0·9% [0·7—1·2] DALY for sexual violence intimate partner violence, which accounted for 1·5% (1·0—2·1) of DALYs
Service users’ barriers to disclosure of domestic violence.
Professionals’ barriers to enquiry of domestic violence.
A wide range of individual psychological interventions have been demonstrated to show improvements for women with depression and post-traumatic stress disorder including for levels of depressive symptoms, post-traumatic stress symptoms and self-esteem (comprehensively reviewed by Feder et al (Feder et al. 2009). In particular, two trials of cognitive behavioural therapy for women with post traumatic stress disorder who were no longer experiencing violence suggest that cognitive behavioural approaches are helpful (Kubany ES et al. 2003; Kubany ES et al. 2004). There are also studies of group psychological interventions which show improvement in psychological outcomes though these have major methodological limitations (Feder et al, 2009). However, these findings cannot be extrapolated to women still in abusive relationships, nor for women with more severe psychiatric illnesses in contact with mental health services. Domestic violence advocacy
Box plot of identification and referrals to advocacy agencies of women experiencing domestic violence Vertical lines denote interquartile range.
Post Traumatic Stress Disorder Scale (PDS), which has been used to identify PTSD in domestic violence survivors (Foa et al, 1993) and psychiatric outpatients (Foa et al, 1997); Composite Abuse Scale (Hegarty et al, 2005), a validated scale measuring physical and sexual abuse, emotional abuse, severe combined abuse and harassment; Adult Service Use Schedule (AD-SUS), an interview measure of hospital and community health and social services, criminal justice sector resources, accommodation and productivity losses for use in the assessment of costs and cost-effectiveness (Barratt et al, 2006); EQ-5D measure of health related quality of life capable of generating a generic cardinal index of health-related well being to calculate quality adjusted life years (The Euroqol Group, 1990);
Commented on the improved response of MH prof to disclosures of abuse, which in past experiences hasn’t always been positive Process of staff documenting abuse Support from Advisors to improve safety
Integrated support of Advisors and MH prof greatly valued: Spoke of double support for MH and DV problems Ability to speak to both professionals about experiences Advisors able to provide clients with access to Freedom programme – looking at challenging abusers behaviour and meeting with other survivors to talk through experiences
Identified concerns: MH focus on separation from partner Some identified a limited discussion of abuse experiences by prof – Felt because prof felt Advisors responding to DV so they did not bring it up
Our findings suggest that mental health service users experience significant barriers to disclosure of domestic violence. This is concerning as people with severe mental illness are at increased risk of victimisation compared with the general population. Therefore these findings suggest the needs of people with experiences of domestic violence and mental illness are currently being unmet. Our findings regarding barriers to disclosure are similar to those of a recent systematic review of other healthcare settings. Research indicates that women in the perinatal period and people with a mental illness are at an increased risk of domestic violence victimisation. Taking in to account these findings the DoH now recommend Clinicians ask about violence and abuse in both obstetric and psychiatric settings
Mhrn dv and mental health lmh
Domestic Violence and mental health Louise HowardProfessor & Head of Section of Women’s Mental Health
Domestic violence“Any incident of threatening behaviour violenceor abuse (psychological, physical, sexual,financial or emotional) between adults who areor have been an intimate partner or familymembers, regardless of gender or sexuality”(Home Office 2006)New definition to include coercive behavioursand age 16/17 (HO 2013)
Domestic violenceGlobal Burden Disease 2010 project:• 200 000 deaths/yr attributable to IPV• 1·5% (1·0—2·1) of DALYsWHO multi-country study:• Up to 69% of women report that an intimate partner has physically abused them at least 1x• Up to 59% of women report forced sex, or attempted force, by an intimate partner• Up to 28% of women report they physical abuse during pregnancy by an intimate partner Garcia-Moreno et al 2006; Lozano et al 2013; Murray et al 2013
Domestic violence prevalenceBritish Crime Survey• Lifetime prevalence rates of isolated domestic violence are comparable for men and women in general population• Women are at greater risk of repeated coercive, sexual or severe physical assault• Two women are murdered by their partner or ex- partner every week in England and Wales• Higher risk when, or soon after, leaving partner• 40% female (7% male) homicide victims killed by current or former partner Tjaden & Thoennes 2000; Walby & Allen 2004
Figure 1. Flow Diagram of Screened and Included Papers.Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
Table 1. Characteristics of included studies (n = 41).Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
Figure 3. Pooled odds estimates for past year intimate partner violence among women with depressive disorders.Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
Figure 5. Pooled odds estimates for past year intimate partner violence among women with anxiety disorders.Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
Figure 6. Pooled odds estimates for lifetime intimate partner violence among women with post- traumatic stress disorder.Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
Other findings of Systematic Reviews• Association found for all diagnostic categories• In men and women• More prevalent in women• More studies in women• Few longitudinal studies• In longitudinal studies of perinatal populations, Population Attributable Fraction for PND=12% Howard et al In Press; Trevillion et al 2012
Prevalence of domestic violence in mental health service users Median prevalence of lifetime domestic violence (in high-quality papers): 30% (IQR 26% - 39%) female inpatients 33% (IQR 31% - 53%) female outpatients One high quality study for male patients: 18.4% for inpatients ;4.4% for outpatients. Low rates of detection (10-30%)Howard et al, 2010; Oram et al, In Press
Domestic violence and mental health - ?causal• No diagnostic specificity – increased prevalence for all disorders• Severity of abuse ass with severity of symptoms; symptoms when abuse stops• Pre-existing mental health problems associated with being in unsafe environments and relationships• Prospective data shows women who are involved in abusive relationships have higher risk of subsequent psych morbidity• Antenatal DV associated with subsequent child psychological morbidity and adult mental disorders• Women who experience domestic violence are less likely to receive mental healthcare Ehrensaft et al. 2006; Golding 1999; Howard et al 2010; Trevillion et al 2012
How should services respond? Interventions• Limited evidence but CBT effective in improving symptoms and self esteem in women who have left abusive relationships• Standard psychological interventions that are not adapted for this population likely to be ineffective• One small RCT of trauma (not specifically domestic violence) focussed CBT for patients with severe mental illness• Intensive (>12 hrs) advocacy for women at a refuge quality of life, safety behaviours and abuse at 12- 24mths• Brief advocacy intervention (<12 hrs) improves safety behaviours• Telephone intervention for women at a family violence unit safety behavioursRamsay et al, 2009; Howard et al, 2009; McFarlane et al, 2002; Meuser et al, 2008; Sullivan & Bybee 1999
Figure 2IRIS outcomes - Box plot of identification and referrals to advocacyagencies of women experiencing domestic violence(Vertical lines denote interquartile range) Source: The Lancet 2011; 378:1788-1795 (DOI:10.1016/S0140-6736(11)61179-3) Terms and Conditions
LARA pilot study: Intervention Linking• Domestic violence training of CMHT staff Abuse and Recovery through – 2 didactic/interactive workshops with on-going training Advocacy• LARA Advisors trained by mental health professionals and domestic violence sector• Clear referral pathways to LARA Advisors• LARA Advisors integrated within teams• Control CMHTs
LARA pilot study: measures Linking Abuse and• Professional knowledge and attitudes: Recovery through Advocacy PREMIS (Professional Readiness to Manage Domestic Violence)• Service user outcomes – Composite Abuse Scale – MANSA Quality of Life – Adult Service Use Schedule – Safety Behaviour Checklist – Camberwell Assessment of Need/CAN-M – Social inclusion• Process measures – Referrals and number of sessions (LARA advisors) – Nature of support provided by advisors – Experience of the intervention for service users
MARACs (Multi-Agency Risk Assessment Conferences)•Often police-led - primary focus is to safeguard the adult victim•Information shared on very high-risk domestic abuse casespatients•Attendance incls representatives of local police, probation, health,child protection, housing practitioners, independent domesticviolence advisors•Representatives discuss options for increasing the safety of thevictim•Create a coordinated action plan.• Victim does not attend the meeting but is represented by an IDVA• Evaluations have found that their use reduces recidivism, even forthe highest risk patients, and improves professionals’ practice andthe safety of victims and their children
What Works for Service Users? Qualitative data Linking Abuse and Recovery through AdvocacyImproved health professional response to disclosures:“This way I’m actually getting help it’s not just been pen to paper;cause in the past that’s what it was”.Documentation of abuse:“It’s a bit of a relief….that if anything did happen to me, you know,things did go too far at least it was all on record”Securing safety:“Yeah speaking to her [Advisor] and asking her to help me do thedoor, was a best plus….the door’s safe, so I know that no one canbust it” .
What Works for Service Users? Qualitative data Linking Abuse and Recovery through AdvocacyIntegrated support:“I just feel so much better knowing that…I’ve got a support networkaround me that I can….talk too or talk about my issues…beforehand I just felt like a bit isolated, I didn’t have no one”“I could speak to any of them [referring to Advisors and mentalhealth professionals]…so I had like two sets of people that I couldcontact, which was fantastic”
What Doesn’t work for Service Users? Linking Abuse and Recovery through AdvocacyProfessional focus on separation from partner:“He [referring to professional] wanted me to leave [partner] straightaway and because I didn’t have the strength to do it he said, sortof, he can’t work with me anymore….I didn’t find that bit helpful atall, because I thought that he should have supported meregardless”.Limited discussion of DV by health professionals:“I could have done with a bit more support actually. I could havedone with a few phone calls or some letters or some moreinformation…. the CPN, the team haven’t asked me anything elseabout it”
+ Improvements in quality of life and social inclusion Reduction in number of unmet needs
LARA Conclusions Linking Abuse and • Increased prevalence of domestic violence Recovery through experienced by mental health service users Advocacy • Mental health service users experience significant barriers to disclosure of domestic violence • Barriers to enquiry are similar to those reported in other settings; knowledge and practice not optimal • Training on safe assessment and treatment needed for mental health professionals • Integration of multi-faceted intervention (training with domestic violence advocacy) into mental health services may be helpfulThis presentation presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient BenefitProgramme (PB-PG-0906-11026). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or theDepartment of Health.
Acknowledgements Linking Abuse and ALSPAC Team:LARA Team: Recovery throughRoxane Agnew- Jonathan Evans Advocacy Davies Clare Flach PROVIDESarah Byford Team: Gene FederGene Feder Gene Feder Jonathan HeronDiana Rose Sian OramKylee Trevillion Morven Leese Kylee TrevillionAnna Woodall Debbie Sharp This presentation reports independent research commissioned by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the
ReferencesTrevillion K, Oram S, Feder G, Howard LM. Experiences ofDomestic Violence and Mental Disorders: A Systematic Reviewand Meta-Analysis. PLoS ONE 7(12): e51740.doi:10.1371/journal.pone.0051740Howard LM, Trevillion K, Khalifeh H, Woodall A, Agnew-Davies R,Feder G. Domestic violence and severe psychiatric disorders:prevalence and interventions. Psychological Medicine 2010 40,881–893.Howard LM, Trevillion K, Agnew-Davies R. Domestic violence andmental health. International Review of Psychiatry October 2010;22(5): 525–534Rose D, Trevillion K, Woodall A, Morgan C, Feder G, Howard LM.Barriers and Facilitators of Disclosures of Domestic Violence bymental health service users: a qualitative study. British Journal ofPsychiatry. March 2011 198:189-94.Flach C, Leese M, Heron J, Evans J, Feder G, Sharp D, HowardLM and the ALSPAC team. Antenatal Domestic Violence andSubsequent Child Behaviour. BJOG 2011; 118 (11), 1383–1391