Types of non-psychotic mental disorders in adult women who suffered intimate partner violence: an integrative review

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2018;52:e03328 1 Universidade Federal do Piauí, Programa de Pós-Graduação em Enfermagem, Teresina, PI, Brazil. ABSTRACT Objective: Identifying the types of non-psychotic mental disorders in adult women who suffered intimate partner violence in the literature. Method: An integrative review carried out in the MEDLINE, CINAHL, LILACS, Web of Science and SCOPUS databases. Results: We selected 19 articles published in international journals in English, with a predominance of cross-sectional study studies (78.9%). The most common types of non-psychotic mental disorders were: depression (73.7%) and post-traumatic stress disorder (52.6%). It was observed that 78.9% of the articles presented a 2C level of evidence. Conclusion: Studies have shown that adult women who are victims of intimate partner violence mostly suffer from depression and post-traumatic stress disorder, as well as other morbidities; a fact that highlights how devastating violence by an intimate partner can impact on the mental health of those who experience it.


INTRODUCTION
Non-psychotic mental disorders have high prevalence among the worldwide population (1) , generating high social and economic costs, as they can be disabling and lead to absenteeism at work and increase health service demands (2) .
Among other causes, the development of non-psychotic mental disorders among women may be related to the occurrence of intimate partner violence (IPV).Among the most frequent mental morbidities regarding the victims of marital violence are depression, anxiety, and post-traumatic stress disorder (PTSD) (3) .
When exposed to routine events of IPV, women can become sad, experience low self-esteem, high levels of frustration and distrust, consequently leading to a lower quality of life (4)(5) .It is presumed that in order to embrace these women, it is necessary that nurses and other health professionals take on a position of responsibility in an intersubjective relationship with them and their family members, so that they can understand and intervene together with their care needs in an attitude of perspective reciprocity (6) .
However, victims of intimate partner violence who have developed non-psychotic mental disorders may not receive adequate treatment, returning to the service repeatedly.This is because health teams not only have difficulties identifying and treating IPV, but also the types of non-psychotic mental disorders related to it.This puts a burden on the health system, increasing public expenditures with unnecessary testing and drug interventions (4) , aspects that have a great impact on public health.Thus, understanding these disorders and their associated factors becomes essential for identifying and developing specific early interventions which contribute to improving the prognosis (7) .For this reason it is important to include non-psychotic mental disorders as one of the priorities in health care (8) .In view of this situation, it is necessary to systematize searches for the types of non-psychotic mental disorders in primary health care and to establish specific mental health care actions (9) .
The role of the nurses in this context is important, considering that these professionals have more closeness to the patients during follow-ups.In this sense, nurses should exercise listening as a mechanism for care humanization, as well as to use it as a method which is effective in obtaining essential information for the embracement of each patient, considering that each clinical and psychosocial condition must be taken into account by the health professional in an individualized way.
In an extensive search in the literature, it is worth pointing out that no Brazilian studies on the types of non-psychotic mental disorders in adult IPV female victims have been found.Thus, it is relevant to conduct a study on the subject since it can be marked by invisibility and have severe consequences on victims' lives.In view of the above, this study aimed to identify in the literature the types of non-psychotic mental disorders among adult female victims of intimate partner violence.

METHOD
This is an integrative review.Six different phases were followed to guide this research: definition of the theme and forming the objectives and the guiding question; a literature search and delimiting the inclusion of the studies; categorizing the studies; evaluation of the studies; interpretation of the results and a presentation of the review/synthesis of knowledge (10) .
The research question was organized according to the PICO strategy (P − population; I − intervention/area of interest; C − comparison; O − outcomes (11) .The following structure was considered: P -women, women who suffered violence; I -intimate partner violence, marital abuse; C -No comparison; O -mental disorders.Thus, the following question was elaborated: What is the evidence available in the literature on the types of non-psychotic mental disorders that affect adult women, victims of intimate partner violence?
The controlled descriptors used are inserted in the Bank of Health Sciences Descriptors (DeCS) (Women, Battered Women, Intimate Partner Violence, Spouse Abuse, Mental Disorders), in the Medical Subject Headings (MeSH) and in the CINAHL titles (Women; Battered Women; Intimate Partner Violence; Spouse Abuse; Mental Disorders; Stress, Psychological).The uncontrolled terms (keywords) were: woman, violence against an intimate partner, abuse, mental disorder, mental illness, psychological stress, mental suffering and their corresponding terms in English.
The data collection took place in June 2017, and the databases used were: PubMed/MEDLINE, of the National Library of Medicine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean of Health Sciences Information System (LILACS), SCOPUS (Elsevier) and Web of Science.
In order to systematize the sample collection, the Boolean operators "OR" and "AND" were used.Different search strategies were applied considering that the databases have different peculiarities and characteristics.The search syntax for each database is described in Chart 1.
Chart 1 -Syntaxes applied to the respective databases during the search for studies -Teresina, PI, Brazil, 2017.The inclusion criteria for the studies were: articles that addressed non-psychotic mental disorders in adult women aged 18-59 years, who suffered intimate partner violence, publications from June 2012 to June 2017, in Portuguese, English or Spanish.Articles that addressed violence against children, adolescents, the elderly, pregnant women, secondary studies or letters to the editor, annals of scientific events, theses, dissertations or duplicate studies were excluded.

Databases
The decision for the time period cut from 2012 to 2017 was based on the authors' intention to seek updated references on the subject in question; also, the start of adulthood was established according to the legal concept defined by the age of majority, which is currently the age of 18 in Brazil and in many other countries.The exclusion of pregnant and postpartum women, even though in adulthood, was made considering that this population may present hormonal changes, which in turn can influence their mental health.
After applying the inclusion and exclusion criteria, a final sample of 19 articles was obtained, which were read and analyzed in full (Figure 1).An instrument for collection of pertinent information to the study was prepared containing the following information: authors, study country of origin, year of publication, journal, database, sample, study design, type of mental disorder identified, level of evidence.
The level of evidence was determined according to the Oxford Center for Evidence-based Medicine (12) , in which: 1A -systematic review of randomized controlled clinical trials; 1B -randomized controlled clinical trial with a narrow confidence interval; 1C -therapeutic results of the "all or nothing" type; 2A -systematic review of cohort studies; 2B -cohort study (including randomized clinical trial of lower quality); 2C -observation of therapeutic results or ecological studies; 3A -systematic review of case-control studies; 3B -case-control study; 4 -report of cases (including cohort or case control of lower quality); 5 -expert opinion.
In order to reduce probable systematic errors or biases of the studies due to misunderstandings in interpreting the outcomes and in the design of the studies, the research was carried out by two independent reviewers in order to guarantee the accuracy of the method and the reliability of the results.The sample articles were selected by means of the sequence: title reading, reading the abstract and reading the full text.In cases where there were disagreements, there was discussion between the two evaluators and analysis by a third party to reach a consensus.
Only published articles were included in conducting this revision, and the principle of respecting the intellectual property of the authors of the articles that comprised the sample was followed by referencing them using complete and thorough citations (13) .
The critical analysis and the qualitative synthesis of the selected studies were carried out in a descriptive way and subdivided into four analytical categories according to the aspects that characterize non-psychotic mental disorders: depressive-anxious mood, somatic symptoms, decreased vital energy and depressive thoughts.

RESULTS
The sample composed of 19 articles had the highest number of publications in the year 2013 (n=07; 36.8%).The databases with the highest number of articles selected was PUBMED (n=09; 47.4%).All selected articles were published in international journals and in the English language.Regarding study design, the majority (n=15; 78.9%) were cross-sectional studies.
Among the types of non-psychotic mental disorders found, the most common was depression (n=14; 73.7%), followed by post-traumatic stress disorder (PTSD) (n=10; 52.6%).It should be emphasized that more than one type of disorder might have been included in each study.
Regarding the level of evidence, most of the articles analyzed (n=15; 78.9%) were classified as 2C.The studies were selected according to the authors, the publication year, the journal, the database, the sample, the design, the country, the type of mental disorder and the level of evidence (Chart 2).
Chart 2 -Summary table of the characteristics of the studies included in the review -Teresina, PI, Brazil, 2017.

Authors (year)
Journal/ database Sample/ Design/ Country Type of Mental Disorder

DISCUSSION
The results of this review revealed that there were more articles addressing depression and PTSD among adult women IPV victims; however, it was noted that the presence of other non-psychotic mental disorders in this population was also frequent.Thus, we could show that the psychological damage resulting from intimate partner violence, often neglected by society, health, safety, and public management professionals, may be as or perhaps more devastating in women's lives than physical wounds.
It was possible to identify that the number of articles about the subject of this study was higher in 2013 and 2014 and decreasing in the last 3 years, so that only four studies were selected in 2015, only two in 2016, and no articles up to the month of June of 2017 that specifically addressed all the criteria adopted in this study were identified.
It is noteworthy that all articles found were international; a fact that demonstrates the need for Brazilian publications on the subject given its considerable relevance.It was also observed that most of the evaluated articles had levels of evidence of 2C; this means a reasonable level to support the recommendation.Thus, we emphasize the need to carry out further studies with strong scientific evidence.
The primary studies included in this review were classified into four thematic categories: depressive-anxious mood, somatic symptoms, decreased vital energy and depressive thoughts.

Depressive-anxious mooD
Most of the selected articles mainly included depression and PTSD.A study carried out in Jordan showed that more than half of the women suffering IPV reported a serious level of depressive symptoms.On the stress subscale, more than a third had stress ranging from moderate to extremely severe levels (14) .In a survey conducted in Greece, the symptoms of depression were also higher in women who had experienced IPV compared to women who had never experienced it (26) .
Depression varies according to the type of exposure to IPV.In Bolivia, a research carried out with 10,119 women showed that approximately half of those who suffered psychological and physical violence presented anxiety, while those who were sexually abused by their intimate partners expressed recurrent feelings of fear (20) .
The adjusted analysis of a study demonstrated an association between depression and marital violence (21) .In this perspective, the exposure of women to behavioral control and physical and sexual violence perpetrated by an intimate male partner is clearly associated with symptoms of depression.
A multicenter study conducted in Africa, Latin America, India and Alaska has shown that PTSD symptoms among women are directly and indirectly related to IPV and with inappropriate use of alcohol (15) .Other studies in Africa have shown that psychological and physical IPV were directly related to the severity of post-traumatic stress and depression.It has been noted that the more severe the physical and psychological violence suffered, the greater the propensity to these types of non-psychotic mental disorders.However, no associations were found between sexual abuse and PTSD or depression (17,(24)(25) .
A multicenter study conducted in Japan, Singapore, South Korea and Taiwan found that the co-experience between victimization and perpetration of physical IPV was associated with borderline personality traits and PTSD, but not with depression.It is worth pointing out that gender hostility and the socialization of violence were significant predictors for borderline personality traits, depression and PTSD (32) .
Studies in the United States have also found similar results, demonstrating that prior trauma caused by IPV is a risk factor for developing PTSD (28,31) .Another study in the United States indicated that 74% of women who suffered intimate partner violence reported depression symptoms, and 67% of them had criteria for PTSD (16) .

Authors (year)
Journal/ database Sample/ Design/ Country Type of Mental Disorder

PTSD and depression 2C …continuation
A cross-sectional study conducted in Nigeria found that women are ten times more likely to develop depression and were 17 times more likely to report anxiety if they were in violent relationships.This fact demonstrates the negative implications of IPV for the mental health of Nigerian women (18) .
An investigation carried out with 613 Chinese subjects observed that among the forms of IPV, controlling actions (threats and physical violence) are those that have the most negative consequences on the mental health of women.These victims need to use medical services more frequently because they have more depression and post-traumatic stress disorder symptoms (29) .
It is worth emphasizing that the nurse and the multiprofessional health team need to be prepared to recognize and treat these women so that they can develop singular and humanized care.This individualization of treatment becomes relevant, since people respond differently to applied behaviors.
A randomized controlled trial developed with Greek IPV women victims who suffered some non-psychotic mental disorder observed that the perceived stress in the intervention group was significantly decreased after 8 weeks of relaxation (exercises), however no significant outcome was observed for hours of sleep and depression (27) .There is also evidence that empowering women abused by their partners can be a protective factor against negative results to their mental health (16) .

somatic symptoms
Only two studies were included in this category; however, both were performed with a large sample of women, a fact that increases the power of statistical association.
A cross-sectional study developed with 6,303 women from states in India noted that the most commonly reported problems were feeling under tension, depressed or unhappy, causing them to lose sleep from worrying (19) .
A study carried out in Bolivia with 10,119 women pointed out that somatic symptoms such as seizures were present among those who experienced sexual abuse, followed by physical abuse and psychological abuse (20) .These somatic symptoms can affect the quality of life of victimized women and can generate even more serious problems.
It is important to emphasize that health professionals often look into somatic symptoms only considering their biological aspects, without investigating their possible causes (33) , evidencing the fragility of access and comprehensiveness in the care provided to mental health cases.

DecreaseD vital energy
This analytical category was also represented by only two articles; however, it was possible to identify several symptoms that characterize its insertion in this topic.
In a large study developed in Bolivia which already included results belonging to the other two analytical categories of this review, the percentage of women who reported feeling "tired all the time" remained significantly higher among those who suffered sexual abuse, followed by those who suffered psychological and physical abuse, respectively.The results for "difficulty in doing daily activities" and "difficulty in making decisions" showed that psychological and physical abuse have almost equal effects, whereas sexual abuse has a stronger effect on these two patterns (20) .
A longitudinal study developed in the United States corroborates this information by showing that intimate partner violence generates difficulties during the performance of cognitive tasks in adult women (31) .In this way, IPV causes considerable socioeconomic impact due to the decrease in women's working capacity and unnecessary demand for health services, in addition to the suffering generated to the individuals (2) .

Depressive thoughts
In the four articles that fit into this topic, it was possible to notice the presence of serious symptoms that, if untreated, can lead to lethal consequences for women assaulted by their partners.
In a mixed study developed in the United States, there were reports of suicidal ideation and suicide attempts among women IPV victims.In addition, 34% of women reported regularly taking various medications for their mental and physical health.This research also showed that stress, sadness, depression and unhappiness were present in the lives of most abused women (23) .Also in the United States, a survey showed greater propensity for self-mutilation among adult women assaulted by their spouses (28) .
A study in Nicaragua showed that women who attempted suicide experienced substantially more IPV events.These experiences of violence and the lower social support were especially related to suicide attempts among the interviewees (30) .Another study developed in Rwanda, Africa, found that physical, sexual and psychological violence considerably increased the risk of all mental disorders studied, including depression, suicidal ideation and PTSD (22) .
After analyzing the four thematic categories, we observed that IPV among adult women is related to the development of non-psychotic mental disorders in different domains and with different severities.It was also possible to observe that the studies showed similarity regarding the encountered results, and that the same study could be considered in more than one analytical category.

CONCLUSION
The studies evidenced that the main non-psychotic mental disorders in adult women IPV victims were depression and PTSD, respectively.However, they also included: stress, suicidal ideation, decreased vital energy, somatic symptoms, self-mutilation, anxiety and sleep disorders.This shows how desolating IPV can become for the mental health of women who experience it.
This study may contribute to information for planning and redirecting public policies and to nursing practice regarding the types of non-psychotic mental disorders experienced by adult women abused by an intimate partner, so that improvement actions are implemented to manage this problem.
between IPV and the specific consequences of these injuries on the mental health of these adult women, even in spite of the existence of several investigations that verify association between intimate partner violence and mental disorders.It is important to point out that no Brazilian studies were found which included the types of non-psychotic mental disorders in adult women IPV victims and also encompassed all the necessary criteria for inclusion in this review.Thus, we suggest the development of field studies that can verify the consequences of IPV on the mental health of adult women, with emphasis on the types of non-psychotic mental disorders caused.
Regarding limitations, it was observed that investigations with a cross-sectional study design predominated in this review, making it impossible to verify cause-and-effect relationships between IPV and non-psychotic mental disorders.However, the studies found have a high magnitude considering that they mostly have representative samplings of their populations and show statistically significant associations between the two conditions.