A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

Shr-Jie Wang, Ardiana Bytyçi, Selvi Izeti, Melita Kallaba, Feride Rushiti, Edith Montgomery, Jens Modvig, Shr-Jie Wang, Ardiana Bytyçi, Selvi Izeti, Melita Kallaba, Feride Rushiti, Edith Montgomery, Jens Modvig

Abstract

Background: Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012-14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo.

Methods: A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score.

Results: Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45-137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance.

Conclusions: The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability.

Trial registration: Clinicaltrials.gov (NCT01696578).

Figures

Fig. 1
Fig. 1
CONSORT flow diagram for enrolment
Fig. 2
Fig. 2
a Mean of mental health outcomes over time: PTSD, depression and anxiety disorders. b Mean of pain outcomes over time: numbers of bodily pain sites and SF-MPQ. c Mean of physical health outcomes over time: handgrip strength, standing balance and BMI
Fig. 3
Fig. 3
a Proportion of binary outcome over time: PTSD, depression and anxiety disorders. b Proportion of binary outcome over time: pain intensity and frequency. c Proportion of binary outcome over time: emotional well-being
Fig. 4
Fig. 4
Functioning and social outcomes over time: employment rate, monthly income and disability score

References

    1. Wang SJ, Rushiti F, Sejdiu X, Pacolli S, Gashi B, Salihu F, Modvig J. Survivors of war in northern Kosovo (III): The role of anger and hatred in pain and PTSD and their interactive effects on career outcome, quality of sleep and suicide ideation. Confl Heal. 2012;6(1):4. doi: 10.1186/1752-1505-6-4.
    1. Eytan A, Gex-Fabry M. Use of healthcare services 8 years after the war in Kosovo: role of post-traumatic stress disorder and depression. Eur J Public Health. 2012;22(5):638–643. doi: 10.1093/eurpub/ckr096.
    1. Kashdan TB, Morina N, Priebe S. Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: experiential avoidance as a contributor to distress and quality of life. J Anxiety Disord. 2009;23(2):185–196. doi: 10.1016/j.janxdis.2008.06.006.
    1. Lopes Cardozo B, Kaiser R, Gotway CA, Agani F. Mental health, social functioning, and feelings of hatred and revenge of Kosovar Albanians one year after the war in Kosovo. J Trauma Stress. 2003;16(4):351–360. doi: 10.1023/A:1024413918346.
    1. Wenzel T, Rushiti F, Aghani F, Diaconu G, Maxhuni B, Zitterl W. Suicidal ideation, post-traumatic stress and suicide statistics in Kosovo. An analysis five years after the war. Suicidal ideation in Kosovo. Torture. 2009;19(3):238–247.
    1. Wang SJ, Pacolli S, Rushiti F, Rexhaj B, Modvig J. Survivors of war in the Northern Kosovo (II): baseline clinical and functional assessment and lasting effects on the health of a vulnerable population. Confl Heal. 2010;4:16. doi: 10.1186/1752-1505-4-16.
    1. Wang SJ, Salihu M, Rushiti F, Bala L, Modvig J. Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict. Confl Heal. 2010;4:11. doi: 10.1186/1752-1505-4-11.
    1. Patel N, Kellezi B, Williams AC. Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Syst Rev. 2014;11:CD009317.
    1. McFarlane CA, Kaplan I. Evidence-based psychological interventions for adult survivors of torture and trauma: a 30-year review. Transcult Psychiatry. 2012;49(3–4):539–567. doi: 10.1177/1363461512447608.
    1. Johnson RE, Jones GT, Wiles NJ, Chaddock C, Potter RG, Roberts C, Symmons DP, Watson PJ, Torgerson DJ, Macfarlane GJ. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 2007;32(15):1578–1585. doi: 10.1097/BRS.0b013e318074f890.
    1. Dysvik E, Kvaloy JT, Stokkeland R, Natvig GK. The effectiveness of a multidisciplinary pain management programme managing chronic pain on pain perceptions, health-related quality of life and stages of change–a non-randomized controlled study. Int J Nurs Stud. 2010;47(7):826–835. doi: 10.1016/j.ijnurstu.2009.12.001.
    1. van Koulil S, van Lankveld W, Kraaimaat FW, van Helmond T, Vedder A, van Hoorn H, Donders R, de Jong AJ, Haverman JF, Korff KJ, et al. Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia. Arthritis Care Res (Hoboken) 2010;62(10):1377–1385. doi: 10.1002/acr.20268.
    1. Glombiewski JA, Hartwich-Tersek J, Rief W. Two psychological interventions are effective in severely disabled, chronic back pain patients: a randomised controlled trial. Int J Behav Med. 2010;17(2):97–107. doi: 10.1007/s12529-009-9070-4.
    1. Palic S, Elklit A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture. 2009;19(3):248–270.
    1. Ryan PB, Lee-Wilk T, Kok BC, Wilk JE. Interdisciplinary rehabilitation of mild TBI and PTSD: a case report. Brain Inj. 2011;25(10):1019–1025. doi: 10.3109/02699052.2011.597044.
    1. Sjolund BH, Kastrup M, Montgomery E, Persson AL. Rehabilitating torture survivors. J Rehabil Med. 2009;41(9):689–696. doi: 10.2340/16501977-0426.
    1. Vijayalakshmy P, Hebert C, Green S, Ingram CL. Integrated multidisciplinary treatment teams; a mental health model for outpatient settings in the military. Mil Med. 2011;176(9):986–990. doi: 10.7205/MILMED-D-11-00070.
    1. Carlsson JM, Olsen DR, Kastrup M, Mortensen EL. Late mental health changes in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis. 2010;198(11):824–828. doi: 10.1097/NMD.0b013e3181f97be3.
    1. Gordon JS, Staples JK, Blyta A, Bytyqi M, Wilson AT. Treatment of posttraumatic stress disorder in postwar Kosovar adolescents using mind-body skills groups: a randomized controlled trial. J Clin Psychiatry. 2008;69(9):1469–1476. doi: 10.4088/JCP.v69n0915.
    1. Foa EB. Prolonged exposure therapy: past, present, and future. Depress Anxiety. 2011;28(12):1043–1047. doi: 10.1002/da.20907.
    1. Foa EB, Zoellner LA, Feeny NC, Hembree EA, Alvarez-Conrad J. Does imaginal exposure exacerbate PTSD symptoms? J Consult Clin Psychol. 2002;70(4):1022–1028. doi: 10.1037/0022-006X.70.4.1022.
    1. McLean CP, Foa EB. Prolonged exposure therapy for post-traumatic stress disorder: a review of evidence and dissemination. Expert Rev Neurother. 2011;11(8):1151–1163. doi: 10.1586/ern.11.94.
    1. Nacasch N, Foa EB, Huppert JD, Tzur D, Fostick L, Dinstein Y, Polliack M, Zohar J. Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: a randomized control comparison with treatment as usual. J Clin Psychiatry. 2011;72(9):1174–1180. doi: 10.4088/JCP.09m05682blu.
    1. Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clin Psychol Rev. 2010;30(6):635–641. doi: 10.1016/j.cpr.2010.04.007.
    1. Rauch SA, Foa EB, Furr JM, Filip JC. Imagery vividness and perceived anxious arousal in prolonged exposure treatment for PTSD. J Trauma Stress. 2004;17(6):461–465. doi: 10.1007/s10960-004-5794-8.
    1. Rauch SA, Grunfeld TE, Yadin E, Cahill SP, Hembree E, Foa EB. Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder. Depress Anxiety. 2009;26(8):732–738. doi: 10.1002/da.20518.
    1. Meuret AE, Wilhelm FH, Roth WT. Respiratory feedback for treating panic disorder. J Clin Psychol. 2004;60(2):197–207. doi: 10.1002/jclp.10245.
    1. Morina N, Maier T, Bryant R, Knaevelsrud C, Wittmann L, Rufer M, Schnyder U, Muller J. Combining biofeedback and Narrative Exposure Therapy for persistent pain and PTSD in refugees: a pilot study. Eur J Psychotraumatol 2012;3. doi:10.3402/ejpt.v3i0.17660.
    1. Rosaura Polak A, Witteveen AB, Denys D, Olff M. Breathing biofeedback as an adjunct to exposure in cognitive behavioral therapy hastens the reduction of PTSD symptoms: a pilot study. Appl Psychophysiol Biofeedback. 2015;40(1):25–31. doi: 10.1007/s10484-015-9268-y.
    1. Margolis RB, Tait RC, Krause SJ. A rating system for use with patient pain drawings. Pain. 1986;24(1):57–65. doi: 10.1016/0304-3959(86)90026-6.
    1. Lopes Cardozo B, Vergara A, Agani F, Gotway CA. Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA. 2000;284(5):569–577. doi: 10.1001/jama.284.5.569.
    1. Roth G, Ekblad S, Agren H. A longitudinal study of PTSD in a sample of adult mass-evacuated Kosovars, some of whom returned to their home country. Eur Psychiatry. 2006;21(3):152–159. doi: 10.1016/j.eurpsy.2005.11.004.
    1. Halimi R, Dragoti E, Halimi H, Sylejmani-Hulaj N, Jashari-Ramadani S. Socio-cultural context and feelings of hatred and revenge in war veterans with post-traumatic stress disorder 15 years after war in Kosovo. Ment Illn. 2015;7(1):5609.
    1. Roth G, Ekblad S, Prochazka H. A study of aggression among mass-evacuated Kosovo Albanians. Torture. 2009;19(3):227–237.
    1. Terai T, Yukioka H. [Assessment of postoperative pain using face scale judged by nurses: comparison between hepatectomy and esophagectomy] Masui. 1999;48(9):981–985.
    1. Dworkin RH, Turk DC, Revicki DA, Harding G, Coyne KS, Peirce-Sandner S, Bhagwat D, Everton D, Burke LB, Cowan P, et al. Development and initial validation of an expanded and revised version of the Short-form McGill Pain Questionnaire (SF-MPQ-2) Pain. 2009;144(1–2):35–42. doi: 10.1016/j.pain.2009.02.007.
    1. Wong D, Baker C. Wong-Baker FACES® pain rating scale. 2015.
    1. Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996;11(6):368–374. doi: 10.1016/S0882-5963(96)80081-9.
    1. Garra G, Singer AJ, Domingo A, Thode HC., Jr The Wong-Baker pain FACES scale measures pain, not fear. Pediatr Emerg Care. 2013;29(1):17–20. doi: 10.1097/PEC.0b013e31827b2299.
    1. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). . Accessed 2010.
    1. Ustun TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Epping-Jordan J, Saxena S, von Korff M, Pull C. Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ. 2010;88(11):815–823. doi: 10.2471/BLT.09.067231.
    1. Wang SJ, Haque MA, Masum SU, Biswas S, Modvig J. Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims. BMC Int Health Hum Rights. 2009;9:31. doi: 10.1186/1472-698X-9-31.
    1. Fess EE. Clinical assessment recommendations. 2. Chicago: American Society of Hand Therapists; 1992.
    1. Hermodsson Y, Ekdahl C, Persson BM, Roxendal G. Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study with healthy subjects. Prosthet Orthot Int. 1994;18(3):150–158.
    1. Moher D, Schulz KF, Altman D. The CONSORT Statement: revised recommendations for improving the quality of reports of parallel-group randomized trials 2001. Explore (NY) 2005;1(1):40–45. doi: 10.1016/j.explore.2004.11.001.
    1. Rantanen T, Guralnik JM, Foley D, Masaki K, Leveille S, Curb JD, White L. Midlife hand grip strength as a predictor of old age disability. JAMA. 1999;281(6):558–560. doi: 10.1001/jama.281.6.558.
    1. Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis. 2005;193(10):651–657. doi: 10.1097/01.nmd.0000180739.79884.10.
    1. Halvorsen JO, Stenmark H. Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: a preliminary uncontrolled trial. Scand J Psychol. 2010;51(6):495–502. doi: 10.1111/j.1467-9450.2010.00821.x.
    1. Long SJ, Benton D. Effects of vitamin and mineral supplementation on stress, mild psychiatric symptoms, and mood in nonclinical samples: a meta-analysis. Psychosom Med. 2013;75(2):144–153. doi: 10.1097/PSY.0b013e31827d5fbd.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel