Psychological therapies for women who experience intimate partner violence

Mohajer Hameed; Lorna O'Doherty; Gail Gilchrist; Judit Tirado-Muñoz; Angela Taft; Patty Chondros; Gene Feder; Melissa Tan; Kelsey Hegarty

doi:10.1002/14651858.CD013017.pub2

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Figure 1

Trial flow diagram

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Figure 2

Risk of Bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.

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Figure 3

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Figure 4

Funnel plot of comparison: 1 Intervention vs Control, outcome: 1.1 Depression (continuous).

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Analysis 1.1

Comparison 1: Intervention vs Control, Outcome 1: Depression (continuous)

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Analysis 1.2

Comparison 1: Intervention vs Control, Outcome 2: Depression (categorical)

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Analysis 1.3

Comparison 1: Intervention vs Control, Outcome 3: Depression (recruitment setting of participants)

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Analysis 1.4

Comparison 1: Intervention vs Control, Outcome 4: Depression (type of intervention)

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Analysis 1.5

Comparison 1: Intervention vs Control, Outcome 5: Depression (intensity of intervention)

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Analysis 1.6

Comparison 1: Intervention vs Control, Outcome 6: Depression (person delivering the intervention)

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Analysis 1.7

Comparison 1: Intervention vs Control, Outcome 7: Self‐efficacy

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Analysis 1.8

Comparison 1: Intervention vs Control, Outcome 8: Dropouts from treatment

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Analysis 1.9

Comparison 1: Intervention vs Control, Outcome 9: Mental health

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Analysis 1.10

Comparison 1: Intervention vs Control, Outcome 10: Anxiety (continuous)

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Analysis 1.11

Comparison 1: Intervention vs Control, Outcome 11: Anxiety (categorical)

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Analysis 1.12

Comparison 1: Intervention vs Control, Outcome 12: Post‐traumatic stress disorder (continuous)

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Analysis 1.13

Comparison 1: Intervention vs Control, Outcome 13: Quality of life

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Analysis 1.14

Comparison 1: Intervention vs Control, Outcome 14: Re‐exposure to IPV (continuous)

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Analysis 1.15

Comparison 1: Intervention vs Control, Outcome 15: Re‐exposure to IPV (categorical)

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Analysis 1.16

Comparison 1: Intervention vs Control, Outcome 16: Safety planning and/or safety behaviour (continuous)

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Analysis 1.17

Comparison 1: Intervention vs Control, Outcome 17: Safety planning and/or safety behaviour (categorical)

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Analysis 1.18

Comparison 1: Intervention vs Control, Outcome 18: Use of healthcare and IPV services

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Analysis 1.19

Comparison 1: Intervention vs Control, Outcome 19: Social support (continuous)

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Analysis 1.20

Comparison 1: Intervention vs Control, Outcome 20: Social support (categorical)

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Summary of findings 1. Psychological therapies for women who experience intimate partner violence

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (trials)	Certainty of the evidence (GRADE)	Comments
Psychological therapies compared to comparator intervention (e.g. usual care, no treatment or minimal treatment) for women who experience intimate partner violence
Patient or population: women aged 16 years and older who self‐report previous or current experience of intimate partner violence Setting: healthcare settings, community, shelter and refuge settings Intervention: psychological therapies, classified according to Cochrane Common Mental Disorder's psychological therapies list to include (but not limited to) a wide range of interventions that target cognition, motivation and behaviour which aim at alleviating distress or impairment Comparison: comparator intervention (e.g. usual care, no treatment or minimal treatment)
Outcomes	Risk with comparator intervention (e.g. usual care, no treatment or minimal treatment)	Risk with psychological therapies	Relative effect (95% CI)	№ of participants (trials)	Certainty of the evidence (GRADE)	Comments
Depression score Scales: Beck Depression Inventory, Center for Epidemiologic Studies Short Depression Scale, Patient Health Questionnaire Direction: lower better Follow‐up: medium‐term (6 to under 12 months)	The mean depression score ranged from 11.1 to 24.2	SMD 0.24 lower (0.47 lower to 0.01 lower)	‐	600 (4 RCTs)	⊕⊕⊕⊝ Moderate^a	This corresponds to a small effect according to conventions proposed by Cohen 1992
Self‐efficacy score Scale: Generalized Self‐Efficacy Scale Direction: higher better Follow‐up: medium‐term (6 to under 12 months)	The mean self‐efficacy score was 28.1	SMD 0.12 lower (0.33 lower to 0.09 higher)	‐	346 (1 RCTs)	⊕⊕⊝⊝ Low^b	This effect approaches zero
Dropouts from treatment Follow‐up: medium‐term (6 to under 12 months)	Trial population		OR 1.04 (0.75 to 1.44)	840 (5 RCTs)	⊕⊕⊝⊝ Low^a,c	This effect approaches zero
	263 per 1000	271 per 1000 (211 to 340)	OR 1.04 (0.75 to 1.44)	840 (5 RCTs)	⊕⊕⊝⊝ Low^a,c	This effect approaches zero
Anxiety score Scales: Beck Anxiety Inventory, State‐Trait Anxiety Inventory and Depression, Anxiety, and Stress Scale Direction: lower better Follow‐up: short‐term (under 6 months)	The mean anxiety score ranged from 8 to 53.1	SMD 0.96 lower (1.29 lower to 0.63 lower)	‐	158 (4 RCTs)	⊕⊕⊝⊝ Low^d	This corresponds to large effect according to conventions proposed by Cohen 1992
Post‐traumatic stress disorder Score Scale: Clinician Administered PTSD Scale, Posttraumatic Stress Symptoms— Interview, Posttraumatic Stress Disorder Checklist Direction: lower better Follow‐up: medium‐term (6 to under 12 months)	The mean post‐traumatic stress disorder score ranged from 19.5 to 36.5	SMD 0.24 lower (0.54 lower to 0.06 higher)	‐	484 (4 RCTs)	⊕⊕⊝⊝ Low^a,c	This corresponds to a small effect according to conventions proposed by Cohen 1992. However the 95% confidence interval indicate we are uncertain whether psychological therapies reduce post‐traumatic stress disorder
Re‐exposure to IPV score Scales: Revised Conflict Tactics Scales, Composite Abuse Scale Direction: lower better Follow‐up: medium‐term (6 to under 12 months)	The mean re‐exposure to IPV score was 6.1 and 8.7	SMD 0.03 higher (0.14 lower to 0.20 higher)	‐	547 (2 RCTs)	⊕⊕⊝⊝ Low^a,e	This effect approaches zero
Safety planning and/or safety behaviour score Service use and activities questionnaire Direction: higher better Follow‐up: medium‐term (6 to under 12 months)	The mean safety planning and/or safety behaviour score was 4.2	SMD 0.04 higher (0.18 lower to 0.25 higher)	‐	337 (1 RCT)	⊕⊕⊝⊝ Low^b	This effect approaches zero
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aDowngraded one level due to unclear risk of bias in allocation concealment (risk of bias). ^bDowngraded two level due to very small number of trials / participants (imprecision). ^cDowngraded one level due to inconsistency of results across trials (inconsistency). ^dDowngraded two level due to high risk of bias in allocation concealment (risk of bias). ^eDowngraded one level due to small number of trials / participants (imprecision).

Summary of findings 1. Psychological therapies for women who experience intimate partner violence

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Comparison 1. Intervention vs Control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Depression (continuous) Show forest plot	17		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1.1 Short‐term FU (under 6 months)	15	1247	Std. Mean Difference (IV, Random, 95% CI)	‐0.45 [‐0.67, ‐0.22]
1.1.2 Medium‐term FU (6 to under 12 months)	4	600	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.47, ‐0.01]
1.1.3 Long‐term FU (12 months and above)	3	503	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.30, 0.14]
1.2 Depression (categorical) Show forest plot	2		Odds Ratio (IV, Fixed, 95% CI)	Subtotals only

1.2.1 Medium‐term FU (6 to under 12 months)	2	528	Odds Ratio (IV, Fixed, 95% CI)	0.68 [0.47, 0.98]
1.2.2 Long‐term FU (12 months and above)	1	195	Odds Ratio (IV, Fixed, 95% CI)	0.50 [0.29, 0.89]
1.3 Depression (recruitment setting of participants) Show forest plot	17	1729	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.55, ‐0.17]

1.3.1 Healthcare	6	519	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.38, 0.01]
1.3.2 Community	5	469	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.62, 0.15]
1.3.3 Shelter / refuge	1	52	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐1.13, 0.02]
1.3.4 Various	5	689	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.96, ‐0.13]
1.4 Depression (type of intervention) Show forest plot	16	1604	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.37, ‐0.11]

1.4.1 Cognitive behavioral therapy	4	262	Std. Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.55, ‐0.06]
1.4.2 Humanistic therapies	4	161	Std. Mean Difference (IV, Random, 95% CI)	‐0.47 [‐0.91, ‐0.03]
1.4.3 Integrative therapies	6	892	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.23, 0.04]
1.4.4 Other psychologically‐oriented interventions	2	289	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.99, 0.16]
1.5 Depression (intensity of intervention) Show forest plot	17	1729	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.55, ‐0.17]

1.5.1 Up to four sessions	5	644	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.18, 0.13]
1.5.2 Five or more sessions	12	1085	Std. Mean Difference (IV, Random, 95% CI)	‐0.49 [‐0.73, ‐0.25]
1.6 Depression (person delivering the intervention) Show forest plot	15	1342	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.57, ‐0.16]

1.6.1 healthcare workers	10	649	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.73, ‐0.11]
1.6.2 non‐healthcare workers	5	693	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.39, ‐0.03]
1.7 Self‐efficacy Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.7.1 Short‐term FU (under 6 months)	3	279	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.22, 0.63]
1.7.2 Medium‐term FU (6 to under 12 months)	1	346	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.33, 0.09]
1.7.3 Long‐term FU (12 months and above)	1	331	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.45, ‐0.01]
1.8 Dropouts from treatment Show forest plot	33		Odds Ratio (IV, Random, 95% CI)	Subtotals only

1.8.1 Short‐term FU (up to 6 months)	22	3022	Odds Ratio (IV, Random, 95% CI)	1.21 [0.98, 1.48]
1.8.2 Medium‐term FU (6 to 12 months)	5	840	Odds Ratio (IV, Random, 95% CI)	1.04 [0.75, 1.44]
1.8.3 Long‐term FU (greater than 12 months)	6	1655	Odds Ratio (IV, Random, 95% CI)	1.08 [0.85, 1.38]
1.9 Mental health Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.9.1 Short‐term FU (under 6 months)	2	353	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.55, ‐0.13]
1.9.2 Medium‐term FU (6 to under 12 months)	2	219	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.38, 0.16]
1.9.3 Long‐term FU (12 months and above)	2	355	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.48, ‐0.06]
1.10 Anxiety (continuous) Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.10.1 Short‐term FU (under 6 months)	4	158	Std. Mean Difference (IV, Random, 95% CI)	‐0.96 [‐1.29, ‐0.63]
1.10.2 Long‐term FU (12 months and above)	1	166	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.51, 0.10]
1.11 Anxiety (categorical) Show forest plot	1		Odds Ratio (IV, Random, 95% CI)	Subtotals only

1.11.1 Medium‐term FU (6 to under 12 months)	1	192	Odds Ratio (IV, Random, 95% CI)	0.82 [0.45, 1.49]
1.11.2 Long‐term FU (12 months and above)	1	195	Odds Ratio (IV, Random, 95% CI)	0.87 [0.48, 1.57]
1.12 Post‐traumatic stress disorder (continuous) Show forest plot	10		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.12.1 Short‐term FU (under 6 months)	9	1150	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.80, ‐0.16]
1.12.2 Medium‐term FU (6 to under 12 months)	4	484	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.54, 0.06]
1.12.3 Long‐term FU (12 months and above)	1	170	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.57, 0.04]
1.13 Quality of life Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.13.1 Short‐term FU (under 6 months)	2	382	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.04, 0.36]
1.13.2 Medium‐term FU (6 to under 12 months)	2	557	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.07, 0.27]
1.13.3 Long‐term FU (12 months and above)	4	699	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.04, 0.25]
1.14 Re‐exposure to IPV (continuous) Show forest plot	9		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.14.1 Short‐term FU (under 6 months)	7	749	Std. Mean Difference (IV, Random, 95% CI)	‐0.00 [‐0.29, 0.29]
1.14.2 Medium‐term FU (6 to under 12 months)	2	547	Std. Mean Difference (IV, Random, 95% CI)	0.03 [‐0.14, 0.20]
1.14.3 Long‐term FU (12 months and above)	4	837	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.20, 0.07]
1.15 Re‐exposure to IPV (categorical) Show forest plot	7		Odds Ratio (IV, Random, 95% CI)	Subtotals only

1.15.1 Short‐term FU (under 6 months)	5	797	Odds Ratio (IV, Random, 95% CI)	0.45 [0.21, 0.96]
1.15.2 Medium‐term FU (6 to under 12 months)	1	186	Odds Ratio (IV, Random, 95% CI)	1.29 [0.55, 3.01]
1.15.3 Long‐term FU (12 months and above)	2	381	Odds Ratio (IV, Random, 95% CI)	0.77 [0.28, 2.11]
1.16 Safety planning and/or safety behaviour (continuous) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.16.1 Medium‐term FU (6 to under 12 months)	1	337	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.18, 0.25]
1.16.2 Long‐term FU (12 months and above)	1	318	Std. Mean Difference (IV, Random, 95% CI)	0.00 [‐0.22, 0.22]
1.17 Safety planning and/or safety behaviour (categorical) Show forest plot	2		Odds Ratio (IV, Random, 95% CI)	Subtotals only

1.17.1 Short‐term FU (under 6 months)	1	138	Odds Ratio (IV, Random, 95% CI)	1.38 [0.66, 2.89]
1.17.2 Medium‐term FU (6 to under 12 months)	1	191	Odds Ratio (IV, Random, 95% CI)	1.25 [0.68, 2.27]
1.17.3 Long‐term FU (12 months and above)	1	192	Odds Ratio (IV, Random, 95% CI)	2.14 [1.18, 3.91]
1.18 Use of healthcare and IPV services Show forest plot	2		Odds Ratio (IV, Random, 95% CI)	Subtotals only

1.18.1 Short‐term FU (under 6 months)	1	371	Odds Ratio (IV, Random, 95% CI)	1.60 [0.68, 3.76]
1.18.2 Medium‐term FU (6 to under 12 months)	1	364	Odds Ratio (IV, Random, 95% CI)	1.21 [0.44, 3.33]
1.18.3 Long‐term FU (12 months and above)	2	526	Odds Ratio (IV, Random, 95% CI)	0.79 [0.21, 2.97]
1.19 Social support (continuous) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.19.1 Short‐term FU (under 6 months)	2	245	Std. Mean Difference (IV, Random, 95% CI)	0.31 [‐0.38, 1.00]
1.19.2 Medium‐term FU (6 to under 12 months)	2	235	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.21, 0.31]
1.20 Social support (categorical) Show forest plot	1		Odds Ratio (IV, Random, 95% CI)	Totals not selected

1.20.1 Short‐term FU (under 6 months)	1		Odds Ratio (IV, Random, 95% CI)	Totals not selected
1.20.2 Medium‐term FU (6 to under 12 months)	1		Odds Ratio (IV, Random, 95% CI)	Totals not selected
1.20.3 Long‐term FU (12 months and above)	1		Odds Ratio (IV, Random, 95% CI)	Totals not selected

Comparison 1. Intervention vs Control

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