Depression treatment
Can lay counsellors deliver one flexible therapy for many problems?
Open access · cc by · source: Europe PMC
Refugees treated by briefly trained local counsellors using a mix-and-match therapy improved far more on depression and trauma symptoms than people waiting for treatment.
Study at a glance
- Design
- RCT — Single-site, two-arm, 1:1, assessor-blinded wait-list randomised controlled trial with baseline and ~4-month follow-up
- N
- N=347 · 347 randomised adults in the intention-to-treat sample; 274 had follow-up assessments (missing data multiply imputed)
- Population
- Burmese adult trauma survivors displaced to Mae Sot, Thailand, with moderate-to-severe depression and/or post-traumatic stress symptoms
- Outcome
- Depression (locally adapted HSCL-25) and post-traumatic stress symptoms (adapted HTQ); secondary: functional impairment, anxiety, aggression, alcohol use
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Key findings
Both groups improved, but the CETA group improved much more: the extra reduction in depression and post-traumatic stress scores corresponded to very large effect sizes (d = 1.16 and d = 1.19). Anxiety (d = 0.79), functional impairment (d = 0.60) and aggression (d = 0.58) also improved more with CETA, but alcohol use fell similarly in both arms. Results held when people lost to follow-up were assumed to have much worse outcomes, and clients who finished CETA averaged about 9.7 weekly sessions.
Methodology
The researchers first used qualitative interviews to adapt symptom questionnaires and a therapy called the Common Elements Treatment Approach (CETA) for Burmese refugees in Thailand. CETA teaches counsellors a menu of therapy components (such as psychoeducation, cognitive coping and gradual exposure to trauma memories) and rules for choosing, ordering and dosing them for each client. Adults with trauma exposure and moderate-to-severe depression or post-traumatic stress symptoms were randomly assigned to weekly CETA sessions with lay refugee counsellors or to a wait-list, and interviewers who did not know group assignment reassessed everyone about 4 months later.
Limitations
Because the comparison was a wait-list rather than an active treatment, the trial cannot separate the specific CETA techniques from the general benefit of regular supportive contact with a counsellor. Participants knew their group, so expectation effects are possible, and only 79% of participants were reassessed, with more losses among controls. Outcomes were measured only once, shortly after treatment, so durability is unknown, and the intensive supervision from US-based trainers may not be sustainable in routine services.
How this study connects
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