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    <p class="title-left"><span class="bold">Association of COVID-19 With Intimate Partner Violence</span></p>
    <p class="byline-regular">Ahmed Saeed Yahya, MRCPsych<span class="superscript">a</span>; Shakil Khawaja, MRCPsych<span class="superscript">a</span>; and Jude Chukwuma, MRCPsych<span class="superscript">b</span></p>
    <p class="drop-cap-with-body-text"><span class="bold-14pt-for-cap"><span class="bold">T</span></span>he acute pathogenesis of coronavirus disease 2019 (COVID-19) has caused destruction globally. Government strategies have enforced “draconian” lockdown measures to provide containment and prevent overwhelming already stretched health care services. The fear and anxiety generated by this outbreak coupled with various socially restrictive policies are predicted to cause an upsurge in newly diagnosed mental disorders and relapse of those with existing illness.</p>
    <p class="body-text">At times of economic austerity and emotional crisis, there may be an elevation in harmful alcohol consumption, with those in remission relapsing and some potentially developing a new alcohol use disorder.<span class="htm-cite"><a href="#ref1">1</a></span> Individuals with predisposing vulnerabilities such as trait impulsivity or mental health difficulties and those with established neuroadaptive dysfunction from chronic alcohol abuse are at particular risk.<span class="htm-cite"><a href="#ref1">1</a></span></p>
    <p class="body-text">There is an association between excessive alcohol use in both the victims and perpetrators of intimate partner violence (IPV).<span class="htm-cite"><a href="#ref2">2</a></span> IPV more commonly affects those from minority groups who are socially isolated and financially deprived.<span class="htm-cite"><a href="#ref3">3</a></span> The relationship with psychiatry is bidirectional, as mental illness can increase vulnerability to IPV exposure while the abuse can also trigger illness onset.<span class="htm-cite"><a href="#ref4">4</a></span></p>
    <p class="body-text">IPV is a silent but major public health concern with associated psychiatric and physical health comorbidity.<span class="htm-cite"><a href="#ref4">4</a></span> Women are more likely to disclose to a health care professional than to contact law enforcement agencies.<span class="htm-cite"><a href="#ref4">4</a></span> The clinician would need to establish a therapeutic alliance while being adept at direct inquiry to aid this disclosure. However, IPV remains underdetected globally with limited screening in primary care,<span class="htm-cite"><a href="#ref4">4</a></span> which is where individuals may initially present with emotional difficulties or signs of physical injury.</p>
    <p class="body-text">IPV is conceptualized as physical, sexual, or psychological harm between 2 people who are or were involved in a romantic relationship, which differentiates it from other variants of domestic violence.<span class="htm-cite"><a href="#ref2">2</a>,<a href="#ref3">3</a></span> In the United Kingdom, records indicate that there were 173 domestic violence–related homicides in 2018.<span class="htm-cite"><a href="#ref5">5</a></span> The UK Office for National Statistics estimated in the year ending March 2019 that approximately 1.6 million women and 786,000 men had experienced domestic abuse in England and Wales.<span class="htm-cite"><a href="#ref5">5</a></span></p>
    <div class="clinical-article">
      <div class="heading"><img src="/publishingimages/new_tocs/clinical_points.gif" alt="clinical points"></div>
      <ul>
        <li class="clinical-points">The enforced government social isolation and added fear generated by COVID-19 may explain the rise in global intimate partner violence (IPV) cases.</li>
        <li class="clinical-points">Alcohol intoxication is implicated in the etiology of IPV, and the numbers of those misusing harmful substances has possibly increased during the COVID-19 crisis.</li>
        <li class="clinical-points">It is important that primary care physicians are attuned to and proactively identify cases of IPV.</li>
      </ul>
    </div>
    <p class="body-text">COVID-19–related anxieties and associated government policy have expectedly created a rise in the number of domestic violence incidents globally. From March 24, 2020, to March 27, 2020, the UK charity SafeLives sent a survey to frontline domestic violence services. Their data revealed that 22% of the 119 domestic violence agencies that responded had an increase in their respective caseloads.<span class="htm-cite"><a href="#ref6">6</a></span> One-third of these 119 agencies reported a decrease in staff numbers, with 22% also stating that they are unable to effectively support adult victims during this critical time.<span class="htm-cite"><a href="#ref6">6</a></span> The UK government has recently directed more funding toward organizations to tackle this growing national crisis.<span class="htm-cite"><a href="#ref5">5</a></span> </p>
    <p class="body-text">In the United States, there was recently a potential COVID-19–linked murder-suicide, which was allegedly precipitated by a male perpetrator believing both parties had contracted the virus.<span class="htm-cite"><a href="#ref7">7</a></span> It remains uncertain whether there was a previous history of IPV or if the assailant had an underlying mental disorder. We suspect that current attentions may have been diverted to treat the physical ramifications of the pandemic with less oversight of this escalating problem.</p>
    <p class="body-text">There is a strong relationship between IPV and poor mental health outcomes in victims. In their retrospective cohort study, Chandan et al<span class="htm-cite"><a href="#ref8">8</a></span> reported a 2-fold–increased risk of developing anxiety disorders in those exposed to IPV. They also found a 3-fold increase in the risk of developing depression or a serious mental illness.<span class="htm-cite"><a href="#ref8">8</a></span> The burden and adverse impact of IPV can extend to children and adolescents who may be direct witnesses. This exposure can cause significant psychological distress and trigger the emergence of a psychiatric disorder in this vulnerable group.<span class="htm-cite"><a href="#ref9">9</a></span></p>
    <p class="body-text">The early identification and timely management of cases may halt progression and curb the pattern of abuse. The use of the online platform may be an effective and discrete method<span class="htm-cite"><a href="#ref10">10</a></span> to reach victims at a time when face-to-face contact is limited. It remains vital that primary care physicians routinely inquire for IPV<span class="htm-cite"><a href="#ref11">11</a></span> and act on their clinical intuition. If detected, we advise the employment of simple strategies such as signposting to relevant organizations including advocacy (<a href="#box1">Box 1</a>), using motivational interviewing techniques to empower the victim, and collaboratively formulating a safety plan.<span class="htm-cite"><a href="#ref4">4</a></span> The ultimate goal may be to separate the victim and assailant.</p>
    <div id="box1">
      <p class="subheads_subhead-1">Box 1. Online Resources for Clinicians and Patients</p>
      <div>
        <p class="body-text"><span class="semibold">Organizations in the United States</span></p>
        <ul>
          <li class="graphic-styles_table-text-bullet">Futures Without Violence <a href="https://www.futureswithoutviolence.org/resources-events/get-help/" target="_blank">https://www.futureswithoutviolence.org/resources-events/get-help/</a><br/>
            Provides programs to end violence against women and children around the world</li>
          <li class="graphic-styles_table-text-bullet">National Domestic Violence Hotline <a href="http://thehotline.org/" target="_blank">http://thehotline.org/</a><br/>
            Provides lifesaving tools and immediate support to enable victims to find safety and live lives free of abuse</li>
          <li class="graphic-styles_table-text-bullet">Love Is Respect <a href="https://www.loveisrespect.org/" target="_blank">https://www.loveisrespect.org/</a><br/>
            Provides advocates trained in advising and supporting on issues related to dating abuse and establishing healthy relationships</li>
        </ul>
        <p class="body-text"><span class="semibold">Organizations in the United Kingdom</span></p>
        <ul>
          <li class="graphic-styles_table-text-bullet">Domestic Violence Assist <a href="https://www.dvassist.org.uk/" target="_blank">https://www.dvassist.org.uk/</a><br/>
            Offers assistance in obtaining emergency injunctions</li>
          <li class="graphic-styles_table-text-bullet">Women’s Aid Domestic Violence <a href="https://www.womensaid.org.uk/" target="_blank">https://www.womensaid.org.uk/</a><span class="underline"><br />
            </span>Provides a free 24-hour national helpline run by Women’s Aid and Refuge</li>
          <li class="graphic-styles_table-text-bullet">Men’s Advice Line <a href="https://mensadviceline.org.uk/" target="_blank">mensadviceline.org.uk</a><br/>
            Provides a confidential helpline for male victims of domestic abuse</li>
          <li class="graphic-styles_table-text-bullet">National LGBT Domestic Abuse <a href="https://www.galop.org.uk/domesticabuse/" target="_blank">https://www.galop.org.uk/domesticabuse/</a><br/>
            Offers emotional and practical support</li>
          <li class="graphic-styles_table-text-bullet">National Centre for Domestic Violence <a href="https://www.ncdv.org.uk/" target="_blank">https://www.ncdv.org.uk/</a><br/>
            Provides a free, fast emergency injunction service</li>
        </ul>
      </div>
    </div>
    <p class="end-matter"><span class="bold-italic">Received:</span> April 14, 2020.</p>
    <p class="end-matter"><span class="bold-italic">Published online:</span> May 7, 2020.</p>
    <p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
    <p class="end-matter"><span class="bold-italic">Funding/support:</span> None. </p>
    <p class="references_references-heading"><span class="bold">REFERENCES</span></p>
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    <p class="references-references-text-1-9"><a name="ref7"></a><span class="htm-ref"> 7. </span>Coronavirus fears linked to Illinois pair’s murder-suicide. BBC News website<span class="underline">. </span><a href="https://www.bbc.com/news/world-us-canada-52192842" target="_blank"><span class="underline">https://www.bbc.com/news/world-us-canada-52192842</span></a>. Accessed April 28, 2020.</p>
    <p class="references-references-text-1-9"><a name="ref8"></a><span class="htm-ref"> 8. </span>Chandan JS, Thomas T, Bradbury-Jones C, et al. Female survivors of intimate partner violence and risk of depression, anxiety and serious mental illness [published online ahead of print June 7, 2019]. <span class="italic">Br J Psychiatry</span>. 2019:1–6. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31171045&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1192/bjp.2019.124" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
    <p class="references-references-text-1-9"><a name="ref9"></a><span class="htm-ref"> 9. </span>Black D. Witnessing adults’ violence: the effects on children and adolescents. <span class="italic">Adv Psychiatr Treat</span>. 1998;4(4):202–210. <a href="https://doi.org/10.1192/apt.4.4.202" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
    <p class="references-references-text-10-99"><a name="ref10"></a>10. Hegarty K, Tarzia L, Valpied J, et al. An online healthy relationship tool and safety decision aid for women experiencing intimate partner violence (I-DECIDE): a randomized controlled trial. <span class="italic">Lancet Public Health</span>. 2019;4(6):e301–e310. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31155223&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/S2468-2667(19)30079-9" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
    <p class="references-references-text-10-99"><a name="ref11"></a>11. Hegarty K, Taft A, James-Hanman D, et al. Interventions for intimate partner violence. <span class="italic">Lancet</span>. 2015;385(9963):111–112. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=25706460&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/S0140-6736(15)60013-7" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
    <div id="affilDiv">
      <p class="front-matter-rule front-matter"><span class="superscript">a</span>Waltham Forest Mental Health Team, North East London Foundation Trust, Red Oak Lodge, London, England</p>
      <p class="front-matter"><span class="superscript">b</span>Barnet Enfield and Haringey Mental Health NHS Trust, London, England</p>
      <p class="front-matter"><span class="asterisk">*</span><span class="italic">Corresponding author:</span> Ahmed Saeed Yahya, MRCPsych, Waltham Forest Mental Health Team, North East London Foundation Trust, Red Oak Lodge, London, England E11 4HU <span class="hyperlink">(<a href="mailto:a.yahya@nhs.net">a.yahya@nhs.net</a>)</span>. </p>
      <p class="abstract-citation front-matter"><span class="italic">Prim Care Companion CNS Disord 2020;22(3):20com02634</span></p>
      <p class="to-cite front-matter"><span class="bold-italic">To cite:</span> Yahya AS, Khawaja S, Chukwuma J. Association of COVID-19 with intimate partner violence. <span class="italic">Prim Care Companion CNS Disord</span>. 2020;22(3):20com02634.</p>
      <p class="doi-line front-matter"><span class="bold-italic">To share:</span> https://doi.org/<span class="doi">10.4088/PCC.20com02634</span></p>
      <p class="abstract-copyright front-matter"><span class="italic">© Copyright 2020 Physicians Postgraduate Press, Inc.</span></p>
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