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Psychological therapies for the treatment of mental disorders in low‐ and middle‐income countries affected by humanitarian crises

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Background

People living in humanitarian settings in low‐ and middle‐income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post‐traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population.

Objectives

To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises.

Search methods

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews.

Selection criteria

All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises.

Data collection and analysis

We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random‐effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post‐traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes.

Main results

We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub‐Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.

Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).

Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive‐behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).

In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) ‐1.07, 95% confidence interval (CI) ‐1.34 to ‐0.79; 1272 participants; 16 studies; low‐quality evidence). The effect is smaller at one to four months (SMD ‐0.49, 95% CI ‐0.68 to ‐0.31; 1660 participants; 18 studies) and at six months (SMD ‐0.37, 95% CI ‐0.61 to ‐0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD ‐0.86, 95% CI ‐1.06 to ‐0.67; 1254 participants; 14 studies; low‐quality evidence). Similar to PTSD symptoms, follow‐up data at one to four months showed a smaller effect on depression (SMD ‐0.42, 95% CI ‐0.63 to ‐0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD ‐0.74, 95% CI ‐0.98 to ‐0.49; 694 participants; five studies; low‐quality evidence) and at one to four months' follow‐up after treatment (SMD ‐0.53, 95% CI ‐0.66 to ‐0.39; 969 participants; seven studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).

In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD ‐1.56, 95% CI ‐3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).

We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings.

Authors' conclusions

There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow‐up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow‐up.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Talking therapy for the management of mental health in low‐ and middle‐income countries affected by mass human tragedy

Why is this review important?

Adults and children and adolescents living in humanitarian contexts (such as in the aftermath of a crisis triggered by natural hazards) in low‐ and middle‐income countries (LMICs) are exposed to multifaceted stressors that make them more vulnerable to developing post‐traumatic stress disorder (PTSD), major depression, anxiety, and other negative psychological outcomes.

Who will be interested in this review?

People who are directly exposed to humanitarian crises and their families and caregivers will be interested in this review, as will healthcare professionals and paraprofessionals working both in LMICs and in high‐income settings. Moreover, policy makers, humanitarian programming staff, guideline developers, and agencies (such as non‐governmental organisations (NGOs)) working in health and non‐health sectors (e.g. those providing protection to populations living in humanitarian contexts) may be interested in this review.

What questions does this review aim to answer?

Are psychological therapies more effective than control comparator conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) in reducing (symptoms of) PTSD and major depressive, anxiety, and somatoform and related disorders (conditions in which people present physical symptoms (e.g. pain) that cannot be explained medically) in people of any age, gender, or religion living in LMICs affected by humanitarian crises?

Which studies were included in this review?

Review authors searched databases up to February 2016 to find and include all relevant published and unpublished trials. Studies had to include children and/or adults living in LMICs affected by humanitarian crises. Studies also had to be randomised controlled trials (RCTs), which means that people were allocated at random (by chance alone) to receive the treatment or comparator condition.

We included 33 trials with a total of 3523 participants that examined a range of psychological therapies.

What does evidence presented in the review tell us?

In adults, low‐quality evidence shows greater benefit from psychological therapies than from control comparators in reducing (symptoms of) PTSD, major depression, and anxiety disorders. This evidence supports the approach of providing psychological therapies to populations affected by humanitarian crises, although we identified no studies that looked at the effectiveness or acceptability of psychological therapies for depressive and anxiety symptoms beyond six months. Only a small proportion of included trials reported data on children and adolescents, which provided very low‐quality evidence of greater benefit derived from psychological treatments. With regard to acceptability, moderate‐ to low‐quality evidence suggests no differences in dropout rates among adults and children and adolescents. Reviewers found no studies evaluating psychological treatments for (symptoms of) somatoform disorders or medically unexplained physical symptoms (MUPS) in adults, nor in children or adolescents, respectively.

What should happen next?

Researchers should conduct higher‐quality trials to further evaluate the effectiveness of psychological therapies provided over longer periods to adults and to children and adolescents. Ideally, trials should be randomised, should use culturally appropriate and validated instruments to evaluate outcomes, and should assess correlates of reductions in treatment effects over time; in addition, researchers should make every effort to ensure high rates of follow‐up beyond six months after completion of therapy.

Authors' conclusions

Implications for practice

Currently low‐quality evidence suggests the effectiveness of psychological therapies over control comparators in decreasing PTSD and depressive and anxiety symptoms, and moderate‐quality evidence shows the acceptability of these treatments for adults. Very low‐quality evidence suggests that psychological therapies may decrease PTSD symptoms in children and adolescents (with no evidence available with regard to depression and anxiety in children/adolescents) immediately after treatment, and low‐quality evidence suggests that these treatments may be acceptable. Heterogeneity between studies was high. We found large treatment benefits at short‐term follow‐up.

Implications for research

Results from this review show that psychological therapies are effective in decreasing PTSD and depressive and anxiety symptoms in adults and in children and adolescents. Identification of a short‐term benefit is important for populations living in humanitarian settings in LMICs. Having said this, however, this review revealed a gap in the knowledge base at longer term and in the child and adolescent population. More evidence is needed to evaluate the effectiveness of psychological therapies for longer than six months after the intervention, and for children and adolescents living in humanitarian settings in LMICs. Future trials should be randomised, should use socioculturally appropriate and validated instruments to measure outcomes, and should provide higher rates of follow‐up over the longer term. Moreover, the following would be important.

  1. To describe in greater detail the types of trauma and the sociocultural and family contexts in which participants live, including, for example, details on socioeconomic status, living arrangements, ethnicity, and healthcare preferences. A full description of humanitarian conditions is particularly important, as factors such as poverty, discrimination, stigma, and lack of social networks may negatively impact psychological and physical health, and thus outcomes of treatment (Miller 2016; Purgato 2016b). Even though we were able to collect a good quantity of information on traumatic events and settings (and to perform subgroup analyses accordingly), this goal would best be achieved by making individual participant data available for meta‐analysis.

  2. To (continue to) pay attention to cultural applicability of research design, measurement, and interpretation across socioculturally diverse populations, given variation in mental health experiences, prioritisation, and care preferences (Haroz 2016; Kaiser 2015). (Continued) involvement of people from the affected population throughout the research process will prove helpful in gaining an appropriate understanding and interpretation of clinical symptoms, and in assessing and delivering interventions.

  3. To choose pragmatic, meaningful, and easily to assess outcomes.

  4. To receive due attention to some methodological key issues such as allocation concealment, blinding, and availability of longer‐term follow‐ups. Moreover, with summary statistics, quality and completeness of information are essential. Meta‐analyses of poor quality studies may be seriously misleading because the bias associated with defects in the conduct of primary studies (RCTs) can seriously affect the overall estimate of intervention (Savović 2012). Systematic review authors (not only within Cochrane) should routinely assess risk of bias in trial results.

Summary of findings

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Summary of findings for the main comparison. Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Patient or population: adults exposed to traumatic events
Setting: humanitarian settings in LMICs
Intervention: psychological therapy
Comparison: wait list; no treatment; treatment as usual

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with psychological therapy

Post‐traumatic stress disorder at endpoint

(measured with IES‐R; HTQ; CAPS; UCLA‐PTSD‐RI; PDS; PCL‐5)

SMD 1.07 lower
(1.34 lower to 0.79 lower)

1272
(16 RCTs)

⊕⊕⊝⊝
Lowa,b

This is a large effect according to Cohen 1992

Depression at endpoint

(measured with BDI‐II, HSCL‐25, HADS)

SMD 0.86 SD lower
(1.06 lower to 0.67 lower)

1254
(14 RCTs)

⊕⊕⊝⊝
Lowa,c

This is a large effect according to Cohen 1992

Anxiety at endpoint

(measured with HADS‐A; HSCL‐25)

SMD 0.74 SD lower
(0.98 lower to 0.49 lower)

694
(5 RCTs)

⊕⊕⊝⊝

Lowd,e

This is a moderate effect according to Cohen 1992

Dropouts for any reason

Study population

RR 0.98
(0.82 to 1.16)

2950
(23 RCTs)

⊕⊕⊕⊝
Moderatea

195 per 1000

191 per 1000
(160 to 227)

Somatic symptoms and related disorders

No data are available

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

BDI: Beck Depression Inventory

CAPS: Clinician Administered Post‐traumatic stress disorder Scale

HADS: Hospital Anxiety and Depression Scale

HSCL: Hopkins Symptoms Checklist

IES‐R: Impact of Event Scale‐Revised

LMIC: low‐ and middle‐income countries

PCL: Post‐traumatic stress disorder Check List

PDS: Post‐traumatic stress disorder Diagnostic Scale

UCLA‐PTSD‐ RI: University College of Los Angeles Post‐traumatic stress disorder Reaction Index

aDowngraded one level owing to study limitations (outcome assessment was not described as masked in all RCTs)

bDowngraded one level owing to inconsistency (I2 was higher than 75%)

cDowngraded one level owing to inconsistency (I2 was 55%)

dDowngraded one level owing to imprecision (the CI includes no effect)

eDowngraded one level owing to study limitations (high risk of bias detected: performance bias, attrition bias, and concerns about therapist/investigator allegiance)

Open in table viewer
Summary of findings 2. Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Patient or population: children exposed to traumatic events

Settings: humanitarian settings in LMICs

Intervention: psychological therapy

Comparison: wait list; no treatment; treatment as usual

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with psychological therapy

Post‐traumatic stress disorder at endpoint

(measured with UCLA‐PTSD‐RI; CRIES)

SMD ‐1.56
(‐3.13 lower to 0.01 higher)

130
(3 RCTs)

⊕⊕⊝⊝
Very lowa,b,c

This is a large effect according to Cohen 1992

Depression at endpoint

No data are available

Anxiety at endpoint

No data are available

Dropouts for any reason

Study population

RR 1.87 (0.47 to 7.47)

138
(3 RCTs)

⊕⊕⊝⊝
Lowa,d

352 per 1000

658 per 1000
(165 to 1000)

Somatic symptoms and related disorders

No data are available

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

CRIES: Children Revised Impact of Events Scale

LMIC: low‐ and middle‐income countries

UCLA‐PTSD‐ RI: University College of Los Angeles Post‐traumatic stress disorder Reaction Index

aDowngraded one level owing to study limitations (outcome assessment was not described as masked in all RCTs)

bDowngraded one level owing to inconsistency (I2 was higher than 75%)

cDowngraded one level owing to imprecision (outcome based on small number of participants and confidence interval is wide)

dDowngraded one level owing to imprecision (CI includes no effect)

Background

Description of the condition

The term 'humanitarian crises' is used to refer to a broad group of emergencies, including those triggered by natural, technological, and industrial hazards, as well as armed conflicts (Tol 2011). Humanitarian crises are commonly defined as rapid and serious deteriorations in safety, with numerous victims or numerous people whose lives are in danger or who are in great distress, along with substantial material destruction, forced displacement or population movement, and great difficulty or incapacity of institutional management in handling the situation (Josse 2009). The most commonly affected populations live in low‐ and middle‐income countries (LMICs) (Guha‐Sapir 2014; Themner 2014). Humanitarian crises have a wide range of impacts on the mental health of individual survivors. Mental health consequences may include improved mental health (e.g. through post‐traumatic growth); maintained mental health and wellbeing despite exposure to adversity (i.e. resilience); transient acute stress reactions and bereavement; and a range of mental disorders (Kane 2017).

Mental health epidemiology in humanitarian settings has most commonly focused on disorders and conditions specifically associated with exposure to stressors, such as post‐traumatic stress disorder (PTSD). In classifying outcomes of interest, we followed the Diagnostic and Statistical Manual of Mental Disorders (DSM‐V) classification. Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, persistent avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity associated with the traumatic event (APA 2013; O'Donnell 2014).

Moreover, studies have identified heightened prevalence of disorders that can occur in the absence of exposure to stressors, such as:

  1. anxiety disorders, which include disorders that share features of excessive fear and anxiety and related behavioural disturbances;

  2. depressive disorders, which are characterised by the presence of sad, empty, or irritable mood, and accompanied by somatic and cognitive changes that affect the individual's capacity to function (APA 2013); and

  3. somatic symptom and related disorders (this is an umbrella term introduced in the DSM‐V that includes the conditions listed in the DSM‐IV as somatoform disorders), including medically unexplained physical symptoms (MUPS) (APA 2013; van Dessel 2014).

Steel et al conducted a meta‐analysis of epidemiological studies with adult conflict‐affected populations across 181 surveys in 40 countries. In a subset of rigorous studies, prevalence rates were 15.4% for PTSD (30 studies using representative sampling and diagnostic interviews) and 17.3% for depression (26 studies using representative sampling and diagnostic interviews). Predictors of PTSD were torture, cumulative exposure to potentially traumatic events (PTEs), time since conflict, and level of political terror in the territory. For depression, predictors were number of PTEs, time since conflict, torture, and residency status (Charlson 2016).

Description of the intervention

The World Health Organization (WHO) Mental Health Gap Action Program (mhGAP) has developed guidelines specifically focused on the needs of people living in LMICs (WHO 2013; WHO 2016). Pharmacological treatments are available for individuals with PTSD (Hoskins 2015). However, psychological therapies, together with other types of psychosocial interventions, are generally considered the first‐line option according to mhGAP guidelines (e.g. for management of acute stress, PTSD, and bereavement) (WHO 2013; WHO 2016).

Psychological therapies are widely used in the management of (symptoms of) PTSD, anxiety, depression, somatoform disorders, MUPS, and related disorders, and are recommended in the mhGAP Intervention Guide (WHO 2016). mhGAP guidelines contain both recommendations on psychological interventions for adults and a specific section dedicated to treatment of children and adolescents. Different types of psychological therapies are available, such as different forms of cognitive‐behavioural therapy (CBT), including CBT with a trauma focus (CBT‐T), Brief Behavioural Activation treatment (BA), narrative exposure therapy (NET), and the common elements treatment approach (CETA); eye movement desensitisation and reprocessing (EMDR); interpersonal therapy (IPT); thought field therapy (TFT); and psychodynamic therapy.

CBT is often used as an umbrella term that encompasses a wide range of therapeutic approaches, techniques, and systems that share some common elements. CBTs include psychological treatments that combine cognitive components (aimed at thinking differently, for example, by identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example, by helping the person to participate in more rewarding activities) (WHO 2016). CBTs assume that psychopathology, or emotional disturbance, is the result of biased cognitions and unhelpful behaviour; these treatments aim to improve symptoms of anxiety by addressing these unhelpful cognitions and behaviours. They are used to treat individuals with depression and somatoform disorders (Allen 2010), and they are used in children and adolescents as well as in adults (James 2015; Olthuis 2015; Watts 2015).

CBT has been applied to all disorders of interest in this review (with various modifications/various emphases for different disorders).

These include the following.

  1. CBT‐T (cognitive‐behavioural therapy with a trauma focus): based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of reminders of the event and a sense of current threat. Treatment usually includes exposure to those reminders and to challenging unhelpful trauma‐related thoughts or beliefs (WHO 2016).

    1. Among CBT‐Ts, NET (narrative exposure therapy) is a standardised short‐term approach to trauma‐related disorders based on the patient's construction of a narrative about his/her life from birth up to the present situation with focus on detailed exploration of the traumatic experience, while combining testimony therapy and CBT‐T exposure elements (Schauer 2011).

    2. CETA (common elements treatment approach): transdiagnostic treatment approach specifically designed to be delivered in low‐resource settings, which allows therapists to combine evidence‐based treatment elements depending on individual symptom presentation, including psychoeducation, anxiety management, cognitive coping/restructuring, and elements of exposure (Murray 2014).

    3. BA (Brief Behavioural Activation): a manualised type of CBT that is focused on reducing depressive symptoms by helping individuals engage in positive activities on a daily basis, according to the values and goals of that individual in multiple life areas (i.e. relationships, career, and spirituality) (Jakupcak 2010).

  2. EMDR (eye movement desensitisation and reprocessing): based on the idea that negative thoughts, feelings, and behaviours result from unprocessed memories of traumatic events. Treatment involves standardised procedures that include focusing simultaneously on:

    1. associations of traumatic images, thoughts, emotions, and bodily sensations; and

    2. bilateral stimulation that most commonly occurs in the form of repeated eye movements (WHO 2016).

  3. IPT (interpersonal psychotherapy): helps people understand their feelings as useful signals of interpersonal encounters (Markowitz 2014). IPT is considered an evidence‐based therapy for major depression that focuses specifically on the connection between depressive symptoms and interpersonal problems (Dennis 2007;WHO 2016); it has also been evaluated in the treatment of anxiety disorders, PTSD, and somatoform and related disorders (Markowitz 2015; van Dessel 2014).

  4. TFT (thought field trauma): brief trauma intervention that utilises a sequence of self‐tapping to stimulate specific acupuncture points while recalling a traumatic event or cue. It facilitates the relaxation response while the person experiences exposure to the problem by simply thinking about the problem (Callahan 2000).

  5. Psychodynamic therapy: focused on integration of the traumatic experience into the life experience of the person as a whole, often considering childhood issues as important (Brom 1989).

  6. Other interventions, such as generic, problem‐solving, or trauma‐focused counselling: commonly less structured than psychotherapies and targeting specific needs and problems as expressed by patients. Interventions may also focus on rebuilding skills and coping strategies in social situations while improving communication and social interaction skills, to reduce stress in everyday life (WHO 2016).

How the intervention might work

These different treatments are based on their own various theoretical models describing putative treatment mechanisms. Previous reviews of psychological treatments for PTSD ‐ Bisson 2013 and Gillies 2016, depression ‐ Cuijpers 2009,Gloaguen 1998,Rigmor 2010, and Watanabe 2007, and anxiety disorders ‐ Abbass 2014 found psychological treatments to be effective. For PTSD in adults, treatments that included specific elements focused on trauma were more effective than treatments that did not include such elements (Bisson 2013). In children and adolescents, CBT interventions appeared to be more effective than control conditions for PTSD (Gillies 2016), depression (Watanabe 2007), and anxiety disorders (James 2015).

For all clinical conditions considered in this review, the mechanism of action of CBT had been explored and categorised as follows.

  1. Cognitive mechanisms: increase in adaptive cognitions that may occur through restructuring of maladaptive thought patterns, correction of misinterpretations, changes in attentional focus, and development of adaptive coping thoughts.

  2. Behavioural mechanisms: increase in adaptive behavioural responses that may occur through habituation, extinction of maladaptive responses, behavioural activation, associative learning, and reinforcement of adaptive responding.

  3. Physiological mechanisms: normalisation of physiological arousal that may occur through habituation, incompatible response training, or changes in autonomic nervous system activity (DePaulo 2014).

CBT for depression is based on the assumption that the person's mood is related to his or her patterns of thought (thoughts tend to be unrealistic or distorted); therefore CBT can help a person learn to recognise negative patterns of thought, to evaluate their validity, and to replace these thoughts with different and functional ways of thinking (Beck 1979;WHO 2016). CBT for anxiety addresses negative patterns/distortions related to the way we look at the world and at ourselves. This involves a cognitive component (focused on how negative thoughts, or cognitions, contribute to anxiety) and a behavioural component (focused on behaviours that trigger anxiety). CBT is based on the premise that fear and anxiety are learnt responses that can be 'unlearnt' (James 2015). CBT has also been used for somatoform‐related disorders (van Dessel 2014).

CBT‐T is based on the idea that people with PTSD have unhelpful thoughts and beliefs related to a traumatic event and its consequences, and that these beliefs result in unhelpful avoidance of reminders of the event with a sense of current threat. Cognitive‐behavioural interventions with a trauma focus usually work with imaginal and/or in vivo (real life) exposure treatment and/or direct challenging of unhelpful trauma‐related thoughts and beliefs (WHO 2013). CBT‐T protocols usually involve different components such as psychoeducation, anxiety management, exposure, and cognitive restructuring (Bisson 2013). NET is a type of CBT‐T that is thought to contextualise the particular associative elements of the fear network ‐ the sensory, affective, and cognitive memories of trauma ‐ to understand and process the memory of a traumatic event in the course of the patient's life. In NET, the patient (with the assistance of the therapist) constructs a chronological narrative of his life story with a focus on traumatic experiences. Fragmented reports of these traumatic experiences will be transformed into a coherent narrative. Empathic understanding, active listening, congruency, and unconditional positive regard are key components of the therapist’s behaviour (Schauer 2011). CETA is a transdiagnostic approach that tailors the selection of elements that are common to evidence‐based psychotherapies to each individual's symptom profile. It consists of delivering specific components tailored to the individual's needs and culture. Components are engagement, psychoeducation, anxiety management, cognitive restructuring, imaginal gradual exposure, in vivo exposure, safety, and alcohol use assessment (Murray 2014).

BA is a structured CBT program for depression that reinforces positive activities in different areas of an individual's life (e.g. talking and exchanging ideas with others; interacting with and helping other; working). Engagement in these activities is initially supported by the therapist (actively) and is intended to become more intrinsic as activities lead to more positive experiences and the satisfaction that comes from living according to one's own goals and values.

TFT is a brief treatment that identifies feelings elicited by thinking about the problem and asking the patient to rate the emotional intensity that he/she feels when thinking about the problem by stimulating selected acupoints on the surface of the skin in a sequence that is specific to the identified emotions. The theory behind TFT is that precisely encoded information becomes activated when an individual thinks about a problem, either subconsciously or consciously (Callahan 2000).

EMDR is based on the idea that negative thoughts, feelings, and behaviours are the result of unprocessed memories. Treatment involves standardised procedures that include simultaneous focus on spontaneous associations of traumatic images, thoughts, emotions, and bodily sensations; and bilateral stimulation, most commonly in the form of repeated eye movements (WHO 2013).

IPT is an evidence‐based treatment for individuals with major depression. It is designed to help a person identify and address problems in relationships with family, friends, partners, and other significant people (WHO 2016). IPT addresses the person’s ability to assert his/her needs and wishes in interpersonal encounters, to validate the person’s anger as a normal interpersonal signal and to encourage its efficient expression, and to take appropriate social risks. Reviewing the person's accomplishments during treatment helps him/her feel more capable and independent (Markowitz 2004).

Psychodynamic therapies aim to resolve inner conflicts arising from the traumatic event by placing emphasis on the unconscious mind. These therapies have also been used in depression, anxiety disorders, and somatic symptom and related disorders.

Why it is important to do this review

Humanitarian crises impact a large part of the world's population, often affecting populations already beset by adversity (e.g. poverty, gender‐based violence, social marginalisation). For example, the Machel report states that just over 1 billion children globally are affected by armed conflicts (UN General Assembly 1996; UNICEF 2009). It is important to note that given the known high burden associated with mental disorders and conditions in these populations, application of treatments with known efficacy has the potential to improve individual functioning while widening wellbeing and economic productivity.

Mental health and psychosocial support interventions are becoming a standard part of humanitarian programmes. Although this was an ideologically divided field, agreement on best practices appears to be growing, as evidenced by international consensus‐based documents (IASC 2007; The Sphere Project 2011). These documents advocate for multi‐layered systems of care intended to address the diversity of mental health and psychosocial needs in humanitarian settings. As part of such systems of care, pharmacological and psychological treatments are intended to target more severe mental health problems. This review focuses on psychological therapies, given conflicting views in current guidelines on the benefits of pharmacological approaches for conditions specifically related to stress, such as PTSD (Forbes 2010;WHO 2013). In two parallel reviews, we will evaluate the effectiveness of psychosocial approaches in preventing mental disorders and promoting (positive aspects of) mental health and psychosocial well‐being.

Bisson et al conducted a systematic review of randomised controlled trials (RCTs) of individual CBT‐T, EMDR, CBT without a specific trauma focus, and other therapies (supportive therapy, non‐directive counselling, psychodynamic therapy, and present‐centred therapy), as well as group CBT‐T and group CBT for PTSD (70 studies; n = 4761) (Bisson 2013). Researchers found that CBT‐T and EMDR were effective in reducing clinician‐rated PTSD. Individual CBT‐T, EMDR, and CBT appeared to be equally effective immediately post treatment, and some evidence shows that CBT‐T and EMDR were superior to CBT at follow‐up. Individual CBT‐T, EMDR, and CBT are more effective than other therapies. A recent Cochrane review on PTSD in children and adolescents included 51 studies (n = 6201) with participants exposed to various kinds of traumatic events. Trial authors found evidence to support the effectiveness of psychological therapies for reducing PTSD in children and adolescents (Gillies 2016). However, even though informative, these reviews were not specifically focused on humanitarian settings in LMICs.

In summary, given the broad impact of humanitarian settings on mental health, this review aims to provide a comprehensive evaluation of the effectiveness and acceptability of psychological treatments, across a range of disorders in children and adolescents as well as adults. In conducting this systematic review, we will follow the protocol that we published in the Cochrane Database of Systematic Reviews (Purgato 2015).

Objectives

To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises.

Methods

Criteria for considering studies for this review

Types of studies

We included RCTs. We also included in the review trials employing a cross‐over design ‐ whilst acknowledging that this design is rarely used in psychological treatment studies ‐ using data from the first randomised stage only. We excluded quasi‐randomised trials, such as those allocating treatments on alternate days of the week. We considered cluster‐randomised trials as eligible for inclusion.

Types of participants

Participant characteristics

We included participants of any age, gender, ethnicity, or religion. We conducted separate meta‐analyses for studies with children and adolescents (younger than 18 years) and for adults (18 years of age or older) on different trial outcomes. We categorised studies including mixed populations of children and adults according to the mean age of participants.

We have decided for the first version of this review to consider children and adolescents, as well as adults, according to the methods followed by Tol 2011.

Setting

We considered studies conducted in LMICs in humanitarian settings, that is, in contexts affected by armed conflicts or by disasters associated with natural, technological, or industrial hazards. We used World Bank criteria for categorising a country as low‐ or middle‐income (World Bank 2013). For 2016, low‐income economies were defined as those with a gross national income (GNI) per capita, as calculated using the World Bank Atlas method, of $1,025 or less in 2015; middle‐income economies as those with a GNI per capita between $1,026 and $12,475; and high‐income economies as those with a GNI per capita of $12,476 or more (www.worldbank.org/). We excluded studies undertaken in high‐income countries or focused on refugees currently living in high‐income countries. Therapies may be delivered in healthcare clinics or in other healthcare facilities, refugee camps, schools, communities, survivors’ homes, and detention facilities. We included studies recruiting inpatients and outpatients. We included studies with populations during humanitarian crises, as well as during the period after acute humanitarian crises (e.g. post‐conflict settings).

Diagnosis

We included studies that applied any standardised diagnostic criteria, including Diagnostic and Statistical Manual of Mental Disorders (DSM) III (APA 1980), DSM‐III‐R (APA 1987), DSM‐IV (APA 1994), DSM‐IV‐TR (APA 2000), DSM‐V (APA 2013), or International Classification of Diseases (ICD‐10) criteria (WHO 1992), for the following disorders.

  1. PTSD.

  2. Anxiety disorders (e.g. separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, substance/medication‐induced anxiety disorder).

  3. Depressive disorders (e.g. major depressive disorder).

  4. Somatoform symptom and related disorders, including medically unexplained physical symptoms (MUPS).

We included studies that assessed the presence of a mental disorder using a structured psychiatric diagnostic interview (e.g. the Mini International Neuropsychiatric Interview (Sheehan 1998)) or scoring above established cutoffs on commonly used rating scales (e.g. the Impact of Events Scale ‐ Revised, for PTSD (Weiss 1997); the Hamilton Depression Rating Scale (HDRS) (Hamilton 1960); or the Beck Depression Inventory for Depression (Beck 1961). Earlier studies may have used ICD‐9 (WHO 1978), but ICD‐9 is not based on operationalised criteria, so we excluded from this review studies that used ICD‐9.

We excluded studies that had a primary focus on the following disorders: substance misuse; dissociative disorders; obsessive‐compulsive disorders; and child behavioural disorders. We recognise the importance of these disorders, but we found scant epidemiological data on their prevalence in LMIC humanitarian settings, and we assumed that few studies have evaluated psychological treatments for these disorders in humanitarian settings (Charlson 2016; WHO 2012).

WHO estimates that humanitarian crises may be associated with an increase of 1% to 2% in prevalence of (pre‐existing) severe neuropsychiatric disorders such as psychosis and epilepsy (WHO 2012). Although it is critical to recognise the importance of these severe neuropsychiatric disorders for humanitarian programming (Jones 2012), we do not discuss them as part of the current review.

Researchers have described the importance of culturally patterned descriptions of symptoms in humanitarian settings that do not fit current psychiatric classification systems. Such cultural concepts of distress have been the topic of epidemiological studies but have not commonly been part of outcome evaluation studies (Kohrt 2013); therefore we did not review them here.

Comorbidity

We included studies recruiting participants with mental disorder comorbidities (i.e. various combinations of the disorders listed above) and physical comorbidities. We conducted a subgroup analysis to investigate whether the presence of comorbidities affected trial results.

Types of interventions

Experimental interventions

Any psychological therapies aimed at treating patients with (symptoms of) PTSD or major depressive, anxiety, somatoform, or related disorders in humanitarian settings in LMICs.

  1. CBT (BA and CBT‐T: NET, CETA, other CBT).

  2. EMDR.

  3. IPT.

  4. TFT.

  5. Psychodynamic therapy.

  6. Other psychological therapies.

Comparators

Control comparators included the following.

  1. No treatment.

  2. Treatment as usual (TAU) (also called standard/usual care): Participants could receive any appropriate medical care during the course of the study on a naturalistic basis, as deemed necessary by the clinician.

  3. Wait list (WL): delayed delivery of the intervention to the control group until after participants in the intervention group have completed treatment. As in TAU, participants in the WL condition could receive any appropriate medical care during the course of the study on a naturalistic basis.

  4. Attention placebo: defined as a control condition that is regarded as inactive by both researchers and participants in a trial.

  5. Psychological placebo: defined as a control condition that is regarded by researchers as inactive but is regarded by participants as active.

Participants may receive any appropriate medical care during the course of the study on a naturalistic basis, including pharmacotherapy, as deemed necessary by the healthcare staff. We documented any additional intervention(s) received naturalistically by participants allocated to both control and active arms. In the present review, we assessed the effectiveness of psychological therapies as delivered in typical clinical settings (not necessarily under ideal experimental conditions).

Format of psychological therapies

Psychological treatment may be delivered through any means, including, for example, face‐to‐face meetings, Internet, telephone, or self‐help booklets between participant(s) and trained professional(s) or para‐professional(s). Both individual and group psychological treatments were eligible for inclusion, with no limit applied to the number of sessions.

Excluded interventions

We excluded from this review pharmacological treatments, as well psychosocial interventions aimed at preventing mental disorders or promoting (positive aspects of) mental health and psychosocial well‐being. Separate parallel reviews have covered the latter two.

Types of outcome measures

We included studies that met the above inclusion criteria regardless of whether they reported on the following outcomes.

Primary outcomes

  1. Efficacy outcome (symptom severity)

    1. PTSD: mean change from baseline to study endpoint on the Harvard Trauma Questionnaire (HTQ) (Mollica 1992), the Posttraumatic Stress Disorder Checklist ‐ Civilian version (PCL‐C) (Weathers 1993), the Clinician‐Administered PTSD Scale for adults (CAPS) (Blake 1995), the Clinician‐Administered PTSD Scale for Children and Adolescents (CAPS‐CA) (Nader 1996), or other rating scales

    2. Anxiety disorders: mean change from baseline to study endpoint on the Hospital Anxiety and Depression Scale ‐ Anxiety Subscale (HAD‐A) for adults (Zigmond 1983), the Screen for Anxiety Related Emotional Disorders (SCARED‐5) for children and adolescents (Birmaher 1997), or any other commonly used rating scale

    3. Major depressive disorder: mean change scores from baseline to study endpoint on the Depression Self‐Rating Scale (Birleson 1987), the Beck Depression Inventory (Beck 1961), the Hamilton Depression Rating Scale (HDRS) (Hamilton 1960), the Montgomery‐Asberg Depression Rating Scale (MADRS) (Montgomery 1979), or any other commonly used rating scale

    4. Somatic symptom and related disorders: mean change scores from baseline to study endpoint on Somatic Symptom Scale‐8 (Gierk 2014), Patient Health Questionnaire‐15 (Kroenke 2002), or any other commonly used rating scale

  2. Acceptability outcome

    1. Number of participants who dropped out of psychological treatment for any reason

Secondary outcomes

  1. Functional impairment: mean change scores from baseline to study endpoint on the Function Impairment Measure (Tol 2011a), the WHO Disability Assessment Schedule 2.0 (WHO 2010), the Global Assessment of Functioning (APA 2000), or other commonly used rating scales

  2. Quality of life: mean change scores from baseline to study endpoint on the WHO Quality of Life Scale (WHO 1997), or on other commonly used rating scales

  3. Presence or absence of a formal or clinical diagnosis of PTSD, anxiety disorders, depression, or somatic symptom and related disorders evaluated by psychiatric diagnostic interviews. If a psychiatric diagnostic interview was not used, we included studies that applied commonly used symptom checklists

Timing of outcome assessment

Our primary endpoint was assessed immediately after treatment (zero to four weeks after intervention). We also collected information on every other available follow‐up assessment. We categorised follow‐up data as follows: follow‐up immediately after treatment (at endpoint: zero to four weeks); follow‐up at one to four months; and follow‐up at six or more months.

Hierarchy of outcome measures

When more than one outcome measure was available in the domain of interest, as defined in outcomes, and both described the domain adequately, we chose the measure with the most detailed psychometric evaluation or that was used by other trials in the analysis. Secondarily, we chose any measure that trial authors stated was tested for suitability in the population of interest. For primary outcomes, if data from several commonly used rating scales were available, we used the following: for PTSD ‐ HTQ, PCL‐C, CAPS, and CAPS‐CA; for anxiety ‐ HAD‐A for adults (Zigmond 1983) and SCARED‐5 for children and adolescents (Birmaher 1997); for depression ‐ HDRS (Hamilton 1960); and for somatic symptom and related disorders ‐ Somatic Symptom Scale‐8 (Gierk 2014).

Search methods for identification of studies

Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR)

The Cochrane Common Mental Disorders Group (CCMD) maintains two archived clinical trials registers at its editorial base in York, UK: a references register and a studies‐based register. The CCMDCTR‐References Register contains over 40,000 reports of RCTs in depression, anxiety, and neurosis. Approximately 50% of these references have been tagged to individual, coded trials. The coded trials are held in the CCMDCTR‐Studies Register, and records are linked between the two registers through the use of unique Study ID tags. Coding of trials is based on the EU‐Psi coding manual, using a controlled vocabulary (please contact the CCMD Information Specialists for further details). Reports of trials for inclusion in the Group's registers are collated from routine (weekly), generic searches of MEDLINE (1950 to 2016), Embase (1974 to 2016), and PsycINFO (1967 to 2016); quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); and review‐specific searches of additional databases. Reports of trials are also sourced from international trial registers via the WHO trials portal (the International Clinical Trials Registry Platform (ICTRP)), pharmaceutical company websites, and handsearching of key journals, conference proceedings, and other (non‐Cochrane) systematic reviews and meta‐analyses.

Details of CCMD generic search strategies (used to identify RCTs) can be found on the Group's website, with an example of the core MEDLINE search used to inform the register displayed in Appendix 1.

Electronic searches

1. Cochrane Specialised Register

We cross‐searched the CCMDCTR‐Studies and References Register using terms to represent humanitarian crises in LMICs (only), as this is a specialist mental health database, so already indicative of the diagnosis (3 February 2016).

#1. (altruis* or humanitarian or human right*):ti,ab,kw,ky,emt,mh,mc
#2. (catastrophe* or disaster* or drought* or earthquake* or evacuation* or famine* or flood or floods or hurricane or cyclone* or landslide* or “land slide*” or “mass casualt*” or tsunami* or tidal wave* or volcano*):ti,ab,kw,ky,emt,mh,mc
#3. (genocide or “armed conflict*” or “mass execution*” or “mass violence”):ti,ab,kw,ky,emt,mh,mc
#4. ((war or conflict) NEAR2 (affect* or effect* or expos* or related or victim* or survivor*)):ti,ab,kw,ky,emt,mh,mc
#5. (displac* NEAR (internal or forced or mass or person* or people* or population*)):ti,ab,kw,ky,emt,mh,mc
#6. (“forced migration” or refugee*):ti,ab,kw,ky,emt,mh,mc
#7. (politic* NEAR (persecut* or prison* or imprison* or violen*)):ti,ab,kw,ky,emt,mh,mc
#8. (#1 or #2 or #3 or #4 or #5 or #6 or #7)
#9. (bereav* or orphan* or widow*):ti,ab,kw,ky,emt,mh,mc
#10. (abuse* or conflict or persecut* or rape or torture or violen* or victim* or survivor* or war):ti,ab,kw,ky,emt,mh,mc
#11. (aid or relief or rescue or peace*):ti,ab,kw,ky,emt,mh,mc
#12. emergenc*:ti or (emergency NEXT (service* or setting)):ti,ab,kw,ky,emt,mh,mc
#13. (“critical incident” or “crisis intervention” or CISD):ti,ab,kw,ky,emt,mh,mc
Lines #9 to #13 will be limited to LMIC countries, using a search filter developed by the Norwegian satellite of the Cochrane Effective Practice and Organisation of Care Group (Appendix 2).

2. Other database searches

We conducted complementary searches on the following bibliographic databases in February 2015/2016 and September 2017, using relevant subject headings (controlled vocabularies) and search syntax, appropriate to each resource.

a. OVID PsycINFO (all years to 1/9/17).

b. ProQuest PILOTS database (Published International Literature on Traumatic Stress) (all years to 3/2/16).

c. Cochrane Central Register of Controlled Trials (CENTRAL) (all years to 2017, Issue 8).

d. OVID MEDLINE (1946 to 1/9/17).

e. OVID Embase (1974 to 1/9/17).

f. International Trial Registries (ClinicalTrials.gov and the WHO ICTRP) (1/9/17).

We applied no restrictions on date, language, or publication status to the searches, however only studies identified from search results to 3 February 2016 have been fully incorporated into the qualitative and quantitative analysis. Studies identified in the 2017 update search have been placed in awaiting classification and will be incorporated into the next version of the revew as appropriate

In the update search (1 September 2017), we made a series of amendments and back‐dated where necessary. We added a list of demonyms to the LMIC search strategy (PsycINFO, CENTRAL, MEDLINE, and Embase) to denote the natives or inhabitants of a particular country, and appended terms for warfare to the searches. We also added keywords to identify resource‐poor settings (developing nations) (PsycINFO only). At this time we did not repeat the search of the PILOTS database or the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), because the former search did not yield any unique studies in previous searches (to February 2016), and the latter had fallen out of date in the summer of 2016, with the move of the Editorial Group from Bristol to York.

We have reported the search strategies in Appendix 3.

4. We searched international trial registries via the WHO trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies.

Searching other resources

Grey literature

We searched sources of grey literature, including dissertations and theses, humanitarian reports, evaluations published on websites, and clinical guidelines and reports from regulatory agencies (when appropriate). In addition, we searched key agencies and initiatives in this field for relevant reports.

Handsearching

We handsearched relevant conference proceedings and academic literature (titles not already indexed in Embase or PsycINFO, or already handsearched within the Cochrane Collaboration).

Reference lists

We checked the reference lists of all included studies and relevant systematic reviews (both Cochrane and non‐Cochrane) to identify additional studies missed by the original electronic searches (e.g. unpublished or in‐press citations). We also conducted a cited reference search on the Web of Science.

Correspondence

We contacted trialists and subject experts for information on unpublished and ongoing studies or to request additional trial data.

Data collection and analysis

Selection of studies

Two review authors (MP, DP) independently screened titles and abstracts against the inclusion criteria listed above for all studies identified by the search strategy for possible inclusion in the review. We added to a preliminary list all studies rated as possible candidates by either of the two review authors, and we retrieved their full texts. Moreover, we identified and recorded reasons for exclusion of ineligible studies.

We resolved any disagreements through discussion or, if required, by consultation with a third review author (CB). We identified and excluded duplicate records, and we collated multiple reports that related to the same study, so that each study rather than each report is the unit of interest in the review. We recorded the selection process in sufficient detail to complete a PRISMA flow diagram and Characteristics of excluded studies table.

Data extraction and management

We used a data collection form that had been piloted on at least one study in the review to extract study characteristics and outcome data. Two review authors (MP, CG) independently extracted study characteristics and outcome data from included studies. We discussed any disagreements with an additional review author (CB), and when necessary, we contacted study authors to collect further information.

We extracted the following study characteristics.

  1. Methods: phase of humanitarian crisis (ongoing, post‐conflict, etc.), type of humanitarian crisis, duration of psychological treatment, number of study centres and locations, study setting and dates of study, inclusion criteria, and exclusion criteria.

  2. Participants: N, mean age, age range, gender, baseline scores on commonly used rating scales, and type of psychological disorder.

  3. Psychological therapies and comparisons (type of therapy administered, who administered therapy, etc.).

  4. Outcomes: primary and secondary outcomes specified and collected, and time points reported.

  5. Notes: funding for trial and notable conflicts of interest of trial authors.

We extracted data for the following planned comparisons.

  1. Psychological treatments versus control for adults.

  2. Psychological treatments versus control for children/adolescents.

We analysed each comparison listed above separately for children and adolescents (younger than 18 years) and for adults (18 years or older) on the different outcomes. Moreover, we looked at whether the type of psychological therapy has an impact on the overall treatment effect by performing a subgroup analysis within each of the main comparisons for each disorder type.

We noted in the Characteristics of included studies table if outcome data were not reported in a usable way. We resolved disagreements by reaching consensus or by involving a third person (CB). Two review authors (CG, DP) working independently transferred data into the Review Manager 5.3 file. We double‐checked that data had been entered correctly by comparing data presented in the systematic review against the study reports. A third review author (MP) spot‐checked study characteristics and outcomes that had been extracted.

Assessment of risk of bias in included studies

Two review authors (MP, CG) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreements by discussion or by involving another review author (CB). We assessed risk of bias according to the following domains.

  1. Random sequence generation.

  2. Allocation concealment.

  3. Blinding of participants and personnel.

  4. Blinding of outcome assessment.

  5. Incomplete outcome data.

  6. Selective outcome reporting.

  7. Other bias.

We also included a set of cluster‐randomised trials, which we evaluated according to Section 16.3.2 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). In particular, we considered:

  1. recruitment bias;

  2. baseline imbalance;

  3. loss of clusters;

  4. incorrect analysis; and

  5. comparability with individually randomised trials.

In particular for each cluster‐RCT, we verified, when possible, whether:

  1. all clusters were randomised at the same time;

  2. samples were stratified on variables likely to influence outcomes;

  3. clusters were pair‐matched;

  4. baseline comparability between interventions and control groups was evident.

Moreover, we included the following additional items in the 'Risk of bias' assessment (according to the review carried out by Patel 2014): therapist qualifications; treatment fidelity; therapist allegiance.

We judged each potential source of bias as high, low, or unclear, and we provided a supporting quotation from the study report together with a justification for our judgement in the 'Risk of bias' table. We summarised 'Risk of bias' judgements across different studies for each of the domains listed. When information on risk of bias was related to unpublished data or correspondence with a trialist, we noted this in the 'Risk of bias' table.

Measures of treatment effect

We performed all comparisons between psychological therapy and no treatment, treatment as usual, attention placebo, and wait list.

Dichotomous data

For dichotomous data, we calculated risk ratios (RRs) with a 95% confidence interval (CI). For statistically significant results, we calculated the number needed to treat for an additional beneficial outcome and the number needed to treat for an additional harmful outcome.

Continuous data

We analysed continuous data as mean differences (MDs) when studies reported outcomes using the same rating scale. We used standardised mean differences (SMDs) when studies assessing the same outcome measured it by using different rating scales (Higgins 2011). We entered data presented as a scale with a consistent direction of effect. We narratively described skewed data reported as medians and interquartile ranges.

Unit of analysis issues

Cluster‐RCTs

We included cluster‐RCTs when healthcare facilities, schools, or classes within schools rather than single individuals were the unit of allocation (Barbui 2011). Given that variation in response to psychological treatment between clusters may be influenced by cluster membership, we included, when possible, data adjusted with an intracluster correlation coefficient (ICC). When the ICC was not reported or was not available from trialists, we assumed that it was 0.1 (Higgins 2011; Ukoumunne 1999).

Cross‐over trials

We included trials employing a cross‐over design. With cross‐over trials, there is the possibility of 'carry‐over' treatment effect from one period to the next. This means that the observed difference between treatments depends upon the order in which treatments were received; hence the estimated overall treatment effect will be affected (Higgins 2011). Whilst acknowledging that this design is rarely used in psychological treatment studies, we used data from the first randomised stage only.

Studies with multiple treatment groups

We included studies with two or more formats of the same therapy in meta‐analysis by combining group arms into a single group, as recommended in Section 16.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Conversely, we included studies with two or more different therapies in meta‐analysis without combining group arms of the study into a single group but while considering each intervention and each control group separately. To avoid inclusion of the same group of participants in the same meta‐analysis, we followed Section 16.5.4 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Dealing with missing data

We contacted investigators or study sponsors to verify key study characteristics and to obtain missing numerical outcome data when possible. We documented all correspondence with trialists and reported in the full review which trialists responded. For cluster‐RCTs, we contacted study authors for an ICC when data were not adjusted and could not be identified from the trial report. When ICCs were not available from trial reports nor from trialists directly, we assumed the ICC to be 0.1 (Higgins 2011; Ukoumunne 1999).

For continuous data: We applied an intention‐to‐treat analysis, whereby all participants with at least one post‐baseline measurement are represented by their last observations carried forward. When only the standard error, t‐statistics, or P values were reported, we calculated standard deviations according to Altman (Altman 1996).

For dichotomous data: We applied an intention‐to‐treat analysis, whereby we considered all dropouts not included in the analyses as negative outcomes (i.e. it was assumed they would have experienced the negative outcome by the end of the trial).

Assessment of heterogeneity

We quantified heterogeneity using the I2 statistic, which calculates the percentage of variability due to heterogeneity rather than to chance.

According to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), we used the following thresholds for interpretation of I2.

  1. 0% to 40%: might not be important.

  2. 30% to 60%: may represent moderate heterogeneity.

  3. 50% to 90%: may represent substantial heterogeneity.

  4. 75% to 100%: may represent considerable heterogeneity.

The importance of the observed I2 depends on the magnitude and direction of intervention effects and the strength of evidence for heterogeneity (Higgins 2011; Purgato 2012).

Assessment of reporting biases

To the greatest degree possible, we minimised the impact of reporting biases by undertaking comprehensive searches of multiple sources and increasing efforts to identify unpublished material including protocols of randomised trials without language restrictions.

We used visual inspection of funnel plots to identify asymmetry in any of the comparisons between psychological treatments and comparators. We are aware that funnel plots are of limited power to detect small‐study effects. We did not use funnel plots for outcomes when we included 10 or fewer studies, or when all studies were of similar size. In other cases, when funnel plots were possible, we asked for statistical advice regarding their interpretation.

Data synthesis

We used a random‐effects model meta‐analysis, given the potential heterogeneity of psychological therapies. A random‐effects model has the highest generalisability in empirical examination of summary effect measures for meta‐analyses (Furukawa 2002), and this model is based on the assumption that different studies are estimating different, yet related, intervention effects (this deserves particular attention as we included different types of psychological therapies) (der Simonian 1986). We examined the robustness of this summary measure by checking the results under a fixed‐effect model. We reported material differences between the models.

For dichotomous data, we calculated risk ratios with 95% CI. We analysed continuous scores from different rating scales using SMDs (with 95% CI).

Subgroup analysis and investigation of heterogeneity

We carried out the following subgroup analyses for primary outcomes.

  1. Types of psychological therapies.

  2. Diagnosis: PTSD; major depressive, anxiety, somatoform, and related disorders. Participants with different diagnoses might respond differently to trial interventions. When possible, we conducted separate analyses for participants with PTSD, major depressive, and anxiety disorders.

  3. Presence of comorbidities, as symptoms related to other clinical conditions might influence the response to psychological therapies.

  4. Type of traumatic event: We considered the following categories: bereavement, displacement, sexual and other forms of gender‐based violence, torture, witness of violence/atrocities, other traumatic events (IASC 2007). Different types of traumatic events might influence the effectiveness of therapies, as authors have identified different strength of association with negative psychological consequences (US Department of Health and Human Services 2014).

  5. Type of humanitarian crisis: We considered the following categories: protracted emergencies such as wars and armed conflicts; communal violence; food shortages; disasters triggered by natural hazards such as geophysical (earthquakes, tsunamis, volcanic eruptions), hydrological (floods, avalanches), climatological (droughts), meteorological (storms, cyclones), or biological hazards (epidemics, plagues); disasters triggered by technological and industrial hazards (e.g. nuclear accidents; oil spills) (reliefweb.int/). We hypothesised that the type of humanitarian crisis may differentially impact mental health outcomes as people's needs, vulnerabilities, and capacities (including their capacity to respond to psychological therapies) may vary according to the different humanitarian contexts in which they live (The Sphere Project 2011).

  6. Phase of humanitarian crisis: We hypothesised that the phase of the humanitarian crisis may impact outcomes, as it influences individual vulnerability, capacity to use resources, and psychological reactions (Colliard 2014).

  7. Type of interventionist (professional vs paraprofessional): We expected the types of interventionists delivering treatment to have an impact on outcomes. We noted debate in the literature regarding the role of professionals and paraprofessionals in delivering psychological interventions (Montgomery 2010). Given the cost of healthcare interventions and the minimal resources available in humanitarian settings in LMIC, it is important for researchers to investigate potential differences.

  8. Type of control: no treatment, treatment as usual, wait list, attention placebo, and psychological placebo.

Sensitivity analysis

We carried out the following sensitivity analyses.

  1. Excluding trials with high risk of bias in the following domains: incomplete outcome data and selective reporting. These biases might impact trial results and interpretation in terms of an intervention's effectiveness estimate, in accordance with availability and completeness of outcome data from study participants,

  2. Excluding trials with follow‐up performed immediately at the end of the psychological treatment. We kept only studies with at least one follow‐up after the first evaluation to assess the long‐term outcomes of psychological therapies.

'Summary of findings' tables

We employed the GRADE approach to interpret findings (Langendam 2013), and use of GRADEpro allowed us to import data from Review Manager 5.3 to create 'Summary of findings' tables. These tables provide outcome‐specific information concerning the overall quality of evidence from studies included in the comparison, the magnitude of effect of the psychological therapies examined, and the sum of available data on the outcomes considered. We adhered to standard methods for preparation and presentation of results as outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

We included the following outcomes in the 'Summary of findings' tables.

  1. PTSD.

  2. Major depressive disorder.

  3. Anxiety disorders.

  4. Somatoform and related disorders (including MUPS).

  5. Acceptability (dropout rate).

Results

Description of studies

Results of the search

From 3655 records (identified from searches to February 2016), we identified 68 studies (33 RCTs for inclusion, 31 excluded studies, 2 awaiting classification and 2 ongoing) (see Figure 1 for the search flow diagram).


Study flow diagram.

Study flow diagram.

The update search in September 2017 retrieved 574 new records and after screening these we identified a further 8 studies which we've added to awating classification and 1 additional ongoing study. Only results of searches to 3 February 2016 have been formally incorporated into the analysis at this stage (and are reported in the PRISMA flow diagram).

We included 33 RCTs (36 studies, as 3 of the RCTs were multi‐armed trials) with a total of 3523 participants (see Characteristics of included studies) and excluded 31 studies (see Characteristics of excluded studies). All included studies were RCTs. We identified no cluster‐randomised trials. We have not yet assessed 10 studies ‐ one because it requires translation, another because the full‐text was not available to determine eligibility for this review and the remaining studies are from the 2017 update search, which will be assessed for eligibility in the next version of the revew (Characteristics of studies awaiting classification). We also identified a total of three ongoing studies (Characteristics of ongoing studies).

Included studies

See Characteristics of included studies.

Settings

Four of the included studies were done in Turkey (Acarturk 2015; Acaturk 2016; Basoglu 2005; Basoglu 2007); two in Iran (Ahmadizadeh 2013; Azad Marzabadi 2014); two in Kurdistan (Bass 2016; Bolton 2014a); two in Pakistan (Rahman 2016a; Rahman 2016b); one in Kosovo (Wang 2016); three in Thailand (Bolton 2014b; Bryant 2011; Pityaratstian 2015); one in Sri Lanka (Puvimanasinghe 2016); five in China (Chen 2014; Jiang 2014; Wang 2013a; Zang 2013; Zang 2014), and two in Iraq (Knaevelsrud 2015; Weiss 2015a). The remaining 11 studies were undertaken in Africa: three in Uganda (Bolton 2007; Ertl 2011; Neuner 2008a); three in Rwanda (Connolly 2011; Connolly 2013; Jacob 2014); three in the Democratic Republic of the Congo (Hermenau 2013; McMullen 2013; O' Callaghan 2013); one in Mozambique (Igreja 2004); and one in Egypt (Meffert 2014).

We categorised humanitarian crises into five main categories: war or armed conflict (Acarturk 2015; Acaturk 2016; Ahmadizadeh 2013; Azad Marzabadi 2014; Bass 2016; Ertl 2011; Hermenau 2013; Igreja 2004; Jacob 2014; Knaevelsrud 2015; McMullen 2013; Meffert 2014; Neuner 2008a; O' Callaghan 2013; Rahman 2016a; Rahman 2016b; Weiss 2015a); disasters triggered by natural events (Basoglu 2005; Basoglu 2007; Chen 2014; Pityaratstian 2015; Zang 2013; Zang 2014); communal violence (Bolton 2014a; Bolton 2014b; Connolly 2011; Connolly 2013); food shortages (Bryant 2011); and other types (Puvimanasinghe 2016; Wang 2013a). The context of treatment varied across studies: 13 of the included studies delivered interventions in healthcare clinics or facilities (Ahmadizadeh 2013; Azad Marzabadi 2014; Bass 2016; Bolton 2014a; Bryant 2011; Jiang 2014; Meffert 2014; Rahman 2016a; Rahman 2016b; Wang 2016; Weiss 2015a; Zang 2013; Zang 2014); five in community settings (Basoglu 2005; Bolton 2014b; Ertl 2011; Hermenau 2013; Puvimanasinghe 2016); four in refugee camps (Acarturk 2015; Acaturk 2016; Bolton 2007; Neuner 2008a); three at school (Chen 2014; McMullen 2013; Pityaratstian 2015); two at home (Igreja 2004; Jacob 2014); and the remaining six in other settings (Basoglu 2007; Connolly 2011; Connolly 2013; Knaevelsrud 2015; O' Callaghan 2013; Wang 2013a). Most included studies delivered psychological treatments after the acute crisis period had ended.

Sample sizes

Included studies consisted of 3523 participants, and the number of participants in each trial ranged from 22 in Meffert 2014 to 347 in Bolton 2014b.

Participants

Included participants in four studies were children and adolescents between 5 and 18 years of age (Chen 2014; McMullen 2013; O' Callaghan 2013; Pityaratstian 2015). Three studies included mixed populations (two studies included participants between 12 and 25 years of age (Ertl 2011; mean age 18.66 years, standard deviation (SD) 3.77 in the CBT group; mean age 18.06 years, SD 3.55 years in the control group; Hermenau 2013; mean age of the whole sample 19 years, SD 2.02), and one study included participants between 16 and 65 years of age (Basoglu 2005; mean age of the whole sample 36.3 years, SD 11.5 years in the control group). Remaining studies included adult populations (18 years or older). In studies with mixed populations, we considered mean age and SD reported in the papers to categorise populations into children or adults for meta‐analysis.

In 24 studies, most (more than 50%) participants were female. In the remaining nine studies, most (more than 50%) participants were male.

Regarding types of traumatic events, participants were exposed to bereavement in four studies (Basoglu 2005; Basoglu 2007; Bryant 2011; Chen 2014); displacement in seven studies (Acarturk 2015; Acaturk 2016; Ertl 2011; Meffert 2014; Neuner 2008a; Zang 2013; Zang 2014); sexual and other forms of gender‐based violence in one study (O' Callaghan 2013); torture and witness to violence or atrocities in 11 studies (Ahmadizadeh 2013; Azad Marzabadi 2014; Bass 2016; Bolton 2014a; Connolly 2011; Connolly 2013; Hermenau 2013; Jacob 2014; McMullen 2013; Wang 2013a; Weiss 2015a); and compound stressors or other types of stressors in the remaining studies.

Regarding types of mental disorders, 25 studies included participants with PTSD, three with PTSD and/or depression, two with anxiety and/or depression and/or emotional distress, and three with depression.

Interventions and comparators

Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). The psychological therapy was categorised as belonging to a type of group CBT in 27 studies, that is, CBT in 16 studies (Ahmadizadeh 2013; Azad Marzabadi 2014; Basoglu 2005; Basoglu 2007; Bolton 2014a; Bryant 2011; Chen 2014; McMullen 2013; O' Callaghan 2013; Pityaratstian 2015; Rahman 2016a; Rahman 2016b; Wang 2013a; Wang 2013b; Wang 2016; Weiss 2015a), NET in eight studies (Ertl 2011; Hermenau 2013; Igreja 2004; Jacob 2014; Neuner 2008a; Puvimanasinghe 2016; Zang 2013; Zang 2014), BA in one study (Bolton 2014a), and CETA in two studies (Bolton 2014b; Weiss 2015b).

IPT was studied in three studies (Bolton 2007; Jiang 2014; Meffert 2014), TFT in two studies (Connolly 2011; Connolly 2013), EMDR in two comparisons (Acarturk 2015; Acaturk 2016), and trauma/supportive counselling in two comparisons (Bass 2016; Neuner 2008b). Although psychological therapies were grouped into these categories, several psychotherapeutic elements were common to a range of therapies. In particular, a focus on psychoeducation and/or coping skills was common to most interventions. Most included trials delivered psychological therapy at the individual level (24 studies); six compared group delivery or mixed delivery (individual and group) of psychological therapies versus control; and the remaining three studies were unclear about the type of delivery provided.

Interventionists were professionals (i.e. trained psychologists or psychiatrists) in 14 comparisons, and paraprofessionals (i.e. trained lay counsellors; community health workers) in the remaining trials.

Outcomes

At the end of the reviewing process, 28 RCTs provided data for meta‐analysis. For primary outcomes, 19 RCTs provided continuous data on PTSD at endpoint, 14 RCTs provided data on depression at endpoint, and five RCTs provided data on anxiety at endpoint. For the primary outcome of acceptability, 26 RCTs provided data on total dropouts for any cause.

Overall, 1402 participants were included in the efficacy analysis for the continuous outcome PTSD at endpoint (1272 adults and 130 children); 1254 were included in the efficacy analysis for the continuous outcome depression at endpoint (all adults: 651 participants randomised to psychological therapy and 603 randomised to control); and 694 participants were included in the continuous outcome anxiety at endpoint (all adults: 370 participants randomised to psychological therapy and 324 randomised to control). A total of 3098 participants were included in the primary outcome of acceptability (2960 adults and 138 children).

For secondary outcomes, 686 participants were included in the efficacy analysis for the continuous outcome function impairment at endpoint (359 participants randomised to psychological therapy and 327 randomised to control); 325 participants were included in the efficacy analysis for the continuous outcome quality of life at endpoint (187 participants randomised to psychological therapy and 138 randomised to control); and 440 participants were included in the efficacy analysis for the dichotomous outcome diagnosis of PTSD at endpoint (402 adults and 36 children).

Excluded studies

See Characteristics of excluded studies.

Thirty‐one studies initially selected did not meet our inclusion criteria and were excluded because of wrong setting (no humanitarian crisis in LMICs) for eight studies; wrong design (no RCT or incorrect randomisation procedure) for nine studies; and wrong comparison (no psychological therapy compared with control) for three studies. Moreover, we excluded 11 RCTs assessing the effectiveness of preventive psychosocial interventions. We will include these studies in the Cochrane review specifically focused on preventive psychosocial interventions in humanitarian settings in LMICs (Purgato 2016a).

Studies awaiting classification

We classified 10 records as awaiting classification, as we did not have the elements needed to evaluate their eligibility.

See Characteristics of studies awaiting classification.

Ongoing studies

We classified three studies as ongoing: One is just finished, and results are planned to be published in 2018 (ISRCTN65771265), one is estimated to be completed in 2018 (NCT03012451), and one is at the beginning of the recruitment phase (NCT031090028). See Characteristics of ongoing studies.

Risk of bias in included studies

See Characteristics of included studies. For graphical representations of overall risk of bias in included studies, see Figure 2 and Figure 3.


Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.


Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Researchers described generation of a random sequence that we considered to lead to low risk of bias in 26 comparisons (Acarturk 2015; Acaturk 2016; Azad Marzabadi 2014; Bass 2016; Bolton 2007; Bolton 2014a; Bolton 2014b; Bryant 2011; Connolly 2011; Connolly 2013; Hermenau 2013; Jacob 2014; Jiang 2014; Knaevelsrud 2015; McMullen 2013; Meffert 2014; O' Callaghan 2013; Rahman 2016a; Rahman 2016b; Wang 2013a; Wang 2013b; Wang 2016; Weiss 2015a; Weiss 2015b; Zang 2013; Zang 2014) and to unclear risk of bias in the remaining studies. Regarding allocation concealment, we considered nine of the included trials to be at low risk (Basoglu 2005; Bolton 2014a; Bolton 2014b; Connolly 2013; McMullen 2013; O' Callaghan 2013; Rahman 2016a; Weiss 2015a; Weiss 2015b). The 24 remaining RCTs did not describe allocation concealment; we therefore rated them as having unclear risk.

Blinding

Performance bias

Participants (both personnel and study participants) would have been aware of whether they had been assigned to an intervention group or a control group in 24 trials (Acarturk 2015; Acaturk 2016; Basoglu 2005; Basoglu 2007; Bass 2016; Bolton 2007; Bolton 2014b; Chen 2014; Ertl 2011; Knaevelsrud 2015; McMullen 2013; Meffert 2014; Neuner 2008a; Neuner 2008b; O' Callaghan 2013; Pityaratstian 2015; Rahman 2016a; Rahman 2016b; Wang 2013a; Wang 2013b; Weiss 2015a; Weiss 2015b; Zang 2013; Zang 2014); therefore, we rated these studies as having high risk of performance bias. We rated the remaining trials as having unclear risk of performance bias.

Detection bias

We rated trials as having low risk of bias when researchers described blinded assessment of outcomes (Acarturk 2015; Acaturk 2016; Bass 2016; Bolton 2007; Bolton 2014b; Bryant 2011; Ertl 2011; Jacob 2014; McMullen 2013; Neuner 2008a; Neuner 2008b; O' Callaghan 2013; Pityaratstian 2015; Rahman 2016a; Rahman 2016b; Wang 2013a; Wang 2013b; Wang 2016; Weiss 2015a; Weiss 2015b; Zang 2013; Zang 2014). We rated three trials as having high risk of bias, as the assessors were likely to be aware of participant allocation (Basoglu 2007; Jiang 2014; Meffert 2014); we rated risk in the remaining trials as unclear (Ahmadizadeh 2013; Azad Marzabadi 2014; Basoglu 2005; Bolton 2014a; Chen 2014; Connolly 2011; Connolly 2013; Hermenau 2013; Igreja 2004; Knaevelsrud 2015; Puvimanasinghe 2016).

Incomplete outcome data

Risk of attrition bias was low in 19 studies, as researchers clearly reported low dropout rates (Acarturk 2015; Azad Marzabadi 2014; Basoglu 2007; Bass 2016; Bolton 2007; Bryant 2011; Ertl 2011; Jacob 2014; McMullen 2013; Meffert 2014; O' Callaghan 2013; Pityaratstian 2015; Rahman 2016b; Wang 2013b; Wang 2016; Weiss 2015a; Weiss 2015b; Zang 2013; Zang 2014). We considered eight trials to have high risk of attrition bias because researchers reported incomplete outcome data. We rated the remaining trials as having unclear risk.

Selective reporting

Even though the study protocol was not available for many of the included studies, most included studies showed consistency between Results and Methods sections (31 comparisons).

Other potential sources of bias

We rated risk of other bias as low in nine trials and as unclear in the remaining trials.

We visually inspected funnel plots to identify asymmetry in any of the comparisons between psychological treatments and comparators when we identified 10 or more studies. We did not identify any asymmetry in the distribution of studies.

We included in our risk of bias evaluation the following additional items.

  1. Therapist qualification: We considered 16 trials as having low risk of bias with regard to the qualifications of therapists, as trained professionals in mental health (mainly psychologists or psychiatrists) delivered psychological therapy (Acarturk 2015; Acaturk 2016; Ahmadizadeh 2013; Basoglu 2005; Basoglu 2007; Bryant 2011; Hermenau 2013; Igreja 2004; Jacob 2014; Jiang 2014; Knaevelsrud 2015; McMullen 2013; Pityaratstian 2015; Wang 2016; Zang 2013; Zang 2014). For the remaining trials, we evaluated the risk as unclear.

  2. Treatment fidelity: Sixteen trials described the system used to monitor treatment fidelity, and we rated their risk of bias as low (Acarturk 2015; Acaturk 2016; Bass 2016; Bryant 2011; Connolly 2011; Connolly 2013; Ertl 2011; Hermenau 2013; Jiang 2014; Neuner 2008a; O' Callaghan 2013; Rahman 2016a; Wang 2016; Weiss 2015a; Zang 2013; Zang 2014). We evaluated risk as unclear for the remaining trials because researchers provided no details about fidelity checks.

  3. Therapist/investigator allegiance: We rated the risk of therapist or investigator allegiance as high in 17 trials and as unclear in the remaining trials.

Effects of interventions

See: Summary of findings for the main comparison Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises; Summary of findings 2 Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

All results of this systematic review must be interpreted with consideration of the characteristics and risk of bias profile of each included study (see Characteristics of included studies).

Psychological therapy versus control

1. Primary outcomes
1.1 PTSD symptoms

Adults: Scores for PTSD symptoms were significantly lower for psychological therapy conditions than for control conditions at study endpoint (standardised mean difference (SMD) ‐1.07, 95% confidence interval (CI) ‐1.34 to ‐0.79; 1272 participants; 16 RCTs; Analysis 1.1). We also collected information on PTSD symptoms at one to four months after completion of the intervention and at six months after the intervention or later. Data indicated that the psychological therapy effect was reduced at one to four months after the intervention (SMD ‐0.49, 95% CI ‐0.68 to ‐0.31; 1660 participants; 18 RCTs; Analysis 1.2) and at six months after the intervention or later (SMD ‐0.37, 95% CI ‐0.61 to ‐0.14; 400 participants; 5 RCTs; Analysis 1.3).

Children and adolescents: We found that PTSD symptoms were lesser for psychological therapy conditions (all CBT) than for control conditions at endpoint (SMD ‐1.56, 95% CI ‐3.13 to 0.01; 130 participants; 3 RCTs; Analysis 2.1). We did not find a significant effect of psychological therapies over control interventions at one to four months after the intervention (Analysis 2.2). Data for six months after completion of the intervention or later were not available.

The most commonly reported rating scales for PTSD were the Clinician Administered PTSD Sscale (CAPS), Children's Revised Impact of Event Scale (CRIES), the Harvard Trauma Questionnaire (HTQ), the Posttraumatic Stress Disorder Checklist (PCL‐5), the Impact of Event Scale ‐ Revised (IES‐R), the University of California at Los Angeles post‐traumatic stress disorder reaction index (UCLA‐PTSD), and the Posttraumatic Diagnostic Scale (PDS).

1.2 Anxiety symptoms

Adults: In general, we observed significant differences between psychological therapies and controls for anxiety symptoms at endpoint (SMD ‐0.74, 95% CI ‐0.98 to ‐0.49; 694 participants; five RCTs; Analysis 3.1) and at one to four months after the intervention (SMD ‐0.53, 95% CI ‐0.66 to ‐0.39; 969 participants; seven RCTs; Analysis 3.2). We did not identify any significant differences between psychological therapies and controls at six months after the intervention or later (Analysis 3.3).

Children and adolescents: No study provided data on this outcome for children.

The most commonly reported rating scales for anxiety were the Hospital and Anxiety Depression Scale (HADS) and the Hopkins Symptoms Checklist for anxiety (HSCL‐25).

1.3 Depressive symptoms

Adults: Scores for depressive symptoms were significantly lower for psychological therapy conditions than for control conditions at endpoint (SMD ‐0.86, 95% CI ‐1.06 to ‐0.67; 1254 participants; 14 RCTs; Analysis 4.1). All types of psychological therapy were significantly effective for this outcome. Data on depressive symptoms at one to four months after therapy showed reduced effects of psychological therapies over controls (SMD ‐0.42, 95% CI ‐0.63 to ‐0.21; 1386 participants; 16 RCTs; Analysis 4.2). However, data at six months or later failed to show a significant difference between psychological therapies and controls (Analysis 4.3).

Children and adolescents: No study provided data on this outcome for children.

The most commonly reported rating scales for depression were the Beck Depression Inventory (BDI‐II), HADS, and HSCL‐25.

1.4 Somatoform symptoms and related disorders, including medically unexplained physical symptoms (MUPS)

No data were available for this outcome.

1.5 Dropouts for any reason

Adults: We found no difference in the proportions of participants lost to follow‐up (RR 0.98, 95% CI 0.82 to 1.16; 2960 participants; 23 RCTs; Analysis 5.1).

Children and adolescents: We found no difference in the proportions of children and adolescents lost to follow‐up (RR 1.87, 95% CI 0.47 to 7.47; 138 participants; three RCTs; Analysis 6.1). Only data on CBT were available for this population.

2. Secondary outcomes
2.1 Functional impairment

Adults: We observed significant differences in favour of psychological therapies over controls for functional impairment at endpoint (SMD ‐0.54, 95% CI ‐0.79 to ‐0.29; 686 participants; five RCTs; Analysis 7.1). At one to four months after the intervention, we observed a reduced but statistically significant treatment effect (SMD ‐0.35, 95% CI ‐0.54 to ‐0.15; 1061 participants; seven RCTs; Analysis 7.2). The effect on functional impairment was not maintained at six months after completion of the intervention or later (Analysis 7.3).

No data on this outcome were available for children.

The most commonly reported rating scales for functional impairment were Social Functioning Impairment (SFI) and the Sri Lanka Index of Psychosocial Status (SLIPSS‐A).

2.2 Quality of life

Adults: Quality of life was significantly improved in the psychological therapy group compared with the control group at endpoint (SMD ‐0.73, 95% CI ‐1.22 to ‐0.25; 325 participants; four studies; Analysis 8.1). No follow‐up data were available for this outcome.

Children: No study provided data on this outcome for children and adolescents.

The most commonly reported rating scales for quality of life were Quality of LIfe and the Quality of Life Index.

2.3 Formal or clinical diagnosis of PTSD

Adults: We noted no significant differences between psychological therapies and control interventions for this outcome (Analysis 9.1).

Children and adolescents: We observed significant differences in favour of psychological therapy over control intervention for this outcome (RR 0.59, 95% CI 0.38 to 0.90; 36 participants; one RCT; Analysis 10.1).

2.4 Formal or clinical diagnosis of major depressive disorder

Adults: We identified a significant difference in favour of psychological therapy (IPT) versus control for this outcome (RR 0.30, 95% CI 0.11 to 0.80; 49 participants; one RCT; Analysis 11.1).

Children and adolescents: No study provided data for this outcome.

2.5 Formal or clinical diagnosis of anxiety disorders

Adults: No study provided data for this outcome.

Children: No study provided data for this outcome.

2.6 Formal or clinical diagnosis of somatoform and related disorders

Adults: Researchers provided no data for this outcome.

Children and adolescents: Researchers provided no data for this outcome.

Subgroup analyses

According to availability of data, we were able to undertake most planned subgroup analyses in adult populations; the small number of RCTs that focused on children and adolescents did not allow us to undertake subgroup analyses in child and adolescent populations.

1. Types of psychotherapies
1.1 PTSD symptoms

At endpoint and at one to four months' follow‐up, we identified a difference between subgroups when comparing the effects of psychological therapy versus control for type of psychological therapy (P = 0.0007; Analysis 1.1; and P < 0.0001; Analysis 1.2), but at six months, we identified no differences between subgroups (P = 0.81; Analysis 1.3). For children and adolescents, population testing for subgroup analysis was not applicable.

1.2 Anxiety symptoms

For this outcome, subgroup analyses were not possible.

1.3 Depressive symptoms

We found evidence of a difference between subgroups at endpoint and at one to four months' follow‐up when comparing effects of psychological therapy versus control interventions for type of psychological therapy (P = 0.04; Analysis 4.1; and P = 0.010; Analysis 4.2). We detected no differences between subgroups at six months' follow‐up (P = 0.94; Analysis 4.3).

1.4 Dropouts for any cause

We did not identify any differences between subgroups for this outcome in adults (P = 0.32; Analysis 5.1). For children and adolescents, population subgroup analyses were not possible.

1.5 Functional impairment

For this outcome, subgroup analyses were not possible.

1.6 Quality of life

We did not identify any differences between subgroups for this outcome in adults (P = 0.72).

1.7 Diagnosis of PTSD

We found evidence of a difference between subgroups when comparing psychological therapy versus control for this outcome (P = 0.04; Analysis 9.1). For children and adolescents, population testing for subgroup analysis was not applicable.

2. Types of traumatic events
2.1 PTSD symptoms

In subgroup analyses according to the type of traumatic event, we found significant differences between subgroups in terms of PTSD symptoms (P = 0.004; Analysis 12.1). At one to four months after the intervention, we identified a significant difference between subgroups (P = 0.02; Analysis 12.2). At six months after therapy (or later), only data for displaced populations and torture and witnessing violence or atrocities were available. We found no evidence of a difference between subgroups (P = 0.71) when comparing effects of psychological therapy over control for displacement, and effects of psychological therapy over control for torture and witnessing of violence or atrocities (see Analysis 12.3).

2.2 Anxiety symptoms

We noted that the effect of psychotherapy over control was significant for displacement (SMD ‐1.30, 95% CI ‐1.92 to ‐0.67; 52 participants; two RCTs). We found no evidence of a difference for the subgroup other types of traumatic events at endpoint (P = 0.07; Analysis 12.4). At one to four months, we found significant differences between subgroups for anxiety symptoms (P = 0.009; Analysis 12.5). No data were available for six months after intervention or later, and no data were available for survivors of sexual and other forms of gender‐based violence.

2.3 Depressive symptoms

At endpoint, we found no evidence of a difference between subgroups (P = 0.72; Analysis 12.6). We found no evidence of a difference between subgroups (P = 0.55) when comparing effects of psychological therapy over control for displacement (see Analysis 12.7). At six months, we noted no significant differences between the two traumatic event subgroups for which data were available (displaced populations and those surviving torture and witnessing violence or atrocities) (see Analysis 12.8). Available data were not sufficient for analysis of impacts on the subgroup sexual and other forms of gender‐based violence for any time points.

2.4 Dropouts for any reason

We detected significant differences between subgroups in the outcome dropouts for any reason (P = 0.009; Analysis 12.9).

2.5 Functional impairment

We found no evidence of differences between subgroups for the outcome functional impairment (P = 0.74; Analysis 12.10). At one to four months' follow‐up, we identified significant differences between subgroups (P = 0.007; Analysis 12.11).

2.6 Quality of life

We found no evidence of a difference between subgroups (P = 0.72) when comparing effects of psychological therapy over control for the outcome quality of life (Analysis 12.12). Follow‐up data were not available for this outcome.

2.7 Diagnosis of PTSD

We identified significant differences between subgroups for this outcome (P = 0.004; Analysis 12.13).

3. Types of humanitarian crisis
3.1 PTSD symptoms

In subgroup analyses according to types of humanitarian crisis, we found no evidence of a difference between subgroups (P = 0.28) when comparing effects of psychological therapy over control interventions (see Analysis 13.1). At one to four months, we did not find evidence of a difference between subgroups (P = 0.57; Analysis 13.2). At six months or later, only data on war/armed conflict were available; they showed maintained benefit (see Analysis 13.3).

3.2 Anxiety symptoms

We found evidence of differences between subgroups for this outcome (P = 0.04; Analysis 13.4). Data at one to four months showed differences between subgroups (P = 0.03; Analysis 13.5). No data were available for this outcome at six months.

3.3 Depressive symptoms

For this outcome, we found no evidence of differences between subgroups (P = 0.72; Analysis 13.6). After one to four months, we identified significant differences between subgroups (P < 0.00001; Analysis 13.7). At six months' follow‐up or later, only data for populations affected by armed conflict were available (see Analysis 13.8).

3.4 Dropouts for any reason

We did not detect significant differences between subgroups for this outcome (Analysis 13.9).

3.5 Functional impairment

Psychological therapy was more effective than control for this outcome for the subgroups war/armed conflict (SMD ‐0.68, 95% CI ‐0.93 to ‐0.43; 261 participants; two RCTs). We found no evidence of differences between subgroups (P = 0.74) when comparing effects of psychological therapy over control intervention for communal violence; Analysis 13.10). At one to four months' follow‐up, we found significant effects for the subgroup communal violence (SMD ‐0.36, 95% CI ‐0.63 to ‐0.08; 281 participants; two RCTs). We found no evidence of a difference between subgroups (P = 0.29) when comparing effects of psychological therapy over control intervention for war/armed conflict (SMD ‐0.44, 95% CI ‐0.75 to ‐0.14; 659 participants; four RCTs; Analysis 13.11). No data were reported at six months after completion of the intervention or later.

3.6 Quality of life

We found no evidence of differences between subgroups (P = 0.72) when comparing psychological therapy over control for the outcome quality of life (see Analysis 13.12). No data were reported for this outcome at follow‐up.

3.7 Diagnosis of PTSD

We found no evidence of differences between subgroups when comparing effects of psychological therapy over control for this outcome (P = 0.27; Analysis 13.13).

4. Types of interventionists
4.1 PTSD symptoms

We found no differences between subgroups (P = 0.14) for this outcome (see Analysis 14.1). Research data confirmed no differences (P = 0.34) between subgroups at one to four months' follow‐up (see Analysis 14.2) and no differences at six months' follow‐up (P = 0.34; Analysis 14.3).

4.2 Anxiety symptoms

We observed significant differences between subgroups for the outcome anxiety symptoms at endpoint (P = 0.04; Analysis 14.4). Data at one to four months highlighted no differences between subgroups (P = 0.07; Analysis 14.5). No data were reported at six months' follow‐up.

4.3 Depressive symptoms

We noted significant differences between subgroups for the outcome depressive symptoms at endpoint (P = 0.02; Analysis 14.6). Data at one to four months after completion of the intervention showed no differences between subgroups (P= 0.92; Analysis 14.7); at six months, it was not possible to compare subgroups, as data were reported for paraprofessionals only (see Analysis 14.8).

4.4 Dropouts for any cause

We did not detect any significant differences between subgroups for this outcome (Analysis 14.9).

4.5 Functional impairment

Only data for the subgroup paraprofessionals were available for this outcome (see Analysis 14.10 and Analysis 14.11).

4.6. Quality of life

Only data for the subgroup professionals were available for this outcome (see Analysis 14.12).

4.7 Diagnosis of PTSD

We detected differences between subgroups for this outcome (P = 0.03; Analysis 14.13).

5. Types of controls
5.1 PTSD symptoms

At endpoint and at 1‐4 months, we found differences between subgroups for the outcome PTSD symptoms (P < 0.00001; Analysis 15.1; Analysis 15.2). After 6 months, we found no evidence of differences between subgroups (P = 0.39) for this outcome (see Analysis 15.3).

5.2 Anxiety symptoms

At endpoint, we found no evidence of a difference between subgroups (P = 0.63) when comparing effects of psychological therapy over control for type of control (see Analysis 15.4). At 1‐4 months, we found no evidence of differences between subgroups (P = 0.06; Analysis 15.5). It was not possible to make comparisons between subgroups according to the type of control for this outcome after 6 months (Analysis 15.6).

5.3 Depressive symptoms

We found a difference between subgroups for the outcome depressive symptoms at endpoint (P= 0.0001; Analysis 15.7) and at 1‐4 months (P = 0.0001; Analysis 15.8). At six months, only a small proportion of RCTs provided data, showing no differences between subgroups (P = 0.49; Analysis 15.9).

5.4 Dropouts for any cause

We found evidence of a difference between subgroups (P = 0.04) in the comparison of psychological therapy versus control for the outcome dropout rate (see Analysis 15.10).

5.5 Functional impairment

We found no differences between subgroups (P = 0.42) when comparing the effect of psychological therapy over control for type of control (see Analysis 15.11). A difference between subgroups was present at one to four months' follow‐up (P = 0.007; Analysis 15.12). It was not possible to make comparisons between subgroups according to the type of control for this outcome at six months (Analysis 15.13).

5.6. Quality of life

It was not possible to make comparisons between subgroups according to the type of control for this outcome.

5.7 Diagnosis of PTSD

We found no significant differences between subgroups according to the type of control for this outcome.

5.8 Diagnosis of depression

It was not possible to make comparisons between subgroups according to the type of control for this outcome.

5.9 Coping

It was not possible to make comparisons between subgroups according to the type of control for this outcome.

6. Phases of humanitarian crisis
6.1 PTSD symptoms

We did not identify any differences between subgroups (P = 0.07) when comparing the effect of psychological therapy over control for the phase of humanitarian crisis at endpoint (see Analysis 16.1); at one to four months after the intervention (P = 0.07; Analysis 16.2); and after six months (P = 0.23; Analysis 16.3).

6.2 Anxiety symptoms

At endpoint, we did not detect any differences between subgroups for the outcome anxiety symptoms (P = 0.63; Analysis 16.4). At one to four months, we found evidence of a difference between subgroups (P = 0.01; Analysis 16.5).

6.3 Depressive symptoms

For this outcome at endpoint, we identified no differences between subgroups (P = 0.15; Analysis 16.6). Data at one to four months showed a difference between subgroups (P = 0.003; Analysis 16.7). At six months, we did not detect any differences between subgroups (P = 0.49; Analysis 16.8).

6.4 Dropouts for any cause

We did not identify any differences between subgroups for this outcome (see Analysis 16.9).

6.5 Functional impairment

We found no evidence of differences between subgroups (P = 0.69) when comparing the effect of psychological therapy over control for the phase of humanitarian crisis (see Analysis 16.10). We found no differences between subgroups after one to four months (P = 0.28; Analysis 16.11). We did not have data on this outcome for six months' follow‐up or later.

6.6. Quality of life

We found no differences between subgroups (P = 0.81; Analysis 16.12).

6.7 Diagnosis of PTSD

It was not possible to compare different subgroups for this outcome (see Analysis 16.13).

Sensitivity analyses

Owing to the small number of RCTs that focused on child and adolescent populations, it was possible to carry out sensitivity analyses only for RCTs including adult populations.

1. Incomplete outcome data
1.1 PTSD symptoms

Upon performing this sensitivity analysis, we did not identify any material differences in comparison with standard meta‐analysis including all RCTs (see Analysis 17.1; Analysis 17.2; Analysis 17.3).

1.2 Anxiety symptoms

By performing this sensitivity analysis, we did not identify any material differences compared with standard meta‐analysis results (see Analysis 17.4; Analysis 17.5).

1.3 Depressive symptoms

Upon performing this sensitivity analysis, we did not identify any material differences in comparison with standard meta‐analysis including all RCTs (see Analysis 17.6); Analysis 17.7; Analysis 17.8).

1.4 Dropouts for any cause

By performing this sensitivity analysis, we did not identify any significant differences compared with standard meta‐analysis results (see Analysis 17.9).

1.5 Functional impairment

By performing this sensitivity analysis, we found that the effect of psychological treatment was not significant at endpoint (SMD ‐0.25, 95% CI ‐0.74 to 0.24; 141 participants; two RCTs). At one to four months after completion of the intervention, we did not identify any differences compared with standard meta‐analysis results (see Analysis 17.10; Analysis 17.11).

1.6 Quality of life

Although meta‐analysis including all RCTs highlighted a significant effect of psychological therapy over control, we found no significant effects of psychotherapy over control by performing this sensitivity analysis (see Analysis 17.12).

1.7 Diagnosis of PTSD

Results of meta‐analysis did not significantly change after we performed this sensitivity analysis. However, IPT psychotherapy was no longer more effective than control, and NET was more effective than control for this outcome (see Analysis 17.13).

2. Selective reporting
2.1 PTSD symptoms

We did not identify any material change by performing this sensitivity analysis (see Analysis 18.1; Analysis 18.2).

2.2 Dropouts for any cause

We did not identify any material change by performing this sensitivity analysis (see Analysis 18.3).

2.3 Functional impairment

By performing this sensitivity analysis, we did not identify any significant difference compared with results of standard meta‐analysis for this outcome (see Analysis 18.4).

2.4 Quality of life

For this outcome, we did not identify any material difference in comparison with results of standard meta‐analysis including all RCTs (see Analysis 18.5).

Discussion

Summary of main results

With regard to primary outcomes, we observed that symptoms of post‐traumatic stress disorder (PTSD) decreased substantially among adults who received psychological therapies compared with those who received treatment as usual, received no treatment, or were on a wait list (low‐quality evidence). This beneficial effect was observed immediately after completion of therapy, as well as at medium‐term (one to four months after therapy) and long‐term follow‐up (six months or more after completion of psychological therapy). For children and adolescents, a beneficial effect of psychological therapy was observed immediately after the intervention (very low‐quality evidence). However, this effect was not maintained at follow‐up (one to four months after the intervention), and long term data were not available.

For depression and anxiety symptom outcomes, only data on adults were available. Low‐quality evidence highlighted substantial improvement in depressive and anxiety symptoms in the psychological therapy group compared with the control group both at endpoint and at medium‐term follow‐up (one to four months). At six months, we did not find substantial treatment benefits and noted reduced strength of effect at each follow‐up. Data on depression at six months were derived from just a few studies (with few participants).

The likelihood of leaving the study prematurely for any reason was similar in psychological therapy and control groups for both adults (moderate‐quality evidence) and children (low‐quality evidence). Data from studies on children and adolescents are based on small numbers of studies and participants.

With regard to secondary outcomes, results show a difference in favour of psychological therapy over control in reducing functional impairment at endpoint for adults and children and adolescents. Follow‐up data were available only for adults, and (similar to depression and anxiety symptoms) showed maintained (but reduced) treatment benefit over the medium term but not over the long term. Long‐term data on functional impairment are based on a few participants enrolled in one randomised controlled trial (RCT). The outcome quality of life was available only for adults at endpoint, and we identified a difference between intervention and control conditions in favour of psychological intervention. The likelihood of receiving a diagnosis of PTSD was reduced at endpoint for children and adolescents who received psychological therapy compared with those allocated to the control condition. However, only data from one small study were available for this outcome. For adults, we did not identify any substantial differences for this outcome at endpoint. No follow‐up data were available for this outcome. Regarding a diagnosis of depression, only endpoint data for adults were available from a small study, indicating a positive effect of psychological therapy over control. No data were available on benefits regarding anxiety and somatoform and related diagnoses.

Overall, these findings indicate the benefit of psychological therapies for PTSD symptoms for adults in low‐ and middle‐income country (LMIC) humanitarian settings but show lack of maintained treatment benefit in these settings over the longer term for depression and anxiety symptoms and functional impairment. For children and adolescents, we found that treatment benefits for PTSD symptoms were not maintained at medium term, and these were the only data available regarding maintenance. For children and adolescents, data from one small study highlighted an effect of psychological treatment in reducing PTSD diagnoses. Collectively, these results appear to present a more modest picture of what can be achieved through psychological therapies as opposed to what may be expected from results of meta‐analyses of psychological treatments for selected outcomes in other settings. In general, little evidence of low quality was available for outcomes among children and adolescents. Future researchers should aim to understand the reasons for consistent reduction in treatment effects over time in low‐resource humanitarian settings, but it is possible that this reduction in benefit of psychological treatments is related to continued exposure to stressors in LMIC humanitarian settings, including chronic poverty, continued (gender‐based) violence, and negative impacts of humanitarian crises on social relationships that may protect mental health.

Even though the beneficial effects of psychological therapies have decreased over time, relief of psychological symptoms is an important goal for populations affected by humanitarian crises. Access to mental healthcare services is a right for populations living in humanitarian settings, as elsewhere. Humanitarian crises are often associated with denial of health as a human right both for adults and for children and adolescents. It is clear that the fundamental right to health should be an urgent priority for the humanitarian community, and that provision of psychological therapies is an important part of securing this right (The Lancet 2016).

We were able to conduct most of our planned subgroup analyses for adults, but not for children and adolescents. Firm conclusions based on subgroup analyses are challenging because subgroup analyses could rely on fewer RCTs and study participants. With regard to subgroup analyses for types of traumatic events, we found evidence of a difference between subgroups for PTSD outcome both at endpoint and at medium term. However, such maintained benefits were not found at medium term for displaced populations (PTSD, depression, and anxiety symptoms). For subgroup analyses looking at different types of humanitarian crises, we could not discern clear patterns, and we found no evidence of differences between subgroups for PTSD. Similarly, subgroup analyses by phase of humanitarian crisis and by type of therapist did not appear to result in obvious relationships. Overall, these results indicate that the benefit of psychological treatment for populations exposed to humanitarian crises in low‐resource settings is moderated by contextual variables such as types of traumatic events experienced and type of crisis. A larger body of high‐quality RCTs would provide a better understanding of how these and other variables can influence treatment benefits.

In addition, an important focus for future research, in our opinion, is to improve understanding of how initial benefits of psychological treatments may be maintained over time. This could be achieved, for example, through (1) booster sessions (e.g. at six months after treatment); (2) more systematic incorporation of problem‐solving skills to address ongoing stressors in humanitarian settings; and/or (3) integration of psychological treatments with social interventions that address critical ongoing stressors in humanitarian settings (e.g. poverty alleviation, violence protection interventions).

Overall completeness and applicability of evidence

Psychological therapies included a relatively wide range of interventions, and we identified no psychodynamic interventions. With regard to the psychological therapies included, many were trauma focused and cognitive‐behavioural therapy (CBT) based and/or derived; a small proportion of interventions were based on more generic counselling. Most expected outcomes were reported in these studies, including dropouts for any reason and functioning outcomes. However, data on anxiety and somatoform and related disorder diagnoses were not reported in the included RCTs. Data on children and adolescents were not available for some important outcomes, or were not available at medium‐ and long‐term follow‐up. For children, it was not possible to undertake the planned subgroup and sensitivity analyses ‐ owing to the small number of RCTs ‐ leaving a gap in evidence related to the role of specific variables influencing intervention effects. Regarding control conditions, we found that the wait list was the most reported control compared with no treatment and treatment as usual, and psychological placebo was not used as a control condition (in RCTs with adults and in RCTs with children and adolescents). Having said this, however, we acknowledge a level of complexity in defining specific ingredients that compose psychological placebo. For example, studies using control conditions defined as "individual counselling" could potentially be considered as using psychological placebo controls (Bass 2013). We will consider these distinctions/definitions in the next update of this review, depending on the quantity of randomised evidence available on this topic at that time.

Additionally, and for the same reason, we will consider the comparison of psychosocial interventions with active controls in the next update of this review. Comparing active psychosocial interventions will lead to a better understanding of the mechanisms of action of psychosocial interventions.

Quality of the evidence

We have included risk of bias assessment of included RCTs in Figure 2 and in Figure 3. We added into the risk of bias evaluation items related to psychological therapy and interventionist characteristics, according to the Cochrane review published by Patel (Patel 2014).

The risk of bias assessment is crucial in influencing interpretation of trial results and therefore deserves due attention. All included studies were RCTs, but their quality is not easy to assess, especially given the complexity of psychological therapies. Even though a RCT is the design of choice for evaluating the efficacy and acceptability of healthcare interventions (Jüni 2001; Purgato 2010), the evidence upon which the findings of this review are based is relatively poor as evaluated with the Cochrane risk of bias tool, and this is consistent with our grading within the 'Summary of findings' tables (from very low to moderate). Overall, we defined risk of allocation bias as low or unclear because some study authors provided insufficient details to permit a judgement. We considered most of the included RCTs to have high risk of performance bias, as participants were probably aware of whether they were receiving the psychological therapy or the control condition. Having said this, however, we have to acknowledge that in studies focused on psychological interventions, it is very challenging or even impossible to maintain participants' and therapists' blinding to treatment allocation. On the contrary, we evaluated most trials as having low risk of attrition and reporting bias. Regarding the specific items on psychological therapies, most studies failed to describe in detail therapist qualifications, and we evaluated a small proportion of RCTs as having low risk of bias for this item (e.g. RCTs in which the therapist was clearly described as a trained clinical psychologist). Many included RCTs described methods to check treatment fidelity in sufficient detail, but for others, we judged the risk of bias as unclear owing to insufficient information provided. Most included trials did not report details on therapist/investigator allegiance; we evaluated them as having unclear risk of bias. Remaining studies provided information on this item, and we evaluated them as having high risk of bias because investigators who developed psychological interventions were involved in conducting the RCT and in training therapists. Additional possible sources of bias not included in the risk of bias assessment are those specifically related to the topic of this review: socio‐cultural differences in relation to psychological suffering; transposition of mental health concepts and therapies from Western to non‐Western cultures (Kaiser 2015), with very different understandings and ways of dealing with psychological distress; and social norms and ways of discussing distress with strangers (such as therapists and interpreters) (Barbui 2017). Moreover, even though we were able to collect information about some basic characteristics of therapists (i.e. whether a professional or a paraprofessional), researchers did not always report details on therapists' language and nationality, social/economic class, education, geography, age, and background. These characteristics might have an influence on the establishment of relationship and trust, and thus on study outcomes.

For adults, we judged the quality of evidence on PTSD, depression, and anxiety at endpoint as low, indicating that additional data from further studies may very likely have an important impact on our confidence in the estimate of effect. The low‐quality judgement was due to high levels of heterogeneity across studies, as well as the high risk of performance bias and attrition bias and concerns about the therapist/investigator allegiance. The quality of evidence for the outcome dropouts was moderate, indicating that further research may likely have an important impact on our confidence in the estimate of the effect. We made this judgement as researchers in all RCTs did not describe the outcome assessment as masked. For children, we rated the quality of evidence on the outcome PTSD and dropouts, respectively, as very low and low, indicating for the first outcome uncertainty regarding the estimate of the effect, and for the second outcome, that additional data from further studies may very likely have an important impact on our confidence in the estimate of effect. No data were available on the other outcomes. We based this judgement on high levels of heterogeneity detected between studies, description of the outcome assessment as not masked, and a wide confidence interval that included no effect of the intervention.

In general, we found high levels of heterogeneity between studies, which means that studies had different trends in outcomes. Even though some levels of heterogeneity are expected in studies focused on complex clinical interventions (such as psychological therapies), one should consider this issue when interpreting results and drawing conclusions.

Potential biases in the review process

Although we attempted to access studies through an extensive search of the literature (including grey literature), it is still possible that we have missed one or more (unpublished) studies. Although it is unlikely that RCTs would be conducted and would not be publicly accessible, not all those conducting research may necessarily value academic publications, so work may be disseminated through other channels.

Data generated from these included RCTs had some limitations. Some RCTs were very small, often including fewer than 100 participants, and in some cases fewer than 20. This lack of statistical power may have affected the findings. Another limitation of this review is that included studies did not report information on some outcomes, such as somatic symptom and related disorders, and broader wellbeing outcomes, such as quality of life and functioning (especially in child and adolescent populations). Moreover, only a small proportion of studies reported data on child and adolescent populations, even though it is known that psychological suffering during childhood and adolescence can negatively impact future achievements (also at academic and work levels) and raise serious risks for health, such as substance abuse and suicidal ideation (Fergusson 2005). In addition, most RCTs reported only short‐term or medium‐term data, and longer‐term follow‐up data were available in only a small proportion of studies. This limits conclusions that can be drawn from this review.

To facilitate data reading and interpretation, we decided to pool together data on different types of psychological therapies. We also tested for differences between different types of therapies as part of subgroup analyses.

Agreements and disagreements with other studies or reviews

Findings of this review are consistent with those of Cochrane reviews that found good evidence for the effectiveness of some types of psychological therapies for children and adolescents exposed to trauma (in particular, CBT) (Gillies 2016); and for adults with PTSD (Bisson 2013). The Cochrane review published by Patel et al was focused on torture survivors and did not identify substantial differences between psychological therapies and controls in terms of immediate effects on PTSD symptoms, distress, or quality of life. Moreover, we rated the quality of included RCTs as very low according to the GRADE system (Patel 2014). Results of this review are also consistent with those of the Tol et al review published in 2011 (Tol 2011), which identified substantial beneficial effects of psychological interventions versus control conditions for adults with symptoms of PTSD. For children and adolescents, the Tol review detected a non‐substantial trend in favour of interventions versus control conditions for PTSD symptoms, along with a substantial effect for internalising symptoms. Other recent systematic reviews and meta‐analyses of psychological interventions for children and adolescents in low‐ and middle‐income countries affected by mass violence (Jordans 2016; Morina 2017; Purgato 2018) have analysed effects of a wider range of interventions compared with our separate analysis of treatment and (in parallel reviews), prevention, and promotion interventions. The systematic review conducted by Morina and colleagues included 21 RCTs on any type of psychological interventions for treating war‐related PTSD and depressive symptoms as compared with control conditions (wait list) for survivors of mass violence 19 years of age or younger; and the review conducted by Jordans and colleagues examined the type and effectiveness of psychosocial and mental health interventions in conflict‐affected children as reported in 24 articles. These systematic reviews and meta‐analyses identified an overall effect for this broad group of interventions. Morina et al found small and medium effects after correcting for publication bias, and Jordans et al noted benefits commonly limited to subgroups of children. These trial authors highlight the need for additional high‐quality studies with this population.

Study flow diagram.
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Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 1 PTSD at endpoint.
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Analysis 1.1

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 1 PTSD at endpoint.

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 2 PTSD at 1 to 4 months.
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Analysis 1.2

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 2 PTSD at 1 to 4 months.

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 3 PTSD ≥ 6 months.
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Analysis 1.3

Comparison 1 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults, Outcome 3 PTSD ≥ 6 months.

Comparison 2 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children, Outcome 1 PTSD at endpoint.
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Analysis 2.1

Comparison 2 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children, Outcome 1 PTSD at endpoint.

Comparison 2 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children, Outcome 2 PTSD at 1 to 4 months.
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Analysis 2.2

Comparison 2 Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children, Outcome 2 PTSD at 1 to 4 months.

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 1 Anxiety at endpoint.
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Analysis 3.1

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 1 Anxiety at endpoint.

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 2 Anxiety at 1 to 4 months.
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Analysis 3.2

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 2 Anxiety at 1 to 4 months.

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 3 Anxiety ≥ 6 months.
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Analysis 3.3

Comparison 3 Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults, Outcome 3 Anxiety ≥ 6 months.

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 1 Depression at endpoint.
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Analysis 4.1

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 1 Depression at endpoint.

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 2 Depression at 1 to 4 months.
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Analysis 4.2

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 2 Depression at 1 to 4 months.

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 3 Depression ≥ 6 months.
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Analysis 4.3

Comparison 4 Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults, Outcome 3 Depression ≥ 6 months.

Comparison 5 Psychological therapy vs control comparator ‐ dropout ‐adults, Outcome 1 Dropout.
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Analysis 5.1

Comparison 5 Psychological therapy vs control comparator ‐ dropout ‐adults, Outcome 1 Dropout.

Comparison 6 Psychological therapy vs control comparator ‐ dropout ‐ children, Outcome 1 Dropout.
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Analysis 6.1

Comparison 6 Psychological therapy vs control comparator ‐ dropout ‐ children, Outcome 1 Dropout.

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 1 Functional impairment at endpoint.
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Analysis 7.1

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 1 Functional impairment at endpoint.

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 2 Functional impairment at 1 to 4 months.
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Analysis 7.2

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 2 Functional impairment at 1 to 4 months.

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 3 Functional impairment ≥ 6 months.
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Analysis 7.3

Comparison 7 Psychological therapy vs control comparator ‐ functional impairment ‐ adults, Outcome 3 Functional impairment ≥ 6 months.

Comparison 8 Psychological therapy vs control comparator ‐ quality of life ‐ adults, Outcome 1 Quality of life at endpoint.
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Analysis 8.1

Comparison 8 Psychological therapy vs control comparator ‐ quality of life ‐ adults, Outcome 1 Quality of life at endpoint.

Comparison 9 Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ adults, Outcome 1 Diagnosis of PTSD.
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Analysis 9.1

Comparison 9 Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ adults, Outcome 1 Diagnosis of PTSD.

Comparison 10 Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ children, Outcome 1 Diagnosis of PTSD.
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Analysis 10.1

Comparison 10 Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ children, Outcome 1 Diagnosis of PTSD.

Comparison 11 Psychological therapy vs control comparator ‐ diagnosis of depression ‐ adults, Outcome 1 Diagnosis of depression.
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Analysis 11.1

Comparison 11 Psychological therapy vs control comparator ‐ diagnosis of depression ‐ adults, Outcome 1 Diagnosis of depression.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 1 PTSD symptoms at endpoint.
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Analysis 12.1

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
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Analysis 12.2

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.
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Analysis 12.3

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
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Analysis 12.4

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
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Analysis 12.5

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 6 Depressive symptoms at endpoint.
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Analysis 12.6

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 6 Depressive symptoms at endpoint.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.
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Analysis 12.7

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.
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Analysis 12.8

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 9 Dropout.
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Analysis 12.9

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 9 Dropout.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 10 Functional impairment at endpoint.
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Analysis 12.10

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 10 Functional impairment at endpoint.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.
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Analysis 12.11

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 12 Quality of life at endpoint.
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Analysis 12.12

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 12 Quality of life at endpoint.

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 13 Diagnosis of PTSD.
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Analysis 12.13

Comparison 12 Subgroup analysis: type of traumatic events ‐ adults, Outcome 13 Diagnosis of PTSD.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 1 PTSD symptoms at endpoint.
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Analysis 13.1

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
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Analysis 13.2

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.
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Analysis 13.3

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
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Analysis 13.4

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
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Analysis 13.5

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 6 Depressive symptoms at endpoint.
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Analysis 13.6

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 6 Depressive symptoms at endpoint.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.
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Analysis 13.7

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.
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Analysis 13.8

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 9 Dropout.
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Analysis 13.9

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 9 Dropout.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 10 Functional impairment at endpoint.
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Analysis 13.10

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 10 Functional impairment at endpoint.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.
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Analysis 13.11

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 12 Quality of life at endpoint.
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Analysis 13.12

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 12 Quality of life at endpoint.

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 13 Diagnosis of PTSD.
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Analysis 13.13

Comparison 13 Subgroup analysis: type of humanitarian crisis ‐ adults, Outcome 13 Diagnosis of PTSD.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 1 PTSD symptoms at endpoint.
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Analysis 14.1

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
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Analysis 14.2

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 3 PTSD symptoms ≥6 months.
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Analysis 14.3

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 3 PTSD symptoms ≥6 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
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Analysis 14.4

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
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Analysis 14.5

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 6 Depressive symptoms at endpoint.
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Analysis 14.6

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 6 Depressive symptoms at endpoint.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.
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Analysis 14.7

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.
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Analysis 14.8

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 9 Dropout.
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Analysis 14.9

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 9 Dropout.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 10 Functional impairment at endpoint.
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Analysis 14.10

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 10 Functional impairment at endpoint.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.
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Analysis 14.11

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 12 Quality of life at endpoint.
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Analysis 14.12

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 12 Quality of life at endpoint.

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 13 Diagnosis of PTSD.
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Analysis 14.13

Comparison 14 Subgroup analysis: type of interventionists ‐ adults, Outcome 13 Diagnosis of PTSD.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 1 PTSD symptoms at endpoint.
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Analysis 15.1

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
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Analysis 15.2

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.
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Analysis 15.3

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
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Analysis 15.4

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
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Analysis 15.5

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 6 Anxiety symptoms ≥ 6 months.
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Analysis 15.6

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 6 Anxiety symptoms ≥ 6 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 7 Depressive symptoms at endpoint.
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Analysis 15.7

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 7 Depressive symptoms at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 8 Depressive symptoms at 1 to 4 months.
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Analysis 15.8

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 8 Depressive symptoms at 1 to 4 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 9 Depressive symptoms ≥ 6 months.
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Analysis 15.9

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 9 Depressive symptoms ≥ 6 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 10 Dropout.
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Analysis 15.10

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 10 Dropout.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 11 Functional impairment at endpoint.
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Analysis 15.11

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 11 Functional impairment at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 12 Functional impairment at 1 to 4 months.
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Analysis 15.12

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 12 Functional impairment at 1 to 4 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 13 Functional impairment ≥ 6 months.
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Analysis 15.13

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 13 Functional impairment ≥ 6 months.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 14 Quality of life at endpoint.
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Analysis 15.14

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 14 Quality of life at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 15 Diagnosis of PTSD.
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Analysis 15.15

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 15 Diagnosis of PTSD.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 16 Diagnosis of depression.
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Analysis 15.16

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 16 Diagnosis of depression.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 17 Coping at endpoint.
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Analysis 15.17

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 17 Coping at endpoint.

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 18 Coping at 1 to 4 months.
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Analysis 15.18

Comparison 15 Subgroup analysis: type of control ‐ adults, Outcome 18 Coping at 1 to 4 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 1 PTSD symptoms at endpoint.
Figures and Tables -
Analysis 16.1

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
Figures and Tables -
Analysis 16.2

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.
Figures and Tables -
Analysis 16.3

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
Figures and Tables -
Analysis 16.4

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
Figures and Tables -
Analysis 16.5

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 6 Depressive symptoms at endpoint.
Figures and Tables -
Analysis 16.6

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 6 Depressive symptoms at endpoint.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.
Figures and Tables -
Analysis 16.7

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 7 Depressive symptoms at 1 to 4 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.
Figures and Tables -
Analysis 16.8

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 8 Depressive symptoms ≥ 6 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 9 Dropout.
Figures and Tables -
Analysis 16.9

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 9 Dropout.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 10 Functional impairment at endpoint.
Figures and Tables -
Analysis 16.10

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 10 Functional impairment at endpoint.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.
Figures and Tables -
Analysis 16.11

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 12 Quality of life at endpoint.
Figures and Tables -
Analysis 16.12

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 12 Quality of life at endpoint.

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 13 Diagnosis of PTSD.
Figures and Tables -
Analysis 16.13

Comparison 16 Subgroup analysis: phase of humanitarian crisis ‐ adults, Outcome 13 Diagnosis of PTSD.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 1 PTSD symptoms at endpoint.
Figures and Tables -
Analysis 17.1

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
Figures and Tables -
Analysis 17.2

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.
Figures and Tables -
Analysis 17.3

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 3 PTSD symptoms ≥ 6 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 4 Anxiety symptoms at endpoint.
Figures and Tables -
Analysis 17.4

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 4 Anxiety symptoms at endpoint.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.
Figures and Tables -
Analysis 17.5

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 5 Anxiety symptoms at 1 to 4 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 6 Depressive symptoms ≥ 6 months.
Figures and Tables -
Analysis 17.6

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 6 Depressive symptoms ≥ 6 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 7 Depressive symptoms at endpoint.
Figures and Tables -
Analysis 17.7

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 7 Depressive symptoms at endpoint.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 8 Depressive symptoms at 1 to 4 months.
Figures and Tables -
Analysis 17.8

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 8 Depressive symptoms at 1 to 4 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 9 Dropout.
Figures and Tables -
Analysis 17.9

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 9 Dropout.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 10 Functional impairment at endpoint.
Figures and Tables -
Analysis 17.10

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 10 Functional impairment at endpoint.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.
Figures and Tables -
Analysis 17.11

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 11 Functional impairment at 1 to 4 months.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 12 Quality of life at endpoint.
Figures and Tables -
Analysis 17.12

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 12 Quality of life at endpoint.

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 13 Diagnosis of PTSD.
Figures and Tables -
Analysis 17.13

Comparison 17 Sensitivity analysis: incomplete outcome data ‐ adults, Outcome 13 Diagnosis of PTSD.

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 1 PTSD symptoms at endpoint.
Figures and Tables -
Analysis 18.1

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 1 PTSD symptoms at endpoint.

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.
Figures and Tables -
Analysis 18.2

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 2 PTSD symptoms at 1 to 4 months.

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 3 Dropout.
Figures and Tables -
Analysis 18.3

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 3 Dropout.

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 4 Functional impairment at endpoint.
Figures and Tables -
Analysis 18.4

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 4 Functional impairment at endpoint.

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 5 Quality of life at endpoint.
Figures and Tables -
Analysis 18.5

Comparison 18 Sensitivity analysis: selective reporting ‐ adults, Outcome 5 Quality of life at endpoint.

Summary of findings for the main comparison. Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Patient or population: adults exposed to traumatic events
Setting: humanitarian settings in LMICs
Intervention: psychological therapy
Comparison: wait list; no treatment; treatment as usual

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with psychological therapy

Post‐traumatic stress disorder at endpoint

(measured with IES‐R; HTQ; CAPS; UCLA‐PTSD‐RI; PDS; PCL‐5)

SMD 1.07 lower
(1.34 lower to 0.79 lower)

1272
(16 RCTs)

⊕⊕⊝⊝
Lowa,b

This is a large effect according to Cohen 1992

Depression at endpoint

(measured with BDI‐II, HSCL‐25, HADS)

SMD 0.86 SD lower
(1.06 lower to 0.67 lower)

1254
(14 RCTs)

⊕⊕⊝⊝
Lowa,c

This is a large effect according to Cohen 1992

Anxiety at endpoint

(measured with HADS‐A; HSCL‐25)

SMD 0.74 SD lower
(0.98 lower to 0.49 lower)

694
(5 RCTs)

⊕⊕⊝⊝

Lowd,e

This is a moderate effect according to Cohen 1992

Dropouts for any reason

Study population

RR 0.98
(0.82 to 1.16)

2950
(23 RCTs)

⊕⊕⊕⊝
Moderatea

195 per 1000

191 per 1000
(160 to 227)

Somatic symptoms and related disorders

No data are available

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

BDI: Beck Depression Inventory

CAPS: Clinician Administered Post‐traumatic stress disorder Scale

HADS: Hospital Anxiety and Depression Scale

HSCL: Hopkins Symptoms Checklist

IES‐R: Impact of Event Scale‐Revised

LMIC: low‐ and middle‐income countries

PCL: Post‐traumatic stress disorder Check List

PDS: Post‐traumatic stress disorder Diagnostic Scale

UCLA‐PTSD‐ RI: University College of Los Angeles Post‐traumatic stress disorder Reaction Index

aDowngraded one level owing to study limitations (outcome assessment was not described as masked in all RCTs)

bDowngraded one level owing to inconsistency (I2 was higher than 75%)

cDowngraded one level owing to inconsistency (I2 was 55%)

dDowngraded one level owing to imprecision (the CI includes no effect)

eDowngraded one level owing to study limitations (high risk of bias detected: performance bias, attrition bias, and concerns about therapist/investigator allegiance)

Figures and Tables -
Summary of findings for the main comparison. Psychological therapy compared with control for treatment of adults with mental disorders in low‐ and middle‐income countries affected by humanitarian crises
Summary of findings 2. Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises

Patient or population: children exposed to traumatic events

Settings: humanitarian settings in LMICs

Intervention: psychological therapy

Comparison: wait list; no treatment; treatment as usual

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with psychological therapy

Post‐traumatic stress disorder at endpoint

(measured with UCLA‐PTSD‐RI; CRIES)

SMD ‐1.56
(‐3.13 lower to 0.01 higher)

130
(3 RCTs)

⊕⊕⊝⊝
Very lowa,b,c

This is a large effect according to Cohen 1992

Depression at endpoint

No data are available

Anxiety at endpoint

No data are available

Dropouts for any reason

Study population

RR 1.87 (0.47 to 7.47)

138
(3 RCTs)

⊕⊕⊝⊝
Lowa,d

352 per 1000

658 per 1000
(165 to 1000)

Somatic symptoms and related disorders

No data are available

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

CRIES: Children Revised Impact of Events Scale

LMIC: low‐ and middle‐income countries

UCLA‐PTSD‐ RI: University College of Los Angeles Post‐traumatic stress disorder Reaction Index

aDowngraded one level owing to study limitations (outcome assessment was not described as masked in all RCTs)

bDowngraded one level owing to inconsistency (I2 was higher than 75%)

cDowngraded one level owing to imprecision (outcome based on small number of participants and confidence interval is wide)

dDowngraded one level owing to imprecision (CI includes no effect)

Figures and Tables -
Summary of findings 2. Psychological therapy compared with control for treatment of children with mental disorders in low‐ and middle‐income countries affected by humanitarian crises
Comparison 1. Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD at endpoint Show forest plot

16

1272

Std. Mean Difference (IV, Random, 95% CI)

‐1.07 [‐1.34, ‐0.79]

1.1 EMDR vs control ‐ Adults

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐2.01 [‐2.50, ‐1.52]

1.2 CBT vs control ‐ Adults

12

1008

Std. Mean Difference (IV, Random, 95% CI)

‐0.85 [‐1.13, ‐0.58]

1.3 IPT vs control ‐ Adults

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.45 [‐2.46, ‐0.43]

1.4 TFT vs control ‐ Adults

1

145

Std. Mean Difference (IV, Random, 95% CI)

‐1.27 [‐1.63, ‐0.91]

2 PTSD at 1 to 4 months Show forest plot

17

1590

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.68, ‐0.31]

2.1 EMDR vs control ‐ Adults

1

64

Std. Mean Difference (IV, Random, 95% CI)

‐1.76 [‐2.34, ‐1.18]

2.2 CBT vs control ‐ Adults

15

1488

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.54, ‐0.26]

2.3 IPT vs control ‐ Adults

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.99 [‐1.67, ‐0.32]

3 PTSD ≥ 6 months Show forest plot

5

400

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.61, ‐0.14]

3.1 CBT vs control ‐ Adults

3

150

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐0.82, ‐0.09]

3.2 Trauma/supportive counselling vs control ‐ Adults

2

250

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.84, 0.08]

Figures and Tables -
Comparison 1. Psychological therapy vs control comparator ‐ PTSD symptoms ‐ adults
Comparison 2. Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD at endpoint Show forest plot

3

130

Std. Mean Difference (IV, Random, 95% CI)

‐1.56 [‐3.13, 0.01]

1.1 CBT vs control ‐ Children

3

130

Std. Mean Difference (IV, Random, 95% CI)

‐1.56 [‐3.13, 0.01]

2 PTSD at 1 to 4 months Show forest plot

1

36

Std. Mean Difference (IV, Random, 95% CI)

‐0.57 [‐1.24, 0.10]

2.1 CBT vs control ‐ Children

1

36

Std. Mean Difference (IV, Random, 95% CI)

‐0.57 [‐1.24, 0.10]

Figures and Tables -
Comparison 2. Psychological therapy vs control comparator ‐ PTSD symptoms ‐ children
Comparison 3. Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Anxiety at endpoint Show forest plot

5

694

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.98, ‐0.49]

1.1 CBT vs control ‐ Adults

5

694

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.98, ‐0.49]

2 Anxiety at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.53 [‐0.66, ‐0.39]

2.1 CBT vs control ‐ Adults

6

969

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.53 [‐0.66, ‐0.39]

3 Anxiety ≥ 6 months Show forest plot

1

188

Mean Difference (IV, Fixed, 95% CI)

‐0.15 [‐0.42, 0.12]

3.1 Trauma/Supportive counselling vs control ‐ Adults

1

188

Mean Difference (IV, Fixed, 95% CI)

‐0.15 [‐0.42, 0.12]

Figures and Tables -
Comparison 3. Psychological therapy vs control comparator ‐ anxiety symptoms ‐ adults
Comparison 4. Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Depression at endpoint Show forest plot

14

1254

Std. Mean Difference (IV, Random, 95% CI)

‐0.86 [‐1.06, ‐0.67]

1.1 EMDR vs control ‐ Adults

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐1.43 [‐1.88, ‐0.99]

1.2 CBT vs control ‐ Adults

10

926

Std. Mean Difference (IV, Random, 95% CI)

‐0.81 [‐1.02, ‐0.60]

1.3 IPT vs control ‐ Adults

2

229

Std. Mean Difference (IV, Random, 95% CI)

‐0.84 [‐1.60, ‐0.08]

2 Depression at 1 to 4 months Show forest plot

15

1386

Std. Mean Difference (IV, Random, 95% CI)

‐0.42 [‐0.63, ‐0.21]

2.1 EMDR vs control ‐ Adults

1

64

Std. Mean Difference (IV, Random, 95% CI)

‐1.21 [‐1.74, ‐0.67]

2.2 CBT vs control ‐ Adults

13

1284

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.56, ‐0.13]

2.3 IPT vs control ‐ Adults

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.77 [‐1.43, ‐0.11]

3 Depression ≥ 6 months Show forest plot

2

242

Mean Difference (IV, Fixed, 95% CI)

‐0.19 [‐0.44, 0.07]

3.1 CBT vs control ‐ Adults

1

54

Mean Difference (IV, Fixed, 95% CI)

‐0.13 [‐1.72, 1.46]

3.2 Trauma/Supportive counselling vs control ‐ Adults

1

188

Mean Difference (IV, Fixed, 95% CI)

‐0.19 [‐0.45, 0.07]

Figures and Tables -
Comparison 4. Psychological therapy vs control comparator ‐ depressive symptoms ‐ adults
Comparison 5. Psychological therapy vs control comparator ‐ dropout ‐adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dropout Show forest plot

26

2960

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.82, 1.16]

1.1 EMDR vs control ‐ Adults

2

127

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.40, 1.42]

1.2 CBT vs control ‐ Adults

19

2206

Risk Ratio (M‐H, Random, 95% CI)

1.06 [0.86, 1.30]

1.3 IPT vs control ‐ Adults

3

280

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.39, 2.73]

1.4 Trauma/Supportive counselling vs control ‐ Adults

2

347

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.57, 1.04]

Figures and Tables -
Comparison 5. Psychological therapy vs control comparator ‐ dropout ‐adults
Comparison 6. Psychological therapy vs control comparator ‐ dropout ‐ children

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dropout Show forest plot

3

138

Risk Ratio (M‐H, Random, 95% CI)

1.87 [0.47, 7.47]

1.1 CBT vs control ‐ Children

3

138

Risk Ratio (M‐H, Random, 95% CI)

1.87 [0.47, 7.47]

Figures and Tables -
Comparison 6. Psychological therapy vs control comparator ‐ dropout ‐ children
Comparison 7. Psychological therapy vs control comparator ‐ functional impairment ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.29]

1.1 CBT vs control ‐ Adults

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.29]

2 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.54, ‐0.15]

2.1 CBT vs control ‐ Adults

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.54, ‐0.15]

3 Functional impairment ≥ 6 months Show forest plot

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.59, 0.09]

3.1 Trauma/Supportive counselling vs control ‐ Adults

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.59, 0.09]

Figures and Tables -
Comparison 7. Psychological therapy vs control comparator ‐ functional impairment ‐ adults
Comparison 8. Psychological therapy vs control comparator ‐ quality of life ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Quality of life at endpoint Show forest plot

4

325

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.25]

1.1 IPT vs control ‐ Adults

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

1.2 CBT vs control ‐ Adults

3

287

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.35, ‐0.07]

Figures and Tables -
Comparison 8. Psychological therapy vs control comparator ‐ quality of life ‐ adults
Comparison 9. Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Diagnosis of PTSD Show forest plot

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

1.1 IPT vs control ‐ Adults

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.31 [0.09, 1.02]

1.2 CBT vs control ‐ Adults

2

214

Risk Ratio (M‐H, Random, 95% CI)

1.28 [0.28, 5.77]

1.3 Trauma/Supportive counselling vs control ‐ Adults

1

139

Risk Ratio (M‐H, Random, 95% CI)

2.27 [0.88, 5.85]

Figures and Tables -
Comparison 9. Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ adults
Comparison 10. Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ children

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Diagnosis of PTSD Show forest plot

1

36

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.38, 0.90]

1.1 CBT vs control ‐ Children

1

36

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.38, 0.90]

Figures and Tables -
Comparison 10. Psychological therapy vs control comparator ‐ diagnosis of PTSD ‐ children
Comparison 11. Psychological therapy vs control comparator ‐ diagnosis of depression ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Diagnosis of depression Show forest plot

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.30 [0.11, 0.80]

1.1 IPT vs control ‐ Adults

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.30 [0.11, 0.80]

Figures and Tables -
Comparison 11. Psychological therapy vs control comparator ‐ diagnosis of depression ‐ adults
Comparison 12. Subgroup analysis: type of traumatic events ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

15

1250

Std. Mean Difference (IV, Random, 95% CI)

‐1.10 [‐1.39, ‐0.81]

1.1 Bereavement

4

320

Std. Mean Difference (IV, Random, 95% CI)

‐0.62 [‐0.85, ‐0.40]

1.2 Displacement

5

171

Std. Mean Difference (IV, Random, 95% CI)

‐2.19 [‐3.00, ‐1.37]

1.3 Tortures/witnesses of violence/atrocities

5

485

Std. Mean Difference (IV, Random, 95% CI)

‐0.84 [‐1.14, ‐0.55]

1.4 Other traumatic events

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.79 [‐1.04, ‐0.54]

2 PTSD symptoms at 1 to 4 months Show forest plot

16

1421

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.69, ‐0.29]

2.1 Bereavement

5

462

Std. Mean Difference (IV, Random, 95% CI)

‐0.65 [‐0.83, ‐0.46]

2.2 Displacement

4

170

Std. Mean Difference (IV, Random, 95% CI)

‐0.59 [‐1.43, 0.25]

2.3 Tortures/witnesses of violence/atrocities

6

658

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.61, ‐0.16]

2.4 Other traumatic events

1

131

Std. Mean Difference (IV, Random, 95% CI)

‐0.07 [‐0.41, 0.28]

3 PTSD symptoms ≥ 6 months Show forest plot

5

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Displacement

3

182

Std. Mean Difference (IV, Random, 95% CI)

‐0.46 [‐0.82, ‐0.10]

3.2 Tortures/witnesses of violence/atrocities

2

218

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.78, 0.07]

4 Anxiety symptoms at endpoint Show forest plot

5

694

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.98, ‐0.49]

4.1 Displacement

2

52

Std. Mean Difference (IV, Random, 95% CI)

‐1.30 [‐1.92, ‐0.67]

4.2 Tortures/witnesses of violence/atrocities

1

159

Std. Mean Difference (IV, Random, 95% CI)

‐0.78 [‐1.10, ‐0.46]

4.3 Other traumatic events

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.48 [‐0.72, ‐0.24]

4.4 Bereavement

1

209

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.02, ‐0.45]

5 Anxiety symptoms at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Random, 95% CI)

‐0.91 [‐1.45, ‐0.37]

5.1 Displacement

2

52

Std. Mean Difference (IV, Random, 95% CI)

0.06 [‐0.50, 0.63]

5.2 Tortures/witnesses of violence/atrocities

3

611

Std. Mean Difference (IV, Random, 95% CI)

‐1.35 [‐2.20, ‐0.51]

5.3 Bereavement

1

306

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.97, ‐0.51]

6 Depressive symptoms at endpoint Show forest plot

13

1232

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.09, ‐0.71]

6.1 Bereavement

3

268

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.15, ‐0.65]

6.2 Displacement

6

380

Std. Mean Difference (IV, Random, 95% CI)

‐1.11 [‐1.54, ‐0.68]

6.3 Tortures/witnesses of violence/atrocities

3

310

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.24, ‐0.18]

6.4 Other traumatic events

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.15, ‐0.65]

7 Depressive symptoms at 1 to 4 months Show forest plot

14

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

7.1 Bereavement

5

462

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.90, ‐0.23]

7.2 Displacement

4

170

Std. Mean Difference (IV, Random, 95% CI)

‐0.17 [‐0.95, 0.61]

7.3 Tortures/witnesses of violence/atrocities

5

732

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.61, ‐0.16]

8 Depressive symptoms ≥ 6 months Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 Displacement

1

54

Std. Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.58, 0.49]

8.2 Tortures/witnesses of violence/atrocities

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.61, 0.08]

9 Dropout Show forest plot

24

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

9.1 Bereavement

4

483

Risk Ratio (M‐H, Random, 95% CI)

1.18 [1.00, 1.40]

9.2 Displacement

9

734

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.63, 0.95]

9.3 Tortures/witnesses of violence/atrocities

10

1209

Risk Ratio (M‐H, Random, 95% CI)

1.16 [0.76, 1.78]

9.4 Other traumatic events

1

347

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.53, 1.19]

10 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

10.1 Tortures/witnesses of violence/atrocities

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐1.30, 0.40]

10.2 Other traumatic events

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.80, ‐0.32]

10.3 Bereavement

2

261

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐0.93, ‐0.43]

11 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

11.1 Tortures/witnesses of violence/atrocities

6

758

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.45, ‐0.12]

11.2 Bereavement

1

303

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐0.90, ‐0.44]

12 Quality of life at endpoint Show forest plot

4

325

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.25]

12.1 Bereavement

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

12.2 Tortures/witnesses of violence/atrocities

3

287

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.35, ‐0.07]

13 Diagnosis of PTSD Show forest plot

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

13.1 Bereavement

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.31 [0.09, 1.02]

13.2 Displacement

2

277

Risk Ratio (M‐H, Random, 95% CI)

2.34 [1.14, 4.80]

13.3 Tortures/witnesses of violence/atrocities

1

76

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.63, 0.95]

Figures and Tables -
Comparison 12. Subgroup analysis: type of traumatic events ‐ adults
Comparison 13. Subgroup analysis: type of humanitarian crisis ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

15

1250

Std. Mean Difference (IV, Random, 95% CI)

‐1.10 [‐1.39, ‐0.81]

1.1 War/armed conflict

7

568

Std. Mean Difference (IV, Random, 95% CI)

‐1.06 [‐1.51, ‐0.61]

1.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

3

84

Std. Mean Difference (IV, Random, 95% CI)

‐2.31 [‐4.22, ‐0.39]

1.3 Communal violence

2

419

Std. Mean Difference (IV, Random, 95% CI)

‐1.01 [‐1.48, ‐0.54]

1.4 Food shortages

1

28

Std. Mean Difference (IV, Random, 95% CI)

‐0.97 [‐1.77, ‐0.18]

1.5 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.64 [‐0.97, ‐0.31]

2 PTSD symptoms at 1 to 4 months Show forest plot

16

1568

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.66, ‐0.29]

2.1 War/armed conflict

7

958

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.88, ‐0.23]

2.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

5

180

Std. Mean Difference (IV, Random, 95% CI)

‐0.52 [‐0.88, ‐0.17]

2.3 Communal violence

1

281

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.65, ‐0.09]

2.4 Food shortages

1

28

Std. Mean Difference (IV, Random, 95% CI)

‐0.62 [‐1.39, 0.15]

2.5 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.19 [‐0.55, 0.17]

3 PTSD symptoms ≥ 6 months Show forest plot

5

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 War/armed conflict

5

400

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.61, ‐0.14]

4 Anxiety symptoms at endpoint Show forest plot

4

535

Std. Mean Difference (IV, Random, 95% CI)

‐0.76 [‐1.10, ‐0.42]

4.1 Natural hazards (geophysical: earthquake; volcanic eruptions)

2

52

Std. Mean Difference (IV, Random, 95% CI)

‐1.30 [‐1.92, ‐0.67]

4.2 Communal violence

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.48 [‐0.72, ‐0.24]

4.3 War/armed conflict

1

209

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.02, ‐0.45]

5 Anxiety symptoms at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Random, 95% CI)

‐0.42 [‐0.70, ‐0.14]

5.1 War/armed conflict

3

636

Std. Mean Difference (IV, Random, 95% CI)

‐0.69 [‐1.03, ‐0.36]

5.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

2

52

Std. Mean Difference (IV, Random, 95% CI)

0.06 [‐0.50, 0.63]

5.3 Communal violence

1

281

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.49, 0.07]

6 Depressive symptoms at endpoint Show forest plot

14

1378

Std. Mean Difference (IV, Random, 95% CI)

‐0.89 [‐1.06, ‐0.72]

6.1 War/armed conflict

7

841

Std. Mean Difference (IV, Random, 95% CI)

‐0.96 [‐1.20, ‐0.73]

6.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

3

84

Std. Mean Difference (IV, Random, 95% CI)

‐1.10 [‐1.58, ‐0.63]

6.3 Communal violence

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.15, ‐0.65]

6.4 Food shortages

1

28

Std. Mean Difference (IV, Random, 95% CI)

‐0.80 [‐1.58, ‐0.01]

6.5 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐1.20, 0.14]

7 Depressive symptoms at 1 to 4 months Show forest plot

14

1093

Std. Mean Difference (IV, Random, 95% CI)

‐0.60 [‐1.05, ‐0.15]

7.1 War/armed conflict

4

608

Std. Mean Difference (IV, Random, 95% CI)

‐0.57 [‐1.04, ‐0.10]

7.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

6

202

Std. Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.71, 0.11]

7.3 Communal violence

1

134

Std. Mean Difference (IV, Random, 95% CI)

‐3.56 [‐4.15, ‐2.98]

7.4 Food shortages

1

28

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐1.13, 0.38]

7.5 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.13 [‐0.49, 0.23]

8 Depressive symptoms ≥ 6 months Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 War/armed conflict

2

242

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.49, 0.09]

9 Dropout Show forest plot

25

2354

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.78, 1.11]

9.1 War/armed conflict

16

1529

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.74, 1.15]

9.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

4

106

Risk Ratio (M‐H, Random, 95% CI)

9.94 [0.61, 160.94]

9.3 Communal violence

2

494

Risk Ratio (M‐H, Random, 95% CI)

1.01 [0.54, 1.91]

9.4 Food shortages

1

28

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

9.5 Other

2

197

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.12, 2.67]

10 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

10.1 Communal violence

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.80, ‐0.32]

10.2 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐1.30, 0.40]

10.3 War/armed conflict

2

261

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐0.93, ‐0.43]

11 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

11.1 War/armed conflict

4

659

Std. Mean Difference (IV, Random, 95% CI)

‐0.44 [‐0.75, ‐0.14]

11.2 Communal violence

1

281

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.63, ‐0.08]

11.3 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.08 [‐0.43, 0.28]

12 Quality of life at endpoint Show forest plot

4

325

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.25]

12.1 War/armed conflict

3

287

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.35, ‐0.07]

12.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

13 Diagnosis of PTSD Show forest plot

4

299

Risk Ratio (M‐H, Random, 95% CI)

0.74 [0.46, 1.17]

13.1 War/armed conflict

2

214

Risk Ratio (M‐H, Random, 95% CI)

1.28 [0.28, 5.77]

13.2 Natural hazards (geophysical: earthquake; volcanic eruptions)

2

85

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.29, 0.92]

Figures and Tables -
Comparison 13. Subgroup analysis: type of humanitarian crisis ‐ adults
Comparison 14. Subgroup analysis: type of interventionists ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

16

1298

Std. Mean Difference (IV, Random, 95% CI)

‐1.21 [‐1.52, ‐0.90]

1.1 Professionals

8

400

Std. Mean Difference (IV, Random, 95% CI)

‐1.51 [‐2.13, ‐0.90]

1.2 Paraprofessionals

8

898

Std. Mean Difference (IV, Random, 95% CI)

‐0.99 [‐1.33, ‐0.65]

2 PTSD symptoms at 1 to 4 months Show forest plot

16

1568

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.66, ‐0.29]

2.1 Professionals

9

476

Std. Mean Difference (IV, Random, 95% CI)

‐0.57 [‐0.96, ‐0.19]

2.2 Paraprofessionals

7

1092

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.61, ‐0.26]

3 PTSD symptoms ≥6 months Show forest plot

5

400

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.61, ‐0.14]

3.1 Professionals

1

30

Std. Mean Difference (IV, Random, 95% CI)

‐0.72 [‐1.46, 0.03]

3.2 Paraprofessionals

4

370

Std. Mean Difference (IV, Random, 95% CI)

‐0.34 [‐0.58, ‐0.09]

4 Anxiety symptoms at endpoint Show forest plot

4

535

Std. Mean Difference (IV, Random, 95% CI)

‐0.76 [‐1.10, ‐0.42]

4.1 Professionals

2

52

Std. Mean Difference (IV, Random, 95% CI)

‐1.30 [‐1.92, ‐0.67]

4.2 Paraprofessionals

2

483

Std. Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.85, ‐0.35]

5 Anxiety symptoms at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.71, ‐0.15]

5.1 Professionals

2

52

Std. Mean Difference (IV, Random, 95% CI)

0.06 [‐0.50, 0.63]

5.2 Paraprofessionals

4

917

Std. Mean Difference (IV, Random, 95% CI)

‐0.52 [‐0.81, ‐0.23]

6 Depressive symptoms at endpoint Show forest plot

13

1232

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.09, ‐0.71]

6.1 Professionals

7

370

Std. Mean Difference (IV, Random, 95% CI)

‐1.13 [‐1.35, ‐0.90]

6.2 Paraprofessionals

6

862

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.98, ‐0.50]

7 Depressive symptoms at 1 to 4 months Show forest plot

14

1364

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.61, ‐0.18]

7.1 Professionals

7

272

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.80, 0.05]

7.2 Paraprofessionals

7

1092

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.66, ‐0.15]

8 Depressive symptoms ≥ 6 months Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 Paraprofessionals

2

242

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.49, 0.09]

9 Dropout Show forest plot

24

2791

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.80, 1.16]

9.1 Professionals

9

394

Risk Ratio (M‐H, Random, 95% CI)

1.38 [0.56, 3.38]

9.2 Paraprofessionals

15

2397

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.78, 1.15]

10 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.29]

10.1 Paraprofessionals

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.29]

11 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

11.1 Paraprofessionals

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

12 Quality of life at endpoint Show forest plot

3

297

Std. Mean Difference (IV, Random, 95% CI)

‐0.59 [‐1.10, ‐0.08]

12.1 Professionals

3

297

Std. Mean Difference (IV, Random, 95% CI)

‐0.59 [‐1.10, ‐0.08]

13 Diagnosis of PTSD Show forest plot

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

13.1 Professionals

2

125

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.20, 1.59]

13.2 Paraprofessionals

2

277

Risk Ratio (M‐H, Random, 95% CI)

2.34 [1.14, 4.80]

Figures and Tables -
Comparison 14. Subgroup analysis: type of interventionists ‐ adults
Comparison 15. Subgroup analysis: type of control ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

16

1272

Std. Mean Difference (IV, Random, 95% CI)

‐1.07 [‐1.34, ‐0.79]

1.1 EMDR vs wait list

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐2.01 [‐2.50, ‐1.52]

1.2 IPT vs wait list

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.45 [‐2.46, ‐0.43]

1.3 CBT vs wait list

8

696

Std. Mean Difference (IV, Random, 95% CI)

‐1.08 [‐1.47, ‐0.68]

1.4 CBT vs no treatment

2

52

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.98, 0.12]

1.5 TFT vs wait list

1

145

Std. Mean Difference (IV, Random, 95% CI)

‐1.27 [‐1.63, ‐0.91]

1.6 CBT vs TAU/enhanced usual care

2

260

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.81, ‐0.31]

2 PTSD symptoms at 1 to 4 months Show forest plot

17

1590

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.68, ‐0.31]

2.1 EMDR vs wait list

1

64

Std. Mean Difference (IV, Random, 95% CI)

‐1.76 [‐2.34, ‐1.18]

2.2 CBT vs wait list

13

1160

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.49, ‐0.21]

2.3 IPT vs TAU

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.99 [‐1.67, ‐0.32]

2.4 CBT vs no treatment

1

22

Std. Mean Difference (IV, Random, 95% CI)

‐1.12 [‐2.04, ‐0.21]

2.5 CBT vs TAU/enhanced usual care

1

306

Std. Mean Difference (IV, Random, 95% CI)

‐0.63 [‐0.86, ‐0.40]

3 PTSD symptoms ≥ 6 months Show forest plot

5

400

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.61, ‐0.14]

3.1 Trauma/Supportive counselling vs wait list

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.57, 0.12]

3.2 Trauma/Supportive counselling vs no treatment

1

62

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.46, ‐0.02]

3.3 CBT vs no treatment

3

150

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐0.82, ‐0.09]

4 Anxiety symptoms at endpoint Show forest plot

4

535

Std. Mean Difference (IV, Random, 95% CI)

‐0.76 [‐1.10, ‐0.42]

4.1 CBT vs wait list

3

326

Std. Mean Difference (IV, Random, 95% CI)

‐0.92 [‐1.61, ‐0.23]

4.2 CBT vs TAU/enhanced usual care

1

209

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.02, ‐0.45]

5 Anxiety symptoms at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.71, ‐0.15]

5.1 CBT vs wait list

5

663

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.67, ‐0.03]

5.2 CBT vs TAU/enhanced usual care

1

306

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐0.97, ‐0.51]

6 Anxiety symptoms ≥ 6 months Show forest plot

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.52, 0.16]

6.1 Trauma/Supportive counselling vs wait list

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.52, 0.16]

7 Depressive symptoms at endpoint Show forest plot

14

1254

Std. Mean Difference (IV, Random, 95% CI)

‐0.86 [‐1.06, ‐0.67]

7.1 EMDR vs wait list

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐1.43 [‐1.88, ‐0.99]

7.2 CBT vs wait list

8

696

Std. Mean Difference (IV, Random, 95% CI)

‐0.85 [‐1.08, ‐0.61]

7.3 IPT vs wait list

2

229

Std. Mean Difference (IV, Random, 95% CI)

‐0.84 [‐1.60, ‐0.08]

7.4 CBT vs no treatment

1

22

Std. Mean Difference (IV, Random, 95% CI)

0.11 [‐0.73, 0.95]

7.5 CBT vs TAU/enhanced usual care

1

208

Std. Mean Difference (IV, Random, 95% CI)

‐0.89 [‐1.18, ‐0.60]

8 Depressive symptoms at 1 to 4 months Show forest plot

15

1386

Std. Mean Difference (IV, Random, 95% CI)

‐0.42 [‐0.63, ‐0.21]

8.1 EMDR vs wait list

1

64

Std. Mean Difference (IV, Random, 95% CI)

‐1.21 [‐1.74, ‐0.67]

8.2 CBT vs wait list

11

956

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.45, ‐0.08]

8.3 IPT vs TAU

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.77 [‐1.43, ‐0.11]

8.4 CBT vs no treatment

1

22

Std. Mean Difference (IV, Random, 95% CI)

‐1.07 [‐1.98, ‐0.16]

8.5 CBT vs TAU/enhanced usual care

1

306

Std. Mean Difference (IV, Random, 95% CI)

‐0.85 [‐1.08, ‐0.62]

9 Depressive symptoms ≥ 6 months Show forest plot

2

242

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.49, 0.09]

9.1 Trauma/Supportive counselling vs wait list

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.61, 0.08]

9.2 CBT vs no treatment

1

54

Std. Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.58, 0.49]

10 Dropout Show forest plot

25

2801

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.81, 1.19]

10.1 EMDR vs wait list

2

127

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.40, 1.42]

10.2 CBT vs wait list

14

1575

Risk Ratio (M‐H, Random, 95% CI)

1.02 [0.76, 1.38]

10.3 CBT vs TAU/enhanced usual care

2

406

Risk Ratio (M‐H, Random, 95% CI)

1.17 [0.99, 1.39]

10.4 IPT vs wait list

2

231

Risk Ratio (M‐H, Random, 95% CI)

0.61 [0.30, 1.27]

10.5 CBT vs no treatment

2

66

Risk Ratio (M‐H, Random, 95% CI)

9.47 [1.29, 69.52]

10.6 Trauma/Supportive counselling vs no treatment

1

138

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.57, 1.08]

10.7 IPT vs TAU

1

49

Risk Ratio (M‐H, Random, 95% CI)

2.17 [0.65, 7.23]

10.8 Trauma/Supportive counselling vs wait list

1

209

Risk Ratio (M‐H, Random, 95% CI)

0.67 [0.29, 1.56]

11 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

11.1 CBT vs wait list

3

425

Std. Mean Difference (IV, Random, 95% CI)

‐0.48 [‐0.91, ‐0.06]

11.2 CBT vs TAU/enhanced usual care

2

261

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐0.93, ‐0.43]

12 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

12.1 CBT vs wait list

6

758

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.45, ‐0.12]

12.2 CBT vs TAU/enhanced usual care

1

303

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐0.90, ‐0.44]

13 Functional impairment ≥ 6 months Show forest plot

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.59, 0.09]

13.1 Trauma/Supportive counselling vs wait list

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.59, 0.09]

14 Quality of life at endpoint Show forest plot

4

325

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.25]

14.1 CBT vs wait list ‐ Adults

3

287

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.35, ‐0.07]

14.2 IPT vs wait list ‐ Adults

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

15 Diagnosis of PTSD Show forest plot

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

15.1 Trauma/Supportive counselling vs wait list

1

139

Risk Ratio (M‐H, Random, 95% CI)

2.27 [0.88, 5.85]

15.2 IPT vs TAU

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.31 [0.09, 1.02]

15.3 CBT vs wait list

2

214

Risk Ratio (M‐H, Random, 95% CI)

1.28 [0.28, 5.77]

16 Diagnosis of depression Show forest plot

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.30 [0.11, 0.80]

16.1 IPT vs wait list

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.30 [0.11, 0.80]

17 Coping at endpoint Show forest plot

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.60, 0.05]

17.1 CBT vs wait list

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.60, 0.05]

18 Coping at 1 to 4 months Show forest plot

2

121

Std. Mean Difference (IV, Random, 95% CI)

0.07 [‐0.49, 0.64]

18.1 CBT vs wait list

2

121

Std. Mean Difference (IV, Random, 95% CI)

0.07 [‐0.49, 0.64]

Figures and Tables -
Comparison 15. Subgroup analysis: type of control ‐ adults
Comparison 16. Subgroup analysis: phase of humanitarian crisis ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

15

1250

Std. Mean Difference (IV, Random, 95% CI)

‐1.10 [‐1.39, ‐0.81]

1.1 During the acute crisis

7

566

Std. Mean Difference (IV, Random, 95% CI)

‐1.14 [‐1.58, ‐0.69]

1.2 After the acute crisis

6

533

Std. Mean Difference (IV, Random, 95% CI)

‐1.33 [‐1.92, ‐0.73]

1.3 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.64 [‐0.97, ‐0.31]

2 PTSD symptoms at 1 to 4 months Show forest plot

16

1568

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.66, ‐0.29]

2.1 During the acute crisis

5

728

Std. Mean Difference (IV, Random, 95% CI)

‐0.78 [‐1.18, ‐0.38]

2.2 After the acute crisis

9

719

Std. Mean Difference (IV, Random, 95% CI)

‐0.33 [‐0.50, ‐0.17]

2.3 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.19 [‐0.55, 0.17]

3 PTSD symptoms ≥ 6 months Show forest plot

5

400

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.61, ‐0.14]

3.1 During the acute crisis

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.57, 0.12]

3.2 After the acute crisis

4

212

Std. Mean Difference (IV, Random, 95% CI)

‐0.51 [‐0.84, ‐0.18]

4 Anxiety symptoms at endpoint Show forest plot

4

535

Std. Mean Difference (IV, Random, 95% CI)

‐0.76 [‐1.10, ‐0.42]

4.1 After the acute crisis

3

326

Std. Mean Difference (IV, Random, 95% CI)

‐0.92 [‐1.61, ‐0.23]

4.2 During the acute crisis

1

209

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.02, ‐0.45]

5 Anxiety symptoms at 1 to 4 months Show forest plot

6

969

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.71, ‐0.15]

5.1 During the acute crisis

3

636

Std. Mean Difference (IV, Random, 95% CI)

‐0.69 [‐1.03, ‐0.36]

5.2 After the acute crisis

3

333

Std. Mean Difference (IV, Random, 95% CI)

‐0.16 [‐0.41, 0.08]

6 Depressive symptoms at endpoint Show forest plot

13

1232

Std. Mean Difference (IV, Random, 95% CI)

‐0.90 [‐1.09, ‐0.71]

6.1 During the acute crisis

6

514

Std. Mean Difference (IV, Random, 95% CI)

‐1.05 [‐1.26, ‐0.85]

6.2 After the acute crisis

5

567

Std. Mean Difference (IV, Random, 95% CI)

‐0.82 [‐1.03, ‐0.60]

6.3 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐1.20, 0.14]

7 Depressive symptoms at 1 to 4 months Show forest plot

14

1670

Std. Mean Difference (IV, Random, 95% CI)

‐0.42 [‐0.61, ‐0.23]

7.1 During the acute crisis

5

1034

Std. Mean Difference (IV, Random, 95% CI)

‐0.70 [‐0.93, ‐0.47]

7.2 After the acute crisis

7

515

Std. Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.44, 0.00]

7.3 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.13 [‐0.49, 0.23]

8 Depressive symptoms ≥ 6 months Show forest plot

2

242

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.49, 0.09]

8.1 During the acute crisis

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.61, 0.08]

8.2 After the acute crisis

1

54

Std. Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.58, 0.49]

9 Dropout Show forest plot

24

2773

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.80, 1.16]

9.1 During the acute crisis

9

1134

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.78, 1.48]

9.2 After the acute crisis

13

1442

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.73, 1.28]

9.3 Other

2

197

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.12, 2.67]

10 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.29]

10.1 After the acute crisis

1

274

Std. Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.79, ‐0.30]

10.2 Other

2

151

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐1.30, 0.40]

10.3 During the acute crisis

2

261

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐0.93, ‐0.43]

11 Functional impairment at 1 to 4 months Show forest plot

7

1061

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.55, ‐0.16]

11.1 During the acute crisis

3

633

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.81, ‐0.13]

11.2 After the acute crisis

2

307

Std. Mean Difference (IV, Random, 95% CI)

‐0.34 [‐0.60, ‐0.08]

11.3 Other

2

121

Std. Mean Difference (IV, Random, 95% CI)

‐0.08 [‐0.43, 0.28]

12 Quality of life at endpoint Show forest plot

4

325

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.25]

12.1 During the acute crisis

1

159

Std. Mean Difference (IV, Random, 95% CI)

‐0.83 [‐1.16, ‐0.51]

12.2 After the acute crisis

3

166

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.49, 0.04]

13 Diagnosis of PTSD Show forest plot

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

13.1 After the acute crisis

4

402

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.43, 2.68]

Figures and Tables -
Comparison 16. Subgroup analysis: phase of humanitarian crisis ‐ adults
Comparison 17. Sensitivity analysis: incomplete outcome data ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

9

401

Std. Mean Difference (IV, Random, 95% CI)

‐1.27 [‐1.76, ‐0.78]

1.1 EMDR vs control

1

29

Std. Mean Difference (IV, Random, 95% CI)

‐1.65 [‐2.51, ‐0.79]

1.2 CBT vs control

7

352

Std. Mean Difference (IV, Random, 95% CI)

‐1.21 [‐1.80, ‐0.63]

1.3 IPT vs control

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.45 [‐2.46, ‐0.43]

2 PTSD symptoms at 1 to 4 months Show forest plot

12

943

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.58, ‐0.22]

2.1 CBT vs control

11

905

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.54, ‐0.20]

2.2 IPT vs control

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.99 [‐1.67, ‐0.32]

3 PTSD symptoms ≥ 6 months Show forest plot

3

272

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.56, ‐0.03]

3.1 Trauma/Supportive counselling vs control ‐ Adults

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.57, 0.12]

3.2 CBT vs control

2

84

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.85, 0.03]

4 Anxiety symptoms at endpoint Show forest plot

3

211

Std. Mean Difference (IV, Random, 95% CI)

‐0.98 [‐1.42, ‐0.54]

4.1 CBT vs control

3

211

Std. Mean Difference (IV, Random, 95% CI)

‐0.98 [‐1.42, ‐0.54]

5 Anxiety symptoms at 1 to 4 months Show forest plot

5

663

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.67, ‐0.03]

5.1 CBT vs control

5

663

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.67, ‐0.03]

6 Depressive symptoms ≥ 6 months Show forest plot

2

242

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.49, 0.09]

6.1 Trauma/Supportive counselling vs control

1

188

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.61, 0.08]

6.2 CBT vs control

1

54

Std. Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.58, 0.49]

7 Depressive symptoms at endpoint Show forest plot

8

529

Std. Mean Difference (IV, Random, 95% CI)

‐0.89 [‐1.09, ‐0.68]

7.1 EMDR vs control

1

29

Std. Mean Difference (IV, Random, 95% CI)

‐1.17 [‐1.97, ‐0.37]

7.2 CBT vs control

5

271

Std. Mean Difference (IV, Random, 95% CI)

‐1.02 [‐1.28, ‐0.77]

7.3 IPT vs control

2

229

Std. Mean Difference (IV, Random, 95% CI)

‐0.84 [‐1.60, ‐0.08]

8 Depressive symptoms at 1 to 4 months Show forest plot

10

739

Std. Mean Difference (IV, Random, 95% CI)

‐0.52 [‐1.07, 0.03]

8.1 IPT vs control

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.77 [‐1.43, ‐0.11]

8.2 CBT vs control

9

701

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐1.09, 0.11]

9 Dropout Show forest plot

17

1535

Risk Ratio (M‐H, Random, 95% CI)

1.22 [0.83, 1.79]

9.1 EMDR vs control

1

29

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

9.2 CBT vs control

12

1017

Risk Ratio (M‐H, Random, 95% CI)

1.53 [0.92, 2.54]

9.3 IPT vs control

2

231

Risk Ratio (M‐H, Random, 95% CI)

0.61 [0.30, 1.27]

9.4 IPT vs control

1

49

Risk Ratio (M‐H, Random, 95% CI)

2.17 [0.65, 7.23]

9.5 Trauma/Supportive counselling vs control

1

209

Risk Ratio (M‐H, Random, 95% CI)

0.67 [0.29, 1.56]

10 Functional impairment at endpoint Show forest plot

2

141

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.74, 0.24]

10.1 CBT vs control

2

141

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.74, 0.24]

11 Functional impairment at 1 to 4 months Show forest plot

4

637

Std. Mean Difference (IV, Random, 95% CI)

‐0.32 [‐0.50, ‐0.14]

11.1 CBT vs control

4

637

Std. Mean Difference (IV, Random, 95% CI)

‐0.32 [‐0.50, ‐0.14]

12 Quality of life at endpoint Show forest plot

3

297

Std. Mean Difference (IV, Random, 95% CI)

‐0.59 [‐1.10, ‐0.08]

12.1 IPT vs control

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

12.2 CBT vs control

2

259

Std. Mean Difference (IV, Random, 95% CI)

‐0.48 [‐1.20, 0.23]

13 Diagnosis of PTSD Show forest plot

2

125

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.20, 1.59]

13.1 IPT vs control

1

49

Risk Ratio (M‐H, Random, 95% CI)

0.31 [0.09, 1.02]

13.2 CBT vs control

1

76

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.63, 0.95]

Figures and Tables -
Comparison 17. Sensitivity analysis: incomplete outcome data ‐ adults
Comparison 18. Sensitivity analysis: selective reporting ‐ adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 PTSD symptoms at endpoint Show forest plot

15

1127

Std. Mean Difference (IV, Random, 95% CI)

‐1.05 [‐1.35, ‐0.75]

1.1 EMDR vs control

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐2.01 [‐2.50, ‐1.52]

1.2 CBT vs control

12

1008

Std. Mean Difference (IV, Random, 95% CI)

‐0.85 [‐1.13, ‐0.58]

1.3 IPT vs control

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.45 [‐2.46, ‐0.43]

2 PTSD symptoms at 1 to 4 months Show forest plot

16

1459

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐0.71, ‐0.34]

2.1 EMDR vs control

1

64

Std. Mean Difference (IV, Random, 95% CI)

‐1.76 [‐2.34, ‐1.18]

2.2 CBT vs control

14

1357

Std. Mean Difference (IV, Random, 95% CI)

‐0.44 [‐0.58, ‐0.31]

2.3 IPT vs control

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.99 [‐1.67, ‐0.32]

2.4 BATD vs control

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2.5 NET vs control

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2.6 CETA vs control

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Dropout Show forest plot

24

2753

Risk Ratio (M‐H, Random, 95% CI)

1.01 [0.84, 1.21]

3.1 EMDR vs control

2

127

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.40, 1.42]

3.2 CBT vs control

18

2208

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.86, 1.33]

3.3 IPT vs control

2

71

Risk Ratio (M‐H, Random, 95% CI)

1.97 [0.68, 5.67]

3.4 Trauma/Supportive counselling vs control

2

347

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.57, 1.04]

4 Functional impairment at endpoint Show forest plot

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

4.1 CBT vs control

5

686

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

5 Quality of life at endpoint Show forest plot

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

5.1 IPT vs control

1

38

Std. Mean Difference (IV, Random, 95% CI)

‐0.88 [‐1.55, ‐0.21]

Figures and Tables -
Comparison 18. Sensitivity analysis: selective reporting ‐ adults