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 25th November 2015 Jayne.bailey@Bristol.ac.uk

The presentation 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? 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 Higher in clinical populations 30 24 17 12 9 7

Risk factors most demographic and social characteristics not consistently associated with increased risk exceptions: 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: 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 WSI - Men in general practice WSII - Mental Health WSIII - Men in sexual health clinic WSIV - Synthesis and help-seeking Collaborative – PI Professor Gene Feder

Main objectives (mental health):   Estimate prevalence of DVA in people with mental health disorders, and articulate their health care needs in relation to DVA Evaluate a psychological intervention delivered by DVA advocates to women 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) What is the extent of the association between mental disorders and DVA? What is the prevalence of DVA among mental health service users? What are the responses of mental health services to disclosures of domestic violence? (All references available in conference information) This presentation will explore the following four questions in relation to addressing the intersection of domestic violence and mental disorders

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%) Anxiety: 28.4% (IQR 26%-42%) Lifetime DV prevalence PTSD: 61% (IQR 41%-80%) Odds Ratio Depression: 3.31 (2.35-4.68) Anxiety: 2.29 (1.31-4.02) PTSD: 7.34 (4.50-11.98) 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) Most common disorders studied – depression (n=13) / anxiety (n=7) / PTSD (n=4) Past year prevalence data indicates: Women with depressive disorders 3 times more likely to experience DV than women with a mental disorder Women with anxiety disorders 2 times as likely to experience DV than women without a mental disorder Due to insufficient data, only able to calculate lifetime prevalence of PTSD and found: Women with PTSD over 6 times more likely to report DV than women without disorder Eating disorders: 8 papers EDs associated with a high prevalence and increased odds of lifetime IPV women and men Perinatal review: 67 papers. Pooled estimates = women are 3 times more likely to have high levels of depression in postnatal period after experiencing violence in pregnancy (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? About one third of all patients in mental health services have a lifetime history of DVA However: Median prevalence estimates (high-quality papers) Lifetime DVA in female inpatients: 30% (IQR 26%-39%) 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) Mental health service responses to DVA Low rates of detection (only 10-30% detected in clinical practice) SO PROBABLY AN UNDERESTIMATE In light of the high rates of victimisation reported among people with severe mental illness we also reviewed evidence on the prevalence of DV among mental health service users. Our findings indicate that MHSUs are equally if not slightly more vulnerable to DV than the general population Despite the number of MHSUs affected by DV mental health services have very low rates of detection of DV. Why is this? We conducted interviews with 25 mental health professionals – exploring their experience of enquiry of DV and interviews with 24 MHSUs to explore their experience of disclosure of DV (Khlaifeh et al 2014; Oram et al 2013; Howard et al 2010)

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 Linking Abuse and Recovery through Advocacy Domestic violence training of Community Mental Health Team LARA Advisors trained by mental health professionals and domestic violence sector Clear referral pathways to LARA Advisors LARA Advisors integrated within teams Control Teams Training manual;

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

randomised controlled trial 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

All measured at 1 year from baseline PATH: The method pragmatic trial compare usual DVA advocacy support (control) usual support plus a 10 session psychological intervention (intervention). outcomes primary: psychological well-being (Clinical Outcomes in Routine Evaluation–Outcome Measure – CORE-OM) depressive symptoms (PHQ-9) 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: 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

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.

Perpetrator in past year Victim/Perpetrator in past year Past-year victims and perpetrators – mental health problems (see Hester et al, 2015 BMJ Open reference) Mental health variable Victim in past year Perpetrator in past year Victim/Perpetrator in past year Current or past-year % of above Mild anxiety (self-reported - current) 81% (21/26) (13/16) 78% (25/32) Mild depression 30% (8/27) 50% (8/16) 36% (12/33) Mental health problem (GP-documented – past year) (7/23) (7/14) 43% (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 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)

PROVIDE: Workstream IV Help-seeking data from interviews across PROVIDE Morgan, K., Buller, A. M., Evans, M., Trevillion, K., Williamson, E. & Malpass, A.

Barriers to help-seeking Facilitators to help-seeking   Study Informal support Formal Support Barriers to help-seeking Facilitators to help-seeking 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 Mixed experience of family support Health professionals not always asking PATH WS1 (hetero men) Reciprocity – friends/family also discussing issues Reciprocity, confidentiality and privacy are key issues Very occasional visits for stress/depression WS3 (MSM) Empathy, confidentiality and privacy are key issues Rarely (if ever) approached family doctor because had never discussed sexuality. Methodology (2)

What are key messages from PROVIDE? High level of mental ill health across cross-sectional and review studies Interventions are promising Health Professionals are well placed to increase recognition and understanding of people who have experienced DVA. Increased access of DVA survivors to appropriate support. 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. 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 IMPROVE

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.