Date Published: September 24, 2019
Publisher: Public Library of Science
Author(s): Aseel Hamid, Nimisha Patel, Amanda C. de C. Williams, Charlotte Hanlon
Abstract: BackgroundTorture 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 findingsWe 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.ConclusionsOur 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.
Partial Text: Despite 156 countries having signed the United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment , torture is widespread, and Amnesty International has documented torture and other forms of ill treatment in 141 countries in 2014 . Long-standing and ongoing armed conflict has likely led to the increased use of torture since. Worldwide, 352,000 fatalities resulting from organised violence were identified between 2014 and 2016 alone . The prevalence of torture and resulting fatalities are likely higher but difficult to estimate given that perpetrators often obscure the use of torture, and there are multiple barriers to disclosure for survivors.
From an initial screen of 1,805 abstracts and titles, 6 RCTs since 2014 met our inclusion criteria [17–22] and were combined with the 9 RCTs identified in the previous meta-analysis (Fig 1) [23–31]. The characteristics of the 15 included studies are summarised in S1 Table. All eligible studies were of psychological interventions. Trials included 1,373 participants at the end of treatment (mean per study = 92) of the 1,585 that started treatment; a mean study completion rate of 86.6% with a range from 50% to 100%. Studies included 589 females and 784 males. Seven trials were conducted in Europe, 5 in Asia, and 3 in Africa. The most commonly used intervention was narrative exposure therapy (4 studies) or testimony therapy (3 studies), both of which draw on creating a testimony of traumatic events. Of the 6 new studies, all provided analysable data after calculating the standard deviation from CIs or standard errors. When neither CIs nor mean scores were available [14,21], the author was contacted, and the mean scores and standard deviations were obtained.
This systematic review and meta-analysis of 15 studies of interventions for torture survivors included 1,373 participants from 10 countries. Six of the 15 studies were published since the previous review, but the sample size increased 3-fold. The range of treatments was somewhat wider, but treatments were still most often compared with inactive controls rather than with other treatment. The problems of torture survivors were largely conceptualised in terms of PTSD symptoms that constituted the focus of treatment and, often, the primary outcome. Meta-analysis demonstrated few benefits of treatment: a statistically significant but clinically small decrease in PTSD symptoms at the end of treatment—from varied psychological interventions compared to mostly inactive controls—not found at follow-up. Other outcomes—PTSD caseness, psychological distress, usually depression and often of clinical severity—were not significantly different either at the end of treatment or at follow-up, with the exception of a worsening of PTSD caseness at follow-up, a poorer outcome than in the previous review  and clinically very disappointing. Few studies assessed functioning or quality of life, so results must be interpreted with caution, but they showed no improvement in quality of life and only in functioning, at the end of treatment but not at follow-up.