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Kaminer D, Booysen D, Ellis K, Kristensen CH, Patel AR, Robjant K, Sardana S. Improving access to evidence-based interventions for trauma-exposed adults in low- and middle-income countries. J Trauma Stress 2024; 37:563-573. [PMID: 38459223 DOI: 10.1002/jts.23031] [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] [Received: 02/02/2024] [Revised: 02/11/2024] [Accepted: 02/11/2024] [Indexed: 03/10/2024]
Abstract
In low- and middle-income countries (LMICs), the mental health consequences of trauma exposure pose a substantial personal, societal, and economic burden. Yet, the significant need for evidence-based mental health treatment remains largely unmet. To unlock the potential for mental health care for trauma survivors in lower-resource contexts, it is critical to map treatment barriers and identify strategies to improve access to evidence-based, culturally appropriate, and scalable interventions. This review, based on an International Society for Traumatic Stress (ISTSS) briefing paper, describes the treatment gap facing adults with traumatic stress in LMICs and identifies the barriers that contribute to this gap. We then highlight strategies for enhancing access to effective treatments for these populations, including task-sharing, the use of culturally adapted and multiproblem interventions, and digital tools to scale access to appropriate care. Finally, we offer recommendations for policymakers, researchers, and service providers to guide an agenda for action to close the treatment gap for trauma survivors in LMICs.
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Affiliation(s)
- Debra Kaminer
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Duane Booysen
- Department of Psychology, Rhodes University, Grahamstown, South Africa
| | - Kate Ellis
- Department of Psychology, American University in Cairo, New Cairo, Egypt
| | - Christian Haag Kristensen
- School of Health and Life Sciences, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Anushka R Patel
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, Massachusetts, USA
| | - Katy Robjant
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Srishti Sardana
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Melani MS, Paiva JM, Mendlowicz MV, Vilete L, Luz MP, Ventura PR, Passos RBF, Berger W. Are There Differences Among Evidence-Based Psychotherapies for Treating Different DSM-5 PTSD Symptom Clusters? A Systematic Review and Meta-analysis of Controlled Clinical Trials. J Nerv Ment Dis 2024; 212:332-343. [PMID: 38810096 DOI: 10.1097/nmd.0000000000001769] [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: 05/31/2024]
Abstract
ABSTRACT Posttraumatic stress disorder (PTSD) is a heterogeneous disease defined by four Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) symptom clusters: reexperiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal. There are effective evidence-based psychotherapies (EBPs) for PTSD. However, given the variety of PTSD clinical presentations, we conducted the first meta-analysis investigating whether DSM-5 PTSD symptom clusters show different responses to EBPs. We systematically reviewed the literature for controlled clinical trials in five databases, performed a meta-analysis, and evaluated the methodological quality of the studies. We screened 633 studies and included seven. Three showed high risk, two showed some concerns, and one showed a low risk of bias. The symptom clusters do not seem to respond differently to EBPs (SMD cluster B: -0.40; 95% confidence interval [CI], -0.87 to 0.08; cluster C: -0.49; 95% CI, -0.90 to -0.08; cluster D: -0.44; 95% CI, -0.94 to 0.05; cluster E: -0.54; 95% CI, -1.07 to -0.0), even when analyzed by the therapeutic focuses. The findings dovetail nicely with the network theory of PTSD symptom, as although it is a heterogeneous disorder, the EBPs seem to promote a kind of cascade of symptom improvement.
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Affiliation(s)
- Marina S Melani
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
| | - Jéssica M Paiva
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
| | | | - Liliane Vilete
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
| | - Mariana P Luz
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
| | - Paula Rui Ventura
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
| | | | - William Berger
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry, Universidade Federal do Rio de Janeiro
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Bangpan M, Felix L, Soliman F, D’Souza P, Jieman AT, Dickson K. The impact of mental health and psychosocial support programmes on children and young people's mental health in the context of humanitarian emergencies in low- and middle-income countries: A systematic review and meta-analysis. Glob Ment Health (Camb) 2024; 11:e21. [PMID: 38572260 PMCID: PMC10988149 DOI: 10.1017/gmh.2024.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/20/2023] [Accepted: 01/30/2024] [Indexed: 04/05/2024] Open
Abstract
Humanitarian emergencies pose a significant global health challenge for children and young people's mental and psychological health. This systematic review investigates the effectiveness of mental health and psychosocial support (MHPSS) programmes delivered to children and young people affected by humanitarian emergencies in low- and middle-income countries (LMICs). Twelve electronic databases, key websites and citation checking were undertaken. Forty-three randomised controlled trials (RCTs) published in English between January 1980 and May 2023 were included in the review. Overall, the findings suggest that cognitive behavioural therapy may improve depression symptoms in children and young people affected by humanitarian emergencies. Narrative exposure therapy may reduce feelings of guilt. However, the impact of the other MHPSS modalities across outcomes is inconsistent. In some contexts, providing psychosocial programmes involving creative activities may increase the symptoms of depression in children and young people. These findings emphasise the need for the development of MHPSS programmes that can safely and effectively address the diverse needs of children and young people living in adversarial environments.
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Affiliation(s)
- Mukdarut Bangpan
- The Evidence for Policy and Practice information and Co-ordinating Centre (EPPI-Centre), UCL Social Research Institute, University College London, London, United Kingdom
| | - Lambert Felix
- School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, United Kingdom
| | - Farida Soliman
- Linguistics Department, Queen Mary University of London, London, United Kingdom
| | - Preethy D’Souza
- The Evidence for Policy and Practice information and Co-ordinating Centre (EPPI-Centre), UCL Social Research Institute, University College London, London, United Kingdom
| | - Anna-Theresa Jieman
- Department of Biological and Experimental Psychology, School of Biological and Behavioural Sciences, Queen Mary University of London, London, United Kingdom
| | - Kelly Dickson
- The Evidence for Policy and Practice information and Co-ordinating Centre (EPPI-Centre), UCL Social Research Institute, University College London, London, United Kingdom
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de Haan A, Meiser-Stedman R, Landolt MA, Kuhn I, Black MJ, Klaus K, Patel SD, Fisher DJ, Haag C, Ukoumunne OC, Jones BG, Flaiyah AM, Catani C, Dawson K, Bryant RA, de Roos C, Ertl V, Foa EB, Ford JD, Gilboa-Schechtman E, Tutus D, Hermenau K, Hecker T, Hultmann O, Axberg U, Jaberghaderi N, Jensen TK, Ormhaug SM, Kenardy J, Lindauer RJL, Diehle J, Murray LK, Kane JC, Peltonen K, Kangaslampi S, Robjant K, Koebach A, Rosner R, Rossouw J, Smith P, Tonge BJ, Hitchcock C, Dalgleish T. Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:28-39. [PMID: 37980918 DOI: 10.1016/s2352-4642(23)00253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators. METHODS This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954. FINDINGS We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms. INTERPRETATION This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Anke de Haan
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Richard Meiser-Stedman
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Markus A Landolt
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Isla Kuhn
- Medical Library, University of Cambridge, Cambridge, UK
| | - Melissa J Black
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Kristel Klaus
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Shivam D Patel
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - David J Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Christina Haag
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Obioha C Ukoumunne
- National Institute for Health and Care Research Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, UK
| | - Benjamin G Jones
- National Institute for Health and Care Research Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, UK; Exploristics, Belfast, UK
| | | | - Claudia Catani
- Department of Clinical Psychology and Psychotherapy, Bielefeld University, Bielefeld, Germany
| | - Katie Dawson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Carlijn de Roos
- Academic Centre for Child and Adolescent Psychiatry, Amsterdam University Medical Center (location AMC), Amsterdam, Netherlands; Levvel, Academic Centre for Child and Adolescent Psychiatry, Amsterdam, Netherlands
| | - Verena Ertl
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania Medical School, Philadelphia, PA, USA
| | - Julian D Ford
- Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, USA
| | - Eva Gilboa-Schechtman
- Emotional Processing Laboratory, Department of Psychology and the Gonda Brain Science Center, Bar-Ilan University, Ramat Gan, Israel
| | - Dunja Tutus
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Katharin Hermenau
- University Clinic of Child and Adolescent Psychiatry and Psychotherapy, Protestant Hospital Bethel, University Medical Centre EWL, Bielefeld University, Bielefeld, Germany
| | - Tobias Hecker
- Division of Clinical Developmental Psychopathology, Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Ole Hultmann
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Ulf Axberg
- Faculty of Social Studies, VID Specialized University, Oslo, Norway
| | - Nasrin Jaberghaderi
- Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tine K Jensen
- Department of Psychology, University of Oslo, Oslo, Norway; Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Silje M Ormhaug
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Justin Kenardy
- School of Psychology, University of Queensland, Brisbane, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ramon J L Lindauer
- Academic Centre for Child and Adolescent Psychiatry, Amsterdam University Medical Center (location AMC), Amsterdam, Netherlands; Levvel, Academic Centre for Child and Adolescent Psychiatry, Amsterdam, Netherlands; Department of Child and Adolescent Psychiatry, Public Mental Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Julia Diehle
- WODC-Research and Documentation Centre, Ministry of Justice and Security, The Hague, Netherlands
| | - Laura K Murray
- Department of Mental Health and International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Jeremy C Kane
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA
| | - Kirsi Peltonen
- INVEST Research Flagship Centre, University of Turku, Turku, Finland
| | - Samuli Kangaslampi
- Faculty of Social Sciences, Psychology, Tampere University, Tampere, Finland
| | - Katy Robjant
- Clinical and Neuropsychology, Department of Psychology, University of Konstanz, Konstanz, Germany; Vivo International, Konstanz, Germany
| | - Anke Koebach
- Clinical and Neuropsychology, Department of Psychology, University of Konstanz, Konstanz, Germany; Development Research Group, Department of Politics and Administration, University of Konstanz, Konstanz, Germany; Vivo International, Konstanz, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Jaco Rossouw
- Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa; Centre for Cognitive-Behavioural Therapy, Cape Town, South Africa
| | - Patrick Smith
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Bruce J Tonge
- Centre for Developmental Psychology and Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Caitlin Hitchcock
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK.
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Cénat JM, Moshirian Farahi SMM, Rousseau C, Bukaka J, Darius WP, Derivois D, Dalexis RD, Luyeye N. Prevalence and Factors Related to Post-traumatic Stress Disorder and Depression Symptoms Among Children and Adolescents Survivors and Orphans of Ebola Virus Disease in Democratic Republic of the Congo Eastern Regions During the COVID-19 Pandemic. J Adolesc Health 2023; 73:1019-1029. [PMID: 37737753 DOI: 10.1016/j.jadohealth.2023.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE Although previous studies have shown a high prevalence of mental health problems among adult Ebola virus disease survivors, no studies have yet been conducted on mental health problems among children and adolescents in affected regions. Consequently, the current study aimed to examine the prevalence and factors associated with depression and post-traumatic stress disorder (PTSD) among children and adolescent survivors and orphans by utilizing a cross-sectional survey following the 2018-2020 epidemic in Eastern Democratic Republic of the Congo. METHODS A total of 146 survivors (mean age = 13.62, standard deviation [SD] = 2.50, 49.32% female), 233 orphans (mean age = 13.18, SD = 2.96, 53.32% female), and 34 orphan-survivor participants (mean age = 13.39, SD = 2.87, 44.12% female) were recruited. Participants completed measures assessing depression and PTSD symptoms, traumatic experiences, and stigma related to Ebola and COVID-19. RESULTS The prevalence of depression and PTSD symptoms was 87.32% and 44.42%, respectively. Results showed significant differences in depression and PTSD symptoms between orphan-survivors (100% and 97.06%), survivors (90.21% and 75.86%), and orphans (83.48% and 16.52%; χ2(2) = 9.02; p = .011 and χ2(2) = 168.85; p < .001). Experience of traumatic events, Ebola stigmatization, and COVID-19 stigmatization positively predicted depression and PTSD symptoms. The regression models explained 61%-72% of the variance of depression and PTSD. DISCUSSION The results reveal that the Ebola virus disease and its associated grief severely jeopardize the mental health of children and adolescents in affected regions. Despite the relative paucity of resources, intervention programs may be helpful to minimize associated stigma and promote psychological support.
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Affiliation(s)
- Jude Mary Cénat
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada; Interdisciplinary Centre for Black Health, University of Ottawa, Ottawa, Ontario, Canada; University of Ottawa Research Chair on Black Health, School of Psychology, University of Ottawa, Ottawa, Ontario, Canada.
| | | | - Cécile Rousseau
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, Québec, Canada
| | - Jacqueline Bukaka
- Department of Psychology, University of Kinshasa, Kinshasa, DR of Congo
| | - Wina Paul Darius
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Derivois
- Department of Psychology, Université Bourgogne Franche Comté, Bourgogne, France
| | - Rose Darly Dalexis
- Interdisciplinary School of Health Sciences, University of Ottawa, Ontario, Canada
| | - Noble Luyeye
- Department of Psychology, University of Kinshasa, Kinshasa, DR of Congo
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Raeder R, Clayton NS, Boeckle M. Narrative-based autobiographical memory interventions for PTSD: a meta-analysis of randomized controlled trials. Front Psychol 2023; 14:1215225. [PMID: 37829075 PMCID: PMC10565228 DOI: 10.3389/fpsyg.2023.1215225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction The aim of this systematic review and meta-analysis is to evaluate the efficacy of narrative-based interventions (NBIs) for individuals with post-traumatic stress disorder (PTSD). Investigating the efficacy of NBIs should yield insight on autobiographical memory (AM) phenomena implicated in PTSD onset and recovery, leading to improved intervention protocols. Furthermore, by analyzing how NBIs influence maladaptive AM distortions, we hope to shed light on the theorized narrative architecture of AM more generally. Methods A systematic literature search was conducted according to PRISMA and Cochrane guidelines in MEDLINE, EMBASE, PsychINFO, and PubMed. Additional studies were then also identified from the reference lists of other relevant literature and considered for inclusion. Studies were then evaluated for adherence to the inclusion/exclusion criteria and assessed for risk of bias. Various meta-analyses were performed on included studies to understand how NBIs may or may not influence the overall effect size of treatment. Results The results of the meta-analysis of 35 studies, involving 2,596 participants, suggest that NBIs are a viable and effective treatment option for PTSD, yielding a statistically significant within-group effect size and decrease in PTSD symptomatology at both post-treatment [g = 1.73, 95% CI (1.23-2.22)] and 3-9 month follow-up assessments [g = 2.33, 95% CI (1.41-3.26)]. Furthermore, the difference in effect sizes between NBIs compared to active and waitlist controls was statistically significant, suggesting that NBIs are superior. Sub-analyses showed that NET provided a stronger effect size than FORNET, which may be due to the nature of the traumatic event itself and not the treatment protocol. While evidence of small study and publication bias was present, a weight-function model and trim-and-fill method suggested it was not influencing the overall results. Discussion This meta-analysis presents strong evidence supporting the use of NBIs in the treatment of PTSD. Clear similarities can be identified between NBIs included in this analysis that make them distinct from non-NBI interventions, which are reviewed in the discussion. Controlled comparisons between NBIs and non-NBIs would help to further understand AM mechanisms of action implicated in recovery and how various interventions facilitate them. Future research should also aim to elucidate the full range of AM impairment in individuals with PTSD to gain insight on how other memory capabilities, such as the ability to mentally simulate the future, are implicated in the pathogenesis of PTSD.
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Affiliation(s)
- Robert Raeder
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Nicola S. Clayton
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Markus Boeckle
- Scientific Working Group, Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Transitory Psychiatry, University Hospital Tulln, Tulln, Austria
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Yu R, Perera C, Sharma M, Ipince A, Bakrania S, Shokraneh F, Sepulveda JSM, Anthony D. Child and adolescent mental health and psychosocial support interventions: An evidence and gap map of low- and middle-income countries. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1349. [PMID: 37621301 PMCID: PMC10445093 DOI: 10.1002/cl2.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Background Mental disorders affect about one in seven children and adolescents worldwide. Investment in effective child and adolescent mental health prevention, promotion and care is essential. To date, however, the evidence from this field is yet to be comprehensively collected and mapped. Objectives The objective of this evidence and gap map (EGM) is to provide an overview of the existing evidence on the effectiveness of interventions aimed at promoting mental health and reducing or preventing mental health conditions among children and adolescents in lower-middle-income countries (LMICs). Search Methods We searched for studies from a wide range of bibliographic databases, libraries and websites. All searches were conducted in December 2021 and covered the period between 2010 and 2021. Selection Criteria We included evidence on the effectiveness of any Mental Health and Psychosocial Support (MHPSS) interventions targeting children and adolescents from 0 to 19 years of age in LMICs. The map includes systematic reviews and effectiveness studies in the form of randomised control trials and quasi-experimental studies, and mixed-methods studies with a focus on intervention effectiveness. Data Collection and Analysis A total of 63,947 records were identified after the search. A total of 19,578 records were removed using machine learning. A total of 7545 records were screened independently and simultaneously by four reviewers based on title and abstract and 2721 full texts were assessed for eligibility. The EGM includes 697 studies and reviews that covered 78 LMICs. Main Results School-based interventions make up 61% of intervention research on child and adolescent mental health and psychosocial support. Most interventions (59%) focusing on treating mental health conditions rather than preventing them or promoting mental health. Depression (40%, N = 282) was the most frequently researched outcome sub-domain analysed by studies and reviews, followed by anxiety disorders (32%, N = 225), well-being (21%, N = 143), and post-traumatic stress disorder (18%, N = 125). Most included studies and reviews investigated the effectiveness of mental health and psychosocial support interventions in early (75%, N = 525) and late adolescence (64%, N = 448). Conclusions The body of evidence in this area is complex and it is expanding progressively. However, research on child and adolescent MHPSS interventions is more reactive than proactive, with most evidence focusing on addressing mental health conditions that have already arisen rather than preventing them or promoting mental health. Future research should investigate the effectiveness of digital mental health interventions for children and adolescents as well as interventions to address the mental health and psychosocial needs of children in humanitarian settings. Research on early childhood MHPSS interventions is urgently needed. MHPSS research for children and adolescents lacks diversity. Research is also needed to address geographical inequalities at the regional and national level. Important questions also remain on the quality of the available research-is child and adolescent MHPSS intervention research locally relevant, reliable, well-designed and conducted, accessible and innovative? Planning research collaborations with decision-makers and involving experts by experience in research is essential.
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Affiliation(s)
- Ruichuan Yu
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | - Camila Perera
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | - Manasi Sharma
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | - Alessandra Ipince
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | - Shivit Bakrania
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | - Farhad Shokraneh
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
| | | | - David Anthony
- UNICEF Innocenti—Global Office of Research and Foresight, UNICEF HQFlorenceItaly
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Serpeloni F, Narrog JA, Pickler B, Avanci JQ, Assis SGD, Koebach A. Treating post-traumatic stress disorder in survivors of community and domestic violence using narrative exposure therapy: a case series in two public health centers in Rio de Janeiro/Brazil. CIENCIA & SAUDE COLETIVA 2023; 28:1619-1630. [PMID: 37255140 DOI: 10.1590/1413-81232023286.16532022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 11/15/2022] [Indexed: 06/01/2023] Open
Abstract
Prevalence of violence in Brazil is high, which contributes to an increasing number of trauma-related disorders, especially post-traumatic stress disorder (PTSD). This study aims to present a case series of PTSD patients treated with narrative exposure therapy (NET) in two public health centers in Rio de Janeiro (Brazil). Health professionals were trained in a two-week workshop to deliver NET. Exposure to violence and other potentially traumatic events, as well as PTSD were assessed by interviewers before treatment and six months later in follow-up interviews conducted by blind assessors. Multiple traumatic events, including different types of childhood and sexual abuse, intimate partner violence and community violence were reported. Five patients were exposed to community violence, and one to domestic violence, during or after NET treatment. Treatment delivery was integrated into the routine of health centers. Eight patients completed NET and presented a substantial reduction in PTSD severity at six-month follow-up. NET is a feasible and effective treatment for PTSD patients exposed to ongoing violence, and can be integrated into established public health services.
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Affiliation(s)
- Fernanda Serpeloni
- Departamento de Estudos sobre Violência e Saúde Jorge Careli, Fundação Oswaldo Cruz (Claves/Fiocruz). Av. Brasil 4.036, sala 700, Manguinhos. 21040-361 Rio de Janeiro RJ Brasil.
- ONG vivo international. Konstanz Alemanha
| | | | - Bianca Pickler
- Departamento de Estudos sobre Violência e Saúde Jorge Careli, Fundação Oswaldo Cruz (Claves/Fiocruz). Av. Brasil 4.036, sala 700, Manguinhos. 21040-361 Rio de Janeiro RJ Brasil.
| | - Joviana Quintes Avanci
- Departamento de Estudos sobre Violência e Saúde Jorge Careli, Fundação Oswaldo Cruz (Claves/Fiocruz). Av. Brasil 4.036, sala 700, Manguinhos. 21040-361 Rio de Janeiro RJ Brasil.
| | - Simone Gonçalves de Assis
- Departamento de Estudos sobre Violência e Saúde Jorge Careli, Fundação Oswaldo Cruz (Claves/Fiocruz). Av. Brasil 4.036, sala 700, Manguinhos. 21040-361 Rio de Janeiro RJ Brasil.
- Programa de Pós-Graduação em Neurologia, Universidade Federal do Estado do Rio de Janeiro. Rio de Janeiro RJ Brasil
| | - Anke Koebach
- ONG vivo international. Konstanz Alemanha
- Departamento de Psicologia, Universidade de Konstanz. Alemanha
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9
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Arega NT. Mental Health and Psychosocial Support Interventions for Children Affected by Armed Conflict in low-and middle-income Countries: A Systematic Review. CHILD & YOUTH CARE FORUM 2023:1-26. [PMID: 37360764 PMCID: PMC9990564 DOI: 10.1007/s10566-023-09741-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 06/28/2023]
Abstract
Background . Armed conflicts continue to threaten a vast number of children across the world, especially in low-and middle-income countries (LMICs). Evidence-based interventions are vital to adequately address the mental health needs in these groups. Objective . This systematic review aims to provide a comprehensive update of the most current developments in mental health and psychosocial support (MHPSS) interventions for children affected by armed conflict in LMICs, since 2016. Such an update may be useful in determining where the current focus of interventions lies and whether there are changes in types of interventions that are commonly implemented. Methods . The main medical, psychological and social sciences databases (PubMed, PsycINFO, Medline) were searched to identify interventions aimed at improving or treating mental health problems in conflict-affected children in LMICs. For the period 2016-2022, a total of 1243 records were identified. Twenty-three articles met the inclusion criteria. A bio-ecological lens was used to organize the interventions and the presentation of findings. Results . Seventeen forms of MHPSS interventions with a wide range of treatment modalities were identified in this review. The reviewed articles focused mainly on family-based interventions. Very few studies empirically evaluated community-level interventions. Conclusion . Current focus of interventions is family-based; the addition of caregiver wellbeing and parenting skills components had the potential to enhance the effects of interventions designed to improve children's mental health. Future trials for MHPSS interventions need to give more attention to community-level interventions. Community-level supports such as person-to-person support, solidarity groups, and dialogue groups stand to reach large numbers of children and families.
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Affiliation(s)
- Natnael Terefe Arega
- PhD in Applied Developmental Psychology, Institute of Education and Behavioral Sciences, Ambo University, Ambo, Ethiopia
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10
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Schmitt S, Robjant K, Elbert T, Carleial S, Hoeffler A, Chibashimba A, Hinkel H, Koebach A. Breaking the cycles of violence with narrative exposure: Development and feasibility of NETfacts, a community-based intervention for populations living under continuous threat. PLoS One 2022; 17:e0275421. [PMID: 36534649 PMCID: PMC9762574 DOI: 10.1371/journal.pone.0275421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 08/10/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Interpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat. METHOD The NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment. RESULTS Implementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms. CONCLUSION NETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.
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Affiliation(s)
- Sabine Schmitt
- Department of Clinical and Neuropsychology, University of Konstanz, Konstanz, Germany
- Non-Governmental Organization Vivo International e.V., Konstanz, Germany
| | - Katy Robjant
- Department of Clinical and Neuropsychology, University of Konstanz, Konstanz, Germany
- Non-Governmental Organization Vivo International e.V., Konstanz, Germany
| | - Thomas Elbert
- Department of Clinical and Neuropsychology, University of Konstanz, Konstanz, Germany
- Non-Governmental Organization Vivo International e.V., Konstanz, Germany
| | - Samuel Carleial
- Department of Clinical and Neuropsychology, University of Konstanz, Konstanz, Germany
| | - Anke Hoeffler
- Department of Politics and Public Administration, University of Konstanz, Konstanz, Germany
| | - Amani Chibashimba
- Non-Governmental Organization Vivo International e.V., Konstanz, Germany
| | | | - Anke Koebach
- Department of Clinical and Neuropsychology, University of Konstanz, Konstanz, Germany
- Non-Governmental Organization Vivo International e.V., Konstanz, Germany
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11
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Dumke L, Haer R, Zawadka A, Salmen C, Hecker T. The role of violence perpetration in driving externalizing problems and offending behavior among youth from eastern Democratic Republic of Congo. J Trauma Stress 2022; 35:1696-1708. [PMID: 36047455 DOI: 10.1002/jts.22871] [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] [Received: 03/01/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 12/24/2022]
Abstract
Youth in conflict-affected regions are exposed to a multitude of traumatic events. These individuals often witness violence; experience it firsthand; and, in some cases, become perpetrators. The interplay of events shapes systematic trauma histories that may have unique implications for youths' mental health. In a cross-sectional study conducted in eastern Democratic Republic of Congo (DRC), we interviewed 295 war-affected youth (63.4% boys, Mage = 16.70 years), including former child soldiers (n = 171), regarding their traumatic experiences and mental health. Using latent class analysis, we identified four common trauma history classes categorized by (a) low exposure, (b) medium exposure, (c) high exposure, and (d) high exposure/perpetration. Across the sample, gradual increases in trauma load corresponded with increased vulnerability to posttraumatic stress disorder (PTSD) symptoms, ηp 2 = .36, and internalizing problems, ηp 2 = .12; however, only youth from the high exposure/perpetration class differed significantly from other youth in their levels of externalizing problems, ηp 2 = .13, and offending behaviors, ηp 2 = .17. A longer time in armed groups was related to a higher risk of both experiencing and perpetrating violence. The results indicate that it is not child soldier status, per se, but the perpetration of violence that reinforces a cycle of violence in conflict-affected societies by contributing to increased externalizing problems and offending behaviors. In conflict regions, integrated approaches are needed to address both trauma and externalizing problems of war-affected youth.
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Affiliation(s)
- Lars Dumke
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Roos Haer
- Institute of Political Science, University of Leiden, Leiden, Netherlands
| | - Annika Zawadka
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | | | - Tobias Hecker
- Department of Psychology, Bielefeld University, Bielefeld, Germany
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12
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Serfioti D, Murphy D, Greenberg N, Williamson V. Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review. BMJ Mil Health 2022:e002155. [PMID: 36442888 DOI: 10.1136/military-2022-002155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood. METHODS This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates. RESULTS 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger. CONCLUSIONS The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.
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Affiliation(s)
- Danai Serfioti
- University of Derby, Derby, UK
- KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London, UK
- Nottingham Trent University, Nottingham, UK
| | | | - N Greenberg
- Academic Department for Military Mental Health, King's College London, London, UK
| | - V Williamson
- KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London, UK
- University of Oxford, Oxford, UK
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13
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Robjant K, Schmitt S, Carleial S, Elbert T, Abreu L, Chibashimba A, Hinkel H, Hoeffler A, Rukundo Zeller AC, Rockstroh B, Koebach A. NETfacts: An integrated intervention at the individual and collective level to treat communities affected by organized violence. Proc Natl Acad Sci U S A 2022; 119:e2204698119. [PMID: 36306329 PMCID: PMC9636916 DOI: 10.1073/pnas.2204698119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
War and crises affect mental health, social attitudes, and cultural norms, which can exacerbate the state of long-term insecurity. With decades of armed conflict, the Democratic Republic of Congo is one example, and violence has become normalized in civilian settings. In this study, we tested the effectiveness of the NETfacts health system, an integrated model of evidence-based individual trauma treatment (Narrative Exposure Therapy [NET]) and a trauma-informed community-based intervention (NETfacts). Alongside changes in mental health outcomes (posttraumatic stress disorder, depression, social disapproval, and shame) we also investigated change in attitudes, including rape myth acceptance, stigmatization of survivors of sexual violence, and skepticism about the reintegration of former combatants. To test whether the additional community intervention is superior to individual NET alone, we implemented a randomized controlled design with six villages and interviewed a sample of 1,066 community members. Our results demonstrate that the NETfacts health system in comparison with NET alone more effectively reduced rape myth acceptance and with it ongoing victimization and perpetration. Community members of the NETfacts group also presented with less stigmatizing attitudes against survivors of sexual violence. Skepticism about the reintegration of former combatants declined in both groups. NETfacts appears to have increased motivation to engage in individual treatment. Synergizing the healing effects of individual and collective trauma exposure, the NETfacts health system appears to be an effective and scalable approach to correct degrading or ignominious norms and restore functioning and mental health in postconflict communities.
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Affiliation(s)
- Katy Robjant
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
| | - Sabine Schmitt
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
| | - Samuel Carleial
- Department of Psychology, Clinical and Neuropsychology, University of Konstanz, 78457 Konstanz, Germany
| | - Thomas Elbert
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
- Department of Psychology, Clinical and Neuropsychology, University of Konstanz, 78457 Konstanz, Germany
| | - Liliana Abreu
- Department of Politics and Administration, Development, University of Konstanz, 78457 Konstanz, Germany
| | - Amani Chibashimba
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
| | | | - Anke Hoeffler
- Department of Politics and Administration, Development, University of Konstanz, 78457 Konstanz, Germany
| | - Anja C. Rukundo Zeller
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
- Department of Psychology, Clinical and Neuropsychology, University of Konstanz, 78457 Konstanz, Germany
| | - Brigitte Rockstroh
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
| | - Anke Koebach
- Nongovernment organization vivo international e.V., 78430 Konstanz, Germany
- Department of Psychology, Clinical and Neuropsychology, University of Konstanz, 78457 Konstanz, Germany
- Department of Politics and Administration, Development, University of Konstanz, 78457 Konstanz, Germany
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14
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Lange BCL, Nelson A, Lang JM, Stirman SW. Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review. Implement Sci Commun 2022; 3:108. [PMID: 36209138 PMCID: PMC9548160 DOI: 10.1186/s43058-022-00348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/16/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted. METHODS Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question. RESULTS Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention. CONCLUSIONS Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment. TRIAL REGISTRATION The protocol for this systematic review was published with PROSPERO (CRD42020149536).
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Affiliation(s)
- Brittany C. L. Lange
- grid.475976.eChild Health and Development Institute of Connecticut, Inc., Farmington, USA
| | - Ashley Nelson
- grid.475976.eChild Health and Development Institute of Connecticut, Inc., Farmington, USA
| | - Jason M. Lang
- grid.475976.eChild Health and Development Institute of Connecticut, Inc., Farmington, USA ,grid.208078.50000000419370394Department of Psychiatry, UCONN Health, Farmington, USA ,grid.47100.320000000419368710Child Study Center, Yale School of Medicine, New Haven, USA
| | - Shannon Wiltsey Stirman
- grid.429666.90000 0004 0374 5948National Center for PTSD, Washington, D.C., USA ,grid.168010.e0000000419368956Stanford University, Stanford, USA
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15
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Al-Tamimi SAGA, Leavey G. Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2022; 15:441-450. [PMID: 35600528 PMCID: PMC9120315 DOI: 10.1007/s40653-021-00373-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 06/15/2023]
Abstract
Where low- and middle-income countries have limited economic resources to provide individualized mental health services to people exposed to conflict, community-based interventions may be more appropriate. We aimed to evaluate community level interventions for improving mental health outcomes in Low- and Middle-income countries (LMIC). A realist review of community-based interventions (CBIs) to improve mental health for people in LMIC following conflict. Five databases (Cochrane, PubMed, PsychINFO, Medline, and CINAHL) and a manual search of individual papers. We found 1318 articles, of which 29 were selected. Out of the 29 primary articles, 19 showed successful results, 4 showed mixed results, 1 showed inconclusive results, and 1 showed unsuccessful results. After analyzing the results, we found 3 mechanisms that may influence the effectiveness of these CBIs: the use of lay community members as intervention deliverers, the application of transdiagnostic approaches, and customized outcome assessment tools. Community-based approaches to improve mental health in LMICs are rare and evidence for their effectiveness is limited. Interventions that have a wide scope, train lay mental health workers, and use contextually adapted outcome assessment tools show promise.
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16
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Psychological Interventions for Survivors of Intimate Partner Violence in Humanitarian Settings: An Overview of the Evidence and Implementation Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052916. [PMID: 35270610 PMCID: PMC8910593 DOI: 10.3390/ijerph19052916] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023]
Abstract
This paper provides an analytical overview of different types of psychological interventions that have demonstrated efficacy in low-income and/or humanitarian settings and points to special considerations that may be needed if used with women who have been subjected to gender-based violence (GBV). This paper reviews diverse therapeutic modalities and contrasts them across several domains, including their conventional use and principles; their documented use and efficacy in humanitarian settings; any special considerations or modifications necessary for GBV-affected clients; and any additional resources or implementation concerns when working in low-income contexts. By examining the evidence base of multiple interventions, we hope to provide clinicians and GBV-prevention advocates with an overview of tools/approaches to provide survivor-centered, trauma-informed responses to GBV survivors. This analysis responds to the growing recognition that gender-based violence, in particular intimate partner violence and sexual violence, is strongly associated with mental health problems, including anxiety, depression, and post-traumatic stress. This is likely to be exacerbated in humanitarian contexts, where people often experience multiple and intersecting traumatic experiences. The need for mental health services in these settings is increasingly recognized, and a growing number of psychological interventions have been shown to be effective when delivered by lay providers and in humanitarian settings.
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17
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Mabrouk A, Mbithi G, Chongwo E, Too E, Sarki A, Namuguzi M, Atukwatse J, Ssewanyana D, Abubakar A. Mental health interventions for adolescents in sub-Saharan Africa: A scoping review. Front Psychiatry 2022; 13:937723. [PMID: 36061286 PMCID: PMC9429610 DOI: 10.3389/fpsyt.2022.937723] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Globally, adolescents are vulnerable to mental health problems, particularly those from sub-Saharan Africa (SSA) due to impoverished living conditions and a higher prevalence of chronic conditions such as HIV/AIDS in the region. The COVID-19 pandemic has further exacerbated this risk. This calls for an urgent need for evidence-based adolescent mental health interventions to reduce the risk and burden of mental health problems in SSA. The review aims to identify and characterize existing adolescent mental health interventions in SSA, as well as to evaluate their implementation strategies and effectiveness. METHODS We systematically searched PubMed, African Index Medicus, PsycINFO, Web of Science, and CINAHL databases for relevant articles. Furthermore, we searched gray literature databases, including Think Tank search, open gray, NGO search engine, and IGO search engine for additional relevant articles. The scoping review was conducted to identify original research articles on mental health interventions among adolescents in sub-Saharan Africa published from database inception to 31 December 2021. We carried out a narrative synthesis to report our findings. RESULTS Our literature search generated 4,750 studies, of which 1,141 were duplicates, 3,545 were excluded after screening, and 64 articles met the inclusion criteria. The 64 studies describe a total of 57 unique mental health interventions comprising 40,072 adolescents. The nature of these interventions was diverse, encompassing various implementation strategies such as economic-based, family strengthening, psychoeducation, interpersonal psychotherapy, Cognitive Behavioral Therapy, and resilience training, among others. Most of the interventions were selective interventions that targeted adolescents at high risk of developing mental health problems including adolescents living with HIV, war-affected adolescents, orphans, adolescents from poorer backgrounds, and survivors of sexual violence. Half of the interventions were delivered by lay persons. Sixty-two of the eligible studies examined the effectiveness of the mental health interventions, of which 55 of them reported a positive significant impact on various mental health outcomes. CONCLUSIONS The review findings show that there exist several diverse interventions that promote mental health among adolescents in sub-Saharan Africa. These interventions can be implemented in diverse settings including schools, communities, health facilities, and camps, and can be delivered by lay persons.
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Affiliation(s)
- Adam Mabrouk
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Gideon Mbithi
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Esther Chongwo
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Ezra Too
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Ahmed Sarki
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda.,Family and Youth Health Initiative (FAYOHI), Dutse, Jigawa State, Nigeria
| | - Mary Namuguzi
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Joseph Atukwatse
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Derrick Ssewanyana
- Alliance for Human Development, Lunenfeld Tanenbaum Research Institute, Toronto, ON, Canada
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya.,Neurosciences Group, KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
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18
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Fan Y, Shi Y, Zhang J, Sun D, Wang X, Fu G, Mo D, Wen J, Xiao X, Kong L. The effects of narrative exposure therapy on COVID-19 patients with post-traumatic stress symptoms: A randomized controlled trial. J Affect Disord 2021; 293:141-147. [PMID: 34186232 PMCID: PMC8234566 DOI: 10.1016/j.jad.2021.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/11/2021] [Accepted: 06/13/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND With the global attack of Coronavirus Disease 2019 (COVID-19), cases with Post-traumatic Stress Disorder (PTSD) have been increasing steadily, which seriously affects the quality of life of patients and as such, seeking effective treatments is an urgent matter. Narrative Exposure Therapy (NET) is a typical cognitive behavioral therapy targeting trauma-related psychological disorders and may be an effective intervention. METHODS A total of 111 COVID-19 patients near the discharge stage with positive screening results for posttraumatic stress symptoms (PTSS) were randomly assigned (1:1) to either the study group or the control group. The study group received NET and personalized psychological intervention, while the control group only received personalized psychological intervention. PTSS, depression, anxiety and sleep quality were measured pre- and post-intervention to evaluate the effect of NET. This trial was registered with the International Standard Randomized Clinical Trial Registry (No. ChiCTR2000039369). RESULTS NET participants showed a significantly greater PTSS reduction in comparison with the control group after the intervention. Improvement in sleep quality, anxiety and depression after the intervention were pronounced but not significantly different between the two treatment groups. LIMITATIONS The assessors weren't blinded for the convenience of measurement and protection of participants' psychological security. CONCLUSIONS NET likely had a positive impact on PTSS of COVID-19 patients. Clinical staff should consider applying NET to improve the psychological well-being of patients who have experienced an epidemic such as COVID-19.
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Affiliation(s)
- Ying Fan
- Bachelor of Nursing, Wuhan University School of Health Sciences, Xiangzhou District People's Hospital in Hubei Province, China
| | - Yuxin Shi
- Bachelor of Nursing, Wuhan University School of Health Sciences, China
| | - Jun Zhang
- Associate Professor, Wuhan University School of Health Sciences, China.
| | - Dingwen Sun
- Associate chief physician, Vice President of Xiangzhou District People's Hospital, Xiangyang city, Hubei Province, China
| | - Xuefei Wang
- Bachelor of Nursing; Wuhan University School of Health Sciences, Xiangyang Central Hospital in Hubei Province, China
| | - Gaizhi Fu
- Associate professor of nursing, Director of psychological Outpatient Department, Xiangzhou District People's Hospital, Xiangyang city, Hubei Province, China
| | - Daorong Mo
- Associate professor of nursing; Xiangzhou District People's Hospital, Xiangyang city, Hubei Province, China
| | - Juan Wen
- Associate professor of nursing, Xiangzhou District People's Hospital, Xiangyang city, Hubei Province, China
| | - Xuexia Xiao
- Associate professor of nursing, Xiangyang Hospital of Traditional Chinese Medicine in Hubei Province, China
| | - Lingai Kong
- Bachelor of Public health, Wuhan University School of Health Sciences, China
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19
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Carleial S, Nätt D, Unternährer E, Elbert T, Robjant K, Wilker S, Vukojevic V, Kolassa IT, Zeller AC, Koebach A. DNA methylation changes following narrative exposure therapy in a randomized controlled trial with female former child soldiers. Sci Rep 2021; 11:18493. [PMID: 34531495 PMCID: PMC8445994 DOI: 10.1038/s41598-021-98067-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/02/2021] [Indexed: 02/08/2023] Open
Abstract
The aftermath of traumatization lives on in the neural and epigenetic traces creating a momentum of affliction in the psychological and social realm. Can psychotherapy reorganise these memories through changes in DNA methylation signatures? Using a randomised controlled parallel group design, we examined methylome-wide changes in saliva samples of 84 female former child soldiers from Eastern DR Congo before and six months after Narrative Exposure Therapy. Treatment predicted differentially methylated positions (DMPs) related to ALCAM, RIPOR2, AFAP1 and MOCOS. In addition, treatment associations overlapped at gene level with baseline clinical and social outcomes. Treatment related DMPs are involved in memory formation-the key agent in trauma focused treatments-and enriched for molecular pathways commonly affected by trauma related disorders. Results were partially replicated in an independent sample of 53 female former child soldiers from Northern Uganda. Our results suggest a molecular impact of psychological treatment in women with war-related childhood trauma.Trial registration: Addressing Heightened Levels of Aggression in Traumatized Offenders With Psychotherapeutic Means (ClinicalTrials.gov Identifier: NCT02992561, 14/12/2016).
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Affiliation(s)
- Samuel Carleial
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany
| | - Daniel Nätt
- grid.5640.70000 0001 2162 9922Division of Neurobiology, Department of Biomedical and Clinical Sciences, University of Linköping, Building 463, Room 12.023, Linköping, Sweden
| | - Eva Unternährer
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,grid.6612.30000 0004 1937 0642Child- and Adolescent Research Department, Psychiatric University Hospitals Basel (UPK), University of Basel, Basel, Switzerland
| | - Thomas Elbert
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Katy Robjant
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Sarah Wilker
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.7491.b0000 0001 0944 9128Department of Psychology and Sports Science, University of Bielefeld, 33501 Bielefeld, Germany
| | - Vanja Vukojevic
- grid.6612.30000 0004 1937 0642Psychiatric University Clinics, Transfaculty Research Platform, University of Basel, Wilhelm Klein-Strasse 27, CH-4012 Basel, Switzerland
| | - Iris-Tatjana Kolassa
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.6582.90000 0004 1936 9748Department of Clinical and Biological Psychology, Institute of Psychology & Education, University of Ulm, Ulm University, Ulm, Germany
| | - Anja C. Zeller
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Anke Koebach
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
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20
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Abreu L, Koebach A, Díaz O, Carleial S, Hoeffler A, Stojetz W, Freudenreich H, Justino P, Brück T. Life With Corona: Increased Gender Differences in Aggression and Depression Symptoms Due to the COVID-19 Pandemic Burden in Germany. Front Psychol 2021; 12:689396. [PMID: 34385959 PMCID: PMC8353131 DOI: 10.3389/fpsyg.2021.689396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/11/2021] [Indexed: 12/30/2022] Open
Abstract
Gender differences (GD) in mental health have come under renewed scrutiny during the COVID-19 pandemic. While rapidly emerging evidence indicates a deterioration of mental health in general, it remains unknown whether the pandemic will have an impact on GD in mental health. To this end, we investigate the association of the pandemic and its countermeasures affecting everyday life, labor, and households with changes in GD in aggression, anxiety, depression, and the somatic symptom burden. We analyze cross-sectional data from 10,979 individuals who live in Germany and who responded to the online survey "Life with Corona" between October 1, 2020 and February 28, 2021. We estimate interaction effects from generalized linear models. The analyses reveal no pre-existing GD in aggression but exposure to COVID-19 and COVID-19 countermeasures is associated with sharper increases in aggression in men than in women. GD in anxiety decreased among participants with children in the household (with men becoming more anxious). We also observe pre-existing and increasing GD with regards to the severity of depression, with women presenting a larger increase in symptoms during the hard lockdown or with increasing stringency. In contrast to anxiety, GD in depression increased among participants who lived without children (women > men), but decreased for individuals who lived with children; here, men converged to the levels of depression presented by women. Finally, GD in somatic symptoms decreased during the hard lockdown (but not with higher stringency), with men showing a sharper increase in symptoms, especially when they lived with children or alone. Taken together, the findings indicate an increase in GD in mental health as the pandemic unfolded in Germany, with rising female vulnerability to depression and increasing male aggression. The combination of these two trends further suggests a worrying mental health situation for singles and families. Our results have important policy implications for the German health system and public health policy. This public health challenge requires addressing the rising burden of pandemic-related mental health challenges and the distribution of this burden between women and men, within families and for individuals who live alone.
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Affiliation(s)
- Liliana Abreu
- Development Research Group, Department of Politics and Public Administration, University of Konstanz, Konstanz, Germany
| | - Anke Koebach
- Development Research Group, Department of Politics and Public Administration, University of Konstanz, Konstanz, Germany
- Clinical Neuropsychology, Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Oscar Díaz
- ISDC – International Security and Development Center, Berlin, Germany
| | - Samuel Carleial
- Clinical Neuropsychology, Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Anke Hoeffler
- Development Research Group, Department of Politics and Public Administration, University of Konstanz, Konstanz, Germany
| | - Wolfgang Stojetz
- ISDC – International Security and Development Center, Berlin, Germany
| | - Hanna Freudenreich
- Leibniz Institute of Vegetable and Ornamental Crops, Großbeeren, Germany
| | - Patricia Justino
- World Institute for Development Economic Research, United Nations University, Helsinki, Finland
| | - Tilman Brück
- ISDC – International Security and Development Center, Berlin, Germany
- Leibniz Institute of Vegetable and Ornamental Crops, Großbeeren, Germany
- Natural Resources Institute, University of Greenwich, Chatham Maritime, United Kingdom
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21
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Ennis N, Sijercic I, Monson CM. Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review. Clin Psychol Rev 2021; 88:102049. [PMID: 34139653 DOI: 10.1016/j.cpr.2021.102049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/18/2021] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
Some individuals with posttraumatic stress disorder (PTSD) are at elevated risk of reexposure to trauma during treatment. Trauma-focused cognitive-behavioral therapies (CBT) are recommended as first-line PTSD treatments but have generally been tested with exclusion criteria related to risk for trauma exposure. Therefore, there is limited knowledge on how to best treat individuals with PTSD under ongoing threat of reexposure. This paper systematically reviewed the effectiveness of CBTs for PTSD in individuals with ongoing threat of reexposure. Literature searches yielded 21 studies across samples at ongoing risk of war-related or community violence (n = 14), domestic violence (n = 5), and work-related traumatic events (n = 2). Medium to large effects were found from pre to posttreatment and compared with waitlist controls. There were mixed findings for domestic violence samples on long-term outcomes. Treatment adaptations focused on establishing relative safety and differentiating between realistic threat and generalized fear responses. Few studies examined whether ongoing threat influenced treatment outcomes or whether treatments were associated with adverse events. Thus, although the evidence is promising, conclusions cannot be firmly drawn about whether trauma-focused CBTs for PTSD are safe and effective for individuals under ongoing threat. Areas for further inquiry are outlined.
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Affiliation(s)
- Naomi Ennis
- Department of Psychology, Ryerson University, Canada; National Crime Victims Research & Treatment Center (NCVRTC), Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina.
| | - Iris Sijercic
- Department of Psychology, Ryerson University, Canada
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22
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Schmitt S, Robjant K, Koebach A. When reintegration fails: Stigmatization drives the ongoing violence of ex-combatants in Eastern Democratic Republic of the Congo. Brain Behav 2021; 11:e02156. [PMID: 33942549 PMCID: PMC8213920 DOI: 10.1002/brb3.2156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/01/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022] Open
Abstract
Reintegration of ex-combatants involves multiple challenges. In addition to the trauma-related psychological sequelae, social obstacles in the community can aggravate psychopathological aggressive tendencies and lead to the continuation of violence in civilian life. However, the association between others' negative attitudes and ex-combatants' ongoing perpetration of violence remains largely unexplored. Between September 2018 and May 2019, we assessed a representative community sample of adults in Eastern DR Congo (N = 1,058) and measured trauma exposure, perpetration, mental health problems (PTSD, depression, and appetitive aggression), perceived stigma (shame, perceived lack of social acknowledgement), experienced stigma, and skepticism toward reintegration with ex-combatants. Male ex-combatants (12%, n = 129) had more past trauma and violence perpetration than other community members and a greater number of recent conflicts (including both victimization and perpetration) within the community and with strangers/organized violence. They reported more experienced stigma, more severe PTSD symptoms but were less skeptical about reintegration. Ex-combatants' ongoing violence was predicted by an interplay of the community's skepticism toward reintegration and ex-combatants' perceived and recently experienced stigma (often attributed to the armed group history) and mental health problems, in addition to lifetime traumatization. These findings promote the need for combined interventions that address individual mental health problems including aggression and collective discriminatory attitudes and behaviors.
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Affiliation(s)
- Sabine Schmitt
- Department of PsychologyUniversity of KonstanzKonstanzGermany
- Non‐Governmental Organization Vivo InternationalKonstanzGermany
| | - Katy Robjant
- Department of PsychologyUniversity of KonstanzKonstanzGermany
- Non‐Governmental Organization Vivo InternationalKonstanzGermany
| | - Anke Koebach
- Department of PsychologyUniversity of KonstanzKonstanzGermany
- Non‐Governmental Organization Vivo InternationalKonstanzGermany
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23
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Simmons C, Meiser-Stedman R, Baily H, Beazley P. A meta-analysis of dropout from evidence-based psychological treatment for post-traumatic stress disorder (PTSD) in children and young people. Eur J Psychotraumatol 2021; 12:1947570. [PMID: 34377359 PMCID: PMC8344790 DOI: 10.1080/20008198.2021.1947570] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Despite the established evidence base of psychological interventions in treating PTSD in children and young people, concern that these trauma-focused treatments may 'retraumatise' patients or exacerbate symptoms and cause dropout has been identified as a barrier to their implementation. Dropout from treatment is indicative of its relative acceptability in this population. OBJECTIVE Estimate the prevalence of dropout in children and young people receiving a psychological therapy for PTSD as part of a randomized controlled trial (RCT). METHODS A systematic search of the literature was conducted to identify RCTs of evidence-based treatment of PTSD in children and young people. Proportion meta-analyses estimated the prevalence of dropout. Odds ratios compared the relative likelihood of dropout between different treatments and controls. Subgroup analysis assessed the impact of potential moderating variables. RESULTS Forty RCTs were identified. Dropout from all treatment or active control arms was estimated to be 11.7%, 95% CI [9.0, 14.6]. Dropout from evidence-based treatment (TFCBTs and EMDR) was 11.2%, 95% CI [8.2, 14.6]. Dropout from non-trauma focused treatments or controls was 12.8%, 95% CI [7.6, 19.1]. There was no significant difference in the odds of dropout when comparing different modalities. Group rather than individual delivery, and lay versus professional delivery, were associated with less dropout. CONCLUSIONS Evidence-based treatments for children and young people with PTSD do not result in higher prevalence of dropout than non-trauma focused treatment or waiting list conditions. Trauma-focused therapies appear to be well tolerated in children and young people.
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Affiliation(s)
- Caroline Simmons
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK.,Child and Adolescent Mental Health Services Eating Disorder Pathway, Cambridgeshire and Peterborough Mental Health Foundation Trust (CPFT)
| | - Richard Meiser-Stedman
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Hannah Baily
- Child and Adolescent Mental Health Services Eating Disorder Pathway, Cambridgeshire and Peterborough Mental Health Foundation Trust (CPFT)
| | - Peter Beazley
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
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24
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Koebach A, Robjant K. NETfacts: a community intervention integrating trauma treatment at the individual and collective level. Eur J Psychotraumatol 2021; 12:1992962. [PMID: 34868485 PMCID: PMC8635579 DOI: 10.1080/20008198.2021.1992962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this article is to present a research-based rationale for NETfacts, a newly developed integrated approach at the individual and the community level in order to mitigate the mental and social sequelae of war and crisis. To this end, we provide a selective review of relevant literature from neuroscience, clinical psychology, and social science. In psychotraumatology, individual avoidance describes the effort to prevent exposure to trauma reminders. Among patients with post-traumatic stress disorder (PTSD), this becomes pathological, exacerbating distress and preventing recovery. This silence resonates in traumatized communities and consequently taboo builds - ultimately to the advantage of the perpetrators. The resulting collective avoidance leads to a fragmented collective memory about trauma or human rights violations in the community so that a shared account of the group's history becomes impossible. The deficient collective memory promotes ambiguous truths and anxiety, enabling a reactive construction of safety based on selective information that leads to an endorsement of extreme opinions. Ongoing insecurity, violence and crime lead to increasing anxiety and fear. The self-interest of the perpetrators and the abnormal behaviour of survivors leads to an escalation in stigma and social exclusion resulting in the prevention or limitation of community exposure to traumatic material, i.e., to reduce tension and protect the construction of safety. The exposure to and recognition of traumatic facts subject to avoidance is key to a coherent collective memory and sense of communion, and to prevent further cycles of violence. The NETfacts health system combines individual and community-based intervention to treat the structure of memory at both the individual and collective levels. Abbreviations: NET: narrative exposure therapy; FORNET: narrative exposure therapy for forensic offender rehabilitation; NETfacts: facts derived from narrative exposure therapy.
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Affiliation(s)
- Anke Koebach
- University of Konstanz, Department of Psychology; and Department of Politics and Public Administation, Konstanz, Germany.,NGO vivo international, Konstanz, Germany
| | - Katy Robjant
- University of Konstanz, Department of Psychology; and Department of Politics and Public Administation, Konstanz, Germany
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25
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Schmitt S, Robjant K, Elbert T, Koebach A. To add insult to injury: Stigmatization reinforces the trauma of rape survivors - Findings from the DR Congo. SSM Popul Health 2020; 13:100719. [PMID: 33365381 PMCID: PMC7749416 DOI: 10.1016/j.ssmph.2020.100719] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 12/09/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Survivors of sexual violence are frequently condemned and socially excluded. Myths about rape may translate into stigmatization, diminish disclosure, prevent help-seeking from support structures and worsen mental health. Areas of conflict or organized violence remain the evident hotspots of sexual victimization. However, little is known about prevalence and predictors of rape myths in these settings or their association with survivors' disclosure, stigmatization and psychopathology. METHOD Between September 2018 and May 2019, we assessed in a representative sample of 1066 individuals from six communities in Eastern DRC traumatic exposure, sexual perpetration, threats to social integrity, perceived stigmatization (perceived lack of social acknowledgement, shame), stigmatizing attitudes towards survivors (negative attitudes and willingness to provide support, rape myths acceptance), and mental illness (PTSD, depression). RESULTS Survivors of sexual violence (33%, n = 184 of women, 16%, n = 84 of men) reported more traumatic exposure, threats to social integrity, shame, perceived lack of social acknowledgement, PTSD symptoms and depression. Their social environment affirmed various stigmatizing attitudes (5-89% affirmations). Beliefs in rape myths were predicted by its average acceptance in the community, education, and witness of others' sexual victimization. The rates of cases whose history of sexual victimization was socially disclosed were higher in communities and among survivors with low rape myths acceptance and disclosure showed associations with perceived stigmatization. Rape myths acceptance among individuals without a history of sexual victimization was associated with survivors' recently experienced threats to social integrity which predicted their stigma perceptions and mental illness. CONCLUSION Rape myths acceptance in the community is associated with stigma and trauma-related mental illness of sexual violence survivors. This adds up to the psychic burden of trauma.
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Affiliation(s)
- Sabine Schmitt
- Department of Psychology, University of Konstanz, Germany.,vivo international e.V., Konstanz, Germany
| | - Katy Robjant
- Department of Psychology, University of Konstanz, Germany.,vivo international e.V., Konstanz, Germany
| | - Thomas Elbert
- Department of Psychology, University of Konstanz, Germany.,vivo international e.V., Konstanz, Germany
| | - Anke Koebach
- Department of Psychology, University of Konstanz, Germany.,vivo international e.V., Konstanz, Germany
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26
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Siehl S, Robjant K, Crombach A. Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators. Psychother Res 2020; 31:695-710. [PMID: 33205713 DOI: 10.1080/10503307.2020.1847345] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET).Method: Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression.Results: In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.Conclusions: NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.
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Affiliation(s)
- Sebastian Siehl
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany.,Graduate School of Economic and Social Sciences, University of Mannheim, Mannheim, Germany.,Non-Governmental Organization vivo international e.V., Konstanz, Germany
| | - Katy Robjant
- Non-Governmental Organization vivo international e.V., Konstanz, Germany
| | - Anselm Crombach
- Non-Governmental Organization vivo international e.V., Konstanz, Germany.,Department of Psychology at the University of Konstanz, Experimental Clinical Psychology with a Teaching Focus on Clinical Psychology of Childhood and Adolescence.,Non-Governmental Organization Psychologues sans Frontières, Burundi, Bujumbura, Burundi.,Department of Clinical Psychology, Université Lumière de Bujumbura, Bujumbura, Burundi
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27
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Zeller AC, Conrad D, Schneider A, Behnke A, Pfeiffer A, Blum GF, Wilker S, Elbert T, Kolassa I. A combination of combat experience, early abduction, and severe traumatization fuels appetitive aggression and violence among abductees of rebel war in Northern Uganda. Aggress Behav 2020; 46:465-475. [PMID: 32643160 DOI: 10.1002/ab.21914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022]
Abstract
Individuals who perpetrate violence may likely perceive violence as appealing and infliction of violence to derive pleasure is termed as appetitive aggression. Individuals who were abducted as children into an armed group often experience a higher number of traumatic event types, that is traumatic load and are usually socialized in a violence-endorsing environment. This study aims to investigate the interaction between age at initial abduction with that of traumatic load, and their influence on appetitive aggression along with perpetration of violent acts by former members of an armed rebel group of both sexes. Semi-structured interviews were conducted among a target group of formerly abducted rebel-war survivors (including participants with and without combat experience) from Northern Uganda. Participants included 596 women and 570 men with N = 1,166 (Mage = 32.58, SDage = 9.76, range: 18-80 years). We conducted robust linear regression models to investigate the influence of age at initial abduction, traumatic load, combat experience, and biological sex on appetitive aggression as well as their perpetrated violent acts. Our study shows, appetitive aggression and the number of perpetrated violent acts were specifically increased in individuals who were abducted young, experienced several traumatic events in their lifetime, and with previous combat experience. For perpetrated violence men showed increased levels whereas for appetitive aggression the association was independent of biological sex. Therefore, early abducted individuals with a higher traumatic load, who have combat experience, need to be given special intervention to prevent any further violence.
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Affiliation(s)
- Anja C. Zeller
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- vivo international e.V. Konstanz Germany
| | - Daniela Conrad
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Anna Schneider
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Alexander Behnke
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | | | - Gerrit F. Blum
- Institute of Psychology and Education Ulm University Ulm Germany
| | - Sarah Wilker
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Thomas Elbert
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- vivo international e.V. Konstanz Germany
| | - Iris‐Tatjana Kolassa
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
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28
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Robjant K, Schmitt S, Chibashimba A, Carleial S, Elbert T, Koebach A. Trauma, Aggression, and Post Conflict Perpetration of Community Violence in Female Former Child Soldiers-A Study in Eastern DR Congo. Front Psychiatry 2020; 11:533357. [PMID: 33132929 PMCID: PMC7574907 DOI: 10.3389/fpsyt.2020.533357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/13/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Former combatants are exposed to multiple traumatic stressors during conflict situations and usually participate in perpetration of violence. Ongoing perpetration of violence in post conflict areas, linked to mental health problems and appetitive aggression, destabilises peace keeping efforts. The aim of this study is to investigate lifetime exposure to violence and the relationship between this exposure and mental health and current violent behaviour in a sample of female former child soldiers with a history of perpetration of violence in Eastern DR Congo. METHODS 98 female former child soldiers who had been abducted and forcibly recruited during the M23 insurgency (2012-2014) were assessed for lifetime exposure to trauma including perpetration of violence, clinical outcomes (PTSD and appetitive aggression), and current violent behaviour. RESULTS Female former child soldiers had been exposed to extremely high levels of trauma including perpetration of violence and presented with high levels of mental health problems. Linear regression models showed that current violent behaviour was predicted by both PTSD and appetitive aggression. CONCLUSIONS Trauma exposure predicts ongoing perpetration of violence post conflict via the resulting mental health problems. The findings imply that if PTSD and appetitive aggression symptoms are successfully treated, ongoing violent behaviour in the community post conflict will also decrease.
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Affiliation(s)
- Katy Robjant
- Department of Psychology, University of Konstanz, Konstanz, Germany
- vivo international e.V., Konstanz, Germany
| | - Sabine Schmitt
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Amani Chibashimba
- Department of Psychology, University of Konstanz, Konstanz, Germany
- vivo international e.V., Konstanz, Germany
| | - Samuel Carleial
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | - Thomas Elbert
- Department of Psychology, University of Konstanz, Konstanz, Germany
- vivo international e.V., Konstanz, Germany
| | - Anke Koebach
- Department of Psychology, University of Konstanz, Konstanz, Germany
- vivo international e.V., Konstanz, Germany
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29
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Aguirre-Dávila E. Identity Development of Female Adolescents Belonging to Illegal Armed Groups in Colombia. UNIVERSITAS PSYCHOLOGICA 2020. [DOI: 10.11144/javeriana.upsy19.idfa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The article presents the results of the research on the identity of the female adolescent soldiers who, at the time of the study, were in the Colombian government’s rehabilitation programs. The life history interviews methodology was used, 20 adolescents and young women participated, with an average age of 18.9 years. When they entered the illegal armed groups, they had an average of 12.5 years and remained in the groups an average of 4.4 years. From the narratives of the participants, it was discovered that the development of their identity went through three key moments: the first is the product of family interactions, and it is expressed in the tension of assuming the traditional role of women and the decision to join to illegal groups; the second is the result of their permanence in the groups and is defined by the strong masculine culture of war; and the third moment is a consequence of the transit of these women through of the governmental rehabilitation programs, and it is characterized by assuming control of their lives from the exercise of citizenship.
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30
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Fazel M, Stratford HJ, Rowsell E, Chan C, Griffiths H, Robjant K. Five Applications of Narrative Exposure Therapy for Children and Adolescents Presenting With Post-Traumatic Stress Disorders. Front Psychiatry 2020; 11:19. [PMID: 32140112 PMCID: PMC7043101 DOI: 10.3389/fpsyt.2020.00019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/09/2020] [Indexed: 12/21/2022] Open
Abstract
Narrative exposure therapy (NET) is an individual therapeutic approach that has an emerging evidence base for children. It was initially trialed with refugee and asylum seeking populations, in low, middle and high-income settings, utilizing either lay or professional therapists. The results of treatment trials for PTSD in refugee children with NET (or the child "KIDNET" adaptation) demonstrates how this is an effective intervention, is scalable and culturally dexterous. This paper describes, in five cases from clinical practice settings, the applicability of NET into broader, routine practice. The cases outlined describe the use of NET with adolescents with: autism spectrum disorders, psychotic symptoms, and intellectual disabilities; histories of forced abduction into child soldiering; complex physical health problems needing multiple interventions; and victims of childhood sexual abuse. The cases are discussed with regards to how the NET lifeline facilitated engagement in treatment, practical adaptations for those with intellectual disabilities and how NET, with its relatively short training for health professionals, can be modified to different contexts and presentations. The importance of improving access to care is discussed to ensure that young people are supported with their most complex and disruptive memories.
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Affiliation(s)
- Mina Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom.,Children's Psychological Medicine, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Hannah J Stratford
- Highfield Adolescent Unit, Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Eleanor Rowsell
- The Sue Nicholls Centre, Oxford Health NHS Foundation Trust, Aylesbury, United Kingdom
| | - Carmen Chan
- Horizon (Supporting Young People and Families Affected by Sexual Harm), Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Helen Griffiths
- Children's Psychological Medicine, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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