Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review

Randomised clinical trial investigating memory training for recovery-adolescents in addressing psychiatric concerns among adolescents in Iraq

Background

In this randomised clinical trial, we investigated the efficacy of MEmory Training for Recovery-Adolescent (METRA) in improving psychiatric symptoms among adolescents in Iraq.

Methods

In the study, we included adolescents aged 10-19 years with heightened psychiatric distress living in Kirkuk. It was a parallel-group trial comparing METRA with treatment as usual (TAU), with a three-month follow-up. The study occurred between July 2023 and January 2024. Participants assigned to METRA received a 10-session group-intervention comprised of memory specificity training and writing for recovery. Assessments occurred at baseline, post-intervention, and three months after treatment. Primary outcome measures were self-reported posttraumatic stress disorder (PTSD) and depression symptoms post-intervention. Secondary outcomes were measures of anxiety and psychiatric difficulties. We also examined the costs and affordability of METRA in a humanitarian context. The sample size for primary analyses included 67 adolescents in the METRA group and 65 adolescents in TAU.

Results

Following the intention-to-treat principle, linear mixed effects models found at post-intervention the METRA group had a 10.96-point decrease (95% confidence interval (CI) = -13.82, -8.09) in PTSD symptoms and a 3.27-point decrease (95% CI = -4.67, -1.87) in depression symptoms. Improvements were maintained at the three-month follow-up. While the time main effects were significant (P < 0.001), the group × time interactions were not significant (P = 0.61 for PTSD and P = 0.71 for depression); thus, there was no evidence that these improvements were superior to the symptom improvements observed in TAU.

Conclusions

In this study, we found that while METRA was not more effective than TAU, it was less costly, offering an option for replacing current practice. The findings highlight a need for further research in this area of global mental health.

Registration

Australian New Zealand Clinical Trials Registry (ACTRN12622001413718).

Adolescent health research and initiatives in the occupied Palestinian territory: a scoping review

OBJECTIVE

Adolescence is a period characterised by profound changes that warrant special attention, particularly for adolescents living in conflict-stricken regions. The dearth of available information regarding observational health research and interventions in the occupied Palestinian territory emphasises the need for a comprehensive examination of all accessible data. The aim of this review is to conduct a thorough analysis of the existing literature and initiatives focusing on adolescent health in the occupied Palestinian territory.

DESIGN

Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) framework.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, CINAHL and PsycINFO, along with grey literature, were searched for the period between 2012 and 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Research studies, programmes or interventions targeting adolescents aged 10-19 years, conducted in the occupied Palestinian territory, and published between 2012 and 2023 were considered. Both peer-reviewed articles and grey literature were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers conducted abstract and full-text screening of the selected articles. Discrepancies were resolved through discussion, with a third reviewer consulted when necessary. Data extraction was performed using Excel software by two independent reviewers. Extracted data were categorised as either intervention or observational research. For analysis, the extracted data underwent an explanatory frequency analysis using SPSS software.

RESULTS

Our search yielded 114 research projects and 19 interventions from peer-reviewed and grey literature searches. The most frequently addressed topic was non-communicable diseases, with health awareness being the most common method employed in interventions. The studies targeted both male and female participants, with a particular focus on adolescents aged 10-19 years. The majority of the included studies received funding from international sources and were conducted by foreign and local researchers.

CONCLUSION

This review sheds light on the current framework of adolescent health interventions, identifies areas where research is lacking and advocates for evidence-based practices to enhance the well-being of Palestinian adolescents. Future interventions should encompass the younger age group, and research should strive to provide precise information for each age group independently.

Recovery-oriented and trauma-informed care for people with mental disorders to promote human rights and quality of mental health care: a scoping review

BACKGROUND

In several countries, the growing emphasis on human rights and the ratification of the Convention on the Rights of Persons with Disabilities (CRPD) have highlighted the need for changes in culture, attitudes and practices of mental health services. New approaches, such as recovery-oriented care (ROC) and trauma-informed care (TIC) emphasize the users' needs and experiences and promote autonomy and human rights.

AIMS

To provide an overview of the literature on recovery-oriented care (ROC) and trauma-informed care (TIC) and their relevance to the promotion of human rights and quality of mental health care.

METHOD

We conducted a scoping review by searching the following databases: PubMed, Scopus, PsycINFO. We performed a qualitative synthesis of the literature aimed at reviewing: (1) current conceptualisations of recovery in mental health care; (2) recovery-oriented practices in mental health care; (3) current conceptualizations of trauma and TIC in mental health care; (4) trauma-informed practices in mental health care; (5) the relationship between ROC and TIC, with a particular focus on their shared goal of promoting alternatives to coercion, and on trauma-informed and/or recovery oriented alternatives to coercion.

RESULTS

According to prevailing conceptual frameworks, ROC and TIC share many underlying principles and should be regarded as complementary. Both approaches affirm the conceptualization of service users as persons, foster their autonomy and rely on their involvement in designing and monitoring mental health services. Both approaches promote human rights. A wider consensus on conceptual frameworks, tools and methodologies is needed to support ROC and TIC implementation and allow comparison among practices. Recovery-oriented and trauma-informed models of care can contribute to the implementation of non-coercive practices, which show promising results but warrant further empirical study.

CONCLUSIONS

Recovery-oriented and trauma-informed practices and principles may contribute to the shift towards rights-based mental health care and to the implementation and successful uptake of alternatives to coercion. Local and international work aimed to promote and test these approaches may provide a contribution to improving mental health care world-wide. Future research should focus on the outcomes of all involved stakeholders' and include the perspectives of both staff members and service users in different contexts.

Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War

OBJECTIVE

More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions.

METHOD

Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network.

RESULTS

The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear.

CONCLUSION

There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions.

PLAIN LANGUAGE SUMMARY

Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support for children and adolescents living in war affected regions. In this scoping review, the authors identified 1 study evaluating digital mental health interventions for children and adolescents affected by war and 5 for those affected by disasters. In addition, 35 interventions were identified through expert consultation as of possible relevance. The authors found very limited evidence for the use of digital mental health interventions for children and adolescents affected by war, and given this provide a framework to inform the development of new interventions.

DIVERSITY & INCLUSION STATEMENT

We actively worked to promote sex and gender balance in our author group.

STUDY PREREGISTRATION INFORMATION

Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.

The youth mental health crisis: analysis and solutions

Background

Since the mid-20th century, mental illness has become a leading cause of health burden, particularly among adolescents and emerging adults, with most disorders emerging before the age of 25. Over the past two decades, mental ill health has surged to alarming levels, with evidence confirming that the increase is not just due to better awareness or diagnosis but reflects a genuine public health crisis.

Study design/method

We explore the evolving landscape of youth mental health and its contributing factors, including family dynamics, educational pressures, climate change, social media, and socio-economic challenges, potentially linked to neoliberal policies. A narrative review methodology was employed to analyze these factors and their role in the trends of mental ill-health among young people.

Study results

We document mental health trends since the mid-1990s, focusing on mental and substance use disorders among young people and their current needs. Potential new explanatory factors and megatrends, potentially flowing from a paradigm shift in the global political economy which has largely passed under the radar, yet which has produced fragmentation and inequality, are identified, with the COVID-19 pandemic further intensifying these trends. We discuss methodologies to estimate the contribution of these megatrends and outline potential barriers to implementation, along with strategies to overcome them.

Conclusion

This review calls for a comprehensive global action plan, emphasizing prevention, early intervention, and improved treatment strategies. In addition to strengthening prevention, which may take time and be elusive, immediate action is needed to innovate and expand services, which are currently under-resourced and overwhelmed.

Brief CBT-based psychological interventions to improve mental health outcomes in refugee populations: a systematic review and meta-analysis

Background: Refugees, asylum seekers, and internally displaced people experience a high burden of mental health problems owing to their experiencing traumas and stressful events.Objective: To summarise the available evidence and analyse the efficacy of brief psychological interventions (< 3 months) on improving mental health outcomes, including depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms in refugees.Method: We searched Medline, EMBASE, PsycINFO, CINAHL, and Global Index Medicus from inception to 19 December 2023. We included controlled studies using any cognitive behavioural therapy (CBT) or CBT-based therapies delivered over a short time (< 3 months), which reported mental health outcomes pre-and post-intervention. We conducted meta-analyses using random effects to derive pooled summary statistics. The quality of the evidence was assessed with the Cochrane Risk of Bias (RoB2) and ROBINS-I tools. This study is registered on the Open Science Framework, DOI 10.17605/OSF.IO/9CXU4.Results: 34 eligible studies across 37 publications were retrieved for analysis, and 33 studies with 4479 participants were included in the meta-analysis. There was an overall improvement in immediate mental health outcomes for all three domains, with analysis of 13 studies on anxiety outcomes (SMD -1.12, 95% CI -1.72 to -0.52), 20 studies on depression (SMD -1.04, 95% CI -1.97 to -0.11), and 24 studies on PTSD (SMD -0.82, 95% CI -1.20 to -0.45). At 3 to 6-month follow-up, however, analysis of mental health outcomes shows no significant change from baseline, with a SMD of 0.24 (95% CI -0.94 to 1.42) across 4 studies, -0.73 (95% CI -2.14 to 0.68) across 9 studies, and 0.29 (95% CI -0.94 to 1.53) across 12 studies for anxiety, depression, and PTSD respectively.Conclusion: Low-quality evidence shows brief psychological interventions have a positive immediate effect on refugees and internally displaced people's mental well-being. However, these effects do not persist in the short-term follow up. Heterogeneity was high, even among subgroups, impacting our findings' generalisability.

Suicidal ideation amongst medical students in Shiraz, South of Iran: a cross-sectional study

Suicide is a preventable act, but irreversible once committed; Hundreds of thousands of people commit suicide annually around the globe. One of the groups at high risk of suicide is medical students. Suicidal ideation (SI) is a forerunner to suicidal attempts which could be assessed. Since there are not enough data about this issue among Iranian medical students, we aimed to estimate the prevalence of SI and risk factors among Shiraz University of Medical Sciences (SUMS) undergraduate medical students. An institutional-based cross-sectional study was conducted from December 2022 to February 2023 in the medical school of SUMS. Students willing to participate were recruited by stratified random sampling technique. Data were collected using a self-administered questionnaire along with Beck Scale for Suicidal Ideation (BSSI) and Depression, Anxiety, and Stress Scale (DASS-21). Bivariate analysis and multivariate logistic regression model were carried out using BlueSky software. The study identified that 76 out of 308 attendees (24.7%, 95% CI: 19.9%-29.5%) reported experiencing suicidal ideation. Very severe depression [AOR= 26.705, 95% CI: (8.825 - 91.046)], Severe depression [AOR= 17.142, 95% CI: (5.567 - 58.121)], positive family history of psychiatric disorders [AOR= 4.181, 95% CI: (1.773 - 10.014)], comorbid mental illness [AOR= 2.502, 95% CI: (1.123 - 5.553)], were found to be statistically related to having SI. This study showed that one out of every four undergraduate medical students at SUMS has SI, which warns everyone to plan and act to prevent the loss of more lives. Depression, family history of psychiatric disorders, and comorbid mental diseases were found to be strongly associated with SI.

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

Teaching Recovery Techniques (TRT) to Ukrainian children and adolescents to self-manage post-traumatic stress disorder (PTSD) symptoms following the Russian invasion of Ukraine in 2022 - The first 7 months

BACKGROUND

The Russian invasion of Ukraine in February 2022 prompted many to provide mental health input, especially trauma management, to Ukrainian children and adolescents (C/A) exposed to it.

METHODS

Rapid cascade training of 200 Ukrainian psychologists during 2022 to provide, in pairs, free of charge and without selection, TRT courses of 4-6, 90 min sessions online or face to face to C/A 7 to 23 years in Ukraine and those migrating abroad. CRIES-8 PTSD questionnaires were administered at the beginning and end of the courses during May-December 2022. Age, gender, their geographical war risk, and whether C/A had stayed or migrated elsewhere were collected. A CRIES-8 score of ≥17/40 defined likely PTSD.

RESULTS

3123 C/A completed an initial CRIES-8 questionnaire with matching demographics, 2737 a questionnaire at the end and 1798 both. At entry to TRT, likely PTSD was greater in females (65 %) than males (52 %, p < 0.001) declining with increasing age, particularly in males (p < 0.001). Migration had mixed effects and moving to lower war risk areas or abroad did not reduce PTSD risk. TRT benefited 68 % of C/A overall by reducing CRIES-8 from ≥17 to <17, the rate increasing the more experienced the TRT facilitators became (p < 0.0001). Online and face to face outcomes were the same.

LIMITATIONS

The chaos of war prevented capture of all potential C/A questionnaires and long-term repeat testing not yet undertaken.

CONCLUSIONS

Even in the chaos of war, effective mental health input can be rapidly and cheaply (c.50 USD/child) provided and should be encouraged.

Impact of Syrian Conflict on the Oral Health of Adolescents: A Cross-Sectional Study

BACKGROUND

The Syrian conflict has had a negative impact on the psychological and overall health of adolescents. However, little is known about the oral health of those who are internally displaced.

AIMS

The purpose of this study was to investigate the relationship between mental health state and self-reported oral health and habits in Syrian adolescents.

METHODS

A total of 99 adolescents living in Syria were included in the study. The participants were given four questionnaires: the International Trauma Questionnaire (ITQ), the Depression Anxiety Stress Scale-21 (DASS-21), the Epworth Sleepiness Scale (ESS), and the World Health Organization (WHO) Oral Health Questionnaire for Children (2013). The relationship between self-reported oral and mental health was evaluated.

RESULTS

Adolescents with symptoms of mental disturbances or abnormal sleep conditions were statistically more likely to self-report the health of their teeth and gums as below average, less likely to brush their teeth regularly, and reported more frequent smoking (p<0.05). Moreover, symptoms of mental disturbances and abnormal sleep conditions were statistically more likely in adolescents living in rural areas and whose parents' education did not exceed secondary school (p<0.05).

CONCLUSION

Syrian adolescents reported mental disturbances, which were reflected in their poor oral health and habits. These findings confirm the need for psychiatric and oral health care programs for Syrians who remain in areas of conflict.

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

BACKGROUND

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

AIM

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

METHOD

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

FINDINGS

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