Data from nationally representative samples have estimated that 12% to 15% of women in the U.S. report being raped at some point in their lives (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993
; Tjaden & Thoennes, 1998
) and that an estimated 683,000 women experience rape each year (Kilpatrick, Edmunds, & Seymour, 1992
). Rape and other sexual assault are also prevalent among adolescents, with contact sexual assault experienced by 7% to 13% of adolescent girls (Ageton, 1983
; Kilpatrick et al., 2000
). Compared to nonvictims, women who experience rape are at significantly increased risk for mental health problems that include posttraumatic stress disorder (PTSD); depression; drug, alcohol, and nicotine use and abuse; other anxiety disorders and health risk behaviors (Kessler et al., 1995
; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997
; Kilpatrick et al., 2003
; Resick, 1993
; Resnick, et al., 1993
; Steketee & Foa, 1987
Rape-related PTSD is prevalent. Rothbaum et al. (1992)
found that 94% of rape victims who reported to police or other authorities met symptom criteria for PTSD at 2 weeks post-rape and 50% continued to meet criteria 3 months later. Findings from epidemiological studies indicate that rape or completed sexual assault as compared to other traumatic events is associated with greatest risk of PTSD (Kessler et al., 1995
; Kilpatrick, et al., 1989
; Norris, 1992; Resnick et al., 1993
Rape also results in significant levels of depression, particularly during the weeks following victimization (Atkeson, Calhoun, Resick, & Ellis, 1982
; Kilpatrick, Resick, 1993; Resick, & Veronen, 1981; Steketee & Foa, 1987
). Frank and Stewart (1984)
found that approximately 43% of rape victims met criteria for depression when assessed within 1 month post-rape. Moreover, the co-occurrence of depression and PTSD is common, ranging from one-third to one half of those with PTSD (Kessler et al., 1995
) meeting criteria for major depression. In a longitudinal study of victims of a range of traumatic events, Shalev et al. (1998)
found that 30% had PTSD at 1 month post-event and 17.5% met criteria at 4 months. Among those with PTSD, over 40% met criteria for depression at each time point.
The intensity of acute distress, including peri-traumatic panic reactions (Bryant & Panasetis, 2001
; Galea et al., 2002
), dissociation symptoms (Ozer et al., 2000), and physiological arousal as measured by heart rate within hours or days of a traumatic event (Bryant, Harvey, Guthrie, & Moulds, 2000
; Shalev et al., 1998
; for an exception see Blanchard et al., 2002) has been found to be a significant predictor of PTSD. These findings are consistent with learning and cognitive models of PTSD (e.g. Kilpatrick et al., 1981
; Foa & Kozak, 1986
) and depression (Kilpatrick, Veronen, & Resick, 1977
; Lewinsohn, 1974
). Thus, intensity of acute distress could facilitate conditioned anxiety and secondary avoidance, resulting in reduced reinforcement (depression) or pathological fear structure (PTSD).
Meta-analytic studies across a range of different types of traumatic events indicate that other risk factors for PTSD and other psychopathology observed across studies include prior exposure to traumatic events, prior adjustment (Brewin, Andrews, & Valentine, 2000
; Ozer, Best, Lipsey, & Weiss, 2003
), low socioeconomic status, and low social support (Brewin et al., 2000
). Such risk factors may be important to control when evaluating the potential impact of interventions targeting PTSD or other mental health problems following exposure to an extreme stressor such as rape.
Because rape victims may suffer acute physical injury during assaults, they should receive immediate medical care to treat acute injuries and to prevent sexually transmitted diseases (STDs) or possible rape-related pregnancy (Koss & Heslet, 1992
). Standardized protocols are available to address medical and forensic needs of rape victims who report the crime to police or other authorities (Ahrens et al., 2000
). For example, Resnick et al. (2000)
found that 26% of all women who experienced rape as adults received medical care, with the majority receiving treatment within the first few days after assault. Those who received care were more likely to report fear of death or injury during assault and receipt of injury, characteristics that have been associated with increased risk of later psychopathology. Thus, although not all rape victims receive immediate medical care, those who receive care appear to be at increased risk of mental health difficulties including PTSD.
Although it has not been formally used as such, the routine forensic rape exam presents a clear opportunity to provide intervention for sexual assault victims who are at high risk for PTSD and other mental health difficulties. Given the high number of women and adolescent girls who are affected by sexual assault and rape each year, the associated increased risk of PTSD and depression, and data indicating associations between acute and later distress, effective treatments at this point of care might reduce later problems in functioning. In addition, for some women and girls who do not seek subsequent treatment it may be the only opportunity to provide such services.
The possibility of reducing risk for significant mental health problems via early intervention following rape is an important area of research. Previous studies have predominantly evaluated early interventions administered in the first few weeks post-assault (Foa, Hearst-Ikeda, & Perry, 1995
; Kilpatrick & Veronen, 1984
) as opposed to hours post-assault (e.g., at the standardized forensic exam room). Considering the former group of studies, Kilpatrick and Veronen (1984)
found no significant benefit among rape victims who received a 4–6 hour early cognitive behavioral skills-based intervention delivered at 6 to 21 days post-rape compared to a control condition. Foa et al. (1995)
found a brief multi-session intervention that included both imaginal and in-vivo exposure effective, at least in the short term, with 20 women who were less than one month post-assault (including rape). Results indicated that significantly fewer subjects in the treatment group still met PTSD criteria at post-treatment than those in an assessment group, but no differences were noted in terms of PTSD criteria at a 5.5 month assessment point. A more recent study by Foa, Zoellner, and Feeny (2006)
with a sample of recent sexual and physical assault victims receiving treatment an average of one month post-assault found that a multi-session early intervention based in cognitive and behavioral principles showed some efficacy relative to supportive counseling (but not an assessment only condition) in the short term. Results did not show clear long term benefits.
Based on findings that indicate that recent rape victims are at high risk of PTSD and major depression and comorbid problems (e.g., drug and alcohol abuse, Kilpatrick et al., 1997
), we developed and evaluated an early intervention designed to reduce risk for these mental health problems. The intervention was unique in terms of a secondary prevention approach in that it was delivered as a videotape within hours of assault and prior to the post-rape forensic medical exam, and it was specifically designed to both help prepare women for the exam itself, and to provide instruction in adaptive coping strategies to reduce dysfunctional avoidance. The video did not include any imaginal exposure component related to describing the assault incident.
We have previously reported findings related to the potential impact of the intervention on drug abuse (Acierno, Resnick, Flood, & Holmes, 2003
). Data indicated that women in the video group were significantly less likely to meet criteria for marijuana abuse than women receiving standard care at an assessment that took place approximately 6 weeks post-rape. We also reported findings from the time of the forensic medical exam within a sample of 205 women, 97 of whom were in the video condition and 108 who received standard care (Resnick, Acierno, Kilpatrick, & Holmes, 2005
). These data indicated greater decrease in pre-to post-exam subjective units of distress (SUDs) ratings among women in the video vs. nonvideo groups. Finally, Resnick et al. (2005)
reported that among rape victims with a prior history of rape, a probable diagnosis of PTSD based on the PTSD symptom scale self-report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993
) was significantly lower at 6 weeks post-rape among 123 women and adolescent girls who were in the video condition than among those in the standard care condition.
In contrast to the 2005 report, the current report presents comprehensive data on standardized continuous measures of PTSD, depression, and general anxiety assessed at short and long term study follow-up assessments targeted for 6 weeks and 6 months post-rape among the full follow-up sample of 140 women who completed at least one assessment. The current report further examines the role of prior history of rape as a potential moderator of the impact of the intervention on PTSD, depression, and other anxiety over time, controlling for potentially critical risk factors based on the empirical literature that included acute distress and effects of economic resources. Finally, both regression analyses and growth curve modeling were used to evaluate functioning over time.