title: A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq.
abstract: BACKGROUND
  Experiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.
  
  
  METHODS
  Twenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.
  
  
  RESULTS
  Adult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004).
  
  
  CONCLUSIONS
  Both interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.
  
  
  BACKGROUND
  ClinicalTrials.Gov NCT00925262 . Registered June 3, 2009.
authors.affiliation: Center for Refugee and Disaster Response and Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E8646, Baltimore, MD, 21205, USA. pbolton1@jhu.edu.|Applied Mental Health Research Group, Center for Refugee and Disaster Response, Johns Hopkins University Bloomberg School of Public Health, c/o 159 Tilden Road, Scituate, MA, 02066, USA. pbolton1@jhu.edu.
authors.forename: Paul
authors.initials: P
authors.lastname: Bolton
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA. jbass1@jhu.edu.
authors.forename: Judith K
authors.initials: JK
authors.lastname: Bass
authors.affiliation: Heartland Alliance International, 208 S. LaSalle Street, Suite 1300, Chicago, IL, 60604, USA. gsabir@heartlandalliance.org.
authors.forename: Goran Abdulla Sabir
authors.initials: GA
authors.lastname: Zangana
authors.affiliation: Fine Arts Institute, University of Sulaimani, Kurdistan Region, Iraq. talar_kamal@yahoo.com.
authors.forename: Talar
authors.initials: T
authors.lastname: Kamal
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA. smurray9@jhu.edu.
authors.forename: Sarah McIvor
authors.initials: SM
authors.lastname: Murray
authors.affiliation: Department of Psychiatry & Behavioral Sciences, University of Washington, 1100 NE 45th Street, Suite 300, Seattle, WA, 98105, USA. dkaysen@uw.edu.
authors.forename: Debra
authors.initials: D
authors.lastname: Kaysen
authors.affiliation: Department of Psychology, Center for Addictions, Personality, and Emotion Research (CAPER), University of Maryland, College Park, MD, 20742-5141, USA. clejuez@umd.edu.
authors.forename: Carl W
authors.initials: CW
authors.lastname: Lejuez
authors.affiliation: Center for the Study of Health and Risk Behaviors, University of Washington, 1100 NE 45th, Suite 300, Seattle, WA, 98105, USA. kpl9716@uw.edu.
authors.forename: Kristen
authors.initials: K
authors.lastname: Lindgren
authors.affiliation: Division of Preventive and Behavior Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA. Sherry.Pagoto@umassmed.edu.
authors.forename: Sherry
authors.initials: S
authors.lastname: Pagoto
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA. lmurra15@jhu.edu.
authors.forename: Laura K
authors.initials: LK
authors.lastname: Murray
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA. sskaven1@jhu.edu.
authors.forename: Stephanie Skavenski
authors.initials: SS
authors.lastname: Van Wyk
authors.affiliation: Trauma Rehabilitation and Training Center, and Department of Community Health, Sulaimania Polytechnic University, Sulaimania, Kurdistan Region, Iraq. ahmed.ammin@gmail.com.
authors.forename: Ahmed Mohammed Amin
authors.initials: AM
authors.lastname: Ahmed
authors.affiliation: University of Sulaimani, Kurdistan Region, Iraq. nazar.amin@gmail.com.
authors.forename: Nazar M Mohammad
authors.initials: NM
authors.lastname: Amin
authors.affiliation: Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room E3616, Baltimore, MD, 21205, USA. mrosen@jhu.edu.
authors.forename: Michael
authors.initials: M
authors.lastname: Rosenblum
mesh_terms: D000328:Adult; D001521:Behavior Therapy / Q000379:methods; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D007493:Iraq; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*; D017741:Survivors / Q000523:psychology*; D014754:Violence / Q000523:psychology*