Tuesday, May 24, 2011

Police suicides

Pondicherry police - kepis
Five police constables from Pune committed suicide this year. Suicide by police personnel the world over has been extensively reported. It is generally known that the occupation is stressful and associated with psychological stressors that make personnel prone to suicide. However, there is a marked variance in reported rates and stressors. Local factors may overshadow any generalisations even within the country. For instance, in the US/Europe firearms are the most common suicide method used by police (61-77%), but in Pune hanging was the only method used.

Sources of stress in police personnel

There is conflicting evidence as to the extent to which police constitute a high risk group for suicide. A study of well-being in police at Bangalore showed they were were better adjusted and had a better quality of life than comparable middle class urban factory workers (Geetha 1998). However, they had poorer social contact and support beyond the immediate family. This was attributed to their long working hours, requirement to be on duty during holidays, and the prevalent negative attitude of the public towards the police in general. Traffic policemen, personnel with higher education, and freshly recruited personnel were found to be under greater stress.

Police suicides are an interaction of personal vulnerabilities, workplace stressors, and environmental factors as is  seen with other worker groups. Two risk factors have been consistently delineated for suicide by police personnel; workplace trauma that increases vulnerability to posttraumatic stress disorders and organisational stressors that lead to burnout. Mental health interventions and organisational change are usually implemented to mitigate these factors. However, little attention is paid to the third leg of police suicide - personal factors (Stuart 2008). Personal factors had a major role to play in the Pune police suicides.

Suicide rates in police

Data on suicide rates for police in India is not available. However, the suicide rate in Pune is more than the national average. This rate is still increasing and is 17.3/100000 as of 2009.

Suicide rates in police personnel vary depending on geography. They can be higher than the general population as in Germany (25/100000 vs 20/100000), the same as the general population as in the US (14.9/100000) or half that of the comparable general population as in Canada (14.1/100000).

Suicide rates in police personnel also vary when calculated over long or short time frames, indicating the influence of clustering. This underlines the need for using longer time frames while studying this population (Loo 2003). A historical survey of police suicide from 1843-1992 in Queensland showed the rates reduced from 60/100000 to 20/100000 (Cantor 1995).

The accuracy and validity of police suicide rates are controversial. Under reporting of police suicide is significant (Violanti 2010). Up to 17% of police deaths in the US are classified as undetermined as compared to 8% for military deaths. Official police suicide rates are less accurate and less valid than suicide rates published for other working populations (Violanti 1996). We have already discussed the reasons and results of underestimating suicide rates in India.

What needs to be done

  1. Personal factors that contribute to suicide need special attention. These factors play alongside the workplace and environmental stressors in police personnel. These include psychiatric illnesses, alcoholism, physical ill health and interpersonal and marital problems. These problems are similar to those of the general population.
  2. An early warning system for stressful police events needs to be implemented. The LEOSS (Law Enforcement Officer Stress Survey) is a short 25-item questionnaire specifically designed to evaluate stress in police personnel (Van Hasselt 2003).
  3. Police personnel need easy access to mental health services. The barriers are formidable; psychiatric evaluation can result in job sanctions, reassignment, restriction of firearm privileges, missed promotions, and stigmatisation (Mazurk 2002). 
Need for more organisational change?

  1. Cantor CH, Tyman R, Slater PJ. A historical survey of police suicide in Queensland, Australia, 1843-1992. Suicide Life Threat Behav. 1995 Winter;25(4):499-507.
  2. Geetha PR, Subbakrishna DK, Channabasavanna SM. Subjecitive well being among police personnel. Indian J. Psychiat., 1998, 40(2), 172-179
  3. Loo R. A meta-analysis of police suicide rates: findings and issues. Suicide Life Threat Behav. 2003 Fall;33(3):313-25.
  4. Marzuk PM, Nock MK, Leon AC, Portera L, Tardiff K. Suicide among New York City police officers, 1977-1996. Am J Psychiatry. 2002 Dec;159(12):2069-71.
  5. Stuart H. Suicidality among police. Curr Opin Psychiatry. 2008 Sep;21(5):505-9.
  6. Van Hasselt VB, Sheehan DC, Sellers AH, Baker MT, Feiner CA. A behavioral-analytic model for assessing stress in police officers: phase I. Development of the Law Enforcement Officer Stress Survey (LEOSS). Int J Emerg Ment Health. 2003 Spring;5(2):77-84.
  7. Violanti JM, Vena JE, Marshall JR, Petralia S. A comparative evaluation of police suicide rate validity. Suicide Life Threat Behav. 1996 Spring;26(1):79-85.
  8. Violanti JM. Suicide or undetermined? A national assessment of police suicide death classification. Int J Emerg Ment Health. 2010 Spring;12(2):89-94.

Tuesday, May 17, 2011

Treatment of social anxiety, phobia and self-consciousness

social phobia
Avoiding social situations because they make you self conscious and anxious? You are likely to have a social phobia or social anxiety disorder. One in 10 persons experiences social phobia between the age of  9-33years. The incidence is highest in adolescence (Beesdo et al 2007). Men and women are equally likely to suffer. However, men are more likely to seek treatment when their performance at work is impaired.

Social anxiety usually begins in childhood or early adolescence. There is often a history of childhood shyness. A stressor or humiliating social experience can precipitate the problem. In fact paediatric social phobia affects 5-10% of children. In children it is often associated with ADHD (Attention Deficit Hyperactivity Disorder), depression or separation anxiety disorder. Longstanding social phobia increases the risk of depression, substance abuse, and alcoholism later in adulthood.

Recognising social phobia

“My mind went blank during the interview. I break into a sweat, my voice changes. I know what is being asked but I am just not able to concentrate and answer with confidence.”
You have social phobia when you feel that everyone is staring at you or judging you during social interactions. There is a persistent and intense fear of being embarrassed and humiliated by your own actions. This especially occurs in public places such as at work, during office 14meetings, while shopping and at social gatherings. The feelings persist even though rationally you know its not true. These fears may become so severe that they interfere with your work, school or college. They make it hard for you to socialise and make or keep friends.

When you decide to confront these fears and join the party or attend a meeting, you are anxious for days beforehand in anticipation of the dreaded situation. Thoughts of a discussion with your boss make you break into a sweat. You may have panic attacks. Your sleep may be increasingly disturbed as the day of the meeting approaches. Reasoning and reassuring yourself as to the non-threatening nature of the situation brings no relief. You are sweating and can feel your heart race during the encounter. After the encounter you worry about how you were judged for hours afterwards. You feel ashamed that you did not perform better. It becomes easier for you to just stay away from social situations and avoid other people altogether.
“I hesitate to enter the room when the group is already seated. When it comes to my turn to speak my mouth goes dry and I feel choked. I don't speak a word during the meeting even when I have something to contribute.”
People with social anxiety can present with different secondary symptoms
  • Some people cannot write in public (as on a blackboard), their hand will shake, their cheques bounce
  • They experience severe anxiety about eating and drinking in public and often spill food and drop their cutlery
  • Others find it a torture to speak in front of people, they just ‘clam up,’ speak in monosyllables or stammer
  • One of the worst circumstances is meeting people who are authority figures- bosses, supervisors, interviewers at work; or teachers & examiners at school. A job interview is torture, more so because the person knows that he would be good at the job if only he could get through the interview.

People with social phobia avoid situations in which they feel embarrassment and anxiety. Initially they are comfortable with this avoidance. Later, they see avoidance as an impediment to achieving their full potential in their chosen careers. They see their social lives as stale and restricted. To address these problems people mistakenly enrol for ‘personality development’, meditation and other courses. But this is not the shyness of introversion. This shyness results from overwhelming anxiety and embarrassment. They are frustrated when there is no resolution. The underlying social phobia has not been addressed.

In a child with social phobia this anxiety expresses itself as tantrums, crying or just “freezing up”. In school, the child typically does not participate in classroom activities, is reluctant to stand up and answer, has no friends and frequently misses school with complaints of stomach ache or headache. Outside school these children have few or no friends. They may communicate only with family members.
“My daughter doesn't speak a word when we have visitors. The other children are playing together, she has to be pulled out of her room to join them.”

How is social phobia best treated?

The best treatments of social anxiety include
  1. Medication: is usually for a limited period, under supervision. Do not stop taking medication abruptly. Discuss any side effects, if any, with your psychiatrist.
  2. Cognitive Behaviour Therapy – CBT: and systematic desensitisation properly administered for 6-12 sessions can produce long lasting, permanent relief. You have to be motivated to persist in the practice of the simple methods and techniques that are explained to you. Do not use any advice available online without due thought and discussion with your psychiatrist

What you can do for a family member with social phobia

  • Be supportive. Help the individual seek psychiatric treatment. Many a career has been advanced or saved by a supportive spouse. Family interaction and communication also improves.
  • Don’t trivialise (‘its normal to be nervous when you meet new people, you do not have to go for therapy’).
  • Don’t perpetuate their symptoms (‘let it be, stay at home if you are not feeling well’).
Family support helps during behavioural desensitisation therapy and decreases the social isolation of the individual. Social phobias and anxieties are treatable conditions. Treatment and therapies are effective and easily accessed.

  1. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug;64(8):903-12.

Sunday, May 8, 2011

Sleeplessness, sleep disturbances, insomnia and parasomnias

Sleepless in Pune. Sleeplessness, disturbed sleep, and shift work related sleep problems are interfering with our citizens recovery after a hard days (nights) work. Insomnias and parasomnias are common sleep problems. Once recognised these are treatable.
  • Does it take you more than 30 minutes to fall asleep at night?
  • Do you wake up too early or frequently at night and have difficulty going back to sleep?
  • Do you feel groggy and lethargic when you wake up?
  • Do you feel drowsy during the day?
  • Do you depend on coffee to get through the day?

If you answer "yes" to any of the above questions; you have a sleep problem. You are not alone. 9-18% of adults suffer from treatable insomnia

What is insomnia?

The inability to fall asleep or remain asleep is insomnia (Latin for ‘no sleep’). In a broader sense insomnia is the inability to get the amount of sleep you need to wake up feeling refreshed.

How much sleep do you need?
As a rule of thumb an adult requires 7-9 hours of sleep. However individual needs differ. You can gauge how much sleep you require by monitoring your own response to different amounts of sleep. Are you productive, healthy and happy on 7 hours sleep or does it require 9 hours of sleep to make you feel good?

What are the effects of chronic insomnia?
Sleeping too little inhibits productivity, ability to remember & consolidate information (cognitive impairment). Chronic insomnia also has serious health consequences and can jeopardize your safety and those of people near you.

Treating insomnia

  1. The first step to treating insomnia is to determine whether the insomnia is Primary i.e it is occurring independently from other disorders or Secondary i.e due to other associated medical conditions, (most importantly due to psychiatric disorders such as stress, depression, anxiety and panic disorder). The underlying condition needs to be addressed for the treatment to be effective.
    That is why our assessment includes a medical history, and a physical examination along with your sleep history and daily routine.
  2. Behavioural therapy is part of any treatment for insomnia. This includes:
    • Stimulus Control Therapy
    • Cognitive therapy
    • Sleep Restriction Therapy
  3. Medication most commonly used in treatment for sleep problems. It should be taken under medical supervision, after evaluation, and with appropriate sleep promoting practices.

Self medication and OTC drugs

Why you should avoid them
Medications which help induce and maintain sleep (sedatives and hypnotics) are prescription drugs the world over and for good reason. They can sometimes cause confusion, headaches, memory problems, daytime drowsiness leading to accidents at work and on the road, rebound insomnia when stopped suddenly after continued use. Many have drug interactions and some are addicting. You may develop tolerance and require larger doses.

Don’t let a pharmacist prescribe you a “safe” hypnotic. Consult a doctor who can treat your insomnia and the underlying cause. Follow your doctor’s instructions strictly about drug dosage, timing & duration and follow good sleep practices.

Alcohol and Sleep

Alcohol may help you to relax and thereby decrease the time taken to fall asleep, however sleep later in the night is fragmented and of poor quality. Continued use of alcohol can destroy normal sleep.

Shift work related sleep disorder

Shift work related sleep problems occur due to a lack of synchrony between the individual’s internal biological clock and the desired sleep-wake cycle. Frequently changing shifts, change from night or evening to daytime shifts are associated with greater sleep disorders.

The sleep disorder can vary from excessive sleepiness during the ‘wake’ period, to insomnia during the ‘sleep’ cycle. It is further aggravated by social commitments during weekends. The unsatisfactory quantity, quality and timing of sleep can cause marked distress and interference in daily functioning and living.

Parasomnias (sleep disturbing behaviours)


Repeated awakening from sleep with detailed and vivid recall of intensely frightening dreams. A major stressful life event precedes the onset in 60% of cases.

Sleep terrors

Repeated occasions of awakening from sleep beginning with a cry or scream and signs of extreme fright (sweating, rapid breathing, pounding heart) but with no recall of the content of dreams.


Repeated episodes of rising from bed and walking about for several minutes. The child has a blank, staring face, is relatively unresponsive and can be awakened only with considerable difficulty. Upon awakening there is no memory of the event.

Bedwetting or Sleep enuresis

Associated with severe embarrassment, shame and guilt, leading to lifelong psychosocial impairment. More common in children but also seen in 1% of the adult population, properly administered behavioural therapy with judicious medication is effective.

Principles of good sleep practice

You don't need to follow all the points at one shot. Select two or three of them that appeal to you. The first point is essential.
  • Set the alarm clock for a particular time and get up no matter how tired you are
  • Establish routine times for retiring and waking
  • Engage in quiet activities for about an hour or so before bedtime. Follow a relaxing bedtime routine and reduce ambient lighting 1 hour before bedtime
  • Avoid engaging in stressful activities or unpleasant tasks near bedtime
  • Avoid eating large meals and limit fluid intake immediately before bedtime
  • Avoid caffeine for at least 6 hours before bedtime
  • Exercise regularly but avoid exercising at least 3 hours before bedtime
  • Make your environment right, i.e. your bedroom should be quiet, dark, and at a comfortable temperature.
  • Use your bedroom only for sleep and sex, not for work or watching TV
  • Avoid daytime naps

Saturday, April 30, 2011

Exercise addiction - distorted pursuit of attractiveness?

exercise addiction

Overexercising - obsessive weight-lifting or running, compulsive gym routines, or psychological dependence on exercise - is an illness. The health and fitness benefits of exercising are undeniable. However by overexercising the distorted pursuit of attractiveness takes precedence over fitness. Exercise addiction indicates a body image disorder; a distortion of the individual's mental representation of his or her own body. When I first commented on this phenomenon in 2001 body image disorders were a rarity in India (Misquitta 2001).

Pune is fascinated with its physique. Witness the mushrooming gyms and spas in every neighbourhood. Men dissatisfied with their appearance throng them to reduce or gain weight in pursuit of an ideal muscularity depicted on huge sports hoardings. An 18 year old ‘hunk’ is ashamed to wear T-shirts convinced his pectorals are too thin. He has no time to left to socialise at the end of his daily 5-hour workout. Women join gyms to lose weight and attain a waif-like slenderness. A 23 year old is advised by her trainer to cut down on her punishing exercise regimen - she changes her gym and continues to lose further weight. Exercising is no longer about fitness - it's about beauty.

From an evolutionary perspective attractiveness has universal criteria. These serve as cues to a persons reproductive ability. Males and females select partners that will enhance their reproductive success. Body characteristics signal reproductive advantage and render one individual more ‘desirable’ than another

Males desire muscular mesomorphism - the ideal body shape of broad shoulders, a muscular stomach, chest and shoulders, and a thin waist. This usually means about 10kg more muscle and 4kg less fat than their current physique. Positive characteristics of strength, bravery, health, and good looks are associated with this physique. Males also feel that looking fit is essential to career advancement. This discrepancy between actual physique and the desired culturally ‘ideal’ muscular physique is pushed at us from magazine covers, movies, posters, and toys (Todd G 2006).

For women body image is related to weight rather than shape (Viren Swami 2006). Urbanisation has placed unprecedented opportunities and demands on women. Slim women are used by the media to portray desirability. These socio-cultural demands have altered the evolutionary ‘hour-glass’ ideal for women. The emphasis is on slender and glamorously adorned women, striving for career accomplishment while maintaining their attractiveness. Increase in affluence also brings with it an epidemic of obesity that legitimises the pursuit of thinness and fear of fatness. Women exercise to lose body fat and improve muscle tone without increasing muscle mass.

Exercising is distorted into a pursuit of attractiveness for some individuals. These individuals pump iron, creatine, and steroids if they are males; or run and starve themselves if they are females. They lose their sense of perspective. Their bodies turn grotesque or gaunt. But when they look in the mirror they see some more work that requires to be done on some particular body mass.

At this stage they have developed body image distortions. Experiments have consistently shown that high mileage runners have a distorted perception of body size, they overestimate their waist size as compared to recreational runners (Wheeler 1986). Overexercising males who join gyms to increase muscle mass, and underweight females who overexercise are more likely to have body image disorders (Sergia-Garcia 2010). These body image disorders include anorexia nervosa in females and muscle dysmorphia (reverse anorexia or bigorexia) in males.

Muscle dysmorphia in males is the end stage of excessive exercising for muscularity (Pope 1997).
  • Preoccupation with the appearance of the body
  • Concern with not being sufficiently large or muscular
  • Persistent weight lifting and dieting

Anorexia nervosa in females is the result of excessive exercising for slimness.
  • Fear of fatness
  • Dieting and exercising to maintain low body weight or continue losing body weight
  • Underweight at least 15%
  • Absence of three consecutive menstrual cycles

When should you suspect a body image disorder in an exercise freak (James E Leone 2005)?
  1. Excessive and inordinate time is spent on grooming and appearance. The exercise is done with the aim of enhancing appearance rather than performance. When the person is not exercising he or she spends time being worried, depressed or anxious about appearance
  2. Avoidance of social and work obligations either due to a sacrosanct exercise schedule or embarrassment due to perceived deformities in appearance
  3. Dieting, supplements and drugs to enhance physical appearance. A large proportion of income could go towards this

What to do for someone who is obsessed with exercising?
  • Verify the facts discretely to substantiate warning signs as noted above
  • Chose a comfortable setting where you are not going to be disturbed
  • Offer some of the information that raised red flags on body image concerns when the person asks what it’s all about.
  • Deal with denial which is the first response. You need to listen, acknowledge, and submit your previously gathered observations non-confrontationally
  • Suggest psychiatric referral and offer to accompany the individual
  • Deal firmly with refusal which is the next response. Show concern that this is a serious disorder and that you would be irresponsible if you didn’t get the individual to consult a psychiatrist.

Exercise for fitness - attractiveness will follow

  1. James E Leone, Edward J Sedory, and Kimberly A Gray. Recognition and Treatment of Muscle Dysmorphia and Related Body Image Disorders J Athl Train. 2005 Oct–Dec; 40(4): 352–359.
  2. Misquitta NF. Anorexia Nervosa : A Caucasian Syndrome Rare in Asia. 2001 Jan; 57(1): 82-3
  3. Pope HG Jr, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics. 1997 Nov-Dec;38(6):548-57.
  4. Segura-García C, Ammendolia A, Procopio L, Papaianni MC, Sinopoli F, Bianco C, De Fazio P, Capranica L. Body uneasiness, eating disorders, and muscle dysmorphia in individuals who overexercise. J Strength Cond Res. 2010 Nov;24(11):3098-104.
  5. Viren Swami. The influence of body weight and shape in the determination of female and male physical attractiveness. In: Body Image: New research. Marlene V Kindes Ed. Nova Science Publishers. New York. 2006. pp35-61
  6. Todd G Morrison, Melanie A Morrison, Leigh McCann. Striving for Bodily Perfection? An overview of the drive for muscularity. In: Body Image: New research. Marlene V Kindes Ed. Nova Science Publishers. New York. 2006. pp1-34
  7. Wheeler GD, Wall SR, Belcastro AN, Conger P, Cumming DC. Are anorexic tendencies prevalent in the habitual runner? Br J Sports Med. 1986 Jun;20(2):77-81.

Thursday, April 21, 2011

Relationship conflict and strain in youth

Precious stone inlay - Deeg, Rajashtan

Some relationships are characterised by conflict and strain and this can be detrimental to mental health in youth. Romantic relationships are important for mental health during the transition from adolescence to adulthood. Satisfaction in the relationship is strongly related to regard and empathy with the partner (Cramer 2003). Intimacy increases positive feelings in the relationship. The perceived quality of a relationship depends more on the presence of intimacy than on absence of conflict (Laurenceau 2005).

We have already noted the various the reactions to breakup of relationships. We now take a look at some psychological aspects of conflict and strain in ongoing relationships of young persons.

Gender aspects of ongoing relationships

For a young woman an ongoing and current relationship is associated with feelings of psychological well-being. For her just being in a romantic relationship provides a social identity and increases feelings of self- worth. This need to be in a relationship increases especially when there is gender inequality in the family. After a recent breakup; the altered social identity and reduction of self-worth make her prone to clinical depression.

For young men the quality of the ongoing relationship is more important. Men’s identity and feelings of self-worth are greatly affected by the support or strain they experience from their partner. This is because their romantic partner is their primary source of intimacy. In contrast young women have intimate relationships with family and friends. (Simon & Barrett, 2010). Men benefit more than women from support gained through a relationship; they are also more disturbed than women by strain in an ongoing relationship. When in a strained relationship men are likely to develop substance abuse problems.

Conflict in relationships

The quality of conflict negotiation between the partners in a relationship evolves over time. Initially the romantic bond overshadows the ability to acknowledge and deal with differences. The partners downplay their disagreements and fail to negotiate their differences. Later on, in stable relationships there is an increasing capability to recognize and face disagreements and to negotiate them in a better manner (Shulman 2008).

Personal characteristics and attachment style also play a role. Self-directed and autonomous people are generally less defensive and more understanding in their response to conflict (Knee 2005). Insecure, anxious individuals experience more conflict with their dating partners. Their conflicts tend to escalate in severity. These individuals require daily support to experience satisfaction with the relationship. As perceptions of satisfaction and intimacy change, commitment to the relationship is eroded over time (Campbell 2005). Family background of the partner is also important. The individual's style of handling conflict is learned through interactions with the mother and with siblings. This persists into the romantic relationship (Reese-Weber 2005).

Predictors of break-up

  • Breakup of the romance is imminent when the pattern of interaction between partners is characterised by criticism, unrealistic expectations, or withdrawal.
  • The best single predictor of impending breakup is contempt. This is especially so when the female partner displays contempt (Gottman 1994).
  • Substance abuse problems in any of the partners increases conflict and hostility in the relationship (Floorsheim 2008).
  • Adolescents with personality disorders are more likely to have conflict in their relationships (Chen 2004).

  1. Campbell L, Simpson JA, Boldry J, Kashy DA. Perceptions of conflict and support in romantic relationships: the role of attachment anxiety. J Pers Soc Psychol. 2005 Mar;88(3):510-31.
  2. Chen H, Cohen P, Johnson JG, Kasen S, Sneed JR, Crawford TN. Adolescent personality disorders and conflict with romantic partners during the transition to adulthood. J Pers Disord. 2004 Dec;18(6):507-25.
  3. Cramer D. Facilitativeness, conflict, demand for approval, self-esteem, and satisfaction with romantic relationships. J Psychol. 2003 Jan;137(1):85-98.
  4. Florsheim P, Moore DR. Observing differences between healthy and unhealthy adolescent romantic relationships: substance abuse and interpersonal process. J Adolesc. 2008 Dec;31(6):795-814. Epub 2007 Nov 26.
  5. Gottman JM: What Predicts Divorce? The Relationship Between Marital Processes and Marital Outcomes. Erlbaum, Hillsdale, NJ, 1994.
  6. Knee CR, Lonsbary C, Canevello A, Patrick H. Self-determination and conflict in romantic relationships. J Pers Soc Psychol. 2005 Dec;89(6):997-1009.
  7. Laurenceau JP, Troy AB, Carver CS. Two distinct emotional experiences in romantic relationships: effects of perceptions regarding approach of intimacy and avoidance of conflict. Pers Soc Psychol Bull. 2005 Aug;31(8):1123-33.
  8. Reese-Weber M, Kahn JH. Familial predictors of sibling and romantic-partner conflict resolution: comparing late adolescents from intact and divorced families. J Adolesc. 2005 Aug;28(4):479-93.
  9. Shulman S, Mayes LC, Cohen TH, Swain JE, Leckman JF. Romantic attraction and conflict negotiation among late adolescent and early adult romantic couples. J Adolesc. 2008 Dec;31(6):729-45. Epub 2008 Oct 4.
  10. Robin W. Simon and Anne E. Barrett. Nonmarital Romantic Relationships and Mental Health in Early Adulthood: Does the Association Differ for Women and Men? Journal of Health and Social Behavior 2010:51(2) 168–182 DOI: 10.1177/0022146510372343