Poverty and mental illness interact in a vicious cycle in low and middle-income countries (LMIC) (Lund et al. 2010). On the one hand, circumstances of poverty, which are marked by income and food insecurity, increased exposure to negative life events (including trauma), unemployment and fragile social networks all increase risk for mental illness. On the other hand, people who live with mental illness drift into or remain in poverty as a result of the disability of their condition, stigma and increased healthcare expenditure. Yet there is emerging evidence that individuals and families in LMIC who receive mental health interventions experience both improvements in mental health status and improvements in economic status (Lund et al. 2011). These economic outcomes include improved ability to engage in productive work, improved employment rates, reduction in work related disability, increased income and reduction in the impact of mental illness on the family’s finances and working patterns.

In a similar vein, there is strong evidence that intimate partner violence (IPV) is associated with a range of negative mental health outcomes, including depression, anxiety, posttraumatic stress disorder, and alcohol use (Mullen et al. 1988, Devries et al. 2013).  IPV may comprise physical, sexual, and psychological violence, which can affect mental health through traumatic stress pathways and undermining protective factors such as self-esteem and social support. Similar to the relationship between poverty and mental health, longitudinal research indicates that the relationship between IPV and mental health is bi-directional. Women exposed to IPV are at increased risk of mental health problems, and these mental health problems subsequently place them at greater risk of IPV (Tsai et al 2016). There is also some emerging evidence that mental health interventions can lead to reductions in IPV, including reductions in victimization and perpetration (Gevers & Dartnall 2014, Iverson et al 2011). However, to our knowledge a systematic review of the effects of mental health interventions on IPV perpetration and victimization has not been conducted. Little is known regarding IPV outcomes that are being assessed in current mental health trials in LMIC. Furthermore, little is known regarding the potential mechanisms by which mental health interventions might lead to a reduction in IPV perpetration or victimization.

Given the historical neglect of mental health and IPV in international development policy, it is vital to generate new evidence for the economic and IPV impacts of mental health interventions. In particular, we need to identify the cognitive, affective and behavioural mechanisms that mediate the effect of mental health interventions on economic and IPV outcomes. Measurement tools are essential to further our understanding of the impact of these interventions. Filling this gap in our knowledge could pave the way for the development of novel interventions that target the mechanisms of poverty, IPV and mental illness cycles. These interventions could be evaluated in future randomized controlled trials, providing transformative interventions that will improve the lives of vulnerable populations exposed to IPV or living in poverty with mental illness in LMIC.

The EconIPV-MH project thus aims to generate new knowledge on the cognitive, affective and behavioural mechanisms by which mental illness, IPV and poverty cycles are interrupted, and to apply it to reach affected populations with effective programs.

This is being achieved through conducting two systematic reviews of mental health interventions in low- and middle-income countries, to examine the impact of these interventions on 1) economic outcomes, and 2) IPV outcomes. The economic systematic review has found enough evidence to conduct a meta-analysis. Both reviews are registered on Prospero, and results will be published shortly.

Prospero links:

Economic outcomes: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=58930

IPV outcomes: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=64660

Following the reviews, we will collaborate with investigators to create standardized economic and IPV measures that can be used in future assessments of trials in LMICs.

The project will then publish a set of recommended economic and IPV outcome measures for inclusion in mental health trials, together with conceptual frameworks and mechanisms to target in future trials. Along with the findings of the reviews, these will be presented to key funders, colleagues, and policymakers in the field.

Prof Crick Lund is the project PI, and the project is running from January 2017 to December 2018.