Intimate partner violence and mental health: lessons from the COVID-19 pandemic
Domestic violence and abuse is a global public health issue adversely impacting both physical and mental health. Intimate partner violence is one of the most common forms, and includes physical, sexual and emotional abuse (including technology-enabled abuse) and controlling or coercive behaviour from a partner or ex-partner.
Women and girls are particularly at risk for intimate partner violence. Globally, 27% of ever-partnered women aged 15 years and older have experienced this violence, with the highest prevalence in low-income countries1. Risk factors can occur at four levels: a) individual (e.g., disability); b) relationship (e.g., partner exposure to parental violence, substance misuse); c) community (e.g., poverty, crime) and d) societal (e.g., inequitable gender roles, humanitarian and conflict settings, inadequate laws, such as those regarding marital rape, or inadequate law enforcement)2. The risk of intimate partner violence may increase during the perinatal period, particularly in unplanned pregnancies.
Public health restrictions during the COVID-19 pandemic have led to an increase in time at home with partners, with an associated rise in intimate partner violence, as evidenced by an increase in calls to helplines and contact with other support services3. In many countries, frequent lockdowns and quarantine rules have resulted in women having poor access to transport, shelters, safe houses and third sector services, compounding the problem. Remote delivery of health care has also presented new challenges for practitioners identifying and responding to intimate partner violence and addressing its effects on mental health.
While many of the studies in this area are cross-sectional, there is longitudinal evidence from high- and lower-income countries that exposure to violence and abuse across the life course can increase the risk of subsequent mental ill health4. Possible confounders of this association include socioeconomic adversity and early life exposure to violence and abuse.
However, the relationship between intimate partner violence and mental health is complex. There is also evidence that people with mental disorders across the diagnostic spectrum are disproportionately affected4. Evidence from meta-analyses suggests that women with depression and anxiety disorders are three to four times more likely to be exposed than those without, and exposure may affect up to 60% of women with severe mental illness4. Men with severe mental illness are also at increased risk.
While the majority of people with a mental disorder are not violent, there is some evidence for an association between being diagnosed with a mental disorder and violence perpetration, including intimate partner violence, although the absolute risk is low. This appears to be largely mediated by substance misuse. However, it may also be confounded by familial factors such as early exposure to family violence4.
Clinical guidelines highlight the need to ask about experiences of intimate partner violence in people presenting with mental ill health, as part of any routine mental health assessment, but this practice is not uniformly followed. The World Health Organization (WHO) and the World Psychiatric Association (WPA), supported by qualitative meta-syntheses, recommend facilitating disclosure and response through a “LIVES” approach: Listening non-judgmentally and empathically, Inquiring about needs and concerns, Validating experiences, Enhancing safety for victim and family, and Supporting and connecting to information and services5.
Risk assessment of violence perpetration is routine within mental health assessment, but has tended not to focus on risk to partners or ex-partners. A recent meta-synthesis of six studies found that barriers to disclosure of intimate partner violence perpetration to health care staff included perpetrators' negative emotions and attitudes towards their abusive behaviours and lack of trust in practitioners’ abilities to address the problem6. Facilitators of disclosure included experiencing social consequences of abusive behaviours and receiving offers of emotional and practical support. However, there is only weak evidence for effectiveness of interventions in health care settings; early evidence suggests that cognitive behavioural and motivational interviewing interventions addressing alcohol use may reduce intimate partner violence.
Systematic reviews from both high- and lower-income settings report a range of psychological interventions that can improve mental health outcomes, including depression and anxiety, in women experiencing intimate partner violence and mental ill health4. However, there is little evidence on interventions for other disorders, such as post-traumatic stress disorder, or in male victims. It is also unclear the extent to which the effectiveness of the interventions is moderated by recent, current or historical abuse.
There is evidence that advocacy interventions reduce abuse. Where advocates also train mental health or primary care practitioners on domestic violence, with care pathways to deliver both advocacy and mental health interventions, both abuse can be reduced and mental health improved. However, the success of this may be moderated by the extent to which advocates are integrated within the clinical teams with whom they work. A recent meta-synthesis reported that practitioners perceive themselves to be more ready to address intimate partner violence when they collaborate both with expert team members internal to their organizations and with specialist professionals outside their team, and when supported by the health system7.
The COVID-19 pandemic has emphasized the need for these collaborations. A reliance on online and tele-consultations has highlighted the need to assess abuse and deliver mental health interventions remotely in a manner that does not compromise safety8. Several organizations have produced guidance on how to provide mental health support by telephone, and in many parts of the world there has been an expansion in helplines alongside investment in shelters and other safe accommodation options.
A number of innovative interventions have been devised for those without access to mobile technology during the pandemic. These include utilizing existing public places such as pharmacies and shops by providing helpdesks or phone booth stations where support can be given. Other more discrete strategies include the use of code words, silent alarms or other signals that can be presented at the site of a support organization, or displayed outside the home9. Potentially these strategies could also be implemented by mental health facilities, although they have not been used to our knowledge to date.
The WPA has developed a curriculum and core competencies for psychiatrists focusing on intimate partner violence and sexual violence against women5. Similar undergraduate and postgraduate training initiatives are needed for other practitioners, including community health workers in low- and middle-income countries, with research to establish how best to intervene. Moreover, mental health policies should recognize the need for trauma-informed approaches that support the identification and response to intimate partner violence. During the pandemic, the WPA, the International Association of Women’s Mental Health and the International Marcé Society for Perinatal Mental Health have provided webinars to promote shared learning and discussion among health care professionals supporting those affected by intimate partner violence.
Services should provide routine data collection on intimate partner violence, and research should ensure measurement and analysis of the impact of this violence – in trials of (pharmacological and non-pharmacological) interventions, in observational cohort studies, and in the evaluation of public health interventions that have the potential to reduce the extent of the problem (e.g., minimum alcohol pricing). Finally, through the WHO, United Nations and national bodies, psychiatrists could also be advocates for wider changes that focus on tackling the social and structural drivers of intimate partner violence, and in doing so reduce its burden on mental health.
