Cognitive Processing Therapy for the Treatment of Acute Stress Disorder Following Sexual Assault: A Randomised Effectiveness Study

A Systematic Review of Evidence-Based Treatments for Adolescent and Adult Sexual Assault Victims

BACKGROUND

Sexual assault (SA) is a serious crime that is a prevalent mental and public health problem.

AIMS

Addressing the needs of SA victims and providing appropriate treatment are essential to reduce potential adverse short- and long-term outcomes.

METHODS

Our team undertook an extensive systematic literature review (published between January 2006 and July 2021) to provide evidence-based mental health intervention recommendations for adolescent and adult victims of SA. Where SA-specific research was limited, the literature and clinical practice guidelines on treatments for trauma-induced post-traumatic stress disorder (PTSD) were reviewed to provide additional information to formulate recommendations.

RESULTS

Findings strongly support several primary psychotherapy treatments: cognitive behavioral therapy, cognitive processing therapy, eye movement desensitization and reprocessing, narrative exposure therapy, and prolonged exposure therapy. Complementary (aerobic exercise, art, drama, and music therapy) and pharmacological treatments were explored.

CONCLUSIONS

Mental health nurses who provide services for victims of SA can utilize this overview to guide recommendations for treatment of SA trauma and related PTSD symptoms to mitigate the short- and long-term negative impacts after a traumatic event. When victims of SA receive optimal mental health treatments, our communities benefit as victims heal and recover.

Outcomes of trauma-informed care on the psychological health of women experiencing intimate partner violence: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: Women are more likely to experience intimate partner violence (IPV) than men; 19.2%-69.0% of women have experienced IPV, and the percentage is increasing. Survivors of IPV suffer from physical, psychological, social and reproductive health problems and numerous adverse health consequences such as post-traumatic stress disorder, depression and anxiety. These are considered IPV comorbidities, especially among women. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study reviews and reinforces existing scientific knowledge regarding the application of trauma-informed care (TIC), including intervention content or type, frequency, duration of session and length. This study focused on the effects of TIC. Furthermore, it examines short-term (3 months) and medium-term (6 months) outcome effects, which are more significant for clinical practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Development of a standardized protocol to address specific needs for TIC in IPV care settings. Among multidisciplinary teams, nurses are the ideal professionals to support women experiencing IPV. They can understand their traumatic experiences better, improve their therapeutic relationships and engage patients in collaborative care.

ABSTRACT

INTRODUCTION: Post-traumatic stress disorder (PTSD), depression and anxiety are considered intimate partner violence (IPV) comorbidities, especially among women. Trauma-informed care (TIC) is the most common element of IPV care.

AIM

This study analysed the short-term (3 months) and medium-term (6 months) outcomes of TIC on PTSD, depression and anxiety in women experiencing IPV.

METHOD

The Preferred Items for Systematic Reviews and Meta-Analysis guidelines were followed, and databases were searched from their inception to September 2022.

RESULTS

Thirteen randomized controlled trials included 850 women randomly assigned to the TIC and usual care groups. Overall, TIC showed a superior psychological health-improving effect. Depression and anxiety significantly improved after treatment and at three and 6 months. No difference was observed in PTSD between the two groups at 3 and 6 months.

DISCUSSION

The growing evidence demonstrates that the lack of IPV intervention effects reported by reviews may be due to the attributes of PTSD, heterogeneity of TIC intervention design and components of TIC. Therefore, its clinical efficacy remains inconclusive.

IMPLICATIONS FOR PRACTICE

We analysed studies by stratifying intervention frequencies of once or twice a week. Regardless of the intervention frequency, length and design, PTSD decreased immediately after the TIC intervention. However, a significant difference in depression was observed after a TIC intervention of above 9 weeks.

Systematic review and data synthesis on the treatment of sexual violence victimization by an intimate partner

This study aims to conduct a systematic review and synthesis on the treatment of sexual violence victimization by an intimate partner evaluating specifically the impact of treatment on mental health outcomes of female sexual intimate partner violence (IPV) survivors. We followed the Cochrane Handbook for Systemic Reviews of Interventions guidelines for the process of conducting systematic reviews. We were unable to conduct meta-analyses due to the substantial heterogeneity of the interventions for IPV. A qualitative summary of 6 controlled studies identified no benefit to the treatment of sexual coercion, posttraumatic stress disorder, depression, or anxiety for female sexual IPV survivors. However, we are limited by a paucity of data for each outcome on this subject. In conclusion, sexual coercion is a complex issue that has adverse effects on mental health and the well-being of the survivors. More research is needed that investigates what kind of interventions are effective for this specific population.

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Cognitive Processing Therapy Versus Medication for the Treatment of Comorbid Substance Use Disorder and Post-Traumatic Stress Disorder in Egyptian patients (Randomized Clinical Trial)

"Earlier research has established that posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently coexist. Aims: Cognitive Processing Therapy was compared to Sertraline and a placebo in an RCT for treating patients with comorbid SUD and PTSD. Methods: 150 patients with SUD and PTSD were interviewed by clinicians and asked to fill out the Clinician-Administered PTSD Scale (CAPS-5), Posttraumatic Stress Disorder Checklist (PCL-5), Beck Depression Inventory (BDI-II), Timeline Follow Back Interview (TLFB), and Brief Addiction Monitor (BAM). Patients were randomly assigned to the following conditions: CPT (n=50), Sertraline (n=50), or Placebo (n=50). Pretreatment, posttreatment, six and, twelve-month follow-up assessments were conducted. Results: When compared to the sertraline group, CPT resulted in much higher reductions in CAPS scores at posttreatment assessment (d=0.93, p < .000). When compared to the control group, CPT considerably reduced PTSD symptoms (the effect size, d=1.9, p < .000). Sertraline resulted in many significant decreases in CAPS when compared to control groups (the effect size , d=1.11, p<.000). At posttreatment, SUD and depression severity were significantly reduced in both CPT and Sertraline groups. After six and twelve months of follow-up, these differences persisted. Conclusion: Comparatively to the control group, CPT and Sertraline significantly decreased PTSD, SUD, and depression."

Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault

Sexual assault and rape are common forms of sexual violence/abuse. The psychological/health consequences represent significant and ongoing harm. It seems imperative that victim/survivors receive evidence-based support within first response settings. To assess what psychosocial interventions work for victim/survivors of a recent sexual assault. Twenty-seven electronic databases were systematically searched. Narrative data synthesis was used to read across studies. Reporting format follows PRISMA checklist. Ten studies were identifed including range of interventions. The evidence is sparse and scientifically weak, common flaws are reviewed. There is some weak evidence for the impact of video and cognitive behavioural therapy (CBT) based interventions, especially trauma processing. There is a gap in the evidence base on psychosocial interventions for victim/survivors of sexual assault and higher quality research is required.

Predicting response to Cognitive Processing Therapy for PTSD: A machine-learning approach

Cognitive Processing Therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, not every client achieves optimal outcomes. Data were pooled from four randomized trials in which female interpersonal trauma survivors completed CPT (N = 179). Random forests of classification trees were used to investigate the role of both baseline (e.g., demographics, trauma history, comorbid disorders) and session PTSD and depressive symptom scores on predicting trajectory and outcome. Of particular focus was whether those on track for poor outcome (e.g., non-response, partial treatment response) could be identified early in therapy. Results demonstrated inconsistent findings for discrimination between delayed responders (no early change but full response after 12 weeks of therapy) and those who either showed a partial response to treatment or did not respond at all; level of discrimination depended on the assessment point under study and the chosen comparison group. Those defined as clear and early responders, however, could be reliably differentiated from the other groups by session 4. Although it is possible to identify clients who will recover from PTSD by the middle of the CPT protocol, further work is needed to accurately identify those who will ultimately not recover from PTSD during a course of CPT.

Trauma informed interventions: A systematic review

BACKGROUND

Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.

METHODS

We performed database searches- PubMed, Embase, CINAHL, SCOPUS and PsycINFO-to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.

RESULTS

More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).

CONCLUSIONS

There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Preventing the onset of post traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a common mental health condition that requires exposure to a traumatic event. This provides unique opportunities for prevention that are not available for other disorders. The aim of this review was to undertake a systematic review and evaluation of randomized controlled trials (RCTs) of interventions designed to prevent PTSD in adults. Searches involving Cochrane, Embase, Medline, PsycINFO, PILOTS and Pubmed databases were undertaken to identify RCTs of pre-incident preparedness and post-incident interventions until May 2019. Six pre-incident and 69 post-incident trials were identified that could be included in meta-analyses. The overall quality of the evidence was low. There was emerging evidence that some interventions may be helpful but an absence of evidence for any intervention that can be strongly recommended for universal, selected or indicated prevention before or within the first three months of a traumatic event. The strongest results were found for cognitive-behavioural therapy with a trauma focus (CBT-T) in individuals with a diagnosis of acute stress disorder which supports calls to detect and treat individuals with significant symptoms rather than providing blanket preventative interventions. Further research is required to optimally configure existing interventions with some evidence of effect and to develop novel interventions to address this major public health issue.

Early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce the severity of post-traumatic stress symptoms in recent rape victims: a randomized controlled trial

BACKGROUND

About 40% of rape victims develop post-traumatic stress disorder (PTSD) within three months after the assault. Considering the high personal and societal impact of PTSD, there is an urgent need for early (i.e. within three months after the incident) interventions to reduce post-traumatic stress in victims of rape.

OBJECTIVE

To assess the effectiveness of early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce symptoms of post-traumatic stress, feelings of guilt and shame, sexual dysfunction, and other psychological dysfunction (i.e. general psychopathology, anxiety, depression, and dissociative symptoms) in victims of rape.

METHOD

This randomized controlled trial included 57 victims of rape, who were randomly allocated to either two sessions of EMDR therapy or treatment as usual ('watchful waiting') between 14 and 28 days post-rape. Psychological symptoms were assessed at pre-treatment, post-treatment, and 8 and 12 weeks post-rape. Linear mixed models and ANCOVAs were used to analyse differences between conditions over time.

RESULTS

Within-group effect sizes of the EMDR condition (d = 0.89 to 1.57) and control condition (d = 0.79 to 1.54) were large, indicating that both conditions were effective. However, EMDR therapy was not found to be more effective than watchful waiting in reducing post-traumatic stress symptoms, general psychopathology, depression, sexual dysfunction, and feelings of guilt and shame. Although EMDR therapy was found to be more effective than watchful waiting in reducing anxiety and dissociative symptoms in the post-treatment assessment, this effect disappeared over time.

CONCLUSIONS

The findings do not support the notion that early intervention with EMDR therapy in victims of rape is more effective than watchful waiting for the reduction of psychological symptoms, including symptoms of post-traumatic stress. Further research on the effectiveness of early interventions, including watchful waiting, for this specific target group is needed.

Secondary prevention for posttraumatic stress and related symptoms among women whohave experienced a recent sexual assault: A systematic review and meta-analysis

BACKGROUND

Women who have experienced a recent sexual assault (SA) are at high risk for posttraumatic stress disorder (PTSD) and related conditions, with approximately half of women experiencing SA meeting criteria for PTSD. There are no guidelines for the prevention of PTSD and other common mental health disorders after SA. Thus, the purpose of this systematic review and meta-analysis is to synthesize research on secondary preventions for PTSD after SA, determine efficacy whether any intervention seems promising, and ascertain when, how, and to whom interventions should be delivered.

METHODS

After searching electronic databases for secondary preventions for PTSD and related conditions among women who have experienced a recent SA, 17 studies were reviewed, their quality was rated on the clinical trial assessment measure, and 10 studies were meta-analyzed (7 were excluded, as they were not randomized controlled trials or due to the absence of heterogeneity).

RESULTS

Results suggested a small-to-moderate effect of prevention on reducing PTSD and related symptoms. There was no moderating effect of medication versus psychosocial interventions, timing, treatment modality, or targeted versus universal prevention. Half of the studies were of high quality.

CONCLUSION

Cognitive-behavioral secondary preventions for PTSD appear to be safe and effective among women who have experienced a recent SA. Future research should identify best practices and mechanisms of treatment, and once identified, it should move toward implementation science.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review

BACKGROUND

Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.

METHODS

A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.

RESULTS

We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.

CONCLUSIONS

This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

Usability Testing of a Mobile Health Intervention to Address Acute Care Needs after Sexual Assault

Sexual assault is associated with a range of poor mental health outcomes. To enhance access to care by this population, technology-based mental health interventions have been implemented in the emergency room; however, more accessible and easily disseminated interventions are needed. The aim of the present study was to test the usability of a mobile health intervention targeting alcohol and drug misuse, suicide prevention, posttraumatic stress symptoms, coping skills, and referral to formal assistance for individuals who have experienced sexual assault. Feedback on the usability of the intervention was collected from individuals who received a sexual assault medical forensic examination (n = 13), and feedback on the usability and likelihood of recommending the application was collected from community providers (n = 25). Thematic analysis was used to describe qualitative data. Content themes related to aesthetics, usability, barriers to resources, and likes/dislikes about the intervention arose from interviews following the intervention. Participants found the intervention to be user friendly and endorsed more likes than dislikes. Providers rated the intervention as being helpful and would recommend it to survivors of sexual assault. Findings suggest that the intervention is usable and fit for future effectiveness testing, filling an important gap in treatment for individuals who experience sexual assault.

Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania

BACKGROUND

Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.

METHODS

Formative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).

RESULTS

We designed an 8-session intervention, termed Nguvu ('strength'), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.

CONCLUSIONS

We found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.

TRIAL REGISTRATION

ISRCTN65771265, June 27, 2016.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate.

SELECTION CRITERIA

We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD.

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author.

MAIN RESULTS

This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I² = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I² = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I² = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I² = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I² = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I² = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I² = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I² = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I² = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

Identification and Management of Domestic and Sexual Violence in Primary Care in the #MeToo Era: an Update

PURPOSE OF REVIEW

We discuss recent evidence around the identification and response to domestic and sexual violence in primary care for perpetrators and victims, in the context of feminist social media movements such as #MeToo.

RECENT FINDINGS

There is no recent research on identification and response to perpetrators in health settings. There is some limited recent evidence for how health settings can address domestic and sexual violence for female victims and their children. Recent studies of mixed quality focus on advocacy and empowerment, integrated interventions (with alcohol and drug misuse) and couples counselling for domestic violence and cognitive behavioural or processing therapy for sexual violence. Further research on perpetrator interventions in primary care is urgent. Larger sample sizes and a focus on sexual violence are needed to develop the evidence base for female survivors. Clinicians need to ask about violence and provide a first-line response depending on the patient's needs.

Do early interventions prevent PTSD? A systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault

Objective: To review the safety and efficacy of early interventions after sexual assault in reducing or preventing posttraumatic stress disorder (PTSD). Method: Systematic searches were performed on studies (1980-2018) that examined the efficacy of interventions for PTSD within 3 months after sexual assault. Results: The review identified 7 studies (n = 350) with high risk of bias that investigated 5 interventions. Only two studies reported on safety. Contact with the authors of six studies provided no indications for the occurrence of adverse events. Two studies reported the efficacy using PTSD diagnosis as dependent variable but found no difference between groups. All studies reported on efficacy using PTSD severity as dependent variable. For the meta-analysis, 4 studies (n = 293) were included yielding significantly greater reductions of PTSD severity than standard care at 2 to 12 months follow-up (g = -0.23, 95% CI [-0.46, 0.00]), but not at 1 to 6 weeks post-intervention (g = -0.28, 95% CI [-0.57, 0.02]). The heterogeneity of the interventions precluded further analyses. Discussion: Findings suggest that early interventions can lead to durable effects on PTSD severity after sexual assault. However, due to limited availability of data, it is impossible to draw definite conclusions about safety and efficacy of early interventions, and their potential to prevent PTSD.

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12-16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 - 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.

Early psychological intervention following recent trauma: A systematic review and meta-analysis

Background: Post-traumatic stress disorder (PTSD) is a common and debilitating disorder which has a significant impact on the lives of sufferers. A number of early psychological interventions have been developed to try to prevent chronic difficulties. Objective: The objective of this study was to establish the current evidence for the effectiveness of multiple session early psychological interventions aimed at preventing or treating traumatic stress symptoms beginning within three months of trauma exposure. Methods: Randomized controlled trials of early multiple session psychological interventions aimed at preventing or reducing traumatic stress symptoms of individuals exposed to a traumatic event, fulfiling trauma criteria for an ICD or DSM diagnosis of PTSD were identified through a search of the Cochrane Common Mental Disorders Group Clinical Trials Registers database, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and PILOTS. Two authors independently extracted study details and data and completed risk of bias assessments. Analyses were undertaken using Review Manager software. Quality of findings were rated according to 'Grades of Recommendation, Assessment, Development, and Evaluation' (GRADE) and appraised for clinical importance. Results: Sixty-one studies evaluating a variety of interventions were identified. For individuals exposed to a trauma who were not pre-screened for traumatic stress symptoms there were no clinically important differences between any intervention and usual care. For individuals reporting traumatic stress symptoms we found clinically important evidence of benefits for trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy without exposure and eye movement desensitization and reprocessing (EMDR). Differences were greatest for those diagnosed with acute stress disorder (ASD) and PTSD. Conclusions: There is evidence for the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms following trauma exposure, especially for those meeting the diagnostic threshold for ASD or PTSD. Evidence is strongest for trauma-focused CBT.