An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial

English version

Autoři: Alvin Kuowei Tay ^aff001; Hau Khat Mung ^aff001; Mohammad Abdul Awal Miah ^aff003; Susheela Balasundaram ^aff004; Peter Ventevogel ^aff005; Mohammad Badrudduza ^aff001; Sanjida Khan ^aff006; Karen Morgan ^aff007; Susan Rees ^aff001; Mohammed Mohsin ^aff001; Derrick Silove ^aff001
Působiště autorů: School of Psychiatry, Faculty of Medicine, University of New South Wales, Australia ^aff001; Perdana University-Centre for Global Health and Social Change (PU-GHSC), Selangor, Malaysia ^aff002; Perdana University-Centre for Research Excellence (PU-CRE), Selangor, Malaysia ^aff003; Health Unit, United Nations High Commissioner for Refugees (UNHCR), Kuala Lumpur, Malaysia ^aff004; Public Health Section/ Division of Programme Support & Management, United Nations High Commissioner for Refugees (UNHCR), Geneva, Switzerland ^aff005; Department of Psychology, Jagannath University, Dhaka, Bangladesh ^aff006; Perdana University-Royal College of Surgeons in Ireland (PU-RCSI) School of Medicine, Selangor, Malaysia ^aff007
Vyšlo v časopise: An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial. PLoS Med 17(3): e1003073. doi:10.1371/journal.pmed.1003073
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003073

Souhrn

Background

This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience.

Methods and findings

We conducted a single-blind RCT (October 2017 –May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1–27) of traumatic events. We applied a single-blind design in which independent assessors of pre -⁠ and posttreatment indices were masked in relation to participants’ treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor–Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were −0.08 (95% CI: −0.14 to −0.02, p = 0.012) for PTSD, −0.07 (95% CI: −0.14 to −0.01) for CPTSD, −0.07 for MDD (95% CI: −0.13 to −0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06–0.026, p ≤ 0.001), −0.12 (95% CI: −0.20 to −0.03, p ≤ 0.001) for ASI-1 (safety/security), −0.10 for ASI-2 (traumatic losses; 95% CI: −0.18 to −0.02, p = 0.02), −0.03 for ASI-3 (injustice; (95% CI: −0.11 to 0.06, p = 0.513), −0.12 for ASI-4 (role/identity disruptions; 95% CI: −0.21 to −0.04, p ≤ 0.001), and −0.18 for ASI-5 (existential meaning; 95% CI: −0.19 to −0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up.

Conclusions

Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings.

Trial registration

The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381

Klíčová slova:

Anxiety – Depression – Chin – Mental health and psychiatry – Mental health therapies – Post-traumatic stress disorder – Psychological stress – Psychotherapy

Zdroje

1. Stein DJ, Bass JK, Hofmann SG, editor. Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low-and Middle-Income Countries: Academic Press; 2019.

2. Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological Treatments for the World: Lessons from Low -⁠ and Middle-Income Countries. Annu Rev Clin Psychol. 2017;13 : 149–81. doi: 10.1146/annurev-clinpsy-032816-045217 28482687

3. Bolton P. Global mental health and psychotherapy: Importance of task-shifting and a systematic approach to adaptation. In: Stein DJ, Bass JK, Hofmann SG, editor. Global Mental Health and Psychotherapy: Academic Press; 2019. p. 11–24.

4. Dawson KS, Bryant RA, Harper M, Tay AK, Rahman A, Schafer A, et al. Problem Management Plus (PM+): a WHO transdiagnostic psychological intervention for common mental health problems. World psychiatry: official journal of the World Psychiatric Association (WPA). 2015;14(3):354–7. doi: 10.1002/wps.20255 26407793

5. Epping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, Garcia-Moreno C, et al. Self-Help Plus (SH+): a new WHO stress management package. World psychiatry: official journal of the World Psychiatric Association (WPA). 2016;15(3):295–6. doi: 10.1002/wps.20355 27717271

6. Murray LK, Dorsey S, Haroz E, Lee C, Alsiary MM, Haydary A, et al. A Common Elements Treatment Approach for Adult Mental Health Problems in Low -⁠ and Middle-Income Countries. Cognitive and behavioral practice. 2014;21(2):111–23. doi: 10.1016/j.cbpra.2013.06.005 25620867

7. Tay AK, Silove D. The ADAPT model: bridging the gap between psychosocial and individual responses to mass violence and refugee trauma. Epidemiology and Psychiatric Sciences.2017; 26(2):142–145 doi: 10.1017/S2045796016000925 27974083

8. Silove D. The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings Intervention. 2013; 11(3), 237–248 https://doi.org/10.1097/WTF.0000000000000005

9. Silove D. The challenges facing mental health programs for post-conflict and refugee communities. Prehosp Disaster Med. 2004;19(1):90–6. doi: 10.1017/s1049023x00001539 15453165

10. Tay AK, Rees S, Chen J, Kareth M, Silove D. Examining the broader psychosocial effects of mass conflict on PTSD symptoms and functional impairment amongst West Papuan refugees resettled in Papua New Guinea (PNG). Soc Sci Med. 2015;132 : 70–8. doi: 10.1016/j.socscimed.2015.03.020 25795990

11. Tay AK, Rees S, Chen J, Kareth M, Silove D. Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees. Soc Psychiatry Psychiatr Epidemiol. 2015; 51(3):395–406. doi: 10.1007/s00127-015-1099-x 26228854

12. Silove D, Momartin S, Marnane C, Steel Z, Manicavasagar V. Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma. J Trauma Stress. 2010;23(1):169–72. doi: 10.1002/jts.20490 20135680

13. Tay AK, Rees S, Tam N, Kareth M, Silove D. Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua. Psychological medicine. 2018 : 49 (9):1481–1489. doi: 10.1017/S0033291718002027 30149819

14. Rees S, Silove D, Verdial T, Tam N, Savio E, Fonseca Z, et al. Intermittent explosive disorder amongst women in conflict affected Timor-Leste: associations with human rights trauma, ongoing violence, poverty, and injustice. PLoS One. 2013 : 8(8). doi: 10.1371/journal.pone.0069207 23950885

15. Tay AK, Rees S, Chen J, Kareth M, Silove D. The coherence and correlates of intermittent explosive disorder amongst West Papuan refugees displaced to Papua New Guinea. J Affect Disord. 2015;177 : 86–94. doi: 10.1016/j.jad.2015.02.009 25754605

16. Başoǧlu M, Livanou M, Crnobarić C, Frančišković T, Suljić E, Durić D, et al. Psychiatric and cognitive effects of war in former Yugoslavia association of lack of redress for trauma and posttraumatic stress reactions. J Am Med Assoc. 2005;294(5):580–90+e1-e2. doi: 10.1001/jama.294.5.580 16077052

17. Somasundaram D, Sivayokan S. Rebuilding community resilience in a post-war context: developing insight and recommendations—a qualitative study in Northern Sri Lanka.International journal of mental health systems. 2013;7(1):3. doi: 10.1186/1752-4458-7-3 23305538

18. Thomas FC, Roberts B, Luitel NP, Upadhaya N, Tol WA. Resilience of refugees displaced in the developing world: a qualitative analysis of strengths and struggles of urban refugees in Nepal. Confl Health. 2011;5(1):20. doi: 10.1186/1752-1505-5-20 21943401

19. Ssenyonga J, Owens V, Kani Olema D. Posttraumatic growth, resilience, and posttraumatic stress disorder among refugees. World Conferenxe on Psychology and Sociology 2013;82 : 144–8. https://doi.org/10.1016/j.sbspro.2013.06.238

20. Tay AK, Miah MAA, Khan S, Badrudduza M, Morgan K, Balasundaram S, et al. Theoretical background, first stage development and adaptation of a novel Integrative Adapt Therapy (IAT) for refugees. Epidemiology and Psychiatric Sciences. 2019;1–8. doi: 10.1017/S2045796019000416 31441397

21. Tay AK, Miah MAA, Khan S, Badrudduza M, Alam R, Balasundaram S, et al. Implementing Integrative Adapt Therapy with Rohingya refugees in Malaysia: a training-implementation model involving lay counsellors. Intervention. 2019 : 17 : 267.

22. Turrini G, Purgato M, Acarturk C, Anttila M, Au T, Ballette F, et al. Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2019 : 1–13. doi: 10.1017/S2045796019000027 30739625

23. Wampold BE. How important are the common factors in psychotherapy? An update. World psychiatry: official journal of the World Psychiatric Association (WPA). 2015;14(3):270–7. doi: 10.1002/wps.20238 26407772

24. Tay AK, Mohsin M, Rees S, Tam N, Kareth M, Silove D. Factor structures of Complex Posttraumatic Stress Disorder and PTSD in a community sample of refugees from West Papua. Comprehensive psychiatry. 2018;85 : 15–22. doi: 10.1016/j.comppsych.2018.05.001 29936226

25. Tay AK, Rees S, Chen J, Kareth M, Silove D. The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees. BMC Psychiatry.2015 : 15, 111. doi: 10.1186/s12888-015-0480-3 25947101

26. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of American Medical Association. 2009;302. doi: 10.1001/jama.2009.1132 19654388

27. Tay AK, Mohsin M, Rees S, Tam N, Kareth M, Silove D. The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua. Social Psychiatry and Psychiatric Epidemiology. 2019 : 1–10. doi: 10.1007/s00127-019-01666-1 30778622

28. Tay AK, Rees S, Tam N, Kareth M, Silove D. Developing a measure of adaptive stress arising from the psychosocial disruptions experienced by refugees based on a sample of displaced persons from West Papua. International Journal of Methods in Psychiatric Research. 2019;1770 : 1–11. doi: 10.1002/mpr.1770 30740811

29. Ager W, Horn R, Mozumder MK, Riley A, Ventevogel P. From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees. Intervention. 2019;17(2):117–21

30. Mahmuda M, Miah MAA, Elshazly M, Khan S, Tay AK, Ventevogel P. Contextual adaptation and piloting of Group Integrative Adapt Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh. Intervention. 2019 : 17(2): 149–159

31. Tay AK, Rees S, Chen J, Kareth M, Mohsin M, Silove D. The Refugee-Mental Health Assessment Package (R-MHAP); rationale, development and first-stage testing amongst West Papuan refugees. International journal of mental health systems. 2015;9(1):1–13. doi: 10.1186/1752-4458-9-1

32. Momotaz H, Ahmed H, Jalal Uddin MM, Karim R, Khan M, Al-Amin R, et al. Implementing the Mental Health Gap Action Programme in Cox’s Bazar, Bangladesh. Intervention. 2019;17(2):243–51.

33. Bernal G, Sáez‐Santiago E. Culturally centered psychosocial interventions. Journal of Community Psychology. 2006;34(2):121–32. https://doi.org/10.1002/jcop.20096

34. Tay AK, Islam R, Riley A, Welton-Mitchell C, Duchesne B, Waters V, et al. Culture, Context and Mental Health of Rohingya Refugees: A review for staff in mental health and psychosocial support programmes for Rohingya refugees. Geneva: United Nations High Commissioner for Refugees (UNHCR), 2018.

35. Tay AK, Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, et al. The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review. Epidemiology and Psychiatric Sciences. 2019 : 28(5), 489–494. doi: 10.1017/S2045796019000192 31006421

36. Tarannum S, Elshazly M, Harlass S, Ventevogel P. Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR. Intervention. 2019;17(2):130–9.

37. Maercker A, Brewin CR, Bryant RA, Cloitre M, van Ommeren M, Jones LM, et al. Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World psychiatry: official journal of the World Psychiatric Association (WPA). 2013;12(3):198–206. doi: 10.1002/wps.20057 24096776

38. Tay AK, Rees S, Miah MAA, Khan S, Badrudduza M, Morgan K, et al. Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia. Translational Psychiatry. 2019;9(1):213. doi: 10.1038/s41398-019-0537-z 31477686

39. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82. doi: 10.1002/da.10113 12964174

40. Ziaian T, de Anstiss H, Antoniou G, Baghurst P, Sawyer M. Resilience and Its Association with Depression, Emotional and Behavioural Problems, and Mental Health Service Utilisation among Refugee Adolescents Living in South Australia. International Journal of Population Research. 2012;1–9. http://dx.doi.org/10.1155/2012/485956

41. Ahmed AS. Post-traumatic stress disorder, resilience and vulnerability. Advances in Psychiatric Treatment. 2007;13 : 369–75.https://doi.org/10.1192/apt.bp.106.003236

42. International Society for Traumatic Stress Studies. Posttraumatic Stress Disorder Prevention and Treatment Guidelines: Methodology and Recommendations. USA: Chicago International Society for Traumatic Stress Studies, 2019.

43. Feingold A. A regression framework for effect size assessments in longitudinal modeling of group differences. Review of General Psychology. 2013 : 17 : 111–121. doi: 10.1037/a0030048 23956615

44. Cohen J. Statistical power analysis for the behavioral sciences: Routledge, 2013.

45. Dragioti E, Dimoliatis I, Fountoulakis KN, Evangelou E. A systematic appraisal of allegiance effect in randomized controlled trials of psychotherapy. Annals of General Psychiatry. 2015;14(1):25. doi: 10.1186/s12991-015-0063-1 26379758

46. Wilson GT, Wilfley DE, Agras WS, Bryson SW. Allegiance Bias and Therapist Effects: Results of a Randomized Controlled Trial of Binge Eating Disorder. Clinical psychology: a publication of the Division of Clinical Psychology of the American Psychological Association. 2011;18(2):119–25. doi: 10.1111/j.1468-2850.2011.01243.x 25089079

47. Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson Cet al. A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Med. 2014 : 11: e1001757. doi: 10.1371/journal.pmed.1001757 25386945

48. Sleijpen M, Mooren T, Kleber RJ, Boeije HR. Lives on hold: A qualitative study of young refugees’ resilience strategies. Childhood (Copenhagen, Denmark). 2017;24(3):348–65. doi: 10.1177/0907568217690031 28845087

49. Pickren W. What Is Resilience and How Does It Relate to the Refugee Experience? Historical and Theoretical Perspectives. 2014. p. 7–26.

50. Carlsson JM, Olsen DR, Kastrup M, Mortensen EL. Late mental health changes in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis. 2010;198(11):824–8. doi: 10.1097/NMD.0b013e3181f97be3 21048474

51. Baardseth TP, Goldberg SB, Pace BT, Wislocki AP, Frost ND, Siddiqui JR, et al. Cognitive behavioural therapy versus other therapies: redux. Clinical psychology review. 2013;33(3):395–405. doi: 10.1016/j.cpr.2013.01.004 23416876

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