Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK.
Khyber Medical University, Peshawar, Pakistan.
Lancet. 2019 Apr 27;393(10182):1733-1744. doi: 10.1016/S0140-6736(18)32343-2. Epub 2019 Apr 1.
Many women are affected by anxiety and depression after armed conflict in low-income and middle-income countries, yet few scalable options for their mental health care exist. We aimed to establish the effectiveness of a brief group psychological intervention for women in a conflict-affected setting in rural Swat, Pakistan.
In a single-blind, cluster, randomised, controlled trial, 34 community clusters in two union councils of rural Swat, Pakistan, were randomised using block permutation at a 1:1 ratio to intervention (group intervention with five sessions incorporating behavioural strategies facilitated by non-specialists) or control (enhanced usual care) groups. Researchers responsible for identifying participants, obtaining consent, enrolment, and outcome assessments were masked to allocation. A community cluster was defined as neighbourhood of about 150 households covered by a lady health worker. Women aged 18-60 years who provided written informed consent, resided in the participating cluster catchment areas, scored at least 3 on the General Health Questionnaire-12, and at least 17 on the WHO Disability Assessment Schedule were recruited. The primary outcome, combined anxiety and depression symptoms, was measured 3 months after the intervention with the Hospital Anxiety and Depression Scale (HADS). Modified intention-to-treat analyses were done using mixed models adjusted for covariates and clusters defined a priori. The trial is registered with the Australian New Zealand Clinical Trials Registry, number 12616000037404, and is now closed to new participants.
From 34 eligible community clusters, 306 women in the intervention group and 306 women in the enhanced usual care (EUC) group were enrolled between Jan 11, 2016, and Aug 21, 2016, and the results of 288 (94%) of 306 women in the intervention group and 290 (95%) of 306 women in the EUC group were included in the primary endpoint analysis. At 3 months, women in the intervention group had significantly lower mean total scores on the HADS than women in the control group (10·01 [SD 7·54] vs 14·75 [8·11]; adjusted mean difference [AMD] -4·53, 95% CI -7·13 to -1·92; p=0·0007). Individual HADS anxiety scores were also significantly lower in the intervention group than in the control group (5·43 [SD 4·18] vs 8·02 [4·69]; AMD -2·52, 95% CI -4·04 to -1·01), as were depression scores (4·59 [3·87] vs 6·73 [3·91]; AMD -2·04, -3·19 to -0·88). No adverse events were reported in either group.
Our group psychological intervention resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months, and might be a feasible and effective option for women with psychological distress in rural post-conflict settings.
WHO through a grant from the Office for Foreign Disaster Assistance.
在中低收入国家，许多女性在武装冲突后会受到焦虑和抑郁的影响，但针对她们的精神卫生保健，几乎没有可行的选择。本研究旨在确定在巴基斯坦斯瓦特农村的一个受冲突影响地区，对女性实施简短的团体心理干预的有效性。
这是一项单盲、整群、随机、对照试验，在巴基斯坦斯瓦特农村的两个联合委员会的 34 个社区群中，采用区块随机排列，按 1:1 的比例随机分为干预组（接受五次团体干预，其中包含行为策略，由非专业人员实施）或对照组（强化常规护理）。负责识别参与者、获得同意、入组和进行结果评估的研究人员对分配情况进行了盲法处理。社区群被定义为大约 150 户家庭组成的邻里，由一名女卫生工作者覆盖。招募的女性年龄在 18 至 60 岁之间，且签署了书面知情同意书、居住在参与的社区群集水区内、一般健康问卷-12 得分为 3 分或以上、世界卫生组织残疾评定量表得分为 17 分或以上。主要结局是采用医院焦虑和抑郁量表（HADS）在干预后 3 个月评估的合并焦虑和抑郁症状。使用混合模型进行的改良意向治疗分析，针对协变量和预先定义的群集进行了调整。该试验在澳大利亚和新西兰临床试验注册中心注册，编号为 12616000037404，目前已停止招募新参与者。
在符合条件的 34 个社区群中，306 名干预组女性和 306 名强化常规护理（EUC）组女性于 2016 年 1 月 11 日至 2016 年 8 月 21 日入组，干预组 306 名女性中的 288 名（94%）和 EUC 组 306 名女性中的 290 名（95%）纳入了主要终点分析。在 3 个月时，干预组女性的 HADS 总分显著低于对照组（10.01 [7.54] vs 14.75 [8.11]；调整后的平均差值 [AMD] -4.53，95%CI -7.13 至 -1.92；p=0.0007）。干预组女性的 HADS 焦虑评分也明显低于对照组（5.43 [4.18] vs 8.02 [4.69]；AMD -2.52，95%CI -4.04 至 -1.01），抑郁评分也低于对照组（4.59 [3.87] vs 6.73 [3.91]；AMD -2.04，-3.19 至 -0.88）。两组均未报告不良事件。
我们的团体心理干预在 3 个月时导致焦虑和抑郁症状出现了有临床意义的减轻，对于农村冲突后环境中患有心理困扰的女性来说，可能是一种可行且有效的选择。
世卫组织通过对外灾害援助办公室的一项赠款提供资金。
