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

Abstract

BackgroundTorture 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 findingsWe 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.ConclusionsOur 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 studi...

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

“…Evaluating nine studies of cognitive behavioural therapy (CBT) and narrative exposure therapy (NET) with torture survivors, a Cochrane review found no immediate posttreatment effect. In contrast, three NET studies, and a CBT study elicited medium effect sizes on trauma symptoms at six-month follow-up (Patel, Kellezi, & Williams, 2014), while a meta-analysis of torture survivors found that psychological interventions significantly reduced PTSD symptoms by the end of treatment, with a small SMD that remained at follow-up (Hamid, Patel, & Williams, 2019). Recently, three recent systematic reviews of the treatment of refugees and asylum seekers resettled in highincome countries have demonstrated the efficacy of psychosocial interventions on PTSD symptoms (Nosè et al, 2017;Thompson, Vidgen, & Roberts, 2018;Turrini, Purgato, Acarturk, & Anttila, 2019).…”

“…Evaluating nine studies of cognitive behavioural therapy (CBT) and narrative exposure therapy (NET) with torture survivors, a Cochrane review found no immediate posttreatment effect. In contrast, three NET studies, and a CBT study elicited medium effect sizes on trauma symptoms at six-month follow-up (Patel, Kellezi, & Williams, 2014 ), while a meta-analysis of torture survivors found that psychological interventions significantly reduced PTSD symptoms by the end of treatment, with a small SMD that remained at follow-up (Hamid, Patel, & Williams, 2019 ).…”

Rehabilitation for torture survivors: Six evidence myths and their implications for future research

“…One of the major ones is that of restricting eligibility for the trial according to population characteristics, discussed under myth 4, but often excluding people with multiple problems, or who are more likely to drop out of psychological care; examples are people with insecure accommodation or undetermined legal status, as is common in torture survivor populations, or who do not speak fluently the language of the rehabilitation service provider. Some RCTs on psychological interventions with torture survivors (see reviews by Hamid et al 2019;Patel et al 2014) have recognised these issues and taken a more inclusive approach to recruitment, not without its own difficulties. Another disadvantage is that the interventions are multi-component -they consist of a series of separate or combined components of presumed therapeutic benefit, delivered by a trained therapist -and no RCT can disaggregate the effects of each component from the others, yet the assumption that they are always synergistic, and to all participants, is rarely tested or even raised as a concern.…”

“…Our systematic reviews and meta-analyses (Patel et al, 2014;Hamid et al, 2019; see also Patel et al, 2016) found relatively few studies (restricted to randomised controlled trials); all were of individual psychological 'treatment', usually compared to 'no treatment', and primarily aimed at reducing post-traumatic stress disorder (PTSD), a psychiatric disease category. Benefits of these interventions were few and weak; confidence intervals were wide and methodological biases common, undermining confidence in estimates of 'treatment' effects.…”

Offering care for victims of torture among a migrant population in a transit country: a descriptive study in a dedicated clinic from January 2017 to June 2019

“… 8 There is limited information about the types of services provided to torture survivors and the outcomes of such services. 9 These services can include the provision of psychological interventions (at individual, family or group level) aiming to change cognitive, emotional or behavioural outcomes, which have been reported to improve the psychological distress of torture survivors. 9 …”