Music therapy was noninferior to verbal standard treatment of traumatized refugees in mental health care: Results from a randomized clinical trial

Psychological Interventions for PTSD, Depression, and Anxiety in Child, Adolescent and Adult Forced Migrants: A Systematic Review and Frequentist and Bayesian Meta-Analyses

OBJECTIVE

The number of forced migrants has been rising for years. Many forced migrants suffer from post-traumatic stress disorder (PTSD), depression, and/or anxiety and need treatment. Here, we evaluate the effectiveness of psychological interventions (CBT, EMDR, expressive/art, mindfulness, mixed elements, NET and psychoeducation) in reducing symptoms of PTSD, depression, and anxiety in forced migrants.

DESIGN AND DATA SOURCES

Systematic searches in PubMed and Web of Science and searches of preprint servers and grey literature were performed (final search date: 1 September 2023). Random-effects frequentist and Bayesian meta-analyses were used for data synthesis.

RESULTS

We included 84 studies on treatment effects in adults (pooled N = 6302) and 32 on children and adolescents (pooled N = 1097). Our data show a reduction in symptoms of PTSD, depression and anxiety symptoms in both adults and child/adolescent forced migrants. Pooled pre- to post-treatment effects (effect size Cohen's d) ranged from -1.03 to -0.26 for PTSD, from -0.91 to -0.11 for depression and from -0.91 to -0.60 for anxiety, without there being differences in outcome per study design (i.e., RCT comparison vs. non-RCT comparison vs. single arm treatment study). Treatment effects remained evident over follow-up, and not a single type of treatment stood out as being superior to other treatment types. Structural differences in populations (e.g., regarding country of origin) over studies, however, could have hampered the validity of the comparisons between study characteristics such as treatment type.

CONCLUSION

Our findings support the effectiveness of psychological treatment in adult and child/adolescent forced migrants.

Survival, Attachment, and Healing: An Evolutionary Lens on Interventions for Trauma-Related Dissociation

Purpose

Dissociation is a necessary part of our threat response system, common to all animal species, normally temporarily activated under conditions of extreme or inescapable threat. Pathological dissociation, however, continues to occur after the initial threat has passed, in response to reminders or inaccessibility of safety and security. Present across the spectrum of psychiatric diagnoses, recurrent dissociative symptoms are linked to severe trauma exposure, insecure attachment, treatment non-response, and maladaptive coping behaviors such as substance use, suicidality, and self-harm. However, empirical studies testing treatments specific to dissociative processes remain scarce. This narrative review summarizes existing studies and provides theoretical, neurobiological, and evolutionary perspectives on dissociative processes and treatments for pathological dissociation.

Methods

A systematic search of five databases (MEDLINE, EMBASE, APA PsycINFO, CINAHL plus, Scopus) was conducted on April 13, 2023. Peer-reviewed clinical studies with adult participants, assessing intervention effects on dissociative symptoms, were included. Results were thematically analyzed and summarized.

Results

Sixty-nine studies were identified, mainly focused on posttraumatic stress disorder, trauma-exposed populations, and borderline personality disorder. Psychotherapy was studied in 72.5% of studies; other interventions included medications and neurostimulation. The majority reported positive outcomes, despite the heterogeneous spectrum of interventions. However, treatment of dissociative symptoms was the primary objective in only a minority.

Conclusion

Pathological dissociation is a complex phenomenon involving brain and body systems designed for perceiving and responding to severe threats, requiring an individualized approach. A literature is emerging regarding potentially evidence-based treatments to help those impacted by recurrent dissociative symptoms. When contextualized within a neurobiological and evolutionary perspective, these treatments can be understood as facilitating an internal and/or relational sense of safety, resulting in symptom reduction. Further studies are needed to explore effective treatments for dissociative symptoms.

Uncovering multi-level mental healthcare barriers for migrants: a qualitative analysis across China, Germany, Netherlands, Romania, and South Africa

BACKGROUND

Forced displacement is a significant issue globally, and it affected 112 million people in 2022. Many of these people have found refuge in low- and middle-income countries. Migrants and refugees face complex and specialized health challenges, particularly in the area of mental health. This study aims to provide an in-depth qualitative assessment of the multi-level barriers that migrants face in accessing mental health services in Germany, Macao (Special Administrative Region of China), the Netherlands, Romania, and South Africa. The ultimate objective is to inform tailored health policy and management practices for this vulnerable population.

METHODS

Adhering to a qualitative research paradigm, the study centers on stakeholders' perspectives spanning microsystems, mesosystems, and macrosystems of healthcare. Utilizing a purposive sampling methodology, key informants from the aforementioned geographical locations were engaged in semi-structured interviews. Data underwent thematic content analysis guided by a deductive-inductive approach.

RESULTS

The study unveiled three pivotal thematic barriers: language and communication obstacles, cultural impediments, and systemic constraints. The unavailability of professional interpreters universally exacerbated language barriers across all countries. Cultural barriers, stigmatization, and discrimination, specifically within the mental health sector, were found to limit access to healthcare further. Systemic barriers encompassed bureaucratic intricacies and a conspicuous lack of resources, including a failure to recognize the urgency of mental healthcare needs for migrants.

CONCLUSIONS

This research elucidates the multifaceted, systemic challenges hindering equitable mental healthcare provision for migrants. It posits that sweeping policy reforms are imperative, advocating for the implementation of strategies, such as increasing the availability of language services, enhancing healthcare providers' capacity, and legal framework and policy change to be more inclusive. The findings substantially contribute to scholarly discourse by providing an interdisciplinary and international lens on the barriers to mental healthcare access for displaced populations.

The Effects of Music Therapy on Patients Undergoing Colonoscopy in a Tertiary Care Hospital at Karachi, Pakistan: A Comparative Study

A colonoscopy is a procedure commonly used for the diagnosis of colorectal diseases but may be associated with high levels of anxiety and discomfort, which can lead to complications during sedation and decreased patient comfort and cooperation. This study was conducted at a tertiary care hospital in Karachi to assess the effectiveness of music therapy on pre-procedural anxiety, sedation requirements, pain, and procedure duration among patients undergoing colonoscopies. This comparative study included 110 outpatients. The intervention arm received non-lyrical soft music through earphones before and during the colonoscopy procedure, while the control group did not receive any music. In the intervention arm, significant reductions were seen in pre-procedural anxiety scores (p < 0.001), physiological measures (p < 0.001), sedation doses (p < 0.001), and procedure durations (p < 0.05). Control arm showed an increase in heart rate and systolic blood pressure (p < 0.001). Pain scores were similar for both groups. Music therapy is an effective tool to reduce patient anxiety pre- procedure. It is a simple, safe, and noninvasive relaxing intervention that could be used as an adjunct to sedative medications before and during the colonoscopy procedure.

Efficacy and acceptability of music therapy for post-traumatic stress disorder: a systematic review and meta-analysis of randomized controlled trials

Background: Music therapy is increasingly examined in randomized controlled trials (RCTs) and shows potential in treating post-traumatic stress disorder (PTSD).Objective: This systematic review and meta-analysis critically evaluates the current clinical evidence supporting the efficacy and acceptability of music therapy for PTSD.Method: RCTs comparing music therapy in addition to care as usual (CAU) versus either CAU alone or CAU combined with standard psychotherapy/pharmacotherapy for PTSD were retrieved from major English - and Chinese-language databases. Standardized mean differences (SMDs) for post-treatment PTSD symptom scores and risk differences (RDs) for retention rates upon treatment completion were calculated to assess the efficacy and acceptability of music therapy, respectively. The Cochrane risk of bias (RoB) tool 2.0 and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) were used to assess the RoB of included studies and certainty of the evidence, respectively.Results: Nine studies, incorporating 527 PTSD patients, were included, all with high RoB. The post-treatment PTSD symptom scores were significantly lower in the music therapy group than the inactive control group (SMD = -1.64, P < .001), but comparable between the music therapy group and the active control group (SMD = -0.28, P = .330). The retention rates did not differ significantly between the music therapy group and both control groups (RD = 0.03, P = .769; RD = 0.16, P = .829). The GRADE rated certainty level of evidence as low.Conclusions: Although meta-analytic findings suggest that music therapy is effective in reducing post-traumatic symptoms in individuals with PTSD, with its therapeutic effect comparable to that of standard psychotherapy, the low level of certainty limits its generalizability. More methodologically stringent studies are warranted to strengthen the clinical evidence for the efficacy and acceptability of music therapy for PTSD.

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

Musical experience prior to traumatic exposure as a resilience factor: a conceptual analysis

Resilience mechanisms can be dynamically triggered throughout the lifecourse by resilience factors in order to prevent individuals from developing stress-related pathologies such as posttraumatic stress disorder (PTSD). Some interventional studies have suggested that listening to music and musical practice after experiencing a traumatic event decrease the intensity of PTSD, but surprisingly, no study to our knowledge has explored musical experience as a potential resilience factor before the potential occurrence of a traumatic event. In the present conceptual analysis, we sought to summarize what is known about the concept of resilience and how musical experience could trigger two key mechanisms altered in PTSD: emotion regulation and cognitive control. Our hypothesis is that the stimulation of these two mechanisms by musical experience during the pre-traumatic period could help protect against the symptoms of emotional dysregulation and intrusions present in PTSD. We then developed a new framework to guide future research aimed at isolating and investigating the protective role of musical experience regarding the development of PTSD in response to trauma. The clinical application of this type of research could be to develop pre-trauma training that promotes emotional regulation and cognitive control, aimed at populations at risk of developing PTSD such as healthcare workers, police officers, and military staffs.

Nursing students' perceptions of spiritual needs at the end of life. A qualitative study

Spirituality is defined as the meaning of life, being the very essence of life made up of all of the aspects inherent to it. During end-of-life processes, this need is shown to be particularly altered in patients and yet it is an aspect that the health professionals accompanying patients in this situation report being least equipped to address, alongside therapies that could help to meet these needs, such as art therapy. An exploratory qualitative study was conducted, adheres to the guidelines of COREQ (41). The study population were final year students undertaking a nursing degree at the University of Huelva, Spain. The sample was selected via intentional sampling using snowball recruitment from the study population. Stratification according to gender was performed due to the feminised nature of the population. Sample size was determined progressively during the research, with recruitment ceasing at 13 informants once information saturation was achieved. Inclusion criteria required that participants were to be final year students enrolled on a nursing degree who had provided consent to participate voluntarily in the research. The analysis Realized was interpretive phenomenological (IPA) as described by Smith (43-45). The present study revealed that students perceive their training on spiritual care to be deficient. Despite them reporting that they possess the skills and tools to provide end-of-life care, this is not enough to provide effective accompaniment, given that this moment brings them into touch with their own insecurities. Students verbalized the need to learn strategies to address this shortcoming regarding final accompaniment, for instance, through art, with creativity being one of the skills with the potential to uncover the meaning of life.

Ventral tegmental area dopaminergic action in music therapy for post-traumatic stress disorder: A literature review

Post-traumatic stress disorder (PTSD) is a debilitating sequela of extraordinary traumatic sufferings that threaten personal health and dramatically attenuate the patient's quality of life. Accumulating lines of evidence suggest that functional disorders in the ventral tegmental area (VTA) dopaminergic system contribute substantially to PTSD symptomatology. Notably, music therapy has been shown to greatly ameliorate PTSD symptoms. In this literature review, we focused on whether music improved PTSD symptoms, based on VTA dopaminergic action, including the effects of music on dopamine (DA)-related gene expression, the promotion of DA release and metabolism, and the activation of VTA functional activities. In addition, the strengths and limitations of the studies concerning the results of music therapy on PTSD are discussed. Collectively, music therapy is an effective approach for PTSD intervention, in which the VTA dopaminergic system may hold an important position.

A Neurobiological Framework for the Therapeutic Potential of Music and Sound Interventions for Post-Traumatic Stress Symptoms in Critical Illness Survivors

Overview: Post traumatic stress disorder (PTSD) has emerged as a severely debilitating psychiatric disorder associated with critical illness. Little progress has been made in the treatment of post-intensive care unit (ICU) PTSD. Aim: To synthesize neurobiological evidence on the pathophysiology of PTSD and the brain areas involved, and to highlight the potential of music to treat post-ICU PTSD. Methods: Critical narrative review to elucidate an evidence-based neurobiological framework to inform the study of music interventions for PTSD post-ICU. Literature searches were performed in PubMed and CINAHL. The Scale for the Assessment of Narrative Review Articles (SANRA) guided reporting. Results: A dysfunctional HPA axis feedback loop, an increased amygdalic response, hippocampal atrophy, and a hypoactive prefrontal cortex contribute to PTSD symptoms. Playing or listening to music can stimulate neurogenesis and neuroplasticity, enhance brain recovery, and normalize stress response. Additionally, evidence supports effectiveness of music to improve coping and emotional regulation, decrease dissociation symptoms, reduce depression and anxiety levels, and overall reduce severity of PTSD symptoms. Conclusions: Despite the lack of music interventions for ICU survivors, music has the potential to help people suffering from PTSD by decreasing amygdala activity, improving hippocampal and prefrontal brain function, and balancing the HPA-axis.