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Cited by 215Mental Health Treatment and AccessPosttraumatic Stress Disorder ResearchMigration, Health and Trauma

Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises

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Purgato, Marianna, Gastaldon, Chiara, Papola, Davide, van Ommeren, Mark, Barbui, Corrado, Tol, Wietse A·2018·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd011849.pub2PMC PMC6513488
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Abstract

BACKGROUND: People living in humanitarian settings in low- and middle-income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post-traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population. OBJECTIVES: To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises. DATA COLLECTION AND ANALYSIS: We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post-traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes. MAIN RESULTS: We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub-Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive-behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) -1.07, 95% confidence interval (CI) -1.34 to -0.79; 1272 participants; 16 studies; low-quality evidence). The effect is smaller at one to four months (SMD -0.49, 95% CI -0.68 to -0.31; 1660 participants; 18 studies) and at six months (SMD -0.37, 95% CI -0.61 to -0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD -0.86, 95% CI -1.06 to -0.67; 1254 participants; 14 studies; low-quality evidence). Similar to PTSD symptoms, follow-up data at one to four months showed a smaller effect on depression (SMD -0.42, 95% CI -0.63 to -0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD -0.74, 95% CI -0.98 to -0.49; 694 participants; five studies; low-quality evidence) and at one to four months' follow-up after treatment (SMD -0.53, 95% CI -0.66 to -0.39; 969 participants; seven studi

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  • A Cochrane review of psychological treatments in humanitarian settings in low- and middle-income countries found a drop in effect size for post-traumatic stress disorder symptoms from -1·07 immediately after treatment (16 studies), to -0·49 at 1-3 months after intervention (18 studies), and -0·37 at 6 months after intervention (five studies).

    “A Cochrane review of psychological treatments-mostly consisting of relatively higher resource-intensive interventions-in humanitarian settings in low-income and middle-income countries found a drop in effect size for post-traumatic stress disorder symptoms from -1·07 immediately after treat­ ment (16 studies), to -0·49 at 1-3 months after intervention (18 studies), and -0·37 at 6 months”

    From Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: A cluster randomised trial (2020) · cites this paper as [3]

    Section 1.1, “PTSD symptoms,” reports the stated effect sizes and study counts for adults and describes a declining effect over follow-up. Its follow-up windows are one to four months, not one to three months, and six months or later, not precisely six months. The passages do not establish the citing sentence’s description of the interventions as mostly relatively resource-intensive. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Research focused on men affected by violence has largely focused on former combatants and not on other men in the community in need of services.

    “The little research that has focused on men affected by violence has largely focused on former combatants [16]”

    From Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar – a qualitative investigation (2021) · cites this paper as [16]

    The review lists trials involving former child soldiers and ex-combatants (Implications for research; page unavailable), so it supports the point that they have been studied. But its Participants section does not establish that research on men affected by violence has largely focused on former combatants rather than other men in the community; it reports only that nine included studies had mostly male participants. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • In a recent systematic review of 29 trials of mental health treatments in LMICs, four focused specifically on men - largely ex-combatants - and five included 50% or more men in the sample.

    “In a recent systematic review of 29 trials of mental health treatments in LMICs, four focused specifically on men – largely ex-combatants – and five included 50% or more men in the sample [16].”

    From Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar – a qualitative investigation (2021) · cites this paper as [16]

    The Participants section reports that nine studies had more than 50% male participants, broadly consistent with the claim’s male-participation total. But Figure 1 reports 33 RCTs, not 29, and the passages do not establish the claimed split between four men-only studies and five other male-majority studies or that the men-only studies largely involved ex-combatants. Page numbers were not available in our copy. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

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Authors
Purgato, M., Gastaldon, C., Papola, D., van Ommeren, M., Barbui, C., & Tol, W. A.
Affiliations
  • University of Verona (IT)
  • World Health Organization; Department of Mental Health and Substance Abuse; Avenue Appia Geneva Switzerland CH-1211
  • Johns Hopkins University (US)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2018-07-05
Volume
2018
Issue
7
Pages
CD011849-CD011849
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd011849.pub2
PMC
PMC6513488
OpenAlex
W1788921434
Cited by
215
References
181
Citations by year
2026: 6 · 2025: 12 · 2024: 27 · 2023: 21 · 2022: 40 · 2021: 52 · 2020: 38 · 2019: 13 · 2018: 2 · 2012: 3
FWCI
3.96
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
World Health Organization
Topics
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
Keywords
psychotherapy, mental illness, humanitarian crisis, post-traumatic stress disorder, depression, anxiety disorders, medically unexplained physical symptoms, somatoform disorders, low- and middle-income countries, armed conflict, disaster mental health, treatment effectiveness, treatment acceptability, children and adolescents, waitlist control, internally displaced persons
MeSH terms
Armed Conflicts, Adolescent, Adult, Age Factors, Aged, Anxiety Disorders, Behavior Therapy, Child, Child, Preschool, Major Depressive Disorder, Developing Countries, Disasters, Humans, Middle Aged, Patient Dropouts, Psychotherapy, Somatoform Disorders, Stress Disorders, Post-Traumatic, Stress, Psychological, Violence, Waiting Lists, Randomized Controlled Trials as Topic, Eye Movement Desensitization Reprocessing, Narrative Therapy

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