Community-implemented trauma therapy for former child soldiers in Northern Uganda: a randomized controlled trial

Verena Ertl, Anett Pfeiffer, Elisabeth Schauer, Thomas Elbert, Frank Neuner
JAMA 2011 August 3, 306 (5): 503-12

CONTEXT: The psychological rehabilitation of former child soldiers and their successful reintegration into postconflict society present challenges. Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers.

OBJECTIVE: To assess the efficacy of a community-based intervention targeting symptoms of posttraumatic stress disorder (PTSD) in formerly abducted individuals.

DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial recruiting 85 former child soldiers with PTSD from a population-based survey of 1113 Northern Ugandans aged 12 to 25 years, conducted between November 2007 and October 2009 in camps for internally displaced persons. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD and trauma-related feelings of guilt were measured using the Clinician-Administered PTSD Scale. The respective sections of the Mini International Neuropsychiatric Interview were used to assess depression and suicide risk, and a locally adapted scale was used to measure perceived stigmatization. Symptoms of PTSD, depression, and related impairment were assessed before treatment and at 3 months, 6 months, and 12 months postintervention.

INTERVENTION: Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.

MAIN OUTCOME MEASURES: Change in PTSD severity, assessed over a 1-year period after treatment. Secondary outcome measures were depression symptoms, severity of suicidal ideation, feelings of guilt, and perceived stigmatization.

RESULTS: PTSD symptom severity (range, 0-148) was significantly more improved in the narrative exposure therapy group than in the academic catch-up (mean change difference, -14.06 [95% confidence interval, -27.19 to -0.92]) and waiting-list (mean change difference, -13.04 [95% confidence interval, -26.79 to 0.72]) groups. Contrast analyses of the time × treatment interaction of the mixed-effects model on PTSD symptom change over time revealed a superiority of narrative exposure therapy compared with academic catch-up (F(1,234.1) = 5.21, P = .02) and wait-listing (F(1,228.3) = 5.28, P = .02). Narrative exposure therapy produced a larger within-treatment effect size (Cohen d = 1.80) than academic catch-up (d = 0.83) and wait-listing (d = 0.81).

CONCLUSION: Among former Ugandan child soldiers, short-term trauma-focused treatment compared either with an academic catch-up program including supportive counseling or with wait-listing resulted in greater reduction of PTSD symptoms.

TRIAL REGISTRATION: Identifier: NCT00552006.

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