A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq

Abstract

BackgroundExperiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.MethodsTwenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.ResultsAdult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004).ConclusionsBoth interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.Trial RegistrationClinicalTrials.Gov NCT00925262. Registered June 3, 2009.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-014-0360-2) contains supplementary material, which is available to authorized users.

Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries

“…Abbreviation: CI, confidence interval; df , degrees of freedom; SD, standard deviation. Bolton 2014a(i): BMC Psychiatry , behavioral activation experimental condition versus control; Bolton 2014a(ii): BMC Psychiatry , cognitive processing therapy experimental condition versus control; Bolton 2014b, PLoS Medicine , common elements treatment approach (CETA) experimental condition versus control; Weiss 2015(i): BMC Psychiatry , cognitive processing therapy experimental condition versus control; Weiss 2015(ii): BMC Psychiatry , common elements treatment approach (CETA) experimental condition versus control.…”

“…Systematic reviews (Clarke et al 2013, van Ginneken et al 2013) have demonstrated that these innovations have been associated with moderate to large effects on clinical and social outcomes in individuals with CMDs. More recently, global mental health has followed trends from high-income countries (HICs), moving toward transdiagnostic, or common element, approaches that address the barrier of focusing on treating a single disorder (Bolton et al 2014a,b; Murray et al 2014). Transdiagnostic treatments teach a set of common practice elements that can be delivered in varying combinations to address a range of problems.…”

The role of context in the implementation of trauma-focused treatments: effectiveness research and implementation in higher and lower income settings

“…A number of studies have examined the feasibility of training primary care staff [30] or paraprofessionals [15] to deliver EBPs, and some have found evidence for effectiveness [15,31]. A growing body of research has begun to examine and compare training models and methods [32,23], but there is often insufficient infrastructure to retain trained personnel after a particular project has been completed [17].…”

Treating Posttraumatic Stress Disorder in Diverse Settings: Recent Advances and Challenges for the Future

“…CPT is a cognitive-behavioral therapy that was first developed to treat trauma symptoms in female survivors of sexual violence. Most recently, CPT has been implemented in Iraq [38–40], the Democratic Republic of Congo (DRC); [41••, 42], and an urban community health center outside Boston [43, 44]. One of the first global randomized controlled trials of CPT occurred in the DRC for survivors of sexual violence [41••].…”

“…This study added a significant contribution to our understanding of the treatment of ongoing trauma: namely, that individuals living in high-violence areas or who are experiencing chronic trauma can achieve significant reduction in PTSD symptoms by receiving CPT, compared to individual supportive therapy, similar to previous trials conducted in low-conflict regions. Additionally, a randomized controlled trial of adapted CPT was performed in Iraq with Kurdish survivors of torture [38]. CPT was effective at reducing depression, dysfunction, anxiety, PTSD symptoms, and traumatic grief, providing support for the finding that CPT (compared to the wait-list control) is not only effective at reducing PTSD symptoms alone, but has secondary effects at reducing other psychopathology symptoms.…”