Depression and post-traumatic stress disorder in females exposed to intimate partner violence

United Nations considered intimate partner violence (IPV) as a serious problem affecting 35% of females all over the world requesting action to face this problem. There is strong evidence that the effect of violence against women has short-term and long-term negative outcomes on women physical health such as pain, wounds, fractures or even death in addition to serious psychiatric disorders for example anxiety, depression, and post-traumatic stress disorder (PTSD). The study aims to evaluate the prevalence of different subtypes of (IPV) in a group sample of married females. Also, the current study will examine the relation of intimate partner violence with subsequent depression and post-traumatic stress disorder disorders among those females. This study highlights subtypes of intimate partner violence among the studied females according to the Composite Abuse Scale (CAS); the highest prevalence type of violence is harassment (72.2%) followed by physical violence (57.8%), severe combined violence (54.4%), emotional violence (53.3%), and finally the last one is sexual abuse (7.8%). Post-traumatic stress disorder distribution among studied females; the highest prevalence (n = 37, 41.1%) had mild PTSD, followed by 23 (25.6%) who were normal, and then n = 20 (22.2%) who had severe PTSD, while the least prevalence (n = 10, 11.1%) had moderate PTSD. In concern to depressive disorder distribution among studied females, the highest prevalence (n = 33, 36.7%) were normal, followed by 29 (32.2%) who had moderate depression, and then n = 12 (1.3%) who had severe depression, n = 9 (10.0%) who had mild depression, while the least prevalence (n = 7, 7.8%) had very severe depressive symptoms. This study found that the prevalence of intimate partner violence among the studied females is high. In addition, the presence of a strong relationship between all subtypes of intimate partner violence and the diagnosis of PTSD and depressive disorder among studied females. Potential implications; these results can be applied clinically as females are exposed to the burden of IPV and should be helped empowered in various ways such as providing psychiatric counselling for those females.


Background
United Nations considered intimate partner violence (IPV) as a serious problem affecting 35% of females all over the world requesting an action to face this problem [1].
The World Health Organization in its 2010 report defines IPV as behavior within an intimate relation resulting in physical, sexual, or psychological harm such as acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors [2].
Females are more exposed to fatal injuries by violence, whatever their nationality, education, or socioeconomic level [3].
IPV is uncommon to occur only one time. It is usually characterized by its recurrent occurrence. Despite that, 39% of IPV is kept secret not documented in a legal form [4].
A recent study [5] reported that in the USA, 22.3% of women were exposed to physical (IPV), 15.8% to sexual violence, and 84% to psychological harm.
In multi-countries study [6], it was found that the prevalence of violence against females is between 15 and 71% with the least occurrence reported in Japan and the highest prevalence\ was reported in Bangladesh and Ethiopia.
The impact of violence against women has short-and long-term negative outcomes on women physical health such as pain, wounds, fractures, or even death in addition to serious psychiatric disorders, for example anxiety, depression, and post-traumatic stress disorder (PTSD) [7].
As the act and the outcome of intimate partner violence are more common to be hidden; this leads to a significant underestimation of the actual frequency and impact of this act [8].
Getting more accurate information about the prevalence and the impact of IPV in society will provide a real chance to improve women mental health and wellbeing.
This study aims to evaluate the prevalence of different subtypes of intimate partner violence in a group sample of married females.
Also, the current study will examine the relation of intimate partner violence with subsequent depression and post-traumatic stress disorder disorders among those females.

Methods
This study is a cross-sectional study which was done at the Psychiatry Department, Faculty of Medicine, Mansoura University Hospitals (MUH).
The study took place during the period from November 2020 to April 2021 (6-month period), convenience sample of 100 female employees working at the Mansoura University Hospitals (MUH) were asked to join this study due to limited time and cost of the study. The aim of the study was explained to them and they were given the choice to participate or not, they were told that all of their answers would be confidential and written consent will be taken from them. n = 3 refused to join the study (not interested, personal issues), and n = 7 were excluded according to exclusion criteria.
Finally, the sample size was ninety (n = 90) participants who joined this study.

Inclusion criteria
• Female • Married • Age 25-45 • No past or family history of depression before marriage.

Exclusion criteria
• Age < 25 years or > 45 years • Presence of past or family history of depression before marriage.
Major depressive episodes and post-traumatic stress disorder were assessed clinically in the examined sample with Structured Clinical Interview for DSM-IV (SCID).

Data collection instrument The Composite Abuse Scale (CAS)
This scale is a self-report scale to assess violence in intimate relationships.
Harassment is a form of vexatious behavior that involves repeated hostile and unwanted words, behavior, or actions that are painful, hurtful, annoying, humiliating, or insulting. While verbal abuse is a type of psychological/mental abuse that involves the use of oral language, gestured language, and written language directed to a victim [11].
Arabic version was prepared by translation and back translation in the Department of Psychiatry, Faculty of Medicine, Mansoura University.

The Hamilton Depression Rating Scale (HDRS)
It is a questionnaire [12] designed for adults, and Arabic version [13] is used to rate the severity of depression by assessing their mood, feelings of guilt, suicide

Post-Traumatic Stress Diagnostic Scale (PDS)
The Post-Traumatic Stress Diagnostic Scale (PDS)-Arabic version [14,15] provides a brief but reliable self-report measure of post-traumatic stress disorder (PTSD) for use in both clinical and research settings. The scale is used to detect the presence of PTSD in persons who were exposed to a traumatic event and to assess symptom severity and functioning. The test is self-administered; the time is within 10-15 min and requires a reading age of 13 years. Questions related to the frequency of re-experience distressing and intrusive thoughts, post-traumatic avoidance, and hyper arousal. The PDS has 49 items. The cut-offs for symptom severity rating are 0 no rating, 1-10 mild, 11-20 moderate, 21-35 moderate to severe, and ≥ 36 severe Table 1.

Results
Socio demographic data of the studied females: n = 90 females mean ± SD is 34.  Table 2 highlights types of intimate partner violence among the studied females according to the Composite Abuse Scale (CAS); the highest prevalence of the type of violence is harassment (72.2%) followed by physical violence (57.8%), and then severe combined violence (54.4%) then emotional violence (53.3%), and finally the last one is sexual abuse (7.8%). Table 3 studied post-traumatic stress disorder distribution among studied females; the highest prevalence (n = 37, 41.1%) had mild PTSD, followed by 23 (25.6%) who were normal, and then n = 20 (22.2%) who had severe PTSD, while the least prevalence (n = 10, 11.1%) had moderate PTSD.   In concern to depressive disorder distribution among studied females, the highest prevalence (n = 33, 36.7%) were normal, followed by 29 (32.2%) who had moderate depression, and then n = 12 (1.3%) who had severe depression, n = 9 (10.0%) had mild depression, while the least prevalence (n = 7, 7.8%) had very severe depressive symptoms. Table 4 revealed the presence of a significant positive relationship (P < 0.001) between sexual, emotional, physical violence, and diagnosis of PTSD among studied females. Table 5 examined a univariate analysis of post-traumatic disorders and types of violence among studied females reporting the presence of a significant positive relationship (P < 0.001) between severe combined, emotional, physical violence, and diagnosis of PTSD among studied females. Figure 1 illustrates a statistically significant positive correlation between sexual violence and post-traumatic stress disorder (r = 0.393). Figure 2 illustrates a statistically significant positive correlation between emotional violence and post-traumatic stress disorder (r = 0.554). Figure 3 illustrates a statistically significant positive correlation between physical violence and post-traumatic stress disorder (r = 0. 649). Figure 4 illustrates a statistically significant positive correlation between harassment and post-traumatic stress disorder (r = 0.589). Table 6 examined the relationship between depressive disorder and types of violence among studied females showing that the presence of a significant positive relationship (P < 0.001) between all types of intimate partner violence and diagnosis and severity of depressive disorder among studied females.     Table 7 assessed univariate analysis of depressive disorders and types of violence among studied females revealing the presence of a significant positive relationship (P < 0.001) between severe combined, emotional, physical violence, harassment, and diagnosis of depressive disorder among studied females. Figure 5 illustrates a statistically significant positive correlation between harassment and depressive disorder (r = 0.637). Figure 6 illustrates a statistically significant positive correlation between physical violence and depressive disorder (r = 0.6 50). Figure 7 illustrates a statistically significant positive correlation between emotional violence and depressive disorder (r = 0.607). Figure 8 illustrates a statistically significant positive correlation between sexual violence and depressive disorder (r = 0.310). Table 8 studied the correlation between PTSD, depressive disorder and types of intimate partner violence among studied females showing that the presence of a significant positive relationship (P < 0.001) between all types of intimate partner violence and diagnosis of PTSD and depressive disorder among studied females.

Statistical analysis and data interpretation
Data were fed to the computer and analyzed using IBM SPSS Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Qualitative data were described using numbers and percentages. Quantitative data were described using mean, the standard deviation for parametric data after testing normality using Kolmogorov-Smirnov test. The significance of the obtained results was judged at the (0.05) level.

Data analysis Qualitative data
• Chi-square test for comparison of two or more groups • Monte Carlo test as correction for chi-square test when more than 25% of cells have count less than 5 in tables (> 2 × 2).

Spearman's correlation
Spearman's rank-order correlation is used to determine the strength and direction of a linear relationship between two non-normally distributed continuous variables and/or ordinal variables.

Discussion
This study aimed to evaluate the prevalence of different subtypes of intimate partner violence in a group sample of married females. Also, the current study examined the relation of intimate partner violence with subsequent depression and post-traumatic stress disorder disorders among those females, it highlights subtypes of intimate partner violence among the studied females according to the Composite Abuse Scale (CAS); the highest prevalence of the type of violence is harassment (72.2%) followed by physical violence (57.8%), severe combined violence (54.4%), emotional violence (53.3%), and finally the last one is sexual abuse (7.8%).
But, it can be easily noticed that sexual violence is the least type of violence; may be due to cultural, social, and religious considerations. Maybe the prevalence is higher if the sample was taken from the gynecology and obstetrics outpatient clinic.
A higher prevalence of intimate partner violence was found in another study [19,20] maybe because the females in the sample of this study were educated, all from urban areas. Uneducated or from rural areas perhaps different results were obtained.
A recent study reported that psychological abuse is more related to PTSD which may be explained by psychological abuse is attacking the female self-concept [21].
Another study agreed with our results about the relation between IPV and major depression disorder suggesting that depression may occur as a result of the IPV experience [22]. A univariate analysis of post-traumatic disorders and types of violence among studied females reporting the presence of a significant positive relationship (P < 0.001) between severe combined, emotional, physical violence, and diagnosis of PTSD among studied females was examined.
Assessed univariate analysis of depressive disorders and types of violence among studied females revealing the presence of a significant positive relationship (P < 0.001) between severe combined, emotional, physical violence, harassment, and diagnosis of depressive disorder among studied females.
Not surprisingly, the examined females reported symptoms of depression and PTSD appeared as a prevalent concern in the current study. Several studies [23, 24] confirmed these findings.
Finally, these results should not be considered as magnifying the negative effect of IPV on females but should be regarded as females are exposed to the burden of IPV and should be helped empowered in various ways such as providing psychiatric counselling for those females. Therapeutic interventions either psychotherapy or pharmacotherapy especially group therapy promise in helping victims of IPV to overcome this painful experience. Before we conclude, we would like to discuss the limitations of this study; the first limitation is the small sample size. Future research should be applied to a larger sample. Another limitation is the presence of important factors which may affect this issue such as education, no of children, age, occupation, and cigarette smoking of the intimate partner.

Conclusions
This study found that the prevalence of intimate partner violence among the studied group of females is high. In addition, the presence of a strong relationship between all types of intimate partner violence and the diagnosis of PTSD and depressive disorder among studied females.
Potential implications: these results can be applied clinically. These results should not be considered as magnifying the negative effect of IPV on females but should be regarded as females are exposed to the burden of IPV and should be helped empowered in various ways such as providing psychiatric counselling for those females. Therapeutic interventions either psychotherapy or pharmacotherapy especially group therapy promise in helping victims of IPV to overcome this painful experience.