Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy.
Cochrane Global Mental Health, University of Verona, Verona, Italy.
Cochrane Database Syst Rev. 2024 May 21;5(5):CD014300. doi: 10.1002/14651858.CD014300.pub2.
BACKGROUND: Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health. OBJECTIVES: To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour. MAIN RESULTS: We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults. AUTHORS' CONCLUSIONS: To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.
背景:由于战争、冲突、迫害、侵犯人权行为和人道主义危机,全球约有 8400 万人被迫流离失所;其中绝大多数人生活在中低收入国家(LMICs)。生活在人道主义环境中的人们受到一系列压力源的影响,这些压力源威胁着他们的心理健康。针对受人道主义危机影响的人们的心理社会干预措施可能有助于促进心理健康的积极方面,例如心理健康、心理社会功能、应对能力和生活质量。以前的综述重点关注治疗和混合促进和预防干预措施。在本次综述中,我们重点关注促进心理健康的积极方面。
目的:评估旨在促进 LMICs 中受人道主义危机影响的人们的心理健康的心理社会干预措施与对照条件(无干预、常规干预或候补名单)相比的效果。
检索方法:我们检索了 CENTRAL、MEDLINE、Embase 和其他七个数据库,检索时间截至 2023 年 1 月。我们还检索了世界卫生组织(WHO)的国际临床试验注册平台和 ClinicalTrials.gov,以确定未发表或正在进行的研究,并检查了相关研究和综述的参考文献列表。
入选标准:比较心理社会干预措施与对照条件(无干预、常规干预或候补名单)以促进 LMICs 中受人道主义危机影响的成年人和儿童心理健康的积极方面的随机对照试验(RCTs)。我们排除了基于精神障碍阳性诊断(或基于在筛查测量上得分超过临界值的代理)招募参与者的研究。
数据收集和分析:我们使用了标准的 Cochrane 方法。我们的主要结局是心理健康、功能、生活质量、韧性、应对能力、希望和亲社会行为。次要结局是可接受性,定义为因任何原因退出试验的参与者人数。我们使用 GRADE 评估心理健康、功能和亲社会行为结局的证据确定性。
主要结果:我们纳入了 13 项 RCT,涉及 7917 名参与者。9 项 RCT 针对儿童/青少年进行,4 项针对成年人进行。所有纳入的干预措施均由非专业人员向小组参与者提供。非专业人员是指不是心理健康或行为健康服务专业人员,但在寻求心理健康护理的人首次接触时提供服务的人。4 项 RCT 在黎巴嫩进行;2 项在印度进行;1 项在刚果民主共和国、约旦、海地、波斯尼亚和黑塞哥维那、巴勒斯坦被占领土(oPT)、尼泊尔和坦桑尼亚进行。平均研究持续时间为 18 周(最短 10 周,最长 32 周)。试验通常由学术机构或非政府组织资助。对于儿童和青少年,心理社会干预与对照条件在研究终点时改善心理健康和亲社会行为方面没有明显差异(心理健康:标准化均数差(SMD)0.06,95%置信区间(CI)-0.17 至 0.29;3 项 RCT,3378 名参与者;极低确定性证据;亲社会行为:SMD -0.25,95% CI -0.60 至 0.10;5 项 RCT,1633 名参与者;低确定性证据),或在中期随访时(心理健康:MD -0.70,95% CI -2.39 至 0.99;1 项 RCT,258 名参与者;亲社会行为:SMD -0.48,95% CI -1.80 至 0.83;2 项 RCT,483 名参与者;两者均为极低确定性证据)。干预措施可能改善功能(MD -2.18,95% CI -3.86 至 -0.50;1 项 RCT,183 名参与者),并具有持续的效果在随访时(MD -3.33,95% CI -5.03 至 -1.63;1 项 RCT,183 名参与者),但证据非常不确定,因为数据来自一项 RCT(均为极低确定性证据)。心理社会干预措施可能在研究终点时略微改善成年人的心理健康(SMD -0.29,95% CI -0.44 至 -0.14;3 项 RCT,674 名参与者;低确定性证据),但在随访时可能没有效果,因为证据不确定,未来的 RCT 可能会证实或反驳这一发现。没有 RCT 测量成年人心理健康和亲社会行为的功能和亲社会行为结局。
结论:迄今为止,关于心理和社会干预措施促进 LMICs 中受人道主义危机影响的人们心理健康的潜在益处的随机证据很少且不确定。研究的纳入标准限制、纳入研究的数量、研究的偏倚风险以及异质性水平都限制了对结果的信心。关于干预措施对积极心理健康结果的疗效的证据太少,无法确定明确的实践和政策影响。本综述发现,在人道主义环境中促进心理健康的研究领域,人们对干预措施的有效性和对心理健康的促进作用知之甚少,这方面仍有很大的差距。
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