An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial.

BACKGROUND: Depression is a common antenatal mental disorder associated with significant maternal morbidity and adverse fetal outcomes. However, there is a lack of research on the effectiveness or cost-effectiveness of psychological interventions for antenatal depression. METHODS: A parallel-group, exploratory randomised controlled trial across five hospitals. The trial compared Guided Self-Help, modified for pregnancy, plus usual care with usual care alone for pregnant women meeting DSM-IV criteria for mild-moderate depression. The trial objectives were to establish recruitment/follow-up rates, compliance and acceptability, and to provide preliminary evidence of intervention efficacy and cost-effectiveness. The primary outcome of depressive symptoms was assessed by blinded researchers using the Edinburgh Postnatal Depression Scale at 14-weeks post-randomisation. RESULTS: 620 women were screened, 114 women were eligible and 53 (46.5%) were randomised. 26 women received Guided Self-Help - 18 (69%) attending ≥4 sessions - and 27 usual care; n = 3 women were lost to follow-up (follow-up rate for primary outcome 92%). Women receiving Guided Self-Help reported fewer depressive symptoms at follow-up than women receiving usual care (adjusted effect size -0.64 (95%CI: -1.30, 0.06) p = 0.07). There were no trial-related adverse events. The cost-effectiveness acceptability curve showed the probability of Guided Self-Help being cost-effective compared with usual care ranged from 10 to 50% with a willingness-to-pay range from £0 to £50,000. CONCLUSIONS AND LIMITATIONS: Despite intense efforts we did not meet our anticipated recruitment target. However, high levels of acceptability, a lack of adverse events and a trend towards improvements in symptoms of depression post-treatment indicates this intervention is suitable for talking therapy services.

Systematic review and meta-analysis of psychiatric disorder and the perpetration of partner violence.

Backgrounds. The extent to which psychiatric disorders are associated with an increased risk of violence to partners is unclear. This review aimed to establish risk of violence against partners among men and women with diagnosed psychiatric disorders. Methods. Systematic review and meta-analysis. Searches of eleven electronic databases were supplemented by hand searching, reference screening and citation tracking of included articles, and expert recommendations. Results. Seventeen studies were included, reporting on 72 585 participants, but only three reported on past year violence. Pooled risk estimates could not be calculated for past year violence against a partner and the three studies did not consistently report increased risk for any diagnosis. Pooled estimates showed an increased risk of having ever been physically violent towards a partner among men with depression (odds ratio (OR) 2.8, 95% confidence intervals (CI) 2.5-3.3), generalized anxiety disorder (GAD) (OR 3.2, 95% CI 2.3-4.4) and panic disorder (OR 2.5, 95% CI C% 1.7-3.6). Increased risk was also found among women with depression (OR 2.4, 95% CI 2.1-2.8), GAD (OR 2.4, 95% CI 1.9-3.0) and panic disorder (OR 1.9, 95% CI 1.4-2.5). Conclusions. Psychiatric disorders are associated with high prevalence and increased odds of having ever been physically violent against a partner. As history of violence is a predictor of current violence, mental health professionals should ask about previous partner violence when assessing risk.

Linking abuse and recovery through advocacy: an observational study.

Aims. High numbers of psychiatric service users experience domestic violence, yet limited interventions exist for these victims. We piloted a domestic violence intervention for community mental health services to explore the feasibility of a future cluster randomized controlled trial. Methods. Quasi-experimental controlled design within five Community Mental Health Teams (three intervention and two control teams). The intervention comprised domestic violence training for clinicians' and referral to domestic violence advocacy for service users. Clinicians' (n = 29) domestic violence knowledge, attitudes and behaviours were assessed before and 6 months post-training. Service users' (n = 34) safety behaviours, unmet needs, quality of life and frequency/severity of abuse were examined at baseline and 3 months follow-up. Process evaluation data were also collected. Results. Clinicians receiving the intervention reported significant improvements in domestic violence knowledge, attitudes and behaviours at follow-up (p < 0.05). Service users receiving the intervention reported significant reductions in violence (p < 0.001) and unmet needs at follow-up (p < 0.05). Conclusions. Interventions comprising domestic violence training for clinicians and referral to domestic violence advocacy may improve responses of psychiatric services. Low rates of identification among teams not receiving training suggest that future trials using service user outcomes are unlikely to be feasible. Therefore, other methods of evaluation are needed.

Prevalence of experiences of domestic violence among psychiatric patients: systematic review.

BACKGROUND: Domestic violence has been linked with many mental disorders, including anxiety, depression, post-traumatic stress disorder, eating disorders and psychosis. AIMS: To estimate the prevalence (adult lifetime and past year) of different types of domestic violence experienced by men and women receiving psychiatric treatment. METHOD: In a systematic review, a search of 18 electronic databases was supplemented by hand searching, citation tracking and updating a recent systematic review of criminal victimisation in psychiatric populations. Two reviewers independently extracted data and appraised study quality. RESULTS: Forty-two studies were included. The median prevalence of lifetime partner violence reported in high-quality papers was 30% (interquartile range (IQR) 26-39) among female in-patients and 33% (IQR 21-53) among female out-patients. Among male patients, one high-quality study reported a lifetime prevalence of 32% across mixed psychiatric settings. No study included a control group. CONCLUSIONS: Psychiatric patients experience a high prevalence of domestic violence but there is limited information on family (non-partner) domestic violence, the prevalence of emotional abuse and the extent of risk compared with non-psychiatric controls.

Domestic violence and severe psychiatric disorders: prevalence and interventions.

BACKGROUND: The lifetime prevalence of domestic violence in women is 20-25%. There is increasing recognition of the increased vulnerability of psychiatric populations to domestic violence. We therefore aimed to review studies on the prevalence of, and the evidence for the effectiveness of interventions in, psychiatric patients experiencing domestic violence. METHOD: Literature search using Medline, PsycINFO and EMBASE applying the following inclusion criteria: English-language papers, data provided on the prevalence of or interventions for domestic violence, adults in contact with mental health services. RESULTS: Reported lifetime prevalence of severe domestic violence among psychiatric in-patients ranged from 30% to 60%. Lower rates are reported for men when prevalence is reported by gender. No controlled studies were identified. Low rates of detection of domestic violence occur in routine clinical practice and there is some evidence that, when routine enquiry is introduced into services, detection rates improve, but identification of domestic violence is rarely used in treatment planning. There is a lack of evidence on the effectiveness of routine enquiry in terms of morbidity and mortality, and there have been no studies investigating specific domestic violence interventions for psychiatric patients. CONCLUSIONS: There is a high prevalence of domestic violence in psychiatric populations but the extent of the increased risk in psychiatric patients compared with other populations is not clear because of the limitations of the methodology used in the studies identified. There is also very limited evidence on how to address domestic violence with respect to the identification and provision of evidence-based interventions in mental health services.