Psychological interventions for common mental disorders in women experiencing intimate partner violence in low-income and middle-income countries: a systematic review and meta-analysis

Abstract

Background: Evidence on the effectiveness of psychological interventions for women with common mental disorders (CMDs) who also experience intimate partner violence is scarce. We aimed to test our hypothesis that exposure to intimate partner violence would reduce intervention effectiveness for CMDs in low-income and middle-income countries (LMICs).

Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, trials registries, 3ie, Google Scholar, and forward and backward citations for studies published between database inception and Aug 16, 2019. All randomised controlled trials (RCTs) of psychological interventions for CMDs in LMICs which measured intimate partner violence were included, without language or date restrictions. We approached study authors to obtain unpublished aggregate subgroup data for women who did and did not report intimate partner violence. We did separate random-effects meta-analyses for anxiety, depression, post-traumatic stress disorder (PTSD), and psychological distress outcomes. Evidence from randomised controlled trials was synthesised as differences between standardised mean differences (SMDs) for change in symptoms, comparing women who did and who did not report intimate partner violence via random-effects meta-analyses. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42017078611.

Findings: Of 8122 records identified, 21 were eligible and data were available for 15 RCTs, all of which had a low to moderate risk of overall bias. Anxiety (five interventions, 728 participants) showed a greater response to intervention among women reporting intimate partner violence than among those who did not (difference in standardised mean differences [dSMD] 0·31, 95% CI 0·04 to 0·57, I²=49·4%). No differences in response to intervention were seen in women reporting intimate partner violence for PTSD (eight interventions, n=1436; dSMD 0·14, 95% CI -0·06 to 0·33, I²=42·6%), depression (12 interventions, n=2940; 0·10, -0·04 to 0·25, I²=49·3%), and psychological distress (four interventions, n=1591; 0·07, -0·05 to 0·18, I²=0·0%, p=0·681).

Interpretation: Psychological interventions treat anxiety effectively in women with current or recent intimate partner violence exposure in LMICs when delivered by appropriately trained and supervised health-care staff, even when not tailored for this population or targeting intimate partner violence directly. Future research should investigate whether adapting evidence-based psychological interventions for CMDs to address intimate partner violence enhances their acceptability, feasibility, and effectiveness in LMICs.

Funding: UK National Institute for Health Research ASSET and King's IoPPN Clinician Investigator Scholarship.

Figure 1

Study selection We followed PRISMA guidelines (appendix pp 17–18). Two of the 15 records were three-group studies and thus provided two data comparisons for meta-analysis. Three of the 15 records reported one of the already included 12 studies. RCT=randomised controlled trial. HIC=high-income country. CMD=common mental disorder.

Figure 2

Random-effects meta-analyses of the difference in psychological intervention study effect sizes (via SMD) between women who did and women who did not report exposure to IPV Data are for women with anxiety (A), PTSD (B), depression (C), and psychological distress (D) symptoms. dSMD=difference in standardised mean differences. IPV=intimate partner violence.

Figure 3

Random-effects meta-analyses of the difference in psychological intervention study effect sizes (via SMD) for depression symptoms between women who did and women who did not report exposure to IPV, by residential setting dSMD=difference in standardised mean differences. IPV=intimate partner violence.

Figure 4

Random-effects meta-analyses of the difference in psychological intervention study effect sizes (via SMD) between women who did and women who did not report exposure to IPV, by number of treatment sessions Data are for women with PTSD (A) and anxiety (B) symptoms. The difference in anxiety symptoms was affected by location (more sessions offered in rural locations) and exposure to conflict (more sessions offered to conflict-exposed populations). For anxiety symptoms, none of the studies offered 7–10 sessions. dSMD=difference in standardised mean differences. IPV=intimate partner violence. PTSD=post-traumatic stress disorder.