Effect of cognitive therapy on depression in rural, battered women

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

Evaluating co-occurrence of depression and sexual dysfunction and related factors among Iranian rural women: A population-based study

Background and objectives

Sexual dysfunction and mood disorders have a high prevalence rate and their co-occurrence has been reported in previous studies. This study aimed to determine the prevalence of co-occurrence of sexual dysfunction and depression and related factors in women.

Materials and methods

This descriptive-analytical study was carried out on 826 married rural women aged 15-49 years in Sari, Iran in 2018, selected by random sampling. The participants filled the demographic and fertility questionnaires, as well as Beck's Depression Inventory and Female Sexual Function Index (FSFI).

Results

In this study, 18% of the participants experienced the co-occurrence of depression and sexual dysfunction. In addition, results of the multiple logistic regression showed that forced marriage (OR = 0.31, CI 95%: 0.15 to 0.64, P < 0.001), a one-level increase in the education of the spouse (OR = 0.76, CI 95%: 0.59 to 0.98, P < 0.041), lack of history of depression (OR = 0.36, CI 95%: 0.20 to 0.66, P < 0.001) and lack of vaginal infection (OR = 0.41, CI 95%: 0.27 to 0.62, P < 0.001) were considered as factors contributing to a decline in the co-occurrence of depression and sexual dysfunction. On the other hand, not having a private bedroom (OR = 1.63, CI 95%: 1.09 to 2.43, P < 0.017), no vehicle (OR = 1.52, CI 95%: 1.02 to 2.27, P < 0.038), a history of sychiatric diseases (OR = 2.09, CI 95%: 1.2.0 to 3.65, P < 0.009), lack of chronic diseases (OR = 2.11, CI 95%: 1.03 to 4.31, P = 0.039) and lack of use of antidepressants (OR = 2.03, CI 95%: 2.03 to 1.03, P < 0.039) increased the co-occurrence of depression and sexual dysfunction.

Conclusion

According to the results of the study, about one-fifth of the married rural women experienced the co-occurrence of depression and sexual dysfunction. If healthcare providers detect one of the disorders of depression or sexual dysfunction in a patient, it is suggested that the person be assessed in terms of the other disorder and the proper treatment be applied. Furthermore, the healthcare personnel must pay attention to factors related to the co-occurrence of these disorders in addition to providing a treatment program.

The efficacy of cognitive behavioural therapy and advocacy interventions for women who have experienced intimate partner violence: a systematic review and meta-analysis

OBJECTIVE

To determine the efficacy of Advocacy and Cognitive Behavioural Therapy interventions (CBT) in reducing physical, psychological, sexual, or any intimate partner violence (IPV).

METHODS

A systematic review and meta-analysis were conducted using randomized control trials (RCTs) published in MEDLINE, PsycINFO, Scopus, Cochrane, and Clinical trials. The occurrence of physical, psychological, sexual, and/or any IPV measured efficacy.

RESULTS

Twelve RCTs involving 2666 participants were included. Advocacy interventions resulted in significant reductions in physical (standardized mean difference (SMD) -0.13; 95% confidence interval (CI) -0.25, -0.00) and psychological (SMD -0.19; 95% CI -0.32, -0.05) but not in sexual (SMD -0.20; 95% CI -0.43, 0.02) or any IPV (SMD -0.32; 95% CI -0.69, 0.04). CBT interventions showed a significant reduction in physical (SMD -0.79; 95% CI -1.26, -0.33) and psychological (SMD -0.80; 95% CI -1.25, -0.36) but not sexual (SMD -0.35; 95% CI -1.73, 1.03) or any IPV (SMD 0.09; 95% CI -0.05, 0.23).

CONCLUSIONS

Both advocacy and CBT interventions reduced physical and psychological IPV but not sexual or any IPV. Limitations include the low number of studies and the heterogeneity of interventions.

Invited commentary: disclosure of gender-based violence in developing countries

The evolving concept of gender-based violence (GBV) is a multifaceted issue of public health significance. Until recently, most studies examining GBV have been conducted in North America. In this issue of the Journal, Palermo et al. (Am J Epidemiol. 2014;179(5):602-612) report their secondary analyses involving approximately 300,000 women from 24 developing countries who participated in Demographic and Health Surveys between 2004 and 2011. The focus of their article is on the prevalence and determinants of disclosure of GBV to formal authorities, including health care or legal professionals, police, and nongovernmental organizations. Their results indicate a wide gap between prevalence of GBV (40%) and GBV disclosure (7%), implying an underestimation of GBV that ranges from 11- to 128-fold, depending on the region and type of reporting. The extent of underreporting of GBV also varied according to personal characteristics such as age, marital status and urban or rural residence. GBV has been linked to a myriad of health problems, and it has been shown that health care utilization is considerably higher among women who have experienced GBV. Primary and secondary prevention efforts should continue to target GBV, and creative ways of addressing GBV nondisclosure should take into account regional variations and personal characteristics of affected women.

Partner violence, depression, and recidivism: the case of incarcerated women and why we need programs designed for them

The number of women in prison in the United States has been growing rapidly over the last 30 years. A large percentage of the incarcerated women have been victimized by violent partners and family members. Some of these women have been forced with threats of violence by their abusers to participate in illegal activities. Most of the women have children and many of the women will never see their children while in prison. Incarcerated women who have experienced intimate partner violence are at risk for depression, posttraumatic stress disorder, anxiety, substance abuse, and suicide. Recidivism for women prisoners is associated with depression. In spite of the cost of recidivism and the growing overcrowded conditions in women's prisons, there are no known studies in the literature that test the effectiveness of a gender-sensitive intervention to reduce depression in incarcerated women as a means of reducing recidivism. The purpose of this paper is to illuminate the need for an effective cognitive therapy program that is designed specifically to reduce women's depression by raising awareness of inherited negative messages, affirmation of self and others, and empowerment through goal setting. The INSIGHT program is introduced as an example of a gender-sensitive program.

Hope and interpersonal psychiatric/mental health nursing: a systematic review of the literature--part one

Psychiatric/mental health (P/MH) nursing is inherently an interpersonal endeavour; one that includes a broad range of 'helping activities'. The interpersonal activities and skills are enshrined in our underpinning philosophy, explored and learned in our curricula (all around the world) and enacted in our everyday clinical practice. Within this interpersonal context and framework, it is heartening to see that understated, abstract and yet-lasting concepts such as hope are gaining more acknowledgement, recognition and subsequently attention. While it is recognized that hope in mental health care is increasingly becoming the focal point of disciplined inquiry, the authors believe it is perhaps necessary and timely to re-examine these two concepts, namely: interpersonal P/MH nursing and hope/inspiring hope in people with mental health problems. Accordingly, this two-part article reports on a systematic review of the literature that focuses on hope (inspiring hope) within interpersonal (counselling) focused P/MH nursing. Part one focuses on the method used and the results, indicating that a total of 57 articles were included in the review: 39 were categorized as empirical studies involving either a quantitative or qualitative methodological design, and 18 were considered theoretical/clinical/review articles. Though not a product of an empirical investigation per se, it was clear that many of the articles shared and covered common ground. Thus, these were arranged into six 'loose' thematic groupings. The first three of these areas, schizophrenia, suicidality and depression form the remainder of part one of this article, and the remaining areas are included in part two.

Meaning of INSIGHT participation among women who have experienced intimate partner violence

This phenomenological study explored the meaning that women with violent partners found in participating in a 20-week group cognitive therapy program called INSIGHT. Through a two-step interview process, ten women who had experienced intimate partner violence described what it meant to them to decide to participate in INSIGHT; what was meaningful about the program; and what influence the program had on their lives. Findings indicated an overarching theme that described a process of Rescuing Self. This study adds support for the utility of interventions, such as INSIGHT, that nurture self-emergence among women who have experienced intimate partner violence.

The evaluation of cognitive-behavioral group therapy on patient depression and self-esteem

We evaluated the impact of cognitive-behavioral group therapy on the depression and self-esteem of clinically depressed patients. This longitudinal study involved 26 experimental group patients who received 12 weeks of cognitive-behavioral group therapy and 25 comparison subjects. Two weeks before the study, immediately upon therapy completion, and 1 month later, all the participants underwent pretest, posttest, and follow-up, respectively. The experimental group patients experienced greater cognitive improvements (i.e., depression relief, self-esteem increase) as compared with the comparison group subjects. One month after therapy completion, the depressive symptoms and self-esteem of the experimental group patients remained slightly but significantly better than those of the comparison group subjects.

Instrument development of the self-efficacy scale for abused women

The development of a scale to measure an abused woman's self-efficacy is described. The Self-Efficacy Scale for Abused Women (SESAW) originally was a 27-item 100-mm visual analog scale. It underwent face and content validity testing and was administered to a community sample of abused women (N = 50). The SESAW was tested for internal consistency, test-retest reliability, and construct validity. Cronbach's alphas were.95 and.96 at times 1 and 2, respectively. The bivariate correlation between the SESAW at times 1 and 2 was r =.85, p <.01. Construct validity was established by a moderate bivariate correlation with the criterion as measured by the Self-Efficacy Scale-general/global subscale (r =.64, p <.01 at time 1, and r =.78, p <.01 at time 2). The SESAW was streamlined to 19 items. The SESAW is an acceptable measure of situation-specific self-efficacy in community-based abused women.