Mental Health Diagnoses among Women Experiencing Recent Intimate Partner Violence: Need for Integrated Care
Melissa E. Dichter, PhD, MSW
February 2, 2018
Intimate partner violence (IPV) is the term used to refer to violence and abuse in various forms (including psychological, physical, sexual, financial), perpetrated by a current or former intimate partner (including spouse or other romantic or sexual partner; World Health Organization, United Nations Development Programme & United Nations Office on Drugs and Crime, 2014). In the United States, it is estimated that more than one in three women experience rape, physical violence, or stalking from an intimate partner in their lifetimes (Black et al., 2011); prevalence and incident rates vary by measurement tools and constructs measured. IPV is associated with numerous adverse outcomes, including physical injuries, chronic health conditions, trauma-related mental health symptoms, unhealthy substance use, housing instability, and suicidality.
Women who have served in the military face particularly high rates of both lifetime IPV exposure and mental health conditions (Dichter, Cerulli, & Bossarte, 2011; Frayne et al. 2014). Among women veterans receiving primary care from the Veterans Health Administration (VHA), survey research finds that nearly one in five report experiencing IPV in the prior year (Kimerling, Iverson, Dichter, Rodriguez, Wong, & Pavao, 2016). Women who are spouses or dependents of male veterans and who use VHA indicate particularly high rates of recent IPV (Dichter, Haywood, Butler, Bellamy, & Iverson, 2017). Along with other healthcare systems, the VHA has recently begun to implement routine screening for recent IPV experience among the female patient population. We analyzed VHA health records of nearly 9,000 women patients to identify the relationship between recent IPV experience based on clinical screening responses and mental health diagnoses (see Dichter, Butler, Bellamy, Medvedeva, Roberts, & Iverson, in press, for full study report).
We found that women patients screening positive for past-year IPV were more than twice as likely as those screening negative for past-year IPV to have a diagnosed mental health condition in the six months following IPV screening. Past-year IPV exposure was associated with higher rates of diagnoses of anxiety, post-traumatic stress disorder (PTSD), depression, and alcohol or drug abuse, as well as with having two or more mental health diagnoses. Over half of the group screening positive for past-year IPV exposure had a mental health diagnosis, more than one-quarter had two or more mental health diagnoses, one in three had a diagnosis of PTSD, more than one in three had a depression diagnosis, and over seven percent had a diagnosis of alcohol or drug abuse.
To examine categories of IPV experience more closely, we looked at three mutually exclusive groups, based on IPV screening responses:
- Experience of psychological forms of IPV (insulted, screamed at, or threatened by partner) and no physical violence (being physically hurt by partner) or sexual violence (forced to have sexual activity by partner);
- Experience of physical violence (physically hurt), with or without psychological violence, without sexual violence;
- Experience of any sexual violence, with or without physical or psychological violence.
We found that each of these categories of IPV experience was independently associated with increased likelihood of having a mental health diagnosis or multiple mental health diagnoses.
IPV is an experience, not a mental health condition. However, IPV experience can have profound psychologically traumatic effects and contribute to or exacerbate mental health symptoms. Given the high rates and increased risk of mental health conditions among women who have experienced recent IPV, it would be important to assess for mental health symptoms among women who have experienced IPV and to facilitate mental health treatment where appropriate. IPV screening is increasingly becoming weaved into routine primary, women’s health, and emergency medical care. Without coordination with mental health services for patients experiencing mental health symptoms, patients may be left with untreated and ongoing psychological trauma, contributing to adverse health and social outcomes.
The Veterans Health Administration is known as the nation’s largest integrated healthcare system, with primary care/internal medicine and emergency medicine integrated with behavioral healthcare within the same system. Other healthcare systems with less integration of behavioral health into primary care may need to consider ways of coordinating needed mental health care for patients experiencing IPV. Furthermore, in addition to mental health services, patients experiencing IPV are likely to have other social service needs to achieve safety and independence; coordinating with local assistance and advocacy programs may be critical to address patients’ needs for safety planning, housing, financial assistance, legal advocacy, and other resources.
As we continue to develop and expand implementation of IPV screening and response in healthcare systems, we must ensure that we not limit our attention to physical violence. Healthcare providers and patients alike may mistakenly believe that violence or abuse must be physical in nature, must include “hitting” or bruises, to be considered as IPV, have adverse health outcomes, or be deserving of IPV-related services. IPV screening tools and protocols also often fail to specifically assess for experience of sexual forms of violence, including sexual and reproductive coercion in addition to sexual assaults – such forms of violence may feel more stigmatized and less clear, especially within the context of an ongoing intimate relationship. Yet, as we see strong mental health associations with all categories of IPV experience it is critical that we do not limit our assessments or perceptions to “hits.” In fact, women experiencing psychological forms of violence and coercive control have indicated that the physical violence was often not the most damaging and research shows that sexual violence experience can have particularly traumatic impacts (Bonomi, Anderson, Rivara, & Thompson, 2007; Dichter, Marcus, Wagner, & Bonomi, 2014; Pico-Alfonso, Garcia-Linares, Celda-Navarro, Blasco-Ros, Echeburua, & Martinez, 2006). Appropriate mental health and social services coordinated with primary and emergency care are important to offer adequate support to patients experiencing IPV.
References
Black, M. C., Basile, K., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., ... Stephens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf
Bonomi, A. E., Anderson, M. L., Rivara, F. P., & Thompson, R. S. (2007). Health outcomes in women with physical and sexual intimate partner violence exposure. Journal of Women’s Health, 16, 987–997. doi:10.1089/jwh.2006.0239
Dichter, M. E., Butler, A., Bellamy, S., Medvedeva, E., Roberts, C. B., & Iverson, K. M. (in press.). Disproportionate mental health burden associated with past-year intimate partner violence among women receiving care in the Veterans Health Administration. Journal of Traumatic Stress.
Dichter, M. E., Cerulli, C., & Bossarte, R. M. (2011). Intimate partner violence victimization among women veterans and associated heart health risks. Women’s Health Issues, 21(Suppl. 4) , S190–S194. doi:10.1016/j.whi.2011.04.008
Dichter, M. E., Haywood, T. N., Butler, A. E., Bellamy, S. L., & Iverson, K. M. (2017). Intimate partner violence screening in the Veterans Health Administration: demographic and military service characteristics. American Journal of Preventive Medicine, 52, 761-768. doi.org/10.1016/j.amepre.2017.01.003
Dichter, M. E., Marcus, S. C., Wagner, C., & Bonomi, A. E. (2014). Associations between psychological, physical, and sexual intimate partner violence and health outcomes among women veteran VA patients. Social Work in Mental Health, 12, 411-428.
Frayne, S., Phibbs, C., Saechao, F., Maisel, N., Friedman, S., Finlay, A., ... Haskell, S. (2014). Sourcebook: Women Veterans in the Veterans Health Administration. Volume 3. Sociodemographics, Utilization, Costs of Care, and Health Profile. Retrieved from http://www.womenshealth.va.gov/docs/Sourcebook_Vol_3_FINAL.pdf
Kimerling, R., Iverson, K. M., Dichter, M. E., Rodriguez, A. L., Wong, A., & Pavao, J. (2016). Prevalence of intimate partner violence among women veterans who utilize Veterans Health Administration primary care. Journal of General Internal Medicine, 31, 888–894. doi:10.1007/s11606-016-3701-7
Pico-Alfonso, M. A., Garcia-Linares, M. I., Celda-Navarro, N., Blasco-Ros, C., Echeburua, E., & Martinez, M. (2006). The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. Journal of Women’s Health, 15, 599–611. doi:10.1089/jwh.2006.15.599
World Health Organization, United Nations Development Programme, & United Nations Office on Drugs and Crime. (2014). Global Status Report on Violence Prevention 2014. Retrieved from http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/
Reference Article
Dichter, M. E., Sorrentino, A., Bellamy, S., Medvedeva, E., Roberts, C. B. and Iverson, K. M. (2017), Disproportionate Mental Health Burden Associated With Past-Year Intimate Partner Violence Among Women Receiving Care in the Veterans Health Administration. JOURNAL OF TRAUMATIC STRESS, 30: 555–563. doi:10.1002/jts.22241
Author Biography:
Melissa Dichter is a Core Investigator at the U.S. Department of Veterans Affairs Center for Health Equity Research and Promotion, and Assistant Professor in the Department of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine. Dr. Dichter’s research focuses on individuals’ experiences with intimate partner violence and healthcare system responses.