Transcript Domestic Violence and Abuse and Mental Health

Domestic violence and abuse
and mental health
Jayne E Bailey, PhD
School of Social and Community Medicine, University
of Bristol, UK
Gender Violence and Depression
Bochum, Germany
[email protected]
25th November 2015
The presentation
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What is DVA?
Introduction to the PROVIDE Programme of Research
Intervention in mental health services
Psychological Intervention
Men in general practice and sexual health services
Key messages
What is domestic violence?
 Domestic violence
Any incident or pattern of
incidents of controlling,
coercive or threatening
behaviour, violence or abuse
between those aged 16 or over
who are or have been intimate
partners or family members
regardless of gender or
sexuality.
(UK Government)
 Intimate partner
violence
Any behaviour within an
intimate relationship that
causes physical, psychological
or sexual harm
.
(WHO)
 Physical: slapping, hitting, kicking,
beating.
 Sexual: forced intercourse, sexual
coercion
 Psychological: intimidation,
constant belittling.
 Control; isolation, monitoring,
deprivation of basic necessities.
Gender asymmetry
 Compared with male victims of relationship violence, women are
more likely to be injured and feel fearful
 X3 more likely to be injured as a result of violence
 X5 more likely to require medical attention or hospitalisation
 X5 more likely to report fearing for their lives (Statistics Canada 2003).
But...
 Heterosexual men can be victims too
 Victimisation within same sex relationships
Lifetime prevalence
British Crime Survey 2009-2010
30
24
17
12
7
9
Risk factors
 most demographic and social characteristics not consistently
associated with increased risk
 exceptions:
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gender
younger age – (Britain, Canada, USA, developing countries)
relative poverty
separation (serious harm and homicide)
Physical health consequences
Survivors experience a range of chronic health problems
including:
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chronic pain (e.g. headaches, back pain)
increased minor infectious illnesses
neurological symptoms (e.g. fainting and fits)
gastrointestinal disorders (e.g. chronic IBS)
raised blood pressure and coronary artery disease
gynaecological problems (e.g. STIs, vaginal bleeding and infection, chronic UTIs)
Domestic Violence and
Abuse and Mental Health
Findings from the Programme of Research on Violence in Diverse
Domestic Environments
(PROVIDE)
Funded by the National Institute of Health Research (UK)
Programme Grant
What is PROVIDE?
Programme of Research on Violence in Diverse Domestic Environments
• 5 year National Institutes of Health Research Programme Grant
• 4 Workstreams
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WSI
WSII
WSIII
WSIV
- Men in general practice
- Mental Health
- Men in sexual health clinic
- Synthesis and help-seeking
• Collaborative – PI Professor Gene Feder
Main objectives (mental health):
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Estimate prevalence of DVA in people with mental health disorders, and
articulate their health care needs in relation to DVA
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Evaluate a psychological intervention delivered by DVA advocates to women
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Synthesize qualitative data across all studies to explore barriers/facilitators to
enquiry about and response to DVA
For further details and additional objectives, see website:
http://www.bris.ac.uk/social-community-medicine/projects/provide/
Systematic Reviews (Professor Louise Howard and Team)
1) What is the extent of the association between
mental disorders and DVA?
2) What is the prevalence of DVA among mental
health service users?
3) What are the responses of mental health services to
disclosures of domestic violence?
(All references available in conference information)
1) What is the extent of the association between
mental disorders and DVA?
41 papers:
Past year DVA prevalence
Depression: 35.5 % (IQR 16%-40%)
Odds Ratio
Depression:
3.31 (2.35-4.68)
Anxiety: 28.4% (IQR 26%-42%)
Anxiety:
2.29 (1.31-4.02)
PTSD:
7.34 (4.50-11.98)
Lifetime DV prevalence
PTSD: 61% (IQR 41%-80%)
 Eating disorders associated with
prevalence of lifetime DVA
(8 papers, n=6,775 women)
 Women experiencing DVA in pregnancy are over 2 ½ times more likely to develop postnatal
depression (67 papers, n=150,505 women)
(Howard et al 2013; Bundock et al 2013; Trevillion et al 2012)
Link between domestic violence and
perinatal mental health disorders
Press release issued: 28 May 2013
Women who have mental health disorders around the time of birth
are more likely to have previously experienced domestic violence,
according to a study led by researchers from Kings College London
and the University of Bristol and published in this week’s PLOS
Medicine.
The research, led by Professor Louise Howardfrom King’s College
London and Professor Gene Feder from the University of Bristol,
found that high levels of symptoms of perinatal* depression,
anxiety, and post traumatic stress disorder were linked to having
experienced domestic violence either during pregnancy, the past
year, or over a woman’s lifetime.
2) What is the prevalence of DVA among mental health service
users?
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About one third of all patients in mental
health services have a lifetime history of
DVA
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However:
Mental health service responses to DVA
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Low rates of detection (only 10-30%
detected in clinical practice)
 SO PROBABLY AN
UNDERESTIMATE
(Khlaifeh et al 2014; Oram et al 2013; Howard et al 2010)
Median prevalence estimates (high-quality
papers)
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Lifetime DVA in female inpatients: 30% (IQR
26%-39%)
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Lifetime DVA in female outpatients: 33% (IQR
31%-53%)
 Lifetime DVA in male patients (mixed
psychiatric settings): 32%
 No controlled studies (MRC study since found
OR 3.4 and prevalence 69% for lifetime DVA)
Association of Domestic Violence and Mental Illness
 No diagnostic specificity
 Pre-existing mental health problems are associated with being in unsafe
environments and relationships
 Prospective data shows women who are involved in abusive relationships have
higher risk of subsequent psychiatric morbidity
 Women who experience DVA are less likely to receive mental healthcare
(Howard et al 2010; Briere and Jordan 2004 ; Ehrensaft et al 2006; Lipsky & Caetano 2007; McHugo et al 2005;
Zlotnick et al 2006)
LARA pilot study: Intervention
• Domestic violence training of Community Mental Health
Team
Linking
• LARA Advisors trained by mental health professionals and
domestic violence sector
Recovery through
• Clear referral pathways to LARA Advisors
• LARA Advisors integrated within teams
• Control Teams
Abuse and
Advocacy
LARA findings
Clinicians (29) receiving the intervention reported
significant improvements in DVA knowledge, attitudes and
behaviours at follow-up
Service users (34) in the intervention sites reported
significant reductions in violence and unmet needs at
follow-up
Effectiveness of psychological support
for DVA survivors: the Psychological
Advocacy Towards Healing (PATH)
randomised controlled trial
Gene Feder, Roxane Agnew-Davies, Jayne Bailey, Giulia Ferrari, Emma
Howarth, Tim J Peters, Lynnmarie Sardinha
PATH: The Question
• Link between domestic violence and abuse (DVA) and
mental health state
• DVA advocates usually not trained to address
psychological distress in their clients
• PATH: can psychological support from DVA workers
improve women’s mental health?
Domestic violence advocacy interventions
 Definition of advocacy: engagement with individual clients being abused, to
support and empower them, and link them to community services
 Settings: refuges/shelters, antenatal clinics, primary care, public health and
criminal justice settings
 Results: increased social support and quality of life, increased safety behaviours
and accessing of community resources, reduction in abuse but no
improvement in mental health outcomes
PATH: The method
• pragmatic trial
• compare
– usual DVA advocacy support (control)
– usual support plus a 10 session psychological intervention (intervention).
• outcomes
A. primary:
– psychological well-being (Clinical Outcomes in Routine Evaluation–Outcome
Measure – CORE-OM)
– depressive symptoms (PHQ-9)
B. secondary:
– posttraumatic stress (PDS)
– anxiety symptoms (GAD-7)
– exposure to DVA (CAS)
All measured at 1 year from baseline
PATH: Sample and retention (See Ferrari et al 2014)
• 260 women recruited from 2 DVA agencies
– 50% abused as children
– 83% mental health problem in the past
• beginning of study
– 77% posttraumatic stress
– 72% depression symptoms
– 76% psychological distress symptoms
66% still in the study after one year:
– 167/260: 83 intervention, 84 control
PATH: analysis and results
• Statistical analysis:
– Linear and logistic regressions
• Results:
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psychological distress
depressive symptoms
posttraumatic stress
anxiety symptoms
DVA
are all lower among women in intervention group – Paper in preparation
will be available in mid 2016.
‘1 in 6’ - Mental health and
domestic abuse in male GP
(family doctor) patients
Sue K. Jones, Emma Williamson,
Giulia Ferrari, Marianne Hester, Tim Peters, Gene Feder
School of Social & Community Medicine and Centre for Gender &
Violence Research, Bristol University
& Evaluation Team
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Mental health
Measured by:
Questionnaire – HADS (Hospital Anxiety and Depression Score)
Mild anxiety = 8+ on anxiety sub-scale
Mild depression = 8+ on depression sub-scale
Medical Record – any mention of feeling low, depressed, anxious, suicidal, panic
attacks, stress (not relationship stress), or mental illnesses such as bipolar disorder
or schizophrenia.
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Past-year victims and perpetrators –
mental health problems (see Hester et al, 2015 BMJ Open reference)
Mental health variable
Current or past-year
Mild anxiety
(self-reported - current)
Mild depression
(self-reported - current)
Mental health problem
(GP-documented –
past year)
Victim in past year
Perpetrator in past
year
Victim/Perpetrator in
past year
% of above
% of above
% of above
81%
81%
78%
(21/26)
(13/16)
(25/32)
30%
50%
36%
(8/27)
(8/16)
(12/33)
30%
50%
43%
(7/23)
(7/14)
(12/28)
What GPs (family doctors) see in their surgery
GP-documented health
problem (past year)
Lifetime victims or perpetrators
Past-year victims or perpetrators
Proportion of row
total
Per cent of row total
Proportion of row
total
Percent of row total
Past-year mental health
problem (n=75)
36/75
48%
12/74
16%
Past-year alcohol problem
(n=18)
7/18
39%
2/18
11%
Past-year street drug
problem (n=5)
4/5
80%
0/5
0%
Angry Men – in Medical Records
Anger was most common type of DVA perpetration documented in
medical records.
“Anger management issues have cost two marriages, 1 arrest.”
“Long-standing anger. Gets angry, strikes out.”
Psychiatrist recommended anger management.
“Anger outbursts in relation to girlfriend.”
Faculty of Public Health & Policy
Domestic violence and abuse in gay &
bisexual men attending a UK sexual
health service
Dr Ana Maria Buller & Dr Loraine Bacchus
Gender Violence & Health Centre
London School of Hygiene & Tropical Medicine
Improving health worldwide
www.lshtm.ac.uk
Background
• Prevalence of domestic violence in gay and bisexual men) is as high as it is for heterosexual women –
between 30% and 78% (Finneran & Stephenson 2012) and much higher than for heterosexual men
(Welles et al 2011)
• Men who have sex with men (MSM) DVA is associated with (Buller et al 2014):
 Substance misuse
 Depression and anxiety symptoms
 Unprotected anal sex
 HIV
• Sexual health services are opportune points of intervention for female patients affected by domestic
violence (Bacchus et al 2010; McNulty et al 2006)
% Perceived Negative Effects of Behaviours From a
Partner (N=106)
90
80
70
60
50
40
30
20
10
0
Made me feel
anxious or
depressed
Affected my
work or studies
Made me drink
more
alcohol/take
more drugs
Other effects
Damaged my
physcal health
Affected my
relatonship with
my children
PROVIDE: Workstream IV
Help-seeking data from interviews across PROVIDE
Morgan, K., Buller, A. M., Evans, M., Trevillion, K.,
Williamson, E. & Malpass, A.
Study
Informal support
Barriers to help-seeking
Formal Support
Methodology (2)
Facilitators to helpseeking
Family and Friends
Health Professionals
IRIS
Hard to talk about abuse
Severe incident
Protecting families by not telling
them
Visited family doctor hoping to be
asked but reluctant to initiate
LARA
Hard to talk about abuse
Severe incident
Mixed experience of family
support
Health professionals not always
asking
PATH
Hard to talk about abuse
Severe incident
Mixed experience of family
support
Visited family doctor hoping to be
asked but reluctant to initiate
WS1
(hetero
men)
Hard to talk about abuse
Reciprocity –
friends/family also
discussing issues
Reciprocity, confidentiality and
privacy are key issues
Very occasional visits for
stress/depression
WS3
(MSM)
Hard to talk about abuse
Reciprocity –
friends/family also
discussing issues
Empathy, confidentiality and
privacy are key issues
Rarely (if ever) approached family
doctor because had never discussed
sexuality.
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What are key messages from PROVIDE?
• High level of mental ill health across cross-sectional and review studies
• Interventions are promising
1. Health Professionals are well placed to increase recognition and understanding of people who
have experienced DVA.
2. Increased access of DVA survivors to appropriate support.
3. 3. People who have experienced DVA and have associated mental and physical health problems,
can begin their recovery from what may have been many years of living with violence and abuse
and not admitting or seeking help in any way, leading to more appropriate treatment.
What about the children?
 75-90% of children in same or next room.
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Forced to participate
Caught in the crossfire
Contact as an opportunity for abuse
Witnessing the aftermath/hearing accounts
 increased risk of negative mental health outcomes
 Clinical diagnosis 40% vs. 10% (Holden, 1998)
 Associated with long term educational and employment disadvantage
 Increased risk of experience/perpetration of DVA in adulthood
See Howarth et al 2015 for up-to-date systematic review
Acknowledgements
This presentation presents independent research commissioned and funded by the
National Institute for Health Research (NIHR) under its Programme Grants for Applied
Research scheme (RP-PG-0108-10084). The views expressed in this publication are
those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health.
Thanks to all researchers, collaborators, participants and expert
advisors who have been involved in the PROVIDE Programme
over the years.