Intimate partner violence (IPV) is pervasive. According to estimates by the World Health Organization (WHO), close to 1 in 3 women worldwide experience physical violence, sexual, emotional or psychological abuse, and controlling behaviours within an intimate relationship in their lifetime (World Health Organization, 2021). It is unclear to what extent this abuse affects men globally.
Although the adverse mental health consequences of IPV are well documented (Karakurt et al., 2014; Trevillion et al., 2012), what remains far more hidden, are the links between various types of IPV and suicidality and self-harm. The figures that do exist paint an alarming picture. A WHO multi-country study found women who had experienced physical or sexual violence in their lifetime, were three times more likely to have thought about ending their lives and almost four times more likely to attempt suicide, when compared to women who had never experienced partner violence (Devries et al., 2011).
However, much of the extant research has been limited to women or specific sub-populations (e.g., women in refuges) thus are not generalisable to the general population. In addition, the less ‘visible’ forms of abuse (e.g., emotional and financial abuse) are often neglected and lifetime vs. past-year IPV exposure and dose-response effects are rarely investigated. The study by McManus and colleagues (2022) estimates the prevalence of lifetime and past-year IPV in the English general adult population and provides a detailed investigation of the links between various types of IPV and suicidality and self-harm.
Readers who want to update their knowledge about intimate partner violence and mental health should visit the Mental Elf YouTube channel where you can watch the recent (June 2022) #IPVmentalhealth discussion, and the #LancetSuicideSeminar (July 2022) on preventing suicide and self-harm will also be of interest.
1 in 3 women worldwide will experience intimate partner violence in their lifetime, but how does this relate to experiences of suicide and self-harm?
Methods
The authors conducted a secondary analysis of data from the 2014 nationally representative cross-sectional Adult Psychiatric Morbidity Survey (APMS). The sample comprised 7,058 adults (4,183 women and 2,875 men), aged 16 and over, from the English general population. Participants were asked questions related to a) lifetime experience of each IPV type (physical, sexual, economic, and emotional), b) the number of types of IPV ever experienced, c) experience of any IPV ever, and d) experience of any IPV in the past year.
The main outcomes of interest were past-year suicidal thoughts, suicide attempt, and non-suicidal self-harm (hereafter referred to as self-harm). Sociodemographic information and data collected on experience of life adversities (e.g., serious illness or injury, death of an immediate family member, major financial crisis) were also examined. Weighted descriptive analyses were conducted on the overall sample. Multivariable logistic regression models adjusting for sociodemographic and life adversities were generated to examine associations between experience of IPV and suicidal thoughts, suicide attempts, or self-harm.
Results
Approximately a fifth of the English adult general population had experienced any IPV in their lifetime (21.4%) in 2014, with higher prevalence among women (27.2%) than men (15.3%). The most common types of IPV experienced were emotional (14.2%) and physical IPV (14.1%), followed by economic (6.1%) and sexual IPV (2.0%). All indicators of IPV examined were more prevalent in women than men.
People who had ever experienced IPV were more likely to live in rented accommodation and deprived neighbourhoods, and experience five or more life adversities. A higher prevalence of past-year suicide attempt, self-harm, and suicidal thoughts were found among people who had ever experienced IPV compared to those with no such history. Strikingly, almost half (49.7%) of the participants who attempted suicide in the past year had been exposed to IPV in their lifetime (58.4% of women, 34.8% of men) and 23.1% had been exposed in the preceding year (39.6% of women, 9.4% of men).
After adjusting for sociodemographic factors and experience of other adversities, people with a lifetime history of IPV were almost three times more likely to have made a suicide attempt in the past year, compared to people without experience of IPV (2.82 95% CI 1.54 to 5.17). Strong adjusted associations were also found for past-year self-harm (2.20 95% CI 1.37 to 3.53) and suicidal thoughts (1.85 95% CI 1.39 to 2.46) for people who had ever experienced IPV. For people who had experienced IPV within the past year, the likelihood of past-year suicide attempt (3.79 95% CI 1.90 to 7.53), suicidal thoughts (3.05 95% CI 2.04 to 4.56), and self-harm (3.04 95% CI 1.75 to 5.28) were particularly high. Sexual IPV, which was ten times more common in women than men, showed particularly strong associations with suicidality and self-harm. There was also indication of a dose-response relationship, with an increasing risk of suicidality and self-harm for exposure to multiple types of IPV.
People who had experienced lifetime intimate partner violence were almost three times more likely to have made a suicide attempt in the past year, compared to people without experience of intimate partner violence.
Conclusions
The authors concluded that IPV is common in the English adult population, particularly among women. The clear, strong links between IPV, suicidality and self-harm are a cause for concern. These findings signal the need to identify IPV among women and men presenting to services in suicidal distress or following self-harm. Broader strategies to prevent violence should be prioritised at community and national policy levels.
There are clear strong links between intimate partner violence, suicide and self-harm, which are a cause for concern.
Strengths and limitations
This study presents a novel examination of the relationship between IPV and suicidality and self-harm, including investigation by abuse type, dose-response effects, and lifetime vs. past-year IPV. The survey used a robust multi-stage national probability sample of the English general adult population, allowing for comparisons by age and gender. In addition, the study provides a nuanced analysis of suicidal behaviour by distinguishing suicidal thoughts, suicide attempts and non-suicidal self-harm. The study also accounts for multiple potential confounders/mediators. The models showed strong statistical evidence of association even after adjusting for a range of life adversities.
Despite the strengths of the research, there are some methodological limitations that should be considered. The cross-sectional nature of the study design does not allow for causality to be established. Many of the factors under examination (IPV, suicidal thoughts, life adversities) may be persistent over time. The authors acknowledge that longitudinal studies are more suitable to disentangle causal pathways and effects of confounders and mediators.
Given the survey had a 57% response rate, it is possible the study may miss important findings from participants less likely to respond, raising the potential for selection bias. IPV and suicidality are both highly sensitive and stigmatised topics therefore there is also potential for under-reporting, although it should be noted that IPV prevalence estimates in the study were above the official national crime survey estimates. Furthermore, the survey was conducted in 2014. The authors rightly acknowledge that COVID-19 public health measures (e.g., ‘lockdowns’) may have had an impact on the prevalence of IPV and nature of the association with suicidality and self-harm. There is evidence globally that incidents and calls to domestic violence support services increased post-lockdowns and the long-term effects of this ‘shadow pandemic’ are yet to be seen (Kourti et al., 2021; Piquero et al., 2021). Ongoing monitoring and surveillance are needed.
Given participants were recruited from households, ‘hard to reach’ sub-populations at higher risk of IPV, suicidality, and self-harm were out of scope (e.g., people living in refuges, prisons, or homeless). Despite this, the authors did attempt to explore other intersectional inequalities such as differences by ethnicity, although the numbers were small.
The cross-sectional nature of this study makes it impossible to establish a causal link between intimate partner violence and self-harm.
Implications for practice
- IPV is a global public health issue and its links with self-harm and suicidality are not unique to England but have also emerged from other parts of the world (Bandara et al., 2020; Devries et al., 2011; Paiman et al., 2019).
- It is clear that people presenting to services in suicidal distress or following self-harm have a high chance of experiencing IPV, therefore, IPV should be identified among this vulnerable group, and follow-up support provided to reduce and prevent ongoing abuse.
- It is likely we are missing crucial opportunities to intervene. Service providers should be trained and adequately supported to respond.
- Multi-sectoral collaboration between health (including mental health) services, social/welfare services (e.g., refuges), and criminal justice sector is needed to ensure clear referral pathways and appropriate support is provided.
- The prevention of violence should be recognised as an issue of national concern and violence reduction should be incorporated into national suicide prevention strategies.
Multi-sectoral collaboration between health services, social / welfare services and the criminal justice sector is needed to ensure clear referral pathways exist and appropriate support is provided to those experiencing intimate partner violence.
Statement of interests
The author of this blog has previously investigated the relationship between domestic violence and suicidal behaviour in Sri Lanka. She has also collaborated extensively with one of the authors on this paper, Dr Duleeka Knipe.
Links
Primary paper
McManus, S., Walby, S., Barbosa, E. C., Appleby, L., Brugha, T., Bebbington, P. E., … & Knipe, D. (2022). Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England. The Lancet Psychiatry 9(7) 574-583.
Other references
Aitken, R., & Munro, V. (2018). Domestic abuse and suicide: Exploring the links with Refuge’s client base and work force.
Bandara, P., Page, A., Senarathna, L., Kidger, J., Feder, G., Gunnell, D., Rajapakse, T., & Knipe, D. (2020). Domestic violence and self-poisoning in Sri Lanka. Psychological medicine, 1-9.
Devries, K., Watts, C., Yoshihama, M., Kiss, L., Schraiber, L. B., Deyessa, N., Heise, L., Durand, J., Mbwambo, J., Jansen, H., Berhane, Y., Ellsberg, M., & Garcia-Moreno, C. (2011). Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women’s health and domestic violence against women. Social Science & Medicine, 73(1), 79-86.
Devries, K. M., Mak, J. Y., Bacchus, L. J., Child, J. C., Falder, G., Petzold, M., Astbury, J., & Watts, C. H. (2013). Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS medicine, 10(5), e1001439.
Karakurt, G., Smith, D., & Whiting, J. (2014). Impact of intimate partner violence on women’s mental health. Journal of family violence, 29(7), 693-702.
Kourti, A., Stavridou, A., Panagouli, E., Psaltopoulou, T., Spiliopoulou, C., Tsolia, M., Sergentanis, T. N., & Tsitsika, A. (2021). Domestic violence during the COVID-19 pandemic: a systematic review. Trauma, Violence, & Abuse, 15248380211038690.
Paiman, A., Khan, M., Ali, T., Asad, N., & Azam, I. (2019). Psychosocial factors of deliberate self-harm in Afghanistan: a hospital based, matched case-control study. Eastern Mediterranean health journal, 25(11), 798-805.
Piquero, A. R., Jennings, W. G., Jemison, E., Kaukinen, C., & Knaul, F. M. (2021). Domestic violence during the COVID-19 pandemic-Evidence from a systematic review and meta-analysis. Journal of Criminal Justice, 74, 101806.
Trevillion, K., Oram, S., Feder, G., & Howard, L. M. (2012). Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS one, 7(12), e51740.
World Health Organization. (2021). Violence against women prevalence estimates, 2018: global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women (Vol. 2021). World Health Organization.
Photo credits
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