This cross-sectional, hospital-based study was conducted at Kodagu Institute of Medical Sciences (KoIMS) teaching hospital Madikeri, Karnataka. These study subjects were recruited using the purposive sampling method. An Institutional Ethics Committee approval was obtained (KoIMS/IEC/01/17-19) before the study. The study period was from March 2017 to June 2019.

Total of 5810 consecutive subjects visited the psychiatry OPD during the study period. They were diagnosed with conditions like depression (28), anxiety disorder (25), bipolar affective disorder (12), obsessive-compulsive disorder (5), schizophrenia (12) as per the International Classification of Diseases, (Diagnostic Criteria for Research) [9]. All of them were already on treatment and maintaining clinical improvement on mental status examination, assessed during the clinical interview.

Inclusion criteria: Both men and women, in the age range of 18 to 60 years, who would understand and could give written informed consent, were recruited for the study.

Exclusion criteria: Out of 5810 subjects, 5728 patients did not report IPV and had active psychiatric illness even on medications, like schizophrenia with hallucinations, delusions, aggressive, were non-co-operative, had severe depression and anxiety symptoms (18), and did not give written consent (25). Thus, they were excluded.

A specially designed sociodemographic data sheet was used to record the demographic variables. Modified Kuppuswamy’s classification was used for sociodemographic status classification and residence area categorisation was done using available literatures [10,11].

The subjects were assessed by psychiatrists using the HITS Domestic violence tool to assess IPV, experienced as either a single episode or ongoing violence in the last six months and the WHOQOL-BREF scale to assess the quality of life. The HITS is a four-item scale rated on a 5-point Likert scale from 1 (never) to 5 (frequently). This tool was initially developed and tested among family physicians and family practice offices, and since then has been evaluated in diverse outpatient settings. Internal reliability and concurrent validity are acceptable. HITS score of less than 10 indicates less severe IPV, and more than 10 indicates IPV, which warrants clinical intervention was considered for the study [12].

WHOQOL-BREF includes initial questions like “How would you rate your quality of life?” with response includes very poor to very good and “How satisfied are you with your health?” with very dissatisfied to very satisfied as responses. It also consists of four domains namely physical, psychological, social relationship, and environmental. The scoring is from 1 to 5 on a Likert scale and the mean scores of items within each domain are used to calculate the domain score. The total score for each domain after transformation ranges from 0 to 100. Domain scales are scaled in a positive direction i.e., higher scores denote the higher quality of life [13].

The statistical analysis of data was performed using the computer program, Statistical Package for Social Sciences (SPSS for Windows, version 16.0. Chicago, SPSS Inc.) and Microsoft Excel (Redmond, Washington: Microsoft, 2003. Computer Software). Descriptive statistics were used to define the continuous variables. Chi-square test was applied for categorical variables and sample characteristics. One sample Kolmogorov-Smirnov (KS) test was done to test the normality and Mann Whitney-U values were used for quality of life scores and correlation was done using Pearson’s correlation. Statistical significance was considered at a p-value less than 0.05.

Out of 82 study subjects, 61 reported HITS score >10, suggestive of IPV needing clinical intervention, 21 had HITS score <10 which indicates less severe IPV. Mean age of males and females, education and HITS scores of the study subjects is shown in [Table/Fig-1], majority of them were in their third decade in Depression, Anxiety and schizophrenia category. Subjects in BPAD and OCD categories belonged to fourth decade. A p-value of <0.05 is considered significant in this study.

Of the sociodemographic variables, IPV was noted in both males and females. Among females 80.32% and among males 19.67% had HITS score of more than 10, which was statistically significant. Among the diagnoses, depression and anxiety disorder category contributed for majority of the study subjects and the finding among this variable was also statistically significant [Table/Fig-2].

Most of the study subjects with HITS score of more than 10 reported very poor (42.62%) and poor (44.26%) in their overall quality of life and majority were dissatisfied in their health domain as shown in [Table/Fig-3].

Presence of IPV significantly correlated with environmental, psychological, social and physical health domains of quality of life scale as shown in [Table/Fig-4].

The present study assessed the relationship between IPV with quality of life among subjects of various psychiatric diagnostic categories that were maintaining improvement on treatment.

Sociodemographic characteristics: The study subjects belonged to their third decade (Male-35.45 years, Female-36.24 years), having mean education of class 7 (primary schooling) and from a rural background (69.51%). Depression and anxiety disorder were more common as compared to BPAD, OCD and Schizophrenia categories [Table/Fig-2].

A Southern Indian study, which assessed women experiencing IPV and its association with Post-Traumatic Stress Disorder (PTSD) and depression found that a significant number were either not educated or had just primary education. Less educated women and their partners were found to report more violence [14]. A study on educated women found the prevalence of IPV to be 40.5% and physical assault was high in 30-50 years of age. Majority of the group had a technical education or were professionals [15].

Study in a rural centre on IPV among married women noted that, study subjects were in their late fourth decade (mean=49.7±13.2 years), with no formal education (64%), primary school (11%), and middle school (12%), respectively [8]. One study which noted, women that experience IPV reported depression and some of these women also met criteria for syndromal PTSD [14]. Another study among married women treated for depression reported IPV and the use of alcohol by their spouse’s was also a contributory factor [8].

Intimate Partner Violence (IPV): In the present study, psychological violence in terms of insult, threaten with harm, scream or curse was more as compared to physical violence. An Indian study showed IPV in physical, psychological and sexual domains. However, another Indian study showed physical violence was most common as compared to sexual and psychological violence [14,15]. An international study reported IPV in the form of physical violence was more among women seeking termination of pregnancy (29%) as compared to women seeking contraceptive counseling (22%) [16]. However, psychological assault was found to be a more common complaint among educated women, as found in a study from India [15].

Wittenberg E et al., in their study on measuring the effect of IPV on health-related quality of life noted that, emotional and psychological health plays an important role in the overall Health Related Quality of Life (HRQOL) of abused women and Holistic measurement approaches or expanded measures that capture the far-reaching effects of IPV on HRQOL may be needed to accurately measure the effect of this condition on women’s health [5].

Another Indian study on IPV among ever-married women treated for depression in a rural health centre noted that the prevalence of physical IPV and nonphysical IPV was found to be 18% and 7%, respectively. Marital quality was significantly lower among women who experienced IPV. Women with husbands who ever used alcohol were found to have six times more risk of experiencing physical IPV [8].

The sample size was small the findings of the study cannot be generalised and the current study could not establish whether IPV experienced by the study subjects was because of their mental health condition, as various other factors might have contributed for the same.

On the basis of the available limited literature and results of the index study, substantiating the earlier findings, it can be concluded that IPV with impaired quality of life can be present in males and more in females, rural and urban areas and across various age groups, psychiatric conditions like depression and anxiety disorders and educational background. Routine clinical assessment to enquire about IPV is needed for timely intervention.