title: Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial.
abstract: BACKGROUND
  Systematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq.
  
  
  METHODS
  This was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12.
  
  
  RESULTS
  The CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively.
  
  
  CONCLUSIONS
  Both CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings.
  This trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq. The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol . In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. wweiss1@jhu.edu.
authors.forename: William M
authors.initials: WM
authors.lastname: Weiss
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA. lmurra15@jhu.edu.
authors.forename: Laura K
authors.initials: LK
authors.lastname: Murray
authors.affiliation: Heartland Alliance International, Rizgary Taza 408, Alley 32, House 08, Sulaimaniay, Iraq. goransbr@gmail.com.
authors.forename: Goran Abdulla Sabir
authors.initials: GA
authors.lastname: Zangana
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. zayanmahmooth@gmail.com.
authors.forename: Zayan
authors.initials: Z
authors.lastname: Mahmooth
authors.affiliation: Department of Psychology, University of Washington, 335 Guthrie Hall, Seattle, WA, 98195, USA. dkaysen@u.washington.edu.
authors.forename: Debra
authors.initials: D
authors.lastname: Kaysen
authors.affiliation: Department of Psychology, University of Washington, 335 Guthrie Hall, Seattle, WA, 98195, USA. dorsey2@u.washington.edu.
authors.forename: Shannon
authors.initials: S
authors.lastname: Dorsey
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: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. agross14@jhu.edu.
authors.forename: Alden
authors.initials: A
authors.lastname: Gross
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA. smurray9@jhu.edu.
authors.forename: Sarah McIvor
authors.initials: SM
authors.lastname: Murray
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA. jbass1@jhu.edu.
authors.forename: Judith K
authors.initials: JK
authors.lastname: Bass
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. pbolton1@jhu.edu.
authors.forename: Paul
authors.initials: P
authors.lastname: Bolton
mesh_terms: D000328:Adult; D001007:Anxiety / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods; D003156:Community Mental Health Services; D003863:Depression / Q000628:therapy*; D005260:Female; D006801:Humans; D007493:Iraq; D008297:Male; D008875:Middle Aged; D011613:Psychotherapy / Q000379:methods*; D016037:Single-Blind Method; D017741:Survivors / Q000523:psychology*; D014104:Torture / Q000523:psychology*; D014754:Violence / Q000523:psychology; D000067453:War Exposure