Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training

Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening

Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.

Moderate-intensity aerobic exercise training as an adjunct to trauma-focused psychotherapy in traumatized refugees and asylum seekers: study protocol of a randomized controlled trial

Background: Refugees with exposure to multiple traumatic events are at high risk for developing posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an effective treatment for the core symptoms of PTSD, but it does not reliably reduce depressive symptoms. Endurance exercise on the other hand was consistently found to be effective in treating depression making it a promising adjunct to NET. Up to date, no studies exist investigating the combination of NET and endurance exercise in a sample of refugees with PTSD and comorbid depression.Objectives: In the proposed randomized controlled trial, we aim to investigate whether a combination of NET and moderate-intensity aerobic exercise training (MAET) enhances treatment outcome for refugees with PTSD and comorbid depressive symptoms. We expect a greater improvement in psychopathology in participants who receive the combined treatment.Methods and analysis: 68 refugees and asylum seekers with PTSD and clinically relevant depressive symptoms will be recruited in the proposed study. Participants will be randomly assigned to receive either NET only (NET-group) or NET plus MAET (NET+-group). All participants will receive 10 NET sessions. Participants in the NET+-group will additionally take part in MAET. Primary (PTSD, depression) and secondary (general mental distress, agoraphobia and somatoform complaints, sleep quality) outcome measures will be assessed before treatment, after treatment, and at six-month follow-up. The hypotheses will be tested with multiple 2 × 3 mixed ANOVA's.Trial registration: German Clinical Trials Register identifier: DRKS00022145.

Narrative-based autobiographical memory interventions for PTSD: a meta-analysis of randomized controlled trials

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.

Timing of vagus nerve stimulation during fear extinction determines efficacy in a rat model of PTSD

Studies have indicated that vagus nerve stimulation (VNS) enhances extinction learning in rodent models. Here, we investigated if pairing VNS with the conditioned stimulus is required for the enhancing effects of VNS. Adult Sprague-Dawley rats were exposed to intense stress followed by fear conditioning training to produce resistant fear. Rats were then implanted with a cuff electrode around the left vagus. After recovery, rats underwent extinction training paired with VNS (0.5 s, 0.8 mA, 100 µs, and 30 Hz) or with Sham VNS (0 mA). VNS rats were randomized into the following subgroups: During VNS (delivered during presentations of the conditioned stimulus, CS), Between VNS (delivered between CS presentations), Continuous VNS (delivered during the entire extinction session), and Dispersed VNS (delivered at longer inter-stimulation intervals across the extinction session). Sham VNS rats failed to extinguish the conditioned fear response over 5 days of repeated exposure to the CS. Rats that received Between or Dispersed VNS showed modest improvement in conditioned fear at the retention test. During and Continuous VNS groups displayed the greatest reduction in conditioned fear. These findings indicate that delivering VNS paired precisely with CS presentations or continuously throughout extinction promotes the maximum enhancement in extinction learning.

Traumatic events, post-traumatic stress disorders, and gender among Yazidi population after ISIS invasion: A post conflict study in Kurdistan - Iraq

BACKGROUND

Traumatic experiences can lead to a range of mental health problems such as depression, anxiety and post-traumatic stress disorder. The prevalence of post-traumatic stress disorder depends on the cumulative exposure to traumatic stress. The Yazidis (Êzidî) are a Kurdish religious minority living in the north of Iraq, western Iran, eastern Turkey, and northern Syria. Islamic State of Iraq and Syria (ISIS) had sought to destroy the Yazidis population through killings; sexual slavery, enslavement, torture, degrading treatment, and forcible migration causing serious physical and mental disorders. The objectives of the study were to estimate the prevalence of traumatic events and post-traumatic stress disorder among Yazidi population in Yazidi community and to assess the association between post-traumatic stress disorder and gender.

METHODS

A cross-sectional study was conducted during period from June to August 2019. The participants were chosen by a random sampling method from Chammshko camp in Zakho district that it's a city in Kurdistan region - Iraq. The questionnaire consisted of questions for demographical characteristics (e.g., gender, age, marital status, education, and job), and PTSD symptoms was assessed by using Harvard Trauma Questionnaire.

RESULTS

The females consisted 54.7% of the subjects. The majority of the participants were married (54.1%) and 98 (54.1%) of them were uneducated. About 79% of the subjects had PTSD symptoms. There was a statistically significant association between gender and PTSD, the female subjects had higher mean of trauma and PTSD symptoms scores (17.84 ± 3.5), (117.34 ± 13.8) respectively compare to that of male subjects (15.95 ± 3.1), (104.61 ± 18.8) respectively (p < .001).

CONCLUSION

High rate of PTSD among Yazidi population, Female subjects highly suffered from trauma and PTSD.

Protocol for individual participant data meta-analysis of interventions for post-traumatic stress

INTRODUCTION

Several evidence-based treatments are effective for post-traumatic stress disorder (PTSD), yet a substantial proportion of patients do not respond or dropout of treatment. We describe the protocol for a systematic review and individual participant data meta-analysis (IPD-MA) aimed at assessing the effectiveness and adverse effects of psychotherapy and pharmacotherapy interventions for treating PTSD. Additionally, we seek to examine moderators and predictors of treatment outcomes.

METHOD AND ANALYSIS

This IPD-MA includes randomised controlled trials comparing psychotherapy and pharmacotherapy interventions for PTSD. PubMed, Embase, PsycINFO, PTSDpubs and CENTRAL will be screened up till the 11th of January 2021. The target population is adults with above-threshold baseline PTSD symptoms on any standardised self-report measure. Trials will only be eligible if at least 70% of the study sample have been diagnosed with PTSD by means of a structured clinical interview. The primary outcomes of this IPD-MA are PTSD symptom severity, and response rate. Secondary outcomes include treatment dropout and adverse effects. Two independent reviewers will screen major bibliographic databases and past reviews. Authors will be contacted to contribute their participant-level datasets. Datasets will be merged into a master dataset. A one-stage IPD-MA will be conducted focusing on the effects of psychological and pharmacological interventions on PTSD symptom severity, response rate, treatment dropout and adverse effects. Subsequent analyses will focus on examining the effect of moderators and predictors of treatment outcomes. These will include sociodemographic, treatment-related, symptom-related, resilience, intervention, trauma and combat-related characteristics. By determining the individual factors that influence the effectiveness of specific PTSD treatments, we will gain insight into personalised treatment options for PTSD.

ETHICS AND DISSEMINATION

Specific ethics approval for an IPD-MA is not required as this study entails secondary analysis of existing anonymised data. The results of this study will be published in peer-reviewed scientific journals and presentations.

Stress management versus cognitive restructuring in trauma-affected refugees - A follow-up study on a pragmatic randomised trial

BACKGROUND

There is a lack of research and consensus with respect to long-term effective treatments for trauma-affected refugees. The purpose of this follow-up study of a randomised clinical trial was to investigate the effectiveness of Stress Management (SM) versus Cognitive Restructuring (CR) in treating trauma-affected refugees, six and 18 months post-treatment, respectively.

METHODS

From a total of 126 refugees with PTSD, the intention-to-treat sample in the original trial, 74 patients were present at the six-month follow-up (SM; n = 37, CR; n = 37) and 34 patients at the 18-month follow-up (SM; n = 14, CR; n = 20). During the trial, the patients had been offered a total of 16 psychotherapy sessions and 10 sessions with a medical doctor.

RESULTS

Mixed regression analyses at six and 18-month follow-up showed a non-significant small reduction in PTSD symptoms at both follow-up points with no significant between-group differences between the two psychotherapeutic interventions. Statistically significant between-group treatment effects were, however, observed with the patients receiving SM having significantly reduced symptoms of somatisation measured by the Symptom Checklist (β = 0.40), depression (β = 0.29) and anxiety (β = 0.37) (measured by the Hamilton Depression and Anxiety ratings) at 18 months post-treatment compared to the CR group.

LIMITATIONS

Limitations to the present study include the dropout rate at follow-up(s).

CONCLUSIONS

The findings suggest that the consolidation of coping strategies including relaxation, attention-diversion and behavioural activation in SM appears to be more beneficial than CR in reducing long-term somatisation, depression and anxiety symptoms for this population.

PTSD: Past, present and future implications for China

There has been a long history since human beings began to realize the existence of post-traumatic symptoms. Posttraumatic stress disorder (PTSD), a diagnostic category adopted in 1980 in the Diagnostic and Statistical Manual of Mental Disorders-Ⅲ, described typical clusters of psychiatric symptoms occurring after traumatic events. Abundant researches have helped deepen the understanding of PTSD in terms of epidemiological features, biological mechanisms, and treatment options. The prevalence of PTSD in general population ranged from 6.4% to 7.8% and was significantly higher among groups who underwent major public traumatic events. There has been a long way in the studies of animal models and genetic characteristics of PTSD. However, the high comorbidity with other stress-related psychiatric disorders and complexity in the pathogenesis of PTSD hindered the effort to find specific biological targets for PTSD. Neuroimage was widely used to elucidate the underlying neurophysiological mechanisms of PTSD. Functional MRI studies have showed that PTSD was linked to medial prefrontal cortex, anterior cingulate cortex and sub-cortical structures like amygdala and hippocampus, and to explore the functional connectivity among these brain areas which might reveal the possible neurobiological mechanism related to PTSD symptoms. For now, cognitive behavior therapy-based psychotherapy, including combination with adjunctive medication, showed evident treatment effects on PTSD. The emergence of more effective PTSD pharmacotherapies awaits novel biomarkers from further fundamental research. Several natural disasters and emergencies have inevitably increased the possibility of suffering from PTSD in the last two decades, making it critical to strengthen PTSD research in China. To boost PTSD study in China, the following suggestions might be helpful: (1) establishing a national psychological trauma recover project, and (2) exploring the mechanisms of PTSD with joint effort and strengthening the indigenized treatment of PTSD.

Long-term outcomes of psychological treatment for posttraumatic stress disorder: a systematic review and meta-analysis

Several types of psychological treatment for posttraumatic stress disorder (PTSD) are considered well established and effective, but evidence of their long-term efficacy is limited. This systematic review and meta-analysis aimed to investigate the long-term outcomes across psychological treatments for PTSD. MEDLINE, Cochrane Library, PTSDpubs, PsycINFO, PSYNDEX, and related articles were searched for randomized controlled trials with at least 12 months of follow-up. Twenty-two studies (N = 2638) met inclusion criteria, and 43 comparisons of cognitive behavioral therapy (CBT) were available at follow-up. Active treatments for PTSD yielded large effect sizes from pretest to follow-up and a small controlled effect size compared with non-directive control groups at follow-up. Trauma-focused treatment (TFT) and non-TFT showed large improvements from pretest to follow-up, and effect sizes did not significantly differ from each other. Active treatments for comorbid depressive symptoms revealed small to medium effect sizes at follow-up, and improved PTSD and depressive symptoms remained stable from treatment end to follow-up. Military personnel, low proportion of female patients, and self-rated PTSD measures were associated with decreased effect sizes for PTSD at follow-up. The findings suggest that CBT for PTSD is efficacious in the long term. Future studies are needed to determine the lasting efficacy of other psychological treatments and to confirm benefits beyond 12-month follow-up.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD

INTRODUCTION

Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers.

METHODS

Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application.

RESULTS

A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions.

CONCLUSION

CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.

Islamic Trauma Healing: Integrating Faith and Empirically Supported Principles in a Community-Based Program

Access to adequate, much less state-of-the-art, mental health care is a global problem. Natural disasters, civil war, and terrorist conflict have forcibly displaced millions of Muslims and have resulted in a remarkable level of individual and communitywide trauma exposure. As a result, many are at risk for posttraumatic stress and other trauma-related disorders. Many religiously oriented Muslims traditionally rely on Islamic principles and teachings, as well as their community, to cope with and address trauma-related distress. Islamic Trauma Healing is a six-session, lay-led group intervention developed within a Somali Muslim community that integrates evidence-based trauma-focused cognitive-behavioral therapy principles with cultural and religious practices aimed to enhance uptake and create an easily up-scalable intervention for a wide range of trauma. In sessions, narratives of prophets who have undergone trauma (e.g., Prophet Ayyub, faith during hard times) present Islamic principles and facilitate cognitive shifts. Group members spend individual time turning to Allah in dua (i.e., informal prayer), focused on exposure to trauma memories. Program themes arc across suffering to healing to growth following trauma. This paper describes the core theoretical principles and methods in the Islamic Trauma Healing program. We also describe leader perspectives and the program's train-the-trainer model, in which lay leaders are trained to further disseminate the program and allow Islamic Trauma Healing to be owned and sustained by the Muslim community.

Victimology from clinical psychology perspective: psychological assessment of victims and professionals working with victims

Victimology concerns victims of various traumas from accidents, disasters, assaults to wars. Survivors of trauma are also an area in clinical psychology since it is interested in the assessment and diagnosis of psychopathology and psychotherapy. Stress and mental health are intertwined; increased stress results in difficulties in feeling, thinking and behaving. The stress symptoms are an intrusion, avoidance, negative cognitions and mood, and arousal and reactivity. A trauma survivor might develop post-traumatic stress disorder. Healing trauma is so comprehensive that many professionals work from different aspects. From attorneys to mental health workers, many professionals deal with the aftereffects of trauma. Engaging with details of the trauma endangers not only the victims but also the professionals working with the victims. These professionals end up having psychological effects such as secondary trauma, vicarious trauma, compassion fatigue, countertransference and occupational burnout. Trauma has serious effects on its victims but not all effects are negative and paralyzing. Trauma victims might change their priorities in a way that they report more personal control over their life. This phenomenon is called posttraumatic growth. The paper aims to collaborate victimology with clinical psychology by highlighting psychopathology and psychological assessment.

Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators

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.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Does cumulative exposure to traumatic stressors predict treatment outcome of community-implemented exposure-based therapy for PTSD?

Background: Posttraumatic Stress Disorder (PTSD) is associated with high levels of functional impairments such as difficulties in academic or occupational performance and in social relationships. With an increasing number of traumatic event types experienced (trauma load), PTSD risk increases in a dose-dependent manner. Accordingly, high rates of PTSD can impair the reconstruction process in post-conflict societies. In order to meet these high needs for mental health services in societies with little access to professional care, task shifting approaches and community-based interventions have been suggested. Narrative Exposure Therapy (NET) has been developed as a short and pragmatic exposure-based PTSD treatment that can be easily trained to lay personnel. Yet, it remains unclear whether NET can be effectively provided by trained lay counsellors even at high levels of trauma load. Objective: To investigate whether trauma load influences the treatment effectiveness of NET provided by trained and supervised local lay counsellors. Method: Linear mixed models were calculated to investigate the influence of trauma load on treatment effectiveness in a sample of N = 323 rebel war survivors from Northern Uganda with PTSD. Results: We found a strong reduction of PTSD symptoms following NET, which was not influenced by trauma load. However, individuals with higher levels of trauma load reported higher PTSD symptoms before therapy as well as 4 and 10 months following treatment completion compared to individuals with lower trauma load. Conclusions: Treatment with NET by lay counsellors is effective independent of trauma load. However, individuals with higher trauma load have a higher probability to show residual symptoms, which might require additional time, sessions or treatment modules.

Efficacy of Psychological Interventions on Depression Anxiety and Somatization in Migrants: A Meta-analysis

Many studies reveal the effectiveness of different psychological interventions on the adult refugees reporting mental health distress. Aim of this metanalysis was to test the efficacy of different psychological treatments on the depressive, anxiety and somatization symptoms on refugees and asylum seekers. Fifty-two studies, since 1997 to 2019, were included in the systematic review and 27 of those were included in the metanalysis. Studies providing a pre and post treatment methodological design were included. All treatments reported significant effects on the three outcomes. Qualitative observations showed a probability to have a significant pre-post treatment effects on trials with outcome of depression (56%), anxiety (44%), and somatization (42%). Cognitive behavioral treatment resulted the most effective treatment. The status of refugee compared to the status of asylum seeker seems to have a great effect on the effectiveness of the treatment.

A systematic review of factors associated with outcome of psychological treatments for post-traumatic stress disorder

OBJECTIVE

Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap.

METHOD

We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission.

RESULTS

Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome.

CONCLUSION

Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials.

Understanding Supporting and Hindering Factors in Community-Based Psychotherapy for Refugees: A Realist-Informed Systematic Review

Culture, tradition, structural violence, and mental health-related stigma play a major role in global mental health for refugees. Our aim was to understand what factors determine the success or failure of community-based psychotherapy for trauma-affected refugees and discuss implications for primary health care programs. Using a systematic realist-informed approach, we searched five databases from 2000 to 2018. Two reviewers independently selected RCTs for inclusion, and we contacted authors to obtain therapy training manuals. Fifteen articles and 11 training manuals met our inclusion criteria. Factors that improved symptoms of depression, anxiety, and PTSD included providing culturally adapted care in a migrant-sensitive setting, giving a role to other clinical staff (task-shifting), and intervention intensity. Precarious asylum status, constraining program monitoring requirements, and diverse socio-cultural and gender needs within a setting may reduce the effectiveness of the program. Primary care programs may enable community based mental health care and may reduce mental health-related stigma for refugees and other migrants. More research is needed on the cultural constructs of distress, programs delivered in primary care, and the role of cultural and language interpretation services in mental health care.

Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees

BACKGROUND

Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy.

METHODS

To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.

RESULTS

On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.

CONCLUSIONS

Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET.

TRIAL REGISTRATION

NCT02852616.

Evaluating narrative exposure therapy for post-traumatic stress disorder and depression symptoms: A meta-analysis of the evidence base

Narrative exposure therapy (NET) is an intervention for trauma spectrum disorders. Originally developed to treat refugee populations, NET has since been tested for efficacy across different settings. In this review, the NET evidence base is examined through a retrieval, synthesis and appraisal of randomized controlled trials (RCTs) published since 2002. Two independent reviewers (S. R. and N. S.) searched online databases including EMBASE, PsycINFO and PubMed. Twenty-four RCTs were selected for a meta-analysis of three outcomes: post-traumatic stress disorder (PTSD) diagnosis and PTSD and depression symptoms. All outcomes were analysed at short-term (3-4 months), midterm (6-7 months) and long-term (≥12 months) data points. A random-effects model was applied to yield standardized mean differences (SMDs) and odds ratios (ORs) as indicators of NET treatment effect. Subgroup analyses for type of trauma and type of control groups were conducted to examine potential heterogeneity. For the NET group, moderate effect sizes for PTSD symptom severity were observed at midterm and long term and at midterm for depression symptom severity. The number of PTSD diagnoses decreased significantly in the short term for the NET condition, but this was not sustained at the long term. Caution must be exercised when interpreting these results due to high heterogeneity estimates and low quality of evidence across trials. Potential small-study effects further complicate the interpretation of the findings. Recommendations are made for augmenting statistical significance research with qualitative analyses of NET efficacy to better inform clinical practice.

Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta-analysis of randomized controlled trials

Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta-analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow-up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.

Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis

Background: Psychological therapies are the recommended first-line treatment for post-traumatic stress disorder (PTSD). Previous systematic reviews have grouped theoretically similar interventions to determine differences between broadly distinct approaches. Consequently, we know little regarding the relative efficacy of the specific manualized therapies commonly applied to the treatment of PTSD. Objective: To determine the effect sizes of manualized therapies for PTSD. Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: 114 randomized-controlled trials (RCTs) of 8171 participants were included. There was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T), as well as Eye Movement Desensitization and Reprocessing (EMDR), had a clinically important effect. The manualized CBT-Ts with the strongest evidence of effect were Cognitive Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus; guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging evidence for a number of other therapies. Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBT-Ts considered by the review CPT, CT and PE should be the treatments of choice. The findings should guide evidence informed shared decision-making between patient and clinician.

Implementing Narrative Exposure Therapy for unaccompanied asylum-seeking minors with post-traumatic stress disorder: A pilot feasibility report

There are high rates of post-traumatic stress disorder (PTSD) in unaccompanied asylum-seeking minors (UAM) and there is a requirement for feasible, acceptable and evidence-based treatments. Narrative Exposure Therapy (NET) is a short-term treatment for PTSD following multiple traumatic events. This article aims to examine the applicability of NET for UAM in routine clinical practice and to provide preliminary feasibility, acceptability and effectiveness data. The participants were four UAM receiving NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted to understand the acceptability of this approach and standardised measures of PTSD were used to provide preliminary data regarding the effectiveness of NET for these clients. The clients attended NET consistently with few missed appointments. At post-treatment, two clients' symptom scores were below the clinical cut-off for PTSD and all three clients who completed NET met reliable improvement criteria. The clients reported improvements in functional outcomes and mentioned that they would encourage other young people with similar difficulties to engage in NET. This study was limited by the small sample size and naturalistic time limitations in clinicians' contracts. This article highlights that it is possible to implement NET within routine clinical practice and observed improvements in PTSD symptoms and functional outcomes for UAM.

Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

Psychological, social, and welfare interventions for torture survivors: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Torture and other forms of ill treatment have been reported in at least 141 countries, exposing a global crisis. Survivors face multiple physical, psychological, and social difficulties. Psychological consequences for survivors are varied, and evidence on treatment is mixed. We conducted a systematic review and meta-analysis to estimate the benefits and harms of psychological, social, and welfare interventions for torture survivors.

METHODS AND FINDINGS

We updated a 2014 review with published randomised controlled trials (RCTs) for adult survivors of torture comparing any psychological, social, or welfare intervention against treatment as usual or active control from 1 January 2014 through 22 June 2019. Primary outcome was post-traumatic stress disorder (PTSD) symptoms or caseness, and secondary outcomes were depression symptoms, functioning, quality of life, and adverse effects, after treatment and at follow-up of at least 3 months. Standardised mean differences (SMDs) and odds ratios were estimated using meta-analysis with random effects. The Cochrane tool was used to derive risk of bias. Fifteen RCTs were included, with data from 1,373 participants (589 females and 784 males) in 10 countries (7 trials in Europe, 5 in Asia, and 3 in Africa). No trials of social or welfare interventions were found. Compared to mostly inactive (waiting list) controls, psychological interventions reduced PTSD symptoms by the end of treatment (SMD -0.31, 95% confidence interval [CI] -0.52 to -0.09, p = 0.005), but PTSD symptoms at follow-up were not significantly reduced (SMD -0.34, 95% CI -0.74 to 0.06, p = 0.09). No significant improvement was found for PTSD caseness at the end of treatment, and there was possible worsening at follow-up from one study (n = 28). Interventions showed no benefits for depression symptoms at end of treatment (SMD -0.23, 95% CI -0.50 to 0.03, p = 0.09) or follow-up (SMD -0.23, 95% CI -0.70 to 0.24, p = 0.34). A significant improvement in functioning for psychological interventions compared to control was found at end of treatment (SMD -0.38, 95% CI -0.58 to -0.18, p = 0.0002) but not at follow-up from only one study. No significant improvement emerged for quality of life at end of treatment (SMD 0.38, 95% CI -0.28 to 1.05, p = 0.26) with no data available at follow-up. The main study limitations were the difficulty in this field of being certain of capturing all eligible studies, the lack of modelling of maintenance of treatment gains, and the low precision of most SMDs making findings liable to change with the addition of further studies as they are published.

CONCLUSIONS

Our findings show evidence that psychological interventions improve PTSD symptoms and functioning at the end of treatment, but it is unknown whether this is maintained at follow-up, with a possible worsening of PTSD caseness at follow-up from one study. Further interventions in this population should address broader psychological needs beyond PTSD while taking into account the effect of multiple daily stressors. Additional studies, including social and welfare interventions, will improve precision of estimates of effect, particularly over the longer term.

[Psychosocial care of refugees in Germany : Insights from the emergency relief and development aid]

Approximately 1.2 million refugees have arrived in Germany since autumn 2014. They are often appraised as being a challenge for the German healthcare system because the acute need for healthcare support was large and appeared suddenly while at the same time resources were limited. This situation was previously unknown for a western European healthcare system, whereas it constitutes a typical challenge for nongovernmental organizations that are active in the field of emergency relief and development aid and that have developed a large number of successful intervention concepts. Of central importance in this context are the basic principles of equal rights, participation of those affected, the principle of nonmaleficence, the resource orientation instead of a deficit orientation as well as the need for integrated and stepped care models. These can serve as general principles not only in the setting of development aid in crisis areas worldwide but also in the health services provided to refugees in the current situation in Germany.

Evidenced-Based Treatment of Posttraumatic Stress Disorder: An Updated Review of Validated Psychotherapeutic and Pharmacological Approaches

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate psychotherapeutic and pharmacologic approaches to treating patients with posttraumatic stress disorder.

ABSTRACT

A strong evidence base exists for psychological and pharmacological interventions for the treatment of posttraumatic stress disorder (PTSD). The published literature investigating the effectiveness of these treatments in reducing the symptoms and impairments associated with PTSD has expanded substantially in recent years. This review provides a concise overview of the empirical literature examining these treatment approaches. Evidence-based, trauma-focused therapies are recommended as first-line interventions, with the most support for cognitive- and exposure-based approaches. Prolonged exposure and cognitive processing therapy are the two most cited and rigorously investigated. Various other evidence-supported protocols are discussed. Pharmacotherapies can be used when evidence-based psychotherapies are not available or are ineffective, or on the basis of patient preference. Pharmacotherapy with the most support for PTSD includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Evidence supports the implementation of these interventions across genders, populations, and settings. Given that little research directly compares the effectiveness of different PTSD interventions and their mechanisms of action, it remains uncertain how to best select and tailor treatments to optimize individual outcomes. Future directions and novel, ongoing research are discussed.

The management of post-traumatic stress disorder and associated pain and sleep disturbance in refugees

More than 68 million people worldwide have been forcibly displaced and one-third of these are refugees. This article offers an overview of the current literature and reviews the epidemiology and evidence-based psychological and pharmacological management of post-traumatic stress disorder (PTSD), sleep disturbance and pain in refugees and asylum seekers. It also considers the relationship between sleep disturbance and PTSD and explores concepts of pain in relation to physical and psychological trauma and distress. During diagnosis, clinicians must be aware of ethnic variation in the somatic expression of distress. Treatments for PTSD, pain and sleep disturbance among refugees and asylum seekers are essentially the same as those used in the general population, but treatment strategies must allow for cultural and contextual factors, including language barriers, loss of freedom and threat of repatriation.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis

Background: Narrative exposure therapy (NET) is a short-term psychological treatment for post-traumatic stress disorder (PTSD) that has been investigated in various contexts among traumatized refugees and other trauma survivors. Sustained treatment results have been reported, but the methodological quality of the trials needs a more thorough examination. Objective: To evaluate the effectiveness of NET for survivors of trauma, using a quality assessment, an updated meta-analysis, and a meta-regression analysis. Method: Following a systematic literature selection, the methodological quality of the included studies was assessed; Non-controlled and controlled effect sizes (Hedges' g) were estimated using a random effects model. Predictor analyses were performed. Non-controlled effect sizes for PTSD and depression included symptom change at post-treatment and follow-up time-points. Controlled effect sizes included post-treatment comparisons of NET with non-active and active comparators: both trauma-focused (TF) and non-trauma-focused (non-TF) interventions. Results: The selected studies showed high external validity; methodological quality was equivalent to other guideline-supported TF interventions. In 16 randomized controlled trials, involving 947 participants, large non-controlled effect sizes were found for PTSD symptoms, at post-treatment (g = 1.18, 95% confidence interval [0.87; 1.50]) and follow-up (g = 1.37 [0.96; 1.77]). For depression symptoms, medium non-controlled effect sizes were found, at post-treatment (g = 0.47 [0.23; 0.71]) and follow-up (g = 0.60 [0.26; 0.94]). Post-treatment, NET outperformed non-active comparators and non-TF active comparators for PTSD, but not the combined active comparators. For depression, NET only outperformed non-active comparators. Advancing age predicted better treatment results for PTSD and depression symptoms; a history of migration predicted smaller treatment results for depression symptoms. Conclusions:The findings of this meta-analysis suggest that patients and providers may expect sustained treatment results from NET. Controlled comparisons with other guideline-supported TF interventions are not yet available.

Effect of a combined brief narrative exposure therapy with case management versus treatment as usual in primary care for patients with traumatic stress sequelae following intensive care medicine: study protocol for a multicenter randomized controlled trial (PICTURE)

BACKGROUND

Traumatic events like critical illness and intensive care are threats to life and bodily integrity and pose a risk factor for posttraumatic stress disorder (PTSD). PTSD affects the quality of life and morbidity and may increase health-care costs. Limited access to specialist care results in PTSD patients being treated in primary care settings. Narrative exposure therapy (NET) is based on the principles of cognitive behavioral therapy and has shown positive effects when delivered by health-care professionals other than psychologists. The primary aims of the PICTURE trial (from "PTSD after ICU survival") are to investigate the effectiveness and applicability of NET adapted for primary care with case management in adults diagnosed with PTSD after intensive care.

METHODS/DESIGN

This is an investigator-initiated, multi-center, primary care-based, randomized controlled two-arm parallel group, observer-blinded superiority trial conducted throughout Germany. In total, 340 adult patients with a total score of at least 20 points on the posttraumatic diagnostic scale (PDS-5) 3 months after receiving intensive care treatment will be equally randomized to two groups: NET combined with case management and improved treatment as usual (iTAU). All primary care physicians (PCPs) involved will be instructed in the diagnosis and treatment of PTSD according to current German guidelines. PCPs in the iTAU group will deliver usual care during three consultations. In the experimental group, PCPs will additionally be trained to deliver an adapted version of NET (three sessions) supported by phone-based case management by a medical assistant. At 6 and 12 months after randomization, structured blinded telephone interviews will assess patient-reported outcomes. The primary composite endpoint is the absolute change from baseline at month 6 in PTSD symptom severity measured by the PDS-5 total score, which also incorporates the death of any study patients. Secondary outcomes cover the domains depression, anxiety, disability, health-related quality-of-life, and cost-effectiveness. The principal analysis is by intention to treat.

DISCUSSION

If the superiority of the experimental intervention over usual care can be demonstrated, the combination of brief NET and case management could be a treatment option to relieve PTSD-related symptoms and to improve primary care after intensive care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03315390 . Registered on 10 October 2017. German Clinical Trials Register, DRKS00012589 . Registered on 17 October 2017.

Testing the effectiveness and implementation of a brief version of the Common Elements Treatment Approach (CETA) in Ukraine: a study protocol for a randomized controlled trial

BACKGROUND

Mental illness is a major public health concern. Despite progress understanding which treatments work, a significant treatment gap remains. An ongoing concern is treatment length. Modular, flexible, transdiagnostic approaches have been offered as one solution to scalability challenges. The Common Elements Treatment Approach (CETA) is one such approach and offers the ability to treat a wide range of common mental health problems. CETA is supported by two randomized trials from low- and middle-income countries showing strong effectiveness and implementation outcomes.

METHODS/DESIGN

This trial evaluates the effectiveness and implementation of two versions of CETA using a non-inferiority design to test two primary hypotheses: (1) a brief five-session version of CETA (Brief CETA) will provide similar effectiveness for reducing the severity of common mental health problems such as depression, post-traumatic stress, impaired functioning, anxiety, and substance use problems compared with the standard 8-12-session version of CETA (Standard CETA); and (2) both Brief and Standard CETA will have superior impact on the outcomes compared to a wait-list control condition. For both hypotheses, the main effect will be assessed using longitudinal data and mixed-effects regression models over a 6-month period post baseline. A secondary aim includes exploration of implementation factors. Additional planned analyses will include exploration of: moderators of treatment impact by disorder severity and comorbidity; the impact of individual therapeutic components; and trends in symptom change between end of treatment and 6-month assessment for all participants.

DISCUSSION

This trial is the first rigorous study comparing a standard-length (8-12 sessions) modular, flexible, transdiagnostic, cognitive-behavioral approach to a shortened version of the approach (five sessions). Brief CETA entails "front-loading" with elements that research suggests are strong mechanisms of change. The study design will allow us to draw conclusions about the effects of both Brief and Standard CETA as well as which elements are integral to their mechanisms of action, informing future implementation and fidelity efforts. The results from this trial will inform future dissemination, implementation and scale-up of CETA in Ukraine and contribute to our understanding of the effects of modular, flexible, transdiagnostic approaches in similar contexts.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03058302 (U.S. National Library of Medicine). Registered on 20 February 2017.

Stress management versus cognitive restructuring in trauma-affected refugees-A pragmatic randomised study

The aim of this randomised trial was to compare the effectiveness of stress management (SM) versus cognitive restructuring (CR) in trauma-affected refugees. The intention-to-treat sample comprised 126 refugees with PTSD (SM = 62, CR = 64). The treatment consisted of 16 sessions of psychotherapy with manualised SM or CR in addition to 10 sessions with a medical doctor (psychoeducation and pharmacological treatment). The primary outcome was PTSD symptom severity (Harvard Trauma Questionnaire). Secondary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist-25, Hamilton Depression and Anxiety Ratings), quality of life (WHO-5), functioning (Global Assessment of Functioning, Sheehan Disability Scale), pain (Visual Analogue Scale) and somatisation (Symptom Checklist). There was no difference in the primary outcome between groups. A significant group difference was found on the Hamilton Anxiety Rating with the SM group improving more than the CR group (effect size 0.46) indicating that methods in SM could potentially be helpful in this population.

Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi

BACKGROUND

In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.

METHODS

Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants' economic well-being.

RESULTS

Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges' g = 3.44) and depression (Hedges' g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges' g_PTSD = 2.55; Hedges' g_depression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month's worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.

CONCLUSIONS

Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants' privacy.

TRIAL REGISTRATION

UKCR2014 , the 19.06.2014, retrospectively registered.

The impact of an exercise training intervention on cortisol levels and post-traumatic stress disorder in juveniles from an Ugandan refugee settlement: study protocol for a randomized control trial

Background

Latest research demonstrates a significant improvement in stress-related symptoms in psychological disorders as a result of exercise training (ET). Controlled clinical trials further validate the significance of ET by demonstrating lower salivary cortisol levels in patients with post-traumatic stress disorder (PTSD) after intervention. A significant change in cortisol and dehydroepiandrosterone (DHEA) levels can already be found after an 8–12-week ET program. The proposed study aims to investigate the impact of an 8-week ET on PTSD symptoms and changes in cortisol levels in a juvenile refugee sample from the Democratic Republic of the Congo (DRC) at an Ugandan refugee settlement. It is the first to implement an ET intervention in a resource-poor, post-conflict setting.

Methods/design

In a randomized controlled trial, 198 adolescent participants aged 13–16 years from the DRC who, suffer from PTSD, will be investigated. The participants are based at the Nakivale refugee settlement, an official refugee camp in Uganda, Africa, which is among the largest in the world. The participants will be randomized into an Exercise Training (ET) group with a maximum heart rate (HR_max) of > 60%, an Alternative Intervention (AI) group with low-level exercises, and a Waiting-list Control (WC) group. After the 8-week interventional phase, changes in cortisol awakening response (CAR) and DHEA in the ET group that correspond to an improvement in PTSD symptoms are expected that remain at follow-up after 3 months.

Discussion

To date, there is no controlled and reliable longitudinal study examining the effects of an ET program on symptom severity in individuals with PTSD that can be explained with a harmonization of cortisol secretion. The presented study design introduces an intervention that can be implemented with little expenditure. It aims to provide a promising low-threshold and cost-effective treatment approach for the application in resource-poor settings.

Trial registration

German Trials Register, ID: DRKS00014280. Registered prospectively on 15 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2753-x) contains supplementary material, which is available to authorized users.

Hsp90 and FKBP51: complex regulators of psychiatric diseases

Mood disorders affect nearly a quarter of the world's population. Therefore, understanding the molecular mechanisms underlying these conditions is of great importance. FK-506 binding protein 5 (FKBP5) encodes the FKBP51 protein, a heat shock protein 90 kDa (Hsp90) co-chaperone, and is a risk factor for several affective disorders. FKBP51, in coordination with Hsp90, regulates glucocorticoid receptor (GR) activity via a short negative feedback loop. This signalling pathway rapidly restores homeostasis in the hypothalamic-pituitary-adrenal (HPA) axis following stress. Expression of FKBP5 increases with age through reduced DNA methylation. High levels of FKBP51 are linked to GR resistance and reduced stress coping behaviour. Moreover, common allelic variants in the FKBP5 gene are associated with increased risk of developing affective disorders like anxiety, depression and post-traumatic stress disorder (PTSD). This review highlights the current understanding of the Hsp90 co-chaperone, FKBP5, in disease from both human and animal studies. In addition, FKBP5 genetic implications in the clinic involving life stress exposure, gender differences and treatment outcomes are discussed.This article is part of the theme issue 'Heat shock proteins as modulators and therapeutic targets of chronic disease: an integrated perspective'.

Psychotherapeutic Group Intervention for Traumatized Male Refugees Using Imaginative Stabilization Techniques-A Pilot Study in a German Reception Center

Background: Due to persecution, human rights violations and armed conflicts, the prevalence of post-traumatic stress disorder (PTSD) is high in refugee populations. Previous studies indicate that trauma-focused treatments are highly effective in treating PTSD in refugees. However, these approaches rely on the stability of the therapeutic setting, treatment continuity, and safe housing. Although early treatment of PTSD is recommended, these requirements are not met in reception centers. Therefore, we conducted a pilot study to examine the effect of imaginative stabilization techniques derived from psychodynamic psychotraumatology therapy for the early stabilization of traumatized refugees in a reception center. Methods: From May 2017 to April 2018, 86 imaginative stabilization group therapy sessions have taken place. A sample of 43 out of 46 traumatized refugees completed self-report questionnaires assessing PTSD, depression, and anxiety symptoms prior to attending open imaginative stabilization group therapy sessions. Furthermore, participants filled in self-report questionnaires on distress and emotional state (valence/arousal/dominance) before and after each session. After having participated in four consecutive sessions, a sub-group of 17 participants completed a follow-up assessment of PTSD, depression, and anxiety symptoms. Follow-up interviews were conducted with 25 participants 2 weeks after their last session attendance to explore self-practice habits post intervention. Results: The pre-post-intervention comparison of scores indicated a significant reduction of distress (z = -3.35, p < 0.001, r = -0.51) and an improvement of affective reports for valence (z = -4.79, p < 0.001, r = -0.82) and dominance (z = -3.89, p < 0.001, r = -0.59), whereas arousal scores were not affected. We found a significant reduction of anxiety symptoms (z = -2.04, p < 0.05, r = -0.49), whereas PTSD and depression scores remained unchanged. Follow-up interviews revealed that 80% of the participants continued to practice the imaginative stabilization techniques after redistribution to other accommodation. Conclusion: The results indicate that imaginative stabilization techniques are a promising and feasible approach to treat refugees in unstable reception center settings. In regular imaginative stabilization group therapy sessions, we were able to reduce the participants' distress and anxiety symptoms while strengthening their internal resources and increasing their emotional stability.

Psychotherapeutic Intervention in the Demobilization Process: Addressing Combat-related Mental Injuries with Narrative Exposure in a First and Second Dissemination Stage

BACKGROUND

Depending on the exposure to traumatic stressors and combat, 20% to 50% of ex-combatants present with trauma-related disorders, and more than half of the members of armed groups have a proclivity to violence. Therefore, psychotherapeutic assistance should address both, trauma-related suffering and the lowered threshold for aggressive behaviour.

OBJECTIVE

Supporting the demobilization process of ex-combatants in the eastern DR-Congo, we implemented a version of Narrative Exposure Therapy adapted for Forensic Offender Rehabilitation (FORNET).

METHOD

In two successive dissemination stages (DS), local counsellors conducted FORNET. In DS1, they were trained by clinical experts, and in DS2, the by then experienced counsellors trained and supervised a second group of local counsellors (DS2). The training consisted of a 3-week workshop covering theoretical concepts and practical therapeutic skills. In DS1 and DS2, a total of 98 demobilizing combatants received an intervention; treatment-as-usual served as the control condition. Posttraumatic stress disorder, appetitive aggression, depression severity and drug dependence were assessed prior to the intervention and 6 and 12 months later; additionally, we assessed reintegration success.

RESULTS

Six months post-intervention, FORNET significantly reduced Posttraumatic stress disorder symptoms but had less effect on the trait of appetitive aggression; moreover, beneficial effects were found for depression severity and drug dependence as well as for reintegration indices. Treatment gains were retained at 12 months.

CONCLUSIONS

Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET and support the demobilization process in ongoing conflicts. The study suggests that it is possible to pass down psychotherapeutic techniques over generations of counsellors. © 2015 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.

KEY PRACTITIONER MESSAGE

Posttraumatic stress symptoms, depression and clinically relevant levels of drug dependence can effectively be reduced with a version of Narrative Exposure Therapy (NET) adapted for Forensic Offender Rehabilitation (FORNET). The intervention is effective in the context of ongoing conflict. Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET. It is possible to pass down psychotherapeutic techniques like FORNET over generations of counsellors. Psychotherapeutic interventions like FORNET may facilitate the transition to peace in war-torn regions.

A systematic review of psychosocial interventions for adult refugees and asylum seekers

Background: Europe is in the midst of the largest refugee migration since the Second World War; there is an urgent need to provide an updated systematic review of the current best evidence for managing mental distress in refugee populations.Aims: The aim of this review is to provide an exhaustive summary of the current literature on psychosocial interventions, both trauma- and non-trauma-focused, for refugee populations experiencing post-traumatic stress disorder (PTSD), depressive or anxiety symptoms. To produce recommendations for future research and current clinical practice.Method: Searches were conducted in PubMed, PsychINFO (Hosted by Ovid), PILOTS and Social Services Abstracts; 5305 articles were screened and 40 were included.Results: This review found medium to high quality evidence supporting the use of narrative exposure therapy (NET). A lack of culturally adapted treatments was apparent and there was less evidence to support standard cognitive behavioural therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and multidisciplinary treatments.Conclusion: NET produced positive outcomes in refugees from a diverse range of backgrounds and trauma types. There is a general dearth of research in all intervention types: further research should include more "real-world" multidisciplinary interventions that better model clinical practice. Recommendations for evaluating local need, and creating a culturally sensitive workforce are discussed.

Evaluating effectiveness and cost-effectiveness of a group psychological intervention using cognitive behavioural strategies for women with common mental disorders in conflict-affected rural Pakistan: study protocol for a randomised controlled trial

Background

The impact of humanitarian disasters upon mental health is well recognised. The evidence for psychological interventions for mental health is mounting, but few interventions have been rigorously tested in humanitarian settings. To be sustainable in humanitarian settings interventions need to be short, simple, deliverable by nonspecialists under supervision, and adopt a transdiagnostic approach where an array of mental health outcomes are addressed simultaneously. These elements have been incorporated into the newly developed WHO Problem Management Plus (PM+) Group intervention. The aim of this trial is to evaluate the locally adapted PM+ Group intervention for women in Swat, Pakistan.

Methods

This PM+ Group trial is a two-arm, single-blind, cluster randomised controlled trial conducted in a community-based setting with women in rural Pakistan. PM+ is delivered in partnership with the Lady Health Worker (LHW) Programme which provides community-based health care to women in Pakistan. Thirty-four LHW clusters will be randomised in a 1:1 allocation ratio using a permuted-block randomisation method. Participants screened and found to meet the inclusion criteria will be allocated to either the PM+ intervention group (n = 306), or the control arm (n = 306). The manualised PM+ intervention involves five sessions, each lasting 3 h, and introduces four strategies applied by participants to problems that they are facing. It is delivered by local female facilitators with a minimum of 16 years of education who are provided with targeted training and supervision. The primary outcome is individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 20 weeks after baseline. Secondary outcomes include major depression, post-traumatic stress disorder, levels of social support, levels of functioning, and economic effectiveness. Intervention acceptability will be explored through an embedded qualitative study.

Discussion

The PM+ Group trial will provide important evidence on the effectiveness of an empirically supported psychological treatment delivered by nonspecialists in a humanitarian setting. If proven effective, the qualitative component will inform strategies for PM+ Group scale-up in health systems in other humanitarian settings.

Trial registration

Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000037404. Registered on 19 January 2016; WHO Protocol ID RPC705, v.4, 2 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1905-8) contains supplementary material, which is available to authorized users.

[Dissemination of psychotherapy modules for traumatized refugees : Experience gained from trauma work in crisis and conflict regions]

With each additional accumulative exposure to severe and traumatic stressors, the likelihood of developing mental health problems and physical diseases increases. Displaced individuals have usually experienced a number of serious threats to health due to organized violence in their home country or attacks during the flight. Frequently, domestic violence adds additional strain to the stressors experienced. The resulting impairments in psychosocial functioning reduce the resources needed for social adjustment and integration. Social exclusion then in turn often further aggravates the existing mental health complications. For the treatment of trauma spectrum disorders, different evidence-based psychotherapies are available. In high-income countries, trained and licensed psychotherapists are typically in positions to apply such interventions; however, even an advanced system with a high capacity, such as the psychotherapeutic care offered in Germany, severely struggles to manage the demands associated with the rapid addition of hundreds of thousands of displaced people. Germany's mental healthcare system at present lacks the resources, both human and technological, to effectively manage the present demands. Systematic scientific studies in resource-poor regions of war and conflict have demonstrated that the dissemination of effective treatment to local personnel, even with limited training, results in substantial improvements in the mental health challenges within the community: Organized as a cascade model, members of the refugee community learn to identify weakened fellow citizens requiring in-depth diagnostic interviews. Educated, bilingual individuals acquainted with their country's healthcare system (e. g. nurses, teachers and social workers) receive training to conduct structured interviews and evidence-based interventions under the supervision of centrally organized licensed psychotherapists. More complex cases are referred to local psychotherapists, psychiatrists or specialized treatment centers. These humanitarian efforts are based on the convention for the protection of human rights and secure the safety, freedom and dignity of these persons.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

BACKGROUND

Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects.

OBJECTIVES

The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps.

METHODS

A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis.

RESULTS

The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies.

CONCLUSION

The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

Treating Posttraumatic Stress Disorder in Female Victims of Trafficking Using Narrative Exposure Therapy: A Retrospective Audit

BACKGROUND

Human trafficking is a form of modern slavery that involves the forced movement of people internally within countries, or externally across borders. Victims who are trafficked for sexual exploitation are subject to repeated, multiple trauma, and high rates of mental health problems including posttraumatic stress disorder (PTSD) have been found. Narrative exposure therapy (NET) is an evidence-based treatment for PTSD.

METHODS

In this retrospective audit, we record the results of NET to treat 10 women who had been trafficked for sexual exploitation who were diagnosed with PTSD.

RESULTS

All 10 women completed the therapy and experienced a reduction in PTSD severity scores at posttreatment, with improvements that were maintained or further improved at 3-month follow-up. General distress was also significantly reduced following treatment.

CONCLUSION

Although limited by sample size and retrospective design, this audit demonstrates that NET is a feasible treatment for PTSD in this population and warrants further evaluation in a randomized controlled trial. Further adjunctive interventions may also be necessary to treat the additional psychological problems experienced by this population.

Narrative Exposure Therapy: A Proposed Model to Address Intimate Partner Violence-Related PTSD in Parenting and Pregnant Adolescents

Pregnant and parenting adolescents experience high rates of intimate partner violence (IPV) and its sequelae posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an innovative intervention that has demonstrated strong preliminary evidence in improving mental health. The specific aims of this article are 3-fold: (1) provide a brief background about IPV-related PTSD and depression among pregnant and parenting adolescents; (2) describe NET's theoretical principles, its therapeutic process, and provide a review of existing evidence; and (3) discuss NET as a potential treatment to address the mental health burden among adolescents experiencing IPV-related PTSD and depression.

Rethinking the service delivery system of psychological interventions in low and middle income countries

BACKGROUND

Global mental health is a growing field intricately connected to broader health, violence and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75 % of those with need in lower resource settings do not receive intervention. Most studies to date have examined the effectiveness of single-disorder mental health treatments - an approach that may be a significant challenge to scale-up and sustainability in lower resource settings.

MAIN BODY

This paper presents a brief overview of the scientific progress in global mental health, and suggests consideration of an internal stepped care delivery approach. An internal stepped care model is one idea of a delivery system, utilizing a common elements approach, where the same provider could navigate between different elements based on severity and type of problems of the client. It is distinct from traditional stepped care models in that clients remain with the same provider, rather than relying on referral systems.

CONCLUSION

An internal stepped care delivery system based on a simplified common elements approach could be more efficient, scalable, sustainable, and reduce the loss of clients to referrals in lower resource settings.

Efficacy of Narrative Writing as an Intervention for PTSD: Does the Evidence Support Its Use?

Although a number of effective psychotherapies for posttraumatic stress disorder (PTSD) are available, there is a need to develop alternative treatments for those who may not respond optimally to these treatments or who may not have access to clinicians who can competently deliver them. Narrative writing, which involves repeated recounting about a traumatic event in writing, is one treatment that deserves further examination as a potential alternative. In this paper, we describe the most commonly used narrative writing treatment protocols for those with either a diagnosis of PTSD or probable PTSD and discuss the available efficacy data for each of these protocols. We conclude with recommendations for using narrative writing to treat those with PTSD and offer recommendations for future work in this area.

Effects of psychotherapy on DNA strand break accumulation originating from traumatic stress

BACKGROUND

Previous research reveals an association between traumatic stress and an increased risk for numerous diseases, including cancer. At the molecular level, stress may increase carcinogenesis via increased DNA damage and impaired DNA repair mechanisms. We assessed DNA breakage in peripheral blood mononuclear cells from individuals with post-traumatic stress disorder (PTSD) and measured the cellular capacity to repair single-strand breaks after exposure to ionizing X-radiation. We also investigated the effect of psychotherapy on both DNA breakage and DNA repair.

METHODS

In a first study we investigated DNA breakage and repair in 34 individuals with PTSD and 31 controls. Controls were subdivided into 11 trauma-exposed subjects and 20 individuals without trauma exposure. In a second study, we analysed the effect of psychotherapy (Narrative Exposure Therapy) on DNA breakage and repair. Thirty-eight individuals with PTSD were randomly assigned to either a treatment or a waitlist control condition. Follow-up was performed 4 months and 1 year after therapy.

RESULTS

In study 1 we found higher levels of basal DNA breakage in individuals with PTSD and trauma-exposed subjects than in controls, indicating that traumatic stress is associated with DNA breakage. However, single-strand break repair was unimpaired in individuals with PTSD. In study 2, we found that psychotherapy reversed not only PTSD symptoms, but also DNA strand break accumulation.

CONCLUSION

Our results show - for the first time in vivo - an association between traumatic stress and DNA breakage; they also demonstrate changes at the molecular level, i.e., the integrity of DNA, after psychotherapeutic interventions.