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This longitudinal study indicates that exposure to the traumas of mass conflict and subsequent depressive symptoms play an important role in pathways leading to functional impairment in the postconflict period among women of child-rearing age. Our study, conducted in Timor-Leste, involved an analytic sample of 1292 women recruited at antenatal clinics in the capital and its surrounding districts. Women were re-interviewed at home 2 years later (77.3% retention). We applied the Edinburgh Postnatal Depression Scale, the Harvard Trauma Questionnaire for conflict-related traumatic events, the WHO Violence Against Women Instrument covering the past year for intimate partner violence and the WHO Disability Assessment Schedule (WHODAS V.2.0) to assess functional impairment. A longitudinal path analysis tested direct and indirect relationships involving past conflict-related trauma exposure, depressive symptoms measured over the two time points and functional impairment at follow-up. The prevalence of predefined clinically significant depressive symptoms diminished from 19.3% to 12.8%. Nevertheless, there was a tendency for depressive symptoms to persist over time (β=0.20; p<0.001). Follow-up depressive symptoms were associated with functional impairment (β=0.35; p<0.001). Reported conflict-related trauma occurring a minimum of 6 years earlier (β=0.23; p<0.001) and past-year physical intimate partner violence (β=0.26; p<0.001) were each associated with depressive symptoms at baseline and at follow-up. A measure of poverty specific to the context and reported health problems in the mother and infant also contributed to depressive symptoms. The findings highlight the association between ongoing trauma-related depressive symptoms and the capacity of women in the childbearing age to function in multiple areas of their lives in a postconflict country. Recognition of these relationships is important in the formulation and implementation of contemporary international recovery and development policies applied to postconflict countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Previous studies have identified high rates of explosive anger amongst post-conflict populations including Timor-Leste. We sought to test whether explosive anger was integrally associated with symptoms of grief amongst the Timorese, a society that has experienced extensive conflict-related losses. In 2010 and 2011 we recruited adults (n = 2964), 18-years and older, living in an urban and a rural village in Timor-Leste. We applied latent class analysis to identify subpopulations based on symptoms of explosive anger and grief. The best fitting model comprised three classes: grief (24%), grief-anger (25%), and a low symptom group (51%). There were more women and urban dwellers in the grief and grief-anger classes compared to the reference class. Persons in the grief and grief-anger classes experienced higher rates of witnessing murder and atrocities and traumatic losses, ongoing poverty, and preoccupations with injustice for the two historical periods of conflict (the Indonesian occupation and the later internal conflict). Compared to the reference class, only the grief-anger class reported greater exposure to extreme deprivations during the conflict, ongoing family conflict, and preoccupations with injustice for contemporary times; and compared to the grief class, greater exposure to traumatic losses, poverty, family conflict and preoccupations with injustice for both the internal conflict and contemporary times. A substantial number of adults in this post-conflict country experienced a combined constellation of grief and explosive anger associated with extensive traumatic losses, deprivations, and preoccupations with injustice. Importantly, grief-anger may be linked to family conflict in this post-conflict environment.

Introduction: Women in conflict-affected countries are at risk of mental disorders such as posttraumatic stress disorder and depression. No studies have investigated the association between experiences of abuse and injustice and explosive anger amongst women in these settings, and the impact of anger on women's health, family relationships and ability to participate in development., Methods: A mixed methods study including an epidemiological survey (n = 1513, 92.6% response) and qualitative interviews (n = 77) was conducted in Timor-Leste. The indices measured included Intermittent Explosive Disorder, posttraumatic stress disorder; severe distress; days out of role (the number of days that the person was unable to undertake normal activities); gender-specific trauma; conflict/violence; poverty; and preoccupations with injustice., Results: Women with Intermittent Explosive Disorder (n = 184, 12.2%) were more disabled than those without the disorder (for >5 days out of role, 40.8% versus 31.5%, X(2) (2) = 12.93 p = 0.0016). Multivariable associations with Intermittent Explosive Disorder, controlling for the presence of PTSD, psychological distress and other predictors in the model, included the sense of being sick (OR 1.73; 95% CI 1.08-2.77); victimization as a result of helping the resistance movement (OR 2.33, 95% CI 1.48-3.68); war-related trauma specific to being a woman (OR 1.95, 95%, CI 1.09-3.50); ongoing family violence and community conflict (OR 1.88, 95% CI 1.27-2.77); extreme poverty (OR 1.23, 95%, CI 1.08-1.39); and distressing preoccupations with injustice (relating to 2/3 historical periods, OR 2.10, 95% CI 1.35-3.28). In the qualitative study, women elaborated on the determinants of anger and its impact on their health, family and community functioning, child-rearing, and capacity to engage in development. Women reflected on the strategies that might help them overcome their anger., Conclusions: Intermittent Explosive Disorder is prevalent and disabling amongst women in conflict-affected Timor-Leste, impacting on their health, child-rearing and ability to participate fully in socio-economic development.