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Review
Intimate partner violence against adult women and its association with major
depressive disorder, depressive symptoms and postpartum depression: A
systematic review and meta-analysis
Hind A. Beydoun a, *, May A. Beydoun b, Jay S. Kaufman c, Bruce Lo d, Alan B. Zonderman b
a
Graduate Program in Public Health, Eastern Virginia Medical School, Post Ofce Box 1980, Norfolk, VA 23501-1980, USA
b
Laboratory of Behavioral Neuroscience, National Institutes on Aging, NIA/NIH/IRP, Baltimore, MD, USA
c
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
d
Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
a r t i c l e i n f o a b s t r a c t
Article history: To date, few systematic reviews of observational studies have been conducted to comprehensively
Available online 21 May 2012 evaluate the co-morbidity of intimate partner violence (IPV) and specic depression outcomes in women.
In this systematic review and meta-analysis, we summarize the extant literature and estimate the
Keywords: magnitude of the association between IPV and key depressive outcomes (elevated depressive symptoms,
USA diagnosed major depressive disorder and postpartum depression). PubMed (January 1, 1980eDecember
Women
31, 2010) searches of English-language observational studies were conducted. Most of the selected 37
Intimate partner violence
studies had cross-sectional population-based designs, focused on elevated depressive symptoms and
Major depressive disorder
Elevated depressive symptoms
were conducted in the United States. Most studies suggested moderate or strong positive associations
Postpartum depression between IPV and depression. Our meta-analysis suggested two to three-fold increased risk of major
Meta-analysis depressive disorder and 1.5e2-fold increased risk of elevated depressive symptoms and postpartum
depression among women exposed to intimate partner violence relative to non-exposed women. A
sizable proportion (9%e28%) of major depressive disorder, elevated depressive symptoms, and
postpartum depression can be attributed to lifetime exposure to IPV. In an effort to reduce the burden of
depression, continued research is recommended for evaluating IPV preventive strategies.
2012 Elsevier Ltd. All rights reserved.
0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2012.04.025
960 H.A. Beydoun et al. / Social Science & Medicine 75 (2012) 959e975
2002), insomnia (Burke et al., 2005; Campbell, 2002), post-traumatic studies in the English-language published between 1 January 1980
stress disorder (Bradley, Schwartz, & Kaslow, 2005; Koopman et al., and 31 December 2010. Fig. 1 shows the result of the search,
2005; Woods, 2005; Woods et al., 2005), anxiety (Burke et al., 2005; inclusion and exclusion criteria and the nal number of studies.
Campbell, 2002), depression (Al-Modallal, Peden, & Anderson, 2008;
Golding, 1999) and suicidal thoughts (Kramer et al., 2004; Meadows, Inclusion and exclusion criteria
Kaslow, Thompson, & Jurkovic, 2005).
The salience of IPV as a risk factor for mental health problems, in The process of including and excluding studies was initiated by
general, and depression, in particular, requires further evaluation. examining the study titles and abstracts and screening them for
To date, few systematic reviews of observational studies have been immediate relevance to our research question. Papers not excluded
conducted to comprehensively evaluate the co-morbidity of IPV based on their abstracts were obtained as full-text and screened for
and depression in women (Al-Modallal et al., 2008; Golding, 1999). potential inclusion in the systematic review and meta-analysis. The
In addition, no recent meta-analyses have been conducted to esti- studies that were included in the systematic review were those that
mate the magnitude of the association between IPV and specic assessed any type of association between IPV and depression (MDD
types of depressive outcomes. In 1999, Golding published a meta- or PPD) or EDS. Studies included in the meta-analysis were those
analysis to assess the prevalence of mental health problems that presented ndings in terms of risk ratios (RR), hazard ratios
among women with a history of intimate partner violence. The (HR) or odds ratios (OR), and thus had a binary outcome for MDD,
prevalence of mental health problems among women experiencing EDS or PPD and categorical measurement of IPV (usually binary).
IPV was 47.6% in 18 studies of depression, 17.9% in 13 studies of Primary reasons for excluding studies were No relevant data
suicidality, 63.8% in 11 studies of post-traumatic stress disorder, available, Study is a randomized controlled trial, Study subjects
18.5% in 10 studies of alcohol abuse, and 8.9% in 4 studies of drug are not adult women, Outcome is not MDD, EDS or PPD, or
abuse. Odds ratios (OR) representing associations of these mental Exposure is not IPV. No restriction was made on age or setting
health problems with IPV ranged from 3.55 to 5.62, and were (e.g. population-based vs. clinical), and the meta-analysis was
generally consistent across studies (Golding, 1999). In Goldings carried out on all observational study designs including cross-
meta-analysis, no distinction was made regarding specic types of sectional, prospective and retrospective cohort studies. IPV expe-
depression; the estimated OR (95% condence interval) for the rienced by individuals less than 18 years of age may be considered
association between IPV and depression was 3.80 (3.16e4.57) as teenage dating violence. Nevertheless, we decided to include
(Golding, 1999). In this systematic review and meta-analysis, we all studies that included adult women, irrespective of whether
conducted a PubMed (1980e2010) search of population-based and some of the subjects were teenagers.
clinical studies focusing on pregnant and non-pregnant women to A total of 234 manuscript titles and abstracts were initially
summarize the extant literature and estimate the magnitude of the identied for screening. The systematic literature search and
association between IPV and key depressive outcomes (elevated screening of abstracts yielded 83 potentially relevant papers, from
depressive symptoms (EDS) detected by various screening instru- which 37 were eventually selected for review and meta-analysis
ments, diagnosed major depressive disorder (MDD) and post- upon further examination of their full-text. As such, a database
partum depression (PPD)). was created using Endnote version X3 (Endnote, 2010) and an
Excel sheet was used by two authors to extract data on study
Materials and methods characteristics.
The literature search was conducted systematically using the We conducted a meta-analysis of selected studies to assess the
PubMed database by combining the keywords depression and strength of the association between IPV and various outcomes of
intimate partner violence. To avoid heterogeneity in the way interest, namely MDD, EDS and PPD when the study subject was
these concepts were dened, synonymous keywords were not an adult woman. The type of instrument used for each of these
included in the search. We restricted the literature search to human outcomes differed among studies and are listed in Table 1.
Study # First author Year Study name Country Design, Sample size # of outcome casesb Follow-up Outcome Exposure Main ndings Adjustment
setting time, age
1 (Al-Modallal 2010 e Jordan CX, PB N 101 n 40, Age: 25e>40 y EDS, the Center of IPV, lifetime spouse Spousal abuse vs. Age, marital status,
et al., 2010) [Prevtot 39.6%], Epidemiology abuse, items EDS: OR 3.5; 95% education, parity,
[Prev0 36.8%] Study-Depression derived from CI: 1.05, 11.7 income, health
(CES-D); Score 16 a congressional insurance, spouse
(Radloff, 1977) report (Ofce, occupational status.
1998)
2 (Bauer et al., 2000 e US CX, PB N 734 n 242, Age: 18e46 y EDS, self-report of IPV, Abuse EDS vs. IPV: Abused Age and marital
2000) [Prevtot 33%], depressed mood or Assessment Screen in past: OR 2.1; status.
[Prev0 22%] ahedonia over the (McFarlane et al., 95% CI: 1.5, 3.0
past four weeks 1992) Recent abuse:
(Whooley et al., OR 3.5; 95% CI:
1997) 2.2, 5.5
3 (Beydoun et al., 2010 Maternity Canada CX, PB N 6421 n 482, Age: 15 y PPD, Edinburgh IPV, 10-items IPV vs. PPD: Education, income,
2010)a Experience Survey [Prevtot 7.5%], Postpartum screener (MES) OR 1.61; 95% CI: urban-rural,
(MES) [Prev0 7%] Depression Scale; (Dzakpasu, 1.06,2.45 Immigrant status,
961
Table 1 (continued )
962
Study # First author Year Study name Country Design, Sample size # of outcome casesb Follow-up Outcome Exposure Main ndings Adjustment
setting time, age
2006; Verhoek- RR 2.31; 95% CI:
Oftedahl, Pearlman, 1.88, 2.84
& Coutu Babcock,
2000; Vest, Catlin,
Chen, & Brownson,
2002)
7 (Bonomi et al., 2006 Behavioral Risk US CX, PB N 3429 n 687, Age: 18e64 y EDS, ve questions IPV, the Womens EDS vs.: Recent IPV: Age, income, and
2006) Factor Surveillance [Prevtot 20%], from the Center for Experience with RR 2.38; 95% CI: any physical or
System (BRFSS) [Prev0 13.8%] Epidemiological Battering (WEB) 1.98, 2.86 Remote sexual abuse as
Studies-Depression scale and ve IPV: RR 1.51; 95% a child.
(CES-D) scale. questions from the CI: 1.27, 1.80.
Cutoff at 4; range BRFSS survey Physical IPV:
0e15 (Shrout & (Coker et al., 2001; RR 2.61; 95% CI:
Yager, 1989) Coker et al., 2000) 2.02, 3.38 Non-
physical IPV:
RR 2.06; 95% CI:
963
(continued on next page)
Table 1 (continued )
964
Study # First author Year Study name Country Design, Sample size # of outcome casesb Follow-up Outcome Exposure Main ndings Adjustment
setting time, age
Mild through e9 Moderate PPD: the WHO multi- 1.02, 1.88 IPV vs.
Severe PPD 10e14 Severely country study on Moderate PPD:
moderate PPD: 15 violence against OR 2.26; 95% CI:
e19 Severe PPD: 20 women (Garcia- 1.64, 3.12 IPV vs.
e27 Moreno et al., 2006) Severely moderate
IPV: OR 3.88; 95%
CI: 2.64, 5.70 IPV vs.
Severe PPD:
OR 5.19; 95% CI:
2.96, 9.10 IPV
during pregnancy:
IPV vs. Mild PPD:
OR 1.46; 95% CI:
0.94, 2.27 IPV vs.
Moderate PPD:
OR 2.88; 95% CI:
965
(continued on next page)
Table 1 (continued )
966
Study # First author Year Study name Country Design, Sample size # of outcome casesb Follow-up Outcome Exposure Main ndings Adjustment
setting time, age
e6 weeks after Score 12 (Patel, Study on Womens violence vs. lowest: violence vs.
delivery Rodrigues, & Health and OR 2$29; 95% CI: physical or sexual
DeSouza, 2002) Domestic Violence 1$15, 4$57 Physical violence) age, race,
against Women or sexual violence: marital status,
Study Team OR 0.91; 95% years of schooling,
(Garcia-Moreno CI:0.54, 1.54 employment status,
et al., 2006) communication
with present or
most recent
partner, controlling
behavior of present
or most recent
partner, social
support, and length
of follow-up,
history of mental
967
(continued on next page)
968 H.A. Beydoun et al. / Social Science & Medicine 75 (2012) 959e975
Abbreviations: CClinical; CX Cross-sectional; DSM Diagnostic and statistical manual; EDS Elevated depressive symptoms; HR Hazard ratio; IPV Intimate partner violence; IRR Incidence rate ratio; MDD Major
depressive disorder; PB Population-based; PC Prospective cohort; PPD Post-partum depression; NR Not reported; OR Odds ratio; RC Retrospective cohort; RR Risk ratio; WHO World health organization;
Prevtot was calculated from available tabulated data or obtained directly from text. Prev0 was mainly obtained from tabulation data. In some cases, the denominator was smaller than the one presented under the column (sample
drug use, husbands
employment status,
during childhood.
religious activity
Age, alcohol and
ment or diagnostic tool used to measure the outcome. IPV expo-
Adjustment
sures, though dened differently across studies (See Table 1), were
considered comparable as in the case of the outcomes and were
not distinguished for stratication purposes in the meta-analysis.
Although physical and/or sexual forms of IPV are likely to have
a greater impact on depression than psychological/emotional
partner: OR 3.07;
OR 1.93; 95% CI:
physical IPV:
sexual IPV:
EDS, two-question
ORp;ij 1 P0i
(Whooley et al.,
(Radloff, 1977)
RRp;ij 1.1
case nding
P0i ORp;ij
instrument
Outcome
1997)
ln ORucl;ij ln ORlcl;ij
SElnRRij SElnORij 1.2
3:92
Age: 18e50 y
Follow-up
time, age
lnRRp;ij 1:96SEln
RR95%CI;ij e RRp;ij 1.3
data point j; ORp,ij is the point estimate of OR from each study i and
[Prev0 36.0%]
[Prevtot 38%],
(p < 0.05) or xed effect when the set of data points were
homogenous (p > 0.05). The pooled RR was computed by taking
weighted average of the natural logarithm of each relative measure
Design,
CX, PB
points by study design only, that is, data points related to different
outcomes were pooled together. As such, a summary RR was
provided using forest plots for cross-sectional and cohort studies,
separately. At a second stage, estimates were stratied to examine
Study name
2. Clinical. When selecting data points (i.e. RR with 95% CI) from
each study, only fully adjusted models were considered. These
models often included as potential confounders age, a measure of
(Yang et al.,
First author
percentage (PAR%) by pooling data points from all studies together (Shaver & Brennan, 1991) and the General Health Questionnaire
but stratifying by type of outcome. (GHQ) (n 1) (Goldberg, 1972). It is worth noting that the latter
study used a 1-question item, which is problematic due to the high
100 Prexp RRp;lcl;ucl;ij 1 proportion of false positives identied using only this item
PAR%p;lcl;ucl;ij (Goldberg, 1972). For PPD, the most commonly used instrument
1 Prexp RRp;lcl;ucl;ij 1 2.1 was the Edinburgh postpartum depression scale (EPDS)
(Cox, Holden, & Sagovsky, 1987) (n 4), whereas diagnosis of MDD
1 qij 100
was conducted using criteria from the International Classication
of Diseases (ICD-9 or 10) (WHO, 1992) (n 2) or a combination of
2 Diagnostic and Statistical Manual (DSM-IV) (Kessler & Ustun,
Var qij Var 1 qij 1 PARp;ij 2004) and Composite International Diagnostic Interview (CIDI)
2 (A.P.A., 1994) (n 3). The mean prevalence rates of MDD, EDS
Var ln 1 PARp;ij 1 PARp;ij 2.2
. 2 and PPD from the selected studies were 11.4% (range: 4.8%,
ln 1 PARlcl;ij ln 1 PARucl;ij 3:92 24.1%), 26.1% (range: 7.0%, 75.0%) and 30.7% (range: 7.5%, 89.8%),
respectively.
Although IPV was measured differently across studies, there
q
were commonalities in screening tools among the selected studies.
PAR%95%CI;ij PAR%p;ij 1:96 Var qij 100 2.3
For instance, the AAS (McFarlane, Parker, Soeken, & Bullock, 1992),
a commonly used tool for the assessment of IPV, was used in seven
As shown in Equations (2.1)e(2.3), RR (point estimates per study of the 37 studies, while the CTS (Form R) was used in six studies
and data point; 95% CI) was applied to the formula and Prexp was (Strauss & Corbin, 1990). It is worth noting, however, that even if
the estimated prevalence of IPV exposure (recent and lifetime) in several studies have relied on the same IPV screening tool, some
the United States. The estimation of SE for PAR% was obtained using studies may have used all questions, while others may have used
the delta method (Hildebrandt, Bender, Gehrmann, & Blettner, sub-scales to reect specic IPV sub-types, namely physical, sexual
2006). and/or emotional/psychological IPV. One or several data points for
Finally, we used Beggs funnel plots to examine publication bias; each study were entered mainly due to alternative and distinctive
RR point estimates were plotted against their standard errors (SE) ways of dening IPV (e.g. emotional abuse vs. sexual abuse vs.
for each study on a logarithmic scale (Egger, Davey Smith, physical abuse or combinations). Moreover, in studies where
Schneider, & Minder, 1997; Egger, Smith, & Altman, 2001). This doseeresponse was assessed, all reported measures of association
type of bias was formally tested using Begg-adjusted rank corre- (RR) were considered as independent data points.
lation tests (Begg & Mazumdar, 1994) and Eggers regression RR estimates were adjusted for socio-demographic and other
asymmetry test (Egger et al., 1997). All analyses were conducted covariates in most cases (25 out of 37 studies). Some of the most
with STATA 11.0 (StataCorp, College Station, TX) (STATA, 2009). commonly controlled for covariates included age (28 out of 37),
Type I error was set at 0.05. education (20 out of 37), income (16 out of 37), employment status
(13 out of 37) and marital status (13 out of 37). Alcohol and drug
Results dependence was also adjusted for in a number of studies (11 out of
37) and so was childhood sexual abuse (10 out of 37). Other forms
Table 1 characterizes the 37 studies included in our systematic of stressful events or types of violence were adjusted for in 9 out of
review and meta-analysis. Although our literature search spanned 37 studies.
publication years of 1980 until 2010, relevant studies which we
nally selected were published between the years 2000 and 2010. Major depression
Twenty-four of the 37 studies were conducted in the United States;
32 were cross-sectional studies while only ve were prospective or MDD was the outcome related to IPV in ve out of 37 studies
retrospective cohort studies. Sample sizes ranged between 101 and (Bonomi, Anderson, Reid et al., 2009; Chang, Shen, & Takeuchi,
7154 surveyed participants, with about 60% of selected studies 2009; Deyessa et al., 2009; Hazen, Connelly, Kelleher, Landsverk,
having a sample size greater than 1000. The minimum in the age & Barth, 2004; Lipsky, Caetano, & Roy-Byrne, 2009). There was
range reported for each study was 18 years or more in 27 studies consistent evidence for direct relationship between IPV and MDD in
and <18 years in 10 studies. Most studies were population-based all studies. For instance, Bonomi (Bonomi, Anderson, Reid et al.,
(24 of 37), while the remaining 13 were conducted in a clinical 2009) studied 3568 women, 18e64 years, who participated in the
setting (e.g. hospital waiting room). In 17 out of 37 selected studies, Behavioral Risk Factor Surveillance System (BRFSS). MDD was
the primary aim was to examine the relationship between IPV and dened according to ICD-9 criteria (Stareld, Weiner, Mumford, &
depression. Steinwachs, 1991; Weiner, Stareld, & Lieberman, 1992; Weiner,
For the depression outcome, the majority of studies examined Stareld, Steinwachs, & Mumford, 1991); IPV was dened accord-
EDS (n 25), whereas only seven examined PPD and ve examined ing to the WEB scale (Smith et al., 1995) and 5 questions from the
MDD. Seven of the 25 studies with EDS as outcome used the 20- BRFSS (Bonomi et al., 2006; Thompson et al., 2006). Results indi-
item CES-D as the screening tool with a cut-point of 16 cated that the odds of MDD were 3.26 times higher among women
commonly used to reect minor depressive symptoms (Radloff, with an IPV history compared to those without an IPV history
1977). However, other screening tools were also used commonly (Bonomi, Anderson, Reid et al., 2009).
including the shorter versions of the CES-D. Some examples were
the Patient Health Questionnaire (PHQ-9) (Spitzer, Williams, Depressive symptoms
Kroenke, Hornyak, & McMurray, 2000) and its shorter version
(n 2) (Berg, 2002; Corson, Gerrity, & Dobscha, 2004; Li, Friedman, EDS was the outcome related to IPV in 25 out of 37 studies (Al-
Conwell, & Fiscella, 2007; Lowe, Kroenke, & Grafe, 2005; Whooley, Modallal et al., 2010; Bauer, Rodriguez, & Perez-Stable, 2000;
Avins, Miranda, & Browner, 1997), Beck Depression Inventory (BDI) Bonomi, Anderson, Cannon, Slesnick, & Rodriguez, 2009; Bonomi,
(Beck, Steer, & Brown, 2000) and its shorter version (n 5) Anderson, Rivara, & Thompson, 2007; Bonomi et al., 2006;
970 H.A. Beydoun et al. / Social Science & Medicine 75 (2012) 959e975
Caetano & Cunradi, 2003; Coker, Pope, Smith, Sanderson, & test (Z 0.37; P 0.71), which indicated non-signicant publica-
Hussey, 2001; Coker, Smith et al., 2002; Davis, Coker, & tion bias (P > 0.05), and by Eggers regression asymmetry test (bias
Sanderson, 2002; Dunn & Oths, 2004; Gielen, McDonnell, (SE): 0.32 (0.42); p 0.48).
OCampo, & Burke, 2005; Hathaway et al., 2000; Hegarty, Gunn, Fig. 2AeC shows a forest plot for the association between IPV
Chondros, & Small, 2004; Hegarty, Gunn, Chondros, & Taft, and the three depression outcomes (MDD, EDS and PPD) for fully
2008; Hillemeier, Weisman, Chase, & Dyer, 2008; Houry, adjusted models in each cross-sectional study and ndings of our
Kemball, Rhodes, & Kaslow, 2006; Hurwitz, Gupta, Liu, pooled analysis. Pooled RR for IPV and MDD indicated a close to
Silverman, & Raj, 2006; Lehrer, Buka, Gortmaker, & Shrier, three-fold increased risk of MDD when IPV was present compared
2006; Rodriguez et al., 2008; Romito & Grassi, 2007; Schneider, to when IPV was absent (RR 2.70; 95% CI: 2.22, 3.29) (Fig. 2A).
Burnette, Ilgen, & Timko, 2009; Vaeth, Ramisetty-Mikler, & Cae- Pooled RR for EDS and PPD were indicative of increased risk of
tano, 2010; Vung, Ostergren, & Krantz, 2009; Wong, Huang, depression in the presence of IPV. Using a random-effects model of
DiGangi, Thompson, & Smith, 2008; Yang, Yang, Chang, Chen, & 45 data points (from 22 studies) including EDS and IPV, a pooled RR
Ko, 2006). Several of the large population-based cross-sectional of 1.81 was obtained with a 95% CI of (1.63, 2.01) (Fig. 2B). In the
studies used BRFSS data (Bonomi, Anderson, Cannon et al., 2009; case of PPD, the risk was increased by less than 50% (RR 1.43; 95%
Bonomi et al., 2007, 2006; Hathaway et al., 2000; Hurwitz et al., CI: 1.21, 1.69) (Fig. 2C).
2006), and the majority of studies provided evidence for a posi- The associations between IPV and all depression outcomes in
tive association between IPV and EDS. For studies where IPV was the selected cohort studies are presented in Fig. 3. Using a random-
dened as a dichotomous variable, the strongest positive effects model, pooled RR from those cohort study data points was
IPVeEDS association (OR 4.50) was reported by Vung (Vung found to be 1.87 with a 95% CI of (1.42, 2.46). It is worth noting that
et al., 2009), whereas the weakest positive IPVeEDS association this analysis was not stratied by type of outcome at this point due
(OR 1.85) association was reported by Bonomi (Bonomi, to the singular data point found in the case of MDD. In all pooled
Anderson, Cannon et al., 2009). analyses, signicant heterogeneity between data points were found
based on the Q-test (p < 0.001) except for cross-sectional studies
Postpartum depression with MDD as outcome (p 0.19).
Table 2 presents further subgroup analyses for pooled RR of IPV
PPD was the outcome related to IPV in seven out of 37 studies and depression outcomes. The stratifying variables included
(Beydoun, Al-Sahab, Beydoun, & Tamim, 2010; Gao, Paterson, depression outcome type, geographical region, minimum age of
Abbott, Carter, & Iusitini, 2008; Gomez-Beloz, Williams, Sanchez, study subjects and study setting. Heterogeneity was examined
& Lam, 2009; Hayes, Ta, Hurwitz, Mitchell-Box, & Fuddy, 2010; overall and within each of the two study designs (i.e. cross-
Hegarty et al., 2004; Ludermir, Lewis, Valongueiro, de Araujo, & sectional vs. cohort studies). RR of IPV and depression did not
Araya, 2010; Tiwari et al., 2008; Valentine, Rodriguez, Lapeyrouse, differ signicantly across strata in the case of cohort studies.
& Zhang, 2010). Most studies were cross-sectional with only two However, in cross-sectional studies and both study designs
prospective cohort studies (Ludermir et al., 2010; Valentine et al., combined, signicant differences in RR were noted between
2010). For studies that examined IPV as a dichotomous variable in outcome strata, indicating a considerably stronger association
relation to PPD, measures of association between IPV and PPD between IPV and MDD, as compared to PPD and EDS. RR were
ranged between 1.40 (Hayes et al., 2010) and 5.38 (Valentine et al., homogenous across all other strata in cross-sectional studies and in
2010). both designs combined (based on Q-test, p > 0.05).
Seven studies used odds ratios or relative risks to explicitly Fig. 4 shows PAR% which estimates the proportion of disease
examine doseeresponse relations between exposure and outcome, (three depression outcomes) in the study population that is
of which 6 assessed varying degrees of exposure to IPV (Caetano & attributable to the exposure (IPV: lifetime or recent). When
Cunradi, 2003; Chang et al., 2009; Hazen et al., 2004; Houry et al., considering lifetime IPV prevalence in the United States (estimated
2006; Lehrer et al., 2006; Romito & Grassi, 2007) and one consid- at 25%) (Tjaden & Thoennes, 1998a,b; Tjaden & Thoennes, 2000),
ered association of IPV to magnitude of depression severity pooled PAR% were found to be 27.7% (95% CI: 20.6%, 34.8%) for MDD,
(Gomez-Beloz et al., 2009). Among those studies that considered 16.9% (95% CI: 13.7%, 20.1%) for EDS and 9.0% (95% CI: 4.7%, 13.4%)
variation in IPV exposure, 5 measured severity (Caetano & Cunradi, for PPD, indicating that an appreciable percentage of depression
2003; Chang et al., 2009; Gomez-Beloz et al., 2009; Hazen et al., could be averted (on average: 9.0%, 27.7%) by eliminating lifetime
2004; Lehrer et al., 2006) and 2 used the number of exposures to IPV among adult women in the United States. Similar results were
different categories of abuse (e.g. physical, sexual, emotional, etc.) found when considering recent IPV (e.g. within a year), the prev-
(Houry et al., 2006; Romito & Grassi, 2007). All trends were in the alence of which in the United States was estimated at 10% (Tjaden &
expected direction, with more severe types or more categories of Thoennes, 1998a,b; Tjaden & Thoennes, 2000). On average, PAR%
IPV exposure always associated with increased odds of depression ranged between 3% and 13% indicating that these percentages of
outcomes. depression cases can be prevented by eliminating recent IPV among
Our meta-analysis relied on 37 studies with adequate measures women in the United States. It is worth noting that 10% of the
of association that could be pooled together; 80 data points con- United States population of women represents approximately 15
sisted mainly of adjusted OR from multiple logistic regression million women who have been exposed to IPV over the past year. In
models with their CI and were focused on categorical measures of addition, about 12 million women in the United States experience
IPV in relation to MDD, EDS and PPD. clinical depression every year. This PAR% suggests that if IPV was
Publication bias for the data points (n 80) was assessed using prevented, around one million cases of clinical depression could be
primarily the funnel plot which plotted point estimates of RR, OR averted.
and HR on loge scale against standard errors. Those data points
were selected for fully adjusted models with IPV as the main Discussion
exposure variable associated with any of the three main outcome
variables. This plot indicated that all data points lay within the In this study, we conducted a systematic review and a meta-
pseudo 95% condence limits indicating non-appreciable publica- analysis of published research articles (1980e2010) that exam-
tion bias. This was conrmed by a Begg-adjusted rank correlation ined the relationship between IPV and various outcomes related to
H.A. Beydoun et al. / Social Science & Medicine 75 (2012) 959e975 971
Fig. 2. A. Forest plot for associations between intimate partner violence and major depressive disorder, cross-sectional studies (N 9 data points; 4 studies). B. Forest plot for
associations between intimate partner violence vs. elevated depressive symptoms, cross-sectional studies (N 45 data points; 22 studies). C. Forest plot for association between
intimate partner violence and postpartum depression, cross-sectional studies (N 17 data points; 6 studies).
depression, namely MDD, EDS and PPD. Of the selected 37 studies, outcome variables. Interpretation of results pertaining to EDS is
most had a cross-sectional population-based design, were focused complicated since the depression disease spectrum covered by
on EDS as the outcome of interest and were conducted in the different screening instruments varies from mild (not requiring
United States. A large number of studies found a moderate or intervention) to severe (requiring intervention). Although search,
a strong positive association between IPV and depression. This inclusion and exclusion criteria were clearly outlined, no further
meta-analysis suggested two to three-fold increased risk of MDD efforts were made to obtain additional research articles through
and 1.5e2-fold increased risk of EDS and PPD among women cross-references, the Related Articles feature on PubMed or by
exposed to IPV as opposed to women not exposed to IPV. Finally, consulting experts in the area. Finally, PubMed was the only data-
a sizable proportion (9e28%) of MDD, EDS and PPD may be base used and no terms synonymous to intimate partner violence
attributed to lifetime exposure to IPV. and depression were applied.
Careful interpretation of study ndings should take into account To our knowledge, only two similar studies have been con-
the strengths and limitations of the studies selected as well as those ducted so far (Al-Modallal et al., 2008; Golding, 1999). A recent
of our meta-analysis. Whereas most of the selected studies had study by El-Modallal and colleagues evaluated childhood and
relatively large sample sizes, most had a cross-sectional design intimate partner physical abuse as risk factors for depressive
which does not allow for establishing a temporal relationship symptoms among women (Al-Modallal et al., 2008). The scope of
between IPV and depression. In fact, some studies (Lehrer et al., our study was greater for the types of exposures and outcomes that
2006) actually look at depression as a cause of IPV, not vice versa. were examined (Al-Modallal et al., 2008). In addition, our study
Nevertheless, the few prospective cohort studies that were included both a systematic review and a meta-analysis. Consistent
included in our meta-analysis yielded similar estimates of an IPV- with our ndings, the systematic review by El-Modallal and
depression association when compared to cross-sectional studies. colleagues indicated an association between physical abuse expe-
The selected English-language studies were mostly relevant to riences and depressive symptoms, although the association of other
Western societies and were heterogeneous in various respects, risk factors, including other types of abuse, with depressive
including study design, setting and measurement of exposure and symptoms confounded this relationship (Al-Modallal et al., 2008).
972 H.A. Beydoun et al. / Social Science & Medicine 75 (2012) 959e975
Fig. 3. Forest plot for associations between intimate partner violence and depression (all outcomes), cohort studies (N 9 data points; 5 studies).
Given the global burden of depression on the female pop- prevention is a universal effort targeting entire communities and
ulation, IPV prevention provides an opportunity for reducing the aimed at warding off maladaptive behaviors that could lead to IPV.
risk of MDD, EDS and PPD. Preventive efforts can be described as Examples of primary prevention strategies include educational
being either universal (population-based approach) or targeted and media programs that target entire communities with the goal
(high-risk approach) interventions, depending on their scope and of preventing IPV before it is initiated (Stith, 2006a). School-based
coverage (Stith, 2006b). Alternatively, primary, secondary and intervention programs initiated in teenage years have been shown
tertiary prevention programs have been designed to reduce the to be effective at reducing dating violence, a precursor of IPV, even
burden of IPV and its health sequelae on society by targeting the after four years of program implementation (Foshee, Beneeld,
appropriate risk factors for IPV. The task of public health is mainly Ennett, Bauman, & Suchindran, 2004). By contrast, secondary
primary prevention (Last, 2001). In the context of IPV, primary prevention is usually the task of preventive medicine (Last, 2001).
Table 2
Subgroup analyses: pooled relative risk (RRa) and 95% condence interval (CIa) of IPV and depression outcomes among adult women: fully adjusted modelsc,d.
Fig. 4. Population Attributable Risk (PAR) for intimate partner violence vs. depression (all outcomes; cross-sectional and cohort studies combined).
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