Understanding mechanisms of change: An unpacking study of the evidence-based common-elements treatment approach (CETA) in low and middle income countries

Shared genetic links between hypothyroidism and psychiatric disorders: evidence from a comprehensive genetic analysis

Background

Epidemiologic studies have suggested co-morbidity between hypothyroidism and psychiatric disorders. However, the shared genetic etiology and causal relationship between them remain currently unclear.

Methods

We assessed the genetic correlations between hypothyroidism and psychiatric disorders [anxiety disorders (ANX), schizophrenia (SCZ), major depressive disorder (MDD), and bipolar disorder (BIP)] using summary association statistics from genome-wide association studies (GWAS). Two disease-associated pleiotropic risk loci and genes were identified, and pathway enrichment, tissue enrichment, and other analyses were performed to determine their specific functions. Furthermore, we explored the causal relationship between them through Mendelian randomization (MR) analysis.

Results

We found significant genetic correlations between hypothyroidism with ANX, SCZ, and MDD, both in the Linkage disequilibrium score regression (LDSC) approach and the high-definition likelihood (HDL) approach. Meanwhile, the strongest correlation was observed between hypothyroidism and MDD (LDSC: rg=0.264, P=7.35×10-12; HDL: rg=0.304, P=4.14×10-17). We also determined a significant genetic correlation between MDD with free thyroxine (FT4) and thyroid-stimulating hormone (TSH) levels. A total of 30 pleiotropic risk loci were identified between hypothyroidism and psychiatric disorders, of which the 15q14 locus was identified in both ANX and SCZ (P values are 6.59×10-11 and 2.10×10-12, respectively) and the 6p22.1 locus was identified in both MDD and SCZ (P values are 1.05×10-8 and 5.75×10-14, respectively). Sixteen pleiotropic risk loci were identified between MDD and indicators of thyroid function, of which, four loci associated with MDD (1p32.3, 6p22.1, 10q21.1, 11q13.4) were identified in both FT4 normal level and Hypothyroidism. Further, 79 pleiotropic genes were identified using Magma gene analysis (P<0.05/18776 = 2.66×10-6). Tissue-specific enrichment analysis revealed that these genes were highly enriched into six brain-related tissues. The pathway analysis mainly involved nucleosome assembly and lipoprotein particles. Finally, our two-sample MR analysis showed a significant causal effect of MDD on the increased risk of hypothyroidism, and BIP may reduce TSH normal levels.

Conclusions

Our findings not only provided evidence of a shared genetic etiology between hypothyroidism and psychiatric disorders, but also provided insights into the causal relationships and biological mechanisms that underlie their relationship. These findings contribute to a better understanding of the pleiotropy between hypothyroidism and psychiatric disorders, while having important implications for intervention and treatment goals for these disorders.

Adapting brief problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence in rural Ethiopia

OBJECTIVE

To adapt an evidence-based psychological intervention for pregnant women experiencing depressive symptoms and intimate partner violence (IPV) in rural Ethiopia.

METHOD

We conducted a desk review of contextual factors in Sodo, Ethiopia, followed by qualitative interviews with 16 pregnant women and 12 antenatal care (ANC) providers. We engaged stakeholders through participatory theory of change (ToC) workshops, to select the intervention and articulate a programme theory. We used "ADAPT" guidance to adapt the intervention to the context, before mapping potential harms in a "dark logic model".

RESULTS

Brief problem-solving therapy developed for South Africa was the most contextually relevant model. We adapted the delivery format (participants prioritised confidentiality and brevity) and training and supervision (addressing IPV). Consensus long-term outcomes in our ToC were ANC providers skilled in detecting and responding to emotional difficulties and IPV, women receiving appropriate support, and emotional difficulties improving. Our dark logic model highlighted the risk of more severe IPV and mental health symptoms not being referred appropriately.

CONCLUSION

Although intervention adaptation is recommended, the process is rarely reported in depth. We comprehensively describe how contextual considerations, stakeholder engagement, programme theory, and adaptation can tailor psychological interventions for the target population in a low-income, rural setting.

Accessibility and Perceived Impact of a Group Psychosocial Intervention for Women in Ecuador: A Comparative Analysis by Migration Status

There is increasing guidance promoting the provision of mental health and psychosocial support programs to both migrant and host community members in humanitarian settings. However, there is a lack of information on the respective experiences and benefits for migrant and host community members who are participating in mental health and psychosocial support programming. We evaluated a community-based psychosocial program for migrant and host community women, Entre Nosotras, which was implemented with an international non-governmental organization in Ecuador in 2021. Data on participant characteristics and psychosocial wellbeing were collected via pre/post surveys with 143 participants, and qualitative interviews were conducted with a subset (n = 61) of participants. All quantitative analyses were conducted in STATA, and qualitative analysis was done in NVivo. Attendance was higher for host community members. Specifically, 71.4% of host community members attended 4-5 sessions, whereas only 37.4% of migrants attended 4-5 sessions (p = 0.004). Qualitative analysis shows that the intervention was less accessible for migrants due to a variety of structural barriers. However, this analysis also demonstrated that both groups of women felt a greater sense of social connectedness after participating in the program and expressed gratitude for the bonds they formed with other women. Some migrant women described negative experiences with the host community because they felt as though they could not confide in host community women and speak freely in front of them. These results underscore how the migratory context influences the implementation of mental health and psychosocial support (MHPSS) programs. As humanitarian guidelines continue to emphasize the integration of host community members and displaced persons, it is critical to account for how the same intervention may impact these populations differently.

Training non-specialists in teaching recovery techniques (TRT) to help traumatised children in humanitarian settings: a qualitative analysis of experiences gained from 20 years of practice

BACKGROUND

Although several manuals and guidelines have been developed to enhance the quality of task-sharing interventions, it remains challenging to train non-professional personnel in mental health and psychosocial support. Practitioners must translate general recommendations into practical applications to make them relevant in demanding contexts. However, limited research exists on practical experiences with standardised programmes in the field.

AIM

To explore how experiences gained from the training of first-line health providers in a low-threshold intervention for children with trauma symptoms may guide implementation of such interventions in local communities in low-income countries.

METHOD

We summarise 20 years of experience in the training of first-line health providers, teachers, and school counsellors in providing a low-threshold intervention. The intervention is called teaching recovery techniques (TRT), developed by the Children and War Foundation (CAW). Field notes containing notes from trainings and oral, informal feedback from participants are analysed using thematic analysis, a method well-suited for identifying, analysing, and reporting patterns, or themes, within data in qualitative research.

FINDINGS

The analysis showed three main themes/ challenges: (1) Who can conduct the TRT intervention? (2) What form and content should the training take? (3) How can the intervention be used in a responsible way to follow the 'do no harm' principle? We discuss the implications of the findings for trainings in scalable interventions and further research.

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

Common Elements Approaches to Implementation Research and Practice: Methods and Integration with Intervention Science

We propose that common elements approaches can advance implementation research and practice and facilitate pragmatic use of intervention and implementation evidence. Common elements are practices or processes frequently shared by interventions or implementations. Traditional common elements methodologies use synthesis, distillation, and statistics to describe and evaluate the merit of common ingredients in effective interventions. Recent developments include identifying and testing common configurations of elements, processes, and context variables across the literature of effective interventions and implementations. While common elements thinking has grown popular in intervention science, it has rarely been utilized in implementation science, and specifically, combined with the intervention literature. The goals of this conceptual methodology paper are to (1) provide an overview of the common elements concept and how it may advance implementation research and usability for practice, (2) give a step-by-step guide to systematic common elements reviews that synthesizes and distills the intervention and implementation literature together, and (3) offer recommendations for advancing element-level evidence in implementation science. A narrative review of the common elements literature was conducted with attention to applications to implementation research. A six-step guide to using an advanced common elements methodology was provided. Examples of potential results are presented, along with a review of the implications for implementation research and practice. Finally, we reviewed methodological limitations in current common elements approaches, and identified steps towards realizing their potential. Common elements methodologies can (a) synthesize and distill the implementation science literature into practical applications, (b) generate evidence-informed hypotheses about key elements and determinants in implementation and intervention processes and mechanisms, and (c) promote evidence-informed precision tailoring of intervention and implementation to context. To realize this potential, common elements approaches need improved reporting of details from both successful and unsuccessful intervention and implementation research, more data availability, and more testing and investigation of causal processes and mechanisms of change from diverse theories.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00077-4.

Alcohol-focused and transdiagnostic treatments for unhealthy alcohol use among adults with HIV in Zambia: A 3-arm randomized controlled trial

BACKGROUND

Clinical and quality of life outcomes in people living with human immunodeficiency virus (PLWH) are undermined by unhealthy alcohol use (UAU), which is highly prevalent in this population and is often complicated by mental health (MH) or other substance use (SU) comorbidity. In sub-Saharan Africa, evidence-based and implementable treatment options for people with HIV and UAU are needed.

METHODS

We are conducting a hybrid clinical effectiveness-implementation trial at three public-sector HIV clinics in Lusaka, Zambia. Adults with HIV, who report UAU, and have suboptimal HIV clinical outcomes, will be randomized to one of three arms: an alcohol-focused brief intervention (BI), the BI with additional referral to a transdiagnostic cognitive behavioral therapy (Common Elements Treatment Approach [CETA]), or standard of care. The BI and CETA will be provided by HIV peer counselors, a common cadre of lay health worker in Zambia. Clinical outcomes will include HIV viral suppression, alcohol use, assessed by audio computer-assisted self-interview (ACASI) and direct alcohol biomarkers, Phophatidylethanol and Ethyl glucuronide, and comorbid MH and other SU. A range of implementation outcomes including cost effectiveness will also be analyzed.

CONCLUSION

Hybrid and 3-arm trial design features facilitate the integrated evaluation of both brief, highly implementable, and more intensive, less implementable, treatment options for UAU among PLWH in sub-Saharan Africa. Use of ACASI and alcohol biomarkers will strengthen understanding of treatment effects.

Strengthening parental self-efficacy and resilience: A within-subject experimental study with refugee parents of adolescents

Post-migration stress and parenting adolescents can reduce parental self-efficacy. This study tested the effects of strengthening parental self-efficacy in refugee parents of adolescents and whether this makes parental self-efficacy less impacted by post-migration stressors. Using a within-subject experimental design, experience sampling data were collected in 2019 from 53 refugee parents of adolescents (M_age  = 39.7, SD_age  = 5.59, 73% Syrian, 70% mothers) in the Netherlands. Data were analyzed by dynamic structural equation modeling using interrupted time-series analysis. The single-session personalized intervention strengthened parental self-efficacy (small effect: between case standardized mean difference = 0.09) and made refugee parents less vulnerable to post-migration stressors. Findings suggest that parental self-efficacy is malleable and strengthening it fosters refugee parents' resilience. Replications with longer-term follow-ups are needed.

Striving for Happily Ever After: Supportive Interventions for Youth Leaving Residential Placement. A Systematic Review of Reviews

BACKGROUND

Youth who reenter communities after forensic or residential care are overrepresented in prevalence rates for mental disorders, delinquency, incarceration, low academic achievement, and unemployment. Supportive interventions that aid youth in the reentry to their communities can be crucial for successful reintegration. In systematic reviews (SR) on this topic, only specific interventions or programs are described. Therefore, a summary of evidence about transitional interventions for various groups of reentry youth is needed.

METHOD

This overview of SRs was preregistered in PROSPERO. We searched PsycINFO, Ovid MEDLINE, Cochrane Library, Campbell Library, Web of Science, Sociological Abstracts, Criminal Justice Abstracts, Social Care Online, and Epistemonikos. SRs that fit the search criteria were evaluated using the AMSTAR checklist for methodological quality and the GRADE tool for assessing confidence in effect estimates.

RESULTS

We screened 2,349 publications for eligibility. Eight SRs were included for analysis. The methodological quality of five SRs was critically low, two were of low quality, and one was of moderate quality. Recidivism was reported as the only outcome in five SRs. Detrimental outcomes were reported in five SRs. Confidence in effect estimates was low or very low for all outcomes. Ninety-five percent of primary study populations were from the United States.

CONCLUSION

We offer a rigorous appraisal of SRs on transitional interventions. The gaps of knowledge are vast regarding what works, how it works, and for whom. Development of a knowledge base should include defining the term 'recidivism', systematic reporting of demographics, and identifying effective common elements.

Psychiatric comorbidity and psychosocial stressors among people initiating HIV care in Cameroon

Background

Psychiatric comorbidity, the presence of two or more mental health disorders, has been associated with suboptimal HIV treatment outcomes. Little is known about the prevalence of psychiatric comorbidity among people with HIV (PWH) in sub-Saharan Africa.

Methods

We conducted interviews with PWH initiating HIV care in Cameroon between June 2019 and March 2020. Depression, anxiety, post-traumatic stress disorder (PTSD), and harmful drinking were dichotomized to represent those with and without symptoms of each. Psychiatric comorbidity was defined as having symptoms of two or more disorders assessed. Moderate or severe household hunger, high anticipatory HIV-related stigma, low social support, and high number of potentially traumatic events were hypothesized as correlates of psychiatric comorbidity. Bivariable log binomial regression models were used to estimate unadjusted associations between psychosocial stressors and psychiatric comorbidity.

Results

Among 424 participants interviewed, the prevalence of psychiatric comorbidity was 16%. Among those with symptoms of at least one mental health or substance use disorder (n = 161), the prevalence of psychiatric comorbidity was 42%. The prevalence of psychiatric comorbidity was 33%, 67%, 76%, and 81% among those with symptoms of harmful drinking, depression, anxiety, and PTSD, respectively. Among individuals with symptoms of a mental health or substance use disorder, a high number of potentially traumatic events (prevalence ratio (PR) 1.71 [95% CI 1.21, 2.42]) and high anticipatory HIV-related stigma (PR 1.45 [95% CI 1.01, 2.09]) were associated with greater prevalence of psychiatric comorbidity.

Conclusion

Psychiatric comorbidity was common among this group of PWH in Cameroon. The effectiveness and implementation of transdiagnostic or multi-focus mental health treatment approaches in HIV care settings should be examined.

School-based MHPSS interventions in humanitarian contexts: a realist review

OBJECTIVE

The aim of this review is to elucidate the characteristics of school-based mental health and psychosocial support (MHPSS) interventions in humanitarian contexts and the hypothesised mechanisms by which they influence well-being or learning outcomes.

METHODS

We conducted a realist review and searched PubMed, Embase, Global Health, CINAHL, PsychInfo, PILOTS and grey literature through January 2022. Eligible studies included children age 6-12 years, were conducted in humanitarian contexts in low-income or middle-income countries, and focused on universal MPHSS prevention in an educational setting, using any study design. Data were extracted and analysed using narrative synthesis and realist analysis techniques to create 'context-mechanism-outcome' configurations that were iteratively developed to modify, refine and substantiate programme theories.

RESULTS

Twenty-seven articles, representing 19 studies, were included in the review. We analysed data from 26 articles. Eleven evidenced-informed programme theories were developed at the levels of the child (n=4), teacher (n=3), caregiver (n=2), school environment (n=1) and school managers/administrators (n=1). At the child level, mechanisms related to strengthening coping skills, emotion regulation, interpersonal relationships led to improved psychosocial well-being or learning outcomes. At the teacher level, coping skills and the provision of support to students were linked to psychosocial well-being and learning outcomes. At the caregiver level, strengthening interpersonal bonds trigger improved psychosocial well-being, and at the school environment level, fostering feelings of security was linked to psychosocial well-being and learning outcomes. We did not find any evidence supporting the programme theory at the school managers/administrators level. We found limited evidence of positive impacts of the included interventions to support these programme theories.

CONCLUSIONS

These programme theories are a promising start towards ensuring school-based MHPSS interventions in humanitarian contexts better address the well-being and learning needs of children. Future research is needed to support these programme theories and enhance the evidence base.

Dropout from treatment for mental disorders in six countries of the Americas: A regional report from the World Mental Health Surveys

OBJECTIVE

To estimate structural and attitudinal reasons for premature discontinuation of mental health treatment, socio-demographic and clinical correlates of treatment dropout due to these reasons, and to test country differences from the overall effect across the region of the Americas.

METHODS

World Health Organization-World Mental Health (WMH) surveys were carried out in six countries in the Americas: Argentina, Brazil, Colombia, Mexico, Peru and USA. Among the 1991 participants who met diagnostic criteria (measured with the Composite International Diagnostic Interview (WMHCIDI)) for a mental disorder and were in treatment in the prior 12-months, the 236 (12.2%) who dropped out of treatment before the professional recommended were included.

FINDINGS

In all countries, individuals more frequently reported attitudinal (79.2%) rather than structural reasons (30.7%) for dropout. Disorder severity was associated with structural reasons; those with severe disorder (versus mild disorder) had 3.4 (95%CI=1.1-11.1) times the odds of reporting a structural reason. Regarding attitudinal reasons, those with lower income (versus higher income) were less likely to discontinue treatment because of getting better (OR=0.4; 95%CI= 0.2-0.9). Country specific variations were found.

LIMITATIONS

Not all countries, or the poorest, in the region were included. Some estimations couldn´t be calculated due to cell size. Causality cannot be assumed.

CONCLUSION

Clinicians should in the first sessions address attitudinal factors that may lead to premature termination. Public policies need to consider distribution of services to increase convenience. A more rational use of resources would be to offer brief therapies to individuals most likely to drop out of treatment prematurely.

Implementation of a Community-Based Psychosocial Support Focal Point Response for Internally Displaced Persons in Myanmar During COVID-19

Background

In response to the COVID-19 pandemic, the Global Mental Health research group at Johns Hopkins School of Public Health worked with three local partner organizations in Myanmar to develop a psychosocial support (PSS) program that could be delivered by community-based focal points in internally displaced persons camps. This PSS program was designed to be delivered in communities with limited access to regional mental health services due to pandemic travel restrictions. The content of the PSS program was based on materials from an ongoing Common Elements Treatment Approach (CETA) mental health program; CETA counselors based in the three partner organizations were available to provide telephone-based CETA counseling. In April 2020, the partners organizations recruited and trained PSS focal points in 25 IDP camps to establish a multi-tiered system of MHPSS supports.

Implementation

The PSS program including psychoeducation handouts focused on stress and coping during COVID-19 and skills for cognitive restructuring (i.e., changing unhelpful thoughts) in simplified terms, audio recordings of the content of these handouts and referral opportunities for telephone-based services by CETA counselors located outside of the camps. PSS focal points distributed the handouts, had the recordings played via radio and loudspeaker, and were available to answer questions and provide access to a PSS program phones to connect with the CETA counselors. After 6 months of implementation, program monitoring logs were reviewed and a cross-sectional evaluation was conducted to assess the PSS program's reach, understanding, and perceived utility.

Evaluation

Forty-one focal points implemented the PSS program in 25 IDP camps in Kachin and northern Shan States. From May to September 2020, the focal points distributed handouts to 5,725 households and reported 679 visits by IDPs, including facilitating 332 calls to a CETA counselor. Data from the program evaluation (n = 793 participants) found high levels of handout readership and perceived utility of the information, and good comprehension of the content and application of skills.

Discussion

Findings suggest that provision of a multi-tiered MHPSS program, with PSS focal points providing direct information and linkages to further mental health services via telephone, was feasible despite the constraints of the pandemic. Utilizing camp-based focal points was acceptable and successful in delivering basic psychosocial supports to a broad population while serving as points of contact for individuals who wanted and needed telephone-based counseling services.

Integrating a Transdiagnostic Psychological Intervention Into Routine HIV Care: A Mixed-Methods Evaluation of the Common Elements Treatment Approach in Mozambique

INTRODUCTION

We integrated a transdiagnostic psychological intervention (Common Elements Treatment Approach [CETA]) into routine HIV care in Sofala, Mozambique. This task-shared program screens and treats newly diagnosed HIV+ patients with comorbid mental health symptoms.

METHODS

A mixed-methods evaluation included demographics, intake screening scores, mental health symptoms, and barriers/facilitators to implementation examined through interviews. Multilevel models were used to analyze factors associated with symptom improvement and loss to follow-up (LTFU).

RESULTS

From March 2019 to June 2020, 820 individuals were screened for CETA treatment; 382 (46.6%) showed clinically significant mental health symptoms and attended 1484 CETA sessions. Of CETA patients, 71.5% (n = 273/382) had general mental distress, 7.3% (n = 28) had alcohol abuse/dependence, 12.0% (n = 46) had suicidal ideation, and 3.7% (n = 14) had other violent ideation; 66.2% (n = 253) had experienced at least 1 traumatic event at intake. Mental health symptoms decreased by 74.1% (17.0 to 4.4) after 5 CETA sessions, and 37.4% of patients (n = 143) achieved a ≥50% symptom reduction from intake. LTFU was 29.1% (n = 111), but 59.5% of LTFU patients (n = 66) achieved a ≥50% symptom reduction before LTFU. Facilitators for CETA implementation included readiness for change given the unaddressed burden of mental illness. Barriers included complexity of the intervention and stigma.

CONCLUSIONS

Approximately 45% of newly diagnosed HIV+ individuals in Mozambique have clinically significant mental health symptoms at diagnosis. Integrating CETA into routine HIV platforms has in-context feasibility. Future implementation studies can optimize strategies for patient retention and scale-up.

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries

BACKGROUND

Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

METHODS

Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

RESULTS

We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

CONCLUSION

Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017058287 .