Marianna Purgato1, Alden L Gross2, Theresa Betancourt3, Paul Bolton4, Chiara Bonetto5, Chiara Gastaldon5, James Gordon6, Paul O'Callaghan7, Davide Papola5, Kirsi Peltonen8, Raija-Leena Punamaki8, Justin Richards9, Julie K Staples6, Johanna Unterhitzenberger10, Mark van Ommeren11, Joop de Jong12, Mark J D Jordans13, Wietse A Tol14, Corrado Barbui15. 1. WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy; Departments of International Health and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Cochrane Global Mental Health, Verona, Italy. Electronic address: marianna.purgato@univr.it. 2. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 3. Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA. 4. Departments of International Health and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Center for Refugee and Disaster Response, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 5. WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy. 6. The Center for Mind-Body Medicine, Washington, DC, USA. 7. School of Psychology, Queen's University, Belfast, UK. 8. Department of Psychology, Faculty of Social Sciences, University of Tampere, Tampere, Finland. 9. School of Public Health & Charles Perkins Centre, University of Sydney, Sydney NSW, Australia. 10. Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany. 11. Department of Mental Health & Substance Abuse, World Health Organization, Geneva, Switzerland. 12. Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands; Boston University School of Medicine, Boston, MA, USA. 13. Center for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Research and Development Department, War Child Holland, Amsterdam, Netherlands. 14. Departments of International Health and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Peter C Alderman Foundation, Kampala, Uganda. 15. WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy; Cochrane Global Mental Health, Verona, Italy.
Abstract
BACKGROUND: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. METHODS: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0-4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. FINDINGS: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] -0·33, 95% CI -0·52 to -0·14) that was maintained at follow-up (-0·21, -0·42 to -0·01). We also identified benefits at the endpoint for functional impairment (-0·29, -0·43 to -0·15) and for strengths: coping (-0·22, -0·43 to -0·02), hope (-0·29, -0·48 to -0·09), and social support (-0·27, -0·52 to -0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15-18 years (-0·43, -0·63 to -0·23), in non-displaced children (-0·40, -0·52 to -0·27), and in children living in smaller households (<6 members; -0·27, -0·42 to -0·11). INTERPRETATION: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. FUNDING: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.
BACKGROUND: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. METHODS: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0-4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. FINDINGS: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] -0·33, 95% CI -0·52 to -0·14) that was maintained at follow-up (-0·21, -0·42 to -0·01). We also identified benefits at the endpoint for functional impairment (-0·29, -0·43 to -0·15) and for strengths: coping (-0·22, -0·43 to -0·02), hope (-0·29, -0·48 to -0·09), and social support (-0·27, -0·52 to -0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15-18 years (-0·43, -0·63 to -0·23), in non-displaced children (-0·40, -0·52 to -0·27), and in children living in smaller households (<6 members; -0·27, -0·42 to -0·11). INTERPRETATION: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. FUNDING: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.
Authors: Katie S Dawson; Sarah Watts; Kenneth Carswell; Melissa Harper Shehadeh; Mark J D Jordans; Richard A Bryant; Kenneth E Miller; Aiysha Malik; Felicity L Brown; Chiara Servili; Mark van Ommeren Journal: World Psychiatry Date: 2019-02 Impact factor: 49.548