The Lancet Psychiatry Commission on intimate partner violence and mental health: advancing mental health services, research, and policy

Part 1: Introduction Intimate partner violence (IPV) is the most common form of violence worldwide and contributes substantially to the global burden of mental health problems. The Lancet Psychiatry Commission on intimate partner violence and mental health met to consider progress in reducing the prevalence of IPV and associated mental health harms, and to establish a roadmap for strengthening responses across mental health services, research, and policy. Mental health care is delivered predominantly through primary care globally, but the relationship between IPV and severe mental health problems, and how best to address IPV within secondary mental health care, have been neglected. We therefore focus mainly on the changes needed to address IPV within secondary mental health care. Our focus on mental health is pragmatic rather than exclusionary, and we also recognise the need for broader change across multiple disciplines, systems, and institutions. Part 2: Evidence for associations between IPV and mental health problems IPV is a gendered problem. Most victims of IPV are women—globally, an estimated 27% of women and girls aged 15 years or older have experienced physical or sexual IPV—but high rates of IPV are also experienced by other groups, including sexual and gender minorities, people with disabilities, migrants, and people from marginalised ethnic or Indigenous groups. The relationship between IPV and mental health is complex. Exposure to IPV in childhood or adulthood increases the likelihood of developing a range of mental health problems, suicidal ideation, and attempting suicide. The presence of mental health problems also makes individuals more vulnerable to experiencing IPV. Children who are exposed to IPV are at high risk of additional forms of abuse and neglect, and experiencing abuse or being exposed to IPV in childhood greatly increases the risk of both experiencing and perpetrating IPV as an adult. People with diagnosed mental health problems are more likely to commit IPV than those without mental health diagnoses, although absolute rates of IPV perpetration are low. This relationship seems to be partly mediated through substance misuse, with an increased incidence of violence when mental health problems and substance misuse co-occur. Research in this area is controversial: mechanisms still need to be elucidated, and there are concerns about the potentially stigmatising consequences of examining the role of mental health problems in the perpetration of IPV, as well as concerns that diagnoses such as borderline personality disorder pathologise women's responses to violence and oppression. However, associations between mental health problems and experiencing or perpetrating IPV appear to occur across the life course and relate to both the onset and the course of mental health problems. Part 3: IPV across the life course Although IPV is endemic, it is not inevitable. Evidence points to several targets for prevention and intervention in individuals, families, communities, and societies. Some are stage specific, such as parenting programmes to reduce child abuse and neglect, or school-based programmes to address violence-supportive norms and behaviours; others span several stages, or are relevant across the life course, such as the prevention and treatment of substance misuse, and support for secondary or higher education for women. Part 4: Measurement of IPV Measurement of the frequency, severity, and context of IPV, its co-occurrence with other forms of violence, and its effects on mental health is challenging but important. Although substantial strides have been made in assessment methods for IPV, more needs to be done to advance measurement and to harmonise data collection via collaboration across sectors. Administrative data are fragmented and inconsistent between fields, professions, and practitioners. The development of IPV measures should involve people with lived experience of IPV and of mental health problems to ensure that the measures generated are relevant, feasible, and valid. Part 5: Transformation of the mental health system to address IPV Survivors should be fundamental to the development and assessment of support services at every level, from grassroots survivor-led services to statutory mental health services. Mental health systems and providers can make a crucial difference in IPV survivors’ path to healing, but too often the opportunity to do so is unfulfilled, and some survivors experience mental health services as harmful and retraumatising. Survivors and providers alike have called for urgent reform to enable pathways to safety, healing, health, and wellbeing for those experiencing IPV, including through the coproduction of trauma-informed approaches to care. All mental health professionals should have a good understanding of the gendered nature and dynamics of IPV, the effects of IPV on mental health, and the intersections of both IPV and mental health with other forms of oppression including racism, transphobia, ableism, and poverty. Mental health professionals should be enabled to respond appropriately through training and continuous learning, and should be able to count on organisational infrastructure and support. Because mental health services can be difficult to access as a result of poor availability and financial or logistic constraints (especially in marginalised populations and for people in low-income and middle-income countries), efforts to integrate mental health care into primary health care, to strengthen training of lay workers, and to provide grassroots and user-led alternatives to mental health services are essential