Vol:.(1234567890)

Journal of Immigrant and Minority Health (2020) 22:1320–1346https://doi.org/10.1007/s10903-020-01055-w

1 3

REVIEW PAPER

Efficacy of Psychological Interventions on Depression Anxiety and Somatization in Migrants: A Meta‑analysis

Daniela Sambucini1 · Paola Aceto2,3 · Edvaldo Begotaraj1 · Carlo Lai1

Published online: 25 July 2020 © The Author(s) 2020

AbstractMany studies reveal the effectiveness of different psychological interventions on the adult refugees reporting mental health distress. Aim of this metanalysis was to test the efficacy of different psychological treatments on the depressive, anxiety and somatization symptoms on refugees and asylum seekers. Fifty-two studies, since 1997 to 2019, were included in the sys-tematic review and 27 of those were included in the metanalysis. Studies providing a pre and post treatment methodological design were included. All treatments reported significant effects on the three outcomes. Qualitative observations showed a probability to have a significant pre-post treatment effects on trials with outcome of depression (56%), anxiety (44%), and somatization (42%). Cognitive behavioral treatment resulted the most effective treatment. The status of refugee compared to the status of asylum seeker seems to have a great effect on the effectiveness of the treatment.

Keywords Migration · Psychological intervention · Depression · Anxiety · Somatization

Introduction

Geopolitical migration caused the emergency to individuate an efficacy intervention for treating the traumatic symptoma-tology of the migrants [1]. The migrants often originate from countries with governate conditions of war or great poorness that increase the psychological distress [2, 3].

According UNHCR data of the 2015 the number of appli-cations for asylum increased in Europe more than doubling from 2013 [4, 5]; in this period 17 million of refugees and asylum seekers were outside their counties of origin [6].

From 2013 to 2015 Italy State responded positively to about 40% of asylum applications, a percentage that was lowered in 2016 [7].

The number of people in the world who suffer from politi-cal violence and war pursued by the war seems to grow by about 1% every year [8].

The nature of conflict changed in last 20 years consid-ering that the current war victims are civilians rather than combatants [3] causing a phenomenon of forced migration that represents, in many cases, the only option to survive. The forced migration, due to politics or war reasons pro-duces unmistakable psychological signs [5]. Migrants expe-rienced multiple stressful events before, during and after their travel: imprisonment, rape, ethnic cleansing, physical violence and torture. They often witnessed violence against or the death of loved ones [2]; persecutions, bereavement in their origin countries and discrimination in their host countries that contribute, successively, them to develop a “re-traumatization” post migration [5].

The exposure to interpersonal violence associated with emotional, sexual and physical abuse, torture and exploita-tion, and other atrocities committed in war, cause psycholog-ical distress that have strong impact on survivors life. Many psychological sequelae as destructive behaviors, substances misuse, self-harm, unsafe sexual practices and involvement in abusive relationship seems to be due to these traumatic conditions [9].

Moreover, forced migrants could experience deaths or suicides of their loved people, parents, kin, sons etc. These

Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s1090 3-020-01055 -w) contains supplementary material, which is available to authorized users.

* Carlo Lai carlo.lai@uniroma1.it

1 Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli, 1, 00185 Rome, Italy

2 A. Gemelli University Polyclinic, IRCSS Foundation, Rome, Italy

3 Sacred Heart Catholic University, Rome, Italy

1321Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

bereavements could expose the survivor migrant to thoughts of death, to a probability of exacerbation of the psychopatho-logical symptoms that could last many years, and also to suicidal attempts. For this reason, it seems very important to explore what happens after the death or the suicide of a significant other, so to provide a proper and ad hoc care [10]. According to this clinical issue, it is important the knowl-edge of the neurobiological factors that underlie the suicide risk. Recent findings [11] showed an association between a biological dysregulation with the suicide attempts. This dys-regulation has been interpreted as a compensatory mecha-nism that involves the prolactin and the thyroid hormones, useful to corrects the reduced central serotonin activity. In the next future this neurobiological correlate could be use-ful to individuate a suicide risk in the clinical practice [11]. The displacement’s perception, the events that caused the migration and the hostility in the host country post migration (culture shock), seem to decrease life expectancy, and pro-duce insecurity, isolation and poorness, causing the devel-opment of mental illness including anxiety, depression and somatization [5].

In the last 20 years many types of psychological treat-ments—combined or not with pharmacological treatment—have been applied in migrants showing to be efficient [8–12].

Nowadays there are different systematic reviews that summarize the great number of studies on the efficacy of psychological intervention to post-migration symptoms. However, the four metanalysis published in the last ten years are focused on specific post-traumatic stress disorder PTSD outcome. The large number of studies published on this field allowed to perform metanalysis on specific therapeutic approaches and on specific psychological dimensions.

Aim of the present study was to assess, in adult migrants, the outcome of the main psychological interventions on post migration specific symptomatology: depression, anxiety and somatization.

Method

Search Strategy and Data Sources

The present systematic review and metanalysis has been registered on the International Prospective Register of Sys-tematic Reviews (PROSPERO).

The literature search was conducted on health data base that included: Pubmed, Scholar, Psych INFO, Published International Literature on Traumatic Stress (PILOT). Addi-tional studies were identified by cross-referencing.

Inclusion Criteria and Selection of Studies

The search strategy was based on the following main search components: “migrants”, “refugees”, “asylum seekers” (alone and combined). All randomized controlled trials (RCT), multiple perspective cohort trials (MCT) and sin-gle perspective cohort trials (SCT) written in English and assessing psychological and/or pharmacological interven-tion with pre and post evaluation of depression, anxiety, somatization were considered eligible for inclusion. Only experimental groups investigating psychological interven-tions were considered for comparisons. The control groups were eliminated as they included waiting lists or usual treat-ments. Included studies had to report at least one quantita-tive measure of depression and/or anxiety and/or somatiza-tion assessed before and after treatment.

Data Extraction and Coding

A qualitative systematic review for all 52 studies was per-formed (Table 1).

In the first metanalysis a comparison between pre-treat-ment and post-treatment values was been performed for each outcome (depression, anxiety, somatization) differ-entiating the trials based on research design (RCT, MCT, SCT). When two or more measurement scales for the same outcome (for example Hamilton Depression Rating Scale and Beck Depression Inventory) were administered in the same trial, the more frequent scale among all trials included in the meta-analysis was considered. Further sub-analysis, were made dividing the trials according 3 variables: sta-tus (refugees, asylum seekers), provenance (Middle East, Africa, Asia, Latin America), and treatment (narrative expo-sition therapies-NET, cognitive behavioural treatment-CBT, Dynamic therapies, combined psychological treatments, combined pharmacological/psychological treatments). The metanalysis was performed when at least 4 trials were homo-geneous for the considered variables.

Heterogeneity

Evaluation of heterogeneity was reported by the RevMan5.3 program. When the heterogeneity was high (despite the sig-nificance of the result), further sub-analysis (status, prov-enance, single treatment) were made.

Mean Differences

Pre and post intervention data of all the experimental treatments (within group) were inserted to calculate the means difference. For each trial mean difference, standard

1322 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

Des

crip

tion

of th

e 27

/52

studi

es c

onsi

dere

d in

the

met

anal

ysis

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[13]

Aca

rturk

(2

015)

Yes

1 m

mC

BT

(EM

DR

)W

CL(

no

treat

men

t)29 15 14

Refu

gees

Siria

TEI

PTSD

Dep

ress

ion

IES-

RB

DI I

IC

BT

(EM

DR

)7

sess

ions

, 90 

min

, w

eekl

y

PTSD

Dep

ress

ion:

sign

ifica

ntly

lo

wer

. rem

is-

sion

mai

n-ta

ined

[14]

Aca

rturk

(2

016)

Yes

1 m

mC

BT

(EM

DR

Foc

us re

cent

tra

uma

prol

onge

d at

pr

esen

t tim

e)W

CL

(no

treat

men

t)

98 49/3

749

/33

Refu

gees

Siria

TEI

PTSD

Dep

ress

ion

Neu

rops

y-ch

iatri

c sy

mpt

oma-

tolo

gy

HTQ

IES-

RB

DI-

IIH

SCL

25M

INI

CB

T (E

MD

R)

4 se

ssio

nsPT

SDD

epre

ssio

nIm

pact

eve

ntsi

gnifi

cant

ly

sym

ptom

s re

duce

d, a

fter

1 m

onth

mai

n-ta

ined

[15]

Ade

naue

r (2

011)

Yes

4 m

mN

ET (W

rited

by

ther

apist

s an

d re

adin

g hi

gh v

oice

to

subj

ect)

WLC

(no

treat

men

t or

antid

epre

ssan

ts)

34 16/1

118

/8

Refu

gees

Asy

lum

se

eker

s

PTSD

Dep

ress

ion

Dys

timya

Neu

roco

r-re

late

s

MEG

-ssV

EFC

SIC

WD

TECA

PSH

AM

-DM

INI

NET

12 se

ssio

ns, 1

08 m

in,

wee

kly

or b

iwee

kly

PTSD

Dep

ress

ion

sign

ifica

nt

effec

tiven

ess

sign

ifica

nt

Cha

ngin

g of

th

e ne

ural

co

rrel

ates

of

the

proc

essi

ng.

NET

incr

ease

d oc

cipi

tal a

nd

parie

tal a

ctiv

-ity

Afte

r 4 m

m.

mai

ntai

ned

1323Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[16]

Buh

man

n (2

016)

Yes

2 m

m4 

mm

6 m

m8 

mm

CB

T (c

omm

itmen

t the

rapy

an

d m

indf

ulne

ss a

nd

visu

al e

xpos

ition

)C

ombi

ned

Psy

(CB

T an

d ps

ycho

educ

atio

n an

d an

tidep

ress

ants

Com

bine

d Ph

a (p

sych

oe-

duca

tion

and

sertr

alin

e or

m

ians

erin

eW

LC (n

o tre

atm

ent)

280

70/5

271

/62

71/5

568

Refu

gees

Iraq

Iran

Leba

non

Yug

osla

via

Afg

hani

stan

PTSD

Anx

iety

Dep

ress

ion

Som

atiz

a-tio

nSt

ress

Pani

cIn

abili

tyPs

y-ch

ofisi

cal

HTQ

HSC

L25

SCL9

0H

AM

-DH

AM

-AVA

SSD

SW

HO

-5

CB

T16

sess

ions

, wee

kly

Com

bine

d ps

y4

sess

ions

, wee

kly

Com

bine

d ph

a 8

ses-

sion

s, w

eekl

y

Dep

ress

ion:

tre

atm

ent w

ith

antid

epre

ssan

t in

com

bina

-tio

n ps

ycho

e-du

catio

n w

as

asso

ciat

ed w

ith

sign

ifica

nt

decr

ease

and

si

gnifi

cant

ly

decr

ease

in

patie

nts r

ecei

v-in

g m

edic

ine

Anx

iety

: sig

nifi-

cant

effe

ct o

f m

edic

atio

n[1

7]C

arls

son

(201

8)Ye

sC

ombi

ned

Pha

(CB

T SM

fo

r acq

uire

cop

ing

skill

s, re

lax,

div

ided

atte

ntio

n,

beha

vior

al a

ctiv

atio

n)

and

phar

mac

olog

ical

(m

ians

erin

or s

ertra

line)

an

d ps

ycho

tera

pyC

ombi

ned

Pha

(CB

T C

R

psyc

hoed

ucat

ion,

cog

ni-

tive

rebu

ildin

g of

neg

ativ

e id

eas.)

and

pha

rmac

olog

i-ca

l (m

ians

erin

or s

ertra

-lin

e) a

nd p

sych

othe

rapy

TAU

140

62/5

364

/52

Refu

gees

Afg

hani

stan

Yug

osla

via

Iran

Iraq

Le

bano

n

PTSD

Pani

c,A

nxie

tyD

epre

ssio

nSo

mat

iza-

tion

Wel

lbei

ngD

isab

ility

,Fu

nctio

ning

;Sy

mpt

oma-

tolo

gy

HTQ

HSC

L 25

HA

M D

HA

M A

SCL

VAS

WH

OSD

SG

AF

SG

AF

F

Com

bine

d Ph

a(S

M a

nd C

R)

24 se

ssio

ns, a

nd

10 se

ssio

ns w

ith

med

ical

doc

tor,

16

sess

ions

with

psy

-ch

othe

rapi

st. 6

0 m

in

biw

eekl

y

PTSD

Som

atiz

atio

nFu

nctio

ning

Dis

abili

ty:

CR

sign

ifica

nt

effec

tD

epre

ssio

nA

nxie

tySo

mat

izat

ion:

SM si

gnifi

cant

eff

ects

Anx

iety

: bet

a si

gnifi

cant

1324 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[18]

Hen

sel-

Ditt

man

n (2

011)

4 w

w6 

mm

12 m

m

NET

(Req

uire

d by

ther

a-py

sts a

nd c

orre

cted

by

subj

ect w

ith re

adin

g)C

BT

(SIT

: cog

nitiv

e be

havi

our s

emist

ruct

ured

in

terv

entio

n)

28 14/1

013

/10

Asy

lum

se

eker

sPT

SDD

epre

ssio

nN

euro

sym

p-to

mat

olog

y

CAPS

HA

M-D

MIN

I

NET

10 se

ssio

ns, 9

0 m

inC

BT

(SIT

)10

sess

ions

PTSD

Syg

-ni

ficat

ivel

y re

duct

ion

with

N

ETM

aint

aine

d at

6

and

12 m

m[1

9]H

ijazi

Ala

a (2

014)

Yes

2 m

m4 

mm

Brie

f NET

(Writ

e th

e th

erap

ists)

WLC

(no

treat

men

t)

63 41/3

922

Refu

gees

Iraq

PTSD

Dep

ress

ion

Post-

traum

atic

gr

owth

Psyc

holo

gi-

cal w

ellb

e-in

gSy

mpt

oma-

tolo

gy o

f str

ess p

ost-

traum

atic

Som

atiz

a-tio

n

HTQ

PTG

IW

HO

5B

DI-

IIPH

Q-1

5

Brie

f NET

3 se

ssio

ns,

60–9

0 m

in, w

eekl

y

PTSD

Dep

ress

ion

Som

atiz

atio

n:Re

duct

ion

at 2

an

d 4 

mm

Wel

l bei

ng

impr

oved

at 2

an

d 4 

mm

1325Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[20]

Hin

ton

(200

4)22

ww

Com

bine

d Ph

a (I

mm

edia

te

CB

T an

d SS

RI,

benz

odi-

azep

ine,

gab

apen

tin)

Com

bine

d Ph

a (D

elay

ed

CB

T an

d SS

RI,

benz

odi-

azep

ine,

gab

apen

tin)

24 12 12

Refu

gees

Vie

tnam

PTSD

Dep

ress

ion

Anx

iety

Pani

cPs

ycho

-ph

ysic

al

sym

ptom

a-to

logy

HTQ

ASI

HSC

L 25

NPA

SSO

PASS

Com

bine

d Ph

a im

med

iate

CB

T 11

se

ssio

nsC

ombi

ned

Pha

dela

yed

CB

T st

arte

d af

ter 1

1 se

ssio

ns fo

r an

othe

r 11

sess

ions

PTSD

Dep

ress

ion

Anx

iety

:Im

prov

emen

t si

nce

1 as

sess

-m

ent t

o 2

asse

ssm

ent f

or

imm

edia

te a

nd

RET

and

trea

t-m

ents

. Ass

ess-

men

t sin

ce 1

to

3 si

gnifi

cant

im

prov

emen

tPs

ycho

phys

ical

sy

mpt

omat

ol-

ogy,

impr

ove

sign

ifica

ntly

1326 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[21]

Hin

ton

(200

5)28

ww

Com

bine

d Ph

a(im

med

iate

C

BT:

and

SSR

I, C

lona

z-ep

am, s

ocia

l sup

port)

Com

bine

d Ph

a (d

elay

ed

CB

T: a

nd S

SRI,

Con

az-

epam

, soc

ial s

uppo

rt)

40 20 20

Refu

gees

Cam

bogi

aPT

SDA

nxie

tySo

mat

iza-

tion

ASI

CAPS

N-P

ASS

O-P

ASS

N-F

SSO

-FSS

SCL9

0R

Com

bine

d Ph

a im

med

iate

CB

T 12

se

ssio

nsC

ombi

ned

Pha

dela

yed

CB

T af

ter

12 se

ssio

ns fo

r an

othe

r 12

sess

ions

PTSD

Anx

iety

Pani

cO

rthos

tatic

pa

ram

eter

sFl

ashb

acks

:Si

gnifi

cant

gr

oup

effec

t, tim

e eff

ect a

nd

inte

ract

ion

Follo

w u

p:Si

gnifi

cant

tim

e eff

ect a

nd

grou

p eff

ect

and

time

inte

r-ac

tion

On

all m

easu

res

Imm

edia

te

grou

p ha

s si

gnifi

cant

lo

wer

scor

es a

t se

cond

ass

ess-

men

t. D

elay

ed

CB

T im

prov

e-m

ent a

t 3

asse

ssm

ent

1327Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[22]

Neu

ner

(201

0)Ye

s6 

mm

NET

(mor

e of

800

0 w

ords

w

ith su

perv

isio

n)C

BT

(Sta

biliz

atio

n or

ps

ycho

activ

e m

edic

atio

n an

d TF

T)

32 16 16

Turk

eyB

alka

nsA

fric

a

Dep

ress

ion

PTSD

Pain

PDS

CID

IH

SCL2

5CA

PSV

COV

NET

and

CB

T (S

tabi

-liz

atio

n an

d TF

T)9

sess

ions

, 120

 min

, w

eekl

y an

d bi

wee

kly

PTSD

:Si

gnifi

cant

mai

n eff

ect t

ime

and

time

for

treat

men

t int

er-

actio

n. N

ET

sign

ifica

nt d

if-fe

renc

e w

ithin

an

d be

twee

n on

PTS

D, a

lso

to 6

 mm

Pain

::Si

gnifi

cant

tim

e fo

r tre

atm

ent

inte

ract

ion

[23]

Paun

ovic

(2

001)

6 m

mC

ombi

ned

Pha

(CB

T:

Expo

sitio

n an

d tri

cycl

ics

and

SSR

Is) o

r ben

sodi

-az

epin

es o

r neu

role

ptic

s or

mus

cle

rela

xant

s or

neur

olep

tic)

Com

bine

d Ph

a (C

BT:

ex

posi

tion

and

cogn

i-tiv

e th

erap

y an

d co

ntro

l br

eath

ing

and

tricy

clic

s an

d SS

RIs

or b

enso

di-

azep

ines

or n

euro

lept

ics

or m

uscl

e re

laxa

nts o

r ne

urol

eptic

)

40 20 20

Refu

gees

PTSD

Dep

ress

ion

Anx

iety

Even

t im

pact

Qua

lity

life

CAPS

IVH

AM

DH

AM

APS

S-SR

IES

RB

DI

STA

I-S

QO

LIW

AS

BAI

AD

IS

Com

bine

d Ph

aC

BT

Expo

si-

tion,

8 se

ssio

ns,

20–6

0 m

in, w

eekl

yC

BT,

16–

20 se

ssio

ns,

60–1

20 m

in, w

eekl

y

PTSD

Dep

ress

ion

Anx

iety

Even

t im

pact

Qua

lity

life:

CB

T si

gnifi

cant

, be

tter a

t pos

t te

st. B

oth

effica

cy w

ithin

on

all

mea

sure

an

d m

aint

aine

d at

follo

w u

p

1328 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[24]

Sonn

e (2

016)

Yes

Com

bine

d Ph

a (C

BT

and

man

ualiz

ed p

sych

othe

r-ap

y an

d so

cial

cou

nsel

ling

and

min

dful

lnes

s and

Se

rtral

ine

max

75 

mg)

Com

bine

d Ph

a (C

BT

and

man

ualiz

ed p

sych

othe

r-ap

y an

d so

cial

cou

nsel

ling

and

min

dful

ness

and

Venl

afax

ine

max

50 

mg)

Phar

mac

olog

ical

trea

tmen

t (s

ame

Sertr

alin

e)

207

108/

8898

/68

Refu

gees

Mid

dle

East

CPT

SDD

epre

ssio

nA

nxie

tySo

mat

iza-

tion

HTQ

HA

M D

HA

M A

HSC

L 25

SCL

90SD

SG

AF

GA

SVA

SC

SSW

HO

5

Com

bine

d Ph

a24

sess

ions

,10

sess

ions

med

ical

do

ctor

, 16

sess

ions

ps

ycho

logi

st

CPT

SDD

epre

ssio

nA

nxie

ty:

Goo

d re

sults

for

SSR

IFu

nctio

ning

:si

gnifi

cant

diff

er-

ence

with

in

for S

ertra

line

and

sign

ifica

nt

diffe

renc

es

betw

een

for

both

SAS

sign

ifica

nt

diffe

renc

es

both

with

inG

AF

S si

gnifi

-ca

nt d

iffer

ence

be

twee

n

1329Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[25]

Sten

mar

k (2

013)

Yes

1 m

m6 

mm

NET

(no

writ

ten)

CB

T (F

ocal

izat

ion

and

help

for p

sych

olog

ical

pr

oble

m)

81 51/3

830

/22

Refu

gees

A

sylu

m

seek

ers

Mid

dle

East

PTSD

Dep

ress

ion

Neu

rolo

gica

l st

ate

CAPS

HA

M D

MIN

I

NET

: 10

sess

ions

, 90

 min

CB

T (F

ocal

izat

ion)

: 10

sess

ions

86 

min

PTSD

Dep

ress

ion:

Bot

h re

fuge

es

and

asy-

lum

seek

-er

s red

uced

th

eir m

enta

l pr

oble

ms.

Bot

h tre

atm

ent

sym

ptom

ato-

logi

chal

redu

c-tio

n bu

t mor

e pr

onou

nced

for

NET

. Bet

wee

n gr

oup

at 6

 mm

no

sign

ifica

nt

effec

ts. C

APS

an

d H

AM

D

sign

ifica

nt

mai

n eff

ects

of

time

1330 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[26]

Ter H

eide

(2

011)

Yes

3 m

mC

BT

(Sta

biliz

atio

n: h

ere

and

now

on

traum

a m

emor

y)C

BT

(EM

DR

)

20 10/5

10/5

Refu

gees

A

sylu

m

Seek

ers

Afg

hani

stan

Alg

eria

Bos

nia

Turc

hia

Ang

ola

Leba

non

PTSD

Dep

ress

ion

Anx

iety

Qua

lity

life

Neu

rops

y-ch

iatri

c st

ate

HTQ

HSC

L 25

WH

OQ

OL

brie

fSC

DI 1

MIN

I 10

CB

T (S

tabi

lizat

ion

and

EMD

R)

11 se

ssio

ns, w

eekl

y an

d bi

wee

kly

PTSD

: sig

nifi-

cant

diff

eren

ce

betw

een

cond

ition

s, EM

DR

som

e im

prov

emen

t. Si

gnifi

cant

di

ffere

nces

be

twee

n tre

atm

ents

fo

r HSC

L-25

(a

nxie

ty a

nd

depr

essi

on)

and

WH

O-

QO

L, E

MD

R

impr

ovem

ents

[27]

Wan

g (2

017)

Yes

3 m

m6 

mm

Com

bine

d Ps

y im

med

iate

(C

BT

psyc

hoth

erap

y,

grou

p th

erap

y an

d m

ulti-

vita

min

ic)

Com

bine

d Ps

y de

laye

d:

cont

rol (

CB

T ps

ycho

ter-

apy,

gro

upth

erap

y de

laye

d af

ter 3

 mm

and

mul

tivita

-m

inic

imm

edia

te)

34 13 15

Asi

lum

se

eker

sK

osov

oPT

SDD

epre

ssio

nA

nxie

tyPa

nic

HTQ

HSC

L 25

SF.M

PQW

B F

AC

ES

PRS

WH

OD

AS

Com

bine

d Ps

yC

BT

10 se

ssio

ns,

90 m

in, g

roup

th

erap

y 10

sess

ion,

90

 min

wee

kly

PTSD

: Sig

nifi-

cant

the

effec

t of

inte

rven

tion

at 6

 mm

Pain

: at 3

 mm

Mul

tiple

pe

rspe

c-tiv

e co

hort

trial

s

1331Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[28]

Dro

zdek

(2

010)

Yes

6 m

m12

 mm

Com

bine

d Ps

y 3*

3C

ombi

ned

Psy

3*2

Com

bine

d Ps

y 2*

2D

ynam

ic: 1

*1C

ontro

l (Ph

arm

acho

logi

cal)

5 ph

ases

:1

norm

s, va

lues

of g

roup

tre

atm

ent,

psyc

hoed

uca-

tion,

alli

ance

, ass

essm

ent

of p

robl

ems,

treat

men

t go

als a

nd sy

mpt

oms

2 pr

esen

tatio

ns, d

amag

e co

re b

elie

fs, f

ear o

f los

s co

ntro

l, gu

ilt, s

ham

e,

grie

f, ac

know

ledg

emen

t, re

silie

nce

3 te

lling

the

traum

a sto

ry,

expo

sure

and

cog

nitiv

e re

struc

turin

g4

reco

nnec

ting

the

pres

ent

with

pas

t and

futu

re, d

am-

age

core

bel

iefs

, rol

es a

nd

iden

tity,

cop

ing

strat

egie

s, cu

rren

t wor

ries a

nd fu

ture

ou

tlook

, res

ilien

ce5

psyc

hoed

ucat

ion,

rela

pse

prev

entio

n, tr

eatm

ent

eval

uatio

n, fa

rew

ell r

itual

. (e

mpl

oyed

din

amic

and

be

havi

or te

cniq

ues)

88 34 19 11 6 18

Refu

gees

A

sylu

m

seek

ers

Iraq

Iran

Afg

hani

stan

PTSD

Dep

ress

ion

Anx

iety

Stre

ssPs

ycho

fisic

sy

mpt

oms

Psyc

hotic

sy

mpt

oms

HTQ

HSC

L-20

SLC

-90

Psy-

chot

icis

m

scal

e

Spec

ifica

lly:

Gro

up th

erap

y 58

ses-

sion

s, 90

 min

, dai

lyN

o ve

rbal

ther

apy

58 se

ssio

ns, 7

5 m

in,

daily

Com

bine

d Ps

y 3*

3N

o ve

rbal

psy

cho-

ther

apy,

3 se

ssio

ns

(psy

chom

otor

bo

dy th

erap

y, a

rt th

erap

y, m

usic

th

erap

y) G

roup

th

erap

y, 2

sess

ions

, 3 

days

 wee

kC

ombi

ned

Psy

3*2

sam

e th

ing

of 3

*3

but 2

 day

s wee

k)C

ombi

ned

Psy

2*2

psyc

hoth

erap

y 2

sess

ions

Gro

up th

erap

y 1

ses-

sion

s, 2 

days

 wee

kD

ynam

ic 1

*1Su

ppor

t, 48

sess

ions

, w

eekl

y

PTSD

Dep

ress

ion

Anx

iety

Psyc

hotic

ism

Com

bine

d 3*

3 an

d 3*

2 Si

g-ni

fican

t effe

ct

with

inPT

SD (

2*2)

Diff

eren

ces

betw

een

not

stat

istic

ally

si

gnifi

cant

1332 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[29]

Dro

zdek

(2

012)

Yes

12 m

mC

ombi

ned

Psy

3*3

Com

bine

d Ps

y 3*

2C

ombi

ned

Psy

2*2

WC

L (fo

r 6 m

m n

o tre

at-

men

t)5

phas

es:

1 no

rms,

valu

es o

f gro

up

treat

men

t, ps

ycho

educ

a-tio

n, a

llian

ce, a

sses

smen

t of

pro

blem

s, tre

atm

ent

goal

s and

sym

ptom

s2

pres

enta

tions

, dam

age

core

bel

iefs

, fea

r of l

oss

cont

rol,

guilt

, sha

me,

gr

ief,

ackn

owle

dgem

ent,

resi

lienc

e3

telli

ng th

e tra

uma

story

, ex

posu

re a

nd c

ogni

tive

restr

uctu

ring

4 re

conn

ectin

g th

e pr

esen

t w

ith p

ast a

nd fu

ture

, dam

-ag

e co

re b

elie

fs, r

oles

and

id

entit

y, c

opin

g str

ateg

ies,

curr

ent w

orrie

s and

futu

re

outlo

ok, r

esili

ence

5 ps

ycho

educ

atio

n, re

laps

e pr

even

tion,

trea

tmen

t ev

alua

tion,

fare

wel

l ritu

al.

(em

ploy

ed d

ynam

ic a

nd

beha

vior

tech

niqu

es)

71 27 22 7 16

Refu

gees

A

sylu

m

seek

ers

Iran

, Afg

h-an

izta

nPT

SDD

epre

ssio

nA

nxie

tySt

ress

Psyc

ho-

phys

ic

sym

ptom

s

HTQ

HSC

L20

SLC

90

Spec

ifica

lly:

Gro

up th

erap

y 58

ses-

sion

s, 90

 min

, dai

lyN

o ve

rbal

ther

apy

58 se

ssio

ns, 7

5 m

in,

daily

Com

bine

d Ps

y 3*

3N

o ve

rbal

psy

cho-

ther

apy,

3 se

ssio

ns

(psy

chom

otor

bo

dy th

erap

y, a

rt th

erap

y, m

usic

th

erap

y) G

roup

th

erap

y, 2

sess

ions

, 3 

days

 wee

kC

ombi

ned

Psy

3*2

sam

e th

ing

of 3

*3

but 2

 day

s wee

k)C

ombi

ned

Psy

2*2

psyc

hoth

erap

y 2

sess

ions

Gro

up th

erap

y 1

ses-

sion

s, 2 

days

 wee

k

PTSD

Dep

ress

ion

Anx

iety

Stre

ssPs

ycho

phys

ics

sym

ptom

sTh

e tre

atm

ents

w

ere

sign

ifi-

cant

but

2*2

no

t sig

nific

ant

effec

t on

PTSD

No

sign

ifica

nt

diffe

renc

e be

twee

n tre

at-

men

ts a

nd

treat

men

ts a

nd

cont

rol,

but

3*3

and

3*2

mor

e effi

cacy

of

2*2

1333Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[30]

Laks

hmi

Vija

ya-

kum

ar

(201

7)

Yes

6 m

m15

 mm

Dyn

amic

(CA

SP: e

mot

iona

l su

ppor

t con

tact

with

a

volu

ntar

y co

mm

unity

and

su

ppor

t of t

he p

lann

ing

card

s at m

omen

t of d

is-

tress

. Med

ical

doc

tor)

Con

trol

(to p

rovi

de th

e te

leph

one

num

ber t

hat c

an u

se fo

r su

ppor

tive

help

)

485

288/

139

187

Refu

gees

Tam

il N

adu

(Ind

ia)

Dep

ress

ion

Suic

ide

idea

-tio

nPT

SDA

lcoh

ol

abus

e

Bec

k SS

I (in

W

HO

)SU

PRE

MIS

SC

ESD

-RA

UD

ITPC

L

Dyn

amic

(CA

SP)

60 se

ssio

ns, 4

 mm

m

edic

al d

octo

r

PTSD

and

D

epre

ssio

n,

sign

ifica

nt

diffe

renc

es

betw

een

on,

and

redu

ce o

f 2

unite

s the

m

eans

of t

he

scor

es (s

igni

fi-ca

nt w

ithin

)[3

1]W

eins

tein

(2

016)

Yes

Dyn

amic

(Nee

d sa

tisfa

ctio

n B

asic

psy

chol

ogic

al n

eed

Relie

ves t

he fr

ustra

tions

lin

ked

to th

e au

tono

my

com

pete

nces

and

rela

tion-

ship

s nee

ds)

Con

trol:

no tr

eatm

ent

41 24 17

Refu

gees

Siria

Nee

d fr

us-

tratio

nPT

SDdi

tress

Dep

ress

ion

Psyc

holo

gica

l ne

ed sc

ale

PSS

CES

-DST

AI

17 it

ems s

elf

repo

rted

Dyn

amic

(Nee

d sa

tis-

fact

ion)

7 se

ssio

ns, 2

4 m

in,

daily

Dep

ress

ion

and

stres

s de

crea

sed

with

on

e w

eek

long

in

terv

entio

n bu

t not

sig-

nific

antly

and

al

levi

ated

nee

d fr

ustra

tion

Sing

le p

er-

spec

tive

coho

rt tri

als

[32]

Bru

ne

(201

4)C

ombi

ned

Pha

refu

gees

(p

sych

odyn

amic

and

C

BT

and

antid

epre

ssan

t, an

xiol

ytic

, hyp

notic

))C

ombi

ned

Pha

no le

gal s

ta-

tus (

psyc

hody

nam

ic a

nd

CB

T an

d an

tidep

ress

ant,

anxi

olyt

ic, h

ypno

tic))

190

121

69

Refu

gees

A

sylu

m

seek

ers

Yug

osla

via

Am

eric

a La

tina

Turc

hia

Afr

ica

Iraq

Russ

ia

Dep

ress

ion

Psyc

hoso

cial

di

stres

s

HA

M-D

CG

IC

ombi

ned

Pha

daily

,ph

arm

acol

ogi-

cal t

reat

men

t, 22

 mon

ths

Dep

ress

ion:

sig-

nific

ant r

esul

ts

at e

nd th

erap

y fo

r ref

ugee

s. Ps

ycho

soci

al

distr

ess:

no

sign

ifica

nt d

if-fe

renc

es w

ithin

an

d be

twee

n

1334 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[33]

Car

lsso

n (2

010)

9 m

m23

 mm

Com

bine

d Ps

y (p

sych

o-dy

nam

ic, s

ocia

l cou

n-se

lling

, phy

siot

hera

py,

med

ical

ass

istan

ce, s

ome

sero

toni

n)

69/6

2Re

fuge

esIr

aqD

epre

ssio

nA

nxie

tyD

istre

ssPT

SDQ

ualit

y lif

eEv

ent

impa

ct

HTQ

,H

AM

-DH

SCL2

5 W

HO

QO

Lbr

ief

Qua

lity

life:

si

gnifi

cant

di

ffere

nces

at

9 m

mA

nxie

ty: s

ig-

nific

ant d

iffer

-en

ces b

etw

een

9 an

d 23

 mm

Sign

ifica

nt

diffe

renc

es a

t 23

 mm

for a

ll m

easu

res i

n 1/

3 pa

tient

s[3

4]D

’Ard

enne

(2

007)

CB

T re

fuge

es in

terp

rete

r tra

uma

foca

lizat

ion,

ex

posi

tion)

CB

T re

fuge

es n

o in

terp

rete

r (tr

aum

a fo

caliz

atio

n,

expo

sitio

n)C

BT

asyl

um se

eker

s (tr

aum

a fo

caliz

atio

n,

expo

sitio

n)

112

36 31 45

Asy

lum

se

eker

sRe

fuge

es

PTSD

Even

t im

pact

Dep

ress

ion

Qua

lity

life

IES

BD

I Man

-ch

este

r sh

ort

asse

ssm

ent

qual

ity li

fe

CB

T (fo

caliz

atio

n,

expo

sitio

n)9.

1 se

ssio

ns, 6

0 m

in,

wee

kly

Dep

ress

ion:

si

gnifi

cant

di

ffere

nces

fo

r all

grou

ps,

mor

e in

asy

lum

se

eker

sEv

ent i

mpa

ct:

sign

ifica

nt d

if-fe

renc

es fo

r all

grou

ps, m

ore

for a

sylu

m

seek

ers

Qua

lity

life:

si

gnifi

cant

di

ffere

nces

for

refu

gees

no

inte

rpre

ter a

nd

asyl

um se

eker

s

1335Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[35]

Dro

zdek

(2

014)

12 m

m24

 mm

Com

bine

d Ps

y 3*

3C

ombi

ned

Psy

3*2

Com

bine

d Ps

y 2*

22

nonv

erba

l5

phas

es:

1 no

rms,

valu

es o

f gro

up

treat

men

t, ps

ycho

educ

a-tio

n, a

llian

ce, a

sses

smen

t of

pro

blem

s, tre

atm

ent

goal

s and

sym

ptom

s2

pres

enta

tions

, dam

age

core

bel

iefs

, fea

r of l

oss

cont

rol,

guilt

, sha

me,

gr

ief,

ackn

owle

dgem

ent,

resi

lienc

e3

telli

ng th

e tra

uma

story

, ex

posu

re a

nd c

ogni

tive

restr

uctu

ring

4 re

conn

ectin

g th

e pr

esen

t w

ith p

ast a

nd fu

ture

, dam

-ag

e co

re b

elie

fs, r

oles

and

id

entit

y, c

opin

g str

ateg

ies,

curr

ent w

orrie

s and

futu

re

outlo

ok, r

esili

ence

5 ps

ycho

educ

atio

n, re

laps

e pr

even

tion,

trea

tmen

t ev

alua

tion,

fare

wel

l ritu

al.

(em

ploy

ed d

ynam

ic a

nd

beha

vior

tech

niqu

es)

69/6

6(a

ll)Re

fuge

es

Asy

lum

seek

ers

Iran

Afg

han-

istan

PTSD

Dep

ress

ion

Anx

iety

HTQ

HSC

L20

Com

bine

d Ps

y 85

se

ssio

ns:

1 ph

ase

10 se

ssio

ns2

phas

e 20

sess

ions

3 ph

ase

10 se

ssio

ns4

phas

e 30

sess

ions

5 ph

ase

15 se

ssio

nsSp

ecifi

cally

:G

roup

ther

apy

85 se

s-si

ons,

90 m

in, d

aily

No

verb

al th

erap

y85

sess

ions

, 75 

min

, da

ilyC

ombi

ned

Psy

3*3

No

verb

al p

sych

o-th

erap

y, 3

sess

ions

(p

sych

omot

or

body

ther

apy,

art

ther

apy,

mus

ic

ther

apy)

Gro

up

ther

apy,

2 se

ssio

ns,

3 da

ys w

eek

Com

bine

d Ps

y 3*

2 sa

me

thin

g of

3*3

bu

t 2 d

ays w

eek)

Com

bine

d Ps

y 2*

2 ps

ycho

ther

apy

2 se

ssio

nsG

roup

ther

apy

1 se

s-si

ons,

2 da

ys w

eek

Dyn

amic

1*1

Supp

ort,

1 se

ssio

ns,

wee

kly

PTSD

, Anx

iety

, D

epre

ssio

n si

gnifi

cant

re

duct

ion

for

3*3

treat

men

tA

nxie

ty

sign

ifica

nt

diffe

renc

es in

re

fuge

es

1336 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[36]

Hal

vors

en

(201

0)1 

mm

6 m

mN

ET (n

o ve

rbal

exp

ositi

on

all t

raum

atic

eve

nt, t

he

biog

raph

y is

reco

rded

and

co

rrec

ted)

16Re

fuge

es

Asy

lum

se

eker

s

Afg

hani

stan

Eritr

eaK

osov

oEt

iopi

aIr

anSu

dan

Togo

Iraq

PTSD

Dep

ress

ion

CAPS

HA

M-D

Soci

odem

o-gr

aphi

c qu

estio

n-na

ire

NET

3ses

sion

sPT

SD: s

igni

fi-ca

nt d

iffer

ence

pr

e-po

st tre

atm

ent,

pret

reat

men

t-fo

llow

up

and

post

treat

men

t-fo

llow

up

Dep

ress

ion:

sig-

nific

ant d

iffer

-en

ce b

etw

een

pret

reat

men

t- fo

llow

up

Avo

idan

ce:

sign

ifica

nt

diffe

renc

e pr

e-po

st tre

atm

ent,

pret

reat

men

t-fo

llow

up

Hyp

erar

ousa

l: si

gnifi

cant

di

ffere

nce

betw

een

pret

reat

men

t-fo

llow

up

[37]

Rag

hava

n (2

013)

6 m

m18

 mm

Com

bine

d Ph

a (m

edic

ine

prog

ram

of s

urvi

vors

of

tortu

re: i

ndiv

idua

l and

gr

oup

ther

apy,

cou

nsel

-lin

g, fr

ee m

edic

ine)

178/

172

Refu

gees

A

sylu

m

seek

ers

Euro

paA

mer

ica

Afr

ica

Gen

eral

sy

mpt

oms

PTSD

Dep

ress

ion

Anx

iety

Som

atiz

a-tio

n

HTQ

BSI

Com

bine

d Ph

a7.

5 se

ssio

ns, d

aily

Dep

ress

ion

Anx

iety

Som

atiz

atio

nPT

SDsi

gnifi

cant

diff

er-

ence

s at 6

 mm

1337Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Tabl

e 1

(con

tinue

d)

Refe

renc

esRC

T C

ontro

lFo

llow

up

Sam

ples

Subj

ects

(tota

l and

fo

r exp

eri-

men

tal

sam

ples

pre

an

d po

st.

In o

rder

of

sam

ples

)

Stat

usPr

oven

ance

Out

com

eM

easu

res

Expe

rimen

tal s

ampl

esC

BT

treat

men

ts-

NET

-Psy

chod

inam

ic

ther

apy-

Com

bine

d Ps

ycho

logi

cal t

reat

-m

ent (

Com

bine

d ps

y)-C

ombi

ned

Phar

mac

holo

gica

l an

d ps

ycho

logi

cal

treat

men

t (C

ombi

ned

pha)

Find

ings

for

each

trea

tmen

t ap

plie

d ou

tcom

e

[38]

Sier

ra V

an

Wyk

(201

2)

6,9 

mm

Com

bine

d Ps

y (p

sych

oe-

duca

tion,

stru

ctur

ed sk

ills

base

d th

erap

y, e

xpre

s-si

ve th

erap

y, su

ppor

tive

ther

apy,

cou

ples

and

fa

mily

ther

apy,

CB

T,

expo

sitio

n)

70/6

2Re

fuge

esB

urm

aPT

SDD

epre

ssio

nA

nxie

tySo

mat

iza-

tion

HTQ

HSC

L 37

Post

Mig

ra-

tion

Livi

ngD

ifficu

lties

C

heck

list

Com

bine

d Ps

y2–

3 se

ssio

ns,

120–

150 

min

PTSD

Dep

ress

ion

Anx

iety

Som

atiz

atio

n:Si

gnifi

cant

de

crea

se sy

mp-

tom

s[3

9]W

hits

ett

(201

7)12

 mm

Com

bine

d Ps

y(g

roup

and

indi

vidu

al

ther

apy:

CB

T, p

sych

-oe

duca

tion,

com

bing

su

ppor

tive,

inte

rper

sona

l an

d ex

posu

re te

chni

ques

, sl

eep

hygi

ene,

rela

xatio

n,

cogn

itive

restr

uctu

ring,

so

cial

supp

ort)

105

Asy

lum

se

eker

sA

zerb

aija

n B

urki

na

Faso

B

urun

di

Cam

eroo

n C

entra

l A

fric

an

Repu

blic

of

Con

go

Eritr

ea

Ethi

opia

Li

beria

M

ali N

epal

Pa

kist

an

Russ

ia

Rw

anda

Si

erra

Le

one

Togo

U

gand

a

PTSD

Anx

iety

Dep

ress

ion

Tortu

re

HU

RID

OC

SH

TQH

SCL

25

Com

bine

d Ps

y ps

ycho

ther

apy

and

grou

p th

erap

y,

Supp

ortiv

e, p

sych

-oe

duca

tion,

CB

T an

d ex

posi

tion

and

repr

oces

sing

tra

uma,

wee

kly

PTSD

Dep

ress

ion

Anx

iety

:Si

gnifi

cant

re

duct

ion

1338 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

deviation, number of subjects at pre and post intervention for one of the three outcomes were provided.

Metanalytic Techniques Calculation

Mean differences (random effects model) were computed using Review Manager version 5.3. (RevMan5.3). All the mean differences were computed for depression, anxiety and somatization outcome. The program provides the following results: Heterogeneity (Tau2, Chi2, I2) and test for overall effect (Z). Publication bias significance was evaluated by inspecting the funnel plots as implemented in RevMan5.3.

Results

Study Selection

440 research papers about migrants, refugees or asylum seeker, were included as reported in Fig. 1 (PRISMA). Afterwards the research papers on migrants receiving psy-chological or/and pharmacological treatment were selected, resulting 108 studies. A more specific full view paper investigation on this subsample of studies, identified only the research paper on migrants with a psychological and/or pharmacological treatment with pre and post evaluation of depression and/or anxiety and/or somatization, resulting 52 studies (1997–2018). These fifty-two studies were included in the systematic review (Supplementary material). Of these 52 studies, 25 were excluded from the metanalysis due to lacking data. Finally, 27 studies (2004–2018) were included for the metanalysis (Review Manager 5.3 program was set for calculating mean differences, standard deviation and number of subjects through a random effects model.

Excluded Studies

332 on 440 studies were excluded due to the lack of clinical intervention. Of the resulting 108 studies, 56 studies were excluded due to the following reasons: 2 studies were wrote in German language; 1 study was performed on a sample of military personnel; 1 study was conducted on a sample of interpreters; 5 studies were performed on patients who were treated in own country; 11 studies were conducted on patients with multiple trauma; 10 studies were reviews; 14 studies did not present a pre-intervention evaluation; 1 study was conducted on a single case; 11 studies were conducted on an underage sample. Of the resulting 52 studies, 25 stud-ies did not report useful data and the authors did not answer to an email request of data or their email address was not available.

Tabl

e 1

(con

tinue

d)

ASI a

ddic

tion

seve

rity

inde

x, A

UD

IT A

lcoh

ol u

se d

isor

der i

dent

ifica

tion

test,

BD

I Bec

k de

pres

sion

inve

ntor

y, B

eck

SSI s

cale

for s

uici

dal i

deat

ion,

BSI

brie

f sym

ptom

inve

ntor

y, C

AFES

Coff

ee

and

fam

ily e

duca

tion

and

supp

ort,

CBT

cog

nitiv

e be

havi

or tr

eatm

ent,

CES

-D C

ente

r for

Epi

dem

iolo

gic

Stud

ies

Dep

ress

ion

Scal

e, C

ESD

-R C

ente

r for

Epi

dem

iolo

gic

Stud

ies

Dep

ress

ion

Scal

e re

vise

d, C

GI c

linic

al g

loba

l im

pres

sion

, CID

I com

posi

te in

tern

atio

nal d

iagn

ostic

inte

rvie

w, C

ombi

ned

Pha

com

bine

d ps

ycho

logi

cal w

ith p

harm

acol

ogic

al tr

eatm

ents

, Com

bine

d Ps

y co

mbi

ned

psyc

holo

gica

l tre

atm

ents

, CPT

cog

nitiv

e pr

oces

sing

ther

apy,

CR

cogn

itive

restr

uctu

ring,

CRO

P gr

oup

faci

litat

or fo

r cul

ture

sen

sitiv

e an

d re

sour

ces

orie

nted

pee

r, C

SI c

linic

ian

struc

ture

d in

ter-

view

, CSS

cris

is su

ppor

t sca

le, C

VDTE

che

cklis

t of w

ar d

eten

tion

and

tortu

re e

vent

s, D

T dy

nam

ic th

erap

y, E

MD

R ey

e m

ovem

ent d

esen

sitiz

atio

n an

d re

proc

essi

ng, E

MD

R-R-

TEP

eye

mov

emen

t de

sens

itiza

tion

and

repr

oces

sing

rece

nt tr

aum

atic

epi

sode

pro

toco

l, EU

ROH

IS-Q

OL

GAF

glo

bal a

sses

smen

t of f

unct

ioni

ng, h

hou

rs, H

AM-A

Ham

ilton

Anx

iety

ratin

g sc

ale,

HAM

-D H

amilt

on

depr

essi

on ra

ting

scal

e, H

RSD

Ham

ilton

ratin

g sc

ale

depr

essi

on, H

SCL

(20,

25) H

opki

ns S

ympt

om C

heck

list,

HTQ

Har

vard

Tra

uma

Que

stion

naire

, HU

RID

OC

S ev

ents

sta

ndar

d fo

rmat

s: a

tool

fo

r doc

umen

ting

hum

an ri

ghts

vio

latio

ns, I

ES im

pact

of e

vent

sca

le, I

ES-R

impa

ct o

f eve

nts

scal

e re

vise

d, IP

T in

terp

erso

nal p

sych

othe

rapy

, ISE

L In

terp

erso

nal S

uppo

rt Ev

alua

tion

List,

MEG

-ss

VEF

mag

neto

ence

phal

ogra

phy

stead

y-st

ate

visu

al e

voke

d fie

lds,

MG

mon

itorin

g gr

oup,

MIN

I m

ini i

nter

natio

nal n

euro

psyc

hiat

ric in

terv

iew

, NET

nar

rativ

es e

xper

ienc

es tr

eatm

ent,

N-F

SS

neur

al fl

ashb

acks

sev

erity

sca

le, N

-PAS

S ne

ural

par

amet

ers

seve

rity

scal

e, O

FSS

orth

osta

tic fu

nctio

n se

verit

y sc

ale,

OPA

FSS

orth

osta

tic p

aram

eter

s fla

shba

cks

seve

rity

scal

e, O

PASS

orth

osta

tic

para

met

ers

seve

rity

scal

e, P

CL

ptsd

che

cklis

t, PC

L-C

pts

d ch

eckl

ist c

ivili

an v

ersi

on, P

DS

postt

raum

atic

stre

ss d

iagn

ostic

sca

le, P

SS p

hysi

cal s

ympt

om s

core

, PSS

-SR

phys

ical

sym

ptom

sco

re

self

repo

rt, P

TGI

postt

raum

atic

gro

wth

inve

ntor

y, P

TSD

pos

ttrau

mat

ic s

tress

dis

orde

r, SC

ID-5

stru

ctur

ed c

linic

al in

terv

iew

for

DSM

.5, S

CL-

90 s

ympt

om c

heck

list,

SDS

Shee

han

Dis

abili

ty

Scal

e, S

F so

cial

func

tioni

ng, S

F-M

PQ sh

ort-f

orm

McG

ill P

ain

Que

stion

naire

, SIT

stre

ss in

ocul

atio

n tra

inin

g, S

M st

ress

man

agem

ent,

SSI,

supp

lem

enta

l sec

urity

inco

me,

TAU

trea

tmen

t as u

sual

, TC

trau

ma

coun

selli

ng, T

F-C

BT tr

aum

a fo

cuse

d co

gniti

ve b

ehav

iour

al tr

eatm

ent,

TFT

Thou

ght F

ield

The

rapy

, TFT

trau

ma

foca

lized

trea

tmen

t, VA

S vi

sual

ana

logu

e sc

ale,

VC

OV

Che

cklis

t or

gani

zed

viol

ence

, WB-

FAC

ES-P

RS 5

, Won

g B

aker

face

s pai

n ra

ting

scal

e, W

HO

5 w

orld

hea

lth o

rgan

izat

ion

scal

e as

sess

men

t, W

HO

QO

L(5)

WH

O q

ualit

y of

life

, WLC

wai

ting

list c

ontro

l

1339Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Systematic Review

Qualitative analysis of the systematic review included 52 studies, 4 studies with control group, 21 studies with a fol-low up, 21 studies with both follow up and control group, 6 studies without control group and follow up.

Totally, in the 52 studies there were 4720 patients with a pre-treatment evaluation and 3913 with a pre and post treat-ment evaluations.

Eighty-eight trials, from the 52 studies, provided one of the following treatments: 22 trials performed the CBT (classic CBT treatments, eye movement desensitization reprocessing-EMDR, stress inoculation training-SIT, trauma counselling-TC, thought field therapy-TFT, exposition, stabi-lization, focalization, cognitive rebuilding-CR, self-manage-ment-SM), 9 trials performed the NET (wrote or no wrote), 15 trials performed the dynamic therapies (interpersonal psychotherapy-IPT, group facilitator for culture sensitive and resources oriented peer-CROP, Coffee and family education and support-CAFES, contact and safety planning-CSP, tea and family education and support-TAFES, satisfaction, tran-scendental meditation-TM, testimony psychotherapy-TP), 20 trials performed the combined cognitive psychological treat-ment and 23 trials performed the combined pharmacological and psychological treatments.

About legal status category, 31 studies reported refugee samples, 4 studies reported asylum seeker samples, 13 stud-ies reported both refugee and asylum seeker samples and 4 studies reported samples with not specified socio-politic status.

About provenance category, 20 studies treated Middle east populations, 8 studies treated African populations, 7 studies treated Asian populations, one study treated South American populations, 8 studies treated populations of dif-ferent provenience, 8 studies did not specify the provenance.

Mean number of sessions for each treatment category was respectively: CBT, 13 sessions of 81 min; NET, 7 ses-sions of 103 min; dynamic therapies, 22 sessions of 105 min; combined psychological treatments, 35 sessions of 59 min; combined psychological with pharmacological treatments, 18 sessions of 62 min.

In the systematic review each sample was considered and included in one, in two or in all the three outcomes (depres-sion, anxiety and somatization) considering the pre-post effect reported in each of the 52 studies resulting in one or two or three trials.

The systematic review included 52 studies for 107 sam-ples (139 trials). Of these 139 trials, 18 trials were excluded because of were not eligible treatments: 16 samples (16 trials) were usual treatments or wait lists and 2 samples (2 trials) were pharmacological treatments. The samples included in the final systematic review were 89 (121 trials). Qualitative results of the systematic review showed that the

CBT (22 samples with 28 trials) had significant effect on depression (18 trials) in 11/18 trials (61%) and no significant effect in 7/18 trials (39%). The CBT had significant effect on anxiety (8 trials) in 4/8 trials (50%) and no significant effects in 4/8 trials (50%). The CBT had significant effect on somatization (2 trials) in 0/2 (0%) trials and no significant effect in 2/2 trials (100%).

The NET (9 samples with 9 trails) had significant effects on depression in 4/7 trials (57%) and no significant effects in 3/7 trials (43%). There were not trials using NET on the anxiety outcome. The NET had significant effect on soma-tization in 1/2 trials (50%) and had not significant effects in 1/2 trials (50%).

The dynamic therapies (15 samples with 16 trials) had significant effect on depression in 5/10 trials (50%) and had no significant effect in 5/10 trials (50%). The dynamic thera-pies had significant effect on anxiety in 2/4 trials (50%) and had not significant effects in 2/4 trials (50%). The dynamic therapies had significant effect on somatization in 1/2 trials (50%) and had not significant effect in 1/2 trials (50%).

Combined psychological treatments (20 samples with 31 trials) had significant effect on depression in 6/13 trials (46%) and had not significant effect in 7/13 trials (54%). Combined psychological treatments had significant effect on anxiety in 6/13 trials (46%) and had not significant effect in 7/13 trials (54%). Combined psychological treatments had significant effect on somatization in 3/5 trials (60%) and had not significant effect in 2/5 trials (40%).

Combined psychological and pharmacological treatments (23 samples with 37 trials) had significant effect on depres-sion in 8/13 trials (61%) and not significant effect in 5/13 trials (39%). Combined psychological and pharmacologi-cal treatment had significant effect on anxiety in 4/11 trials (36%) and had not significant effect in 7/11 trials (64%). Combined psychological and pharmacological treatments had significant effect on somatization in 5/13 trials (39%) and had not significant effect in 8/13 trials (61%).

Metanalysis

Included Studies Characteristics and Outcome

Metanalysis included 27 studies for 75 trials.15 RCT, 4 of which presented a follow up, 2 showed

a control sample, and 9 reported a follow up and control sample.

4 MCT, one of which reported a control sample and 3 showed follow up and control sample.

8 SCT, 6 of which were planned with follow up, and 2 without a control sample and/or a follow up.

Depression outcome was treated in 26 studies (45 trials): 14 studies were RCT with 26 trials, 4 studies were MCT with 8 trials, and 8 studies were SCT with 11 trials.

1340 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

The anxiety outcome was treated in 14 studies (25 trials): 7 studies were RCT with 14 trials, 2 studies were MCT with 6 trials, and 5 studies were SCT with 5 trials.

The somatization outcome was treated in 3 RCT (5 trials).Moreover, regarding RCT, 6 studies assessed depression,

6 studies investigated depression and somatization, 1 study examined depression, anxiety and somatization, 1 study assessed depression and somatization, and 1 study con-sidered only somatization. With regard to MCT, 2 studies assessed depression and 2 studies examined depression and anxiety. As regard SCT, 5 studies investigated depression and anxiety and 3 studies considered depression.

As regard the treatment areas for RCT, 7 studies tested CBT treatments, 5 studies analyzed NET, 0 studies assessed dynamic therapies, 1 study investigated combined psycho-logical treatments, and 5 studies examined combined psy-chological and pharmacological treatments. About treatment area for MCT, 3 studies tested dynamic therapies, and 2 combined psychological treatments. About treatment area for SCT, 1 study assessed CBT treatment, 1 study analyzed NET, 0 studies investigated dynamic therapies, 4 studies examined combined psychological treatments, and 2 stud-ies explored combined psychological and pharmacological treatments.

Moreover, about the provenience area 11 RCT included Middle East populations and 3 studies tested populations from different provenances. About MCT, 3 studies tested Middle East populations, and one study Asian populations. About SCT, 2 studies included Middle East populations, 4 studies tested populations from different provenances, one study assessed African populations, and 2 studies did not specify the provenance of the participants.

Moreover, about the status area, 9 RCT investigated refu-gees, 2 studies included asylum seekers, 3 studies exam-ined both refugees and asylum seekers, and one study did not specify the status of the migrant participants. As regard MCT, 2 studies included refugees, and 2 studies consid-ered both refugees and asylum seekers. For SCT, 2 studies included refugees, one studies investigated asylum seekers, and 5 studies assessed both refugees and asylum seekers.

Participants of Metanalysis

The 27 selected studies involved the following number of participants (for all outcome): 956 participants pre-treatment and 774 participants post treatment as regard RCT design; 432 participants pre-treatment and 283 participants post treatment for MCT design; 809 participants pre-treatment and 785 participants post treatment regarding SCT design. The participants differentiated for outcome were: depres-sion 20,177 pre-treatment and 1822 post treatment; anxiety 1225 pre-treatment and 1086 post treatment; somatization 207 pre-treatment and 184 post treatment.

The participants were adult men and women, the age range was 19–51 years for RCT, 18–70 years for MCT, and 18–80 years for SCT.

Interventions Comparation of Metanalysis

The mean number of sessions was: 9.57 sessions of 98.7 min as regard RCT for CBT; 8.8 sessions of 96.6 min for NET; 10 sessions of 90 min for combined psychological treat-ments; 11.22 sessions of 70 min for combined pharmaco-logical and psychological treatments. As regard MCT there were found 60 sessions of 24 min for dynamic therapies and 71.5 sessions of 82.5 min for combined psychological treatments. With regard to SCT there were found 9.1 ses-sions of 60 min for CBT; 3 sessions for NET; 22 sessions of 23.25 min for combined psychological treatments; 47.75 sessions for combined pharmacological and psychological treatments.

Comparators

Comparators included the experimental samples and control samples if treated with CBT, NET, dynamic therapies with different manualization or combined psychological treat-ments and combined psychological and pharmacological treatments. There have been excluded the control samples as waiting lists.

Treatments Effects: Effect Size About Metanalysis

Metanalytic analysis was performed on 27 selected stud-ies separating the studies for outcome, depression, anxiety and somatization and for each different study design (RCT, MCT, and SCT). Successively, because of the high hetero-geneity, further sub-metanalysis have been performed fol-lowing the areas of interest (at least 4 trials were sufficient to perform a metanalysis): socio-politic status (asylum seek-ers and refugees), provenance, and treatment’s kind. The sub-metanalysis were performed considering the different outcomes and the different research designs.

Depression Outcome

3 main forest plots (7 forest plots, 2 funnel plots inside Sup-plementary Figures) have been obtained.

RCT-depression  (Fig.  2): 936–754 participants pre-post treatment; Heterogeneity: Tau2 2.3, Chi2 803.72, df 25 (p < 0.00001), I2 97%; test for overall effect: Z 8.93 (p < 0.00001).

MCT-depression: 432–283 participants pre-post treat-ment; heterogeneity: Tau2 0.08, Chi2 25.02, df 7 (p = 0.0008), I2 72%; test for overall effect: Z 4.08 (p < 0.0001).

1341Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

SCT-depression: 809–785 participants pre-post treatment; Heterogeneity: Tau2 0.56, Chi2 269.25, df 10 (p < 0.00001), I2 96%; test for overall effect: Z 6.45 (p < 0.00001).

Sub‑metanalysis Results on the Kind of Treatment for Depression RCT

CBT: 213–162 participants pre-post treatment (7 stud-ies—8 trial). Heterogeneity: Tau2 5.15; Chi2 230.88, df = 7, p < 0.00001; I2 97%; test for overall effect: Z 4.02 p = 0.0001.

NET: 138–114 participants pre-post treatment (5 stud-ies—5 trial). Heterogeneity: Tau2 23.22; Chi2 37.02 df = 4 p < 0.00001; I2 89%; test for overall effect: Z 2.4 p = 0.02.

Fig. 1 Flow chart selection and organization of the inclusion criteria and the studies for outcome (depression, anxiety, somatization) and research design (randomized controlled trial, multiple cohort trial, single cohort trial)

1342 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

Combined psychological and pharmacological treat-ments: 539–442 participants pre-post treatment (5 stud-ies—10 trial). Heterogeneity: Tau2 2.30; Chi2 444.14 df = 9 p < 0.00001; I2 98%; test for overall effect: Z 7.44 p < 0.00001.

Sub‑metanalysis Results on the Kind of Status for Depression RCT

Refugees: 714–585 participants pre-post treatment (8 studies—14 trial). Heterogeneity: Tau2 3.28; Chi2 640.06

Fig. 2 Forest plot that describes the difference pre and post intervention in the depression outcome. RCT research design

Fig. 3 Forest plot that describes the difference pre and post intervention in the anxiety outcome. RCT research design

1343Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

df = 13 p < 0.00001; I2 98%; Test for overall effect: Z 9.34 p < 0.00001.

Asylum seekers: 87–80 participants pre-post treatment (3 studies—6 trial). Heterogeneity: Tau2 0.00; Chi2 3.99 df = 5 p < 0.55; I2 0%; test for overall effect: Z 2.36 p < 0.02.

Sub‑metanalysis Results for Kind of Status for Depression SCT

Refugees: 327–312 participants pre-post treatment (4 studies—5 trial). Heterogeneity: Tau2 1.40; Chi2 143.98 df = 4 p < 0.00001; I2 97%; Test for overall effect: Z 4.03 p < 0.0001.

Sub‑metanalysis Results on the Kind of Provenance for Depression RCT

Middle East: 837–662 participants pre-post treatment (11 studies—20 trial). Heterogeneity: Tau2 2.34; Chi2 654.76 df = 19 p < 0.00001; I2 97%; test for overall effect: Z 7.75 p < 0.00001.

Sub‑metanalysis Results for Kind of Treatment for Depression SCT

Combined psychological treatment: 313–295 participants pre-post treatment (4 studies—4 trial). Heterogeneity: Tau2 0.04; Chi2 15.59 df = 3 p = 0.001; I2 81%; Test for overall effect: Z 4.08 p < 0.0001.

Anxiety Outcome

RCT-anxiety  (Fig.  3): 628–511 participants pre-post treatment; heterogeneity: Tau2 8.09, Chi2 1927.95 df 13 (p < 0.00001), I2 99%; test for overall effect: Z 2.24 (p = 0.03).

MCT-anxiety: 108 participants pre e post treatment; heterogeneity: Tau2 0.49, Chi2 91.99, df 5 (p < 0.00001), I2 95%; test for overall effect: Z 2.69 (p = 0.007).

SCT-anxiety: 489–467 participants pre-post treatment; heterogeneity: Tau2 0.06, Chi2 28.66 df 4 (p = 0.00001), I2 86%; test for overall effect Z 3.40 (p = 0.0007).

Sub‑metanalysis for Kind of Status on Anxiety RCT

Refugees: 605–488 participants pre-post treatment (5 stud-ies—11 trial). Heterogeneity: Tau2 9.31; Chi2 1813.09 df = 10 p < 0.00001; I2 99%; test for overall effect: Z 2.49 p = 0.01.

Sub‑metanalysis for Kind of Provenance on Anxiety RCT

Middle East: 558–443 participants pre-post treatment (4 studies—8 trial). Heterogeneity: Tau2 12.49; Chi2 1664.77 df = 7 p < 0.00001; I2 100%; test for overall effect: Z 1 p = 0.32.

Sub‑metanalysis for Kind of Treatment on Anxiety RCT

Combined psychological with pharmacological treatments: 535–436 participants pre-post treatment (5 studies—10 trial). Heterogeneity: Tau2 9.32; Chi2 1809.25 df = 9 p < 0.0001; I2 100%; test for overall effect: Z 2.69 p = 0.007.

Somatization Outcome

RCT-somatization  (Fig.  4): 207–184 participants pre-post treatment. Heterogeneity: Tau2 0.02, Chi2 66.79, df 4 (p = 0.00001), I2 94%; test for overall effect: Z 2.13 (p = 0.03).

Methodological Quality: Publication Bias

The risk of bias among studies was high for many reasons, 13/27 (metanalysis) 30/52 (systematic review) publications were MCT and SCT studies this was the first issue hamper-ing the methodological quality of the studies. Moreover, in many studies the number of participants at the pre-treatment

Fig. 4 Forest plot that describes the difference pre and post intervention in the somatization outcome. RCT research design

1344 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

phase (T0) decreased in the post treatment (T1). Often treat-ments with the same approach were manualized in different ways. In some studies, the samples included both refugees and asylum seekers. The different status kind could have a different impact on the psychological health of the par-ticipants. Many studies did not have an appropriate random generation assignment sequence and did not report an occul-tation of the assignment sequence. Some trials coming from different studies, sometimes, used different instruments of measure to evaluate the same constructs.

Further, different types of bias were detected in the stud-ies selected for the present metanalysis and included: bias of data base, bias of inclusion, bias of language, and bias of effect size. Moreover, some studies did not report possible risks of bias. The summary of all biases and the high het-erogeneity were reported in two funnel plots. However, the two funnel plots showed a good symmetry.

Discussion

The main finding of the present metanalysis is that all treat-ments categories, and particularly the cognitive behavioural treatments, showed to be efficient on depression.

Moreover, the effect of the treatment was lower on the asylum seekers compared to the refugees.

Specifically, the cognitive behavioural treatments together combined psychological and pharmacological treatments seemed to be more efficacious on depression, even if in a lower number of studies.

The dynamic therapies showed a discrete efficacy trough observational methodological designs, there is a need of fur-ther investigation in this field due to the total lack of RCT.

As regard the migrant’s status (refugee or asylum seeker), the efficacy of the treatment on the depression showed a significant effect only for the status of refugee, whereas the effect was at the limit of significance with null degree of heterogeneity for the state of asylum seeker. This difference be could be due to adherence to the institutional expectation common in the asylum seekers applicants. In facts, they may have distorted the answers to the questionnaires in order to support or to influence the acceptation of their instance to receive an international protection [40]. This social desir-ability bias could modulate the pre-post evaluation dif-ferences or to attenuate the efficacy of the psychological intervention. This finding suggests to consider with great attention the variable of the status, and overall the pending instance condition of the migrant participants in the future studies. Considering that UNHCR data in Italy reported that in the first half of 2017 the total number of applications examined amounted to 41,379; only 4.3 out of 10 had a positive outcome (refugee status: 9%; subsidiary protection: 9.8%; permit for humanitarian reasons: 24.5%); for 51.7%

the exam ended with a denial, and 4.9% of the instances of the applicants were lost [41].

Other important results were that the psychological inter-ventions showed an effect on the mental health of migrants. The more evident effect of the psychological treatments was on the depression, despite the systematic review showed that only the 50% of the RCT found a significant difference between the pre and post evaluation. The specific metanaly-sis and sub-metanalysis showed high significance levels. For all the types of treatments with the exception of the narra-tive exposure therapies, that showed effects at the limit of significance. This finding suggest to conduct further experi-mental studies in order to confirm the efficacy of narrative exposure therapies on the depression outcome. Moreover the combined (psychological and pharmacological/psychologi-cal) treatments seem to show increased benefits compared to the single ones.

The metanalysis on depression in not randomized stud-ies (multiple and single perspective design studies) showed high levels of significance but with high levels of the heterogeneity.

Differently from the depression, the anxiety showed smaller effects of the psychological treatment. Not only the metanalysis showed decreased pre-post treatment effects on anxiety, but also the qualitative observation on the system-atic review showed a probability lower than 50% to have a significant pre-post treatment effects on trials with anxi-ety. Moreover, the number of the studies criteria allowed to perform only the metanalysis on the RCT studies with the combined psychological/pharmacological treatments where the effect was statistically significant. It seems necessary to plane further randomized studies in order to test the efficacy of specific psychological treatments on outcomes other than depression.

Moreover, the metanalysis performed only in middle-east migrant population showed a clear statistical pre-post effect of the psychological treatment on the depression out-come but not on the anxiety outcome. This result could be explained with the cultural characteristics of these popula-tions where the expression of the anxiety is under-repre-sented compared to other cultures [42].

Another important finding of the present study was that, at today, there are few studies on African and Asian popula-tions compared to the Middle East population. In the last years, a large entrance in Europe of the African popula-tion, as well as Syrian and Iranian population, has been observed. It seems to be necessary to increase the trials on the participants who have been involved in the current phe-nomena of migration as African, Asian, Syrian, and Iranian populations.

As regard the somatization outcome, the qualitative observation from the systematic review showed a probabil-ity of 42% to have a significant pre-post treatment effects on

1345Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

randomized control, multiple and single perspective cohort trials of 42%. This limited qualitative evidence was con-firmed by the metanalyses on the RCT where the statistical effect was at the limit of significance. This finding suggests the need to conduct more studies focused on testing the effi-cacy of psychological treatments on somatization, talking into consideration of the population at today involved in the migration phenomena characterized by a culture where somatization could represent a privileged channel to express their psychological disease [43].

Moreover, the limited number of studies with outcome of anxiety and somatization did not allow to compare the effi-cacy of different types of psychological treatment on these outcomes revealing a hole in the literature that it is necessary fil up in the next future.

Future Research

For future developments, we suggest to extend the research to the outcome of psychological support for the migrants using a dynamic approach, possibly through RCT design. Moreover, it seems to necessary to confirm the efficacy of narrative exposure therapy on the depression increasing the studies number on this issue. According to this line, it could be interesting to turn the attention also to the expressive writing treatment of Pennebaker [44]. This treatment shows is more systematized procedure compared to the other nar-rative exposure therapies and it seems to demonstrate a good efficacy in brief times (3–5 days) adopting an exclusively written application modality. Nowadays, this type of treat-ment was not tested on migrants yet.

Finally, it would be useful increases the number of stud-ies of all psychological treatments applied on anxiety and somatization, possibly through RCT design.

Limitations

Few studies among those included in this systematic review treated the asylum seekers respect to the refugees.

Acknowledgements Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement.

Author Contributions DS drafted the protocol and with CL, PA, EB assessed the eligibility of the studies for inclusion, and extracted data. PA and DS developed the statistical code and performed the analyses. All authors contributed to the interpretation of the findings and to the drafting and editing of the manuscript.

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no competing interests.

Open Access This article is licensed under a Creative Commons Attri-bution 4.0 International License, which permits use, sharing, adapta-tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.

References

1. Lely JC, Smid GE, Jongedijk RA, Knipscheer W, Kleber RJ. The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. Eur J Psychotraumatol. 2019;10:1550344.

2. Williams ME, Thompson SC. The use of community-based inter-ventions in reducing morbidity from the psychological impact of conflict-related trauma among refugee populations: a systematic review of the literature. J Immigr Minor Health. 2011;13:780–94.

3. Robjant K, Fazel M. The emerging evidence for narrative expo-sure therapy: a review. Clin Psychol Rev. 2010;30:1030–9.

4. Eurostat E: gas retail tables H1. European Comission; 2016 5. Tribe RH, Sendt KV, Tracy DK. A systematic review of psychoso-

cial interventions for adult refugees and asylum seekers. J Mental Health. 2019;28:662–76.

6. UNHCR W UNAIDS. Policy statement on HIV testing and coun-selling in health facilities for refugees, internally displaced per-sons and other persons of concern to UNHCR. Geneva; 2014.

7. Unhcr R. Syria regional refugee response. Turkey: UNHCR Inter-agency Information Sharing Portal; 2016.

8. Gwozdziewycz N, Mehl-Madrona L. Meta-analysis of the use of narrative exposure therapy for the effects of trauma among refugee populations. Perm J. 2013;17:70.

9. Mahoney A, Karatzias T, Hutton P. A systematic review and meta-analysis of group treatments for adults with symptoms associ-ated with complex post-traumatic stress disorder. J Affect Disord. 2019;243:305–21.

10. Pompili M, Gibiino S, Innamorati M, Serafini G, Del Casale A, De Risio L, Sher L. Prolactin and thyroid hormone levels are associ-ated with suicide attempts in psychiatric patients. Psychiatry Res. 2012;200(2–3):389–94.

11. Pompili M, Shrivastava A, Serafini G, Innamorati M, Milelli M, Erbuto D, Lester D. Bereavement after the suicide of a significant other. Indian J Psychiatry. 2013;55(3):256.

12. Slobodin O, de Jong JT. Family interventions in traumatized immigrants and refugees: a systematic review. Transcult Psychia-try. 2015;52:723–42.

13. Acarturk C, Konuk E, Cetinkaya M, Senay I, Sijbrandij M, Cui-jpers P, Aker T. EMDR for Syrian refugees with posttraumatic stress disorder symptoms: results of a pilot randomized controlled trial. Eur J Psychotraumatol. 2015;6:27414.

14. Acarturk C, Konuk E, Cetinkaya M, Senay I, Sijbrandij M, Gulen B, Cuijpers P. The efficacy of eye movement desensitization and reprocessing for post-traumatic stress disorder and depression

1346 Journal of Immigrant and Minority Health (2020) 22:1320–1346

1 3

among Syrian refugees: results of a randomized controlled trial. Psychol Med. 2016;46:2583–93.

15. Adenauer H, Catani C, Gola H, Keil J, Ruf M, Schauer M, Neuner F. Narrative exposure therapy for PTSD increases top-down pro-cessing of aversive stimuli-evidence from a randomized controlled treatment trial. BMC Neurosci. 2011;12:127.

16. Buhmann CB, Nordentoft M, Ekstroem M, Carlsson J, Mortensen EL. The effect of flexible cognitive–behavioural therapy and med-ical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatized refugees: pragmatic rand-omized controlled clinical trial. Br J Psychiatry. 2016;208:252–9.

17. Carlsson J, Sonne C, Vindbjerg E, Mortensen EL. Stress manage-ment versus cognitive restructuring in trauma-affected refugees: a pragmatic randomized study. Psychiatry Rec. 2018;266:116–23.

18. Hensel-Dittmann D, Schauer M, Ruf M, Catani C, Odenwald M, Elbert T, Neuner F. Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training. Psychother Psychosom. 2011;80:345–52.

19. Hijazi AM, Lumley MA, Ziadni MS, Haddad L, Rapport LJ, Arnetz BB. Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: a preliminary randomized clinical trial. J Trauma Stress. 2014;27:314–22.

20. Hinton DE, Pham T, Tran M, Safren SA, Otto MW, Pollack MH. CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study. J Trauma Stress. 2004;17:429–33.

21. Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG, Pollack MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design. J Trauma Stress. 2005;18:617–29.

22. Neuner F, Kurreck S, Ruf M, Odenwald M, Elbert T, Schauer M. Can asylum-seekers with posttraumatic stress disorder be success-fully treated? A randomized controlled pilot study. Cogn Behav Therapy. 2010;39:81–91.

23. Paunovic N, Öst LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther. 2001;39:1183–97.

24. Sonne C, Carlsson J, Bech P, Vindbjerg E, Mortensen EL, Elk-lit A. Psychosocial predictors of treatment outcome for trauma-affected refugees. Eur J Psychotraumatol. 2016;7:30907.

25. Stenmark H, Catani C, Neuner F, Elbert T, Holen A. Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behav Res Ther. 2013;51:641–7.

26. ter Heide FJJ, Mooren T, Kleijn W, de Jongh A, Kleber R. EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study. Eur J Psychotraumatol. 2011;2:5881.

27. Wang SJ, Bytyçi A, Izeti S, Kallaba M, Rushiti F, Montgomery E, Modvig J. A novel bio-psycho-social approach for rehabilita-tion of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo. Conflict Health. 2017;10:34.

28. Drožđek B, Bolwerk N. Evaluation of group therapy with trauma-tized asylum seekers and refugees: the Den Bosch Model. Trau-matology. 2010;16:117–27.

29. Droždek B, Kamperman AM, Bolwerk N, Tol WA, Kleber RJ. Group therapy with male asylum seekers and refugees with posttraumatic stress disorder: a controlled comparison cohort

study of three day-treatment programs. J Nerv Ment Dis. 2012;200(9):758–65.

30. Lakshimi Vijayakumar L. Challenges and opportunities in suicide prevention in South-East Asia. WHO South-East Asia J Public Health. 2017;6:45–9.

31. Weinstein N, Khabbaz F, Legate N. Enhancing need satisfaction to reduce psychological distress in Syrian refugees. J Consult Clin Psychol. 2016;84:645.

32. Brune M, José Eiroá-Orosa F, Fischer-Ortman J, Haasen C. Effectiveness of psychotherapy for traumatized refugees with-out a secure residency status. Intl J Migrat Health Social Care. 2014;10:52–9.

33. Carlsson JM, Olsen DR, Kastrup M, Mortensen EL. Late mental health changes in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis. 2010;198:824–8.

34. d’Ardenne P, Ruaro L, Cestari L, Fakhoury W, Priebe S. Does interpreter-mediated CBT with traumatized refugee people work? A comparison of patient outcomes in East London. Behav Cogn Psychother. 2007;35:293–301.

35. Drožđek B, Kamperman AM, Tol WA, Knipscheer JW, Kleber RJ. Seven-year follow-up study of symptoms in asylum seekers and refugees with PTSD treated with trauma-focused groups. J Clin Psychol. 2014;70:376–87.

36. Halvorsen JØ, Stenmark H. Narrative exposure therapy for post-traumatic stress disorder in tortured refugees: a preliminary uncontrolled trial. Scand J Psychol. 2010;51:495–502.

37. Raghavan S, Rasmussen A, Rosenfeld B, Keller AS. Correlates of symptom reduction in treatment-seeking survivors of torture. Psychol Trauma. 2013;5:377.

38. Sierre van Wyk S, Schweitzer R, Brough M, Vromans L, Murray K. A longitudinal study of mental health in refugees from Burma: the impact of therapeutic interventions. Aust N Z J Psychiatry. 2012;46:995–1003.

39. Whitsett D, Sherman MF. Do resettlement variables predict psy-chiatric treatment outcomes in a sample of asylum-seeking sur-vivors of torture? Int J Soc Psychiatry. 2017;63:674–85.

40. Heeren M, Wittmann L, Ehlert U, Schnyder U, Maier T, Müller J. Psychopathology and resident status: comparing asylum seekers, refugees, illegal migrants, labor migrants, and residents. Compr Psychiatry. 2014;55(4):818–25.

41. Fondazione I. S. M. U. Ventitreesimo Rapporto sulle migrazioni 2017; Franco Angeli; 2017.

42. Norton PJ. Depression Anxiety and Stress Scales (DASS-21): psychometric analysis across four racial groups. Anxiety Stress Coping. 2007;20:253–65.

43. Rohlof HG, Knipscheer JW, Kleber RJ. Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1793–804.

44. Pennebaker JW, Evans JF. Expressive writing: words that heal: using expressive writing to overcome traumas and emotional upheavals, resolve issues, improve health, and build resilience. Enumclaw: Idyll Arbor; 2014.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.