What is the best approach to screen and manage Intimate Partner Violence (IPV) in a 45-year-old female with a history of depression, anxiety, substance use, and STDs, including herpes, who is sexually active with multiple partners?

Screening and Management of Intimate Partner Violence in This Patient

Immediate Action Required

This 45-year-old woman should be screened for intimate partner violence using a validated brief screening tool administered privately during this annual visit, as she falls within the USPSTF-recommended age range (14-46 years) and has multiple risk factors including depression, anxiety, substance use, and sexual activity with multiple partners. 1

Screening Approach

Use a Validated Brief Screening Tool

• Administer the HITS (Hurt, Insult, Threaten, Scream) 4-item questionnaire, which has sensitivity of 86-100% and specificity of 86-99% in primary care settings 2, 1
• Alternative validated tools include HARK (4 items, sensitivity 81%, specificity 95%) or STaT (3 items, sensitivity 62-96%) 2, 1
• Screen privately, away from any accompanying persons, as joint interviews prevent disclosure of abuse 1

Critical Screening Context

The USPSTF specifically recommends screening all women of childbearing age (14-46 years) for IPV, and this patient fits squarely within this recommendation 1, 3. The American Congress of Obstetricians and Gynecologists recommends screening at routine gynecologic visits, which this annual/well-woman/Pap visit represents 1.

Why This Patient Warrants Heightened Concern

High-Risk Profile Present

• Depression and anxiety are relationship-level risk factors that correlate with both IPV victimization and marital conflict 1
• Marijuana use increases violence risk and is a CDC-identified individual risk factor for IPV 2
• Multiple sexual partners and inconsistent protection use may indicate compromised reproductive autonomy, which is associated with IPV and pregnancy coercion 2
• History of herpes and STDs can be associated with IPV exposure, as abusive relationships often involve compromised sexual decision-making 3

Documentation Shows Screening Gap

The chart documents "no domestic violence" but provides no evidence that validated screening was performed 1. Accepting patient reassurance without structured inquiry is a critical pitfall, as many IPV victims do not spontaneously disclose due to fear, shame, or reprisal 1.

If Screening Is Positive

Immediate Response Protocol

1. Activate social work consultation immediately while the patient is still in the clinic 4

2. Conduct safety assessment asking specifically about:

   • Escalation of violence frequency or severity 1
   • Access to weapons in the home 1
   • Threats of homicide or suicide by partner 1
   • Forced sexual activity 1

3. Provide concrete resources before discharge:

   • Local domestic violence shelter contact information 4
   • National Domestic Violence Hotline number 4
   • Safety planning education focusing on escape routes, safe places to go, and documents to gather 2

Evidence-Based Intervention

Behavioral counseling emphasizing safety behaviors and community resources significantly reduces IPV recurrence (adjusted odds ratio 0.48,95% CI 0.29-0.80) 2. This intervention should include at least one education and advocacy session before the patient leaves 4.

Critical Pitfall to Avoid

Never notify police without the patient's explicit consent unless legally mandated, as this can escalate danger and violate patient autonomy 4. The appropriate response is connecting to support services, not law enforcement notification 4.

Documentation Requirements

• Document screening tool used and results in the medical record 5
• If positive, document specific injuries with precise descriptions of location, size, and pattern 4
• Document safety planning discussions and resources provided 4
• Document patient's stated plan and follow-up arrangements 6

System-Level Implementation

Optimize Screening Rates

• Place screening prompts in the electronic health record for annual well-woman visits 5
• Train nursing staff to administer validated screening tools as part of vital signs collection 5
• Ensure on-site or immediately accessible referral resources are available, as lack of referral services frustrates implementation 6

Maintenance Strategy

Ongoing provider training and consistent institutional support are essential, as only half of IPV screening programs maintain steady screening rates over time 6. Emergency department settings have particularly low reach (47% vs 80% in other settings), highlighting the importance of capturing patients during routine primary care visits 6.

Addressing Substance Use and Mental Health

The combination of depression, anxiety, and marijuana use requires integrated assessment, as these conditions are both risk factors for IPV and consequences of abuse 3. Screen for suicidal ideation, intent, plan, and means, as marital distress and IPV significantly increase suicide risk 1.

Follow-Up Plan

• Schedule follow-up within 2-4 weeks regardless of screening result to reassess safety and provide continuity 7
• Women with recent IPV are more likely to view counseling discussions as a strategic response (adjusted OR 2.7,95% CI 1.008-7.2) 7
• Provide IPV resource brochures in examination rooms for self-referral, as these are taken at higher rates when screening protocols are in place (51 vs 29 per 1000 visits) 5