Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for this condition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various forms of cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomized controlled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest were searched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroup analysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contribute to the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of 0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggesting CPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective in helping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes to recommend one of these therapies above the other.
Warfare and torture occur on a large scale in many countries resulting in widespread death, disability, and trauma [
PTSD was first recognized following the devastating war experiences of soldiers serving in Vietnam. Since then, the concept has been adequately applied in the assessment of various types of traumatic experience [
Even in instances where only a few women are on the front line of combats, they and their children bear the brunt of its physical, socioeconomic, and emotional impacts [
Physical and sexual violence committed against women during war time have always being condemned by institutions but more needs to be done to help the victims pick up the remaining pieces of life, regain confidence, and recover from their trauma. Unfortunately, there is limited and disparate information on what intervention is the most appropriate and effective for this category of victims. The primary objective of this systematic review is to assess whether the different forms of CBT can successfully help adult civilians (specifically women) who experienced war-or-conflict-related trauma (imprisonment, torture, sexual abuse, rape, kidnapping, or detainment against will) cope with the symptoms of PTSD and depression. Secondary, we identify which form of CBT is more efficient in reducing the severity of the previously cited outcomes.
Given the clinical complexity of PTSD, it is not surprising that the development of treatments is quite challenging. Cognitive-behavioral therapy (CBT) includes a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy and acceptance, and commitment therapy [
CBT is the most studied treatments in the general population, and current guidelines recommend it as a first-line treatment for patients [
The recommendations of the Cochrane Handbook for Systematic Reviews of Interventions were followed in the design of the search strategy. The first author worked in collaboration with professionals at the Paramedical library of University of Montreal. Their role was to evaluate the research strategy and advise on the possible missed channels of search. The
The inclusion criteria consisted of studies describing a randomised controlled trial in which the intervention compared any form of CBT to a control (no treatment, delayed treatment, treatment as usual, or non-CBT psychotherapy). The study needed to be designed to reduce PTSD symptoms among civilians who experienced one or multiple trauma during war-or-conflict. Study participants were required to be adults with the status of refugees, asylum seekers, or internally displaced. Trials conducted with participants traumatised by war/conflict related violence who were still living in their country of origin were also included. Studies with participants with comorbidities were accepted provided the primary objective of the trial was the reduction of PTSD symptoms. The main comorbid conditions found in the included studies were depression, anxiety, suicidal ideations, neck-focused and orthostasis-triggered panic attacks, with flashbacks during attacks and somatoform disorders. Most of the studies excluded participants with organic mental disorder, bipolar disorder, mental retardation, schizophrenia, psychosis, and drug abuse. The instruments used for the assessment of PTSD symptoms and severity had to be based on DSM’s or ICD’s criteria for a study to be eligible.
The Cochrane Handbook for Systematic Reviews of interventions [
The first author assessed the risk of bias in included studies considering criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions [
Data was analysed with the available information for each group participants according to their allocation.
A meta-analysis method with a random-effect was chosen since different instruments were used to assess PTSD or depression severity in the included trials. In fact, the use of a random-effects meta-analysis allows the incorporation of the heterogeneity existing among studies.
Two subgroup analyses were conducted with the Review Manager software (RevMan 5): the first assessed the effects of the treatments on PTSD score and the second assessed the effect of the treatments on depression score. The subgroup analyses also compared one form of CBT to the other. Each analysis investigates potential sources of heterogeneity, as differences in the type of intervention, participants’ profile, or intervention setting (e.g., length and number of sessions) may affect the treatment effects. The analyses were conducted according to Deeks et al.’s method, integrated in RevMan 5 software [
Out of 738 trials initially identified from the databases, 33 publications studying the effectiveness of one of the forms of CBT were found. Figure
Participants, measures, characteristics of interventions, and assessments’ timing in the included trials.
Studies | Form of CBT offered (number of sessions and length) | Description of trauma | Participants and repartition by sex | PTSD diagnosis and severity assessment | Depression assessment | Number of assessments and timing |
---|---|---|---|---|---|---|
Hinton et al., 2009 [ | Type of trauma not specified | 24 Cambodians with a pharmacology-resistant PTSD. Participants passed through Cambodian genocide and were at least 6 years old at the beginning of the genocide. | PTSD severity assessed with Clinician Administered PTSD Scale or CAPS (CAPS; Weather et al., 2001) [ | None | 3 assessments for the immediate-treatment group and 2 for the delayed-treatment group. | |
Hinton et al. 2004 [ | Types of trauma not specified. | 12 Vietnamese participants affected to either Immediate treatment (IT) group or Delayed-treatment (DT) group. | PTSD diagnosed with Structured Clinical Interview for DSM-IV (SCID; First et al., 1995) [ | Hopkins Symptom CheckList-25 (HSCL-25) | 3: at pretreatment, after IT finished sessions of CPT and after DT had undergone CPT. | |
Hinton et al. 2005 [ | Types of trauma not specified. | 40 Cambodian participants (survivors of the 1975–1979 Cambodian genocide) affected to either IT or DT groups. | PTSD diagnosed with SCID. PTSD severity assessed with CAPS validated within the Cambodian population. | Symptom Checklist-90-R’s depression subscale. | 4: at pretreatment, after IT finished CPT, after DT finished CPT and at 3 months posttreatment for both groups (followup). | |
Otto et al. 2003 [ | Types of trauma not specified. | 10 participants were allocated to pharmacotherapy alone or pharmacotherapy + psychotherapy. | PTSD diagnosed with SCID (First et al., 1995) [ | HSCL-25 validated for the Khmer population. | One: posttreatment | |
Bischescu et al., 2007 [ | Trauma was experienced during imprisonment. Types were not specified. | 18 participants (former political detainees) were allocated to either NET or PED. | Composite International Diagnostic Interview (CIDI; WHO, 1997) [ | 2: before and after treatment (six months postintervention) | ||
Neuner et al., 2010 [ | Witnessing a violent assault on a familiar person, torture, being in a war zone, and experiencing a violent assault by a stranger. | 32 Asylum seekers with a history of victimisation by organised violence allocated to either NET or treatment as usual (TAU) representing the control. | Posttraumatic Diagnostic Scale (PDS; Foa et al., 1995) [ | HSCL-25. | 2: pre and post treatment | |
Neuner et al., 2004 [ | Witnessing people badly injured or killed; threats with weapons, kidnappings, attacks, torture, combat experiences, sexual assaults and natural disasters. | 43 participants allocated to either NET or SC interventions with PED as control. | CIDI | Self-reporting Questionnaire-20 (SRQ-20; Harding et al., 1980) [ | 4: pre-treatment, post-treatment, 4 months and 1 year after treatment. | |
Neuner et al., 2008 [ | Number of traumatic events was reported, but types of trauma were not. | 277 participants (Rwandan and Somalian refugees) were allocated to either NET, TC (Trauma counselling), or MG (monitoring group). | CIDI and PDS. | None | 3 times for NET and TC groups: at pre-treatment, | |
Ertl et al. 2011 [ | Abduction/ | 85 formerly abducted youths were allocated to one the 3 groups. | CAPS. | MINI. | 4 assessments for each group at pretreatment, 3, 6 and 12 months. | |
Kruse et al. 2009 [ | Torture, mass rape, genocide, expulsion | Participants (Bosnian) were between 18 and 61 years old and without no serious illness or alcohol/drug dependence. | Havard Trauma Questionnaire (PTSD event section); Symptom Checklist (SCL-90R) | None | 2 assessments: before and after intervention. |
Trials excluded from this paper and reason for exclusion.
Study | Authors, year | Form of CBT studied | Reason for exclusion |
---|---|---|---|
[ | D’Ardenne et al., 2007 | CPT | Three intervention groups and no control. Randomization process was not applied. |
[ | Duffy et al., 2007 | CT | 27% of intervention group and 28% of delayed treatment group were police or army officer. |
[ | Grey and Young 2008 | CPT | A case study. |
[ | Hinton and Otto 2006 | Somatically-focused CPT | Describes only the benefit of considering a somatic-focused CBT. |
[ | Schulz et al., 2006 | CPT | Not a randomized controlled trial. |
[ | Stenmark et al., 2008 | NET versus Usual care | Recruitment and interventions ongoing at time of review. |
[ | Heilmann and Måkestad 2008 | NET | Some participants have not experienced war-or-conflict related trauma. Absence of data on control group. |
[ | Jacob et al. submitted | NET | Not yet completed by authors; data not available. |
[ | Halvorsen and Stenmark 2010 | NET | No randomization, only one intervention group was assessed before and after therapy sessions. |
[ | Flaxman and Bond 2010 | SIT versus ACT | Participants were not war/conflict-traumatized civilians. |
[ | Iverson et al., 2011 | CPT | Participants were not war/conflict-traumatized civilians. |
[ | Galovski et al., 2009 | CPT | Participants were not war/conflict-traumatized civilians. |
[ | Otto and Hinton 2006 | Modified ET | No quantitative data reported. |
[ | Paunovic and Öst 2001 | CPT versus ET | No control group. The two groups received a form of CBT. |
[ | Hensel-Dittmann et al., submitted | NET versus SIT | No control group. The two groups received a form of CBT. |
[ | Wagner et al., 2007 | DBT | No quantitative data but only qualitative description. |
[ | Somnier and Genefke 1986 | Not indicated | No quantitative data. Type of therapy unclear. |
[ | Tarrier et al., 1999 | CT versus ET | Patients did not experience war trauma and the two groups received a form of CBT (no control group). |
[ | Tarrier et al., 1999 | CT versus ET | Patients did not experience war trauma and the two groups received a form of CBT (no control group). |
[ | Boehlein et al., 2004 | Not indicated | Not a randomized controlled trial. |
[ | Neuner et al., 2002 | NET | A case report. |
[ | Schulz et al., 2006 | CPT | Not a randomized controlled trial. |
Flow chart of the systematic review.
The two outcomes of interest in this paper (PTSD and depression severity) were monitored with different psychometric instruments and reported on a continuous scale (scores of PTSD and depression) (see Table
Among the ten studies included in this paper one assessed CPT’s effectiveness in PTSD severity reduction [
Two out of ten trials required interpreters for the therapy sessions [
The quality of the included trials varied from one study to the other. Table
Risk-of-bias table of the 9 included trials.
Study | Adequate sequence generation | Allocation concealment | Incomplete outcome data addressed | Blinding of assessors | Blinding of participants |
---|---|---|---|---|---|
Bichescu et al., 2007 [ | Yes: assignment through a random selection procedure (name-cards) to either NET or PED group | No | Yes: no dropout reported among participants who started trial | No: an attempt was made. Blinding was finally impossible due to the large differences in procedures and number of sessions between the 2 groups | No: an attempt was made. Blinding was finally impossible due to the large differences between the two groups |
Hinton et al., 2004 [ | Yes: participants were all randomly assigned but the method was not described | No | Yes: no dropout reported among participants who started trial | No: no attempt was made | No: no attempt was made |
Hinton et al., 2005 [ | Yes: patients were stratified by gender with random allocation to either the IT or DT group decided by a coin toss | No | Yes: no dropout reported among participants who started trial | Yes: but blinding’s integrity was not tested | No: no attempt was made |
Neuner et al., 2004 [ | Yes: patients were randomly assigned to either NET, SC or PED group by using a dice | No | Yes: missing data were estimated with a restricted maximum likelihood procedure. | Yes: interviewers were blinded for participant’s treatment condition. | No: no attempt was made |
Neuner et al., 2008 [ | Yes: patients were randomly allocated to a group by altering allocation of randomly ordered participants. However, method was not described | No | Yes: but partly. Authors reported a high global attrition rate, 23%, 53.1% and 61% at, respectively, 3 months, 6 months and 9 months. Authors chose to apply mixed-effects models instead of a last-observation-carried-forward (LOCF) procedure, considered too conservative. | Yes | No: no attempt was made |
Neuner et al., 2010 [ | Yes: participants were randomized to NET or TAU group with a block permutation procedure with blocks of 4 patients | No | Yes: low dropout rate (6.3%). Authors used mixed effects models instead of an LOCF procedure to handle missing data. This method did not probably introduce a significant bias because of the small number of drop outs (2) | No: blindness could not be maintained in all cases so we cannot rule out an assessor bias | No: no attempt was made |
Otto et al., 2003 [ | Yes: participants were randomly assigned to either Sertraline alone or Sertraline + CBT, but method was not described | No | Yes: no dropout was reported during trial | No: no attempt of blinding assessors was made | No: no attempt was made |
Ertl et al., 2011 [ | Yes | No | Yes: mixed effects model was used | Yes: psychologists were blinded to treatment conditions | No |
Hinton et al., 2009 [ | Yes: random allocation by a coin toss | No | Yes | No | No |
Kruse et al., 2009 [ | Yes: first 35 patients assigned to intervention group | No | Yes | No | No |
Table
Effectiveness of the different forms of CBT, compliance rate to allocated intervention & remission rate in each group.
Trial | Form of CBT | Effectiveness of the therapy on PTSD/depression severity | Compliance rate to allocated intervention | Remission rate in groups |
---|---|---|---|---|
Hinton et al., 2009 [ | 100% in immediate and delayed treatment groups | Not reported | ||
Hinton et al. 2004 [ | 100% | Not reported | ||
Hinton et al. 2005 [ | 100% | Not reported | ||
Otto et al. 2003 [ | 100%. | Not reported | ||
Bischescu et al., 2007 [ | NET versus PED | 100% | At 6 months post-treatment, 5 out of 9 (56%) of NET group participants were PTSD free while only 1 out of 9 (11%) patients of the Psychoeducation group was in remission. | |
Neuner et al., 2010 [ | 87.5% | Not reported. | ||
Neuner et al., 2004 [ | 100% | At 1 year followup, 29% of the NET group (4 participants), 79% of the Supportive counselling group (11 participants) and 80% of the Psychoeducation group (8 participants) were still PTSD positive | ||
Neuner et al., 2008 [ | 96.4% for NET group | At 9 months followup, 69.8% of the NET group (30/43), 65.25% of the Trauma Counseling group (30/46) and only 36.8% of the control group (7/19) no longer fulfilled the criteria for PTSD. | ||
Ertl et al. 2011 [ | 85.7% for NET group | Not reported | ||
Kruse et al. 2009 [ | 97% for CPT group | Not reported |
We did not exclude the Neuner et al., 2008 [
One trial was excluded from the meta-analysis because rather than providing a global score, it provided the scores of severity for each criterion of PTSD symptoms (reexperiencing, avoidance/numbing, and hyperarousal).
The results indicate that culturallyadapted CPT can successfully help the adult civilians who experienced war-or-conflict related trauma. The effect size of 7.04 indicates that the intervention group (immediate treatment) outperformed the control group in terms of reduction of symptoms severity (delayed treatment) by seven times the standard deviation. This effect size is also highly significant at a level of 0.01 (
Figure
According to the results of our analysis, CPT compared to a control group (treatment as usual, which included social support, medical treatment as usual, and psychoeducation) can also successfully help reduce the severity of the PTSD symptoms in patients of our population of interest. The effect size of 7.40 was highly significant at a level of 0.01 (
In addition, a subgroup difference test was conducted. The results indicated that there is a significant difference between the effectiveness of the different forms of CBT versus a control (delayed treatment, treatment as usual, or psychoeducation/trauma counselling). After comparing the effect size, one can say that culturallyadapted CPT and CPT are more effective than NET in reducing the severity of PTSD symptoms.
Forest plot of subgroup analysis culturallyadapted CPT versus NET versus CPT; Outcome: PTSD severity.
As indicated in Figure
Forest plot of subgroup analysis culturallyadapted CPT versus NET versus CPT; Outcome: Depression severity.
This paper summarises the results of ten trials, which recruited a total of 473 men and women, all traumatised during war-or-conflict. The studies took place in different countries (industrialised and developing) characterised by a variety of health systems and existing protocol for psychological support offered to war- and conflict-traumatised individuals. Participants included Cambodian refugees resettled in USA [
The first subgroup analysis revealed that CPT, culturallyadapted CPT, and NET can significantly contribute to the PTSD severity reduction. However, the first two forms of CBT seem to have a higher effect on PTSD severity reduction than NET. We cannot exclude the possibility that those two forms of CBT might be the most adapted to the needs of patients of the population of interest. However, other reasons might have resulted in the superiority effect observed. First, it is possible that culturallyadapted CPT and CPT had a higher effect on PTSD severity reduction because they were all conducted in the participants’ native language by people familiar with their culture. In fact, not all of the NET trials were conducted in the participants’ native language, and the amount of trials available was too low to conduct a subgroup analysis that assesses the impact of interpreters on PTSD severity reduction. The observed difference might have also resulted from the variety of participants included in the NET trials compared to the other forms. In fact, the NET trials were conducted in different countries (Uganda, Germany, and Romania) with different settings and participants from different origins, while all the culturallyadapted CPT were conducted in Massachusetts with participants living in a more stable economic/politic context. It is possible that participants who are still living in the conflict-affected country are less inclined to fully benefit from the success of psychotherapy even when they need it. This idea derived from the comparison of the trial conducted by Bichescu et al. [
The second subgroup analysis conducted revealed that culturallyadapted CPT and NET were effective in reducing the severity of depression in our population of interest. However, the effect size of NET therapy compared to control condition (Psychoeducation, Trauma Counselling or No treatment) was not significant. With regards to PTSD outcome, results show that culturallyadapted CPT is more effective than NET in depression severity reduction. The reasons described earlier might have also caused the results obtained.
A finding that is also important to discuss concerns the heterogeneity between the included trials. As reported earlier, there is a high homogeneity between the culturallyadapted CPT trials, results that can be explained by the fact that the three trials were led by the same therapist with similar participants in terms of type of trauma experienced (Cambodian genocide). In contradiction, a high heterogeneity between the NET trials was found, results that can be easily explained by the different settings of NET trials (several instruments used to assess PTSD severity, different number of sessions, variable length of session, interpreters recruited or not, participants from different origins, etc.).
CPT is the most studied treatment in relation to PTSD symptoms and severity in the general population. Moreover, it is the most recommended treatment in the general population based on the studies conducted in the industrialised countries. This form of CBT also seems efficient in helping war-traumatised adult civilians. In fact, when amalgamated with a meta-analysis, the CPT trials revealed a stronger effect size of the treatment compared to the control group (waiting list or delayed treatment). Our results also indicate that CPT seems the most indicated treatment to reduce depression severity. However, the trials’ small sample sizes and the fact that every trial was conducted with patients originating from three countries (Bosnia for CPT, Vietnam and Cambodia for its culturallyadapted form) make it impossible to generalize CPT’s effectiveness to every post war and conflict traumatised patient. Our results also emphasize the necessity of taking culture into account while designing interventions for PTSD patients or refugees of non-western countries since the culturallyadapted CPT seems more effective than the NET in PTSD and depression severity reduction.
In comparison to CPT, NET is a more contemporary method and more researched method of treatment in the population of interest (5 out of 10 trials compared it to another type of therapy). NET also seems to be the most adapted method to our population of interest because it is designed to suit their need and its effectiveness has been proven in different trials. Our meta-analysis also confirmed that it can help subjects of our population of interest in lowering the severity of their PTSD and depression symptoms. Even if NET does not appear to be the most effective treatment, the fact that it has been applied with success to participants from diverse origins (Romania, Somalia, Sudan, Turkey, Balkans, and Uganda) makes it easier to generalise its effectiveness among the population of interest. We also think that this form of CBT will probably benefit from integrating the variable of culture into the design of their sessions.
As indicated in the title of this paper, we were interested in assessing the effectiveness of the different forms of CBT according to the sex of the participants in order to find which treatment is the most effective for women. Unfortunately, this was not possible because even if most of the trials included men, and women none of them reported their results according to the sex or gender of participants. We think that subsequent trials should assess the difference of treatment effect between men and women since previous studies on PTSD symptoms and its severity revealed a difference of its rate between men and women in the same population, women being at higher risk of developing it [
First, the selection of a specific category of war-traumatised patients (adults) might seem arbitrary. We thought that it is important to separate adults from young ones because the type of CBT and NET treatment used in those categories are not the same. We also separated those categories of age because we felt that the process of healing might be different between an adult who is usually the victim of violence and a child/adolescent who is usually a witness and/or victim of that violence. Secondly, although an extensive list of databases was used for study selection, we cannot rule out the possibility that some articles may have been missed with our research strategy. In fact, since five out of ten of the studies were conducted by German researchers we cannot exclude the fact that some of their studies were not found in the English databases used.
This systematic review demonstrates that culturallyadapted CPT, CPT, and NET can successfully help war-or-conflict-traumatised civilians in reducing their PTSD symptoms. However, only the culturallyadapted CPT seems effective in reducing the depression score of civilians who experienced war-or-conflict related violence. Even if the subgroup analysis clearly demonstrates that CPT and its culturallyadapted form are more effective than NET, more evidence is needed in order to specifically recommend one of the forms of CBT over the other for our population of interest.
More research needs to be carried out on CBT (specifically its culturallyadapted form) and NET treatment effectiveness in PTSD severity reduction within our population of interest. In fact, these people need to cope with the symptoms, in order to be able to contribute to the prosperity and well-being of their societies. It is also important that researchers agree on common characteristics which will allow conduct of a better comparison between studies in the future, in order to recommend a specific treatment. They should agree on the instruments, the number of sessions given, and their length. For example, in the CBT trials the number of sessions was different from one study to another. It is also important that the same type of control group be used for each trial (delayed-treatment or treatment as usual). In fact, there was a difference in the type of control group between the trials that used NET as an intervention. Trials comparing these two methods to a standard treatment might also be a good idea and collaboration between the varying teams (Hinton and Neuner teams) would certainly help this. To ensure the quality of the trials, researchers must also be sure to conceal allocation (none of the reviewed studies did so) and blind the assessors (followed by a test of the blindness integrity). Moreover, researchers must make certain that enough participants in the intervention and control group are included in the trial. In fact, a key limitation in most studies is the sample size. Only one study included an adequate number of participants (
There is not only a question of cultural validity regarding the PTSD itself (and its associated comorbidities), but also the instruments and specialists used to assess it remain important. In fact, some argue that PTSD symptoms may have various values or meanings depending on the different cultures, and some symptoms may not be perceived as distressing among certain groups [
Aside from NET and CPT, different therapies have been studied in our population of interest. One of them,
The research and selection of articles were conducted by N. I. Dossa who also analysed and discussed the results and made the preceding recommendations. M. Hatem helped in the development of the background, the questions and the comparisons and the review of the work at each step of the review process.
N. I. Dossa is a Ph. D. student whose project concerns women victim of war-or-conflict related trauma.
N. I. Dossa received a grant from the Sainte-Justine Hospital for this paper.