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Molendijk M, Baart C, Schaffeld J, Akçakaya Z, Rönnau C, Kooistra M, de Kleine R, Strater C, Mooshammer L. Psychological Interventions for PTSD, Depression, and Anxiety in Child, Adolescent and Adult Forced Migrants: A Systematic Review and Frequentist and Bayesian Meta-Analyses. Clin Psychol Psychother 2024; 31:e3042. [PMID: 39152566 DOI: 10.1002/cpp.3042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/20/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE The number of forced migrants has been rising for years. Many forced migrants suffer from post-traumatic stress disorder (PTSD), depression, and/or anxiety and need treatment. Here, we evaluate the effectiveness of psychological interventions (CBT, EMDR, expressive/art, mindfulness, mixed elements, NET and psychoeducation) in reducing symptoms of PTSD, depression, and anxiety in forced migrants. DESIGN AND DATA SOURCES Systematic searches in PubMed and Web of Science and searches of preprint servers and grey literature were performed (final search date: 1 September 2023). Random-effects frequentist and Bayesian meta-analyses were used for data synthesis. RESULTS We included 84 studies on treatment effects in adults (pooled N = 6302) and 32 on children and adolescents (pooled N = 1097). Our data show a reduction in symptoms of PTSD, depression and anxiety symptoms in both adults and child/adolescent forced migrants. Pooled pre- to post-treatment effects (effect size Cohen's d) ranged from -1.03 to -0.26 for PTSD, from -0.91 to -0.11 for depression and from -0.91 to -0.60 for anxiety, without there being differences in outcome per study design (i.e., RCT comparison vs. non-RCT comparison vs. single arm treatment study). Treatment effects remained evident over follow-up, and not a single type of treatment stood out as being superior to other treatment types. Structural differences in populations (e.g., regarding country of origin) over studies, however, could have hampered the validity of the comparisons between study characteristics such as treatment type. CONCLUSION Our findings support the effectiveness of psychological treatment in adult and child/adolescent forced migrants.
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Affiliation(s)
- Marc Molendijk
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden University Medical Centre, Leiden, The Netherlands
| | - Charlotte Baart
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Jan Schaffeld
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Zeynep Akçakaya
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Charlotte Rönnau
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Marike Kooistra
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Rianne de Kleine
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Celina Strater
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Louise Mooshammer
- Institute of Psychology, Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
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Kleinschmitt A. Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening. Transcult Psychiatry 2024; 61:151-167. [PMID: 38234182 PMCID: PMC10996299 DOI: 10.1177/13634615231187255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.
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Gasnier M, Aouizerat A, Chappell K, Baubet T, Corruble E. Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review. J Psychiatr Pract 2024; 30:104-118. [PMID: 38526398 DOI: 10.1097/pra.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
OBJECTIVE In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees. METHODS This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms. RESULTS While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders. CONCLUSIONS The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.
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Dowllah IM, Melville C. Effectiveness of psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in low- and middle-income countries: A systematic review and meta-analysis. J Health Psychol 2023:13591053231199254. [PMID: 37728258 DOI: 10.1177/13591053231199254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
Refugees and asylum seekers are more prone to posttraumatic stress disorder (PTSD) than the general population. This systematic review aims to determine which psychosocial interventions effectively treat PTSD among refugees and asylum seekers in low- and middle-income countries (LMIC). Relevant papers were retrieved from the bibliographic databases. PTSD symptoms post-intervention was the primary outcome. Ten studies were selected with 1981 participants. In meta-analyses of Randomised control trials (RCTs), psychosocial interventions for PTSD (SMD -0.60, 95% CI -0.96 to -0.23; I2 = 91%; 95% CI 75-100; nine studies, 1789 participants) were shown to be clinically effective. Also, in case of depression (SMD -0.59, 95% CI -0.95 to -0.22; I2 = 84%; 95% CI 50-90; seven studies, 1248 participants). Eye Movement Desensitization and Reprocessing (EMDR) had the greatest effect size among psychosocial therapies for this demographic. However, the number of studies is small, and their methodological rigour is limited, thus future study should concentrate on performing more rigorous trials.
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Nordbrandt MS, Vindbjerg E, Mortensen EL, Carlsson J. Chronicity of posttraumatic stress disorder and comorbid pain as predictors of treatment response for trauma-affected refugees. J Trauma Stress 2022; 35:1393-1404. [PMID: 35446986 DOI: 10.1002/jts.22839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 11/10/2022]
Abstract
Predictors of treatment outcomes have received limited attention in the field of trauma-affected refugees. Symptom chronicity is potentially a particularly relevant predictor, as it would instruct earlier interventions for a population less familiar with psychiatric treatment options, and its identification may also reduce or delay the onset of comorbidities, such as chronic pain. Accordingly, this study examined the impacts of posttraumatic stress disorder (PTSD) chronicity and baseline comorbid pain on treatment response in trauma-affected refugees. Multiple regression was used to analyze data from a randomized controlled trial of 318 trauma-affected refugees with PTSD that was conducted at a specialized psychiatric clinic in Denmark. Treatment response was measured by changes in symptoms of PTSD (Harvard Trauma Questionnaire) and depression (Hopkins Symptom Checklist-25). Duration of functional impairment was found to be a significant predictor of PTSD outcomes, p = .003, ΔR2 = .02, f2 = .03; it was not predictive of outcomes for depression. Baseline pain severity was a significant predictor of outcomes for both PTSD, p = .009, ΔR2 = .02, f2 = .02, and depression, p = .041, ΔR2 = .01, f2 = .01. These findings suggest that trauma-affected refugees with long-lasting functional impairment and a high pain score are likely to show less improvement from treatments for PTSD and depression. This points to a need for early intervention to prevent chronic functional impairment and suggests comorbid pain is an important therapeutic target.
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Affiliation(s)
- Maja Sticker Nordbrandt
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Ballerup, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Erik Vindbjerg
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Ballerup, Denmark
| | - Erik Lykke Mortensen
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Jessica Carlsson
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Ballerup, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Olavarrieta GA, Benuto L. Narrative Exposure Therapy: A Case for Use With Refugees via Telehealth With the use of an Interpreter. Clin Case Stud 2022. [DOI: 10.1177/15346501221077703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rates of PTSD and depression are as high as or higher among samples of refugees than in the general population. There have been few randomized controlled trials of trauma-focused therapies conducted with refugees. Additionally, there has been little research on the use of interpreters in psychotherapy with refugees, but across the studies included in a meta-analysis, a nonsignificant difference between studies that used an interpreter and those that did not was found. Due to COVID-19, mental health providers have had to adapt to the crisis by utilizing telemental health. Research on telemental health with refugee clients is limited, despite a recognition in the literature that telemental health can address some mental healthcare disparities. We review the case of a 26-year-old Afghani/Iranian bilingual diagnosed with post-traumatic stress disorder (PTSD) who presented with intrusive thoughts, panic attacks, nightmares, and flashbacks. Narrative Exposure Therapy (NET) was used with an interpreter via telehealth because it is effective in reducing symptoms of trauma in refugee populations. Treatment success for this case was reflected in the client’s self-reported reduction in symptoms. From this case study, we can conclude that (a) NET is a short-term, cost-effective means for providing trauma-focused care for refugees/asylum-seekers; (b) NET diminishes trauma symptoms with the use of an interpreter via telehealth; (c) a good relationship between therapist, interpreter, and client aids in the effectiveness of NET; and (d) clinician flexibility in the delivery of telemental health and interventions being utilized with refugee/asylum-seeker populations is imperative.
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Zehetmair C, Kaufmann C, Tegeler I, Klippel A, Nagy E, Kindermann D, Friederich HC, Nikendei C. Stabilisierungsgruppe für traumatisierte männliche
Geflüchtete in einer Erstaufnahmeeinrichtung des Landes
Baden-Württemberg: Konzept und Erfahrungen. Psychother Psychosom Med Psychol 2021; 71:473-476. [PMID: 34517421 DOI: 10.1055/a-1584-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungGeflüchtete erleben vielfach traumatisierende Ereignisse im Heimatland
und auf der Flucht, die in dieser Gruppe zu einer erhöhten
Prävalenz der Posttraumatischen Belastungsstörung
führen. Traumaorientierte stabilisierende Techniken können vor
allem in der frühen post-migratorischen Phase eine erste psychosoziale
Stabilisierung traumatisierter Geflüchteter bewirken. In diesem Beitrag
wird das klinische Konzept der offenen Stabilisierungsgruppe für
männliche, traumatisierte Geflüchtete im Erstaufnahme- und
Registrierungszentrum „Patrick-Henry Village“ des Landes
Baden-Württemberg vorgestellt. Die Stabilisierungsgruppe in englischer
Sprache folgt einem offenen Gruppenkonzept mit einer wiederkehrenden Struktur
bestehend aus Begrüßungsrunde, dem gemeinsamen Üben von
Achtsamkeits- und imaginativen Stabilisierungsübungen und einer
Abschlussrunde. Die bisherigen Erfahrungen zeigen, dass das Konzept einer
offenen Stabilisierungsgruppe im Kontext einer Erstaufnahme- und
Registrierungsstelle für Geflüchtete gut implementierbar ist.
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Affiliation(s)
- Catharina Zehetmair
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Claudia Kaufmann
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Inga Tegeler
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Anne Klippel
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Ede Nagy
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - David Kindermann
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Hans-Christoph Friederich
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
| | - Christoph Nikendei
- Klinik für Allgemeine Innere Medizin und Psychosomatik, UniversitätsKlinikum Heidelberg, Heidelberg, Deutschland
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Arundell LL, Barnett P, Buckman JEJ, Saunders R, Pilling S. The effectiveness of adapted psychological interventions for people from ethnic minority groups: A systematic review and conceptual typology. Clin Psychol Rev 2021; 88:102063. [PMID: 34265501 PMCID: PMC8591374 DOI: 10.1016/j.cpr.2021.102063] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 06/10/2021] [Accepted: 06/29/2021] [Indexed: 12/16/2022]
Abstract
This review assessed the efficacy of adapted psychological interventions for Black and minority ethnic (BME) groups. A conceptual typology was developed based on adaptations reported in the literature, drawing on the common factors model, competence frameworks and distinctions between types of cultural adaptations. These distinctions were used to explore the efficacy of different adaptations in improving symptoms of a range of mental health problems for minority groups. Bibliographic searches of MEDLINE, Embase, PsycINFO, HMIC, ASSIA, CENTRAL, CDSR and CINAHL spanned the period from 1965 to December 2020. Adaptations to interventions were categorised: i) treatment specific: therapist-related, ii) treatment-specific: content-related and iii) organisation-specific. Meta-analyses of RCTs found a significant effect on symptom reduction when adapted interventions were compared to non-adapted active treatments (K = 30, Hedge's g = -0.43 [95% CI: -0.61, -0.25], p < .001). Studies often incorporated multiple adaptations, limiting the exploration of the comparative effectiveness of different adaptation types, although inclusion of organisation-specific adaptations may be associated with greater benefits. Future research, practitioner training and treatment and service development pertaining to adapted care for minority groups may benefit from adopting the conceptual typology described.
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Affiliation(s)
- Laura-Louise Arundell
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK; National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK.
| | - Phoebe Barnett
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Joshua E J Buckman
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK; iCope, Camden and Islington Psychological Therapies Services, Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK; National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
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Zehetmair C, Zeyher V, Cranz A, Ditzen B, Herpertz SC, Kohl RM, Nikendei C. A Walk-In Clinic for Newly Arrived Mentally Burdened Refugees: The Patient Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052275. [PMID: 33668936 PMCID: PMC7956492 DOI: 10.3390/ijerph18052275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022]
Abstract
Providing refugees with psychosocial support is particularly important considering the high level of mental health problems prevalent in this population. A psychosocial walk-in clinic operating within a state reception and registration center in Germany has been supporting mentally burdened refugees since 2016. This study focused on patients' perspectives on their mental health burden, the psychosocial walk-in clinic, and future help seeking. We conducted interviews with n = 22 refugees attending the walk-in clinic from March to May 2019. Qualitative analysis focused on the following four topics: (1) mental burden from the patients' perspective, (2) access to the psychosocial walk-in clinic, (3) perception of counseling sessions, and (4) perception of follow-up treatment. The results show that the majority of interviewees were burdened by psychological and somatic complaints, mostly attributed to past experiences and post-migratory stress. Therapeutic counseling and psychiatric medication were found to be particularly helpful. Most of the participants felt motivated to seek further psychosocial support. Key barriers to seeking psychosocial help included shame, fear of stigma, and lack of information. Overall, the psychosocial walk-in clinic is a highly valued support service for newly arrived refugees with mental health issues.
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Affiliation(s)
- Catharina Zehetmair
- Center for Psychosocial Medicine, Department for General Internal Medicine and Psychosomatics, Heidelberg University Hospital, 69115 Heidelberg, Germany; (V.Z.); (A.C.); (C.N.)
- Correspondence: ; Tel.: +49-6221-56-3873
| | - Valentina Zeyher
- Center for Psychosocial Medicine, Department for General Internal Medicine and Psychosomatics, Heidelberg University Hospital, 69115 Heidelberg, Germany; (V.Z.); (A.C.); (C.N.)
| | - Anna Cranz
- Center for Psychosocial Medicine, Department for General Internal Medicine and Psychosomatics, Heidelberg University Hospital, 69115 Heidelberg, Germany; (V.Z.); (A.C.); (C.N.)
| | - Beate Ditzen
- Center for Psychosocial Medicine, Institute of Medical Psychology, Heidelberg University Hospital, 69115 Heidelberg, Germany; (B.D.); (R.M.K.)
| | - Sabine C. Herpertz
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University Hospital, 69115 Heidelberg, Germany;
| | - Rupert Maria Kohl
- Center for Psychosocial Medicine, Institute of Medical Psychology, Heidelberg University Hospital, 69115 Heidelberg, Germany; (B.D.); (R.M.K.)
| | - Christoph Nikendei
- Center for Psychosocial Medicine, Department for General Internal Medicine and Psychosomatics, Heidelberg University Hospital, 69115 Heidelberg, Germany; (V.Z.); (A.C.); (C.N.)
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Vindbjerg E, Carlsson J, Mortensen EL, Makransky G, Nielsen T. A Rasch-based validity study of the Harvard Trauma Questionnaire. J Affect Disord 2020; 277:697-705. [PMID: 32911220 DOI: 10.1016/j.jad.2020.08.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 07/01/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Harvard Trauma Questionnaire (HTQ) is the predominant questionnaire for assessing PTSD in trauma-affected refugees. Although the scale is increasingly used for measuring treatment outcomes, it has never been specifically validated for such use. The current study does so by testing the HTQ with the Rasch model. METHODS The analysis is based on 641 Arabic and Persian speaking refugees, diagnosed with PTSD and undergoing psychiatric treatment in Denmark. The responses were tested against the assumptions of the Rasch model, including unidimensionality, local independence and the absence of differential item function across subgroups. RESULTS Results reveal two subscales that, when accounting for local dependence and differential item functioning, meet criteria for the Rasch model in the included samples: An arousal/intrusion subscale and an avoidance/numbing subscale. LIMITATIONS The included sample was highly chronic and suffered from major depressive disorder. Results may not be fully representative of less chronic populations, e.g. recently arrived refugees. CONCLUSIONS We recommend the use of the arousal/intrusion subscale and the avoidance/numbing subscale as an optimized way of summarizing responses to the HTQ, which remains simple to administer while effectively summarizing all the information available in the scores.
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Affiliation(s)
- Erik Vindbjerg
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark.
| | - Jessica Carlsson
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark
| | - Erik Lykke Mortensen
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Denmark
| | | | - Tine Nielsen
- UCL University College, Department of Applied Research in Education and Social Sciences, Odense, Denmark
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Zehetmair C, Nagy E, Leetz C, Cranz A, Kindermann D, Reddemann L, Nikendei C. Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study. J Med Internet Res 2020; 22:e17906. [PMID: 32965229 PMCID: PMC7542415 DOI: 10.2196/17906] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 01/17/2023] Open
Abstract
Background Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings. Objective This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany. Methods From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone. Results At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations. Conclusions The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.
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Affiliation(s)
- Catharina Zehetmair
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ede Nagy
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Carla Leetz
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Anna Cranz
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - David Kindermann
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Luise Reddemann
- Department of Clinical Psychology, Psychotherapy and Psychoanalysis, University of Klagenfurt, Klagenfurt, Austria
| | - Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
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Melton H, Meader N, Dale H, Wright K, Jones-Diette J, Temple M, Shah I, Lovell K, McMillan D, Churchill R, Barbui C, Gilbody S, Coventry P. Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. Health Technol Assess 2020; 24:1-312. [PMID: 32924926 DOI: 10.3310/hta24430] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. OBJECTIVE To identify candidate psychological and non-pharmacological treatments for future research. DESIGN Mixed-methods systematic review. PARTICIPANTS Adults aged ≥ 18 years with a history of complex traumatic events. INTERVENTIONS Psychological interventions versus control or active control; pharmacological interventions versus placebo. MAIN OUTCOME MEASURES Post-traumatic stress disorder symptoms, common mental health problems and attrition. DATA SOURCES Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. REVIEW METHODS Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. RESULTS One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. LIMITATIONS Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. CONCLUSIONS Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. FUTURE WORK Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. STUDY REGISTRATION This study is registered as PROSPERO CRD42017055523. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hollie Melton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Holly Dale
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Peter Coventry
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Health Sciences, University of York, York, UK
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Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. PLoS Med 2020; 17:e1003262. [PMID: 32813696 PMCID: PMC7446790 DOI: 10.1371/journal.pmed.1003262] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events. METHODS AND FINDINGS We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis. CONCLUSIONS In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.
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Kip A, Priebe S, Holling H, Morina N. Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta-analysis of randomized controlled trials. Clin Psychol Psychother 2020; 27:489-503. [PMID: 32191370 DOI: 10.1002/cpp.2446] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/13/2020] [Accepted: 03/13/2020] [Indexed: 12/13/2022]
Abstract
Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta-analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow-up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.
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Affiliation(s)
- Ahlke Kip
- Institute of Psychology, University of Münster, Münster, Germany
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Heinz Holling
- Institute of Psychology, University of Münster, Münster, Germany
| | - Nexhmedin Morina
- Institute of Psychology, University of Münster, Münster, Germany
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15
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Stabilizing Techniques and Guided Imagery for Traumatized Male Refugees in a German State Registration and Reception Center: A Qualitative Study on a Psychotherapeutic Group Intervention. J Clin Med 2019; 8:jcm8060894. [PMID: 31234487 PMCID: PMC6617260 DOI: 10.3390/jcm8060894] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/14/2019] [Accepted: 06/20/2019] [Indexed: 11/28/2022] Open
Abstract
Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.
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Rometsch-Ogioun El Sount C, Windthorst P, Denkinger J, Ziser K, Nikendei C, Kindermann D, Ringwald J, Renner V, Zipfel S, Junne F. Chronic pain in refugees with posttraumatic stress disorder (PTSD): A systematic review on patients' characteristics and specific interventions. J Psychosom Res 2019; 118:83-97. [PMID: 30078503 DOI: 10.1016/j.jpsychores.2018.07.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/20/2018] [Accepted: 07/25/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Chronic pain in patients with posttraumatic stress disorder (PTSD) is a frequent symptom and a complicating factor in the treatment of patients. The study' purpose is to systematically review the scientific literature on patients' characteristics and the effects of specific interventions implemented for the treatment of chronic pain in traumatized refugees. METHOD A systematic search of the current literature was conducted in PubMed and Web of Science, from 1996 to 2017. A structured screening process in accordance with the PRISMA-statement was used with eligibility criteria based on the modified PICOS-criteria including refugees with chronic pain and diagnosed PTSD to investigate sample size, gender, country of origin, residential status, pain locations, predictors and correlations and type and efficacy of specific interventions. RESULTS The initial search resulted in a total of 2169 references, leading to 15 included studies. Most frequently, patients reported headaches, backaches, and pain in the arms and legs. Pain symptoms were associated with higher age, female gender, general living difficulties and PTSD symptoms. Cognitive behavioral therapy (CBT) and, Narrative Exposure Therapy (NET) with biofeedback, manualized trauma psychotherapy, Traditional Chinese Medicine (TCM) and Emotional Freedom Techniques were evaluated as specific interventions, resulting in positive outcomes for both pain severity and PTSD symptoms. CONCLUSIONS To date, the existing literature shows scarce evidence evaluating specific interventions that address the needs of traumatized refugees with chronic pain. However, the current reported evidence allows for a preliminary evaluation of the characterizations of patient dimensions as well as promising results found in intervention studies.
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Affiliation(s)
- C Rometsch-Ogioun El Sount
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany.
| | - P Windthorst
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
| | - J Denkinger
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
| | - K Ziser
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
| | - C Nikendei
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - D Kindermann
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - J Ringwald
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
| | - V Renner
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany; Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - S Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
| | - F Junne
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany
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Im H, Jettner JF, Warsame AH, Isse MM, Khoury D, Ross AI. Trauma-Informed Psychoeducation for Somali Refugee Youth in Urban Kenya: Effects on PTSD and Psychosocial Outcomes. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2018; 11:431-441. [PMID: 32318166 PMCID: PMC7163889 DOI: 10.1007/s40653-017-0200-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The current study developed and implemented a trauma-informed psychoeducation (TIPE) intervention that is culturally relevant to urban Somali refugees in Nairobi, Kenya. A total of 141 Somali refugee youth completed 12 sessions of peer-led TIPE intervention. A series of pre- and post-tests revealed that TIPE made positive impacts on PTSD symptoms and psychosocial factors, with a differential effect observed according to baseline PTSD symptom report. Participants with high baseline PTSD scores (i.e. above clinical threshold) reported a significant decrease in PTSD symptoms and increase in perceived social support. In the meantime, those with no to mild baseline PTSD symptoms showed an increase in self-awareness of trauma responses and thus PTSD symptom report within the range of normalcy. This research supports the effect of a culturally relevant psychoeducation intervention in addressing the high mental health and psychosocial needs of the marginalized urban Somali refugee community in low resource settings.
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Affiliation(s)
- Hyojin Im
- School of Social Work, Virginia Commonwealth University, 1000 Floyd Ave., Richmond, VA 23804 USA
| | - Jennifer F. Jettner
- School of Social Work, Virginia Commonwealth University, 1000 Floyd Ave., Richmond, VA 23804 USA
| | | | | | - Dalia Khoury
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, USA
| | - Avina I. Ross
- University Health Services, Princeton University, New Jersey, USA
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18
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Beck BD, Lund ST, Søgaard U, Simonsen E, Tellier TC, Cordtz TO, Laier GH, Moe T. Music therapy versus treatment as usual for refugees diagnosed with posttraumatic stress disorder (PTSD): study protocol for a randomized controlled trial. Trials 2018; 19:301. [PMID: 29848343 PMCID: PMC5977477 DOI: 10.1186/s13063-018-2662-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/03/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Meta-analyses of studies on psychological treatment of refugees describe highly varying outcomes, and research on multi-facetted and personalized treatment of refugees with post-traumatic stress disorder (PTSD) is needed. Music therapy has been found to affect arousal regulation and emotional processing, and a pilot study on the music therapy method Trauma-focused Music and Imagery (TMI) with traumatized refugees resulted in significant changes of trauma symptoms, well-being and sleep quality. The aim of the trial is to test the efficacy of TMI compared to verbal psychotherapy. METHODS A randomized controlled study with a non-inferiority design is carried out in three locations of a regional outpatient psychiatric clinic for refugees. Seventy Arabic-, English- or Danish-speaking adult refugees (aged 18-67 years) diagnosed with PTSD are randomized to 16 sessions of either music therapy or verbal therapy (standard treatment). All participants are offered medical treatment, psychoeducation by nurses, physiotherapy or body therapy and social counseling as needed. Outcome measures are performed at baseline, post therapy and at 6 months' follow-up. A blind assessor measures outcomes post treatment and at follow-up. Questionnaires measuring trauma symptoms (HTQ), quality of life (WHO-5), dissociative symptoms (SDQ-20, DSS-20) and adult attachment (RAAS) are applied, as well as physiological measures (salivary oxytocin, beta-endorphin and substance P) and participant evaluation of each session. DISCUSSION The effect of music therapy can be explained by theories on affect regulation and social engagement, and the impact of music on brain regions affected by PTSD. The study will shed light on the role of therapy for the attainment of a safe attachment style, which recently has been shown to be impaired in traumatized refugees. The inclusion of music and imagery in the treatment of traumatized refugees hopefully will inform the choice of treatment method and expand the possibilities for improving refugee health and integration. TRIAL REGISTRATION ClinicalTrials.gov ID number NCT03574228, registered retrospectively on 28 June 2016.
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Affiliation(s)
- Bolette Daniels Beck
- Department of Communication and Psychology, Aalborg University, Aalborg, Denmark
- Clinic for Traumatized Refugees, Køge, Region Zealand Denmark
| | - Steen Teis Lund
- Clinic for Traumatized Refugees, Køge, Region Zealand Denmark
| | - Ulf Søgaard
- Department of Specialized Functions, Psychiatry, Køge, Region Zealand Denmark
| | - Erik Simonsen
- Institute for Clinical Medicine, SUND, Copenhagen University, København, Denmark
- Research Unit in Psychiatry, Slagelse, Region Zealand Denmark
| | | | | | | | - Torben Moe
- Clinic for Traumatized Refugees, Køge, Region Zealand Denmark
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Zehetmair C, Kaufmann C, Tegeler I, Kindermann D, Junne F, Zipfel S, Herpertz SC, Herzog W, Nikendei C. Psychotherapeutic Group Intervention for Traumatized Male Refugees Using Imaginative Stabilization Techniques-A Pilot Study in a German Reception Center. Front Psychiatry 2018; 9:533. [PMID: 30420815 PMCID: PMC6215850 DOI: 10.3389/fpsyt.2018.00533] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/08/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Due to persecution, human rights violations and armed conflicts, the prevalence of post-traumatic stress disorder (PTSD) is high in refugee populations. Previous studies indicate that trauma-focused treatments are highly effective in treating PTSD in refugees. However, these approaches rely on the stability of the therapeutic setting, treatment continuity, and safe housing. Although early treatment of PTSD is recommended, these requirements are not met in reception centers. Therefore, we conducted a pilot study to examine the effect of imaginative stabilization techniques derived from psychodynamic psychotraumatology therapy for the early stabilization of traumatized refugees in a reception center. Methods: From May 2017 to April 2018, 86 imaginative stabilization group therapy sessions have taken place. A sample of 43 out of 46 traumatized refugees completed self-report questionnaires assessing PTSD, depression, and anxiety symptoms prior to attending open imaginative stabilization group therapy sessions. Furthermore, participants filled in self-report questionnaires on distress and emotional state (valence/arousal/dominance) before and after each session. After having participated in four consecutive sessions, a sub-group of 17 participants completed a follow-up assessment of PTSD, depression, and anxiety symptoms. Follow-up interviews were conducted with 25 participants 2 weeks after their last session attendance to explore self-practice habits post intervention. Results: The pre-post-intervention comparison of scores indicated a significant reduction of distress (z = -3.35, p < 0.001, r = -0.51) and an improvement of affective reports for valence (z = -4.79, p < 0.001, r = -0.82) and dominance (z = -3.89, p < 0.001, r = -0.59), whereas arousal scores were not affected. We found a significant reduction of anxiety symptoms (z = -2.04, p < 0.05, r = -0.49), whereas PTSD and depression scores remained unchanged. Follow-up interviews revealed that 80% of the participants continued to practice the imaginative stabilization techniques after redistribution to other accommodation. Conclusion: The results indicate that imaginative stabilization techniques are a promising and feasible approach to treat refugees in unstable reception center settings. In regular imaginative stabilization group therapy sessions, we were able to reduce the participants' distress and anxiety symptoms while strengthening their internal resources and increasing their emotional stability.
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Affiliation(s)
- Catharina Zehetmair
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany.,Department of General Psychiatry, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Claudia Kaufmann
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Inga Tegeler
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - David Kindermann
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital, Tübingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital, Tübingen, Germany
| | - Sabine C Herpertz
- Department of General Psychiatry, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Wolfgang Herzog
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Heidelberg, Germany
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Bemak F, Chung RCY. Refugee Trauma: Culturally Responsive Counseling Interventions. JOURNAL OF COUNSELING AND DEVELOPMENT 2017. [DOI: 10.1002/jcad.12144] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fred Bemak
- Counseling and Development Program; George Mason University
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Tribe RH, Sendt KV, Tracy DK. A systematic review of psychosocial interventions for adult refugees and asylum seekers. J Ment Health 2017; 28:662-676. [PMID: 28485636 DOI: 10.1080/09638237.2017.1322182] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Europe is in the midst of the largest refugee migration since the Second World War; there is an urgent need to provide an updated systematic review of the current best evidence for managing mental distress in refugee populations.Aims: The aim of this review is to provide an exhaustive summary of the current literature on psychosocial interventions, both trauma- and non-trauma-focused, for refugee populations experiencing post-traumatic stress disorder (PTSD), depressive or anxiety symptoms. To produce recommendations for future research and current clinical practice.Method: Searches were conducted in PubMed, PsychINFO (Hosted by Ovid), PILOTS and Social Services Abstracts; 5305 articles were screened and 40 were included.Results: This review found medium to high quality evidence supporting the use of narrative exposure therapy (NET). A lack of culturally adapted treatments was apparent and there was less evidence to support standard cognitive behavioural therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and multidisciplinary treatments.Conclusion: NET produced positive outcomes in refugees from a diverse range of backgrounds and trauma types. There is a general dearth of research in all intervention types: further research should include more "real-world" multidisciplinary interventions that better model clinical practice. Recommendations for evaluating local need, and creating a culturally sensitive workforce are discussed.
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Affiliation(s)
- Rachel H Tribe
- Division of Psychology and Language Sciences, University College London, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK and
| | - Kyra-Verena Sendt
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK and
| | - Derek K Tracy
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK and.,Oxleas NHS Foundation Trust, London, UK
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Bozorgmehr K, Mohsenpour A, Saure D, Stock C, Loerbroks A, Joos S, Schneider C. [Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 59:599-620. [PMID: 27090243 DOI: 10.1007/s00103-016-2336-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects. OBJECTIVES The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps. METHODS A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis. RESULTS The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies. CONCLUSION The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the need for collaborative research to close the existing evidence gaps.
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Affiliation(s)
- Kayvan Bozorgmehr
- Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland.
| | - Amir Mohsenpour
- Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland
| | - Daniel Saure
- Institut für Medizinische Biometrie und Informatik (IMBI), Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Stock
- Institut für Medizinische Biometrie und Informatik (IMBI), Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Adrian Loerbroks
- Institut für Arbeitsmedizin und Sozialmedizin, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Stefanie Joos
- Institut für Allgemeinmedizin und Interprofessionelle Versorgung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Christine Schneider
- Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Deutschland
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Nosè M, Ballette F, Bighelli I, Turrini G, Purgato M, Tol W, Priebe S, Barbui C. Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. PLoS One 2017; 12:e0171030. [PMID: 28151992 PMCID: PMC5289495 DOI: 10.1371/journal.pone.0171030] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/13/2017] [Indexed: 11/27/2022] Open
Abstract
Treatment of post-traumatic stress disorder (PTSD) in refugees and asylum seekers resettled in high-income countries presents specific challenges. This systematic review examined the effectiveness of psychosocial interventions for this group. We searched the Cochrane Central Register of randomised trials, CINAHL, EMBASE, PILOTS, PsycINFO, PubMed and Web of Science up to July 2016. Studies included randomised and controlled clinical trials comparing psychosocial interventions with waiting list or treatment as usual in adult refugees and asylum seekers with PTSD resettled in high-income countries. PTSD symptoms post-intervention was the primary outcome. We computed standardized mean differences (SMD) with 95% confidence intervals (CI). This study is registered with PROSPERO: CRD42015027843. Twelve studies were included in the meta-analysis. Psychosocial interventions were effective in decreasing PTSD symptoms relative to control groups (SMD -1·03, 95% CI -1·55 to -0·51; number needed to treat 4·4; I2 86%; 95% CI 77 to 91). Narrative exposure therapy, a manualized short-term variant of cognitive behavioural therapy with a trauma focus, was the best-supported intervention (5 RCTs, 187 participants, SMD -0·78, 95% CI -1·18 to -0·38, I2 37%; 95% CI 0 to 77). Methodological quality of the included studies was limited. Overall, psychosocial interventions for asylum seekers and refugees with PTSD resettled in high-income countries were found to provide significant benefits in reducing PTSD symptoms. Yet, the number of studies is small and their methodological quality limited, so that more rigorous trials should be conducted in the future.
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Affiliation(s)
- Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Francesca Ballette
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Irene Bighelli
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Giulia Turrini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Wietse Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, United Kingdom
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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Steinert C, Bumke PJ, Hollekamp RL, Larisch A, Leichsenring F, Mattheß H, Sek S, Sodemann U, Stingl M, Ret T, Vojtová H, Wöller W, Kruse J. Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia. Psychol Med 2017; 47:553-564. [PMID: 27804900 DOI: 10.1017/s0033291716002592] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Mental health morbidity in post-conflict settings is high. Nevertheless, randomized controlled trials of psychotherapy on site are rare. Our aim was to integrate rigorous research procedures into a humanitarian programme and test the efficacy of resource activation (ROTATE) in treating post-traumatic stress disorder (PTSD), co-morbid symptoms and impaired functioning in Cambodia. METHOD A total of 86 out-patients with PTSD were randomly assigned to five sessions of ROTATE (n = 53) or a 5-week waiting-list control (WLC) condition (n = 33). Treatment was provided by six Cambodian psychologists who had received extensive training in ROTATE. Masked assessments were made before and after therapy. RESULTS PTSD remission rates according to the DSM-IV algorithm of the Harvard Trauma Questionnaire were 95.9% in ROTATE and 24.1% in the WLC condition. Thus, patients receiving ROTATE had a significantly higher likelihood of PTSD remission (odds ratio 0.012, 95% confidence interval 0.002-0.071, p < 0.00001). Additionally, levels of anxiety, depression and impaired functioning were significantly reduced compared with the WLC condition (p < 0.00001, between-group effect sizes d = 2.41, 2.26 and 2.54, respectively). No harms were reported. CONCLUSIONS ROTATE was efficacious in treating Cambodian patients with high symptom levels of PTSD, emotional distress and impaired functioning. ROTATE is a brief, culturally adaptable intervention focusing on stabilization and strengthening resources rather than trauma confrontation. It can be taught to local professionals and paraprofessionals and enhance access to mental health care for patients in need.
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Affiliation(s)
- C Steinert
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Ludwigstrasse 76,Giessen,Germany
| | - P J Bumke
- Trauma Aid Germany,Schillerstrasse 6,Berlin,Germany
| | - R L Hollekamp
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Ludwigstrasse 76,Giessen,Germany
| | - A Larisch
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Friedrichstrasse 33,Giessen,Germany
| | - F Leichsenring
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Ludwigstrasse 76,Giessen,Germany
| | - H Mattheß
- Psychotraumatology Institute Europe,Großenbaumer Allee 35a,Duisburg,Germany
| | - S Sek
- Department of Psychology,The Royal University of Phnom Penh,Russian Federation Boulevard,Toul Kork,Phnom Penh,Cambodia
| | - U Sodemann
- Trauma Aid Germany,In den Floragärten 41,Berlin,Germany
| | - M Stingl
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Ludwigstrasse 76,Giessen,Germany
| | - T Ret
- Department of Psychology,The Royal University of Phnom Penh,Russian Federation Boulevard,Toul Kork,Phnom Penh,Cambodia
| | - H Vojtová
- Slovak Institute for Psychotraumatology and EMDR,Legionarska 29, Trencin,Slovakia
| | - W Wöller
- Rhein-Klinik, Hospital for Psychsomatic Medicine and Psychotherapy,Luisenstrasse 3, Bad Honnef,Germany
| | - J Kruse
- University of Giessen,Clinic for Psychosomatic Medicine and Psychotherapy,Friedrichstrasse 33,Giessen,Germany
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Buhmann CB, Nordentoft M, Ekstroem M, Carlsson J, Mortensen EL. The effect of flexible cognitive-behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial. Br J Psychiatry 2016; 208:252-9. [PMID: 26541687 DOI: 10.1192/bjp.bp.114.150961] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 01/15/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little evidence exists on the treatment of traumatised refugees. AIMS To estimate treatment effects of flexible cognitive-behavioural therapy (CBT) and antidepressants (sertraline and mianserin) in traumatised refugees. METHOD Randomised controlled clinical trial with 2 × 2 factorial design (registered with Clinicaltrials.gov, NCT00917397, EUDRACT no. 2008-006714-15). Participants were refugees with war-related traumatic experiences, post-traumatic stress disorder (PTSD) and without psychotic disorder. Treatment was weekly sessions with a physician and/or psychologist over 6 months. RESULTS A total of 217 of 280 patients completed treatment (78%). There was no effect on PTSD symptoms, no effect of psychotherapy and no interaction between psychotherapy and medicine. A small but significant effect of treatment with antidepressants was found on depression. CONCLUSIONS In a pragmatic clinical setting, there was no effect of flexible CBT and antidepressants on PTSD, and there was a small-to-moderate effect of antidepressants and psychoeducation on depression in traumatised refugees.
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Affiliation(s)
- Caecilie Böck Buhmann
- Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Merete Nordentoft, MD, DMSc, Psychiatric Center Copenhagen, Copenhagen; Morten Ekstroem, MD, PhD, Jessica Carlsson, MD, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Erik Lykke Mortensen, MSc, Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Merete Nordentoft
- Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Merete Nordentoft, MD, DMSc, Psychiatric Center Copenhagen, Copenhagen; Morten Ekstroem, MD, PhD, Jessica Carlsson, MD, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Erik Lykke Mortensen, MSc, Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Morten Ekstroem
- Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Merete Nordentoft, MD, DMSc, Psychiatric Center Copenhagen, Copenhagen; Morten Ekstroem, MD, PhD, Jessica Carlsson, MD, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Erik Lykke Mortensen, MSc, Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Jessica Carlsson
- Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Merete Nordentoft, MD, DMSc, Psychiatric Center Copenhagen, Copenhagen; Morten Ekstroem, MD, PhD, Jessica Carlsson, MD, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Erik Lykke Mortensen, MSc, Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Erik Lykke Mortensen
- Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Merete Nordentoft, MD, DMSc, Psychiatric Center Copenhagen, Copenhagen; Morten Ekstroem, MD, PhD, Jessica Carlsson, MD, PhD, Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, Ballerup; Erik Lykke Mortensen, MSc, Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
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Erford BT, Gunther C, Duncan K, Bardhoshi G, Dummett B, Kraft J, Deferio K, Falco M, Ross M. Meta-Analysis of Counseling Outcomes for the Treatment of Posttraumatic Stress Disorder. JOURNAL OF COUNSELING AND DEVELOPMENT 2016. [DOI: 10.1002/jcad.12058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Chelsea Gunther
- Education Specialties Department; Loyola University Maryland
| | - Kelly Duncan
- Division of Counseling and Psychology; University of South Dakota
- Now at School of Education; Northern University
| | - Gerta Bardhoshi
- Division of Counseling and Psychology; University of South Dakota
- Now at Department of Rehabilitation and Counselor Education; University of Iowa
| | - Beth Dummett
- Education Specialties Department; Loyola University Maryland
| | - Jennifer Kraft
- Education Specialties Department; Loyola University Maryland
| | - Katie Deferio
- Education Specialties Department; Loyola University Maryland
| | - Michelle Falco
- Education Specialties Department; Loyola University Maryland
| | - Margaret Ross
- Education Specialties Department; Loyola University Maryland
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27
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Varvin S. Psychoanalysis with the traumatized patient: Helping to survive extreme experiences and complicated loss. INTERNATIONAL FORUM OF PSYCHOANALYSIS 2015. [DOI: 10.1080/0803706x.2014.1001785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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28
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Bolton P, Bass JK, Zangana GAS, Kamal T, Murray SM, Kaysen D, Lejuez CW, Lindgren K, Pagoto S, Murray LK, Van Wyk SS, Ahmed AMA, Mohammad Amin NM, Rosenblum M. A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq. BMC Psychiatry 2014; 14:360. [PMID: 25551436 PMCID: PMC4301059 DOI: 10.1186/s12888-014-0360-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Experiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms. METHODS Twenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later. RESULTS Adult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004). CONCLUSIONS Both interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience. TRIAL REGISTRATION ClinicalTrials.Gov NCT00925262 . Registered June 3, 2009.
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Affiliation(s)
- Paul Bolton
- Center for Refugee and Disaster Response and Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E8646, Baltimore, MD, 21205, USA. .,Applied Mental Health Research Group, Center for Refugee and Disaster Response, Johns Hopkins University Bloomberg School of Public Health, c/o 159 Tilden Road, Scituate, MA, 02066, USA.
| | - Judith K Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA.
| | | | - Talar Kamal
- Fine Arts Institute, University of Sulaimani, Kurdistan Region, Iraq.
| | - Sarah McIvor Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA.
| | - Debra Kaysen
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1100 NE 45th Street, Suite 300, Seattle, WA, 98105, USA.
| | - Carl W Lejuez
- Department of Psychology, Center for Addictions, Personality, and Emotion Research (CAPER), University of Maryland, College Park, MD, 20742-5141, USA.
| | - Kristen Lindgren
- Center for the Study of Health and Risk Behaviors, University of Washington, 1100 NE 45th, Suite 300, Seattle, WA, 98105, USA.
| | - Sherry Pagoto
- Division of Preventive and Behavior Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA.
| | - Stephanie Skavenski Van Wyk
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA.
| | - Ahmed Mohammed Amin Ahmed
- Trauma Rehabilitation and Training Center, and Department of Community Health, Sulaimania Polytechnic University, Sulaimania, Kurdistan Region, Iraq.
| | | | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room E3616, Baltimore, MD, 21205, USA.
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29
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Robertson MEA, Blumberg JM, Gratton JL, Walsh EG, Kayal H. A group-based approach to stabilisation and symptom management in a phased treatment model for refugees and asylum seekers. Eur J Psychotraumatol 2013; 4:21407. [PMID: 24371509 PMCID: PMC3871835 DOI: 10.3402/ejpt.v4i0.21407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/16/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Traumatised asylum seekers and refugees may present with significant and complex mental health problems as a result of prolonged, extreme, and multiple traumatic events. This is further complicated by ongoing complex social circumstances. CONCEPTS In our work at the Traumatic Stress Clinic (TSC), the understanding afforded by the concept of complex posttraumatic stress disorder (PTSD) together with the related notion of a phased treatment model, provides a useful framework for organising our work with this population. CLINICAL APPLICATIONS An explication of complex PTSD as it applies to our client group is presented, followed by a description of our phased treatment model and an outline of the core principles, which guide our clinical approach. Our symptom management and stabilisation groups have been developed and refined over time and draw on techniques from a variety of cognitive behavioural therapies. These are described in some detail with illustrative clinical case vignettes. CONCLUSION This paper concludes with some reflections on the challenges inherent to working with this complex client group.
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Affiliation(s)
- Mary E A Robertson
- Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
| | - Jocelyn M Blumberg
- Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
| | - Jacqui L Gratton
- Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
| | - Eileen G Walsh
- Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
| | - Hamodi Kayal
- Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London, UK
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30
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McFarlane CA, Kaplan I. Evidence-based psychological interventions for adult survivors of torture and trauma: a 30-year review. Transcult Psychiatry 2012; 49:539-67. [PMID: 23008355 DOI: 10.1177/1363461512447608] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this paper we review research evidence on psychosocial interventions for adult survivors of torture and trauma. We identified 40 studies from 1980 to 2010 that investigated interventions for adult survivors of torture and trauma. Population subtypes include resettled refugees, asylum seekers, displaced persons, and persons resident in their country of origin. Settings include specialized services for torture and trauma, specialized tertiary referral clinics, community settings, university settings, as well as psychiatric and multidisciplinary mental health services. Interventions were delivered as individual or group treatments and lasted from a single session to 19 years duration. The studies employed randomized controlled trials, nonrandomized comparison studies and single cohort follow-up studies. In all, 36 of the 40 studies (90%) demonstrated significant improvements on at least one outcome indicator after an intervention. Most studies (60%) included participants who had high levels of posttraumatic stress symptomatology. Improvements in symptoms of posttraumatic stress, depression, anxiety, and somatic symptoms were found following a range of interventions. Little evidence was available with regard to the effect on treatment outcomes of the amount, type, or length of treatment, the influence of patient characteristics, maintenance of treatment effects, and treatment outcomes other than psychiatric symptomatology. The review highlights the need for more carefully designed research that addresses the shortcomings of current studies and that integrates the experience of expert practitioners.
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Affiliation(s)
- Colleen A McFarlane
- The Victorian Foundation for Survivors of Torture, 6 Gardiner Street, Brunswick, VIC 3056, Australia.
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Dossa NI, Hatem M. Cognitive-behavioral therapy versus other PTSD psychotherapies as treatment for women victims of war-related violence: a systematic review. ScientificWorldJournal 2012; 2012:181847. [PMID: 22629120 PMCID: PMC3345529 DOI: 10.1100/2012/181847] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 12/05/2011] [Indexed: 11/17/2022] Open
Abstract
Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for this condition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various forms of cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomized controlled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest were searched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroup analysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contribute to the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of 0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggesting CPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective in helping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes to recommend one of these therapies above the other.
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Affiliation(s)
- N Inès Dossa
- Département of Médecine Sociale et Préventive, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada H3C 3J7.
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Wöller W, Leichsenring F, Leweke F, Kruse J. Psychodynamic psychotherapy for posttraumatic stress disorder related to childhood abuse—Principles for a treatment manual. Bull Menninger Clin 2012; 76:69-93. [DOI: 10.1521/bumc.2012.76.1.69] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gruppentherapeutische Interventionen bei traumatisierten Flüchtlingen. GRUPPENPSYCHOTHERAPIE UND GRUPPENDYNAMIK 2011. [DOI: 10.13109/grup.2011.47.3.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Palic S, Elklit A. Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique. J Affect Disord 2011; 131:8-23. [PMID: 20708804 DOI: 10.1016/j.jad.2010.07.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Refugees with posttraumatic stress disorder (PTSD) often present with complicated traumatic symptoms, prolonged and repeated exposure to traumatic events, acculturation, and social problems. A consensus about suitability of psychosocial treatments for refugees does not exist. Never the less there is a need to review the state of knowledge about effective treatments for traumatized refugees, to help guide the practitioners in their choice of treatment methods. METHODS A systematic review of treatment outcome studies was carried out. RESULTS Twenty-five studies were reviewed. The majority were treatment studies of different forms of cognitive-behavioral therapy (CBT). The rest were reports of outcomes of alternative treatments and a small group of studies of multidisciplinary treatments. LIMITATIONS The amount of grey literature not covered by the review could not be estimated precisely. Included studies are methodologically diverse and consist of different refugee populations. This makes a broad interpretation of the treatment results only tentative. CONCLUSIONS Very large effect sizes were obtained in some of the CBT studies, indicating a broad suitability of CBT in the treatment of core symptoms of PTSD in adult refugees. Empirical evidence also points to the possibility that the maladaptive traumatic reactions in refugees can take shape of more complex reactions than those strictly specified in the diagnostic category of PTSD. Effectiveness of CBT treatments has as yet not been tested on the whole range of symptoms in these complex cases. There are few studies of treatments alternative to CBT and they are less methodologically rigorous than the CBT studies.
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Affiliation(s)
- Sabina Palic
- National Centre for Psychotraumatology, University of Southern Denmark, Denmark.
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Ter Heide FJJ, Mooren TM, Kleijn W, de Jongh A, Kleber RJ. EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study. Eur J Psychotraumatol 2011; 2:EJPT-2-5881. [PMID: 22893808 PMCID: PMC3402110 DOI: 10.3402/ejpt.v2i0.5881] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 07/10/2011] [Accepted: 07/18/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Traumatised asylum seekers and refugees are clinically considered a complex population. Discussion exists on whether with this population treatment guidelines for post-traumatic stress disorder (PTSD) should be followed and Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) should be applied, or whether a phased model starting with stabilisation is preferable. Some clinicians fear that trauma-focused interventions may lead to unmanageable distress or may be ineffective. While cognitive-behavioural interventions have been found to be effective with traumatised refugees, no studies concerning the efficacy of EMDR with this population have been conducted as yet. OBJECTIVE In preparation for a randomised trial comparing EMDR and stabilisation with traumatised refugees, a pilot study with 20 participants was conducted. The objective was to examine feasibility of participation in a randomised trial for this complex population and to examine acceptability and preliminary efficacy of EMDR. DESIGN Participants were randomly allocated to 11 sessions of either EMDR or stabilisation. Symptoms of PTSD (SCID-I, HTQ), depression and anxiety (HSCL-25), and quality of life (WHOQOL-BREF) were assessed at pre- and post-treatment and 3-month follow-up. RESULTS Participation of traumatised refugees in the study was found feasible, although issues associated with complex traumatisation led to a high pre-treatment attrition and challenges in assessments. Acceptability of EMDR was found equal to that of stabilisation with a high drop-out for both conditions. No participants dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilisation. Different symptom courses between the two conditions, with EMDR showing some improvement and stabilisation showing some deterioration between pre-treatment and post-treatment, justify the conduct of a full trial. CONCLUSION With some adaptations in study design, inclusion of a greater sample is justifiable to determine which treatment is more suitable for this complex population.
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Nickerson A, Bryant RA, Silove D, Steel Z. A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev 2010; 31:399-417. [PMID: 21112681 DOI: 10.1016/j.cpr.2010.10.004] [Citation(s) in RCA: 313] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 10/22/2010] [Accepted: 10/29/2010] [Indexed: 12/01/2022]
Abstract
Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, NSW 2052, Australia
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Abstract
The aim of this study was to examine long-term changes in symptoms of post-traumatic stress disorder, depression, anxiety, and in health-related quality of life in traumatized refugees 23 months after admission to multidisciplinary treatment. The study group comprised 45 persons admitted to the Rehabilitation and Research Centre for Torture Victims in 2001 to 2002. Data on background, trauma, present social situation, mental symptoms (Hopkins Symptom Checklist-25, Hamilton Depression Scale, Harvard Trauma Questionnaire), and on health-related quality of life (World Health Organization Quality of Life-Bref) were collected before treatment and after 9 and 23 months. No substantial changes in mental health were observed at the 9-month follow-up, and the minor decrease in some symptoms observed between the 9 and 23 months may reflect regression toward the mean or the natural course of symptoms in this cohort. Thus, no clinically significant improvement was observed, but there is a need for further studies, in particular randomized trials evaluating the efficacy of various health-related and social interventions among severely traumatized refugees.
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Therapiekonzeption für traumatisierte Patienten mit schweren Persönlichkeitsstörungen. PSYCHOTHERAPEUT 2009. [DOI: 10.1007/s00278-009-0712-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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