Description of the condition
The definition of severe mental illness is based on diagnosis, duration and disability (NIMH 1987) and includes diagnoses such as schizophrenia (and related disorders), bipolar disorder and affective psychoses. The duration of severe mental illness is defined as at least two years and disability is defined as resulting in considerable impairment in daily functioning (NIMH 1987).
Violent crime is defined as any physical or sexual assault, robbery or attempted robbery, or threats of violence. People with severe mental illness are at a higher risk than the general population of being victims of all forms of violent crime, including domestic violence (perpetrated by partner or family members) and non-domestic violence (perpetrated by strangers or acquaintances) (Choe 2008; Maniglio 2009; Khalifeh 2010; Trevillion 2013). People with severe mental illness are more than 11 times more likely to report experiencing violent victimisation in the previous year than the general population (Teplin 2005). Around one-third of people with severe mental illness have experienced violence in the preceding year (Maniglio 2009).
Recent reviews have found that, compared to the general population, women with severe mental illness are at a greater risk of some types of violent victimisation than men with severe mental illness (Khalifeh 2010; Trevillion 2013). Moreover, people with severe mental illness who have experienced childhood abuse, who are homeless or who abuse substances are at particularly high risk of violent and repeat victimisation (Goodman 1997; Goodman 2001; Ehrensaft 2003; Bebbington 2011).
Violent victimisation among people with severe mental illness is shown to be associated with physical health problems, exacerbation of existing psychiatric symptoms, increased service use and hospitalisation, and poorer functioning and quality of life (Goodman 1997; Neria 2005; Mueser 2008). Victimisation is also found to increase the likelihood of re-victimisation and perpetration of violence among people with severe mental illness (Lam 1998; Hiday 2002; Swanson 2002). Despite these findings, studies have found low levels of routine enquiry about victimisation by mental health professionals, with detection rates of 10% to 30% reported in the literature (Howard 2010). Mental health professionals report low levels of knowledge about domestic violence support services and inadequate referral resources (Nyame 2013).
Description of the intervention
This review will examine interventions aimed at increasing the detection by health professionals of victimisation among people with severe mental illness, followed by either increased referral to external specialist agencies or the provision of appropriate support within the healthcare setting where the screening was conducted.
How the intervention might work
In high-income countries, most people with severe mental illness come to the attention of mental healthcare professionals. Interventions for victims of violence within these settings would have the following aims: (a) to identify people who have been victims of violence (b) to make onward referrals for victims where this is needed and wanted, for example, to advocacy services (c) to provide appropriate support for victims within the mental healthcare setting itself, for example, psychological interventions to address post-traumatic stress, or interventions aimed at addressing risk factors for re-victimisation such as substance misuse. The ultimate aim of these interventions would be to decrease the risk of re-victimisation and improve victims’ health and quality of life (WHO 2013). The existing evidence on interventions within healthcare settings to identify and support victims of violence is largely based in primary and antenatal care settings, with a focus on intimate partner violence (IPV). In those settings, routine screening for IPV increases identification, but there is insufficient evidence that this leads to increased specialist referrals, or to improved health outcomes for victims (Taft 2013; Feder 2009). These findings relate to universal screening of asymptomatic women in primary or obstetric healthcare settings. Universal screening may be appropriate for those presenting with mental health problems within primary or antenatal setting, and to those presenting to mental healthcare services, since this population is at increased risk of IPV and other forms of violence (Oram 2013; Hughes 2012). This is in line with recent World Health Organization (WHO) guidelines, which recommend routine enquiry for IPV in women presenting with depression (WHO 2013). Whether screening is universal or targeted, healthcare professionals need training to help them identify and respond to IPV safely and effectively. In primary care settings, there is evidence that training programmes linked with referral pathways can increase identification of IPV and subsequent referrals to domestic violence advocacy services (Feder 2011). There is preliminary evidence that similar interventions, which comprise training for health professionals, the introduction of a screening tool, and the integration of advocacy workers into mental healthcare teams, are effective at improving detection and external referral in mental healthcare settings.
There is some evidence that individual psychological treatments (such as trauma-focused cognitive behaviour therapy (CBT)) can reduce the adverse psychological or psychiatric consequences of IPV (Feder 2009; Ramsay 2005). Whilst non-mental healthcare settings would refer victims for psychological treatment where appropriate, secondary mental health services would be expected to provide such treatment internally. Mental health service users are a heterogeneous population, and include those with severe affective disorders, psychotic illnesses, personality disorders and substance misuse problems. Whilst the risk of victimisation is high for all diagnostic groups (Trevillion 2012), psychological interventions may not be equally available to all, and indeed is known to be limited for those with psychotic disorders (The Schizophrenia Commission 2012). However, there is evidence that the adverse psychological effects of victimisation can be addressed in people with schizophrenia and related disorders with individual CBT treatment (Mueser 2008). Therefore, enabling access to these treatments is important for those who screen positive for trauma within mental healthcare settings.
As well as providing specialist psychological treatment, mental healthcare professionals are well-placed to co-ordinate a multi-professional response focused on protecting vulnerable patients from further abuse or violence. In the UK, this is expected to be carried out within the ‘Safeguarding Adults’ framework (Mandelstam 2011). Therefore, screening for victimisation within mental healthcare settings needs to be linked to effective use of ‘Safeguarding’ or similar frameworks for multi-agency responses where appropriate.
In summary, we will focus on the effectiveness of screening interventions that aim to increase the detection of victimisation among people with severe mental illness by healthcare professionals (through the use of universal or targeted screening); followed by either (i) increased referral to external specialist agencies such as advocacy services or domestic violence shelters (ii) the provision of support within mental health services to improve health and outcomes among violence victims; such as the provision of specialist psychological treatments or the use of safeguarding procedures.
Why it is important to do this review
Victimisation among people with severe mental illness is highly prevalent and associated with significant psychosocial morbidity (Walsh 2003; Silver 2005; Teplin 2005). This is a considerable public health problem as it is associated with an increase in pre-existing severe mental illness symptoms and a reduction in overall functioning, in addition to the direct physical and emotional impact of violent victimisation and an increased risk of crime perpetration (Pease 1998; Ratcliffe 1998). Despite the high prevalence of violent victimisation among people with severe mental illness, levels of routine enquiry by mental health professionals about victimisation are low (Howard 2010). Detection is an important first step towards intervention and we aim to assess the effectiveness of screening interventions in improving detection rates of victimisation among people with severe mental illness. The effectiveness of screening programmes in decreasing re-victimisation and improving health outcomes for victims are determined not only by whether more cases are detected, but crucially by whether health professionals respond adequately to disclosures of violence (Feder 2013). We will therefore assess the effectiveness of screening followed by external referral or by the provision of support within the healthcare setting where the screening took place. Whilst there are existing systematic reviews of screening for IPV within primary care or antenatal settings, no past systematic reviews have focused on victimisation interventions for people with severe mental illness or within mental healthcare settings. This review aims to address this gap in the literature. Knowledge of such interventions would be invaluable for mental health clinicians, in addition to informing the design of services and allocation of funds within mental health services.