Treating depressive symptomatology in Congolese Refugees in Uganda and Rwanda: Adapting and Evaluating Community-based Sociotherapy

难民的精神健康困难率较高，包括抑郁症和创伤后应激障碍*1、2、3.难民面临影响心理健康的各种日常压力因素(例如，无法获得基本资源、缺乏安全和保障、家庭暴力风险)*4.在紧急情况下提供心理社会支持的指导方针*5，但关于哪种方法最有效仍存在争议，以及这些干预措施是否能以足够的规模提供*6.缺乏高技能的专业人员意味着需要“分担”外行人的角色*7.基于社区的方法为治疗常见的精神障碍提供了希望，为社会所接受，并可以减轻初级医疗保健的压力*8.刚果民主共和国的冲突导致卢旺达和乌干达的大量刚果难民。自2005年以来，以社区为基础的社会治疗(CBS)已在卢旺达向2万多人提供，以促进社区联系和个人福祉，1994年种族灭绝*10。社区社会治疗由业馀辅导员在15个每周3小时的小组会议上提供。世界卫生组织将CBS描述为一种方法，利用个人与其社会环境之间的互动来促进重新建立价值观、规范和关系……同时提供辩论、分享经验和应对机制的机会*11与通常的护理相比，CBS显著增加了公民参与，并在8个月的随访中显著减少了卢旺达受冲突影响的人的痛苦*12。难民署注意到CBS对难民的潜力*13，但它还没有在这些人口中进行评估。该项目将使用多种学科来：1)调整哥伦比亚广播公司和评估措施，用于卢旺达和乌干达的刚果难民；2)调查改编后的CBS(ACBS)在减少刚果难民抑郁症状方面的效力和成本效益，并确定社会资本水平和日常应激源的变化是否是抑郁症状变化所不可或缺的；3)与难民署合作，为不同环境的难民制定适应和传播ACBS的实施指南。在第一阶段，将使用设计、实施、监测和评估(DIME)方法*14(利用关键线人访谈和焦点小组)调整评估措施和ACBS的内容。然后，一项双臂整群随机对照试验(具有试点阶段)将比较ACBS与一如既往的强化护理(即，对非政府组织工作人员进行精神健康指南培训和审查转介途径)。成年刚果难民(有复杂精神健康问题、有自杀念头和/或智力残疾的人除外)将有资格参加。这将避免参与者因使用精神健康标签而被污名的风险。分析将考虑抑郁症状的水平(PHQ-9*15)，以及它们是否符合基线时迷你神经精神病学访谈抑郁模块(MINI*16)上的抑郁标准。总共将招募720名参与者；每个研究小组360人。评估结果将包括痛苦程度(SRQ-2018*17)、功能(WHOQOL-BREF*18)、社会资本(SASCAT*19)、幸福感(WHO-5*20)、日常应激源(CDES*21)和创伤事件清单*21。参与者将在基线、基线后16周和32周进行评估。TSC/DMC将监督试验。将对ACBS的成本效益进行评估。将开展基于标准化过程理论的“过程评估”*22，以探索促进和阻碍与ACBS接触的因素。项目网页、推特账户、简报、知识交流活动、会议报告和学术论文将传播项目成果并影响决策者。

Refugees experience elevated rates of mental health difficulties including depression and post-traumatic stress disorder*1,2,3. Refugees face a wide-range of daily stressors (e.g. lack of access to basic resources, lack of safety and security, risk of family violence) that impact on mental health*4. Guidelines exist for delivering psychosocial support in emergency situations*5, but contention remains about which approaches are most effective, and whether these interventions can be delivered at sufficient scale*6. An absence of highly-skilled professionals means that the 'task-sharing' of roles to lay people is required*7. Community-based approaches offer promise for treating common mental disorders, are socially acceptable, and can decrease pressure on primary healthcare*8,9.Conflict in the Democratic Republic of Congo has led to large numbers of Congolese refugees in Rwanda and Uganda. Community-based Sociotherapy (CBS) has been delivered to over 20,000 people in Rwanda since 2005 to promote community connections and individual wellbeing after the genocide of 1994*10. CBS is delivered by lay-facilitators over fifteen weekly 3-hour group sessions. The WHO described CBS as an approach that uses 'the interactions between individuals and their social environment to facilitate the re-establishment of values, norms, and relationships...and at the same time provide the opportunity for debate, the sharing of experiences and coping mechanisms'*11, Compared with usual care, CBS resulted in significantly increased civic participation and significantly decreased distress in conflict-affected people in Rwanda at 8 months follow-up*12. The UNHCR has noted the potential of CBS for refugees*13, but it has not yet been evaluated in these populations.The project will use a mix of disciplines to: 1) adapt CBS and assessment measures for use with Congolese refugees in Rwanda and Uganda; 2) investigate the efficacy and cost-effectiveness of adapted CBS (aCBS) for reducing depressive symptoms in Congolese refugees, and determine whether changes in levels of social capital and daily stressors are integral to changes in depressive symptoms; 3) develop implementation guidance for adapting and disseminating aCBS for refugees across diverse settings in conjunction with the UNHCR.In the first phase, the Design, Implementation, Monitoring and Evaluation (DIME) approach*14 (which utilises key informant interviews and focus groups) will be used to adapt assessment measures and aCBS content. Then a 2-arm cluster randomised controlled trial (with pilot phase) will compare aCBS to an enhanced care as usual (i.e. training for NGO workers in mental health guidelines and reviewing referral pahways). Adult Congolese refugees (apart from those with complex mental health difficulties, active suicidal ideation and/or intellectual disabilities) will be eligible to participate. This will avoid the risk of participants being stigmatised by the use of mental health labels. Analyses will take account of levels of depressive symptoms (PHQ-9*15), and whether they meet criteria for a depression on the Mini-Internal Neuropsychiatric Interview Depression Module (MINI*16) at baseline. A total of 720 participants will be recruited; 360 per study arm. Assessed outcomes will include levels of distress (SRQ-2018*17), functioning (WHOQoL-BREF*18), social capital (SASCAT*19), wellbeing (WHO-5*20), daily stressors (CDES*21), and Trauma Events Inventory*21. Participants will be assessed at baseline, 16- and 32-weeks post-baseline. A TSC/DMC will monitor the trial. The cost-effectiveness of aCBS will be evaluated. A 'process evaluation'*22 based on Normalisation Process Theory (www.normalizationprocess.org) will be undertaken to explore factors that facilitate and impede engagement with aCBS. A project webpage, Twitter account, briefings, knowledge exchange events, conference presentations and academic papers will disseminate project findings and influence decision makers.