The confluence of violence towards an intimate partner, substance misuse and mental health: a worldwide problem affecting women.

Violence towards an intimate partner, substance misuse and other mental health disorders are problems that tend to cluster together and result in multiple burdens for afflicted individuals (Desjarlais et al, 1995; Wyshak & Modest, 1996; Wyshak, 2000). They are prevalent not only in high-risk groups but also among members of the general public seeking primary healthcare (Bauer et al, 2000; World Health Organization, 2001), where their afflictions often go undiagnosed and untreated (Edlund et al, 2004; Kramer et al, 2004). Furthermore, violence towards an intimate partner, substance misuse and other mental health disorders involve common symptom pathways, such as psychiatric distress, headache, abdominal pain, gastrointestinal problems and multiple somatic complaints (Berwick et al, 1991), which suggests that the use of an integrated set of screening instruments may lead to early detection and treatment for patients who are suffering from one or more of these problems.

The role of gender

Violence directed at an intimate partner disproportionately affects women: between 10% and 69% of women have at some time experienced such violence, according to a review of 48 population-based studies from a variety of countries around the world (Krug et al, 2002). Similarly important, tobacco smoking, alcohol consumption and the use of illicit drugs (excluding ecstasy, solvents and cannabis) cause a total of approximately 6.9 million deaths annually: 4.9, 1.8 and 0.2 million, respectively (World Health Organization, 2002). Although men use these substances at higher rates than women, the health impact for women is no less significant and for some substances may be even greater (Cormier et al, 2004). Furthermore, neuropsychiatric disorders as a whole afflict approximately 450 million individuals worldwide (World Health Organization, 2001). Of these disorders, depression, which disproportionately affects women, is the leading cause of disability worldwide (World Health Organization, 2001).

Violence directed at an intimate partner disproportionately affects women: between 10% and 69% of women have at some time experienced such violence, according to a review of 48 population-based studies from a variety of countries around the world.

Confluence of the three types of problem

Violence towards an intimate partner, substance misuse and other mental health disorders are highly correlated with each other. Substance misuse and other mental health disorders are risk factors for and health outcomes of violence perpetrated by an intimate partner (Riggs et al, 2000). Substance misuse and other mental disorders themselves are highly correlated under the rubric of dual diagnosis. Research specifically addressing these interconnections has found high correlations between the experience of violence, substance misuse and psychiatric distress, characterised by gender and ethnic differences; notably, in women depression and alcoholism are highly correlated (Wyshak & Modest, 1996).

Screening

Wyshak & Modest (1996) have demonstrated the feasibility of screening for these multiple but interrelated problems. Screening efforts for alcohol, drug and mental disorders have increased over time, but recent survey research of primary-care patients in the United States indicates that such screening is generally still lacking. For example, in one survey approximately half of those who reported substance misuse or mental disorder were screened; even among those screened and found to have a disorder, 40% received no treatment (Edlund et al, 2004). Even fewer female respondents (25%) reported being screened for violence in another sample of primary-care patients, although 83% supported the idea (Kramer et al, 2004).

The confluence and common symptom pathways of violence, substance misuse and other mental health disorders call for integrated screening … and treatment interventions for women.

These findings suggest that while screening efforts continue to proliferate, they remain under-used tools for early detection and treatment. Screening instruments that address these interrelated conditions – violence, substance misuse and mental disorders – may lead to improved identification and treatment of afflicted individuals. Moving beyond recognition of violence directed at an intimate partner requires the development and examination of culturally relevant interventions.

Intervention and the role of culture

Effective interventions in mental health and substance misuse exist (World Health Organization, 2001) but the effectiveness of those that seek to reduce violent incidents remains understudied (Wathen & MacMillan, 2003), which presents a barrier to the provision of ethical, safe, evidence-based interventions for women. There is a further problem, in that these interventions have been designed in and for the populations of developed countries: they therefore require context-specific adaptation for their use elsewhere in the world, for different populations. Such adaptation will need to take into consideration the obstacles and resources available, including referral sources in the case of violence towards an intimate partner (Garcia-Moreno, 2002).

Cultural contexts underpin the feasibility and acceptability of any healthcare interventions, but this is especially true where attitudes to violence against women (including victim blaming) as well as the stigma attached to mental illness and substance misuse are to the fore.

Cultural contexts underpin the feasibility and acceptability of any healthcare interventions, but this is especially true where attitudes to violence against women (including victim blaming) as well as the stigma attached to mental illness and substance misuse are to the fore. Therefore, context-specific programming and evaluation are necessary. This will prove difficult given the resource constraints that violence, substance misuse and mental health programmes face worldwide, but especially so in low-income countries.

Conclusions

The confluence and common symptom pathways of violence, substance misuse and other mental health disorders call for integrated screening (Wyshak & Modest, 1996) and treatment interventions for women. This will require training for healthcare providers, to enable them to recognise and treat these interrelated problems, and to deal with the associated ethical issues, such as privacy and confidentiality (Wyshak, 2000). Research and funding are required to develop culturally appropriate interventions and to evaluate their effectiveness (Garcia-Moreno, 2002). These efforts are necessary to ensure that all those women, worldwide, who face these problems receive effective, culturally appropriate health interventions in the primary-care setting.