Correspondence
Why primary health-
care interventions for
intimate partner
violence do not work
In the UK and Australia, more than
a quarter of women are exposed to
intimate partner violence at some
time in their lives.1,2 Yet in spite of this
ongoing public health crisis, funding
for community-based domestic
violence services is in serious jeopardy.
Adding to the dilemma is that primary
health-care interventions for intimate
partner violence (including cognitive
behavioural therapy, counselling to
improve self-efficacy and self-esteem,
and safety planning) have been shown
to be ineffective.3,4 Therefore, it is
timely to consider the possibility that
there is a serious mismatch between
the types of interventions being tested
and the complexity of the problem of
intimate partner violence.
A subpopulation of intimate
partner violence-affected women
have a background of multiple forms
of adversity, a profile that is likely to
account for their poor overall response
to short-term, primary health-care
interventions. Women with multiple
forms of adversity might constitute
up to half of the population affected
by intimate partner violence.1 Partners
of these women tend to have highly
entrenched patriarchal attitudes that
allow them to justify their controlling
and violent behaviours. These men
will do their utmost to discourage
women from seeking help or from
disclosing their symptoms and injuries
to professionals—one of the important
reasons to screen all women attending
primary health-care services, and not
just those with obvious or disclosed
harms.4
Many women with multiple forms
of adversity have been subjected to
childhood sexual abuse,1 experiences
that have a lasting effect on their sense
of self-worth and confidence. High rates
of mental disorder (often arising from
exposure to intimate partner violence),
www.thelancet.com Vol 384 July 19, 2014
including depression and post-traumatic
stress disorder, can impair women’s
capacity to take assertive action.1,5
Many women do not have the social
support or economic resources to
make effective changes to their lives.
In addition, women in chronically
abusive relationships justifiably doubt
the capacity of existing legal and law
enforcement mechanisms to provide
them and their children with effective
protection should they take the bold
step of terminating the relationship.
As high service users, women with
multiple forms of adversity might be
over-represented in the very primary
care trials of short-term interventions
that have been found not to work.
In contrast, community-based
intimate partner violence services
apply a multimodal, integrated,
longer-term approach that includes
protection, refuge, social and mental
health interventions, counselling
aimed at empowering women, and
legal advice—a package of support that
appears to better match the needs of
these women. Personnel working in
these programmes have a long-term
perspective, understanding the
systemic nature of the problem, and
anticipating that change might occur
incrementally. Yet there is a dearth of
contemporary, rigorous evaluation
of the outcomes of multimodal
community programmes.
In summary, cost, brevity, and ease
of delivery (in primary care) cannot
be a substitute for gaining a thorough
understanding of the nature of the
problem of intimate partner violence
in devising appropriate interventions.
Complex problems often need
complex solutions, which in turn need
creative approaches to evaluation.
Failure to heed this principle risks
further failures in intervention trails,
thereby propagating a dangerous
message that, for intimate partner
violence, nothing works.4
We declare no competing interests.
*Susan Rees, Derrick Silove
s.j.rees@unsw.edu.au
Mental Health Centre, Liverpool Hospital, University
of New South Wales, Sydney, NSW 2170, Australia
1 Rees S, Silove D, Chey T, et al. Lifetime
prevalence of gender-based violence in women
and the relationship with mental disorders and
psychosocial function. JAMA 2011; 306: 513.
Jim Varney/Science Photo Library
2 Walby S, Allen J. Domestic violence, sexual
assault and stalking: findings from the British
Crime Survey. Home Office Research,
Development and Statistics Directorate, 2004.
http://www.avaproject.org.uk/media/28384/
hors276.pdf (accessed June 27, 2014).
3 Hegarty K, O’Doherty L, Taft A, et al. Screening
and counselling in the primary care setting for
women who have experienced intimate
partner violence (WEAVE): a cluster
randomised controlled trial. Lancet 2013;
382: 249–58.
4 Jewkes R. Intimate partner violence: the end of
routine screening. Lancet 2013; 382: 190–91.
5 Trevillion K, Oram S, Feder G, Howard LM.
Experiences of domestic violence and mental
disorders: a systematic review and
meta-analysis. PLoS One 2012; 7: e51740.
Treatment of
adolescents with
anorexia nervosa
The treatment model for adolescents
with anorexia nervosa proposed
by Beate Herpertz-Dahlmann
and colleagues (April 5, p 1222) 1
addresses the important issue of
diligent resource allocation in the
management of these patients.
However, a few points in the
methodology particularly pertaining to
choice of outcome parameters need to
be discussed. Considering family-based
interventions were an integral
component of treatment in both
arms of the randomised controlled
trial,1 the baseline assessment and
outcome measures could have
included an assessment of the degree
of cohesion and conflicts in the family,
such as the family environment scale.2
This could have served as a valuable
functional outcome parameter beyond
body-mass index and the individual
psychosocial outcome parameters.
This would have also provided
valuable data regarding the subgroup
of patients who would be more Submissions should be
made via our electronic
suitable for a stepped-care approach
as opposed to conventional inpatient
submission system at
http://ees.elsevier.com/
care. This would have supplemented thelancet/
229
 Correspondence
patient variables such as younger
age, shorter duration of illness, and
better motivation, which support a
stepped-care approach as noted by
Herpertz-Dahlmann and colleagues.1
In addition, assessment of medical
comorbidity at baseline was not
recorded in the study; this could be a
potential confounder in determining
preference for a model of treatment as
well as in the assessment of outcome
of the interventions.
Also, a few considerations in
implementation of the proposed
model merit comment. Restricting
the duration of follow-up to 1 year
is probably the major limitation of
the study, because possible poor
adherence to a stepped-care approach,
attrition during stepping up or down,
patient satisfaction, preference, and
acceptability are to be considered
before implementation of such a
model.3 It is also interesting to note
that about 10% of patients randomised
to brief inpatient stay followed by
outpatient treatment preferred
treatment in a continued inpatient
setting highlighting the issues of
patient’s preference and acceptability.
Use of service-centred outcome
parameters in addition to
disease-centred and patient-centred
parameters might have yielded
valuable data. For example, measures
of therapy suitability and patient’s
expectancy could have been factored
into outcome data that might
have provided valuable insight into
Baseline
IP
Mothers
Criticism 21·8 (4·7)
Emotional overinvolvement 29·4 (3·6)
Fathers
Criticism 21·5 (4·7)
Emotional overinvolvement 27·4 (3·5)
Data are mean (SD) unless otherwise specified; 12-month follow-up data are either at 52 (±6) weeks from the time of admission or to relapse (readmission for eating
disorder) IP= inpatient treatment. DP= day-patient treatment· *p values are for differences between the treatment arms at follow-up. The linear model is adjusted for age,
duration of illness, and baseline values.
Table: Emotions expressed by parents assessed by Family Questionnaire5 at baseline and follow-up
230
the service delivery model. Future
randomised control trials with a longer
duration of follow-up are likely to shed
more light on these issues.
I declare no competing interests.
Sundar Gnanavel
sundar221103@yahoo.com
AIIMS, Department of Psychiatry, Ansari Nagar,
New Delhi 110029, India
1 Herpertz-Dahlmann B, Schwarte R, Krei M, et al.
Day-patient treatment after short inpatient care
versus continued inpatient treatment in
adolescents with anorexia nervosa (ANDI): a
multicentre, randomised, open-label,
non-inferiority trial. Lancet 2014; 383: 1222–29.
2 Boyd CP, Gullone E, Needleman GL, Burt T. The
Family Environment Scale: reliability and
normative data for an adolescent sample.
Fam Process 1997; 36: 369–73.
3 Bower P, Gilbody S. Stepped care in
psychological therapies: access, effectiveness
and efficiency. Brit J Psychiatry 2005;
186: 11–17.
Authors’ reply
We welcome the interest in our study1
assessing day-patient treatment
following short inpatient treatment
in adolescents with anorexia
nervosa. The aim of our trial was to
determine an effective treatment
setting that would qualify for broad
implementation in clinical practice.
Therefore, we did a randomised
controlled trial with few exclusion
criteria. In about 40% of the patients,
the onset of anorexia nervosa is during
adolescence. By covering an age range
from 11 to 18 years in our trial, we
ensured to include the vast majority
of patients with anorexia nervosa,
who were being hospitalised for the
12-month follow-up
DP IP DP
21·8 (5·4) 18·6 (5·0) 20·0 (5·6)
28·6 (4·0) 25·0 (3·7) 25·9 (4·1)
20·3 (5·0) 18·4 (4·6) 18·3 (5·1)
26·5 (3·4) 23·4 (3·6) 23·8 (3·4)
first time. We did not aim to identify
the subgroups that would benefit
most from day-patient treatment.2
Detailed analyses of the mediators
and moderators of treatment will
be presented separately. Body-mass
index was designated a priori as the
primary outcome, because it was
easy to measure and was recently
confirmed as a reliable predictor
of broader recovery in adolescent
anorexia nervosa. 3 One of the
secondary outcome measures, the
Morgan and Russell scores, is the
most frequently applied outcome
parameter in anorexia nervosa. 4
Because we did not intend to assess
the influence of family-based
interventions, as our focus was on
the effect of day-patient treatment,
assessment of family functioning
was not our first priority. However, a
post-hoc analysis presents the results
for the Family Questionnaire,5 which is
a self-report scale assessing parental
criticism and overinvolvement (table).
The family questionnaire is based on
the Camberwell Family Interview—a
reliable instrument for the evaluation
of expressed emotions (threshold
score for high criticism: 23; threshold
score for high overinvolvement:
29 on a scale 10–40).5 At baseline,
mothers and fathers reported
similar scores for parental criticism
and overinvolvement in both the
day-patient treatment and inpatient
treatment (table). At 12-month
follow-up, parents showed
Difference (95% CI) p value*
–0·90 (–2·48 to 0·68) 0·26
–0·19 (–1·54 to 1·15) 0·77
0·95 (–0·75 to 2·66) 0·27
0·37 (–0·96 to 1·69) 0·59
www.thelancet.com Vol 384 July 19, 2014