Brief reportEfficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: A pilot study
Introduction
Although the Internet is increasingly employed in war and conflict regions, providing information even in relatively unsafe areas, it is rarely used for humanitarian purposes. In the Western world, the Internet has opened up the fields of psychology and health. Online interventions for patients with posttraumatic stress disorder (PTSD), in particular, have been developed and shown to produce significant reductions in symptoms, comparable to those reported for regular face-to-face treatments (Wagner and Maercker, 2010). Internet-based therapies (Litz et al., 2007), computer-based virtual reality interventions (Rizzo et al., 2005) and studies (Pietrzak et al., 2010) have been put in place for soldiers and veterans after their tours of duty in war or conflict regions (e.g., Iraq war). However, e-health facilities for the local population in conflict regions such as Iraq or Palestine have not yet been developed and evaluated.
After the first Gulf war, the continued trade embargo meant that Iraq was essentially cut off from medical and scientific developments. During this time, the Iraqi people suffered not only the effects of the war, but also grave and systematic violations of human rights at the hands of the Ba'ath regime. Iraqis were subjected to severe human rights abuses including torture, killings, disappearance, beatings, kidnappings, forced amputation, and rape. After the invasion of Iraq by the US-led coalition forces in 2002, exposure to traumatizing events increased dramatically. The general escalation of violence led to an unprecedented demand for medical and psychological support. Yet comparatively little research has addressed the psychological impact of the high levels of instability and violence threatening the Iraqi population on a day-to-day basis. With the exception of isolated studies about Iraqi asylum seekers and refugees (Laban et al., 2004) and mental disorders among Iraqi children (Al-Jawadi and Abdul-Rhman, 2007), little is known about the mental health of the Iraqi people. Generally, the country's mental health resources are scarce. Given the security situation, most international aid organizations have left the country. Additionally, physicians and mental health professionals have frequently been the targets of kidnappings or random shootings; many have been killed or left the country (Al Sheibani et al., 2006, Burnham et al., 2009). Any treatment received by Iraqis with PTSD is of a minimum standard (Alhasnawi et al., 2009).
Recent developments in communication technology have dramatically expanded the treatment possibilities in clinical psychology, and offer great potential to improve treatment provision in the area of humanitarian aid. Between 2000 and 2008, the online population of the Middle East grew by 1176.8%, with 29.8% of the local population now using the Internet (www.internetworldstats.com, 2010). Internet-based psychotherapy conducted by native-speaking psychiatrists and psychologists who are geographically independent of their clients can provide a unique treatment alternative in underserved post-conflict areas where there is an urgent need for psychological care that is easily accessible, independent of the location of the therapist, and relatively inexpensive.
A highly effective Internet-based cognitive-behavioral treatment approach (“Interapy”) has recently been developed for PTSD (Lange et al., 2001, Lange et al., 2003a, Lange et al., 2003b). The treatment consists of structured writing assignments that take place through a database implemented on the Internet. Communication between therapist and patient is entirely text-based and asynchronous. The treatment manual is based on cognitive-behavioral therapy approaches that have proved effective in regular face-to-face-settings (Bradley et al., 2005). The intervention has been evaluated cross-culturally in numerous randomized controlled trials (Wagner et al., 2005, Wagner et al., 2006, Knaevelsrud and Maercker, 2006, Knaevelsrud and Maercker, 2007, Wagner and Maercker, 2007). All studies found substantial, significant and enduring improvements in symptoms of PTSD, complicated grief, anxiety, and depressed mood.
This pilot study is one of the first to evaluate the effects and sustainability of this Internet-based psychological intervention in a non-Western country that remains highly unstable. We hypothesized that the intervention would yield generalized symptomatic improvement among patients with PTSD.
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Participants
The study attracted considerable international and local media attention in Iraq. It was therefore possible to recruit participants mainly by means of radio, TV, and newspaper publicity. Further information was posted on Arabic health-related websites and made available on a Facebook information page and in a YouTube film clip. Inclusion criteria were a history of torture or trauma, knowledge of Arabic, age between 18 and 65 years, and absence of severe depression with serious suicidal intent,
Results
Table 1 presents the means and standard deviations of the symptom variables at pretreatment and posttreatment. The mean baseline PDS score was 29.13 (S.D. = 9.6), falling within the severe range for PTSD. The mean slopes from baseline to posttreatment of total PTSD, t(14) = − 6.72, p < 0.0001, d = 1.57, intrusions, t(14) = 5.29, p < 0.0001, d = 1.44, avoidance t(14) = − 4.60, p < 0.0001, d = 1.23, and hyperarousal, t(14) = 5.83, p < 0.0001, d = 1.43, were highly significant, indicating that participants' scores decreased
Discussion
This pilot study evaluating the feasibility of an Internet-based treatment for PTSD in an unstable, non-Western conflict region yielded a number of major results. First, the participants reported significantly reduced total PTSD symptoms, as well as significantly reduced symptoms of intrusion, avoidance, and hyperarousal after the intervention. Significant treatment benefits were also observed for symptoms of depression and anxiety and for quality of life, although depression and anxiety levels
Acknowledgments
The research conducted in this study was supported by Misereor, the German Ministry of Foreign Affairs, and the Heinrich Böll Foundation. The authors declare that they have no conflict of interest. The corresponding author had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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