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

Evidence Aid, an organisation dedicated to improving the use of evidence in humanitarian crises, highlights information from Cochrane and other systematic reviews of particular relevance to those involved in humanitarian assistance and, in July 2018, these were added to by a report on psychological therapies for the treatment of mental disorders in low- and middle-income countries. We asked one of the authors, Marianna Purgato from the University of Verona in Italy, to tell us about this new Cochrane Review.

"Whether a humanitarian crisis is triggered by natural hazards or other events, people affected by it in low- and middle-income countries are exposed to many stressors that make them more vulnerable to mental disorders, including post-traumatic stress disorder, major depression and anxiety. They are also more at risk of other negative psychological outcomes. 

Various types of psychological therapy are available to try to manage these conditions, including different forms of cognitive-behavioural therapy, or CBT, including CBT with a trauma focus, Brief Behavioural Activation, narrative exposure therapy, the common elements treatment approach and several others. It’s important, therefore, to know how effective and acceptable these therapies are and we did our review to investigate this for people with mental disorders who are living in humanitarian crises in low- and middle-income countries.

We included 33 randomised trials, involving more than 3500 participants.  The studies are from sub-Saharan Africa, the Middle East and North Africa, and Asia, and were implemented during armed conflicts and disasters triggered by natural hazards, as well as in other types of humanitarian crises. Together, the 33 studies assessed the effects of eight different psychological treatments, each of which was compared against a control group.
Most of the studies were limited to adults, but three included both older children and adults, and four just recruited children and adolescents between 5 and 18 years of age. 

In adults, we found that psychological therapies may substantially reduce post-traumatic stress disorder symptoms by the end of the therapy, but the effect is smaller over the subsequent one to four months and at six months follow-up. There were similar findings for the effects of the therapies on depression, and we found that they may moderately reduce anxiety at the end of the therapy and at one to four months' follow-up.
The evidence was much less clear for children and adolescents. We found very low quality evidence for lower post-traumatic stress disorder symptoms scores after CBT compared to control conditions, and there was no randomised evidence on major depression or anxiety in children.

In summary, our review supports the approach of providing psychological therapies to populations affected by humanitarian crises, although none of the included studies looked at the effectiveness or acceptability of these therapies for depressive and anxiety symptoms beyond six months, and most of the data comes from research in adults. Only a small number of the trials studied children and adolescents, and these provided very low-quality evidence of benefit from the psychological treatments."