Department of Medicine, Division of Preventive and Behavior Medicine
Community Health and Preventive Medicine | Psychiatric and Mental Health | Psychiatry and Psychology | Psychology
Background: Experiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.
Methods: Twenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.
Results: Adult survivors of systematic violence were screened (N inverted question mark= inverted question mark732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p inverted question mark= inverted question mark.003) and dysfunction (p inverted question mark= inverted question mark.007), while CPT had a significant effect on dysfunction only (p inverted question mark= inverted question mark.004).
Conclusions: Both interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.
Trial Registration: ClinicalTrials.Gov NCT00925262. Registered June 3, 2009.
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DOI of Published Version
BMC Psychiatry. 2014 Dec 31;14(1):1693. Link to article on publisher's site
Bolton P, Bass JK, Zangana G, Kamal T, Murray S, Kaysen D, Lejuez CW, Lindgren K, Pagoto SL, Murray LK, Van Wyk S, Ahmed A, Mohammad Amin NM, Rosenblum M. (2014). A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq. Open Access Articles. https://doi.org/10.1186/s12888-014-0360-2. Retrieved from https://escholarship.umassmed.edu/oapubs/2498
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