Routine primary care screening for intimate partner violence and other adverse psychosocial exposures: what’s the evidence?

Abstract

BackgroundFamily physicians and other primary care practitioners are encouraged or expected to screen for an expanding array of concerns and problems including intimate partner violence (IPV). While there is no debate about the deleterious impact of violence and other adverse psychosocial exposures on health status, the key question raised here is about the value of routine screening in primary care for such exposures.DiscussionSeveral characteristics of IPV have led to consideration for routine IPV screening in primary care and during other healthcare encounters (e.g., emergency room visits) including: its high prevalence, concern that it may not be raised spontaneously if not prompted, and the burden of suffering associated with this exposure. Despite these factors, there are now three randomized controlled trials showing that screening does not reduce IPV or improve health outcomes. Yet, recommendations to routinely screen for IPV persist.Similarly, adverse childhood experiences (ACEs) have several characteristics (e.g., high frequency, predictive power of such experiences for subsequent health problems, and concerns that they might not be identified without screening) suggesting they too should be considered for routine primary care screening. However, demonstration of strong associations with health outcomes, and even causality, do not necessarily translate into the benefits of routine screening for such experiences. To date, there have been no controlled trials examining the impact and outcomes – either beneficial or harmful - of routine ACEs screening. Even so, there is an expansion of calls for routine screening for ACEs.SummaryWhile we must prioritize how best to support and intervene with patients who have experienced IPV and other adverse psychosocial exposures, we should not be lulled into a false sense of security that our routine use of “screeners” results in better health outcomes or less violence without evidence for such. Decisions about implementation of routine screening for psychosocial concerns need similar rigorous debate and scrutiny of empirical evidence as that recommended for proposed physical health screening (e.g., for prostate and breast cancer).

Getting to Why: Adverse Childhood Experiences' Impact on Adult Health

“…11 However, no research exists that demonstrates improvement in health outcomes with screening, and neither the US Preventive Services Task Force nor the World Health Organization has made screening recommendations. 32 The lack of high-level evidence needs to be balanced with case study evidence: Kaiser-Permanente has interviewed more than 2,000 patients about childhood adversity in their weight loss program, finding that many patients experience relief in the process. One patient in their obesity recidivism study wrote, "The shame, guilt, and pain for the abuse and molestations in childhood, and being raped, was so great that I had to come forward or die.…”

Family Violence: An Insight Into Perspectives and Practices of Australian Health Practitioners

“…Therefore, having such questionnaires might lower rates of interpersonal misunderstanding and increase patient disclosure (Friedman, Samet, Roberts, Hudlin, & Hans, 1992; Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000). A systematic review has also concluded that training health professionals to engage in effective routine inquiry creates an avenue for greater patient disclosure (Ramsay, Richardson, Carter, Davidson, & Feder, 2002; Taket et al, 2003), although there is a lack of evidence in the health benefits, such as identification and prevention of physical and mental conditions (McLennan & MacMillan, 2016). Recent investigations support these findings and revealed that routine screening was either targeted or routine depending on the guidelines of the country (McLennan & MacMillan, 2016).…”

“…A systematic review has also concluded that training health professionals to engage in effective routine inquiry creates an avenue for greater patient disclosure (Ramsay, Richardson, Carter, Davidson, & Feder, 2002; Taket et al, 2003), although there is a lack of evidence in the health benefits, such as identification and prevention of physical and mental conditions (McLennan & MacMillan, 2016). Recent investigations support these findings and revealed that routine screening was either targeted or routine depending on the guidelines of the country (McLennan & MacMillan, 2016). In Australia, current practices include targeted screening for the general population and routine screening for women during antenatal care (Royal Commission Into Family Violence, 2016).…”

Common health problems in safety‐net primary care: Modeling the roles of trauma history and mental health

“…For example, one study on antidepressants found that persons with a trauma history were less responsive to antidepressants alone and benefit from concurrent therapy, compared with patients without a trauma history (Nemeroff et al, ). Evidence for universal screenings of trauma exposure for all patients is still mixed, and opportunity cost associated with screening time and intervention should also be weighed (McLennan & MacMillan, ). Further research on trauma‐informed treatments for depression/anxiety, particularly those which can be adapted to primary care settings, is necessary to improve mental health and reduce somatization.…”