Interventions Targeting Depression and Posttraumatic Stress Disorder in United States Black Women Experiencing Intimate Partner Violence: A Systematic Review

Abstract

There is a dearth of evidence indicating the effectiveness of psychological interventions targeting depression and/or posttraumatic stress disorder (PTSD) for Black women in the United States (US) exposed to intimate partner violence (IPV). We searched PubMed, MEDLINE, PsycINFO, EBSCOhost, Social Sciences, Social Sciences Full Text, Social Work Abstracts, and Cochrane databases between September 2021 and October 2022, for original studies of randomized control trials (RCTs) reporting depression and/or PTSD interventions delivered to US Black women with histories of IPV. Of the 1,276 articles, 46 were eligible and 8 RCTs were ultimately included in the review; interventions for depression (four interventions, n = 1,518) and PTSD (four interventions, n = 477). Among Depression and PTSD interventions (one intervention, n = 208), Beck’s Depression Inventory II indicated M = 35.2, SD = 12.6 versus M = 29.5, SD = 13.1, <.01, and Davidson Trauma Scale indicated M = 79.4, SD = 31.5 versus M = 72.1, SD = 33.5, <.01, at pre- and post-intervention respectively. Also, some interventions reported severity of depression M = 13.9 (SD = 5.4) versus M = 7.9 (SD = 5.7) < 0.01, and PTSD (M = 8.08 vs. M = 14.13, F(1,117) = 9.93, p < .01) at pre- and post-intervention respectively. Publication bias was moderate and varied between 12 and 17 via the Downs and Black Checklist for Methodological Rigor for RCTs. Psychological interventions targeting depression and/or PTSD for Black women with histories of IPV reflect moderate improvement. Interventions that account for cultural nuances specific to Black women are fundamental for improving outcomes for survivors presenting with depression and/or PTSD.

Introduction

Depression and posttraumatic stress disorder (PTSD) are the most common adverse mental health outcomes among survivors of intimate partner violence (IPV) (Toccalino et al., 2022) and Black women in the United States (US) are disproportionately impacted (Lacey et al., 2015; Sabri et al., 2013). Depression is the leading cause of disability in the US (Greenberg et al., 2021). IPV survivors are more than twice as likely to suffer from depression than women who have never been abused (Mazza et al., 2021). Depression delays IPV survivors’ help-seeking and may help account for higher rates of intimate partner homicide (Mazza et al., 2021; Petrosky et al., 2017). IPV is any physical, sexual, psychological, or financial abuse, or controlling behaviors inflicted by a current or former intimate partner (Breiding et al., 2015). More than 40% of Black women have experienced IPV during their lifetime (Basile et al., 2011). Black women are nearly three times more likely than white women survivors to be exposed to more severe forms of abuse (Sabri et al., 2013), which is predictive of elevated rates of PTSD (Sullivan & Weiss, 2017). Research indicates that white women survivors exhibit more PTSD symptoms than Black women (Nathanson et al., 2012). However, Black women may report fewer symptoms of posttraumatic stress in the presence of more risk (Lilly & Graham-Bermann, 2009) and protective factors, including spirituality and religious involvement (Waller et al., 2021). Despite experiencing poorer mental health outcomes than white women survivors, there is a dearth of literature that examines empirically tested, culturally appropriate mental health interventions for Black women. This systematic review seeks to close this gap.

Social determinants that facilitate the occurrence of IPV for Black women survivors include disproportionately low wealth accumulation, concentrated disadvantage and housing insecurity (Breiding et al., 2017). The latter makes IPV victimization a leading cause of homelessness (Mugoya et al., 2020). For Black men perpetrators, a lack of economic opportunities resulting in poverty, and racial and class differences are disparities that Black men may use to justify their violent behaviors (Waller, 2016). When remanded to batterer intervention programs, Black men are more likely than their white peers to drop out due to treatment incongruence. Batterer program dropout is positively correlated with an increased risk of intimate partner homicide (Waller, 2016).

Racism compounds Black women’s IPV help-seeking experiences. Stereotypes such as the Jezebel, defined as a sexually aggressive, immoral and promiscuous woman; the Mammy, positioned an older, religious, asexual and compliant figure; and the strong Black woman, the notion that they can withstand hardships in a calm and collected manner impacts the perception of Black women (Waller et al., 2021). These tropes have been used to justify the violence and exploitation that is inflicted upon them. Salient to their experiences with the mental health system include underdiagnoses for depression, retraumatization in treatment and misperceptions of hypersexuality in relationship dynamics with Black men (Gillum, 2021; Waller et al., 2021).

Black men, living at the intersection of racism and classism, are empowered to rely on traditional gender roles enforced by patriarchy to define and affirm their masculinity (Taft et al., 2009). Black women are likely to sympathize with the oppression, marginalization, and discrimination that Black men face, especially within the carceral system (Finfgeld-Connett, 2015). As a result, women may simultaneously contend with societal pressures—from their partners, community, and leaders within their religious institutions—to remain silent about their abuse for the sake of image preservation (Taft et al., 2009). These influences inform Black women’s help-seeking when interacting with formal systems that perpetrate institutional racism, namely the mental healthcare, healthcare, and criminal legal systems, or domestic violence support infrastructures, such as emergency housing shelters (Waller et al., 2021). Factors commonly reported among low-income, Black women including anti-Black racism, discrimination, oppression, and poor living conditions further compound a range of deleterious mental health outcomes associated with IPV victimization (Mugoya et al., 2020).

Mental illness remains largely stigmatized within the Black community. This reality often prevents Black women from readily utilizing traditional mental health services (Sabri et al., 2013). Their reluctance to acknowledge or accept their mental health conditions, and/or delayed engagement in mental health help-seeking provides Black women with an escape. They avoid publicizing their weaknesses and maintain cultural expectations of a strong Black woman (Nicolaidis et al., 2010; Sabri et al., 2013). Those who suffer from depression are less likely to seek mental health care than those who have never experienced IPV (Nicolaidis et al., 2010). When they do engage in treatment, they are more likely to drop out of treatment due to the dearth of culturally salient interventions (Nicolaidis et al., 2010, 2013). Furthermore, Black women are less likely to consider antidepressants an acceptable form of treatment because they mistrust physicians’ intentions, fear addiction, and prefer to cope without medicine (Nicolaidis et al., 2013).

Nicolaidis and colleagues (2010) examined Black women’s experiences with mental health providers and found that racism, rather than race, adversely influenced survivors’ help-seeking within the healthcare system. Race is neither a causal factor nor risk factor for mental health conditions—nor is it a biological determinant (Bryant et al., 2022). Therefore, anti-Black racism is the underlying social determinant that informs depressed Black women survivors’ adverse encounters with and negative perceptions of healthcare systems. Participants also expressed that racism was a more salient and problematic barrier to seeking depression treatment than IPV victimization (Nicolaidis et al., 2013). Negative perceptions of seeking depression care are linked to institutional racism and are associated with beliefs that mental health treatment is an effective strategy (Nicolaidis et al., 2010).

Avoidant coping strategies, such as distraction, procrastination, or denial when managing stressors further increase the risk for PTSD symptoms among IPV survivors (Johnson et al., 2021). Engaging with social supports, as well as relying upon spiritual and religious resources, are associated with higher levels of resilience (Anyikwa, 2015; Howell et al., 2018; Mushonga & Henneberger, 2020). Black women’s spirituality and religion are not only common coping strategies, they are also culturally relevant protective factors (Howell et al., 2018). While resilience has been identified as a positive coping strategy, resilience could also be problematic (Anyikwa, 2015; Mushonga et al., 2020). Resilience reinforces the strong Black woman stereotype and may lead survivors to tackle hardships alone.

Micro and macro-level mechanisms of inequities along with cultural and gendered stereotypes socializes Black women’s self-reliance (Waller et al., 2021). Mistrust of health systems resulting from institutional racism typically influences Black survivors’ decision to forgo utilizing traditional mental health services (Nicolaidis et al., 2013)—and few interventions address optimizing resources to rebuild trust. There is a dearth of culturally responsive, accessible, and community-oriented interventions designed to support the sociopolitical and cultural complexities of Black women IPV survivors (Al’Uqdah et al., 2016). This systematic review aims to provide an overview of the existing evidence on the efficacy of mental health interventions that target US Black women IPV survivors with depression and/or PTSD.

Methods

We conducted a systematic review of the literature to examine the depression and/or PTSD interventions that have been implemented for US Black women IPV survivors. The review is registered in PROSPERO, the International Prospective Register of Systematic Reviews (Registration Number: CRD4202234934). Findings are reported in accordance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) (See Figure 1 (Moher et al., 2015).

Figure 1.

PRISMA-P diagram (Moher et al., 2015) of database search included in the systematic review of mental health interventions for US Black women survivors of intimate partner violence.

Study Selection

The search was conducted between September 2021 and October 2022. We accessed the following databases: (a) PubMed, (b) MEDLINE, (c) PsycINFO, (d) EBSCOhost, (e) Social Sciences, (f) Social Sciences Full Text, (g) Social Work Abstracts, and (h) Cochrane. We used the following keywords: IPV, partner violence, or domestic violence; depression or anxiety, PTSD, intervention, or therapy; and African American women or Black women.

Eligibility Criteria

Studies were included if they: (a) examined depression, anxiety, and/or PTSD interventions; (b) described the effectiveness or treatments evaluations; and (c) were peer-reviewed publications that included samples of United States Black women IPV survivors, aged 18 to 66. Eight studies met all three criteria.

Data Extraction

We (BYW and SL) extracted data and organized it using a standardized data collection sheet (Google Sheets 2021; 2Web Technologies). The spreadsheet included the theory, methods, sample, treatment type and duration, study setting, findings, and cultural adaptation(s). Data extraction was validated by the first author (BYW), a licensed therapist who has treated Black women IPV survivors for more than a decade.

Risk of Bias

Three of us (BYW, SL, and NL) met bi-weekly to review findings, discuss discrepancies, and discuss next steps of the research. The methodological quality of the intervention studies was assessed using the Downs and Black Quality Assessment Checklist (Downs & Black, 1998). Study quality ranged from 12 to 16 of a possible 27 points, indicating moderate risk of bias in study design and analysis.

Results

Study Selection

Our search yielded a total of 1,276 articles. We eliminated 893 that were not full-text or otherwise inaccessible. An additional 56 abstracts were removed because studies were neither conducted in the United States nor published in English. Another 281 articles were excluded because they were outside of the scope of this inquiry. These articles specifically focused upon HIV/AIDS co-occurring with depression and/or PTSD, college-age women, rape interventions, or interventions for male offenders. The remaining 46 articles were reviewed in detail. Articles that did not include an intervention, focused on single session interventions, or omitted assessing intervention effectiveness were removed. A separate hand search via Google Scholar netted one additional article. Ultimately, eight articles were included in the review (See Table 1).

Table 1.

Study Characteristics and Relevant Findings.

Serial No.	Citation	Sample	Setting	Intervention	Modality	Instruments	Study Design and Analysis	Findings
	DePrince et al. (2012)	236 women (Black/AA: 29%)	Community-based victim-service agencies referrals	Community-Coordinated Response (CCR) Program (Community-based Outreach or Referral program, 1 year)	Individual	Posttraumatic Stress Diagnostic Scale (PDS), DSM–IV, Beck Depression Inventory–II (BDI), Trauma Appraisal Questionnaire, Revised Conflict Tactics Scale (CTS)	Longitudinal study Randomized Controlled Trial Questionnaire and Individual interview (3 times over 1 year) General linear mixed model (GLMN) 95% CI	Women with outreach condition showed decreased PTSD and depression symptoms and severity of fear than women in referral condition compared to women who participated in referral condition. Those with outreach condition reported more likelihood of readiness to leave the abuser and positive rates of services than women in the referral condition.
2	El-Khorazaty et al. (2007)	1,070 pregnant at 28 weeks gestation or less (AA: 1044)	Parental care clinics	Project DC-HOPE (Integrated counseling and education) (Duration not noted; but evaluated at baseline and 8–10weeks postpartum)	Individual	Audio-Computer-Assisted Self Interview (A-CASI), Classification and Regression Trees (CART)	Experimental study Randomized Clinical Trial	Women with depression risk only, depression and smoking risks, or only IPV risks reported low rates of program completion. Retention strategies included financial incentives, contact information updates regularly, program facilitators recruitment with the same ethnic backgrounds as participants, and employers’ cultural competency.
3	Graham-Bermann and Miller-Graff (2015)	181 mothers exposed to IPV in the past year and have children between ages 6 and 12 (AA: 35%)	Social service agencies, shelters, mental health clinic, outreach center.	Mom’s Empowerment Program (MEP) (Community-based program, 10 weeks)	Group	Severity of Violence against Women Scales, BDI, Parental Child rearing Styles Scale	Experimental study Randomized Control Trial (RCT) Hierarchical linear modeling and descriptive analyses 95% CI	Women in the mother-plus-child intervention showed the greatest improvement in both positive parenting and depression, whereas women in comparison group (no treatment) showed parenting grew worse over time. Women in both mother-plus-child and child-only interventions improved in depression from baseline to the 10 weeks posttreatment period. Women in mother-plus-child was successful in reducing depression over 10 weeks program relatively compared to the group in child-only program whose depression increased in the 8-month follow up.
4	Iverson et al. (2011)	150 battered women (AA: 86)		Cognitive Behavioral Therapy (CBT), 6weeks; I2hr	Individual	Standard Trauma Interview, Conflicts Tactics Scale-Physical Aggression Subscale, PDS, DSM-IV, BDI,	Experimental stuy Randomized Clinical Trial Hierarchical Linear, Non-Linear Modeling, Multilevel regression analyses 95% CI	Survivors who received CBT reported reductions in both PTSD and depressive symptoms during treatment and decreased experience of IPV at a 6-month follow up.
5	Kaslow et al. (2010)	208 low-socioeconomic-status AA women with a recent history of IPV and a suicide attempt	University-affiliated hospital	Grady Nia (Culturally informed and empowerment focused psychoeducational group) (10 sessions)	Group sessions	Index of Spouse Abuse (ISA)—physical and nonphysical subscales (ISA-P, ISA-NP), Beck Scale for Suicidal Ideation, BDI, Brief Symptom Inventory	Experimental study Randomized controlled trial 95% CI Continuous scale	Women who received culturally informed and empowerment-focused psychoeducational intervention showed more rapid reductions in depressive symptoms and general distress initially. In the following intervention, compared with women randomized to treatment as usual, women in culturally informed and empowerment-focused psychoeducational intervention exhibited less severe suicidal ideation when exposed to physical and nonphysical IPV.
6	Kubany et al. (2004)	37 battered women (Black: 3)	Victim service agencies	Cognitive Trauma Therapy for Battered Women (CTT-BW) (8–11 sessions)	Individual	Traumatic Life Events Questionnaire, Clinician-Administered PTSD Scale, The Distressing Event Questionnaire, BDI, Rosenberg Self Esteem Scale, Trauma-Related Guilt Inventory, Sources of Trauma-Related Guilt Survey—Partner Abuse Version (STRGS-PA), Personal Feelings Questionnaire, Client Satisfaction Questionnaire (CSQ-8)	Experimental study Randomized Controlled Clinical Trial Continuous 95% CI	CTT-BW was successful in reducing PTSD symptoms across ethnic diverse women. 87% of women who completed treatment no longer show PTSD diagnostic criteria The intervention significantly reduced participants’ guilt and increased their self-esteem.
7	Nicolaidis et al. (2013)	59 AA women who currently have depressive symptoms and history of IPV	Samples were recruited by community partners: Universities, domestic violence advocates, social work researchers, domestic violence agencies, etc.	Community-Based Depression Care Program with motivational interviewing (MI) and case management (6 months)	Individual sessions for MI and case management **CPT group sessions were removed after the first session due to low attendance.	Patient Health Questionnaire (PHQ-9), Women’s Experiences of Battering Scale (WEB), CTS–Revised	Community-based participatory research Survey Semi-structured interview	Significant improvements in depression severity, self-efficacy, self-management behaviors, and self-esteem were shown, but no increase in use of antidepressants. Participants were satisfied with the program because it was run by and for African American women that fostered trust and lasted values of practical self-management strategies.
8	Zlotnick et al. (2011)	54 pregnant women w recent histories of IPV victimization	Two primary care clinics, one obstetrician-gynecologist (OB-GYN) clinic	Brief Interpersonal Psychotherapy (IPC)	Individual	Revised Conflict Tactic Scale (CTS2), Structured Clinical Interview for the DSM-IV Axis I Disorders Nonpatient Version (SCID-NP), Longitudinal Interval Follow-up Examination (Life), The Edinburgh Postnatal Depression Scale, Davidson Trauma Scale	Pilot RCT Chi Square Tests, One-Way ANOVAs	Not significantly decreased depression or PTSD Moderately reduced depression and PTSD during pregnancy Largely reduces PTSD symptoms up to 3 months postpartum No effect on IPV victimization

Demographic Characteristics

This systematic review included samples of Black women, 18 to 64 years old, who resided in the northeast, mideast, southeast, and west regions of the US. Most of the women were single, unemployed, low-income, and attained less than a high school degree (See Table 2). Study participants were in relationships between 3 and 396 months (33 years), and had a history of IPV victimization between 1 and 24 months. Many of the survivors also reported factors that could confound intervention effectiveness. Specifically, women had varying levels of exposure to adverse childhood experiences and/or poly-victimization, namely child abuse, rape, and exposure to community-level violence. A confluence of these factors could affect levels of depression and/or PTSD experienced among participants in the original studies.

Table 2.

Demographic Characteristics.

Study	Age	Education	Marital Status	Employment/Income
Deprince et al. (2012)	Average: 33.8 (SD = 11.1)	Not mentioned	Cohabitation: 51%	Median Annual income: $7,644
El-Khorazaty et al. (2007)	Average: 24.6 (±5.4)	Less than High school: 28.8% High school/GED: 46.9% College: 24.2%	Married/Cohabitation: 25.1%	Employed: 38%
Graham-Bermann and Miller-Graff (2015)	Average: 33 (SD = 5.29)	High school: 84.6%	Separated/Divorced: 39% Married/Cohabitation: 28% Single:23%	Monthly income: $1,366 (SD = $1,315)
Iverson et al. (2011)	Average: 35.4 (SD = 12.4)	Average years of education: 13.8 (SD = 2.8)	Married/Cohabitation: 20%	Annual income of less than $20,000: 53.7%
Kaslow et al. (2010)	Average: 34.7 (SD = 1.04)	Less than High school: 40.4% High school or equivalent: 33.6% College or technical school: 25.9%	Single/Never married: 30.3% Married/Cohabitation: 26.9% Separated/Divorced: 26.9%	Unemployed: 84.6%
Kubany et al. (2004)	Average: 36.4 (SD = 9.1)	Average years of education: 13.6 (SD = 2.4)	Not mentioned	Not mentioned
Nicolaidis et al. (2013)	Average: 38.4	Less than High school:11% High school: 28% College or more: 62%	Never married: 59% Separated/Divorced: 30% Married: 9%	Annual income less than $10,000: 46 %
Zlotnick et al. (2011)	Average: 23.8 (SD = 4.6)	High school: 57.4%	Single: 44.4%	Employed: 33.3% (full-time) Unemployed: 33.3%

Study Characteristics

Six quantitative studies included randomized controlled trials (RCTs) or clinical trials. Studies employed questionnaires, interviews, or self-report data collection methods. Relative risk was calculated for all studies using categorical and continuous outcomes at either a 99% or 95% confidence interval. Two qualitative studies employed either structured or semi-structured interviews in either individual or focus group format. Study reliability was assessed using Kappa coefficient.

Interventions for depression included a community-based depression care program (CBDP), community-coordinated Response (CCR), motivational interviewing (MI) and case management, mom’s empowerment program (MEP), and Project DC-HOPE. PTSD interventions included cognitive behavioral therapy (CBT) and cognitive trauma therapy for battered women (CTT-BW). Interventions that addressed both depression and PTSD included Grady Nia and brief Interpersonal Psychotherapy (brief IPT/IPC) programs. Interventions were implemented in similar places, such as mental health and victim service agencies, women’s care clinics, domestic violence and homeless shelters, and university-affiliated hospitals.

Depression severity was measured using the revised Beck Depression Inventory (BDI-II), the Patient Health Questionnaire-9 (PHQ-9), and/or the Brief Symptom Inventory. PTSD symptomology was assessed via the Posttraumatic Stress Diagnostic Scale (PDS), Clinician-Administered PTSD Scale, Davidson Trauma Scale (DTS), PTSD Symptom Scale, and/or the Structured Clinical Interview for DSM (SCID). IPV severity was measured via the revised Conflict Tactics Scale (CTS-2), Index of Spouse Abuse (ISA), Severity of Violence Against Women Scale, and Women’s Experiences of Battering (WEB) Scale.

Interventions for Depression

Interventions targeting depression largely employed community-based approaches (DePrince et al., 2012; El-Khorazaty et al., 2007; Graham-Bermann & Miller-Graff, 2015; Nicolaidis et al., 2013; Wahab et al., 2014). CBDP with MI and case management, CCR, MEP, and Project DC-HOPE were delivered by community members who connected survivors with formal and informal services nested within their community. These community-based programs were delivered in 10 weeks (MEP and DC-HOPE), 6 months (CBDP), and 12 months (CCR), respectively. They were implemented via university-affiliated, domestic violence, or counseling agencies, as well as domestic violence shelters. Participants in CBDP reflected a significant decrease in depression severity (PHQ-9 13.9–7.9, p < .001) along with improved self-efficacy (29.0–40.5, p < .001) and self-esteem (18.6–24.9, p < .001) 6 months post-intervention. Participants in CCR and MEP also reflected similar outcomes. Depression severity of CCR program participants decreased, t(206) = 3.61, p = .0004, d 0.37 (0.06, 0.69), 1 year post-intervention. Participants in MEP who were randomized to the mother and children (M+C) treatment group reflected greater reductions in depression symptomology (Cohen’s d = 0.77) compared to those randomized to the child-only (CO) control group (d = −0.30) 8 months post-intervention.

The nature of delivery and tailoring of services contributed to the success of CBDP with MI and case management. The intervention was delivered in 10 individual sessions by Black women or peer IPV advocates within trusted community settings who understood depression. Participants were also taught self-care strategies with culturally sensitive approaches. Women who participated in CBDP’s reflected high rates of satisfaction (94%). Participants reflected a high likelihood of referral (90%) and moderate program completion rates (51%). Six months post-intervention, participants noted feelings of acceptance and shared values with facilitators, which encouraged them to apply their newly acquired self-management and depression coping strategies. Project DC-HOPE similarly provided an integrated approach to mental health service delivery. This intervention combined couseling and psychoeducation for pregnant women at risk for smoking, depression, and/or IPV, as well as a combination of the aforementioned. Women who participated in individual counseling sessions showed reductions in their risks within 3.9 ± 2.8 prenatal sessions. Importantly, women who were at elevated risk of IPV showed low non-completion rates (8%) at 8 and 10 weeks postpartum.

Programs that accounted for survivors’ social determinants of health (SDoH) reflected higher program completion rates and overall intervention success. Adjunctive services included financial incentives, employment, housing, shelter, hospital and/or clinic services, parenting skills training, childcare, and faith-based resources. MEP participants showed significant parenting stress reduction 10 weeks post-intervention. CBDP and MEP participants indicated that feelings of empowerment fostered program participation which led to higher levels of formal and informal mental health and social services utilization. Importantly, participants who received community-based outreach demonstrated greater reductions in depression (28%) compared to those who received referrals (14%) 1 year post-intervention. Monetary incentives and frequent contact with participants reminding them of upcoming sessions were found effective in recruitment and retention efforts. Further, Project DC-Hope found that participants who were matched with program facilitators, staff, and interviewers based upon race/ethnicity reflected higher program completion rates.

Interventions for PTSD

CBT and CTT-BW are used for IPV survivors presenting with PTSD (Iverson et al., 2011; Kubany et al., 2004). CBT targeted women’s maladaptive cognitions, emotional responsiveness, and traumatic stress resulting from IPV victimization. The intervention was delivered via 6 weekly, individual sessions. CBT significantly reduced PTSD symptomology (b1 = −0.17, t = −12.38, p < .001, Δσ2 = .56) during the 6-week intervention. Additionally, CBT highlighted the effects of reducing the likelihood of future IPV through the significant associations between improved symptomology (b = 3.37, t = 3.06, p < .05, pr² = .07) and lower levels of IPV at the 6-month follow-up.

CTT-BW is indicated for women who are no longer in abusive relationships and is designed to help women cope with PTSD symptoms triggered by repeated and multiple traumatic events related to their abuse (Kubany et al., 2004). Based on a strengths-based approach, CTT-BW consisted of between 8 and 11 individual sessions that focused on building survivors’ self-advocacy and stress management skills, and reducing negative self-talk. Three months post-intervention, most (94%) of CTT-BW participants no longer screened positive for PTSD. Participants also noted high program satisfaction with a mean Client Satisfaction Questionnaire-8 (CSQ-8) score of 29.8 (range from 0 to 32, SD = 4.3) post-intervention.

Interventions for Depression and PTSD

Three interventions were efficacious in treating both depression and PTSD. CBT, Grady Nia and brief Interpersonal Psychotherapy (brief IPT/IPC) aimed to reduce survivors’ psychological symptoms, interpersonal problems, and social support (Iverson et al., 2011; Kaslow et al., 2010; Zlotnick et al., 2011). Grady Nia additionally integrates Black women’s cultural identity (Kaslow et al., 2010).

CBT was effective in reducing depressive and PTSD symptomology (Iverson et al., 2011). The manualized intervention included 12 individual sessions over 6 weeks. The treatment targeted cognitive distortions about traumatic events, and included psychoeducation and homework assignments. More than half (57%) of participants dropped out of treatment. Still, there were significant reductions in both depression (M = 12.68 vs. M = 27.00 F(1,117) = 9.18, p < .01) and PTSD symptom severity (M = 8.08 vs. M = 14.13, F(1,117) = 9.93, p < .01) among the 43% who completed treatment. CBT significantly reduced women’s PTSD (b = 3.37, t = 3.06, p < .05, pr² = .07) and depressive symptomology (b = 3.49, t = 2.93, p < .05, pr² = .07). Reductions in depression and PTSD symptomology also corresponded with decreased IPV risk 6 months post-intervention.

Grady Nia was developed to address Black survivors’ suicidal ideation. The intervention incorporates strategies for identifying risk and protective factors through the use of African proverbs, role models, and women mentors. Grady Nia was delivered by Black women during 10 group sessions. This intervention reflected mixed results in its ability to reduce depressive and PTSD symptomology. The intervention indicated a significant reduction in depressive symptoms (M = 35.4, SD = 12.2, vs. M = 22.8, SD = 13.2, p < .01) (Kaslow et al., 2010). Grady Nia was found to reduce participants’ depression 6 months post-intervention compared to the control group. However, it was ineffective in reducing PTSD (effect size = 0.03 at post-intervention and 2.27 throughout the change of 12-month duration). This may be due to lack of individual- and PTSD-focused sessions addressing psychological distress (Graham-Bermann & Miller-Graff, 2015).

Brief IPT (Tandon et al. 2020), commonly known as interpersonal counseling (IPC), is a 4 to 6 session brief derivative of IPT (Weissman et al., 2014). IPT is an effective depression treatment recommended by the World Health Organization (WHO) (Weissman et al., 2008; WHO, 2016). IPC is designed for primary care settings and can be delivered by lay providers (Weissman et al., 2014). IPT and IPC target interpersonal problems (e.g., grief, deficits, disputes, transitions) associated with the onset of depression among women with histories of IPV (Cort et al., 2014; Weissman et al., 2014; Zlotnick et al., 2011). IPC integrates relational and attachment theories, as well as research on social support and stress to assert that interpersonal disruptions underpin survivors’ depression. IPC was delivered via weekly individual sessions for 4 weeks during pregnancy (Zlotnick et al., 2011). A booster session was delivered 2 weeks postpartum. The intervention reflected moderate reductions in depression (F(1, 44) = 3.29, p = .08.) and significant reductions in PTSD symptomology (F(1, 44) = 7.50, p = 0.009) during pregnancy and (d = 0.69) 3 weeks postpartum.

Discussion

We conducted a novel systematic review of the extant literature to examine available interventions that target depression and/or PTSD among US Black women IPV survivors, aged 18 to 66 residing in the northeast, mideast, southeast, and west regions of the country. We searched eight databases between September 2021 and October 2022, for original studies of RCTs reporting depression and/or PTSD interventions delivered to Black women with histories of IPV. Of the 1,276 articles, 46 were eligible and 8 RCTs were ultimately included in the review interventions for depression (four interventions, n = 1,518) and PTSD (four interventions, n = 477). Among Depression and PTSD interventions (one intervention, n = 208), Beck’s Depression Inventory II indicated M = 35.2, SD = 12.6 versus M = 29.5, SD = 13.1, <.01, and DTS indicated M = 79.4, SD = 31.5 versus M = 72.1, SD = 33.5, <.01, at pre- and post-intervention respectively. Also, some interventions reported severity of depression M = 13.9 (SD = 5.4) versus M = 7.9 (SD = 5.7) < 0.01, and PTSD (M = 8.08 vs. M = 14.13, F(1,117) = 9.93, p < .01) at pre- and post-intervention respectively. Publication bias was moderate and varied between 12 and 17 via the Downs and Black Checklist for Methodological Rigor for RCTs. Psychological interventions targeting depression and/or PTSD for Black women with histories of IPV reflect moderate improvement. Interventions that account for cultural nuances specific to Black women are fundamental for improving outcomes for women presenting with depression and/or PTSD.

Black women disproportionately experience elevated rates of more severe, long-term victimization; yet, they significantly delay their help-seeking efforts due to their race-class-gender intersectionality (Waller et al., 2021; Waller et al., 2023). In addition to experiencing stigma and shame, Black women are bound by cultural proclivities of privacy and experience additional barriers resulting from structural racism and racial discrimination (Waller et al., 2023). These psychosocial hindrances prevent survivors from engaging in immediate mental health help-seeking and puts them on the trajectory for experiencing more nocuous, deleterious outcomes (Petrosky et al., 2017; Waller et al., 2023). Understanding which interventions to deliver to this underserved population of women is fundamental to improving their mental health and overall wellbeing.

Findings were mixed regarding treatment duration. There is evidence to support brief delivery when housing is not provided. Zlotnick and Colleagues (2011) delivered a 5 week intervention and reported 15% attrition post-randomization. This is consistent with the extant literature that notes Black women IPV survivors generally prefer brief, short-term therapeutic interventions (Nicolaidis et al., 2013). However, we also found one study that countered the premise that Black women readily drop out of long-term treatment (Nicolaidis et al., 2013). Survivors who resided in the emergency shelter system remained in depression treatment upward of 6 months. We found that interventions that included adjunctive specialty services that accounted for survivors’ SDoH, namely housing, childcare, and/or economic assistance experienced lower rates of attrition and higher satisfaction among participants. Unless providers are also offering housing, childcare, and/or economic assistance with onsite mental health services, it may be more difficult for women to maintain their treatment schedule for more than 6 weeks.

Critically important are the setting and provider who delivers the intervention. Employing community-based settings for implementation was an effective means in increasing trust and completion rates. Moreover, survivors were more likely to remain in treatment when the intervention was delivered by women with similar lived experiences. Specifically, survivors felt a sense of sameness when the provider was a member of the Black community who was an advocate or self-identified as an IPV survivor. Obtaining trust is fundamental to survivors’ ability to receive from the person delivering treatment because victimization shatters their sense of trust (Battaglia et al., 2003). Trust that has been violated by intimate partners generally infringe upon women’s ability to establish trusting romantic and platonic relationships. Black women additionally contend with barriers that further inhibit their crisis help-seeking. Their adverse experiences with formal providers resulting from their intersectionality, compounded by structural inequities, make it more difficult for them to trust traditional mental health providers (Waller et al., 2021). Providers who have racial congruence with survivors may experience less resistance from and negative counter transference resulting from women’s racialized trauma (Cabral & Smith, 2011).

Evidence-based interventions (EBIs) for depression and/or PTSD that incorporated survivors’ culture and spirituality were generally effective remitting women’s symptomology. This finding is consistent with existing scholarship. Black women tend to be wary of traditional mental health providers (Nicolaidis et al., 2013). Instead, they more readily engage with community- and faith-based networks when seeking services and support. In fact, spirituality is inextricably bound in many African-centered cultural practices (Bent-Goodley & Brade Stennis, 2015). Black women’s overall reliance upon religious resources, including prayer and Bible readings when experiencing mental distress (i.e., not clinical depression) is well-documented (Bent-Goodley & Brade Stennis, 2015; Ellison et al., 2007; Shaw et al., 2022). Importantly, nearly 80% of US Black people are religiously affiliated and women are the largest population within the Black church (Cox & Diamant, 2018). Weaving faith-based tenants into EBIs for depression and PTSD may be an effective means of increasing acceptance, improving completion rates, and remitting symptomology.

Limitations

This study is not without limitations. This study is limited by available studies that mostly include US Black women IPV survivors as part of the sample. There is a paucity of scholarship that examines the mental health needs of this underserved population of survivors. Further, it is important to account for the diversity of Black women in the US. Black and African American are often used interchangeably although there are fundamental differences in their histories. African American women are the largest subpopulation of Black women in the United States (Brondolo et al., 2009). Still, it is important to also recognize that there are growing populations of African, Afro Caribbean, Black Latina women who are also residing in the US who may not self-identify as African American (Bent-Goodley & Brade Stennis, 2015). Additionally, studies included in this review did not specifically note whether Black women who are members of the LGBTQ+ community were included in the study. Hence, we are unable to draw any conclusions regarding the efficacy of EBIs targeting depression and/or PTSD among this vulnerable subpopulation of Black women. Only peer-reviewed publications were included in this study. To account for this bias, we searched the gray literature. No additional studies were found.

Conclusion

Culturally salient EBIs are critical for improving the mental health of Black women IPV survivors experiencing depression and/or PTSD. EBIs that encompass their immediate needs create the foundation that facilitates community building, trust, and collaboration between interventionists and this vulnerable and underserved population of survivors. Cost-effective interventions for depression and/or PTSD that convene in community-based settings, provide individualized care, and are infused with elements of Black culture and spirituality also have the opportunity of reducing some barriers to care, emphasizing community, and combating mental health stigma for Black women experiencing IPV.

Critical Findings

• Black women IPV survivors prefer brief (<6 sessions) interventions.

• Interventions should infuse Black women’s faith and/or spirituality.

• Interventions delivered by Black women facilitators increases uptake.

• Women prefer interventions to be delivered in community-based settings.

• A dearth of EBIs currently meet their culturally specific needs.

• Interventions that account for women’s SDoH, that is childcare, transportation, housing, etc., reduces likelihood of attrition.

Study Implications

Practice

• Tailored EBIs should center Black women IPV survivors’ culturally specific needs.

• Future interventions should be grounded in theories that explicate this population’s specific help-seeking and social services needs.

• Interventions should account for women’s SDoH, that is, childcare, transportation, housing, etc.

• Brief EBIs that reduce survivors’ depression and/or PTSD symptomology are needed.

Policy

• More funding is necessary to tailor and implement EBIs that center Black women IPV survivors’ needs.

• Implement funding that allows for research and faith- or community-based partnerships to tailor and implement EBIs for Black women IPV survivors.

Research

• Future research should explore barriers and facilitators of implementing EBIs in faith- and community-based settings.

• Additional research is necessary to understand the contextual factors of implementing EBIs faith- and/or community-based settings.

• Research is needed to understand how to build sustainable practice in faith- and community-based settings.

Biographies

Bernadine Y. Waller, PhD, LMHC, is an NIMH T32 postdoctoral research fellow at Columbia University Irving Medical Center/New York State Psychiatric Institute. Dr. Waller is an implementation scientist who partners with community- and faith-based organizations to tailor and implement evidence-based mental health interventions for underserved survivors of intimate partner violence (IPV). She is also a senior adjunct professor at Adelphi University School of Social Work whose praxis is informed by more than a decade of clinical experience.

Seung Ju Lee, MSW, is a PhD Candidate at Adelphi University School of Social Work. Her research focuses employment-seeking experiences and services and culturally relevant assistance with a focus on the intersections of financial empowerment interventions for marginalized survivors of intimate partner violence: women of color and immigrant women.

Naomi C. Legros, MPH, is a research coordinator in the Division of Environmental Pediatrics at NYU Langone Health. With over 5 years of academic and professional experience in public health, her areas of focus primarily lies within reproductive health and justice and mental health, specifically in depression and suicide prevention; with an interest in Black Diasporic communities.

Bernadette K. Ombayo, MSW, PhD, is an Assistant Professor at The University of Memphis School of Social Work. Her research examines issues related to teen dating violence and its impact on academic outcomes; intimate partner violence and related issues across the lifespan; and social work education.

Jennifer J. Mootz, PhD is a licensed psychologist, Assistant Professor of Clinical Medical Psychology (in Psychiatry) at Columbia University, and Research Scientist at the Research Foundation for Mental Hygiene/New York State Psychiatric Institute. Her NIMH-funded research focuses on reducing the global mental health and substance use treatment gap in low-income and humanitarian settings internationally and in the United States through digitized innovations and consideration of social determinants.

M. Claire Greene, PhD MPH, is an epidemiologist and implementation scientist interested in identifying opportunities to improve population mental health through community- and systems-level interventions. Specifically, her research examines models of integrating mental health and psychosocial support across sectors to enhance the accessibility, relevance, effectiveness, and sustainability of these programs for displaced populations in humanitarian contexts.

Sidney H. Hankerson, MD, MBA, is Associate Professor of Psychiatry, Vice Chair for Community Engagement, Department of Psychiatry at the Icahn School of Medicine at Mount Sinai. His community-engaged research with faith-based organizations focuses on implementing novel interventions to reduce inequities in mental health in the Black community.

Shameika N. Williams, EdD, MPH, is an Assistant Professor, Department of Public Health, State University of New York at Old Westbury. With over a decade of experience working in the health and human services field, she also holds a position with the New York City Department of Health and Mental Hygiene as a City Research Scientist. Her research focuses on the health consequences and impact of incarceration on communities, partners, and children.

Janet E. Williams, MPH, is the Founder and CEO of Terrified No More Sanctuary for Women, Inc. and the Domestic Violence Ministry Leader at the Greater Allen AME Cathedral in Jamaica, NY. For nearly a decade, Ms. Williams has bridged community- and faith-based resources to provide crisis and direct services to Black and Latina survivors of intimate partner violence help-seeking within faith-based organizations.

Milton L. Wainberg, MD, is Professor of Clinical Psychiatry, Director of T32 Global Mental Health Fellowship, Division Co-Chair of Translational Epidemiology and Mental Health Equity, Columbia University/New York State Psychiatric Institute, Director, Columbia University Mental Health Equity Center. He is an expert in community-based participatory research that examines inequities in mental healthcare among underserved populations in low resource areas to implement sustainable comprehensive and effective mental health services leveraging technology.