Talking therapy for the management of mental health in low- and middle-income countries affected by mass human tragedy

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Why is this review important?

Adults and children and adolescents living in humanitarian contexts (such as in the aftermath of a crisis triggered by natural hazards) in low- and middle-income countries (LMICs) are exposed to multifaceted stressors that make them more vulnerable to developing post-traumatic stress disorder (PTSD), major depression, anxiety, and other negative psychological outcomes.

Who will be interested in this review?

People who are directly exposed to humanitarian crises and their families and caregivers will be interested in this review, as will healthcare professionals and paraprofessionals working both in LMICs and in high-income settings. Moreover, policy makers, humanitarian programming staff, guideline developers, and agencies (such as non-governmental organisations (NGOs)) working in health and non-health sectors (e.g. those providing protection to populations living in humanitarian contexts) may be interested in this review.

What questions does this review aim to answer?

Are psychological therapies more effective than control comparator conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) in reducing (symptoms of) PTSD and major depressive, anxiety, and somatoform and related disorders (conditions in which people present physical symptoms (e.g. pain) that cannot be explained medically) in people of any age, gender, or religion living in LMICs affected by humanitarian crises?

Which studies were included in this review?

Review authors searched databases up to February 2016 to find and include all relevant published and unpublished trials. Studies had to include children and/or adults living in LMICs affected by humanitarian crises. Studies also had to be randomised controlled trials (RCTs), which means that people were allocated at random (by chance alone) to receive the treatment or comparator condition.

We included 33 trials with a total of 3523 participants that examined a range of psychological therapies.

What does evidence presented in the review tell us?

In adults, low-quality evidence shows greater benefit from psychological therapies than from control comparators in reducing (symptoms of) PTSD, major depression, and anxiety disorders. This evidence supports the approach of providing psychological therapies to populations affected by humanitarian crises, although we identified no studies that looked at the effectiveness or acceptability of psychological therapies for depressive and anxiety symptoms beyond six months. Only a small proportion of included trials reported data on children and adolescents, which provided very low-quality evidence of greater benefit derived from psychological treatments. With regard to acceptability, moderate- to low-quality evidence suggests no differences in dropout rates among adults and children and adolescents. Reviewers found no studies evaluating psychological treatments for (symptoms of) somatoform disorders or medically unexplained physical symptoms (MUPS) in adults, nor in children or adolescents, respectively.

What should happen next?

Researchers should conduct higher-quality trials to further evaluate the effectiveness of psychological therapies provided over longer periods to adults and to children and adolescents. Ideally, trials should be randomised, should use culturally appropriate and validated instruments to evaluate outcomes, and should assess correlates of reductions in treatment effects over time; in addition, researchers should make every effort to ensure high rates of follow-up beyond six months after completion of therapy.