Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by nodding syndrome in Uganda.

BACKGROUND: Despite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma. METHODS: A non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention. RESULTS: Caregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10-0.62] and 6 months (RR 0.33, 95% CI 0.11-0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers. CONCLUSION: IPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.

Natural Medicines for Psychotic Disorders: A Systematic Review.

Patients with psychotic disorders regularly use natural medicines, although it is unclear whether these are effective and safe. The aim of this study was to provide an overview of evidence for improved outcomes by natural medicines. A systematic literature search was performed through Medline, PsycINFO, CINAHL, and Cochrane until May 2015. In 110 randomized controlled trials, evidence was found for glycine, sarcosine, N-acetylcysteine, some Chinese and ayurvedic herbs, ginkgo biloba, estradiol, and vitamin B6 to improve psychotic symptoms when added to antipsychotics. Ginkgo biloba and vitamin B6 seemed to reduce tardive dyskinesia and akathisia. Results on other compounds were negative or inconclusive. All natural agents, except reserpine, were well tolerated. Most study samples were small, study periods were generally short, and most results need replication. However, there is some evidence for beneficial effects of certain natural medicines.

A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies.

This paper describes how socio-ecological theory and a syndemic health systems and public health approach may help address the plight of youth in situations of political violence and humanitarian emergencies. We describe the treatment gap caused by discrepancies in epidemiological prevalence rates, individual and family needs, and available human and material resources. We propose four strategies to develop a participatory public health approach for these youth, based on principles of equity, feasibility, and a balance between prevention and treatment. The first strategy uses ecological and transgenerational resilience as a theoretical framework to facilitate a systems approach to the plight of youth and families. This theoretical base helps to engage health care professionals in a multisectoral analysis and a collaborative public health strategy. The second strategy is to translate pre-program assessment into mental health and psychosocial support (MHPSS) priorities. Defining priorities helps to develop programs and policies that align with preventive and curative interventions in multiple tiers of the public health system. The third is a realistic budgetary framework as a condition for the development of sustainable institutional capacity including a monitoring system. The fourth strategy is to direct research to address the knowledge gap about effective practices for youth mental health in humanitarian settings.

World Health organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead.

Wietse Tol and colleagues discuss some of the key challenges for implementation of new WHO guidelines for stress-related mental health disorders in low- and middle-income countries. Please see later in the article for the Editors' Summary.

School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial.

BACKGROUND: Armed conflicts are associated with a wide range of impacts on the mental health of children and adolescents. We evaluated the effectiveness of a school-based intervention aimed at reducing symptoms of posttraumatic stress disorder, depression, and anxiety (treatment aim); and improving a sense of hope and functioning (preventive aim). METHODS: We conducted a cluster randomized trial with 329 children in war-affected Burundi (aged 8 to 17 (mean 12.29 years, standard deviation 1.61); 48% girls). One group of children (n = 153) participated in a 15-session school-based intervention implemented by para-professionals, and the remaining 176 children formed a waitlist control condition. Outcomes were measured before, one week after, and three months after the intervention. RESULTS: No main effects of the intervention were identified. However, longitudinal growth curve analyses showed six favorable and two unfavorable differences in trajectories between study conditions in interaction with several moderators. Children in the intervention condition living in larger households showed decreases on depressive symptoms and function impairment, and those living with both parents showed decreases on posttraumatic stress disorder and depressive symptoms. The groups of children in the waitlist condition showed increases in depressive symptoms. In addition, younger children and those with low levels of exposure to traumatic events in the intervention condition showed improvements on hope. Children in the waitlist condition who lived on their original or newly bought land showed improvements in hope and function impairment, whereas children in the intervention condition showed deterioration on these outcomes. CONCLUSIONS: Given inconsistent effects across studies, findings do not support this school-based intervention as a treatment for posttraumatic stress disorder and depressive symptoms in conflict-affected children. The intervention appears to have more consistent preventive benefits, but these effects are contingent upon individual (for example, age, gender) and contextual (for example, family functioning, state of conflict, displacement) variables. Results suggest the potential benefit of school-based preventive interventions particularly in post-conflict settings. TRIAL REGISTRATION: The study was registered as ISRCTN42284825.

Validation of the Kirundi versions of brief self-rating scales for common mental disorders among children in Burundi.

BACKGROUND: In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi. METHODS: Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external 'gold standard' criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL). RESULTS: The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90. CONCLUSIONS: The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.

Pitfalls in the assessment, analysis, and interpretation of routine outcome monitoring (ROM) Data: results from an outpatient clinic for integrative mental health.

There is considerable debate about routine outcome monitoring (ROM) for scientific or benchmarking purposes. We discuss pitfalls associated with the assessment, analysis, and interpretation of ROM data, using data of 376 patients. 206 patients (55 %) completed one or more follow-up measurements. Mixed-model analysis showed significant improvement in symptomatology, quality of life, and autonomy, and differential improvement for different subgroups. Effect sizes were small to large, depending on the outcome measure and subgroup. Subtle variations in analytic strategies influenced effect sizes substantially. We illustrate how problems inherent to design and analysis of ROM data prevent drawing conclusions about (comparative) treatment effectiveness.

Harbingers of Hope: Scientists and the Pursuit of World Peace.

The ongoing wars in many regions-such as the conflict between Israel and Hamas-as well as the effects of war on communities, social services, and mental health are covered in this special editorial. This article emphasizes the need for international efforts to promote peace, offer humanitarian aid, and address the mental health challenges faced by individuals and communities affected by war and violence.

Ethnic differences in utilization of youth mental health care.

OBJECTIVES: There is an overall underutilization of youth mental health care (YMHC). It is unknown whether underutilization differs per ethnic group. Therefore, this study is aimed at gaining insight into the effects of ethnicity, age and gender on this utilization. DESIGN: The sample consisted of outpatient children (age 5-10) (n=1940) and adolescents (age 11-19) (n=2484) admitted to a Dutch YMHC centre. Ethnic background of the patients (patient registration system) was compared to that of the general population (municipality files). Relative risks (RRs) on utilization for non-native groups were calculated with natives as the reference group. RESULTS: With regard to children, female children from Moroccan, Turkish and other non-native western descent were less likely to enter mental health care than native Dutch female children. The RR was 0.24 for Moroccan girls, 0.53 for Turkish girls, and 0.60 for girls from other non-native western countries. Male children from almost all non-native groups were also less likely to enter mental health care than native Dutch male children, with the RRs being between 0.43 and 0.65. With regard to adolescents, most non-native adolescents, were as likely as native adolescents to enter mental health care. An exception were males and females from Morocco and males from Turkey and non-native western countries, who were less likely than Dutch adolescents to enter mental health care (RRs between 0.61 and 0.80). CONCLUSION AND DISCUSSION: Results imply that YMHC is less accessible for children from a minority background than for children from a native background. With adolescents, there is no difference in accessibility between natives and non-natives. Future research should focus on the reasons for this difference in accessibility. Potential mediators such as socioeconomic status, discrimination, acculturation processes, language barriers should be taken into account.

Quality of life after postconflict displacement in Ethiopia: comparing placement in a community setting with that in shelters.

BACKGROUND: The resilience of post-war displaced persons is not only influenced partly by the nature of premigration trauma, but also by postmigration psychosocial circumstances and living conditions. A lengthy civil war leading to Eritrea separating from Ethiopia and becoming an independent state in 1991 resulted in many displaced persons. METHOD: A random sample of 749 displaced women living in the shelters in the Ethiopian capital Addis Ababa was compared with a random sample of 110 displaced women living in the community setting of Debre Zeit, 50 km away from Addis Ababa, regarding their quality of life, mental distress, sociodemographics, living conditions, perceived social support, and coping strategies, 6 years after displacement. RESULTS: Subjects from Debre Zeit reported significantly higher quality of life and better living conditions. However, mental distress did not differ significantly between the groups. Also, Debre Zeit subjects contained a higher proportion born in Ethiopia, a higher proportion married, reported higher traumatic life events, employed more task-oriented coping, and perceived higher social support. Factors that accounted for the difference in quality of life between the shelters and Debre Zeit groups in three of the four quality of life domains of WHOQOL-BREF (physical health, psychological, environment), included protection from insects/rodents and other living conditions. However, to account for the difference in the fourth domain (social relationships), psychosocial factors also contributed significantly. CONCLUSION: Placement and rehabilitation in a community setting seems better than in the shelters. If this possibility is not available, measures to improve specific living conditions in the shelters are likely to lead to a considerable increase in quality of life.

Developing a function impairment measure for children affected by political violence: a mixed methods approach in Indonesia.

OBJECTIVE: Practitioners in political violence-affected settings would benefit from rating scales that assess child function impairment in a reliable and valid manner when designing and evaluating interventions. We developed a procedure to construct child function impairment rating scales using resources available in low- and middle-income countries. DESIGN: We applied a mixed methods approach. First, rapid ethnographic methods (brief participant observation, collection of diaries and a focus group with children) were used to select daily activities that best represented children's functioning. Second, rating scales based on these activities were examined for their psychometric properties. Construct validity was assessed through a confirmatory factor analysis procedure. SETTING: Central Sulawesi, Indonesia. PARTICIPANTS: Qualitative data were collected for 53 children and psychometric testing was done with 403 children [average age: 9.9 (SD = 1.21), 49% girls] and 385 parents. RESULTS: Using locally available resources, we developed separate child-rated and parent-rated scales, both containing 11 items. The child-rated scale evidenced good internal, test-retest and inter-rater reliability and acceptable convergent and discriminant validity. Construct validity was confirmed by fit of the theorized factor structure-a social-ecological clustering of daily activities. CONCLUSIONS: The procedure resulted in a reliable and valid rating scale to assess child function impairment in the context of political violence. Practitioners can apply this procedure to develop new locally adequate rating scales to strengthen epidemiological surveys, baseline assessments, monitoring and evaluation and eventually, interventions. Further research should address the importance of gender differences and criterion-related validity.

Contextualized understanding of depression: A vignette study among the !Xun and Khwe of South Africa.

Colonial misconceptions about the absence of depression and the lack of a psychologization of distress among Africans have long been refuted. However, cultural variation in depression in terms of symptomatic expression, conceptualization, explanatory models, and social responses is widely acknowledged. Insight into the cultural variation of depression is useful for providing appropriate care; however, few studies have explored cultural understandings of depression in African settings. In a depression vignette study of two displaced and marginalized San communities in South Africa, we conducted 20 semistructured interviews to explore causal interpretations and strategies for coping. Causal interpretations consisted of several dimensions, including life struggles and physical, psychological, and spiritual interpretations. Respondents primarily focused on life struggles in terms of socioeconomic and interpersonal problems. They described coping strategies as primarily addressing negative emotional and psychological affect through social support for relief, comfort, distraction, or advice on coping with the situation and emotions. In addition, religious coping and professional support from a social worker, psychologist, support group, or medications were mentioned. Findings illustrate that depression should be understood beyond individual suffering and be situated in its immediate social environment and larger sociopolitical setting. Interventions for depression therefore may benefit from a multilevel approach that addresses socioeconomic conditions, strengthens local resources, and fosters collaboration among locally appropriate informal and formal support structures.

Child witchcraft confessions as an idiom of distress in Sierra Leone; results of a rapid qualitative inquiry and recommendations for mental health interventions.

BACKGROUND: Reports about child witchcraft are not uncommon in sub-Saharan Africa. In this study we approach child witchcraft as an idiom of distress. In an environment that may prohibit children from openly expressing distress, the shared imagery of witchcraft can provide a cultural idiom to communicate about psychosocial suffering. We used an ecological approach to study how some children in distressing circumstances come to a witchcraft confession, with the aim to set out pathways for mental health interventions. METHODS: We employed rapid qualitative inquiry methodology, with an inductive and iterative approach, combining emic and etic perspectives. We conducted 37 interviews and 12 focus group discussions with a total of 127 participants in Freetown, Sierra Leone. Inductive analysis was used to identify risk and protective factors related to witchcraft accusations and confessions. RESULTS: We identified risk and protective factors related to the individual child, the family, peer relations, teachers and other professionals in a child's life, traditional healers, pastors and the wider society. We found that in the context of a macrosystem that supports witchcraft, suspicions of witchcraft are formed at the mesosystem level, where actors from the microsystem interact with each other and the child. The involvement of a traditional healer or pastor often forms a tipping point that leads to a confession of witchcraft. CONCLUSIONS: Child witchcraft is an idiom of distress, not so much owned by the individual child as well as by the systems around the child. Mental health interventions should be systemic and multi-sectoral, to prevent accusations and confessions, and address the suffering of both the child and the systems surrounding the child. Interventions should be contextually relevant and service providers should be helped to address conscious and subconscious fears related to witchcraft. Beyond mental health interventions, advocacy, peacebuilding and legislation is needed to address the deeper systemic issues of poverty, conflict and abuse.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial.

BACKGROUND: In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS: A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS: Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS: A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

Adjustment disorders after severe life-events in four postconflict settings.

BACKGROUND: The present study explores whether severe life-events are associated with adjustment disorders (AD) by reanalyzing the data of a multisite epidemiological survey (de Jong et al. in Lancet 361:2128-2130, 2003). AD were diagnosed according to the new stress-response-model of AD (Maercker et al. in Psychopathology 40(3):135-146, 2007). METHOD: Data from 3048 persons from four different refugee settings in Ethiopia, Algeria, Gaza, and Cambodia were reanalyzed. Life events were assessed by an adapted version of the Life Events and Social History Interview (Mollica et al. in Am J Psychiatry 144:1567-1572, 1987). The current study focuses on non-directly life threatening events related to AD (e.g. loss of property) in contrast to life-threatening events related to Posttraumatic Stress Disorders (PTSD). AD Symptom measures were obtained from available psychopathology assessments: composite international diagnostic interview (WHO in CIDI, Geneva, 1997) and structured interview for disorders of extreme stress (Pelcovitz et al. J Trauma Stress 10:3-16, 1997). RESULTS: The majority of the subjects had experienced one or more AD-related life event. Most common AD-related life events varied across the four sites with bad shelter conditions most prevalent in Ethiopia (100%) and Gaza (32%), forced social isolation in Algeria (61%), and lack of food in Cambodia (41%). Prevalences of AD diagnoses ranged from 6% (Ethiopia) to 40% (Algeria). The highest rates of comorbidity were between AD and PTSD, followed by anxiety disorders. CONCLUSION: The present study shows that the new concept of AD can be of use for psychiatric epidemiology, e.g., in migration contexts. The high-comorbidity rates could indicate that AD and PTSD are parts of a stress response spectrum.

Kiyang-yang, a West-African postwar idiom of distress.

In 1984, a healing cult for young barren women in southern Guinea Bissau developed into a movement, Kiyang-yang, that shook society to its foundations and had national repercussions. "Idiom of distress" is used here as a heuristic tool to understand how Kiyang-yang was able to link war and post-war-related traumatic stress and suffering on both individual and group levels. An individual experience born from a traumatic origin may be generalized into an idiom that diverse sectors of society could embrace for a range of related reasons. We argue that, for an idiom to be understood and appropriated by others, there has to be resonance at the level of symbolic language and shared experiences as well as at the level of the culturally mediated contingent emotions it communicates. We also argue that through its symbolic references to structural causes of suffering, an idiom of distress entails a danger for those in power. It can continue to exist only if its etiology is not exposed or the social suffering it articulates is not eliminated. We finally argue that idioms of distress are not to be understood as discrete diagnostic categories or as monodimensional expressions of "trauma" that can be addressed.

Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda.

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice, desire for revenge, and attitudes toward the Khmer Rouge trials.

CONTEXT: Millions of Cambodians suffered profound trauma during the Khmer Rouge era (1975 to 1979). A joint United Nations-Cambodian tribunal (the "Khmer Rouge trials") was empanelled in 2006 to prosecute top Khmer Rouge leaders and began substantive hearings in March 2009. OBJECTIVES: To establish the prevalence of probable posttraumatic stress disorder (PTSD) among adult Cambodians and to assess correlates of PTSD symptoms and disability with perceived justice, desire for revenge, and knowledge of and attitudes toward the trials. DESIGN, SETTING, AND PARTICIPANTS: A national probability sample of 1017 Cambodians was assembled using a multistage, stratified cluster design, including 813 adults older than 35 years who had been at least 3 years old during the Khmer Rouge era and 204 adults aged 18 to 35 years who had not been exposed to the Khmer Rouge era. Face-to-face interviews were conducted between December 2006 and August 2007. MAIN OUTCOME MEASURES: Prevalence of probable PTSD using the PTSD Checklist, Civilian version (cutoff score of 44), and mental and physical disability using the Medical Outcomes Study 12-item Short Form Health Survey. RESULTS: The prevalence of current probable PTSD was 11.2% (95% confidence interval [CI], 8.6%-13.9%) overall and 7.9% (95% CI, 3.8%-12.0%) among the younger group and 14.2% (95% CI, 11.0%-17.3%) in the older group. Probable PTSD was significantly associated with mental disability (40.2% vs 7.9%; adjusted odds ratio [AOR], 7.80; 95% CI, 3.90-15.60) and physical disability (39.6% vs 20.1%; AOR, 2.60; 95% CI, 1.26-5.39). Although Cambodians were hopeful that the trials would promote justice, 87.2% (n = 681) of those older than 35 years believed that the trials would create painful memories for them. In multivariate analysis, respondents with high levels of perceived justice for violations during the Khmer Rouge era were less likely to have probable PTSD than those with low levels (7.4% vs 12.7%; AOR, 0.54; 95% CI, 0.34-0.86). Respondents with high levels of desire for revenge were more likely to have probable PTSD than those with low levels (12.0% vs 7.2%), but the difference was not statistically significant in the multivariate analysis (AOR, 1.76; 95% CI, 0.99-3.11). CONCLUSIONS: Probable PTSD is common and associated with disability in Cambodia. Although Cambodians had positive attitudes toward the trials, most were concerned that the trials would bring back painful memories. Now that the trials have begun, longitudinal research is needed to determine the impact of the trials on Cambodians' mental health.

Brief multi-disciplinary treatment for torture survivors in Nepal: a naturalistic comparative study.

BACKGROUND: Little is known about the effectiveness of treatment for torture survivors in low-income settings. Multi-disciplinary treatment is an often used approach for this target group. AIMS: This study was aimed at examining the effectiveness of brief multi-disciplinary treatment for torture survivors in Nepal. METHODS: A naturalistic comparative design with help-seeking torture survivors and internally displaced persons assigned to a treatment and a comparison group respectively ( n = 192; treatment group n = 111, comparison group n = 81), with baseline measurements on psychiatric symptomatology, disability, and functioning and a five-month follow-up (n = 107; treatment group n = 62; comparison group n = 45), was employed. Intervention consisted of brief psychosocial services, minimal medical services and/or legal assistance. RESULTS: Study groups were generally comparable and non-completers did not significantly differ from completers. The treatment group improved more than the comparison group on somatic symptoms, subjective well-being, disability and functioning, with mostly moderate effect sizes. CONCLUSION: Treatment was moderately effective, with regards to reducing the nonspecific mental health consequences of torture, but disability scores remained high. For clients presenting with more severe mental health problems, other treatments that are realistic in the resource-poor Nepali context need to be sought.