Epidemiologie, Psychotherapie, und Dissemination

Organized violence has lasting and devastating effects at the individual and community level. Previous studies in crisis regions, including Rwanda, have revealed grave consequences of violence on psychological functioning, as presented in Chapter 1. With the epidemiological study described in Chapter 2, we assessed mental health problems and needs in the post-war Rwandan society. We conducted a cross-sectional survey to examine widows and orphans, two vulnerable groups that are prominently affected during wars. In 2007, 13 years after the 1994 genocide, we trained Rwandan psychology students to conduct psycho-diagnostic interviews. Under expert supervision, they interviewed 406 genocide survivors in five districts of Butare (southern Rwanda) for socio-demographic and clinical variables. The instruments included an event-list adapted to the context of the Rwandan genocide, the validated version of the Posttraumatic Stress Diagnostic Scale (PDS) and the Hopkins Symptom Checklist (HSCL-25), as well as the Prolonged Grief Disorder questionnaire (PG-13) and the Mini International Neuropsychiatric Interview (M.I.N.I.) suicide section C in Kinyarwanda. We recruited orphans from age 18 to 31 and widows without age restrictions. We found that the genocide victims had experienced on average 11.3 different types of potentially traumatic events during their lifetime. Most of them related to the genocide, such as expectation to die (89.9%), forced movement (89.7%), and forced to hide to be saved (88.9%). The most common worst life events were the genocide in general, sexual violence, and witnessing murder or massacre. Mental health problems were very frequent in the sample with 34.7% suffering from Posttraumatic Stress Disorder (PTSD), 7.9% Prolonged Grief Disorder (PGD), 40.9% Major Depression (MD), 50% Anxiety Disorder (AD), and 38.2% suicide ideation. The vulnerability of widows was higher on average. The sum of experienced traumatic event types was the best indicator for an increased risk to suffer from clinically relevant symptoms. At the time of interview, only 5.4% of all participants received professional psychological help.Mental health problems, in particular PTSD, are a major issue in post-conflict countries. I discuss general intervention approaches and specific psychotherapy of trauma-spectrum disorders adequate for application in post-war countries in Chapter 4. The great number of victims resulting from organized violence demands dissemination of effective short-term therapy to local human resources. I further present literature about the feasibility and effectiveness of trauma therapy dissemination for victims of organized violence. Accordingly, we performed a randomized controlled trial in Rwanda representing the second empirical study which, is described in Chapter 5. With the previously conducted cross-sectional epidemiological survey we had identified orphans and widows who had survived the 1994 genocide suffering from chronic PTSD. After a pre-test, we randomly assigned 76 genocide survivors to treatment or to a six-month waiting list (WL). In the first round of dissemination, clinical experts trained Rwandan Psychology graduates (B.A.) in Narrative Exposure Therapy (NET) and Interpersonal Therapy (IPT). The Rwandan Psychologists administered NET/IPT to the patients in the treatment group under constant expert supervision (first dissemination generation). In a second round of dissemination, we conducted a randomized trial to evaluate the train the trainer model. Skilled therapists, who had participated in the first round, trained and supervised a second generation of Rwandan psychologists to offer treatment to the WL group (second dissemination generation). We conducted evaluations before therapy and at three-, six-, and twelve-month follow-up interviews using the main outcome measures for PTSD, PGD, and MD. Participants of the first dissemination generation of NET/IPT therapists reported a significant reduction in PTSD symptoms (Effect Size (ES) = 1.48). Equally, NET/IPT in second dissemination generation was effective (ES = 1.15). PGD, MD, and suicidal tendency reduced substantially over time both in the NET/IPT and the WL group. Participants maintained and increased treatment gains at follow-up interviews. The results indicate that short-term trauma therapy can be disseminated in first and second generation to Rwandan graduates. It proved to be an effective intervention, which implies general feasibility in post-conflict societies. For a broader understanding of the project context, I present an overview of Rwanda s history and culture in the Annex