Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence

In the paper

“Ongoing supervision was provided through a multitiered supervision system that was first used in Uganda 31 and subsequently expanded.32”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [31] 31. Verdeli H, Clougherty K, Bolton P, et al. Adapting group interpersonal psycho- therapy for a developing country: experi- ence in rural Uganda. World Psychiatry 2003;2:114-20.
• Supported

  The Overview describes ongoing supervision at multiple levels: trainers maintain weekly contact with supervisors, who in turn provide feedback to counselors. This supports the quoted description of a multitiered supervision system. (LLM, conf=0.91)

  cites [32] 32. Murray LK, Dorsey S, Bolton P, et al. Building capacity in mental health inter- ventions in low resource countries: an apprenticeship model for training local providers. Int J Ment Health Syst 2011; 5:30. source

In the paper

“Cognitive processing therapy has shown efficacy in high-income countries, with effects lasting for 5 or more years.[13][14][15]”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [13] 13. Chard KM. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol 2005;73:965-71.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [14] 14. Resick PA, Nishith P, Weaver TL, As- tin MC, Feuer CA. A comparison of cogni- tive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867-79.
• Supported

  The Method describes a U.S.-based trial of cognitive processing therapy (CPT) for women with PTSD after rape, with follow-up assessments 5–10 years after enrollment. The Discussion reports marked improvement after CPT and maintenance of treatment gains for an average of six years. This supports the claim as an example of efficacy in a high-income country, though the study itself was not conducted across multiple countries. (LLM, conf=0.91)

  cites [15] 15. Resick PA, Williams LF, Suvak MK, Monson CM, Gradus JL. Long-term out- comes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. J Consult Clin Psy- chol 2012;80:201-10. source

In the paper

“Prior studies have shown that increases in the quality and quantity of clinical supervision can explain some treatment effects.39,40”

What the sources say

• ?Not checked — no full text of the sourcecites [39] 39. Sholomskas DE, Syracuse-Siewert G, Rounsaville BJ, Ball SA, Nuro KF, Carroll KM. We don't train in vain: a dissemina- tion trial of three strategies of training clinicians in cognitive-behavioral therapy. J Consult Clin Psychol 2005;73:106-15. source
• Partly supported

  The Results (page unavailable) associate lack of therapist training and treatment monitoring with smaller outcome effect sizes. The Discussion (page unavailable) cautions that these analyses are exploratory and correlational. The paper does not assess increases in the quality or quantity of clinical supervision specifically, or establish that supervision explains treatment effects. (LLM, conf=0.84)

  cites [40] 40. Stewart RE, Chambless DL. Cogni- tive-behavioral therapy for adult anxiety disorders in clinical practice: a meta- analysis of effectiveness studies. J Consult Clin Psychol 2009;77:595-606. sourceExperimental — accuracy not yet measured

In the paper

“Both the individual-support and therapy groups had significant improvements during treatment, with effects maintained at 6 months (Fig. 2).”

In the paper

“Approximately 70% of participants in the therapy group met our criteria for probable depression or anxiety at baseline, with 10% or less meeting the criteria at either follow-up assessment (Table 2).”

In the paper

“For PTSD symptoms (HTQ) and combined depression and anxiety symptoms (HSCL-25), participants in the therapy group had significantly greater improvements than those in the individual-support group (Table 2) at both follow-up as-sessments, with all treatment-effect sizes greater than 1.0.”

In the paper

“The symptom scores of participants in the therapy group decreased, on average, to less than”

In the paper

“All comparisons were prespecified, and all tests were two-sided.”

In the paper

“Psychosocial assistants who provided therapy underwent 2 weeks of in-person training with trainers based in the United States (the fourth and fifth authors), with the use of a manual 30 that was adapted and translated locally.”

In the paper

“efits were large and were maintained 6 months after treatment ended.”

In the paper

“A total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments.”

In the paper

“Both the HSCL-25 and the HTQ have been used internationally with sexualviolence survivors 20 and have solid psychometric properties with conflict-affected samples [21][22][23]”

What the sources say

• ?Not checked — no full text of the sourcecites [20] 20. Tsutsumi A, Izutsu T, Poudyal AK, Kato S, Marui E. Mental health of female survivors of human trafficking in Nepal. Soc Sci Med 2008;66:1841-7. source
• ?Not checked — no full text of the sourcecites [21] 21. Conybeare D, Behar E, Solomon A, Newman MG, Borkovec TD. The PTSD Checklist -Civilian Version: reliability, validity, and factor structure in a nonclin- ical sample. J Clin Psychol 2012;68:699- 713. source
• ?Not checked — no full text of the sourcecites [22] 22. Ruggiero KJ, Del Ben K, Scotti JR, Ra- balais AE. Psychometric properties of the PTSD Checklist -Civilian Version. J Trauma Stress 2003;16:495-502. source

In the paper

“Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.”

In the paper

“Problems with security and cases in which the wrong women were interviewed reduced the number of follow-up assessments.”

In the paper

“Analyses were performed on data from all participants, regardless of the level of participation.”

In the paper

“Finally, differences in how therapy and individual support were provided may affect our conclusions.”

In the paper

“As compared with participants in the therapy group, those in the individual-support group were younger and less likely to be married, and they lived with fewer people (Table 1).”

In the paper

“Factors that were significantly associated with loss to follow-up were older age (with age as a continuous variable), assignment to individual support, pregnancy at baseline, experience with or witnessing of a wider range of traumas, and language spoken.”

In the paper

“Prior research has suggested that short-term therapies may not be effective for populations exposed to ongoing trauma or multiple severe traumas.37,38”

What the sources say

• ?Not checked — no full text of the sourcecites [37] 37. Cloitre M, Stovall-McClough KC, Nooner K, et al. Treatment for PTSD re- lated to childhood abuse: a randomized controlled trial. Am J Psychiatry 2010; 167:915-24. source
• ?Not checked — no full text of the sourcecites [38] 38. Dorrepaal E, Thomaes K, Smit JH, et al. Stabilizing group treatment for com- plex posttraumatic stress disorder relat- ed to childhood abuse based on psycho- education and cognitive behavioral therapy: a pilot study. Child Abuse Negl 2010;34:284-8. source

In the paper

“Although the clinical meaning of standard cutoff scores is therefore uncertain, the score itself can still be meaningfully interpreted: 1.75 indicates that women are reporting that symptoms occur, on average, nearly a”

In the paper

“Randomization was performed within blocks of two to four villages grouped on the basis of language and proximity”

In the paper

“IRC supervisors monitored the services provided by means of monthly visits and reviews of interim monitoring forms.”

In the paper

“Fidelity to the therapy protocol was assessed with the use of checklists of key treatment elements and global ratings of treatment knowledge and skills, as observed by supervisors during group sessions.”

In the paper

“The results indicate that with appropriate training and supervision, psychotherapeutic treatments such as cognitive processing therapy can be successfully implemented and can have an effect in settings with few mental health professionals.”

In the paper

“Eastern Democratic Republic of Congo is a low-income, conflict-affected region in which political and economic instability are ongoing problems and nearly 40% of women have experienced sexual violence.12”

What the sources say

• ?Not checked — no full text of the sourcecites [12] 12. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Demo- cratic Republic of the Congo. JAMA 2010;304:553-62. source

In the paper

“The checklists were adapted and pilot-tested in each language group.”

• Also stated in: § Setting, Participants, and Assessment Measures · plain

  “Study measures were translated into five local languages: Kibembe, Kifuliro, Kihavu, Mashi, and Swahili.”

In the paper

“The sponsors had no role in the trial design or conduct; the collection, management, analysis, or interpretation of data; or manuscript preparation, review, or approval.”

In the paper

“There may also have been biases in recruitment that resulted in higher average symptom scores in villages that provided individual support because psychosocial assistants recruiting patients knew ahead of time whether they would be providing therapy or individual support.”

In the paper

“An average HSCL-25 score of 1.75 or higher and an average HTQ score of 1.75 or higher were considered to be predictive of clinically significant depression or anxiety and PTSD, respectively, on the basis of data from other conflict-affected populations.24,25”

What the sources say

• ?Not checked — no full text of the sourcecites [24] 24. Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 1987; 144:497-500. source
• ?Not checked — no full text of the sourcecites [25] 25. McDonald SD, Calhoun PS. The diag- nostic accuracy of the PTSD Checklist: a critical review. Clin Psychol Rev 2010;30: 976-87. source

In the paper

“Because therapy, but not individual support, was provided in groups, it is unclear how much of the treatment effect was due to the group context.”

In the paper

“In our study, cognitive processing therapy, as compared with individual support alone, was effective in reducing PTSD symptoms and combined depression and anxiety symptoms and improving functioning in female survivors of sexual violence in eastern Democratic Republic of Congo.”

In the paper

“Because symptoms of these disorders could be nonpathologic reactions to extreme circumstances, it is unclear what proportions of participants actually met clinical criteria.”

In the paper

“Participants in the therapy group attended an average of 8.5 of 12 sessions offered, with 141 participants (90%) completing at least 9 sessions (defined as treatment completion).”

In the paper

“Assuming a 20% dropout rate, we calculated that enrollment of 180 participants in each study group would provide 80% power to detect at least a 0.5-point difference between groups with respect to the reduction in average symptom scores, adjusting for a variance-inflation factor of 2.0.”

In the paper

“The therapy was adapted for illiterate participants and those potentially exposed to ongoing violence.”

In the paper

“Institutional review boards at the Johns Hopkins Bloomberg School of Public Health and Kinshasa School of Public Health approved the protocol.”

In the paper

“In this study of sexual-violence survivors in a low-income, conflict-affected country, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms and improved functioning.”

In the paper

“An additional 4 women who did not meet the inclusion criterion of a total symptom score of at least 55 were mistakenly recruited in one village that provided therapy; these women were included in the analysis.”

In the paper

“After therapy training, one psychosocial assistant was excluded because training-based quizzes and skill observation raised competency concerns; therefore, the village in which she worked was excluded.The trial included 15 study villages (7 that provided therapy and 8 that provided individual support).”

In the paper

“Factors associated with loss to follow-up were identified with the use of lo-gistic regression; those at a significance level of less than 0.20 were used to generate weighting estimates to adjust for loss to follow-up (data were missing for 135 participants [33%] at the end of treatment and for 92 participants [23%] at 6 months after treatment).”

In the paper

“A total of 231 women (57%) completed all three assessments; 352 (87%) completed the baseline assessment and at least one follow-up assessment.”

In the paper

“Cognitive processing therapy is a protocol-based therapy for treating depression, anxiety, and PTSD in sexual-violence survivors.9,[27][28][29]”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [9] 9. Ougrin D. Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry 2011;11:200.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [27] 27. Resick PA, Schnicke MK. Cognitive pro- cessing therapy for sexual assault victims. J Consult Clin Psychol 1992;60:748-56.
• ?Not checked — no full text of the sourcecites [28] 28. Resick PA, Galovski TE, O'Brien Uhl- mansiek M, Scher CD, Clum GA, Young-Xu Y. A randomized clinical trial to dismantle components of cognitive processing thera- py for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol 2008;76:243-58. source

In the paper

“After the exclusion of 1 participant who received therapy owing to paperwork errors, the study included 405 women.”

In the paper

“Functional impairment was based on the degree of difficulty in performing important tasks of daily living that were identified on the basis of qualitative data from the study villages, with the use of methods described elsewhere.16,26”

What the sources say

• ?Not checked — no full text of the sourcecites [16] 16. Bass JK, Ryder RW, Lammers MC, Mukaba TN, Bolton PA. Post-partum de- pression in Kinshasa, Democratic Repub- lic of Congo: validation of a concept using a mixed-methods cross-cultural approach. Trop Med Int Health 2008;13:1534-42. source
• ?Not checked — no full text of the sourcecites [26] 26. Bolton P, Tang AM. An alternative ap- proach to cross-cultural function assess- ment. Soc Psychiatry Psychiatr Epidemiol 2002;37:537-43. source

In the paper

“Our findings are consistent with the results of trials conducted in high-income countries, both for cognitive behavioral interventions in general 36 and for cognitive processing therapy”

• Also stated in: § Discussion · plain

  “specifically, 14,27 with effect sizes of 0.62 and 2.7 in the latter two studies.”

What the sources say

• ?Not checked — no full text of the sourcecites [36] 36. Olatunji BO, Cisler JM, Deacon BJ. Ef- ficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-ana- lytic findings. Psychiatr Clin North Am 2010;33:557-77. source
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [14] 14. Resick PA, Nishith P, Weaver TL, As- tin MC, Feuer CA. A comparison of cogni- tive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867-79.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [27] 27. Resick PA, Schnicke MK. Cognitive pro- cessing therapy for sexual assault victims. J Consult Clin Psychol 1992;60:748-56.

In the paper

“Study participants provided oral informed consent, and none received compensation.”

In the paper

“research assistants, who were unaware of the village treatment assignments, obtained informed consent and administered the study questionnaires.”

• Also stated in: § Study Design · plain

  “For both follow-up assessments, two research assistants, who were unaware of the village treatment assignments, spent 1 week in each village assessing the study participants.”