Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2913 (Published 12 May 2014) Cite this as: BMJ 2014;348:g2913All rapid responses
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The burden and health impact of intimate partner violence (IPV) are well-established and demand an evidence-based response from the health care system. The recent abridged Cochrane review on IPV screening invigorates a long-standing debate about the optimal health care-based solution to addressing violence. After evaluating the evidence on “independent contribution of screening,” the authors conclude that evidence is insufficient to support screening women and girls.
The authors’ conclusion should come as no surprise. We have little reason to believe that IPV screening in the absence of follow-up interventions in the form of safety planning and referrals to support service could improve health and reduce victimization. What is all too evident is that screening in the absence of an integrated system of skilled health care providers that can offer support and referral is unlikely to achieve the necessary benefits in terms of safety and health. This review is sorely disappointing in that it does not address or answer the critical questions necessary to refine an evidence-based response to IPV.
These findings should not dissuade us from pursuing a research-informed health care system response to IPV. Indeed one is well underway. For example, abundant qualitative evidence from IPV survivors affirms the value of screening and brief interventions in the health care setting as opportunities to raise awareness about abuse, reduce her sense of isolation, catalyze the process of seeking help, and make survivors aware of local support resources. Evidence from Kaiser Permanent confirms that a brief and clear provider role in screening and referral, including concrete direction on handling abuse disclosures, enables survivor access to support services.
The Institute of Medicine, U.S. Preventive Services Task Force, and leading national health care organizations recommend IPV screening and counseling within the health care setting, based on survivors’ expressed needs and potential benefits from such interventions. The Affordable Care Act includes IPV screening and brief counseling as part of required free preventive services for women. Necessary research directions include examining the effectiveness of screening and brief counseling interventions across different health settings and populations including in lower resource communities, developing quality measures and patient-centered outcomes, and testing multi-level approaches to improving the uptake and consistent implementation of evidence-informed IPV screening and counseling guidelines within the health care delivery system.
The health sector remains essential in the response to IPV in that the majority of violence survivors never reach out for support services based on a confluence of shame, stigma, lack of recognition of abuse, belief that services are limited in scope (e.g., shelter only), and a host of other concerns. Relying on IPV survivors to step forward and disclose their experiences will miss the vast majority of them. Thus the responsibility to reach survivors with supportive messages and links to care and services shifts to the sectors they are likely to encounter- among them the health system features prominently.
The purpose of IPV screening and brief interventions has long been and must remain an opportunity to link survivors with necessary support, safety planning and validation. The far more pressing research question, and one that remains unanswered by this Cochrane review, is how to and where to optimize, and sustain, these efforts.
Michele R. Decker, ScD
Elizabeth Miller, MD, PhD
Nancy Glass, PhD, MPH, RN, FAAN
Competing interests: No competing interests
Lifetime prevalence rates of domestic violence have been reported to be as high as 40%, and are much more common in certain patient populations compared to others. As a trainee in psychiatry I have certainly found that mental health problems such as alcohol dependency/substance misuse, depression, psychotic illnesses and personality disorders are associated with higher rates of domestic violence (Golding, 1999; Campbell, 2002; Neria et al, 2005; Trevillion et al, 2012), with patients being both victims and perpetrators of the abuse.
Knowing this, I feel that domestic violence is an issue which as clinicians we should always be mindful of and have a responsibility towards exploring. There is still not enough being done to support victims of domestic violence or even providing the opportunity for victims to come forward and speak about their experiences due to a host of barriers including shame, guilt and fear of repercussions. I believe that screening for domestic violence in the mental health population will at the very least identify more victims and create the opportunity to address the abuse and provide support should the victim wish to consider this. An article by Kelsey Hegarty (Domestic violence: the hidden epidemic associated with mental illness) and several other articles highlight these very issues and address the need for more research to be done in this area prior to screening being safely introduced.
References
Prevalence of experiences of domestic violence among psychiatric patients: systematic review
http://bjp.rcpsych.org/content/202/2/94.full
Domestic Violence and Mental Health, edited by Louise Howard, Gene Feder and Roxanne Agnew-Davies www.rcpsych.http://www.rcpsych.ac.uk/files/samplechapter/PUB_DomesticViolenceMHSC.pdf
Domestic violence: the hidden epidemic associated with mental illness http://bjp.rcpsych.org/content/198/3/169.full
Mental Health and Domestic Violence: ‘I Call it Symptoms of Abuse’ http://bjsw.oxfordjournals.org/content/33/2/209.abstract
Competing interests: No competing interests
Re: Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis
This abridged Cochrane systematic review acknowledged that intimate partner violence (IPV)is an important health issue, and that screening for IPV in healthcare settings can identify survivors.
However the author's conclusions implied that universal screening was not warranted, even though they specifically excluded studies that reported screening programmes followed by structured advocacy or therapeutic interventions.
Surely the take home message from their review is that screening should be encouraged and supplemented by clear pathways for intervention and support for survivors, and perpetrators.
Obviously, survivors and or perpetrators will have to decide themselves to try and change their situation and behaviours if there is to be an increase in well being and reduction in violence and harm.
Furthermore, even the reported data which showed "no increase" in referrals to support services, actually showed no statistically significant increase in mean referrals but with a risk ratio 95% CI of 0.9 to 7.2 it is clear that many women did take up the offer of referral to support services even if many (in the included studies) did not. It would be enlightening to know what the "Number Needed to Treat" was for screening to result in one more woman being referred, and in one more woman being protected from harm.
I fear the authors conclusions will do nothing to help reduce IPV and may even discourage health professionals from identifying it and signposting women to help. Their data actually shows that more should be done.
Competing interests: No competing interests