosthuizen PP, Emsley RA, Stein DJ. Linking posttraumatic stress disorder and psychosis: a look at epidemiology, phenomenology, and treatment. J Nerv Ment Dis. 2003;191(10):675–81.PubMedCrossRef

Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher FC, Vidaver R, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998;66(3):493–9.PubMedCrossRef

Hacioglu Yildirim M, Yildirim EA, Kaser M, Guduk M, Fistikci N, Cinar O, et al. The relationship between adulthood traumatic experiences and psychotic symptoms in female patients with schizophrenia. Compr Psychiatry. 2014;55(8):1847–54.PubMedCrossRef

Gearon JS, Kaltman SI, Brown C, Bellack AS. Traumatic life events and PTSD among women with substance use disorders and schizophrenia. Psychiatr Serv. 2003;54(4):523–8.PubMedCrossRef

10.

Cohen CI, Palekar N, Barker J, Ramirez PM. The relationship between trauma and clinical outcome variables among older adults with schizophrenia spectrum disorders. Am J Geriatr Psychiatry. 2012;20(5):408–15.PubMedCrossRef

11.

Alvarez MJ, Roura P, Foguet Q, Oses A, Sola J, Arrufat FX. Posttraumatic stress disorder comorbidity and clinical implications in patients with severe mental illness. J Nerv Ment Dis. 2012;200(6):549–52.PubMedCrossRef

12.

Berry K, Ford S, Jellicoe-Jones L, Haddock G. PTSD symptoms associated with the experiences of psychosis and hospitalisation: a review of the literature. Clin Psychol Rev. 2013;33(4):526–38.PubMedCrossRef

13.

Lommen MJ, Restifo K. Trauma and posttraumatic stress disorder (PTSD) in patients with schizophrenia or schizoaffective disorder. Community Ment Health J. 2009;45(6):485–96.PubMedPubMedCentralCrossRef

14.

Frueh BC, Knapp RG, Cusack KJ, Grubaugh AL, Sauvageot JA, Cousins VC, et al. Patients’ reports of traumatic or harmful experiences within the psychiatric setting. Psychiatr Serv. 2005;56(9):1123–33.PubMedCrossRef

15.

Cascardi M, Mueser KT, DeGiralomo J, Murrin M. Physical aggression against psychiatric inpatients by family members and partners. Psychiatr Serv. 1996;47(5):531–3.PubMedCrossRef

16.

Khalifeh H, Moran P, Borschmann R, Dean K, Hart C, Hogg J, et al. Domestic and sexual violence against patients with severe mental illness. Psychol Med. 2015;45(4):875–86.PubMedCrossRef

17.

Aakre JM, Brown CH, Benson KM, Drapalski AL, Gearon JS. Trauma exposure and PTSD in women with schizophrenia and coexisting substance use disorders: comparisons to women with severe depression and substance use disorders. Psychiatry Res. 2014;220(3):840–5.PubMedPubMedCentralCrossRef

18.

Lu W, Yanos PT, Silverstein SM, Mueser KT, Rosenberg SD, Gottlieb JD, et al. Public mental health clients with severe mental illness and probable posttraumatic stress disorder: trauma exposure and correlates of symptom severity. J Trauma Stress. 2013;26(2):266–73.PubMedPubMedCentralCrossRef

19.

Mueser KT, Salyers MP, Rosenberg SD, Goodman LA, Essock SM, Osher FC, et al. Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates. Schizophr Bull. 2004;30(1):45–57.PubMedCrossRef

20.

Yildirim MH, Yildirim EA, Kaser M, Guduk M, Fistikci N, Cinar O, et al. The relationship between adulthood traumatic experiences and psychotic symptoms in female patients with schizophrenia. Compr Psychiatry. 2014;55(8):1847–54.PubMedCrossRef

21.

Kramer IM, Simons CJ, Myin-Germeys I, Jacobs N, Derom C, Thiery E, et al. Evidence that genes for depression impact on the pathway from trauma to psychotic-like symptoms by occasioning emotional dysregulation. Psychol Med. 2012;42(2):283–94.PubMedCrossRef

22.

Corcoran C, Walker E, Huot R, Mittal V, Tessner K, Kestler L, et al. The stress cascade and schizophrenia: etiology and onset. Schizophr Bull. 2003;29(4):671–92.PubMedCrossRef

23.

Grubaugh AL, Zinzow HM, Paul L, Egede LE, Frueh BC. Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review. Clin Psychol Rev. 2011;31(6):883–99.PubMedPubMedCentralCrossRef

24.

Cougnard A, Marcelis M, Myin-Germeys I, De Graaf R, Vollebergh W, Krabbendam L, et al. Does normal developmental expression of psychosis combine with environmental risk to cause persistence of psychosis? A psychosis proneness-persistence model. Psychol Med. 2007;37(4):513–27.PubMedCrossRef

25.

Lataster J, Myin-Germeys I, Lieb R, Wittchen HU, van Os J. Adversity and psychosis: a 10-year prospective study investigating synergism between early and recent adversity in psychosis. Acta Psychiatr Scand. 2012;125(5):388–99.PubMedCrossRef

26.

Aas M, Djurovic S, Haukvik U, Andreassen OA, Agartz I, Melle I. Childhood trauma as a risk factor in first episode psychosis. Early Interv Psychiatry. 2014;8:98.

27.

Bonoldi I, Simeone E, Rocchetti M, Codjoe L, Rossi G, Gambi F, et al. Prevalence of self-reported childhood abuse in psychosis: a meta-analysis of retrospective studies. Psychiatry Res. 2013;210(1):8–15.PubMedCrossRef

28.

Dorrington S, Zavos H, Ball H, McGuffin P, Rijsdijk F, Siribaddana S, et al. Trauma, post-traumatic stress disorder and psychiatric disorders in a middle-income setting: prevalence and comorbidity. Br J Psychiatry. 2014;205(5):383–9.PubMedPubMedCentralCrossRef

29.

Bendall S, Hulbert CA, Alvarez-Jimenez M, Allott K, McGorry PD, Jackson HJ. Testing a model of the relationship between childhood sexual abuse and psychosis in a first-episode psychosis group: the role of hallucinations and delusions, posttraumatic intrusions, and selective attention. J Nerv Ment Dis. 2013;201(11):941–7.PubMedCrossRef

30.

Devylder JE, Wang JS, Oh HY, Lukens EP. Child loss and psychosis onset: evidence for traumatic experience as an etiological factor in psychosis. Psychiatry Res. 2013;205(1–2):90–4.PubMedCrossRef

31.

Arseneault L, Cannon M, Fisher HL, Polanczyk G, Moffitt TE, Caspi A. Childhood trauma and children’s emerging psychotic symptoms: a genetically sensitive longitudinal cohort study. Am J Psychiatry. 2011;168(1):65–72.PubMedCrossRef

32.

Burns JK, Jhazbhay K, Esterhuizen T, Emsley R. Exposure to trauma and the clinical presentation of first-episode psychosis in South Africa. J Psychiatr Res. 2011;45(2):179–84.PubMedCrossRef

33.

Shevlin M, Dorahy M, Adamson G. Childhood traumas and hallucinations: an analysis of the National Comorbidity Survey. J Psychiatr Res. 2007;41(3–4):222–8.PubMedCrossRef

34.

Galletly C, Van Hooff M, McFarlane A. Psychotic symptoms in young adults exposed to childhood trauma—a 20 year follow-up study. Schizophr Res. 2011;127(1–3):76–82.PubMedCrossRef

35.

Housen T, Lenglet A, Ariti C, Shah S, Shah H, Ara S, et al. Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley. BMJ Glob Health. 2017;2(4): e000419.PubMedPubMedCentralCrossRef

36.

World Health Organization. Mental health atlas. Geneva: WHO Press; 2014.

37.

Fekadu A, Medhin G, Selamu M, Hailemariam M, Alem A, Giorgis TW, et al. Population level mental distress in rural Ethiopia. BMC Psychiatry. 2014;14:194.PubMedPubMedCentralCrossRef

38.

Alem A. Human rights and psychiatric care in Africa with particular reference to the Ethiopian situation. Acta Psychiatr Scand Suppl. 2000;399:93–6.PubMedCrossRef

39.

Ametaj AA, Hook K, Cheng Y, Serba EG, Koenen KC, Fekadu A, et al. Traumatic events and posttraumatic stress disorder in individuals with severe mental illness in a non-western setting: data from rural Ethiopia. Psychol Trauma. 2021;13:684.PubMedPubMedCentralCrossRef

40.

Fekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis TW, et al. Development of a scalable mental healthcare plan for a rural district in Ethiopia. Br J Psychiatry. 2016;208(Suppl 56):S4-12.PubMedPubMedCentralCrossRef

41.

Tiruneh BT, Dachew BA, Bifftu BB. Incidence of road traffic injury and associated factors among patients visiting the emergency department of Tikur Anbessa specialized teaching hospital, Addis Ababa, Ethiopia. Emerg Med Int. 2014;2014: 439818.PubMedPubMedCentralCrossRef

42.

Tsigebrhan R, Shibre T, Medhin G, Fekadu A, Hanlon C. Violence and violent victimization in people with severe mental illness in a rural low-income country setting: a comparative cross-sectional community study. Schizophr Res. 2014;152(1):275–82.PubMedCrossRef

43.

Ng LC, Medhin G, Hanlon C, Fekadu A. Trauma exposure, depression, suicidal ideation, and alcohol use in people with severe mental disorder in Ethiopia. Soc Psychiatry Psychiatr Epidemiol. 2019;54(7):835–42.PubMedPubMedCentralCrossRef

44.

Fekadu A, Medhin G, Kebede D, Alem A, Cleare AJ, Prince M, et al. Excess mortality in severe mental illness: 10-year population-based cohort study in rural Ethiopia. Br J Psychiatry. 2015;206(4):289–96.PubMedCrossRef

45.

Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, et al. PRIME: a programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med. 2012;9(12): e1001359.PubMedPubMedCentralCrossRef

46.

World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization; 2010.

47.

Rucker J, Newman S, Gray J, Gunasinghe C, Broadbent M, Brittain P, et al. OPCRIT+: an electronic system for psychiatric diagnosis and data collection in clinical and research settings. Br J Psychiatry. 2011;199(2):151–5.PubMedPubMedCentralCrossRef

48.

Baron EC, Rathod SD, Hanlon C, Prince M, Fedaku A, Kigozi F, et al. Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol. BMC Psychiatry. 2018;18(1):61.PubMedPubMedCentralCrossRef

49.

Tirfessa K, Lund C, Medhin G, Hailemichael Y, Habtamu K, Fekadu A, et al. Food insecurity and work impairment in people with severe mental disorders in a rural district of Ethiopia: a cross-sectional survey. Soc Psychiatry Psychiatr Epidemiol. 2019;54(9):1055–66.PubMedCrossRef

50.

QSR International Pty Ltd. NVivo qualitative data analysis software. Version 10 ed2014.

51.

Smartt C, Ketema K, Frissa S, Tekola B, Birhane R, Eshetu T, et al. Pathways into and out of homelessness among people with severe mental illness in rural Ethiopia: a qualitative study. BMC Public Health. 2021;21(1):568.PubMedPubMedCentralCrossRef

52.

Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5) National Center for PTSD2013. Available from: http://www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp.

53.

Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov. 2013a.

54.

Hooper LM, Stockton P, Krupnick JL, Green BL. Development, use, and psychometric properties of the trauma history questionnaire. J Loss Trauma. 2011;16(3):258–83.CrossRef

55.

Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov. 2013b.

56.

Gilmoor A, Vallath S, Regeer B, Bunders J. “If somebody could just understand what I am going through, it would make all the difference”: conceptualizations of trauma in homeless populations experiencing severe mental illness. Transcult Psychiatry. 2020;57(3):455–67.PubMedPubMedCentralCrossRef

57.

Gilmoor AR, Vallath S, Peters RMH, van der Ben D, Ng L. Adapting the Trauma History Questionnaire for use in a population of homeless people with severe mental illness in Tamil Nadu, India: qualitative study. BJPsych open. 2021;7(4): e122.PubMedPubMedCentralCrossRef

58.

Patel V. Rethinking mental health care: bridging the credibility gap. Intervention. 2014;12:15–20.CrossRef

59.

Lambert JE, Nantogmah F, Dokurugu AY, Alhassan H, Azuure SS, Yaro PB, et al. The treatment of mental illness in faith-based and traditional healing centres in Ghana: perspectives of service users and healers. Glob Ment Health (Camb). 2020;7: e28.PubMedCrossRef

60.

Alvarez MJ, Roura P, Oses A, Foguet Q, Sola J, Arrufat FX. Prevalence and clinical impact of childhood trauma in patients with severe mental disorders. J Nerv Ment Dis. 2011;199(3):156–61.PubMedCrossRef

61.

Lu W, Mueser KT, Shami A, Siglag M, Petrides G, Schoepp E, et al. Post-traumatic reactions to psychosis in people with multiple psychotic episodes. Schizophr Res. 2011;127(1–3):66–75.PubMedCrossRef

62.

Mueser KT, Lu W, Rosenberg SD, Wolfe R. The trauma of psychosis: posttraumatic stress disorder and recent onset psychosis. Schizophr Res. 2010;116(2–3):217–27.PubMedCrossRef

63.

O’Donoghue B, Lyne J, Hill M, Larkin C, Feeney L, O’Callaghan E. Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services. Eur Psychiatry. 2011;26(4):208–14.PubMedCrossRef

64.

Swartz MS, Swanson JW, Hannon MJ. Does fear of coercion keep people away from mental health treatment? Evidence from a survey of persons with schizophrenia and mental health professionals. Behav Sci Law. 2003;21(4):459–72.PubMedCrossRef

65.

Semrau M, Evans-Lacko S, Alem A, Ayuso-Mateos JL, Chisholm D, Gureje O, et al. Strengthening mental health systems in low- and middle-income countries: the Emerald programme. BMC Med. 2015;13:79.PubMedPubMedCentralCrossRef

66.

Nadkarni A, Hanlon C, Bhatia U, Fuhr D, Ragoni C, de Azevedo Perocco SL, et al. The management of adult psychiatric emergencies in low-income and middle-income countries: a systematic review. Lancet Psychiatry. 2015;2(6):540–7.PubMedCrossRef

67.

Asher L, Fekadu A, Teferra S, De Silva M, Pathare S, Hanlon C. “I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia. Glob Health. 2017;13(1):47.CrossRef

68.

van der Watt ASJ, Nortje G, Kola L, Appiah-Poku J, Othieno C, Harris B, et al. Collaboration between biomedical and complementary and alternative care providers: barriers and pathways. Qual Health Res. 2017;27(14):2177–88.PubMedCrossRef

69.

Varese F, Smeets F, Drukker M, Lieverse R, Lataster T, Viechtbauer W, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull. 2012;38(4):661–71.PubMedPubMedCentralCrossRef

70.

McGrath JJ, Saha S, Lim CCW, Aguilar-Gaxiola S, Alonso J, Andrade LH, et al. Trauma and psychotic experiences: transnational data from the World Mental Health Survey. Br J Psychiatry J Mental Sci. 2017;211(6):373–80.CrossRef

71.

Shevlin M, Houston JE, Dorahy MJ, Adamson G. Cumulative traumas and psychosis: an analysis of the national comorbidity survey and the British Psychiatric Morbidity Survey. Schizophr Bull. 2008;34(1):193–9.PubMedCrossRef

72.

Tais Silveira M, Drukker M, Gadelha A, Pan PM, Salum GA, Manfro GG, et al. The association between psychotic experiences and traumatic life events: the role of the intention to harm. Psychol Med. 2018;48(13):2235–46.CrossRef

73.

Okkels N, Trabjerg B, Arendt M, Pedersen CB. Traumatic stress disorders and risk of subsequent schizophrenia spectrum disorder or bipolar disorder: a nationwide cohort study. Schizophr Bull. 2017;43(1):180–6.PubMedCrossRef

74.

Sareen J, Cox BJ, Goodwin RD, Asmundson GJS. Co-occurrence of posttraumatic stress disorder with positive psychotic symptoms in a nationally representative sample. J Trauma Stress. 2005;18(4):313–22.PubMedCrossRef

75.

Irfan M, Muzaffar S, Rathod S, Naeem F. Psychotherapy for schizophrenia and bipolar disorder. Amsterdam: Elsevier; 2019. p. 223–39.

76.

Padgett DK, Smith BT, Henwood BF, Tiderington E. Life course adversity in the lives of formerly homeless persons with serious mental illness: context and meaning. Am J Orthopsychiatry. 2012;82(3):421–30.PubMedPubMedCentralCrossRef

77.

Ametaj AA, Hook K, Cheng Y, Serba EG, Koenen KC, Fekadu A, et al. Traumatic events and posttraumatic stress disorder in individuals with severe mental illness in a non-western setting: Data from rural Ethiopia. Psychological Trauma: Theory, Research, Practice, and Policy. 2021; No Pagination Specified-No Pagination Specified.

78.

Kabir M, Iliyasu Z, Abubakar IS, Aliyu MH. Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. BMC Int Health Hum Rights. 2004;4(1):3.PubMedPubMedCentralCrossRef

79.

Patel V. Explanatory models of mental illness in sub-Saharan Africa. Soc Sci Med. 1995;40(9):1291–8.PubMedCrossRef

80.

Shibre T, Negash A, Kullgren G, Kebede D, Alem A, Fekadu A, et al. Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Soc Psychiatry Psychiatr Epidemiol. 2001;36(6):299–303.PubMedCrossRef

81.

Arias D, Taylor L, Ofori-Atta A, Bradley EH. Prayer camps and biomedical care in Ghana: is collaboration in mental health care possible? PLoS ONE. 2016;11(9): e0162305.PubMedPubMedCentralCrossRef

82.

Ng LC, Stevenson A, Kalapurakkel SS, Hanlon C, Seedat S, Harerimana B, et al. National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med. 2020;17(5): e1003090.PubMedPubMedCentralCrossRef

83.

Smartt C, Prince M, Frissa S, Eaton J, Fekadu A, Hanlon C. Homelessness and severe mental illness in low- and middle-income countries: scoping review. BJPsych open. 2019;5(4): e57.PubMedPubMedCentralCrossRef

84.

Ng LC, Serba EG, Dubale BW, Fekadu A, Hanlon C. Posttraumatic stress disorder intervention for people with severe mental illness in a low-income country primary care setting: a randomized feasibility trial protocol. Pilot Feasibil Stud. 2021;7(1):149.CrossRef

85.

Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA. 2004;291(21):2581–90.PubMedCrossRef

86.

Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ. 2004;82(11):858–66.PubMedPubMedCentral

87.

Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: where are we now? Lancet. 2007;370(9592):1061–77.PubMedCrossRef

Title: Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study
Authors: Lauren C. Ng
Kimberly Hook
Maji Hailemariam
Medhin Selamu
Abebaw Fekadu
Charlotte Hanlon
Publication date: 01-12-2023
Publisher: BioMed Central
Published in: International Journal of Mental Health Systems / Issue 1/2023
Electronic ISSN: 1752-4458
DOI: https://doi.org/10.1186/s13033-023-00616-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2023

What does receiving autism diagnosis in adulthood look like? Stakeholders’ experiences and inputs

Values and practice of collaboration in a mental health care system in the Netherlands: a qualitative study

Towards measuring effective coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder in São Paulo metropolitan area, Brazil

Attitude of mental healthcare providers toward tele-psychiatry services and associated factors at public referral hospitals in Addis Ababa city, Ethiopia

Predictors of time until return to work and duration of sickness absence in sick-listed precarious workers with common mental disorders: a secondary data-analysis of two trials and one cohort study

The battle for mental well-being in Ukraine: mental health crisis and economic aspects of mental health services in wartime