Skip to main content Accessibility help
×
Home

The effect of flexible cognitive–behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial

  • Caecilie Böck Buhmann (a1), Merete Nordentoft (a2), Morten Ekstroem (a1), Jessica Carlsson (a1) and Erik Lykke Mortensen (a3)...

Abstract

Background

Little evidence exists on the treatment of traumatised refugees.

Aims

To estimate treatment effects of flexible cognitive–behavioural therapy (CBT) and antidepressants (sertraline and mianserin) in traumatised refugees.

Method

Randomised controlled clinical trial with 2×2 factorial design (registered with Clinicaltrials.gov, NCT00917397, EUDRACT no. 2008-006714-15). Participants were refugees with war-related traumatic experiences, post-traumatic stress disorder (PTSD) and without psychotic disorder. Treatment was weekly sessions with a physician and/or psychologist over 6 months.

Results

A total of 217 of 280 patients completed treatment (78%). There was no effect on PTSD symptoms, no effect of psychotherapy and no interaction between psychotherapy and medicine. A small but significant effect of treatment with antidepressants was found on depression.

Conclusions

In a pragmatic clinical setting, there was no effect of flexible CBT and antidepressants on PTSD, and there was a small-to-moderate effect of antidepressants and psychoeducation on depression in traumatised refugees.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The effect of flexible cognitive–behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The effect of flexible cognitive–behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The effect of flexible cognitive–behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial
      Available formats
      ×

Copyright

Corresponding author

Caecilie Böck Buhmann, MD, MPH, PhD, Competence Center for Transcultural Psychiatry, Psykiatric Center Ballerup, Maglevaenget 2, 2750 Ballerup, Denmark. Email: caecilie.boeck.buhmann@regionh.dk

Footnotes

Hide All

The trial was funded by the Capital Region of Copenhagen and Trygfonden.

Declaration of interest

None.

Footnotes

References

Hide All
1 Steel, Z, Chey, T, Silove, D, Marnane, C, Bryant, RA, van, OM. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 2009; 302: 537–49.
2 Bisson, J, Andrew, M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2007; 3: CD003388.
3 Stein, DJ, Ipser, JC, Seedat, S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2006; 1: CD002795.
4 Hetrick, SE, Purcell, R, Garner, B, Parslow, R. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2010; 7: CD007316.
5 Buhman, C, Mortensen, EL, Lundstroem, S, Ryberg, J, Nordentoft, M, Ekstroem, M. Symptoms, quality of life and level of functioning of traumatized refugees at psychiatric trauma clinic in Copenhagen. Torture 2014; 24: 2539.
6 Crumlish, N, O'Rourke, K. A systematic review of treatments for posttraumatic stress disorder among refugees and asylum-seekers. J Nerv Ment Dis 2010; 198: 237–51.
7 Palic, S, Elklit, A. Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique. J Affect Disord 2011; 131: 823.
8 Otto, MW, Hinton, D, Korbly, NB, Chea, A, Ba, P, Gershuny, BS, et al. Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone. Behav Res Ther 2003; 41: 1271–6.
9 Smajkic, A, Weine, S, Djuric-Bijedic, Z, Boskailo, E, Lewis, J, Pavkovic, I. Sertraline, paroxetine, and venlafaxine in refugee posttraumatic stress disorder with depression symptoms. J Trauma Stress 2001; 14: 445–52.
10 Boynton, L, Bentley, J, Strachan, E, Barbato, A, Raskind, M. Preliminary findings concerning the use of prazosin for the treatment of posttraumatic nightmares in a refugee population. J Psychiatr Pract 2009; 15: 454–9.
11 Boehnlein, JK, Kinzie, JD. Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract 2007; 13: 72–8.
12 Neuner, F, Onyut, PL, Ertl, V, Odenwald, M, Schauer, E, Elbert, T. Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. J Consult Clin Psychol 2008; 76: 686–94.
13 Neuner, F, Schauer, M, Klaschik, C, Karunakara, U, Elbert, T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. J Consult Clin Psychol 2004; 72: 579–87.
14 Hinton, DE, Chhean, D, Pich, V, Safren, SA, Hofmann, SG, Pollack, MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design. J Trauma Stress 2005; 18: 617–29.
15 Hinton, DE, Pham, T, Tran, M, Safren, SA, Otto, MW, Pollack, MH. CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study. J Trauma Stress 2004; 17: 429–33.
16 Kruse, J, Joksimovic, L, Cavka, M, Woller, W, Schmitz, N. Effects of trauma-focused psychotherapy upon war refugees. J Trauma Stress 2009; 22: 585–92.
17 Paunovic, N, Ost, LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther 2001; 39: 1183–97.
18 Bass, JK, Annan, J, McIvor Murray, S, Kaysen, D, Griffiths, S, Cetinoglu, T, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med 2013; 368: 2182–91.
19 Carlsson, JM, Mortensen, EL, Kastrup, M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005; 193: 651–7.
20 Palic, S, Elklit, A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture 2009; 19: 248–70.
21 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO, 1993.
22 Wing, JK, Babor, T, Brugha, T, Burke, J, Cooper, JE, Giel, R, et al. SCAN. Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990; 47: 589–93.
23 Taylor, D, Paton, C, Kapur, S. The Maudsley Prescribing Guidelines (10th edn) Informa Healthcare, 2009.
24 Oruc, L, Kapetanovic, A, Culhane, M, Lavelle, J, Miley, K, Forstbauer, S, et al. Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist. Int J Culture Ment Health 2008; 1: 117–33.
25 Kleijn, WC, Hovens, JE, Rodenburg, JJ. Posttraumatic stress symptoms in refugees: assessments with the Harvard Trauma Questionnaire and the Hopkins symptom Checklist-25 in different languages. Psychol Rep 2001; 88: 527–32.
26 Mollica, RF, Caspi-Yavin, Y, Lavelle, J, Tor, S, Yang, T, Chan, S, et al. Harvard Trauma Questionnaire (HTQ). Manual Cambodian, Laotian and Vietnamese versions. Torture. 1996; 1 (Suppl): 2133.
27 Mollica, RF, Caspi-Yavin, Y, Bollini, P, Truong, T, Tor, S, Lavelle, J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992; 180: 111–6.
28 Mollica, RF, Wyshak, G, de Marneffe, D, Tu, B, Yang, T, Khuon, F, et al. Hopkins Symptom Checklist 25. Manual Cambodian, Laotian and Vietnamese versions. Torture 2000; 1: 3642.
29 Mollica, RF, Wyshak, G, de, MD, Khuon, F, Lavelle, J. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 1987; 144: 497500.
30 Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23: 5662.
31 Hamilton, M. The assessment of anxiety states by rating. Br J Med Psychol 1959; 32: 50–5.
32 Derogatis, LR. SCL-90-R: Symptom Checklist-90-R. Administration, Scoring and Procedures Manual (3rd edn). National Computer Systems, 1994.
33 Olsen, DR, Montgomery, E, Boejholm, S, Foldspang, A. Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study. Disability Rehabil 2007; 29: 163–71.
34 Sheehan, KH, Sheehan, DV. Assessing treatment effects in clinical trials with the discan metric of the Sheehan Disability Scale. Int Clin Psychopharmacol 2008; 23: 7083.
35 Lam, RW, Michalak, EE, Swinson, RP. Assessment Scales in Depression, Mania and Anxiety: 152–3. Taylor & Francis, 2005.
36 Bech, P. Clinical Psychometrics. Wiley Blackwell, 2012.
37 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). APA, 2000.
38 Hollifield, M, Warner, TD, Lian, N, Krakow, B, Jenkins, JH, Kesler, J, et al. Measuring trauma and health status in refugees: a critical review. JAMA 2002; 288: 611–21.
39 Ferreri, M, Lavergne, F, Berlin, I, Payan, C, Puech, AJ. Benefits from mianserin augmentation of fluoxetine in patients with major depression non-responders to fluoxetine alone. Acta Psychiatr Scand 2001; 103: 6672.
40 Chung, MY, Min, KH, Jun, YJ, Kim, SS, Kim, WC, Jun, EM. Efficacy and tolerability of mirtazapine and sertraline in Korean veterans with posttraumatic stress disorder: a randomized open label trial. Hum Psychopharmacol 2004; 19: 489–94.
41 Noerregaard, C. Culture and biology in psychopharmacological treatment of ethnic minorities. Ugeskr Laeger 2012; 6: 337–40.
42 Friedman, MJ, Marmar, CR, Baker, DG, Sikes, CR, Farfel, GM. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting. J Clin Psychiatry 2007; 68: 711–20.
43 Panahi, Y, Moghaddam, BR, Sahebkar, A, Nazari, MA, Beiraghdar, F, Karami, G, et al. A randomized, double-blind, placebo-controlled trial on the efficacy and tolerability of sertraline in Iranian veterans with post-traumatic stress disorder. Psychol Med 2011; 41: 2159–66.
Type Description Title
PDF
Supplementary materials

Buhmann et al. supplementary material
Supplementary Table S1-S2

 PDF (118 KB)
118 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

The effect of flexible cognitive–behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial

  • Caecilie Böck Buhmann (a1), Merete Nordentoft (a2), Morten Ekstroem (a1), Jessica Carlsson (a1) and Erik Lykke Mortensen (a3)...
Submit a response

eLetters

No eLetters have been published for this article.

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *