Purgato Marianna, Gastaldon Chiara, Papola Davide, van Ommeren Mark, Barbui Corrado, Tol Wietse A
Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale LA Scuro 10, Verona, Italy, 37134.
Cochrane Database Syst Rev. 2018 Jul 5;7(7):CD011849. doi: 10.1002/14651858.CD011849.pub2.
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.
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.
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 We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies.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.
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.
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.
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 studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD -1.56, 95% CI -3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings.
AUTHORS' CONCLUSIONS: There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow-up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow-up.
生活在低收入和中等收入国家（LMIC）人道主义环境中的人们面临一系列压力源，这使他们易患精神障碍。在这些环境中患病率较高的精神障碍包括创伤后应激障碍（PTSD）、重度抑郁、焦虑、躯体形式障碍（如医学上无法解释的身体症状（MUPS））及相关障碍。一系列心理疗法用于管理该人群的精神障碍症状。
比较心理疗法与对照条件（等待列表、常规治疗、注意力安慰剂、心理安慰剂或不治疗）对生活在受人道主义危机影响的LMIC中患有精神障碍（PTSD、重度抑郁、焦虑、躯体形式及相关障碍）的人的治疗效果和可接受性。
我们检索了Cochrane常见精神障碍对照试验注册库（CCMDCTR）、Cochrane对照试验中央注册库（Wiley）、MEDLINE（OVID）、Embase（OVID）和PsycINFO（OVID），纳入截至2016年2月3日的检索结果。我们还检索了世界卫生组织（WHO）试验门户（ICTRP）和ClinicalTrials.gov以识别任何未发表或正在进行的研究。我们检查了相关研究和综述的参考文献列表。
所有比较心理疗法与对照条件（包括不治疗、常规护理、等待列表、注意力安慰剂和心理安慰剂）以治疗生活在受人道主义危机影响的LMIC中患有精神障碍的成人和儿童的随机对照试验（RCT）。
我们使用标准的Cochrane程序收集数据并评估偏倚风险。我们使用随机效应模型计算连续结局的标准化均值差和二分数据的风险比。我们在终点（治疗后零至四周）、中期（治疗后一至四个月）和长期（六个月或更长时间）分析数据。GRADE（推荐分级、评估、制定和评价）用于评估创伤后应激障碍（PTSD）、抑郁、焦虑和退缩结局的证据质量。
我们纳入了36项研究（33项RCT），共3523名参与者。纳入的研究在撒哈拉以南非洲、中东和北非以及亚洲进行。研究是针对武装冲突、自然灾害引发的灾难以及其他类型的人道主义危机开展的。这33项RCT共比较了八种心理治疗与一种对照比较。四项研究纳入了5至18岁的儿童和青少年。三项研究纳入了混合人群（两项研究纳入了12至25岁的参与者，一项研究纳入了16至65岁的参与者）。其余研究纳入了成人人群（18岁及以上）。纳入的试验比较了心理疗法与对照干预（大多数研究为等待列表；不治疗；常规治疗）。心理疗法主要分类为认知行为疗法（CBT），共23次比较（包括七次聚焦于叙事暴露疗法（NET）的比较、两次聚焦于共同要素治疗方法（CETA）的比较以及一次聚焦于简短行为激活治疗（BA）的比较）；眼动脱敏再处理（EMDR）两次比较；人际心理治疗（IPT）三次比较；思维场疗法（TFT）三次比较；创伤或一般支持性咨询两次比较。尽管干预措施按这些类别描述，但一系列疗法有一些共同的心理治疗要素（即心理教育、应对技巧）。在成人中，与对照条件相比，心理疗法可能会显著减轻终点PTSD症状（标准化均值差（SMD）-1.07，95%置信区间（CI）-1.34至-0.79；1272名参与者；16项研究；低质量证据）。在一至四个月时效果较小（SMD -0.49，95%CI -0.68至-0.31；1660名参与者；18项研究），在六个月时（SMD -0.37，95%CI -0.61至-0.14；400名参与者；五项研究）。与对照条件相比，心理疗法也可能显著减轻终点抑郁症状（SMD -0.86，95%CI -1.06至-0.67；1254名参与者；14项研究；低质量证据）。与PTSD症状类似，一至四个月的随访数据显示对抑郁的影响较小（SMD -0.42，95%CI -0.63至-0.21；1386名参与者；16项研究）。心理疗法可能会在终点适度减轻焦虑（SMD -0.74，95%CI -0.98至-0.49；694名参与者；五项研究；低质量证据）以及在治疗后一至四个月的随访中（SMD -0.53，95%CI -0.66至-0.39；969名参与者；七项研究）。研究条件之间的退出率可能相似（对照为19.5%，心理疗法为19.1%（风险比0.98，95%CI 0.82至1.16；2930名参与者；23项研究，中等质量证据））。在儿童和青少年中，我们发现与对照条件相比，心理治疗条件（CBT）下终点PTSD症状得分较低的证据质量非常低，尽管置信区间较宽（SMD -1.56，95%CI -3.13至0.01；130名参与者；三项研究）。没有RCT提供关于儿童重度抑郁或焦虑的数据。对退缩的影响不确定（风险比1.87，95%CI 0.47至7.47；138名参与者；三项研究，低质量证据）。我们未识别出任何在LMIC人道主义环境中评估心理治疗对躯体形式障碍或MUPS（症状）影响的研究。
有低质量证据表明心理疗法对减轻生活在LMIC人道主义环境中的成年人的PTSD、抑郁和焦虑症状有较大或中等效果。在一至四个月和六个月的随访评估中，治疗效果较小。关注儿童和青少年的试验较少，且它们提供的心理疗法在减轻终点PTSD症状方面有益效果的证据质量非常低。这些发现的可信度受到研究中偏倚风险和相当程度异质性的影响。需要更多的研究证据，特别是针对儿童和青少年的更长随访期研究。
