Laura K. Murray

Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence

BACKGROUND Survivors of sexual violence have high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). Although treatment for symptoms related to sexual violence has been shown to be effective in high-income countries, evidence is lacking in low-income, conflict-affected countries. METHODS In this trial in the Democratic Republic of Congo, we randomly assigned 16 villages to provide cognitive processing therapy (1 individual session and 11 group sessions) or individual support to female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms. One village was excluded owing to concern about the competency of the psychosocial assistant, resulting in 7 villages that provided therapy (157 women) and 8 villages that provided individual support (248 women). Assessments of combined depression and anxiety symptoms (average score on the Hopkins Symptom Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), PTSD symptoms (average score on the PTSD Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), and functional impairment (average score across 20 tasks [range, 0 to 4, with higher scores indicating greater impairment]) were performed at baseline, at the end of treatment, and 6 months after treatment ended. RESULTS A total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments. Mean scores for combined depression and anxiety improved in the individual-support group (2.2 at baseline, 1.7 at the end of treatment, and 1.5 at 6 months after treatment), but improvements were significantly greater in the therapy group (2.0 at baseline, 0.8 at the end of treatment, and 0.7 at 6 months after treatment) (P<0.001 for all comparisons). Similar patterns were observed for PTSD and functional impairment. At 6 months after treatment, 9% of participants in the therapy group and 42% of participants in the individual-support group met criteria for probable depression or anxiety (P<0.001), with similar results for PTSD. CONCLUSIONS 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. (Funded by the U.S. Agency for International Development Victims of Torture Fund and the World Bank; ClinicalTrials.gov number, NCT01385163.).

The role of relationship intimacy in consistent condom use among female sex workers and their regular paying partners in the Dominican Republic

Prior research has demonstrated an important link between relationship intimacy and condom use. Limited research has been conducted on this connection within the realm of female sex work. We examined the association between perceived relationship intimacy and consistent condom use among 258 female sex workers and 278 male regular paying partners who participated in a cross-sectional survey in the Dominican Republic. In multivariate analysis, higher intimacy among sex workers and regular paying partners was negatively associated with consistent condom use. Among those reporting higher perceived intimacy, male participants were more than twice as likely to report consistent condom use as female participants. Female sex workers in relationships of higher perceived intimacy are at greater risk of HIV/AIDS than their male regular paying partners. Gender-sensitive HIV prevention programs are needed to address the differential influence of relationship intimacy on condom use in the context of sex work.

Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers

BackgroundRecent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC).Model and case presentationsThis paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors.EvaluationWe review the challenges experienced with this model, and propose some possible solutions.DiscussionWe describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature.ConclusionIn our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions.

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial

IMPORTANCE Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings. OBJECTIVE To evaluate the effectiveness of lay counselor-provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat. INTERVENTIONS The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. MAIN OUTCOMES AND MEASURES The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. RESULTS At follow-up, the mean item change in trauma symptom score was -1.54 (95% CI, -1.81 to -1.27), a reduction of 81.9%, for the TF-CBT group and -0.37 (95% CI, -0.57 to -0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was -0.76 (95% CI, -0.98 to -0.54), a reduction of 89.4%, and -0.54 (95% CI, -0.80 to -0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. CONCLUSIONS AND RELEVANCE The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01624298.

Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries

Common mental disorders, including depression, anxiety, and posttraumatic stress, are leading causes of disability worldwide. Treatment for these disorders is limited in low- and middle-income countries. This systematic review synthesizes the implementation processes and examines the effectiveness of psychological treatments for common mental disorders in adults delivered by nonspecialist providers in low- and middle-income countries. In total, 27 trials met the eligibility criteria; most treatments targeted depression or posttraumatic stress. Treatments were commonly delivered by community health workers or peers in primary care or community settings; they usually were delivered with fewer than 10 sessions over 2-3 months in an individual, face-to-face format. Treatments included common elements, such as nonspecific engagement and specific domains of behavioral, interpersonal, emotional, and cognitive elements. The pooled effect size was 0.49 (95% confidence interval = 0.36-0.62), favoring intervention conditions. Our review demonstrates that psychological treatments-comprising a parsimonious set of common elements and delivered by a low-cost, widely available human resource-have moderate to strong effects in reducing the burden of common mental disorders.

Child Sexual Abuse

This article begins by defining sexual abuse, and reviews the literature on the epidemiology of child sexual abuse (CSA). Clinical outcomes of CSA are described, including health and mental health. An outline is given of all the services often involved after an incident of CSA, and the need for coordination among them. Treatment strategies and evidence-based recommendations are reviewed. Challenges around dissemination and implementation, cultural considerations, and familial dynamics are described. Possible future directions are discussed.

An evaluation of trauma focused cognitive behavioral therapy for children in Zambia.

To monitor and evaluate the feasibility of implementing Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) to address trauma and stress-related symptoms in orphans and vulnerable children (OVC) in Zambia as part of ongoing programming within a non-governmental organization (NGO). As part of ongoing programming, voluntary care-workers administered locally validated assessments to identify children who met criteria for moderate to severe trauma symptomatology. Local lay counselors implemented TF-CBT with identified families, while participating in ongoing supervision. Fifty-eight children and adolescents aged 5-18 completed the TF-CBT treatment, with pre- and post-assessments. The mean number of traumas reported by the treatment completers (N=58) was 4.11. Post assessments showed significant reductions in severity of trauma symptoms (p<0.0001), and severity of shame symptoms (p<0.0001). Our results suggest that TF-CBT is a feasible treatment option in Zambia for OVC. A decrease in symptoms suggests that a controlled trial is warranted. Implementation factors monitored suggest that it is feasible to integrate and evaluate evidence-based mental health assessments and intervention into programmatic services run by an NGO in low/middle resource countries. Results also support the effectiveness of implementation strategies such as task shifting, and the Apprenticeship Model of training and supervision.

A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq

BackgroundExperiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.MethodsTwenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.ResultsAdult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004).ConclusionsBoth interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.Trial RegistrationClinicalTrials.Gov NCT00925262. Registered June 3, 2009.

Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: the use of TF-CBT in Zambia

BackgroundThe need to address the treatment gap in mental health services in low- and middle-income countries (LMIC) is well recognized and particularly neglected among children and adolescents. Recent literature with adult populations suggests that evidence-based mental health treatments are effective, feasible, and cross-culturally modifiable for use in LMIC. This paper addresses a gap in the literature documenting pre-trial processes. We describe the process of selecting an intervention to meet the needs of a particular population and the process of cross-cultural adaptation.MethodsCommunity-based participatory research principles were implemented for intervention selection, including joint meetings with stakeholders, review of qualitative research, and review of the literature. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) was chosen as the evidence-based practice for modification and feasibility testing. The TF-CBT adaptation process, rooted within an apprenticeship model of training and supervision, is presented. Clinical case notes were reviewed to document modifications.ResultsChoosing an intervention can work as a collaborative process with community involvement. Results also show that modifications were focused primarily on implementation techniques rather than changes in TF-CBT core elements.ConclusionsStudies documenting implementation processes are critical to understanding why intervention choices are made and how the adaptations are generated in global mental health. More articles are needed on how to implement evidence-based treatments in LMIC.

Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial

BackgroundSystematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq.MethodsThis was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12.ResultsThe CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively.ConclusionsBoth CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings.Trial registration and protocolThis trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq.The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol. In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.