Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services

Background Domestic violence and abuse (DVA) are associated with increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services. Objective Our goal was to characterise the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators. Design Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors were analysed. We report the prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. The following mental health measures were used: Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalised Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale to measure posttraumatic stress disorder (PTSD). The Composite Abuse Scale (CAS) measured abuse. Results Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and more than three-quarters of respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA. Conclusions Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.

Measures symptoms of psychological distress. It is non-proprietary and was originally designed to measure the impact of counselling and psychological therapies on patients in the UK. It is made of 34 items, all measured on a Likert scale, with higher scores corresponding to worse states (some items are reversed). It captures four domains: i. subjective wellbeing: measures respondent's emotional wellbeing (4 items) ii. problems/symptoms: questions on anxiety, depression, physical issues and effects of trauma (12 items); iii. functioning: captures respondents' perceptions of their close relationships, general emotional functioning, and their social interactions (12 items); iv. risk to self or others: captures if respondents' behaviour may have caused harm to themselves or others (6 items)

PHQ-9
Nine-item Patient Health Questionnaire (2) Binary: The PHQ--9 is used routinely in general practice in the UK to screen for symptoms of depression.
It includes questions on respondents' perceptions of their own energy levels, worrying patterns, and selfesteem, among others.
It measures how often respondents have felt the way described by each of the items. Each item is scored on a Likert scale, where higher scores indicate higher frequency, equivalent to worse health states.
We computed an indicator equal to 1 if the PHQ--9 score was greater than 9, i.e. suggestive of major depression.

GAD-7
Seven-item Generalised Anxiety Binary: The GAD-7 measures symptoms of anxiety. Each item is scored on a Likert scale, with higher scores indicative of higher frequency spent in the state indicated by the item, i.e. of worse mental health states. Items capture a sense of generalised fear, nervousness and worrying, among others. The CAS is a 30--item self--report measure capturing emotional, physical and severe abuse, as well as harassment (4)(4)(32).
It was designed to measure exposure to coercive control and conflict among women, in response to critiques to existing measures that they only measured conflict and physical or sexual violence.
Items are measured on a Likert scale, where higher scores indicate more frequent exposure to the abuse described by the item, and hence higher exposure to abuse.
The cut-off score for CAS has been established at 3. Due to the high level of exposure to abuse in our sample, we use a continuous measure

Continuous
In-sample range: (0, 50) Weathers' measure of post--traumatic stress is a 12-item checklist that captures the presence of intrusive thoughts regarding respondents' traumatic experiences, feeling of severe anxiety or lack of emotions, of social isolation, and general pessimism or lack of hope for the future. Each item is measured on a Likert scale that captures how frequently respondents have experienced the state or feeling described by each item, with higher values indicative of higher frequencies, and hence of worse post-traumatic stress.

SF-12
Short-Form 12 (7) Two sub-categories, continuous: Aggregate Mental Health T-Score: In-sample range: (6,62) Aggregate Physical Health T-Score: In-sample range: (19,68) The SF-12 is a measure of health status that captures respondents' physical and emotional state and whether these interfere with their daily lives and activities. All indicators are measured along Likert scales where higher scores are indicative of better health status. Respondents rate how they fare along dimension on a 1-5 Likert scale, where 5 is worst and 1 is best.
The final continuous score is assigned on the basis of population scores derived from large surveys.