Development of a Brief Mental Health Screen for Intimate Partner Violence Victims in the Emergency Department

The Centers for Disease Control and Prevention estimates that the total cost of intimate partner violence (IPV) for women in the United States is $5.8 billion annually,1 with $4 billion in direct health care costs.2 In addition, Arias and Corso reported that the average cost per woman victimized by a male intimate partner is $948, including $207 in mental health services.3 Previous research has demonstrated that IPV victims have a 1.6- to 2.3-fold higher rate of medical care use than females who did not disclose victimization.4 Thus, abused women seek treatment for physical injuries, chronic medical illnesses, or mental health sequelae of abuse in emergency departments (EDs) at higher rates than other women. A recent study by Houry et al. found a one-year prevalence rate of 36% for IPV victimization among African American females presenting to an inner-city ED.5 Abbott et al. reported a lifetime prevalence rate of 54% for IPV victimization among female ED patients, as well as an acute incidence rate of 12%.6 Mental health problems also are associated with severe economic burden in the United States. Depression costs $83.1 billion annually, with $26.1 billion in direct costs and $5.4 billion for suicide-related costs.7 Affective disorders average $30.4 billion annually and represent 21% of the cost of all mental illnesses in the United States.8 Individuals with mental health problems often present to the ED, rather than to mental health professionals, and many times their psychiatric symptoms go undetected or undiagnosed in the ED setting.9 In a multicenter study, Kumar et al. found that 30% of ED patients endorsed depressive symptoms.10 Meldon et al. reported that in a sample of 295 ED patients aged 65 years and older, 27% were depressed and emergency physicians failed to recognize depression in all of them.11 Classen and Larkin found that 12% of ED patients acknowledged suicidal ideations, and 25 of the 31 patients planning suicide were undetected during their index visit.12 Previous research also has demonstrated a strong association between IPV victimization and mental health symptoms. In a group of women diagnosed with depression, 61% reported experiencing IPV in their lifetime.13 Caetano and Cunradi reported that, among women who had experienced IPV in the past year, 20%–38% disclosed depressive symptoms.14 IPV victimization also has been associated with posttraumatic stress disorder (PTSD). Estimates of the prevalence of PTSD among women who have experienced IPV in the past year range from 33% to 84%.15–17 In a nationally representative sample of women, physical abuse, sexual abuse, psychological abuse, and stalking were all found to be significantly associated with PTSD.18 Perhaps the most severe mental health problem associated with IPV is suicidal behavior. Kaslow et al. reported that physical (odds ratio [OR], 2.5) and nonphysical (OR, 2.8) partner abuse were risk factors for suicide attempts in low-income, African American women.19 Houry et al. found that women who had experienced three types of IPV (emotional, physical, and sexual) were at increased risk for suicidality (OR, 17.5 for 3) compared with women who did not disclose any IPV.5 In another study, Bergman and Brismar stated that 22 of 117 battered women had made 82 suicide attempts over a period of 16 years.20 Thus, the link between IPV and mental health symptoms should be strongly considered in all IPV victims. The high level of health care utilization by both IPV victims and patients with mental health symptoms provides many opportunities for screening and diagnosis. Many professional organizations have suggested required screening for IPV in hospital EDs, and the Joint Commission on Accreditation of Healthcare Organizations requires all EDs to have policies and procedures in place for screening patients for IPV.21 Because of the strong association between IPV victimization and mental health symptoms, all women who disclose IPV victimization should receive targeted screening for mental health symptoms. Identifying these IPV victims who are at increased risk for moderate to severe mental health symptoms and providing referrals to mental health services should lessen the mental health sequelae associated with their abuse. Targeted treatment and referrals should also improve the health outcomes of these patients, thereby reducing the impact of IPV victimization on their health and daily functioning. However, emergency physicians work in a chaotic and busy environment; any screen must be brief and practical to use in the ED. The objective of this study was to develop a brief mental health screen that could be used feasibly in an ED to screen IPV victims for depressive symptoms, PTSD symptoms, and suicidal ideation. More specifically, our objective was to use validated scales of mental health problems, the Beck Depression Inventory II (BDI-II), the Posttraumatic Stress Diagnostic Scale (PDS), and the Beck Scale for Suicide Ideation (BSS), and from these scales develop a group of questions that would predict moderate to severe mental health symptoms among female IPV victims in the ED.