Morina, N., Malek, M., Nickerson, A., & Bryant, R.A. (2017). Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries. Depression and Anxiety, DOI: 10.1002/da.22618
There is a high prevalence of post-traumatic stress disorder (PTSD) in countries that have experienced civil war and mass violence, and given the number of open conflict, the prevalence is likely increasing. Most people affected are from low- to middle-income countries. Both PTSD and depression confer a large personal, social, health, and economic burden especially when untreated. Research in Western countries show that psychological treatment of PTSD is effective, but there are practical barriers to transporting and adapting these interventions to low- and middle-income countries. In this meta-analysis, Morina and colleagues do a systematic review of psychological interventions for PTSD conducted of adult survivors of war in low- and middle-income countries. Treatments included trauma-focused cognitive-behavioral therapy, interpersonal psychotherapy, eye movement desensitization and reprocessing and several others. In total, 2,124 treated participants and 934 participants in the waitlist condition were included in the analyses. In the 18 trials that were included, symptoms of PTSD and depression were measured. The average drop-out rate was 11.5%. Across all active interventions (k = 16), a large pre–post effect size was found, g = 1.29; 95% CI = [0.99; 1.59] for PTSD. The average between-group effect size comparing active treatments versus control conditions at post-treatment was small to medium, g = 0.39; 95% CI = [0.249; 0.55], and at follow-up was large, g = 0.93; 95% CI = [0.56; 1.31], k = 10. Pre-post effect size for depression was equally large g = 1.28; 95% CI = [0.96; 1.61]. The effect size comparing active treatments versus control conditions for depression at posttreatment (k = 11) was large, g = 0.86; 95% CI = [0.54; 1.18], and at follow-up was medium to large, g = 0.90; 95% CI = [0.49; 1.33], k = 5.
Evidence-based psychological treatments developed in high-income countries are also effective in reducing symptoms of PTSD and depression in adults who experienced war-time conditions in low- and middle-income countries. Although not directly tested, the evidence suggests that different evidence-based treatments were equally effective. Even if drop-out rates were low, practical barriers still existed, including the number of sessions of these treatments (average was 10 sessions), the need for trained personnel, and the need for face to face meetings. The authors suggested that collaborative care models should be evaluated and tested which aim to enhance the reach of efficacious treatments within primary care to optimize the number of patients who can benefit from these interventions.