Psychological advocacy towards healing (PATH): A parallel group individually randomised controlled trial of a psychological intervention for survivors of domestic violence and abuse

Conference: 
SAPC ASM 2015 - Oxford - Evidence and innovation in primary care
Talk Code: 
4D.3

The problem

Experience of domestic violence and abuse (DVA) is associated with short and long term mental illness, particularly depression, anxiety and post-traumatic stress disorder (PTSD). Advocacy has little impact on mental health outcomes of female survivors of DVA and there is uncertainty about the effectiveness of psychological interventions for this population, particularly if the abuse is relatively recent.

The approach

To test the effectiveness of a psychological intervention delivered by advocates to survivors of DVA, we conducted a pragmatic parallel group individually randomised controlled trial of normal advocacy vs. advocacy + psychological intervention (eight specialist psychological advocacy sessions with two follow up sessions). Primary outcomes at 12 months: Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures included anxiety (GAD-7), posttraumatic stress (PTSD checklist), severity and frequency of abuse (CAS). Primary analysis: intention to treat regression model. Secondary analysis: using multiple imputation by chained equations for missing data; instrumental variable analysis. Setting: specialist DVA agencies in two British cities. Participants: Women aged 16 years and older accessing DVA services. Exclusion criteria: attending counselling or other psychological treatments, active psychotic illness, severe drug and alcohol problems, unable to read English.

Findings

263 women recruited (78 in refuge, 185 in community), 128 allocated to intervention and 135 to control arm. Recruitment ended June 2013. 12-month follow up: 66%. Demographic, mental health and abuse characteristics were balanced between trial arms. A high proportion of participants had distress and depression symptoms above clinical thresholds. At 12 month follow up women in the intervention arm had better mental health status than women in the control arm, with improvements in both groups. Difference in average CORE-OM score between intervention and control groups: -3.3 points (95% ci: -5.5 to -1.2. Difference in average PHQ-9 score between intervention and control group: -2.2 (95% ci -4.1 to -0.3). Differences between intervention and control groups for secondary outcomes: PTSD score: -3.9 (95% ci -7.3 to -0.5); level of anxiety: -1.4 (95% ci -3.1 to 0.4); abuse: -6.4 (95% ci -15.6, 2.6). The analysis with imputed values showed similar effect sizes with wider confidence intervals and the instrumental variable analysis showed increased effect sizes.

Consequences

A relatively brief psychological intervention delivered by advocates working in DVA agencies produced clinically relevant improvement in mental health care outcomes compared to normal advocacy care. The scale of mental health morbidity among survivors of DVA means that this intervention could make a substantial difference if implemented and would be an additional rationale for general practices referring patients disclosing DVA to these agencies.

Credits

  • Gene Feder, London School of Hygiene and Tropical Medicine, London, UK
  • Giulia Ferrari, Domestic Violence Training Ltd, London, UK
  • Roxane Agnew-Davies, Kings College London, London, UK
  • Jayne Bailey, London School of Hygiene and Tropical Medicine, London, UK
  • Louise Howard, Cambridge University, Cambridge, UK
  • Emma Howarth
  • Lynmarie Sardhina, London School of Hygiene and Tropical Medicine, London, UK
  • Debbie Sharp, London School of Hygiene and Tropical Medicine, London, UK
  • Tim Peters, Kings College London, London, UK