Predictors of psychotherapy outcome in trauma-affected refugees: secondary analysis of a randomized controlled trial

​1. Title 

Predictors of psychotherapy outcome in trauma-affected refugees: secondary analysis of a randomized controlled trial 

2. Project period 

1.2.2020 – 30.6.2020 

3. Investigator(s) 

Berglind Bernardsdóttir, MSc Psychology Student and Research Intern at CTP 

4. Supervisors and collaborative partners 

  • Jessica Carlsson, MD, PhD 
  • Sabina Palic-Kapic, Psychologist, PhD 
  • Hinuga Sandahl, MD, PhD student 

5. Background 

Studies on psychotherapy for trauma-affected refugees have shown therapy outcome to be quite varied among patients, with some patients benefitting more from therapy than others (Nosè et al., 2017; Turrini et al., 2019). In pragmatic RCTs at the Competence Centre for Transcultural Psychiatry (CTP), where representative clinical populations of trauma-affected refugees are studied, psychotherapy tends to show only small effects (Buhmann et al., 2016; Carlsson et al., 2018). However, little is known about specific patient factors that predict psychotherapy outcome in this population. Increased awareness of such factors can help clinicians identify patients who are not likely to benefit from standardized treatment, and help them take additional measures to tailor treatment to the individual patient. 

The objective of this study is to examine whether motivation for therapy, locus of control, cognitive functioning, and levels of personality functioning assessed prior to psychotherapy can predict psychotherapy outcomes of PTSD, depression, anxiety, and disability in trauma-affected refugees. 

6. Aim/s 

The aim of the study is to identify patient factors that predict psychotherapy outcome in trauma-affected refugees. 

7. Methods 

The study is a secondary analysis of a pragmatic randomized controlled trial at CTP: “Treatment of sleep disturbances in trauma-affected refugees: a randomised controlled trial” (Sandahl et al., 2017). 

7.1 Number of participants (N) 

219 participants 

7.2 Population 

Trauma-affected refugees with a diagnosis of posttraumatic stress disorder, who were referred for treatment at CTP, and agreed to participate in the RCT

7.3 Description of data and data collection 

To identify predictors of psychotherapy outcome we will examine four patient factors assessed by the psychologists at onset of psychotherapy. These factors are: 

  • Cognitive functioning measured on the WHO Disability Assessment Schedule (WHODAS 2.0). 
  • Locus of control measured on the Locus of Control (LoC) scale adjusted to the patient population. 
  • Motivation for therapy measured on the Client Motivation for Therapy Scale (CMTS) adjusted to the patient population. 
  • Personality-related functioning measured on the Levels of Personality Functioning Scale (LPFS). 

The primary outcome in the study are PTSD symptoms measured on the Harvard Trauma Questionnaire (HTQ). Other outcome measures are the Hamilton anxiety and depression scales (HAM-D and HAM-A), and the Sheehan Disability Scale (SDS). 

7.4 Application/acceptance from the Danish Data Protection Agency, the National Committee on Health Research Ethics 


7.5 Analysis 

Structural equation modelling will be used to investigate the association between the predictors and psychotherapy outcome. The model will adjust for sociodemographic information, treatment condition, and the use of interpreter-mediated therapy. 

Data will be analyzed under the intention to treat paradigm using ML to estimate missing values. 

Further exploratory analyses of missing value patterns on the predictors will be conducted. 

8. Expected results 

The study is expected to add new knowledge on patient factors that predict psychotherapy outcome in trauma-affected refugees. Identifying those who will benefit from psychotherapy and those who will not can help clinicians tailor treatment to their patients’ needs and make treatment more effective. 

9. Dissemination of results 

The results will be disseminated in the form of 1) one scientific article to be submitted to a peer reviewed journal. 2) a poster with preliminary results to be presented on the Research Day of the Mental Health Services of the Capital Region in Denmark, 3) feed-back to clinical psychologists about missingness in order to improve data-quality in present trials. 

10. References 

  • Buhmann, C. B., Nordentoft, M., Ekstroem, M., Carlsson, J., & Mortensen, E. L. (2016). 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. The British Journal of Psychiatry, 208(3), 252-259. 
  • Carlsson, J., Sonne, C., Vindbjerg, E., & Mortensen, E. L. (2018). Stress management versus cognitive restructuring in trauma-affected refugees—A pragmatic randomised study. Psychiatry Research, 266, 116-123. 
  • Nosè, M., Ballette, F., Bighelli, I., Turrini, G., Purgato, M., Tol, W., ... & Barbui, C. (2017). Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in highincome countries: Systematic review and meta-analysis. PloS One, 12(2). 
  • Turrini, G., Purgato, M., Acarturk, C., Anttila, M., Au, T., Ballette, F., ... & Hall, J. (2019). Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis. Epidemiology and Psychiatric Sciences, 28(4), 376-388. 
  • Sandahl, H., Jennum, P., Baandrup, L., Poschmann, I. S., & Carlsson, J. (2017). Treatment of sleep disturbances in trauma-affected refugees: Study protocol for a randomised controlled trial. Trials, 18(1), 520.
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