Citation: Tsai AC (2013) Intimate Partner Violence and Population Mental Health: Why Poverty and Gender Inequities Matter. PLoS Med 10(5): e1001440. doi:10.1371/journal.pmed.1001440
Published: May 7, 2013
Copyright: © 2013 Alexander C. Tsai. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No specific funding was received to write this article.
Competing interests: AT acknowledges salary support from U.S. National Institutes of Health K23 MH-096620.
Provenance: Commissioned; not externally peer reviewed.
Linked Research Article
This Perspective discusses the following new study published in PLOS Medicine:
Devries KM, Mak J, Bacchus L, Child J, Falder G, et al. (2013) Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies. PLoS Med 10(5): e1001439. doi:10.1371/journal.pmed.1001439
Karen Devries and colleagues conduct a systematic review of longitudinal studies to evaluate the direction of association between symptoms of depression and intimate partner violence.
Steven Pinker  suggests that the world is becoming less violent. Yet, although it has been nearly two decades since the United Nations issued its Declaration on the Elimination of Violence against Women, the global burden of violence against women still remains alarmingly high . Violence commonly results in physical injury, and other serious physical or psychological sequelae may also result, compounding its contribution to the overall global burden of disease . The systematic review and meta-analysis by Karen Devries and colleagues  in this week's PLOS Medicine brings us one step closer toward understanding the mental health liabilities associated with violence against women. The public health impact of their contribution is substantial, given the lack of resources devoted to the prevention and treatment of mental disorders worldwide ,,.
Their article is not the first to summarize the impacts of various forms of violence and abuse against women on mental health ,, (Table 1). Karen Devries and colleagues  contribute to this body of literature reviews by restricting their focus to longitudinal studies, thereby examining the temporal relationship between intimate partner violence and depression. Although the literature contained few studies examining the impacts of violence on incident depressive disorders, the authors identified enough studies to support a conclusion that violence was associated with incident symptoms of depression. They had intended to also examine the association between victimization and depression among men, but lack of data limited their ability to draw firm conclusions.
Notably, Karen Devries and colleagues  also found that, among women, symptoms of depression were associated with incident experiences of violence. Whether the relationship between violence and depression is truly causal in both directions is unknown. For example, in examining the association between exposure to intimate partner violence during adulthood and incident symptoms of depression, an unmeasured confounder preceding both variables such as childhood abuse—not measured in most of the studies—could be causally related to both irrespective of their temporal relationship with each other, inducing a spurious association that could be mistakenly interpreted as bidirectional. Statistical adjustment for baseline depression symptom severity, which was done in most of the studies, could potentially help with this problem if it is a key pathway through which the confounding effects of childhood abuse are transmitted.
So what do these findings suggest for clinical practice, programming, or policies to prevent violence against women? If depression is causally related to violence, one might consider evidence-based collaborative care management of depression , in order to prevent subsequent experiences of violence. If violence is causally related to depression, one might suggest counseling interventions for women with histories of partner abuse in order to prevent subsequent episodes of depression, but high-quality randomized controlled trials have shown mixed results ,,,. The only randomized trial of universal screening for intimate partner violence yielded null findings . It is possible that screening may exert substantive benefits only in settings where providers also have the ability to refer their clients to a broad array of services (e.g., case management, crisis services, legal advocacy, emergency shelters, transitional housing, and/or parenting and childcare support) , but the effectiveness of such a multipronged approach is as of yet unknown.
This particular gap in the literature redirects our attention to more systemic determinants of the excess burden of violence and depression among women. The simplified conceptual model depicted in Figure 1, informed in part by previously published work ,, suggests not only that violence against women is a consequence of gendered norms about the use violence against intimate partners and power relations ,, but also that its direct and indirect effects serve to reproduce these norms and power relations 23,24,25. The extent to which exposure to violence results in poor mental health outcomes is modified by gendered norms governing how men and women safely negotiate situations of potential danger , as well as by biological differences in physical strength. And finally, poverty offers a hospitable environment for gender-unequal norms , violence against women ,,, and psychological distress , to thrive.
A reduced form of this model might not be obtainable, but at the very least this model suggests that: (a) violence against women may have direct adverse effects on mental health, as suggested by Karen Devries and colleagues ; and, simultaneously, (b) both violence and depression are partly rooted in gender-unequal relations and the unremitting strain of poverty. Meeting this formidable challenge will require complex interventions operating at multiple levels ,. As the epidemiologist Geoffrey Rose succinctly stated in his now-classic work, “Mass diseases and mass exposures require mass remedies”  (p.129). Rose argued that interventions aimed at shifting the entire distribution of disease (rather than interventions aimed at preventing disease in “high-risk” individuals) would yield substantive benefits for population health even if they carry little benefit for a given individual ,. This approach emphasizes the societal changes needed to curtail the production and unequal distribution of violence against women.
With regard to the conceptual model depicted in Figure 1, effective structural interventions would target the conditions that shape women's risks for these co-occurring problems. For example, in one randomized controlled trial conducted in rural South Africa, partnered women who took part in a microfinance intervention experienced a statistically significant decline in intimate partner violence . While the intervention might be considered an “agentic” type of structural intervention that targets individual behavior change ,, it is plausible that participation led to environmental changes on a micro scale, such as improvements in women's bargaining power vis-à-vis their intimate partners. Thus the findings of that study  hint at the possibilities for change on a macro scale. Consistent with their findings, an analysis of macroeconomic data from the US showed that changes in labor market conditions favoring women led to reductions in domestic violence . Related work in India showed that a policy change increasing the number of women in political leadership positions had the effect of weakening stereotypes about gender roles  and raising parental aspirations for their daughters' educational attainment .
It would be imprudent to suggest that Rose's “high-risk” strategy  has no place in violence prevention. The review by Karen Devries and colleagues  reveals major gaps in research on intimate partner violence and depression, including lack of adjustment for childhood sexual abuse or other trauma. A life course perspective, which is missing from much of the research on determinants of violence in general ,, would greatly enrich the field by helping intervention programs better address histories of child abuse and/or family violence in identifying targets for secondary prevention. As we continue to advance the science of developing and testing structural interventions, we should remain vigilant for potential synergies to emerge. Quite likely, the most effective approaches will involve interventions targeting high-risk individuals, complemented with population-based approaches focused on shifting the entire frequency distribution. At this time, the effectiveness of such a combination approach may be speculative. What is clear is that we cannot sit idly by while awaiting Pinker 's long arc of history to avert the persistent psychological scars of violence.
I thank Kristin Hung, Ingrid Katz, Mark Siedner, and Sheri Wieser for helpful comments on an earlier draft of this manuscript.
Contributed to the writing of the manuscript: AT. ICMJE criteria for authorship read and met: AT. Agree with manuscript results and conclusions: AT. Wrote the first draft of the manuscript: AT.
- 1. Pinker S (2011) The better angels of our nature: why violence has declined. New York: Viking Penguin.
- 2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, et al. (2013) A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2224–2260.
- 3. Resnick HS, Acierno R, Kilpatrick DG (1997) Health impact of interpersonal violence. 2: Medical and mental health outcomes. Behav Med 23: 65–78. doi: 10.1080/08964289709596730
- 4. Devries K, Mak J, Bacchus LJ, Child JC, Falder G, et al. (2013) Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS Med 10: e1001439 doi:10.1371/journal.pmed.1001439.
- 5. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, et al. (2009) Setting priorities for global mental health research. Bull World Health Organ 87: 438–446. doi: 10.2471/blt.08.054353
- 6. Tomlinson M, Lund C (2012) Why does mental health not get the attention it deserves? An application of the Shiffman and Smith framework. PLoS Med 9: e1001178 doi:10.1371/journal.pmed.1001178.
- 7. Saxena S, Thornicroft G, Knapp M, Whiteford H (2007) Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370: 878–889. doi: 10.1016/s0140-6736(07)61239-2
- 8. Golding JM (1999) Intimate partner violence as a risk factor for mental disorders: a meta-analysis. J Fam Viol 14: 99–132.
- 9. Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB (2012) Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: a systematic review and meta-analysis. Soc Sci Med 75: 959–975. doi: 10.1016/j.socscimed.2012.04.025
- 10. Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS One 7: e51740. doi: 10.1371/journal.pone.0051740
- 11. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ (2006) Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 166: 2314–2321. doi: 10.1001/archinte.166.21.2314
- 12. Tsai AC, Morton SC, Mangione CM, Keeler EB (2005) A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 11: 478–488.
- 13. Kiely M, El-Mohandes AA, El-Khorazaty MN, Blake SM, Gantz MG (2010) An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstet Gynecol 115: 273–283. doi: 10.1097/aog.0b013e3181cbd482
- 14. El-Mohandes AA, Kiely M, Joseph JG, Subramanian S, Johnson AA, et al. (2008) An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol 112: 611–620. doi: 10.1097/aog.0b013e3181834b10
- 15. Taft AJ, Small R, Hegarty KL, Watson LF, Gold L, et al. (2011) Mothers' AdvocateS In the Community (MOSAIC)–non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care. BMC Public Health 11: 178. doi: 10.1186/1471-2458-11-178
- 16. Tiwari A, Fong DY, Yuen KH, Yuk H, Pang P, et al. (2010) Effect of an advocacy intervention on mental health in Chinese women survivors of intimate partner violence: a randomized controlled trial. JAMA 304: 536–543. doi: 10.1001/jama.2010.1052
- 17. MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, et al. (2009) Screening for intimate partner violence in health care settings: a randomized trial. JAMA 302: 493–501. doi: 10.1001/jama.2009.1089
- 18. Spangaro J, Zwi AB, Poulos R (2009) The elusive search for definitive evidence on routine screening for intimate partner violence. Trauma Violence Abuse 10: 55–68. doi: 10.1177/1524838008327261
- 19. Krieger N (2003) Genders, sexes, and health: what are the connections–and why does it matter? Int J Epidemiol 32: 652–657. doi: 10.1093/ije/dyg156
- 20. Jewkes R (2002) Intimate partner violence: causes and prevention. Lancet 359: 1423–1429. doi: 10.1016/s0140-6736(02)08357-5
- 21. Shannon K, Leiter K, Phaladze N, Hlanze Z, Tsai AC, et al. (2012) Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PLoS One 7: e28739. doi: 10.1371/journal.pone.0028739
- 22. Bourgois P (1996) In search of respect: selling crack in El Barrio. 1st ed. Cambridge: Cambridge University Press.
- 23. Tsai AC, Subramanian SV (2012) Proximate context of gender-unequal norms and women's HIV risk in sub-Saharan Africa. AIDS 26: 381–386. doi: 10.1097/qad.0b013e32834e1ccb
- 24. Hung KJ, Scott J, Ricciotti HA, Johnson TR, Tsai AC (2012) Community-level and individual-level influences of intimate partner violence on birth spacing in sub-saharan Africa. Obstet Gynecol 119: 975–982. doi: 10.1097/aog.0b013e31824fc9a0
- 25. Pallitto CC, O'Campo P (2005) Community level effects of gender inequality on intimate partner violence and unintended pregnancy in Colombia: testing the feminist perspective. Soc Sci Med 60: 2205–2216. doi: 10.1016/j.socscimed.2004.10.017
- 26. Connell RW (1987) Gender and power. Palo Alto: Stanford University Press.
- 27. Blanc AK (2001) The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Stud Fam Plann 32: 189–213. doi: 10.1111/j.1728-4465.2001.00189.x
- 28. Uthman OA, Moradi T, Lawoko S (2009) The independent contribution of individual-, neighbourhood-, and country-level socioeconomic position on attitudes towards intimate partner violence against women in sub-Saharan Africa: a multilevel model of direct and moderating effects. Soc Sci Med 68: 1801–1809. doi: 10.1016/j.socscimed.2009.02.045
- 29. Tsai AC, Leiter K, Wolfe WR, Heisler M, Shannon K, et al. (2011) Prevalence and correlates of forced sex perpetration and victimization in Botswana and Swaziland. Am J Pub Health 101: 1068–1074. doi: 10.2105/ajph.2010.300060
- 30. Cunradi CB, Caetano R, Clark C, Schafer J (2000) Neighborhood poverty as a predictor of intimate partner violence among White, Black, and Hispanic couples in the United States: a multilevel analysis. Ann Epidemiol 10: 297–308. doi: 10.1016/s1047-2797(00)00052-1
- 31. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, et al. (2010) Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med 71: 517–528. doi: 10.1016/j.socscimed.2010.04.027
- 32. Riley ED, Moore K, Sorensen JL, Tulsky JP, Bangsberg DR, et al. (2011) Basic subsistence needs and overall health among human immunodeficiency virus-infected homeless and unstably housed women. Am J Epidemiol 174: 515–522. doi: 10.1093/aje/kwr209
- 33. Krieger N (2008) Proximal, distal, and the politics of causation: what's level got to do with it? Am J Public Health 98: 221–230. doi: 10.2105/ajph.2007.111278
- 34. Krieger N (1994) Epidemiology and the web of causation: has anyone seen the spider? Soc Sci Med 39: 887–903. doi: 10.1016/0277-9536(94)90202-x
- 35. Rose G (2008) Rose's strategy of preventive medicine. New York: Oxford University Press, Inc.
- 36. Rose G (1985) Sick individuals and sick populations. Int J Epidemiol 14: 32–38. doi: 10.1093/ije/14.1.32
- 37. Rose G (1981) Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 282: 1847–1851. doi: 10.1136/bmj.282.6279.1847
- 38. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, et al. (2006) Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 368: 1973–1983. doi: 10.1016/s0140-6736(06)69744-4
- 39. McLaren L, McIntyre L, Kirkpatrick S (2010) Rose's population strategy of prevention need not increase social inequalities in health. Int J Epidemiol 39: 372–377. doi: 10.1093/ije/dyp315
- 40. Tsai AC (2012) A typology of structural approaches to HIV prevention: a commentary on Roberts and Matthews. Soc Sci Med 75: 1562–1567 discussion 1568–1571. doi: 10.1016/j.socscimed.2012.06.033
- 41. Aizer A (2010) The gender wage gap and domestic violence. Am Econ Rev 100: 1847–1859. doi: 10.1257/aer.100.4.1847
- 42. Beaman L, Chattopadhyay R, Duflo E, Pande R, Topalova P (2009) Powerful women: does exposure reduce bias? Q J Econ 124: 1497–1540. doi: 10.1162/qjec.2009.124.4.1497
- 43. Beaman L, Duflo E, Pande R, Topalova P (2012) Female leadership raises aspirations and educational attainment for girls: a policy experiment in India. Science 335: 582–586. doi: 10.1126/science.1212382
- 44. Giordano PC, Schroeder RD, Cernkovich SA (2007) Emotions and crime over the life coruse: a neo-Meadian perspective on criminal continuity and change. Am J Sociol 112: 1603–1661. doi: 10.1086/512710
- 45. Ehrensaft MK, Cohen P, Brown J, Smailes E, Chen H, Johnson JG (2003) Intergenerational transmission of partner violence: a 20-year prospective study. J Consult Clin Psychol 71: 741–753. doi: 10.1037/0022-006x.71.4.741