Post-Traumatic Stress Disorder, Depression, Anxiety, Violence
Conditions
Keywords
Mental Health, Displacement, Torture, Violence, Post-Traumatic Stress Disorder, Depression, Anxiety, Community-based intervention, Prevention trial, Disabled Persons
Brief summary
This study is a community prevention randomized trial with three parallel groups: two intervention groups and one control group in Buenaventura and Quibdó. The aim of the trial is to evaluate the impact of two community interventions on mental health; the intervention groups are designed to decrease depression, anxiety, post-traumatic stress disorders symptoms as well as the level of dysfunctionality in Afro-Colombian victims of violence. Adult people (equal or more than 18 years old) belonging to Afro-Colombian communities in both cities will participate in the enter survey. The subjects will be selected based on the severity of symptoms, traumatic experiences and a level of dysfunction identified using the instruments of this research (i.e. those obtaining an score equal or higher than 49 in symptoms (25% of the total of symptoms)). The fieldwork and the interventions will be conducted by people belonging to the community; they are called Lay Psychosocial Community Workers (LPCW). After six (6) weeks of formal training, they will be able to perform two kinds of interventions, Common Elements Treatment Approach (CETA) based on a cognitive behavioral intervention and Narrative Community Group Therapy (NCGT), for the people affected by violence and displacement that were pre-selected according to the baseline instrument. The LPCW will be under the constant supervision by psychologists of the project, and under weekly supervision by a group of experts from Johns Hopkins University, the Heartland Alliance and The Institute for Research and Development in Violence Prevention and Promotion of Peaceful Coexistence Social (CISALVA) by means of phone calls or monthly visits to the cities. Selected subjects will be randomly allocated to any study branch: CETA, NCGT or the waiting control group. The study subjects will follow their allocated treatment, or waiting in the control group, for 8 to 12 weeks; then they will be re-assessed using the project instrument two weeks after the last session of therapy. The study outcome is the differences in instrument scores between the follow-up and the baseline among the interventions (CETA or NCGT) and control group. Control subjects will be assessed by the project psychologist after the follow-up, and they will receive treatment when necessary.
Detailed description
Colombian armed conflict predominantly affects rural communities; armed conflict has caused thousands of deaths and the displacement of a vast amount of people from rural areas. A considerable amount of the displacement comes from the two most important cities in Pacific coast region: Buenaventura in Valle del Cauca province and Quibdó in Chocó province. This project will assess treatments, Common Elements Treatment Approach (CETA) and Narrative Community Group Therapy (NCGT), to reduce mental symptoms triggered by violence and will develop mechanisms for a sustainable supply of mental health services in the region. Adult Afro-Colombian persons who have responded to the study survey but present symptoms of severe mental illness like schizophrenic, psychotic, suicidal attempters, those who can potentially harm others, or who require specialized treatment will not be included in the study. They will be referred to a project psychologist who will determine whether they require psychiatric treatment, in which case, they will be referred to health institutions through social workers who will ensure treatment is given. Finally, anyone who is related to the LPCW will be excluded. For the CETA arm, new clients will be enrolled as long as a treatment position becomes available (i.e., as long as previous clients have completed the treatment) to keep the providers (LPCW) running at full capacity. These new clients will be chosen from those randomly allocated to receive the CETA treatment; within fifteen (15) days of the completion of treatment the participants will be reassessed. Similarly, the NCGT arm will form new groups as long as place becomes available (i.e, as long as previous group has finished treatment) to keep providers running at full capacity. Group members will be chosen from randomly allocated participant to receive NCGT, selecting enough people each time to fill up a group before the treatment begins. All group members will be reassessed within fifteen (15) days of completing the NCGT. The participants allocated in the control group will undergo a waiting period similar to the period between the initial and final assessments of those receiving CETA and NCGT. This period is estimated to be 3 months, but it could be longer if there are treatment delays. At the end of this time, the participants will be reassessed. after the control group is reassessed they will be evaluated and receive professional attention by psychologists to decide what is the best intervention that we can offer to the clients in both cities. Missing values will be handle using multiple imputation methods and data will be analyzed with an intention to treat basis. Sensitivity analysis will be carried out using non-imputed database and including co-variables in the models the inverse probability weight to lost of follow-up. The anticipated results is a reduction in anxiety, depression and post-traumatic stress disorder symptoms of 20 points among subjects in intervention groups (CETA or NCGT ) compared with those in the control group. An adherence of 70% is expected to generate strategies for the promotion and prevention in mental health for Afro-Colombian victims of violence and displacement.
Interventions
BEHAVIORALCommon Elements Treatment Approach
It was developed for treating symptoms related to violent trauma, i.e. symptoms of depression, anxiety and distress, among a population victimized by violence and torture in Colombia. The most relevant components for treatment of these 3 problematic issues were identified from literature review and a panel of experts. Descriptions and schemes have been developed in order to guarantee facility of use by community counselors who have little background in mental health skills. These counselors, who will be called Lay Psychosocial Community Workers (LPCW), will receive training in this technique before beginning of interventions. Application of this technique will be supervised constantly by mental health professionals (psychologist or social worker) from the project team.
BEHAVIORALNarrative Community Group Therapy
It consists on teaching skills to people in the community to provide mental health therapy. Therapy will be performed by LPCW under constant supervision of mental health professionals (psychologists or social workers). Sessions will begin with a series of introductory activities that motivates participants to propose different problems that they would like to solve in the group. A participant proposed a problem and he/she will be asked to talk about it. LPCW and/or psychologist will support individuals if anyone needs help to solve a psychological crisis. At the end of this narration, participants will be asked about who has had a similar situation, and how they solved it. In this way, proposed solutions will be collected by the LPCW. Finally, session closes with a motivating activity.
OTHERStandby group
Standby group: they will be assessed at baseline with the initial survey and they will wait between 10 and 12 weeks; an exit assessment will be performed with the study instrument. After the exit survey, control group participants will have an appointment with a professional psychologist to determine whether they require a mental health treatment. Those with such necessity will receive treatment in the ACOPLE center by professional psychologists or they will be referred to other health care level according to the type of psychopathology (e.g., psychosis) or its severity. Also, participants in the control group will be monitoring monthly by phone calls and if they have any psychological problem, they will be assessed in the ACOPLE center.
Sponsors
Heartland Alliance
United States Agency for International Development (USAID)
Johns Hopkins Bloomberg School of Public Health
Afrocolombian Displaced Association - AFRODES
Universidad del Valle, Colombia
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adults (18 years of age or older) Afro-Colombian victims of violence and torture who have expressed sadness, suffering psychological trauma caused by violence and when the situation was known by the leaders of Afro-Colombian Displaced Association (AFRODES) or the community leaders contacted by the research team. * Persons with a total symptomatic value greater than or equal to 49 points in the study instrument, with the presence of trauma from violence, and a loss of functionality score greater than zero. * Individuals who signed the informed consent.
Exclusion criteria
* People of ethnicities other than Afro-Colombian. * Children under 18 years old. * Persons who present symptoms of severe mental illness such as schizophrenia, psychotic episodes, suicidal attempters, and those who potentially could harm others. * Anyone who is related with the counselors (LPCW).
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Within the fifteen (15) days after finishing the intervention, either Common Elements Treatment Approach (CETA) or Narrative Community Group Therapy (NCGT). In the control group, 12 weeks after the baseline assessment. | Symptoms, ranging from 0 for never to 3 for all the time being three the worst score, were assessed with adapted versions of Hopkins Symptom Checklist and Harvard Trauma Questionnaire. Constructs of depression (n=15 symptoms), anxiety (n=10 symptoms), and post-traumatic stress symptoms (n=16 symptoms) were extracted and analyzed out of the mentioned surveys. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist (HSCL-25) and symptoms of trauma (PTSS) were assessed using the Harvard Trauma Questionnaire (HTQ). For each scale, the mean was calculated in order to use it as the measure for comparisons. Mean difference in scores of symptoms of anxiety, depression, and post-traumatic stress disorders between the subject's baseline and the final assessments were calculated. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Within the fifteen (15) days after finishing the intervention, either Common Elements Treatment Approach (CETA) or Narrative Community Group Therapy (NCGT). In the control group, 12 weeks after the baseline assessment. | TMHS scale of 64 items, ranging from 0 for never to 3 for all the time being the option three the worst condition, including locally relevant symptoms and sub-scales of depression (n=15 symptoms), anxiety (n=10 symptoms) and post-traumatic stress symptoms (PTSS) (n=16 symptoms). Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist (HSCL-25) and symptoms of trauma (PTSS) were assessed using the Harvard Trauma Questionnaire (HTQ). The Dysfunction measure was a gender-specific questionnaire with 12-items for females and 10-items for males. Each item assessed a task ranging from 0 for no difficulty to 4 for cannot do it, being option four the worst condition. For each scale, the mean was calculated in order to use it as the measure for comparisons. Mean difference in scores of TMHS and Dysfunction between the subject's baseline and the final assessments were calculated. |
Countries
Colombia
Participant flow
Recruitment details
Initial recruitment was done using referrals from key informants, community leaders, who were able to identify people affected by violence. To get more participants a snowball technique was used, participants were asked to refer others with similar problems. The identification numbers on the surveys were then randomized to one of the three arms.
Pre-assignment details
710 people were assessed for eligibility, 189 people were excluded: 175 for not meeting the inclusion criteria, 11 for meeting the exclusion criteria, and 3 refused to participate.
Participants by arm
| Arm | Count |
|---|---|
| ARM 1: Common Elements Treatment Approach Common Elements Treatment Approach (CETA) only
Common Elements Treatment Approach: It was developed for treating symptoms related to violent trauma, i.e. symptoms of depression, anxiety and distress, among victimized population by violence and torture in Colombia. The most relevant components for treatment of these 3 problematic issues were identified from literature review and panel of experts. Descriptions and schemes have been developed in order to guarantee facility of use by community counselors who have little background in mental health skills. These counselors, who will be called Mental Health Community Workers (MHCW), will receive training in this technique before beginning of interventions. Application of this technique will be supervised constantly by mental health professionals (psychologist or social worker) from the project team. | 175 |
| ARM 2: Community Group Therapy Community Group Therapy (CGT) only
Community Therapy Intervention: It consists on teaching skills to people in the community to provide mental health therapy. Therapy will be performed by MHCW under constant supervision of mental health professionals (psychologists or social workers). Sessions will begin with a series of introductory activities that motivates participants to propose different problems that they would like to solve in the group. A participant proposed a problem and he/she will be asked to talk about it. MHCW and/or psychologist will support individuals if anyone needs help to solve a psychological crisis. At the end of this narration, participants will be asked about who has had a similar situation, and how they solved it. In this way, proposed solutions will be collected by the MHCW. Finally, session closes with a motivating activity. | 175 |
| ARM 3: Standby Group Standby group without intervention, but under monthly monitoring.
Standby group: Standby group: they will be assessed at baseline with the initial survey and they will wait between 10 and 12 weeks; then an exit assessment will be performed with the study instrument. After the exit survey, control group participants will have an appointment with a professional psychologist to determine whether they require a mental health treatment. Those with such necessity will receive treatment in the ACOPLE center by professional psychologists or they will be referred to other health care level according to the type of psychopathology (e.g., psychosis) or its severity. Also, participants in the control group will be monitoring monthly by phone calls and if they have any psychological problem, they will be assessed in the ACOPLE center. | 171 |
| Total | 521 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 |
|---|---|---|---|---|
| Overall Study | Death | 1 | 1 | 0 |
| Overall Study | Lost to Follow-up | 31 | 34 | 0 |
| Overall Study | Paperwork errors | 8 | 0 | 0 |
| Overall Study | Protocol Violation | 1 | 0 | 1 |
| Overall Study | Psychologist decision | 1 | 0 | 0 |
| Overall Study | Unknown reasons | 9 | 0 | 0 |
| Overall Study | Withdrawal by Subject | 44 | 50 | 33 |
Baseline characteristics
| Characteristic | ARM 1: Common Elements Treatment Approach | ARM 2: Community Group Therapy | ARM 3: Standby Group | Total |
|---|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 22 Participants | 18 Participants | 22 Participants | 62 Participants |
| Age, Categorical Between 18 and 65 years | 153 Participants | 157 Participants | 149 Participants | 459 Participants |
| Age, Continuous Buenaventura | 40.4 years STANDARD_DEVIATION 14.1 | 39.5 years STANDARD_DEVIATION 13.3 | 41.8 years STANDARD_DEVIATION 14.8 | 40.54 years STANDARD_DEVIATION 14.08 |
| Age, Continuous Quibdó | 46 years STANDARD_DEVIATION 19 | 45.3 years STANDARD_DEVIATION 29.5 | 44.3 years STANDARD_DEVIATION 18.9 | 45.39 years STANDARD_DEVIATION 19.09 |
| Region of Enrollment Colombia | 175 participants | 175 participants | 171 participants | 521 participants |
| Sex: Female, Male Female | 149 Participants | 157 Participants | 150 Participants | 456 Participants |
| Sex: Female, Male Male | 26 Participants | 18 Participants | 21 Participants | 65 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 1 / 175 | 1 / 175 | 0 / 171 |
| other Total, other adverse events | 0 / 175 | 0 / 175 | 0 / 171 |
| serious Total, serious adverse events | 0 / 175 | 0 / 175 | 0 / 171 |
Outcome results
Primary
Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders.
Symptoms, ranging from 0 for never to 3 for all the time being three the worst score, were assessed with adapted versions of Hopkins Symptom Checklist and Harvard Trauma Questionnaire. Constructs of depression (n=15 symptoms), anxiety (n=10 symptoms), and post-traumatic stress symptoms (n=16 symptoms) were extracted and analyzed out of the mentioned surveys. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist (HSCL-25) and symptoms of trauma (PTSS) were assessed using the Harvard Trauma Questionnaire (HTQ). For each scale, the mean was calculated in order to use it as the measure for comparisons. Mean difference in scores of symptoms of anxiety, depression, and post-traumatic stress disorders between the subject's baseline and the final assessments were calculated.
Time frame: Within the fifteen (15) days after finishing the intervention, either Common Elements Treatment Approach (CETA) or Narrative Community Group Therapy (NCGT). In the control group, 12 weeks after the baseline assessment.
Population: Each row represents participants per city
| Arm | Measure | Group | Value (MEAN) |
|---|---|---|---|
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Depression | -0.79 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Depression | -0.48 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Anxiety | -0.89 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Anxiety | -0.63 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Post Traumatic Stress | -0.88 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Post Traumatic Stress | -0.59 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Post Traumatic Stress | -0.29 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Depression | -0.42 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Anxiety | -0.51 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Post Traumatic Stress | -0.48 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Depression | -0.40 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Anxiety | -0.48 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Depression | -0.34 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Post Traumatic Stress | -0.42 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Post Traumatic Stress | -0.40 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Quibdó- Anxiety | -0.50 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Depression | -0.18 units on a scale |
| ARM 3: Standby Group | Score Difference in Symptoms of Anxiety, Depression and Post-traumatic Stress Disorders. | Buenaventura- Anxiety | -0.26 units on a scale |
Secondary
Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction
TMHS scale of 64 items, ranging from 0 for never to 3 for all the time being the option three the worst condition, including locally relevant symptoms and sub-scales of depression (n=15 symptoms), anxiety (n=10 symptoms) and post-traumatic stress symptoms (PTSS) (n=16 symptoms). Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist (HSCL-25) and symptoms of trauma (PTSS) were assessed using the Harvard Trauma Questionnaire (HTQ). The Dysfunction measure was a gender-specific questionnaire with 12-items for females and 10-items for males. Each item assessed a task ranging from 0 for no difficulty to 4 for cannot do it, being option four the worst condition. For each scale, the mean was calculated in order to use it as the measure for comparisons. Mean difference in scores of TMHS and Dysfunction between the subject's baseline and the final assessments were calculated.
Time frame: Within the fifteen (15) days after finishing the intervention, either Common Elements Treatment Approach (CETA) or Narrative Community Group Therapy (NCGT). In the control group, 12 weeks after the baseline assessment.
Population: Each row represents participants per city
| Arm | Measure | Group | Value (MEAN) |
|---|---|---|---|
| ARM 1: Common Elements Treatment Approach | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Total Mental Health Symptoms | -0.74 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Total Mental Health Symptoms | -0.49 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Dysfunction | -0.41 units on a scale |
| ARM 1: Common Elements Treatment Approach | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Dysfunction | -0.08 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Dysfunction | -0.29 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Total Mental Health Symptoms | -0.39 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Dysfunction | -0.31 units on a scale |
| ARM 2: Narrative Community Group Therapy | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Total Mental Health Symptoms | -0.35 units on a scale |
| ARM 3: Standby Group | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Dysfunction | 0.002 units on a scale |
| ARM 3: Standby Group | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Quibdó- Total Mental Health Symptoms | -0.38 units on a scale |
| ARM 3: Standby Group | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Dysfunction | -0.01 units on a scale |
| ARM 3: Standby Group | Score Difference in Total Mental Health Symptoms (TMHS) and Dysfunction | Buenaventura- Total Mental Health Symptoms | -0.28 units on a scale |