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ARTICLE
Year : 2022 | Volume
: 20
| Issue : 2 | Page : 179-187
Cognitive Processing Therapy for the Treatment of PTSD, Depression and Anxiety in Syrian Refugees in Egypt
Amani Safwat ElBarazi1, Rajiv Tikamdas2, Salma Ahmed3, Salma Ramadan3
1 Clinical Practice Department, The British University in Egypt, El-Shorouk City, Cairo; The Center for Drug Research and Development (CDRD), Faculty of Pharmacy, The British University in Egypt, El-Shorouk City, Cairo; Clinical Psychology Clinic, Safwat Elgolf Hospital, Almaza, Nasr City, Cairo, Egypt, 4BSc, Department of Psychology, The British University in Egypt, El-Shorouk City, Cairo, Egypt
2 Clinical Practice Department, The British University in Egypt, El-Shorouk City, Cairo; The Center for Drug Research and Development (CDRD), Faculty of Pharmacy, The British University in Egypt, El-Shorouk City, Cairo, Egypt
3 Department of Psychology, The British University in Egypt, El-Shorouk City, Cairo, Egypt
Correspondence Address:
PhD Amani Safwat ElBarazi
The British University in Egypt, El-Shorouk City, Cairo
Egypt
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_33_21
The purpose of this study is to examine the efficacy of cognitive processing therapy (CPT) in treating posttraumatic stress disorder (PTSD), depression and anxiety among Syrian refugees who have experienced war trauma. Clinicians interviewed 94 patients and asked them to complete the Clinician-Administered PTSD Scale three times: pretreatment, posttreatment and at the 12-month follow-up. In addition, PTSD, depression and anxiety were assessed using the PTSD Checklist, Beck Depression Inventory and Beck Anxiety Inventory at pretreatment, weekly, posttreatment and 12-month follow-up. At posttreatment evaluation, CPT led to decreases in PTSD, depression and anxiety (Ps < 0.000). These decreases continued after a year of follow-up (Ps < 0.000). Among Syrian refugees, the symptoms of PTSD, depression and anxiety all showed significant improvement after receiving CPT.
Keywords: anxiety, cognitive processing therapy (CPT), depression, posttraumatic stress disorder, Syrian refugees
This study suggests that cognitive processing therapy (CPT) has a significant therapeutic effect in the treatment of posttraumatic stress disorder (PTSD) in war-traumatised Syrian refugees.CPT appears to help in the treatment of depression and anxiety in war-traumatised Syrian refugees.CPT is a successful treatment for PTSD in war-traumatised Syrian refugees who have suffered several and severe losses, deprivation, challenges and tragedies. Introduction Posttraumatic stress disorder (PTSD) is a type of trauma and stress disorder that may develop after experiencing or witnessing a stressful, frightening or life-threatening experience, such as combat, catastrophes or sexual assault. PTSD is characterised by intrusive, avoidance and hyperarousal symptoms, and negative alterations in cognitions and mood (American Psychiatric Association, 2013). Psychological consequences of trauma could be in the form of the body’s aches and pains, emotional suffering, destructive thoughts and/or destructive behaviours (Fernandez & Kerns, 2012, Fernandez et al., 1999). Suffering caused by trauma may negatively impact a person’s quality of life which can be manifested as a deterioration in his/her activities, feeling guilty, ashamed and unworthy and having destructive thoughts and behaviours about self, others and the world (Kilpatrick et al., 2013). Patients with PTSD may have psychological comorbidities like depression, anxiety and substance use, interpersonal difficulties and/or suicidal behaviours (Beni et al., 2020; Reavell & Fazil, 2017; Salari et al., 2017).
Since 2011, the Syrian civil conflict has forced millions of people from their homes to neighbouring nations as a result of its atrocities and violence. Egypt is ranked as one of the world’s top refugee-hosting countries (UNHCR, 2021). Syrian refugees have endured a great deal as a result of the conflict and the slaughter preceding it. Their experiences may contribute to the development of significant mental diseases such as depression, anxiety and PTSD (Kandemir et al., 2018; Soykoek et al., 2017; Tinghög et al., 2017).
According to research, PTSD is frequent among Syrian refugees in Turkey, Lebanon and Germany (Acarturk et al., 2021; Alpak et al., 2015; Kazour et al., 2017; Mahmood et al., 2019; Mellor et al., 2021). Syrian refugees may be approximately 10 times more prone to suffer from PTSD and other mental diseases than the average population (Peconga & Høgh Thøgersen, 2020).
Kira et al. (2017) investigated the long-term impact of trauma on 196 Syrian refugees living in Cairo, Egypt. The prevalence of PTSD was 33.5%, and depression was >30%; comorbidity was substantial, with a high likelihood of suicide thoughts or attempts (13.7%). Also, the prevalence of depression-level symptoms in a study among the Syrian refugees living in Canada (n = 1924) was 15% at baseline and 18% in year 2 (P < 0.001; Ahmad et al., 2021).
Syrian refugees have an elevated risk of depression and anxiety as a result of the Syrian conflict (Scherer et al., 2020). Peconga and Høgh Thøgersen (2020) conducted a systematic evaluation of peer-reviewed literature that included data on the prevalence of PTSD, depression and anxiety in adult Syrian refugees. They explained that based on data from 8176 adult Syrian refugees resettled in 10 countries, the prevalence of PTSD was 43.0%, depression was 40.9% and anxiety was 26.6% in adult Syrian refugees. Another study conducted by Acarturk et al. (2021) determined the frequency of anxiety, depression and PTSD symptoms in Syrian refugees in Turkey (n = 1678). They discovered that anxiety, depression and PTSD symptoms were prevalent in 36.1%, 34.7% and 19.6% refugees, respectively. Also, in a study conducted by Khader et al. (2021) to determine the frequency of depression and anxiety in 1773 Syrian adolescent refugees, they discovered that around 28.3% of Syrian adolescent refugees suffered from depression. Male teenage refugees exhibited anxiety at a rate of 19%, while female adolescent refugees exhibited anxiety at a rate of 27.3%.
Cognitive behavioural therapy with a trauma focus, cognitive processing therapy (CPT), cognitive therapy, eye movement desensitisation and reprocessing and prolonged exposure (PE) have been shown to have the greatest evidence for psychological treatments for PTSD (Bisson & Olff, 2021).
The American Psychological Association (APA) established treatment recommendations for PTSD. The guidelines are a collection of advice for therapists who work with people suffering from PTSD. The APA and VA/DoD Clinical Practice Guideline Working Group both endorsed CPT and PE therapy as first-line treatments for comorbid PTSD (American Psychological Association, 2017; VA/DoD Clinical Practice Guideline Working Group, 2017).
We selected CPT to treat PTSD, since it is a very effective and well-established therapy that does not rely on phases (Chard, 2005; Resick et al., 2008; Resick et al., 2017). According to randomised clinical trials, CPT is effective in the treatment of PTSD, having the high impact and effect size of PTSD therapy (Bohus et al., 2020; Lewis et al., 2020). CPT is a 12-session treatment for trauma that focuses on confronting faulty trauma-related thought patterns and emotions (Resick et al., 2016).
While Syrian refugees with PTSD endure severe distress, impairment and a difficult clinical course, there are major gaps in the data about viable treatment choices. Thus, the purpose of this study is to examine the efficacy of CPT in treating PTSD, depression and anxiety among Syrian refugees who have experienced war trauma. The current study appears to be unique research in implementing CPT with Syrian refugees and contributes to the body of knowledge in this area.
MethodsDesign
The current study is a clinical trial, including the repeated assessments of a single sample of Syrian patients. Pretreatment, weekly, posttreatment and 12-month posttreatment assessments were conducted on participants. PTSD severity, depression and anxiety were all assessed as outcomes.
Population and Study Sample
Patients sought therapy for their personal discomfort and emotional sorrow at Cairo’s Safwat Elgolf Hospital. All of the patients were Syrian refugees.
Inclusion criteria were as follows: 1) being a Syrian refugee who witnessed the Syrian war, lives in Egypt and is traumatised as a result of the war; 2) age >18 years and <65; 3) patients meeting current diagnostic criteria for PTSD as defined in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5 (American Psychiatric Association. (2013); and 4) having a good knowledge of English language because all assessments and therapy materials were in English. Exclusion criteria were having: 1) cognitive difficulties and 2) schizophrenia (or any other psychotic disorders).
The study was conducted between January 2017 and December 2020. All patients’ data and demographic information were stored at a secure location at the Safwat Elgolf Hospital. The trial did not take place at the same time for all patients. It was a cumulative study; each patient attended therapy for an average of 3 months before being invited to return after a year to follow-up and assess his mental status.
Setting
The study was conducted at the Safwat ElGolf Hospital, psychiatry department, Cairo, Egypt.
Ethics Statement
The study was approved by the Institutional Review Board of the British University in Egypt (IRB Protocol CL-20-21). The study was registered in Clinical Trials (ClinicalTrials.gov; Identifier: NCT05031728) with all details about the group of the underlying investigation. According to the Declaration of Helsinki, the study was conducted in strict conformity with all human subject protections. The patients signed the participants’ information sheet and consent form. Participants were informed that the experiment included psychological assessments for PTSD, depression and anxiety, and a treatment protocol.
Study Hypotheses
The null hypotheses of this study are: first, there is no significant change in patients’ PTSD scores before, after and 12-months after participating in CPT. Second, there is no significant change in patients’ depression scores before, after and 12-months after participating in CPT. Third, there is no significant change in patients’ anxiety scores before, after and 12-months after participating in CPT.
Study Therapists
The therapist who administered the CPT was a clinical psychologist. Two psychologists were on hand to aid with the therapy. All of them were certified CPT therapists.
Study Interventions
CPT is a manual-guided therapy that employs cognitive processing strategies to alleviate PTSD symptoms (Resick et al., 2016). Each session lasts between 45 and 50 minutes and takes place once a week for 12 weeks. The therapy sessions were structured as follows: the CPT therapist begins by teaching the patient about PTSD and outlining the treatment protocol and reasoning for success. They were asked to write an impact statement outlining their interpretation of the occurrence. Clients were instructed on how to distinguish between events, ideas and emotions, as well as the relationships between them. Through the use of Socratic questions, self- and/or other-blame ideas and other distortions of the circumstance were addressed. Clients were taught how to identify and combat negative thought patterns, as well as how to communicate in a more balanced manner. Clients were invited to examine negative thinking patterns associated with five themes: safety, trust, power/control, self-esteem and intimacy. In the final sessions, their impact statements were revised to incorporate emotional and cognitive insights gained during the CPT.
Supervision and Fidelity
More than half of the recordings of CPT sessions were examined by an expert supervisor for conformity to the guidelines (Resick et al., 2016). The therapists and the supervisor met regularly during the study. There was more supervision offered if manual compliance did not meet the competency criteria. Supervisor fidelity was defined using the Adherence Rating Scale (ARS) for CPT developed by Dittmann et al. (2017). Fidelity was defined as the overall rating of the therapist’s adherence to the manual of ARS on the following scale (0, not adherent to the manual; 1, great deviation; 2, minor deviations and 3, very adherent to the manual). On the basis of past research, we established the cut-off score of two and above as the threshold for sufficient adherence and competency (Marques et al., 2019).
Measures
Throughout the study duration, participants met weekly with clinical psychologists and were required to complete weekly PTSD Checklist (PCL-5), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI) assessments while waiting for their CPT sessions. Additionally, a professional assessor conducted an assessment and requested that patients complete the Clinician-Administered PTSD Scale (CAPS-5), BDI-II and BAI before, during and 12 months following the treatment.
Patient Demographics
Personal information was gathered from participants, including sociodemographic, family-related, social, financial and academic information.
Scales Used
Clinician-Administered PTSD Scale
CAPS-5 (Weathers et al., 2015) is currently the gold standard assessment for PTSD and is used to assess PTSD symptoms at pre- and posttreatment, and 12 months afterwards. This 30-item structured interview was developed by the staff at the US Department of Veterans Affairs National Centre for PTSD. The interview can generally be administered in 45 to 60 minutes. Each question in CAPS-5 asks about both the frequency and the severity of each PTSD symptom. These questions are split into categories. Each criterion has several questions, and scores for each criterion are added up at the end. The CAPS-5 has demonstrated strong psychometric properties (Weathers et al., 2018). In the present study, CAPS-5 demonstrated strong inter-rater reliability (к = 0.88). A random sample of 35 tapes was selected for evaluation of inter-rater reliability for the CAPS-5. Categorical diagnostic analyses revealed that the kappa coefficient (к) for the overall PTSD diagnosis was 1.00 with 100% agreement. Kappa values and percentages of agreement for each of the three clusters of PTSD symptoms were as follows: re-experiencing (κ = 0.91; 94% agreement), avoidance (κ = 0.88; 89% agreement) and arousal (κ = 0.84; 89% agreement). Also, in the current sample, internal consistency (Cronbach alpha) across subscales were excellent at both time points (α = 0.90 and 0.92).
PTSD Checklist
By using the 20 items on the PCL-5 scale, PTSD symptoms were assessed. Individuals self-reported their experience with PTSD symptoms as outlined in DSM-5 using the PCL-5 scale (Weathers et al., 2013). On a five-point Likert scale, items range from zero (not at all) to four (extreme). Items in each of the four PTSD symptom clusters (intrusions, avoidance, negative cognitions and mood and changes in arousal and reactivity) were added together to create scores. According to the evidence, a five to 10-point change in PCL-5 reflects a reliable change, and a 10 to 20-point shift implies a clinically relevant change (Weathers et al., 2013). Psychometric parameters of the PCL-5 have been shown to be acceptable (Sveen et al., 2016). Internal consistency was adequate at both time points in the current experiment (α = 0.80 and 0.90).
Beck Depression Inventory
BDI-II was used to evaluate the severity of depressive symptoms. BDI-II is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression (Beck et al., 1996). The BDI-II takes approximately 10 minutes to complete. Depression levels were defined as follows: minimal range = zero to 13, mild depression = 14 to 19, moderate depression = 20 to 28 and severe depression = 29 to 63. The BDI-II has demonstrated good reliability and validity (Beck et al., 1996). Cronbach alpha was excellent at pre- and posttreatment in the present study (α = 0.90 and 0.91, respectively) and 1-week test–retest stability was high (0.90).
Beck Anxiety Inventory
BAI is a brief measure of anxiety with a focus on somatic symptoms of anxiety such as nervousness, dizziness and inability to relax (Beck et al., 1988). It has a total of 21 items that takes approximately 10 to 15 minutes to complete. Answers are on a four-point Likert scale and range from zero (not at all) to three (severely). The values for each item are summed yielding an overall or total score for all 21 symptoms that can range between zero and 63 points. A total score of zero to seven is interpreted as a “minimal” level of anxiety, eight to 15 as “mild”, 16 to 25 as “moderate” and 26 to 63 as “severe” (Beck & Steer, 1990). The reliability of BAI: internal consistency for the BAI = (Cronbach α = 0.89). Test–retest reliability (1 week) for the BAI was = 0.86.
Procedure
Each patient completed the CAPS-5 at the time of admission. PTSD was diagnosed using DSM-5. Patients gave their consent to take part in the study. The CAPS-5 was administered to patients three times: pretreatment, posttreatment and at the 12-month follow-up. Additionally, PTSD was evaluated pretreatment, weekly, posttreatment and 12 months later using the PCL-5. The BDI-II and BAI were used to measure depression and anxiety at pretreatment, weekly, posttreatment and 12 months afterwards. To encourage patient attendance, each patient was given 250 EGP (250 EGP = 20 USD) for each session (see [Figure 1]).
Notably, although the evaluations and CPT materials were supplied in English, the patients recorded their thoughts and emotions and performed their assignments, homework assignments and tasks in Arabic. Socrates conversations were conducted in Arabic to discuss the patients’ thoughts and cognitions
Outcome Measures
The key outcome measures were: CAPS-5 scores, PCL-5 scores, BDI-II scores and BAI scores. It was determined that the sample size was large enough to detect meaningful differences in primary outcomes using SPSS Sample Power (IBM Corp. Armonk, N.Y.) A two-tailed test of significance, a desired power of 0.8 and an unstructured covariance matrix were used. The correlation coefficient was 0.50 between the repeated assessments and there was a 5% margin of error and a 30% attrition rate from pretreatment to posttreatment. We estimated that the attrition rate would be 30% based on the previous studies (e.g., Gustavson et al., 2012; Hui et al., 2013). With 50 patients, the study has 80% power to detect a treatment difference with a mean effect size of 0.65.
Data Analysis Strategy
The sociodemographics of the sample were described using descriptive statistics (frequencies and percentages).
All analyses were conducted on the sample that was intended to be treated. Generalised estimating equations (GEEs) were used to analyse PTSD, depression and anxiety outcomes (Ballinger, 2004). A temporal within-subjects autoregressive correlation matrix was used to represent people across time points according to the distributions of the outcome measures (Zeger & Liang, 1986). To model CAPS-5, PCL-5, BDI-II and BAI severity ratings, normal distribution identity link functions were used. GEE was used as it extends the generalised linear model, which processes corresponding data from repeat measurements, needs no assumption of parametric distribution and robust inference for an incorrect description of the internal correlation of subjects and has good indications to the within-subject correlations (Zeger et al., 1988). For this reason, findings are provided using parameter estimates for CAPS-5, PCL-5, BDI-II and BAI. Effects with a level of at least (i.e., α < 0.10) were reported (Schneier et al., 2012) and to reduce the probability of type II errors (Selvin, 1996). PTSD, depression and BAI outcomes were all corrected with Bonferroni corrections to exclude type I error. All simple and main effects were deemed significant at the P < 0.01 level of statistical significance (two-tailed). Missing data in significant models were further evaluated using sensitivity analyses with multiple imputations.
ResultsA total of 94 patients met DSM-5 criteria for having current PTSD. All patients’ traumas were caused by the war in Syria. Out of the 94 patients who enrolled in the current study, only 88 patients completed 12-months posttreatment assessments.
Demographic and Baseline Characteristics
[Table 1] shows the demographic and descriptive characteristics of patients at the baseline assessment.
Adherence to Treatment
The fewest number of CPT sessions that the patients attended was nine sessions.
Posttraumatic Stress Disorder
The first research question was if there was a change in patients’ PTSD scores before, after and after 12 months of CPT participation.
As shown in [Table 2], CAPS-5 scores decreased significantly from baseline to end-of-treatment (CPT: M difference = −14.8, 95% confidence interval [CI]: −15.4–−14.2, P < 0.000 and d = 0.9) which were sustained at 12-month follow-up (CPT: M difference = −16.2, 95% CI: −17.3–−15.1, P < 0.000 and d = 0.9). The effect sizes were calculated in line with Feingold (2009) criteria for GEE-based models, and they may be classed as large for posttreatment and 12-month follow-up (Cohen, 1977).
Table 2 Intent-to-Treat Differences in Observed Means of PTSD, Depression and Anxiety Outcomes at Pretreatment, Posttreatment and 12-Month Follow-Up with Model-Based Treatment EffectsAs shown in [Table 2], scores on subscales of CAPS-5 (intrusions, avoidant, cognitive changes and arousal) decreased significantly from baseline to end-of-treatment (Ps < 0.000) which were sustained at 12-month follow-up (Ps < 0.000).
Differences in the number of patients who obtained clinically meaningful improvement, as defined by a 15-point decline in CAPS-5 total score, added to these findings (Weathers et al., 2001). At posttreatment, 32% of patients met this criterion. At 12-month follow-up, the patients maintained a higher rate of improvement (48%).
Depression
The second research question was if there was a change in patients’ BDI-II scores before, after and after 12 months of CPT participation.
As shown in [Table 2], BDI-II scores decreased significantly from baseline to end-of-treatment (CPT: M difference = −8.7, 95% CI: −9.3–−8.1, P < 0.000 and d = 0.8) which were sustained at 12-month follow-up (CPT: M difference = −10.3, 95% CI: −12.5–−8.2, P < 0.000 and d = 0.4).
Anxiety
The third research question was if there was a change in patients’ BAI scores before, after and after 12 months of CPT participation.
As shown in [Table 2], BAI scores decreased significantly from baseline to end-of-treatment (CPT: M difference = −3.7, 95% CI: −4.2–−3.2, P < 0.000 and d = 0.6) which were sustained at 12-month follow-up (CPT: M difference = −4.1, 95% CI: −4.9–−3.4, P < 0.000 and d = 0.5).
DiscussionThe purpose of this study was to examine the efficacy of CPT in treating PTSD, depression and anxiety among Syrian refugees who have experienced war trauma. Our results demonstrated the efficacy of CPT in reducing the symptoms of PTSD, depression and anxiety among Syrian refugees living in Egypt who have undergone war trauma. The patients’ PTSD, depression and anxiety were evaluated before, following and 12 months after therapy. The findings support the hypothesis that CPT is an effective method for controlling and potentially curing PTSD and associated disorders.
Gradual improvement has been noted within the population through self-report and clinicians’ assessments and observations. And drastic improvements have been reported through the periodic psychometric assessments stated. Through weekly sessions following CPT guidelines for 12 weeks, all committed patients showed reduced symptoms of PTSD, anxiety and depression. They gained a collective ability to view traumatic situations differently, gained greater power in their lives and regulated and coped with the intense emotions they continuously encounter because of traumatic experiences.
This pattern of result is consistent with previously conducted studies (e.g., Bohus et al., 2020), once again confirming that CPT is a highly recommended tool for treating PTSD. The findings strongly suggest that CPT has identified significant improvements as well as time and resource savings. Through 12 sessions of CPT, tangible improvements took place that positively altered the profound effects of traumatic experiences of the sample.
Our findings are consistent with previous research that has revealed substantial impacts of CPT for PTSD and other comorbid problems in torture survivors and refugees recruited expressly for PTSD (e.g., Hinton et al., 2004; Schulz et al., 2006b). Further, Schulz et al. (2006a) discovered that CPT+A (involving writing an account of the trauma) was successful in treating PTSD in foreign-born refugees to the United States when provided in their original language in a study of nonveterans. The refugees had an average of 17 sessions, which included numerous assessments before therapy began. The results demonstrated that the refugees’ self-reported PTSD symptoms had significantly improved.
Our data show a relationship between CPT as a method and the health of the participants. By the end of the study, participants in the clinical trial had a better understanding of PTSD as a disorder and could see the link between the traumas they had encountered and their intense emotions. They also reported feeling less distressed about their trauma memories and being able to recollect the events with a more objective perspective. The use of harmful coping mechanisms such as suppression, numbness and avoidance decreased significantly, and participants were able to intentionally establish healthier coping methods such as speaking out their emotions and thoughts. They reported fewer emotions of stress, depression, anxiety, guilt and shame. Overall, CPT has helped all participants improve their daily lives as well as their capacity to be present in the present moment.
It is important to note, however, that the present study has a few significant limitations. First, because the sample size was so small, larger randomised controlled investigations on the therapeutic efficacy of CPT in similar groups are required to corroborate the current findings. Second, to compare the outcomes of the current investigation, a control group was required. It is also necessary to point out that the population’s mother tongue is Arabic and all assessments administered were in English. Although all participants have a good command of English, it would have been much more effective if the assessments conducted were in Arabic. It is also essential to mention that the sample could be described as “privileged” in the sense that they currently have their physiological needs intact and have access to mental health services; therefore, the study’s results could not be generalised to the international Syrian refugee population. However, the results could be generalised to Syrian refugee populations sharing the same conditions.
Despite these limitations, the results obtained from the current study suggest a very significant approach in treating and tackling patients that suffer from PTSD, suggesting both theoretical and practical implications. Although this study supports and states an important practical implication in treating anxiety, depression and most importantly PTSD, it still raises a variety of intriguing questions for further studies. In terms of future research, it would be highly beneficial to extend the current study by examining prevalent patterns within the Syrian refugee population and the symptoms or phenomenon experienced exclusively by them. The Syrian civil war has been an ongoing humanitarian crisis the world has been witnessing for over a decade now, and it is important to shed light on the distinctive clinical manifestation the population is experiencing as the traumas they have faced will be intergenerationally passed down to future generations. It is our responsibility as researchers to expose threats to try and minimise the effects of this crisis. It is also crucial to shed light on complementary alternative modalities and techniques that could be used in parallel to optimise symptom management. It is important to dig deeper and hope for full treatment and transformation rather than mere symptom management.
Overall, the present study suggests and significantly contributes to the growing body of knowledge regarding the treatment of PTSD, anxiety, and depression. Our findings and outcomes offer valuable evidence for the application of CPT.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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