The results of the present study substantiate an independent and consistent association between recent exposure to violence and abuse by an intimate partner on depressive symptoms over a two-year period while accounting for various forms of childhood trauma and previous elevated depressive symptoms. Our main finding is a clear cross-sectional association between IPV/A in the last 5 years and depressive symptoms in this cohort of women. The results also support a moderate, longitudinal association between IPV/A and change in depressive symptoms.
The analyses in this paper were presented in two ways: among the full cohort of women, and among a subset of women with depressive symptoms below threshold at baseline. The relative stability of the depressive construct over time is observed among the full cohort. When women with depressive symptoms above threshold at baseline were excluded, the slope of depressive symptoms remains stable in a manner consistent with a kindling effect, suggesting that women experiencing multiple previous episodes of major depression are less sensitized to the effects of stressful life events than women with fewer depressive episodes (Kendler, Thornton, & Gardner, 2000
). This stability of elevated depressive symptoms over time has been noted in other research with women experiencing significant life stress (Carter, Martinez-Pedraza Fde, & Gray, 2009
). Women who have experienced recent IPV/A not only have consistently higher CES-D 10 scores than their non-abused counterparts, but also their symptoms appear to remit at a slower rate.
There are several strengths to note in this study. For example, the longitudinal design permits analysis of changes within individuals over time and differences among individuals in their baseline level. The web-based administration of the baseline and follow-up questionnaires is an additional strength of this research as it provided a means for participants to complete the survey at work rather than at home where an abusive partner might be present. Also, RE modeling permitted a longitudinal examination of this relationship while accounting for serial correlation of measurements within individuals.
The results of these analyses should be interpreted with respect to several limitations. The CES-D 10 has been shown to be a valid method for assessing depressive symptoms; however, it is subject to criticism as to whether or not the imposed cutpoint successfully reflects the severity, chronicity, and level of impairment that might otherwise be captured with a diagnostic instrument. Similarly, the use of an adapted screening tool as a broad measure of IPV/A did not permit examination of changes in type and severity of abuse over time. Another limitation to these analyses is the lack of information about the quality of the relationship to the perpetrator and whether or not the relationship is ongoing since the baseline interview. Trauma symptoms may dissipate with time, but psychological outcomes may vary according to recency of separation (Anderson & Saunders, 2003
). Several studies point to the eventual amelioration of mental health difficulties, including depression, after leaving an abusive partner (Kernic, et al., 2003
; Mertin & Mohr, 2001
). However, secondary stressors co-occurring with IPV/A may continue to contribute to a depressed state (e.g., financial losses, childcare, shifting social support). The extent to which current, elevated depressive symptoms may detain an abuse victim from exiting the relationship is an area of future research. Although the study is large, all of the participants are employed within one particular health care system, and thus, are not representative of the entire population of victims of violence. However, the prevalence of lifetime IPV and IPA in this cohort of female nursing staff (25.24% and 22.87%, respectively) was similar to that reported by women in population-based studies (Bracken, et al., 2010
). Lastly, the study's 52% response rate raises concern about comparability between respondents and non-respondents. Although the data for such direct comparison is unavailable, we can make comparisons between participants in the Safe at Work Study and participants in similar research. Safe at Work Study participants attained a higher education level, and were younger in age and more ethnically diverse than their regional and national counterparts, as previously described elsewhere (J. C. Campbell et al., 2011
Although the longitudinal study design enabled us to explore the temporal ordering of exposure to violence and depressive symptoms, we cannot infer causality regarding this association. Since the sample included individuals who were and were not exposed to IPV/A at baseline, we are unable to determine whether new exposure of IPV/A was associated with the changes in depressive symptoms over time. As a result, we conducted an additional set of sensitivity analyses (not reported) in which we restricted our sample participants who had not experienced IPV/A at baseline (n=944 and found a similar pattern of findings, whereby a general consistency in strength of association between IPV/A and depressive symptoms was observed in spite of the loss of power.
There are several future research questions which can be examined to better understand the association between IPV/A and major depression. For example, the specific form of IPV/A (physical, sexual, psychological) or its severity may be associated with a particular pattern of depressive symptoms. Similarly, the timing of exposure to IPV/A may be critical to understanding its relationship to depressive symptoms. The present study lacks the granularity to capture the exact timing of IPV or clinically significant depressive symptoms. Future work would benefit from studies that can measure more precisely timing of exposure and onset of major depression.
The results from this study have implications which span interpersonal and professional domains. Depressive symptoms and other psychiatric issues may impair a woman's ability to leave an abusive partner, thereby placing her at risk for continued victimization (Barnett, 2001
). While recent attention has been given to the occupational and health consequences of workplace violence for nursing staff, few studies have investigated the impact of violence occurring outside the hospital. This study adds to the mounting evidence that employed, healthcare professionals are not immune from psychiatric distress resulting from violence and abuse by an intimate partner. The effect of depressive symptoms and violence in this group of healthcare workers is of particular concern. The consequences of IPV/A among healthcare staff and its implications for job performance and health are numerous, including absenteeism, quality of patient care, and workplace violence perpetrated by an intimate partner (Bracken, et al., 2010
). As cessation of IPV/A may result in a decrease in depressive symptoms, employers are encouraged to review policies to help women identify supportive resources, including those to help them transition out of an abusive relationship if that is their desired goal (Gielen et al., 2000
; Kernic, et al., 2003
). Taken together, the results of this study emphasize the importance of addressing depressive symptoms among female healthcare workers, particularly recently victimized women. Possible targets for such intervention include working conditions or community characteristics such as workplace inequality, neighborhood monitoring, social attributes, and communication networks (O'Campo, Burke, Peak, McDonnell, & Gielen, 2005
; O'Campo, Eaton, & Muntaner, 2004
). Institutional resources may be critical to improving depressive symptoms related to violence perpetrated by an intimate partner, although further study is needed to identify appropriate screening methods and intervention types for women with such histories of abuse.