What are the implications and treatment options for a patient who has experienced domestic violence, considering potential physical injuries, mental health concerns such as depression, anxiety, or post-traumatic stress disorder (PTSD), and past medical history?

Implications and Management of Observed or Known Domestic Violence

When you observe or know of domestic violence, you have both immediate clinical responsibilities and legal obligations that directly impact patient safety, morbidity, and mortality—you must assess immediate safety, screen for physical and psychological trauma, provide trauma-informed interventions, and understand mandatory reporting requirements. 1

Immediate Safety Assessment is Critical

Your first priority is determining if the patient is safe to discharge from medical care, as this is a critical decision point that cannot be deferred. 1

• Directly ask patients about safety concerns related to the perpetrator, the perpetrator's friends, or others 1
• Assess whether the patient has been threatened, is afraid of anyone, or if the perpetrator has a history of violence or access to weapons 1
• Evaluate for signs of domestic violence in children, partners and spouses, the elderly, those with intellectual and developmental disabilities, and other vulnerable populations 1
• Do not assume that absence of physical violence means low risk—psychological abuse and coercive control are serious forms of intimate partner violence (IPV) that may not involve physical contact but still cause substantial harm and predict future escalation 2

Physical Health Implications and Management

The physical consequences of domestic violence extend far beyond immediate injuries and significantly impact long-term morbidity:

• Treat all physical injuries immediately, providing proper documentation of the incident and physical findings through photographs and body maps 1
• Be alert to physical examination findings suggestive of abuse and neglect, such as burns, bruises, and repeated suspicious traumatic injury 1
• Women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner compared to men, requiring heightened clinical vigilance 1
• Long-term physical consequences include sexually transmitted diseases, pelvic inflammatory disease, unintended pregnancy, chronic pain, neurologic disorders, gastrointestinal disorders, migraine headaches, and other disabilities 3
• In pregnant women, IPV is associated with preterm birth, low birthweight, and decreased gestational age 3

Mental Health Implications are Profound and Long-Lasting

The psychological and mental health effects are commonly reported by survivors to be most impactful on their lives, with an adjusted incidence rate ratio of 2.77 for mental illness following IPV exposure. 3

Immediate Psychological Screening Required:

• Screen immediately for suicidal ideation, self-harm behaviors, and homicidal ideation, as survivors have significantly elevated rates of depression and self-harm 1
• Recognize that harmful outcomes include not only repercussions of acute trauma, including death or unwanted pregnancy, but also long-term psychiatric disorders such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse 1

Specific Mental Health Conditions to Assess:

• Anxiety disorders (35% prevalence), depressive disorders (32%), and self-inflicted injuries (19%) 3
• Emotional distress, suicidal ideation, suicide attempts, sustained fear, low self-esteem, stress-related headaches, obsessive-compulsive disorder, PTSD, dissociation, sleep disorders, shame, guilt, and self-mutilation 3
• Related behaviors such as substance abuse and eating disorders 3
• For adolescents and young adults: poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, and suicidality 3

Trauma-Informed Treatment Approach

Initiate direct trauma-focused cognitive behavioral therapy (TF-CBT) immediately without a stabilization phase, as current evidence demonstrates that trauma-focused treatment is safe and effective with large effect size reductions in symptoms and low attrition rates (18%). 1

• Provide a supportive nonjudgmental environment that reflects an understanding of trauma and its many effects on health and behavior 1
• Address both physical and psychological safety concerns using a culturally informed strengths-based approach 1
• Do not delay trauma processing or require prolonged stabilization phases, as the outdated phase-based approach is contradicted by current evidence showing that patients can safely engage in focused trauma work immediately 1

Screening and Detection Methods

Screen women of childbearing age for intimate partner violence and provide or refer women who screen positive to intervention services, as this has a moderate net benefit with adequate evidence that effective interventions can reduce violence, abuse, and physical or mental harms. 3

• Consider validated screening instruments such as the HITS (Hurt, Insulted, Threatened, Screamed at) instrument, the Partner Abuse Interview, or the Women's Experience with Battering (WEB) Scale 1, 3
• Be aware that self-administered questionnaires elicit more positive responses than interviewer-administered questionnaires 1
• Available screening instruments can identify current and past abuse or increased risk for abuse with high sensitivity and specificity 3

Comprehensive Medical Interventions

When sexual assault is involved:

• Provide empirical treatment for sexually transmitted infections, such as Chlamydia, gonorrhea, and trichomoniasis 1
• Offer emergency contraception within 120 hours of sexual assault 1
• Initiate or complete hepatitis B virus and HPV immunization series as indicated 1

Special Considerations for Children

Children who witness intimate partner violence are at risk for developmental delay, school failure, violent behavior, and a variety of psychiatric disorders, including depression and oppositional defiant disorder. 1, 3

• If a child or adolescent is considered to be at imminent risk for harm, this is a child protection emergency, and authorities (child protective services and law enforcement) must be contacted immediately 1

Legal and Reporting Obligations

• Inform patients that they are eligible for reimbursement of medical expenses through the U.S. Department of Justice Victim's Compensation Program when the assault is reported to police 1
• Be aware of state-specific mandatory reporting requirements for domestic violence and sexual assault, which vary by jurisdiction 1
• Treatment is most successful when abusers are forced to admit to themselves and others that they have, in fact, committed crimes, emphasizing the importance of legal system involvement 4

Follow-Up Care Coordination

Schedule a visit within 1-2 weeks of initial presentation to assess injuries, medication adherence, mental health functioning, and need for additional psychological counseling. 1

• Provide written instructions for later reference, as many patients will not recall everything said during the initial evaluation 1
• Establish a coordinated care team including relevant specialists, trauma-specialized mental health providers, and primary care 1

Critical Pitfalls to Avoid

• Avoid routine opioid use as first-line analgesia due to complications in vulnerable populations 1
• Do not assume patients will disclose abuse even when there is clear sustained injury—remain vigilant to repeat attendees and patient history 5
• Recognize that emotional and psychological aspects of domestic violence are often more complex and difficult to identify than physical characteristics 5

Prevalence Context

Understanding the scope helps frame the clinical importance:

• Approximately 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year in the United States, with 31% of all women reporting abuse at some point in their lifetimes 1, 3
• Nearly 31% of women and 26% of men report having some form of IPV in their lifetime, with approximately 25% of women and 14% of men experiencing the most severe types 3
• These estimates likely underrepresent actual rates because of underreporting 3
• For elderly or vulnerable adults, reported rates range from 2% to 25%, though the evidence for screening this population remains insufficient 3

Impact on Informal Supporters

Be aware that friends and relatives of domestic violence survivors experience substantial impact on their own health and well-being, potentially experiencing secondary traumatic stress as they journey alongside the survivor. 6