Psychological, social, and welfare interventions for torture survivors: A systematic review and meta-analysis of randomised controlled trials

Article


Hamid, A., Patel, N. and Williams, A. C. de C. 2019. Psychological, social, and welfare interventions for torture survivors: A systematic review and meta-analysis of randomised controlled trials. PLoS Medicine. 16 (Art. e1002919).
AuthorsHamid, A., Patel, N. and Williams, A. C. de C.
Abstract

Background

Torture and other forms of ill treatment have been reported in at least 141 countries, exposing a global crisis. Survivors face multiple physical, psychological, and social difficulties. Psychological consequences for survivors are varied, and evidence on treatment is mixed. We conducted a systematic review and meta-analysis to estimate the benefits and harms of psychological, social, and welfare interventions for torture survivors.

Methods and findings

We updated a 2014 review with published randomised controlled trials (RCTs) for adult survivors of torture comparing any psychological, social, or welfare intervention against treatment as usual or active control from 1 January 2014 through 22 June 2019. Primary outcome was post-traumatic stress disorder (PTSD) symptoms or caseness, and secondary outcomes were depression symptoms, functioning, quality of life, and adverse effects, after treatment and at follow-up of at least 3 months. Standardised mean differences (SMDs) and odds ratios were estimated using meta-analysis with random effects. The Cochrane tool was used to derive risk of bias. Fifteen RCTs were included, with data from 1,373 participants (589 females and 784 males) in 10 countries (7 trials in Europe, 5 in Asia, and 3 in Africa). No trials of social or welfare interventions were found. Compared to mostly inactive (waiting list) controls, psychological interventions reduced PTSD symptoms by the end of treatment (SMD −0.31, 95% confidence interval [CI] −0.52 to −0.09, p = 0.005), but PTSD symptoms at follow-up were not significantly reduced (SMD −0.34, 95% CI −0.74 to 0.06, p = 0.09). No significant improvement was found for PTSD caseness at the end of treatment, and there was possible worsening at follow-up from one study (n = 28). Interventions showed no benefits for depression symptoms at end of treatment (SMD −0.23, 95% CI −0.50 to 0.03, p = 0.09) or follow-up (SMD −0.23, 95% CI −0.70 to 0.24, p = 0.34). A significant improvement in functioning for psychological interventions compared to control was found at end of treatment (SMD −0.38, 95% CI −0.58 to −0.18, p = 0.0002) but not at follow-up from only one study. No significant improvement emerged for quality of life at end of treatment (SMD 0.38, 95% CI −0.28 to 1.05, p = 0.26) with no data available at follow-up. The main study limitations were the difficulty in this field of being certain of capturing all eligible studies, the lack of modelling of maintenance of treatment gains, and the low precision of most SMDs making findings liable to change with the addition of further studies as they are published.

Conclusions

Our findings show evidence that psychological interventions improve PTSD symptoms and functioning at the end of treatment, but it is unknown whether this is maintained at follow-up, with a possible worsening of PTSD caseness at follow-up from one study. Further interventions in this population should address broader psychological needs beyond PTSD while taking into account the effect of multiple daily stressors. Additional studies, including social and welfare interventions, will improve precision of estimates of effect, particularly over the longer term.

JournalPLoS Medicine
Journal citation16 (Art. e1002919)
ISSN1549-1277
Year2019
PublisherPublic Library of Science
Publisher's version
License
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Anyone
Supplemental file
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Anyone
Supplemental file
File Access Level
Anyone
Supplemental file
File Access Level
Anyone
Digital Object Identifier (DOI)doi:10.1371/journal.pmed.1002919
Web address (URL)https://doi.org/10.1371/journal.pmed.1002919
Publication dates
Online24 Sep 2019
Publication process dates
Accepted20 Aug 2019
Deposited02 Oct 2019
FunderCamden & Islington NHS Foundation Trust
Copyright holder© 2019 The Authors
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