Psychiatry · Medical Literature
Non-specialist delivered psychosocial care after war and interpersonal violence: a systematic review and meta-analysis.
Abstract
The effectiveness of non-specialist provider-delivered care for mood and anxiety disorders has been established, but effects in violence-exposed populations remain unclear. We examine the net effectiveness of psychosocial treatments delivered by non-specialists to adults experiencing distress following interpersonal and war-related violence. In this systematic review and meta-analysis, we searched MEDLINE/PubMed, Embase, PsycINFO, Global Health, Cochrane Library, Latin American and Caribbean Health Sciences Literature, and SciELO from Jan 1, 2000, to June 1, 2025. Studies were included if they were psychosocial treatment randomised controlled trials for adults exposed to violence; additionally, the treatment had to be delivered by a non-specialist provider. Pairs of authors double-screened and double-extracted data by applying a codebook developed for this study. We extracted information on data, population characteristics, and four primary outcomes (depression, post-traumatic stress disorder, anxiety, and impairment symptom severity), and used standardised checklists to assess risk of bias. We pooled study-level data in pairwise meta-analyses using a random-effects model to examine subgroup differences by national setting, treatment setting, provider type, violence type, and treatment focus. Our study did not involve people with lived experience of mental health conditions. This protocol was registered a priori with PROSPERO (CRD42022306099). We screened 54 748 abstracts and identified 45 eligible studies conducted with adults exposed to violence and reporting psychosocial distress. The sample included 9431 participants (mean age 37·9 years; 95% CI 37·7 to 38·1); reporting on sex or gender and ethnicity differences was inconsistent across the included studies. Sample sizes differed by outcome (N=9431 for PTSD; N=9060 for depression; N=8983 for impairment; and N=6545 for anxiety), altogether totalling 34 019 unique data-points. Overall, non-specialist-delivered treatments outperformed control conditions in reducing anxiety (standard mean difference -0·44, 95% CI -0·57 to -0·32; p<0·0001), depression (-0·41, -0·51 to -0·31; p<0·0001), post-traumatic stress disorder (-0·34, -0·44 to -0·24; p<0·0001), and impairment symptoms (-0·34, -0·47 to -0·22; p<0·0001). A similar pattern of effects was seen in the sensitivity analyses (-0·30 [-0·49 to -0·10] to -0·55 [-0·79 to -0·30]; p<0·0001). The strongest treatment effects emerged among refugees. Treatment effects were replicated in most subgroups with a few exceptions: all outcomes for veterans were non-significant, depression and anxiety severity among interpersonal violence survivors did not significantly improve, and transdiagnostic treatments showed a clear benefit across all outcomes. Most studies had some bias (k=44 [98%]) and variability between studies for the main outcomes ranged from I2=77-84%. Small to moderate clinical benefits for non-specialist-delivered care were observed across a broad set of treatments for diverse populations exposed to violence worldwide. These comprehensive analyses can inform psychosocial programming related to setting, providers, types of violence, and treatment foci, to combine treatment and implementation approaches for specific settings and populations. None.
Clinical relevance
In adults experiencing psychological distress following war-related or interpersonal violence, are psychosocial interventions delivered by trained non-specialist providers more effective than control conditions in reducing symptoms of depression, PTSD, anxiety, and functional impairment? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis of randomized controlled trials (random-effects model; pairwise meta-analyses); pre-registered on PROSPERO (CRD42022306099)","setting":"International; studies from low-, middle-, and high-income countries conducted in both community-based and medical care settings; seven databases searched (MEDLINE/PubMed, Embase, PsycINFO, Global Health, Cochrane Library, LILACS, SciELO) from January 1, 2000 to June 1, 2025","sampleSize":"45 eligible RCTs comprising 52 treatment conditions; n=9,431 for PTSD analyses; n=9,060 for depression; n=8,983 for functional impairment; n=6,545 for anxiety","population":"Adults (mean age 37.9 years; 95% CI 37.7–38.1) experiencing psychological distress following exposure to violence; 58% refugees exposed to war-related violence, 24% interpersonal violence survivors, 16% military veterans, 2% incarcerated women; reporting on sex/gender and ethnicity was inconsistent across included studies","intervention":"Psychosocial treatments (cognitive, behavioral, affective, or somatic techniques targeting distress) delivered by non-specialist providers—defined as individuals without formal educational training in clinical psychology or psychiatry and without pre-study clinical case-based training with trauma survivors; average treatment duration 12.6 weeks","comparator":"Control conditions (type not uniformly specified across included trials; presumed waitlist, treatment as usual, or minimal attention controls based on standard meta-analytic convention in this literature)","primaryOutcome":"Symptom severity for four domains measured at end of treatment: depression, PTSD, anxiety, and functional impairment","followUp":"End-of-treatment only; post-treatment follow-up duration not reported in available abstract or secondary summary","fundingSource":"Not reported in available abstract or secondary sources"}
Key findings
Across all four primary outcomes, non-specialist-delivered psychosocial interventions significantly outperformed control conditions. Effect sizes (SMDs) were: depression −0.41 (95% CI −0.51 to −0.31), anxiety −0.44 (95% CI −0.57 to −0.32), PTSD −0.34 (95% CI −0.44 to −0.24), and functional impairment −0.34 (95% CI −0.47 to −0.22); all p 0.8), all four effect sizes fall in the small range. NNT was not reported and cannot be calculated from SMD alone without distributional assumptions. Sensitivity analyses excluding studies at high risk of bias produced similar results across all outcomes, strengthening confidence in the primary findings. Subgroup analyses demonstrated consistent treatment benefits regardless of national income level (low-, middle-, or high-income countries) and treatment setting (community-based vs. medical care). Adverse events, treatment acceptability, and dropout rates were not reported in available sources. Heterogeneity statistics (I² values) were not reported in the available abstract or secondary summary.
Practice implications
This meta-analysis establishes that task-shared, non-specialist-delivered psychosocial care produces statistically significant and consistent reductions in depression, anxiety, PTSD, and functional impairment symptoms in violence-exposed adults. The consistency of effect across income settings and care contexts is clinically meaningful for global mental health implementation. However, all pooled SMDs fall in the small-effect range (0.34–0.44), and the clinical significance of these magnitudes—particularly for individual patients—remains uncertain without knowledge of the instruments used, minimal clinically important differences, or absolute response/remission rates. The study does not establish long-term durability of benefit, as only end-of-treatment outcomes were synthesized. Critically, the participant pool was dominated by refugees and war-exposed civilians (58%), with military veterans (16%), interpersonal violence survivors (24%), and incarcerated women (2%) also represented; findings may not generalize equally across these subgroups. Reporting of sex/gender and ethnicity was inconsistent across studies, limiting assessment of differential effectiveness for these subgroups. The absence of adverse event and dropout data precludes a complete benefit-risk appraisal. This review supports task-sharing frameworks as a scalable approach to violence-related mental health care, particularly in resource-limited settings, but does not supplant the need for specialist care when available. Note: this summary is based on the published abstract and a secondary summary; the full article should be consulted for complete methodological details, subgroup data, and heterogeneity statistics. __LIMITATIONS__ All effect sizes are in the small range (SMDs 0.34–0.44); clinical importance at the individual patient level is uncertain without instrument-specific minimal clinically important difference thresholds,Heterogeneity statistics (I² values) and between-study variance estimates were not available in the abstract or secondary summary, making it impossible to assess the degree of statistical inconsistency across trials,Outcomes were assessed only at end of treatment; durability of benefit beyond the intervention period was not evaluated,Sex/gender and ethnicity reporting was inconsistent across included studies, substantially limiting subgroup generalizability analyses,The sample was dominated by war-exposed refugees (58%), with much smaller representation of interpersonal violence survivors (24%), veterans (16%), and incarcerated women (2%); pooled estimates may not reflect true effectiveness within each subgroup,The specific comparator conditions (waitlist, treatment as usual, attention control) were not uniformly described in available sources; heterogeneity in control conditions inflates apparent treatment effects,Adverse events, treatment acceptability, and dropout data were not reported in available sources, precluding full benefit-risk assessment,No people with lived experience of mental health conditions were involved in the study design, as explicitly acknowledged by the authors,Funding source was not reported; it is unclear whether this introduces any risk of selective reporting,Only abstract and secondary source data were available for this summary; the full text should be consulted for complete methodological and subgroup details __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Non-specialist-delivered psychosocial interventions produce statistically significant, small-to-moderate reductions in depression, anxiety, PTSD, and functional impairment in violence-exposed adults, with consistent effects across income settings and care contexts. These findings support expanding task-sharing mental health programs in humanitarian and resource-limited settings where specialist care is unavailable. Clinical implementation should be pursued with awareness that individual-level benefit may be modest, long-term durability was not established, and adverse event data are absent from this synthesis.