Summary of the impact

Domestic violence is a significant public health issue costing the UK £3.8billion for criminal and civil legal services, healthcare, social services, and housing. King's College London (KCL) research established the high prevalence of being a victim of domestic violence in people with mental disorders, which is under-detected by health professionals. This led to commissioning guidelines in England on identification of domestic violence in those with mental health problems, and care pathways for those who have experienced domestic violence. These recommendations are supported by undergraduate and postgraduate training materials for healthcare professionals based on KCL research and national and international guidance.

Underpinning research

Violence and abuse was seen as an area of significant unmet need by mental health service users, especially as it was not being identified by mental health professionals involved in their care. This important area has recently been addressed in studies at Institute of Psychiatry at King's College London (KCL) by Prof Louise Howard (1997-present, Head of the Section of Women's Mental Health), Dr Diana Rose (2001-present, Reader in Service User led research) and Dr Kylee Trevillion (2008-13, Research Associate).

KCL researchers show the extent of domestic violence in psychiatric service users
Through systematic review and meta-analysis, KCL researchers found a higher risk of experiencing adult lifetime partner violence among women with depressive disorders (odds ratio [OR] 2.77), anxiety disorders (OR 4.08), PTSD (OR 7.34) and psychotic disorders (no pooled OR) compared to women without mental disorders (1). They also discovered a particularly high prevalence of lifetime partner violence in psychiatric service users, as shown by a systematic review of 42 studies where the median prevalence was 30% among female in-patients and 33% among female out-patients (2).

Barriers to disclosure of partner violence are confirmed by KCL research
KCL qualitative research and quantitative surveys examined the barriers to disclosure of domestic violence to professionals. In a study involving 18 mental health service users and 20 mental health professionals in a socioeconomically deprived south London borough, service users described how disclosure barriers included fear of consequences, involvement of Social Services and consequent child protection proceedings and fear that disclosure would not be believed and would lead to further violence. They also discussed the hidden nature of the violence, actions of the perpetrator and feelings of shame. The main themes for professionals concerned role boundaries, competency and confidence. Service users and professionals reported that the medical diagnostic and treatment model with its emphasis on symptoms could act as a barrier to enquiry and disclosure. Both groups reported that enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional (3).

Antenatal domestic violence is associated with mental ill health of the mother and child
KCL researchers also investigated domestic violence in women with children in order to detect any causal effects. One such investigation included 13,617 mother and child pairs who were part of the Avon Longitudinal Study of Parents and Children, which aimed to recruit all pregnant women resident in Avon and expected to deliver their child between 1st April1991 and 31st Dec1992. They showed that antenatal domestic violence was associated with high levels of maternal depressive symptoms both prior to (OR 4.02) and after (OR 1.29) birth. Antenatal domestic violence predicted future behavioural problems at 42 months in the child (OR 1.87), which was associated with maternal depressive symptoms pre- and post-birth or domestic violence since birth (4). A systematic review and meta-analysis demonstrate that in longitudinal studies there is a 3-fold increase in the odds of severe depressive symptoms in the postnatal period after experiencing partner violence during pregnancy. Cross-sectional studies also consistently reported increased odds of women with high levels of depressive, anxiety and PTSD symptoms prior to and after birth experiencing domestic violence (5).

References to the research

Grants

• 2008-11. PI: LM Howard. LARA: Linking Abuse and Recovery through Advocacy Maudsley Charity. (Grant no 419). £121,000

• 2008-11. PI: LM Howard. A pilot RCT of advocacy for domestic violence integrated into mental health services. NIHR Research for Patient Benefit. £256,755

• 2010-15. CI G Feder; PI for mental health workstream: L Howard. Improving the healthcare response to domestic violence NIHR Programme Grant for Applied Research. £1,800,000

Details of the impact

Increased training of health care professionals in the UK and abroad
Prior to 2011, reference to domestic violence in the training of health professionals in mental health was primarily in the context of child safeguarding. KCL research on the prevalence of domestic violence experienced by mental health service users, barriers to identification and how to safely detect and respond to domestic violence contributed to training materials for mental healthcare professionals. For instance, after consultation with Prof Howard, the Royal College of Psychiatrists now include such topics in the psychiatric core curriculum for medical students (1a). Prof Howard also co-edited a 2013 Royal College of Psychiatrists-commissioned book: Domestic Violence and Mental Health that gives "practical guidance on how mental health professionals can identify and respond to domestic violence experienced by their patients." This training manual contains first-hand expertise, refers to KCL studies and describes how to develop safe care and referral pathways (1b).

KCL research also contributed to training materials developed by AVA (Against Violence & Abuse) Project, a UK second tier service working to end violence against women and girls. Their course on domestic violence, and toolkit for professionals, references KCL papers, including Trevillion et al. 2012 and Rose et al. 2011 when discussing the relationship between domestic violence and poorer mental health, and professionals' anxiety when enquiring about domestic violence. It also highlights Trevillion et al's 2013 pilot study of a domestic violence intervention for mental health services including training for professionals (3b).

Widespread dissemination of the KCL research as part of training of mental health professionals is occurring. For instance, using KCL research findings, Prof Howard contributed to `Directions in Psychiatry,' a US Continuing Medical Education programme for mental healthcare professionals that provides credits needed to retain a practice licence (1d). Prof Howard and Dr Trevillion have passed on their expertise through workshops for mental healthcare and domestic violence sector professionals, such as at the 2010 conference held by Woman's Aid, a national domestic violence charity (1e) and the Sexual Assault Referral Centre conference 2013 (1f).

National and international policy influences
Reference to KCL research is included in national and international policy guidelines. Findings from Oram et al. 2013 and Trevillion et al. 2012 contributed to National Institute for Health and Care Excellence (NICE)/Social Care Institute for Excellence draft guidance recommending routine enquiry and training about Domestic Violence by mental health professionals (now out for consultation) (2a). Further afield, the Canadian Psychiatric Association's position paper (2013) on Intimate Partner Violence (IPV) draws on Trevillion et al's, 2012 research when discussing why IPV should be of vital interest to mental health professionals (2b). Recent World Health Organization policy guidelines cite a KCL review as evidence for recommendations that "Health-care providers should ask about exposure to IPV when assessing conditions that may be caused or complicated by intimate partner violence" and that "Women with a diagnosed or partner violence-related mental disorder ... who are experiencing IPV should receive mental health care delivered by health-care professionals with a good understanding of violence against women". The 2010 review paper uses several KCL studies including qualitative research (in press at that time, published in Rose et al 2011) and findings of high prevalence with under-detection by professionals published in Howard et al. 2010 (2c).

Effects on the NHS and improved outcomes
Prof Howard was a member of the domestic violence subgroup of several NHS and Department of Health (DH) Taskforce and Implementation Groups between 2009 and 2013. These working groups, drawing on KCL research, highlighted the role of the NHS and mental health services in responding to violence experienced by women and children and led to commissioning guidance on identification and care pathways and recommendations for further research. This led to the DH asking NICE to develop guidelines (see above) and secure research funding from the Policy Research Programme in 2012 for programmes on Violence Against Women (3a, b).

The first evidence of the success of training on the ground in a mental health trust has now been published. The training intervention provided to Community Mental Health teams, with a care and referral pathway to domestic violence advocacy for service users (1b), significantly improves domestic violence knowledge, attitudes and behaviours for clinicians and leads to significant reductions in violence and unmet needs for service users (3c). In this same audit there was also an increased rate of referrals (1-2 per year to 6-8 per year) to local borough Multi-Agency Risk Assessment Conferences (MARACs: borough level meetings for high risk victims of domestic violence shown to reduce agency costs) (3c,d). Improvements in practice have persisted — rates of referral to local domestic violence advocates from the South London and Maudsley (SLaM) NHS Foundation Trust adult mental health services increased from two per year previously, to more than 45 per year in the 2 years since the pilot. In the last year, SLaM revised its domestic violence policy; added prompts with regard to domestic violence; developed care pathways with the local domestic violence sector across the Trust; developed domestic violence e-learning and allocated named nurses from each borough covered by the Trust to attend MARACs (3e). Other Mental Health Trusts are following with new strategies and policies e.g. Surrey and Borders Partnership NHS Foundation Trust; North East London NHS Foundation Trust and South Staffordshire & Shropshire Healthcare NHS Foundation Trust.

Increasing public awareness
The public's understanding of the link between domestic violence and mental health increased through a number of media outlets that have used KCL research or expertise. For instance, the weekly magazine New Statesman (with a circulation of 25,000) used both Rose et al. 2010 and Trevillion et al. 2012 when discussing the occurrence of domestic violence in people with mental health problems and how mental health professionals are reluctant to enquire about such issues (4a). The study by Flach et al. 2011, highlighting the link between antenatal domestic violence and postnatal depression, was discussed in an article in The Telegraph (4b). Additionally, the University of California Los Angeles-based organisation Psychology in Action used Oram et al. 2013 in an article discussing facts and figures associated with domestic violence (4c). Prof Howard has spoken personally about domestic violence and mental health on Radio 4's All in the Mind, a programme dedicated to mental health issues (4d) and on Policy Review TV, an internet-based company that provides quality broadcast media services and specialist knowledge and expertise to offer intelligence based solutions for business, trade and professional associations (4e).

Sources to corroborate the impact

Training of health care professionals in the UK and abroad

a) RCP Curriculum:
http://www.rcpsych.ac.uk/pdf/Undergraduate%20Psychiatry%20Curriculum%202011b.pdf and acknowledgement of Prof Howard's contribution:
http://www.rcpsych.ac.uk/pdf/Curriculum%20acknowledgements%2012%20Jan%2012.pdf

b) Domestic Violence and Mental Health: Eds Howard, Agnew-Davies, Feder. Royal College of Psychiatrists 2013:
http://www.rcpsych.ac.uk/usefulresources/publications/books/rcpp/9781908020567.aspx

c) AVA Project: http://www.avaproject.org.uk/

• Toolkit: http://www.avaproject.org.uk/our-resources/good-practice-guidance--toolkits/complicated-matters-stella-project-toolkit-and-e-learning-(2013).aspx
• References: http://www.avaproject.org.uk/media/124161/ava%20toolkit%20references.pdf
• http://www.avaproject.org.uk/media/106656/promising%20practices%20-%20mental%20health%20trust%20responses%20to%20domestic%20violence.pdf

d) Howard LM. Barriers and facilitators of disclosures of domestic violence. US 2013 Curriculum of Directions in Psychiatry: http://www.directionsinpsychiatry.com/diinpsvo33pr.html

e) Woman's Aid conference (see Workshop Programme): http://www.womensaid.org.uk/domestic-violence-events.asp?itemid=2385&itemTitle=Women's+Aid+National+Conference+2010§ion=000100010017§ionTitle=Events+calendar

f) Sexual Assault Referral Centre conference 2013: http://www.stmaryscentre.org/wp-content/uploads/2013/02/CM11885_SARC_Conf-2013.pdf

2. National and international policy influences

a) NICE/SCIE scope of Guideline on Preventing and reducing domestic violence between intimate partners: http://www.nice.org.uk/nicemedia/live/12116/64783/64783.pdf

b) Canadian Psychiatric Association position paper on partner violence: http://publications.cpa-apc.org/media.php?mid=1524

c) 2013 WHO clinical and policy guideline. Responding to intimate partner violence and sexual violence against women: who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf

3. Effects on the NHS and improved outcomes

a) Responding to violence against women and children — the role of the NHS. Sub-group report (domestic violence). Taskforce on the Health Aspects of Violence Against Women and Children March 2010 (pdf available on request)

b) Letter of professional corroboration: Deputy Director, Developing Well, Department of Health

c) Trevillion K, et al. Linking abuse and recovery through advocacy. Epidemiol Psychiatr Sci 2013 Apr 30:1-15. [Epub]. Doi: http://dx.doi.org/10.1017/S2045796013000206

d) Letter of professional corroboration: Director, Domestic Violence Project, Bede House Association

e) SLaM Mental Health Trust DV policy: Pdf on request

4. Public Awareness

a) New Statesman. Domestic violence and mental illness: "I have honestly never felt so alone in my life." Published 1.5.2013: http://www.newstatesman.com/lifestyle/2013/05/domestic-violence-and-mental-illness-i-have-honestly-never-felt-so-alone-my-life

b) The Telegraph. Domestic violence 'leads to post-natal depression.' 22.6.2011:
http://www.telegraph.co.uk/health/8588917/Domestic-violence-leads-to-post-natal-depression.html

c) Psychology in Action. The Truth about Domestic Violence: 28.3.2013:
http://www.psychologyinaction.org/2013/03/28/the-truth-about-domestic-violence-literature-review/

d) Radio 4. All in the Mind. Mental Illness and Domestic Violence. Aired 9.12.2009:
http://www.bbc.co.uk/programmes/b00p66f8

e) Policy TV. Domestic Violence Research and Policy Forum #dvf122012. 25.6.2012:
http://www.policyreview.tv/conference/781-domestic-violence-research