A randomized controlled trial of a transdiagnostic cognitive-behavioral intervention for Afro-descendants’ survivors of systemic violence in Colombia

Abstract

BackgroundExposure to violence has negative consequences on mental health. Armed-conflict in Colombia has widely affected Afro-descendants in the Pacific region. Evidence regarding effectiveness of mental health interventions is lacking in low-income settings, especially in areas with active conflict. The objective of this study is to evaluate an individualized Common Elements Treatment Approach (CETA), a transdiagnostic psychotherapy model based on Cognitive-Behavioral Therapy, for adult trauma survivors.Methods and findingsA referred sample of 521 adult Afro-descendants from Buenaventura and Quibdó, Colombia, experiencing significant sadness, suffering or fear (score>0.77 in Total Mental Health Symptoms), with history of traumatic experiences, and with associated functional impairment were randomly allocated to CETA intervention, standby group without intervention, but under monthly monitoring, or a Narrative Community-Based Group Therapy. CETA was provided by trained Lay Psychosocial Community Workers without previous mental health experience, supervised by psychologists, during 12–14 weekly, 1.5-hour sessions. Symptoms were assessed with a locally validated survey built based on the Hopkins Symptom Checklist, the Harvard Trauma Questionnaire, the PTSD CheckList–Civilian Version, a qualitative study for additional general symptoms and a gender-specific functional impairment scale. CETA was compared with the control group and the intervention effects were calculated with mixed models using intention to treat analysis. Participant completion of follow-up was 75.1% and 13.2% voluntarily withdrew. Reduction in post-traumatic stress symptoms was significant in both municipalities when comparing intervention and control groups (mean difference), with a with a moderate effect size in Buenaventura (Cohen's d = 0.70) and a small effect size in Quibdó (d = 0.31). In Buenaventura, the intervention also had significant effects on depression (large effect size d = 1.03), anxiety (large effect size d = 0.80) and functional impairment (moderate effect size d = 0.70). In Quibdó, it had no significant effect on these outcomes. Changes in Total Mental Health Symptoms were not significant in neither city.ConclusionsThis trial suggests that CETA, can be effective in improving depression, anxiety, post-traumatic stress and function among victims of systematized violence in low-income and active conflict settings. Nonetheless, the difference of effectiveness between the two cities of intervention may indicate that we cannot assume that a mental health intervention known to be effective in one setting will be effective in another, even in similar circumstances and population. This may have special importance when implementing and reproducing these types of intervention in non-controlled circumstances. Further research should address these concerns. Results can be of use by governmental decision-makers when defining mental health programs for survivors.Trial registrationClinicalTrials.gov NCT01856673 (https://clinicaltrials.gov/ct2/...

A pilot study of a stepped-care brief intervention to help psychologically-distressed women displaced by conflict in Bogotá, Colombia

“…The most successful modification to increase recruitment was the shift in personnel to focus on community-experienced outreach personnel who could operate safely in higher-yield community venues. This aligns with the only similar published study (Bonilla-Escobar et al 2018). Future studies would benefit from approaching communities directly, circumventing as much as possible the politically complicated system currently in place to assist these populations in high need.…”

“…We would need to seekor createour own referral resources rather than rely on existing services. One option would be training human resourcescommunity health workersto handle the milder cases, thus limiting referrals to specialized services to only the highest-risk cases, as done by Bonilla et al (2018). Similar strategies have been effective in other Latin American countries (Araya et al 2003;Fritsch et al 2007) and other parts of the developing world (Chibanda et al 2016;Patel et al 2017).…”

“…Some of the OSITA dropout may have occurred due to participants feeling better after several IPC sessions and not returning. Nevertheless, the other comparable study (Bonilla-Escobar et al 2018) also reported high rates of participant drop-out, suggesting the need to further understand and tackle engagement and access barriers to mental health care within this population.…”

“…Health services are meant to be delivered by teams of professionals based at primary care clinics and by mobile community health teams that visit remote, underserved neighborhoods. Evidence-based approaches to address trauma and diagnosable psychopathology among IDPs have been generally lacking until recently (Murray et al 2014;Bonilla-Escobar et al 2018).…”

Social Impact of a Transformative Service-Learning Experience in a Post-conflict Setting

“…Populations that have experienced the armed conflict and violence in Colombia suffered negative consequences on their mental health (Bonilla-Escobar et al, 2018). Research on mental health interventions in post-conflict contexts posits the need of trained psychologists who can support dissemination and implementation of evidence-based effective health care approaches (Murray et al, 2014).…”