Recovery from depressive symptoms, state anxiety and post-traumatic stress disorder in women exposed to physical and psychological, but not to psychological intimate partner violence alone: A longitudinal study

The present study is part of a larger longitudinal research project in which women who had participated in a previous cross-sectional study conducted between 2000-2002 on the impact of IPV on health (T-1: baseline) [13, 21, 54‐56] were evaluated again three years later (T-2). These women, who had been either physically/psychologically (n = 33) or psychologically abused (n = 23) by their male partners, had originally been recruited through the Centers for Helping Women (which offers information, help from lawyers and social workers, and some psychological interventions for the women) in the three provinces of the Valencian Community of Spain (Alicante, Castellon and Valencia). A control group of women (n = 35) not exposed to IPV was recruited for the project through women's clubs and was included for comparison. For the follow-up assessment, all of the women were contacted again by phone and invited to participate. The study was approved by the University of Valencia research ethics committee, and, after the study was completely described to the subjects, written informed consent was obtained. Subjects did not receive any money or other incentive for their participation. All participants were of Spanish nationality.

The second assessment of the wider study consisted of a structured interview during which two trained female psychologists asked women about their life and health status during the three-year follow-up period. Interviews took place either in the Centers or in the women's homes if conditions were sufficiently safe to allow it. In general, each woman was interviewed by the same psychologist 4-6 times due to the length of the questionnaires, with each session taking 1.5 hours. The results presented in this paper correspond to the course of recovery of mental health status.

A comprehensive questionnaire was designed for a face-to-face structured interview. Most of the questions were devised to yield objective factual reports. All questionnaires were administered at both T-1 and T-2 except the childhood abuse questionnaire (only at T-1) and the life events and social support questionnaires (only at T-2). The questionnaires from which information for the present study was obtained are described below.

Detailed information about the nature of the relationship between the woman and the aggressor/partner (marital status and cohabitation) was acquired.

Detailed information about the pattern of IPV over time was obtained. A questionnaire was constructed to collect specific data about the different types of violence (physical, psychological and sexual) perpetrated by the abusive partner. Each type consisted of one or more of the acts described below. Women were asked to answer "yes" or "no" to the experiencing of each act.

The detailed information given in this paper refers to the previous violent male partner from T-1. Control women were also asked all of the same questions to ensure that they had not experienced IPV at any time. Confirmation or not of any of the acts of physical, psychological or sexual violence was used as the criterion to designate women as abused or nonabused. The occurrence of any acts of physical violence was used to classify abused women into two groups: physically/psychologically abused or psychologically abused.

In the previous T-1 study, information about the experience of abuse independent of the IPV (both during childhood and adulthood) was obtained [see 55 for detailed information]. In the present follow-up study, information was also acquired about any violence perpetrated by individuals other than the previous partner during the interval leading up to T-2.

The Duke-UNC scale (11 item version) was used to measure functional social support [57]. The questionnaire includes 11 Likert-type items with 5 answer options scored from 1 to 5 (ranging from "much less than desired" to "as much as desired"). It has two dimensions, i.e., confidential and affective, and a cut-off point to classify perceived social support as low (≤ 32) or normal (> 32). The Spanish version of this questionnaire was validated in Spain by Bellón et al. (1996) [58]. The internal consistency of the scale and subscales (confidential and affective) were 0.90, 0.88, and 0.79, respectively. The reliability of the administration of the scale by an interviewer was 0.80 (for the Spanish validation).

A questionnaire was designed by the research team with the main objective of gathering information about life events (total number and type) that were spontaneously identified by the women as relevant during the interval between T-1 and T-2. Women could speak freely about as many events as desired or none. Additionally, the degree to which these events forced women to readjust their lives was determined. For this rating, the women were asked to give a subjective weight to each event using a continuous scale from 1 to 10 (1 was the best event and 10 the worst). A total score given by women for each type of event was calculated.

Women were classified into three groups, i.e., nonabused, psychologically abused and physically/psychologically abused, depending on the type of IPV suffered at T-1. The three groups were compared with respect to age, perceived social support and lifetime events, and profile of mental health status using one-way analysis of variance (ANOVA). Level of education, marital status and cohabitation with the aggressor/partner, prevalence of childhood abuse, witnessing violence between parents during childhood, and adulthood victimization by individuals other than the partner were compared using Pearson χ² tests. To compare the mental health measures (depressive symptomatology, anxiety, and PTSD) over time, repeated-measures ANOVAs were performed with the factors of Time and Group to test the temporal effect. Post hoc comparisons were conducted with the Dunnett's T3 test. Student's t-test and McNemar's test were used for within-group comparisons in each group. To determine the relationship between mental health recovery (the difference between T-1 and T-2 scores in depressive, anxiety, and PTSD symptoms) and the course of IPV from T-1 to T-2, lifetime victimization, social support and the other sources of stress, hierarchical multiple regression analyses were carried out after controlling for age, education, psychopharmacological treatment, and mental health status at T-1. B coefficients, estimated odds ratios (ExpB) for each independent variable in the model, and the confidence intervals for the estimated odds ratios were calculated. The level of significance for all analyses was set at 0.05. All the analyses were conducted using SPSS version 16 and PASW version 17.

A sample of 91 women participated in the follow-up study (T-2). They were categorized into three groups depending on the type of IPV suffered at T-1: nonabused (n = 35), psychologically abused (n = 23) and physically/psychologically abused (n = 33) women. There were no differences between groups at T-2 in terms of age [Vw(2,53.97) = 0.11; p = 0.89] or education level (Fisher; p = 0.74) (Table 1).

There was a significant association between IPV and marital status both at T-1 and T-2 (Fisher; p < 0.0005) (Table 1). The percentage of "married" women was higher than expected by chance in the nonabused group of women at both time points and was lower than expected at T-1 in the physically/psychologically abused women and at T-2 in both abused groups. The opposite pattern was observed in the category of "separated/divorced" women. On the other hand, there was a significant association between IPV and cohabitation with the aggressor/partner at the time of the interviews at both T-1 [χ²(2, N = 91) = 22.29; p < 0.0005] and T-2 [χ²(2, N = 91) = 35.87; p < 0.0005]. At both time points, the percentage of women cohabiting with the aggressor/partner was significantly higher and lower than expected by chance in the nonabused and physically/psychologically abused women, respectively. Additionally, the percentage was significantly lower than expected in psychologically abused women at T-2. On the other hand, the percentage of women cohabiting with the aggressor was associated with time in the psychologically abused group (McNemar; p = 0.008), with a decrease over the follow-up period.

The type of IPV that women were exposed to changed over the follow-up period (Figure 1). During the year prior to T-2, IPV ceased in 34.8% but continued in 65.2% of the women who were psychologically abused at T-1. Concerning the evolution of sexual IPV, only one woman continued to be exposed to it concomitantly with psychological IPV. Of the women who were physically and psychologically abused at T-1, IPV completely ceased in 36.4%, was reduced to psychological IPV alone in 51.5%, and continued as both physical and psychological IPV in 12.1%. None of the nonabused women experienced IPV during the follow-up period.

There was a history of childhood abuse and childhood witnessing of violence between parents in all three groups (Table 1), with no association with adult experiences of IPV (childhood abuse: [χ²(2, N = 91) = 1.47; p = 0.48]; childhood witnessing: [χ²(2, N = 91) = 3.53; p = 0.17]). On the other hand, there was a significant association between the violence perpetrated by people other than the intimate partner during the follow-up period (T-2) and IPV [χ²(2, N = 91) = 17.41; p < 0.0005]. The incidence was higher than expected by chance in the physically/psychologically abused group and lower in the nonabused group.

There were significant differences between groups in the perception of social support as measured by the Duke-UNC-11 during the follow-up period (T-2) [Vw(2;47.84) = 6.36; p = 0.004]. Post hoc comparisons revealed a lower level of perceived social support in the physically/psychologically abused women in comparison to the nonabused women (p = 0.008). Differences were found in the confidant [Vw(2;47.82) = 6.18; p = 0.004] and in the affective scale [Vw(2;48.9) = 4.59; p = 0.015].

There were no differences between groups in the subjective perception of lifetime events experienced during the follow-up period [F(2,85) = 2.24; p = 0.11].

There was an association between the percentage of women receiving psychiatric/psychological treatment and IPV at T-1 [χ²(2, N = 91) = 8.05; p = 0.02] and at T-2 [χ²(2, N = 90) = 14.35; p = 0.001]; the incidence was lower than expected in the nonabused group and higher in the physically/psychologically abused group (Table 1). Psychopharmacological treatment was significantly associated with IPV at T-1 [χ²(2, N = 91) = 6.07; p = 0.054]; it was more frequent than expected in the physically/psychologically abused group, with no association at T-2 [χ²(2, N = 91) = 0.07; p = 0.74].

Detailed information about the course of depressive, anxiety and PTSD symptoms as well as the incidence of thoughts and attempts of suicide is given in Table 2.

To determine the variables that contributed to the recovery from depression, anxiety and PTSD symptomatology for the physically/psychologically abused women, hierarchical multiple regression analyses were conducted (Table 3). The analyses showed that with regard to the change in depressive symptoms over time, overall control variables (age, psychopharmacological treatment and depressive baseline scores) were significant predictors over the three-year follow-up period [ΔR² = 0.31, F = (3,83) = 12.22, R² = 0.31; p = 0.001]. Psychopharmacological treatment at T-2 (β = -0.44, p = 0.001) and depressive symptoms at T-1 (β = -0.62, p = 0.001) were the primary factors; less psychotropic drug use during the follow-up period and more depressive symptoms at T-1 predicted higher recovery. On the other hand, the overall variables of stress at T-2 were also significant predictors of the change over time [ΔR² = 0.11, F = (3,76) = 5.17, R² = 0.44; p = 0.003]. Perceived social support at T-2 (β = 0.40, p = 0.001) was the primary factor, and higher social support during the follow-up predicted greater recovery. Additionally, although the evolution of IPV from T-1 to the previous year of T-2 did not account for the change over time, cessation of physical IPV had an independent significant effect (β = 0.23, p = 0.05), and a more marked reduction in physical violence predicted a higher recovery.

Similarly, overall control variables [ΔR² = 0.41, F = (3,83) = 19.33, R² = 0.41; p = 0.001] and overall variables of stress at T-2 [ΔR² = 0.073, F = (3,76) = 3.63, R² = 0.49; p = 0.017] were significant predictors of the change in anxiety symptoms over time, with psychotropic drug use at T-2 (β = -0.20, p = 0.03), anxiety baseline scores at T-1 (β = 0.73, p = 0.001) and perceived social support at T-2 (β = 0.37, p = 0.001) as the primary factors. In contrast, cessation of physical IPV was not a significant predictor of recovery from anxiety. Finally, the variables that contributed significantly to the change in PTSD symptoms over time were similar to those for depression and anxiety; these variables included the overall control variables [ΔR² = 0.29, F = (3,83) = 11.24, R² = 0.29; p = 0.001], with the psychotropic drug use at T-2 (β = -0.21, p = 0.035) and the PTSD baseline scores at T-1 (β = 0.56, p = 0.001) as the primary factors, and the overall variables of stress at T-2 [ΔR² = 0.08, F = (3.76) = 3.15, R² = 0.37; p = 0.03], with the perception of lifetime events (β = -0.21, p = 0.046) and social support (β = 0.24, p = 0.036) as the primary factors. A higher perception of lifetime events predicted less recovery, and higher social support predicted greater recovery. Additionally, cessation of physical IPV was a significant independent predictor of recovery (β = 0.27, p = 0.030).

This study examined the mental health status in women who had been exposed to psychological IPV alone or concomitant physical and psychological IPV longitudinally over a follow-up period of three years. The initial assessment indicated that both groups of abused women had more severe depressive, anxiety and PTSD symptomatology as well as a higher incidence of thoughts and attempts of suicide than nonabused control women. These results indicate that psychological IPV both alone and concomitant with physical IPV have similar consequences on women's mental health, as we and other researchers have previously reported [13, 14, 33‐35]. Because of the impact of IPV on mental health, a high percentage of women exposed to this type of violence received psychiatric and psychological intervention, and half of those exposed to physical and psychological IPV used psychotropic drugs.

The main finding of the present study was that women exposed to concomitant physical and psychological IPV (physically/psychologically abused group) underwent a recovery of their mental health status with a significant decrease in depressive, anxiety and PTSD symptomatology over the 3-year follow-up period in comparison with the initial assessment. Consequently, differences between these women and those who were nonabused no longer existed. This course of recovery agrees with previous studies in which a decrease in depression and anxiety as well as the incidence of PTSD was reported over time for women exposed to IPV [41, 43, 44, 46, 47, 50]. These findings are very important as they give hope to women whose mental health has deteriorated because of being victims of physical and psychological IPV. On the contrary, in the present study no recovery was found in women who had been exposed to psychological IPV alone (psychologically abused group), as they continued to have higher levels of depressive and PTSD symptomatology than nonabused women after the follow-up period of three years, with no significant decrease over time in any of the three assessed mental disorders. However, the incidence of suicidal thoughts and attempts was reduced over time in both abused groups, which might be because the period of time referred to for T-1 was the span of the entire lifetime, whereas at T-2 the period of time only referred to the three-year follow-up period.

Thus, the present results indicate a different course of mental health status between women who had been exposed to psychological IPV alone and those who had suffered both physical and psychological IPV. It is therefore important to determine which personal and social factors contributed to this different pattern and, more specifically, which factors contributed to recovery or to the continuation of the compromised mental health. To this end, hierarchical multiple regression analyses were carried out that showed that the baseline score for each disorder at the initial assessment was a predictor of recovery. This finding indicates that a high level of deterioration did not impede improvement. On the other hand, perceived social support contributed to recovery for the three mental disorders, and the cessation of physical IPV contributed to recovery for depressive and PTSD symptoms. On the contrary, a high intake of psychotropic drugs predicted the continuation of the three disorders, and a high perception of lifetime events contributed to the continuation of PTSD symptoms. Thus, of all variables studied, the only one that impeded the recovery over time was the perception of lifetime events with respect to PTSD symptoms.

The evolution of IPV was different in women exposed to psychological IPV alone when compared to those experiencing both physical and psychological IPV. While IPV continued across both time points in 65.21% of women suffering psychological IPV alone, it continued in only 12.12% of women exposed to physical and psychological IPV and was reduced to psychological IPV alone in 51.5% of participants. This finding may explain why there was a more notable improvement in the women exposed to physical and psychological IPV compared to those experiencing psychological IPV alone. The regression analysis showed that the cessation of physical IPV contributed to the recovery of depressive and PTSD symptoms, which agrees with previous studies [44, 46]. Thus, while women experiencing physical IPV have a higher likelihood of undergoing a cessation or reduction of IPV over time, women exposed to psychological IPV alone have a high probability of continued exposure to the same type of IPV. Factors contributing to these differences deserve increased attention. Thus, understanding the factors that contribute to women's responses to IPV that allow them to become free of the violence is of relevant importance. Some studies have started to assess this issue [33, 67, 68], as it has an important impact on the pattern of recovery of women's mental health. Another relevant aspect to take into account is that in most cases, psychological IPV did not cease while women were cohabiting with the aggressor, and it continued even when the women had separated from the aggressor [43] (authors' unpublished data).

The present results reveal that a high level of perceived social support was a significant predictor of recovery from the three mental disorders over the follow-up period. This finding agrees with the literature, which shows that social support protects against the effects of IPV on mental health and has a beneficial effect on women's decision to take actions to eliminate IPV, thus providing a beneficial impact on their health [9, 44, 49, 67, 69‐72]. Furthermore, social support decreases the risk of revictimization by partners [49, 73]. Thus, all studies highlight the buffering effects of social support on the impact of IPV on women's mental health and the beneficial effects of social support for recovery over time. On the other hand, the finding that a low-level use of psychotropic medication during the follow-up was a predicting factor of recovery from the three mental disorders indicates that women with more deteriorated mental health status are those who have a higher intake. Previous studies and our own study demonstrate that female victims of IPV take more psychoactive drugs than nonabused women [13, 74].

Our results demonstrate that psychological IPV alone is not only highly detrimental to women's mental health but also reduces the likelihood of mental health recovery. These results are important, as psychological IPV is often still considered a minor type of violence and consequently receives less attention than physical IPV by clinicians, lawyers, policy makers, researchers and the female victims themselves. Thus, exposure to psychological IPV alone can no longer be considered a minor type of IPV when assessing and recognizing the impact of IPV on women's mental health. More importantly, psychological IPV alone is more resistant to cessation than physical IPV or psychological IPV concomitant with physical IPV. The possibility of exposure to psychological IPV alone should be considered in patients who have persistent mental problems.