Siân Oram

Experiences of domestic violence and mental disorders: a systematic review and meta-analysis.

Background Little is known about the extent to which being a victim of domestic violence is associated with different mental disorders in men and women. We aimed to estimate the prevalence and odds of being a victim of domestic violence by diagnostic category and sex. Methods Study design: Systematic review and meta-analysis. Data Sources: Eighteen biomedical and social sciences databases (including MEDLINE, EMBASE, PsycINFO); journal hand searches; scrutiny of references and citation tracking of included articles; expert recommendations, and an update of a systematic review on victimisation and mental disorder. Inclusion criteria: observational and intervention studies reporting prevalence or odds of being a victim of domestic violence in men and women (aged ≥16 years), using validated diagnostic measures of mental disorder. Procedure: Data were extracted and study quality independently appraised by two reviewers. Analysis: Random effects meta-analyses were used to pool estimates of prevalence and odds. Results Forty-one studies were included. There is a higher risk of experiencing adult lifetime partner violence among women with depressive disorders (OR 2.77 (95% CI 1.96–3.92), anxiety disorders (OR 4.08 (95% CI 2.39–6.97), and PTSD (OR 7.34 95% CI 4.50–11.98), compared to women without mental disorders. Insufficient data were available to calculate pooled odds for other mental disorders, family violence (i.e. violence perpetrated by a non-partner), or violence experienced by men. Individual studies reported increased odds for women and men for all diagnostic categories, including psychoses, with a higher prevalence reported for women. Few longitudinal studies were found so the direction of causality could not be investigated. Conclusions There is a high prevalence and increased likelihood of being a victim of domestic violence in men and women across all diagnostic categories, compared to people without disorders. Longitudinal studies are needed to identify pathways to being a victim of domestic violence to optimise healthcare responses.

Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review

Siân Oram and colleagues conduct a systematic review of the evidence on the health consequences of human trafficking. They describe a limited and poor-quality evidence base, but some evidence suggests a high prevalence of violence and mental distress among women and girls trafficked for sexual exploitation, among other findings.

Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study.

BackgroundPrevious studies have found high levels of symptoms of depression, anxiety, and post-traumatic stress disorder among women survivors of human trafficking. No previous research has described risk factors for diagnosed mental disorders in this population.MethodsA historical cohort study of women survivors of trafficked women aged 18 and over who returned to Moldova and registered for assistance with the International Organisation for Migration (IOM). Women were approached by IOM social workers and, if they gave informed consented to participate in the study, interviewed by the research team. At 2–12 months post-return to Moldova, a psychiatrist assessed DSM-IV mental disorders blind to information about women’s pre-trafficking and post-trafficking experiences using the Structured Clinical Interview for DSM-IV (SCID). A backwards stepwise selection procedure was used to create a multivariable regression model of risk factors for DSM-IV mental disorder measured at an average of 6 months post-return.Results120/176 (68%) eligible women participated. At an average of 6 months post-return, 54% met criteria for any DSM-IV mental disorder: 35.8% of women had PTSD (alone or co-morbid), 12.5% had depression without PTSD and 5.8% had another anxiety disorder. Multivariable regression analysis found that childhood sexual abuse (Adjusted Odds Ratio [AOR] 4.68, 95% CI 1.04-20.92), increased number of post-trafficking unmet needs (AOR 1.80; 95% CI 1.28-2.52) and post-trafficking social support (AOR 0.64; 95% CI 0.52-0.79) were independent risk factors for mental disorder, and that duration of trafficking showed a borderline association with mental disorder (AOR 1.12, 95% CI 0.98-1.29).ConclusionsAssessment for mental disorders should be part of re-integration follow-up care for women survivors of human trafficking. Mental disorders at that time, most commonly PTSD and depression, are likely to be influenced by a range of predisposing, precipitating and maintaining factors. Care plans for survivors of trafficking must be based on individual needs, and must apply clinical guidelines for the treatment of PTSD and of depression. Evidence is needed on the effectiveness of therapy for PTSD in survivors of human trafficking.

Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review.

BACKGROUND To update and expand on a 2012 systematic review of the prevalence and risk of violence and the prevalence and risk of physical, mental and sexual health problems among trafficked people. METHOD Systematic review and meta-analysis. Searches of 15 electronic databases of peer-reviewed articles and doctoral theses were supplemented by reference screening, citation tracking of included articles and expert recommendations. Studies were included if they reported on the prevalence or risk of violence while trafficked, or the prevalence or risk of physical, mental or sexual health outcomes among people who have been trafficked. Two reviewers independently screened papers for eligibility and appraised the quality of included studies. RESULTS Thirty-seven papers reporting on 31 studies were identified. The majority of studies were conducted in low and middle-income countries with women and girls trafficked into the sex industry. There is limited but emerging evidence on the health of trafficked men and the health consequences of trafficking into different forms of exploitation. Studies indicate that trafficked women, men and children experience high levels of violence and report significant levels of physical health symptoms, including headaches, stomach pain and back pain. Most commonly reported mental health problems include depression, anxiety and post-traumatic stress disorder. Although serological data on sexually transmitted infections are limited, women and girls trafficked for sexual exploitation self-report symptoms suggestive of a high prevalence of infections. Limitations of the review include methodological weaknesses of primary studies and some differences in definition and operationalisation of trafficking, which hinder comparability and generalisability of the results. CONCLUSIONS There is increasing evidence human trafficking is associated with high prevalence and increased risk of violence and a range of physical and mental health problems. Although more studies have emerged in recent years reporting on the health of trafficked men and people trafficked for forms of exploitation other than in the sex industry, further research is needed in this area. Appropriate interventions and support services to address the multiple and serious medical needs, especially mental health, of trafficked people are urgently needed.

Prevalence and risk of experiences of intimate partner violence among people with eating disorders: A systematic review

OBJECTIVES To estimate the prevalence and risk of lifetime and past year intimate partner violence (IPV) among males and females with eating disorders. METHODS Systematic review. We searched 15 electronic databases, supplemented by hand searching, citation tracking, updating a review on victimisation and mental disorder and expert recommendations. RESULTS Eight papers were included, involving 6775 females and 4857 males. Individual studies reported that eating disorders are associated with a high prevalence and increased odds of lifetime IPV among both males and females. Evidence is lacking on eating disorder and past year IPV, on whether associations between eating disorder and IPV vary by type of IPV, and temporality. DISCUSSION More research is needed to investigate the strength and nature of the association between eating disorders and IPV, including with regards to the direction of causality between eating disorders and IPV, and whether associations are mediated by childhood abuse.

Mental illness and domestic homicide: a population-based descriptive study

OBJECTIVE Approximately 10% of convicted homicide perpetrators in England and Wales have symptoms of mental illness at the time of homicide. The prevalence among perpetrators of adult domestic homicide is unclear. METHODS The study was a consecutive case series of all convicted adult domestic homicide perpetrators in England and Wales between 1997 and 2008. Sociodemographic, clinical, and offense characteristics were gathered from the United Kingdom Home Office, the Police National Computer, psychiatric court reports, and, for psychiatric patients, questionnaires completed by supervising clinicians. RESULTS A total of 1,180 perpetrators were convicted of intimate partner homicide, and 251 were convicted of homicide of an adult family member. Fourteen percent of perpetrators of intimate partner homicide and 23% of perpetrators of adult family homicide had been in contact with mental health services in the year before the offense; 20% of intimate partner homicide perpetrators and 34% of adult family homicide perpetrators had symptoms of mental illness at the time of offense. Perpetrators with symptoms of mental illness at the time of offense were less likely than perpetrators without symptoms to have previous violence convictions or history of alcohol abuse. CONCLUSIONS A significant minority of adult domestic homicide perpetrators had symptoms of mental illness at the time of the homicide. Most perpetrators, including those with mental illnesses, were not in contact with mental health services in the year before the offense. Risk reduction could be achieved through initiatives that encourage individuals with mental health problems to access mental health services and that develop closer interagency working, including between mental health services, police, social services, and domestic violence services.

Responding to the health needs of survivors of human trafficking: a systematic review

BackgroundDespite the multiple physical and psychological health consequences associated with human trafficking, there is little evidence-based guidance available for health providers on assessing and meeting the health needs of trafficked people. We aimed to review literature that provided guidance or research on care provision for people who had been trafficked.MethodsWe conducted a systematic review and qualitative analysis of peer-reviewed and grey literature. Data sources included electronic databases, reference list screening, citation tracking, and expert recommendations. Documents were included if they reported on: 1) male or females (adults or children) who were currently or had previously been trafficked; 2) health interventions or service provision; 3) primary, secondary, tertiary or specialist post-trafficking services; and 4) World Bank high income countries. Two reviewers independently screened and quality appraised documents. Framework analysis was used to analyse extracted data.ResultsForty-four documents were included, 19 of which reported findings of primary studies and nine of which exclusively addressed children. Evidence to inform the identification, referral and care of trafficked people is extremely limited. Within current literature on survivor identification, key indicators included signs of physical and sexual abuse, absence of documentation, and being accompanied by a controlling companion. Findings highlighted the importance of interviewing possible victims in private, using professional interpreters, and building trust. For provision of care, key themes included the importance of comprehensive needs assessments, adhering to principles of trauma-informed care, and cultural sensitivity. Further prominent themes were the necessity of multi-agency working strategies and well-defined referral pathways.ConclusionsHuman trafficking survivors require healthcare that is trauma-informed and culturally sensitive to their particular needs. Coordination is needed between health providers and statutory and voluntary organisations. Future research should generate empirical evidence to develop trafficking indicators for use by health providers, alongside validated screening tools, and evaluate the effectiveness of psychological interventions.

Meeting the health needs of trafficked persons

International guidance provides advice on safe and appropriate treatment

The health needs and healthcare experiences of young people trafficked into the UK

Young people who have been trafficked may have experienced significant trauma and violence but little is known about their health and healthcare needs. This UK study aimed to address that gap. It included a health survey and qualitative interviews with 29 young people aged 16–21 trafficked into the UK from other countries who were recruited through voluntary organisations and children’s social services. These data were supplemented by interviews with relevant professionals. Over half the young people had been trafficked for sex work but sexual violence had also been experienced by those trafficked for domestic servitude and labour exploitation. Physical violence, threats, restrictions of liberty and deprivation were also widespread, as were experiences of physical and sexual violence prior to being trafficked. Five young women had become pregnant whilst trafficked; three were parents when interviewed. Two-thirds screened positive for high levels of psychological distress, including PTSD. Twelve reported suicidal thinking. Whilst some were keen for opportunities to talk to health professionals confidentially and wanted practitioners to treat their accounts as credible, others wanted to forget abusive experiences. Complex gatekeeping systems, language barriers and practitioners who failed to take them seriously limited access to healthcare. Support and advocacy were helpful in assisting these young people to navigate healthcare systems. Health professionals need to recognise and respond appropriately to trafficked young people’s often complex mental health needs and refer them to relevant services, as well as facilitating care at later times when they might need support or be more ready to receive help.

Improving mental health service responses to domestic violence and abuse

Abstract Domestic violence and abuse is a considerable international public health problem, which is associated with mental disorders in both women and men. Nevertheless, victimization and perpetration remain undetected by mental health services. This paper reviews the evidence on mental health service responses to domestic violence, including identifying, referring, and providing care for people experiencing or perpetrating violence. The review highlights the need for mental health services to improve rates of identification and responses to domestic violence and abuse, through the provision of specific training on domestic violence and abuse, the implementation of clear information sharing protocols and evidence-based interventions, and the establishment of care referral pathways. This review also highlights the need for further research into mental health service users who perpetrate domestic violence and abuse.