Harbingers of Hope: Scientists and the Pursuit of World Peace.

The ongoing wars in many regions-such as the conflict between Israel and Hamas-as well as the effects of war on communities, social services, and mental health are covered in this special editorial. This article emphasizes the need for international efforts to promote peace, offer humanitarian aid, and address the mental health challenges faced by individuals and communities affected by war and violence.

Child witchcraft confessions as an idiom of distress in Sierra Leone; results of a rapid qualitative inquiry and recommendations for mental health interventions.

BACKGROUND: Reports about child witchcraft are not uncommon in sub-Saharan Africa. In this study we approach child witchcraft as an idiom of distress. In an environment that may prohibit children from openly expressing distress, the shared imagery of witchcraft can provide a cultural idiom to communicate about psychosocial suffering. We used an ecological approach to study how some children in distressing circumstances come to a witchcraft confession, with the aim to set out pathways for mental health interventions. METHODS: We employed rapid qualitative inquiry methodology, with an inductive and iterative approach, combining emic and etic perspectives. We conducted 37 interviews and 12 focus group discussions with a total of 127 participants in Freetown, Sierra Leone. Inductive analysis was used to identify risk and protective factors related to witchcraft accusations and confessions. RESULTS: We identified risk and protective factors related to the individual child, the family, peer relations, teachers and other professionals in a child's life, traditional healers, pastors and the wider society. We found that in the context of a macrosystem that supports witchcraft, suspicions of witchcraft are formed at the mesosystem level, where actors from the microsystem interact with each other and the child. The involvement of a traditional healer or pastor often forms a tipping point that leads to a confession of witchcraft. CONCLUSIONS: Child witchcraft is an idiom of distress, not so much owned by the individual child as well as by the systems around the child. Mental health interventions should be systemic and multi-sectoral, to prevent accusations and confessions, and address the suffering of both the child and the systems surrounding the child. Interventions should be contextually relevant and service providers should be helped to address conscious and subconscious fears related to witchcraft. Beyond mental health interventions, advocacy, peacebuilding and legislation is needed to address the deeper systemic issues of poverty, conflict and abuse.

Contextualized understanding of depression: A vignette study among the !Xun and Khwe of South Africa.

Colonial misconceptions about the absence of depression and the lack of a psychologization of distress among Africans have long been refuted. However, cultural variation in depression in terms of symptomatic expression, conceptualization, explanatory models, and social responses is widely acknowledged. Insight into the cultural variation of depression is useful for providing appropriate care; however, few studies have explored cultural understandings of depression in African settings. In a depression vignette study of two displaced and marginalized San communities in South Africa, we conducted 20 semistructured interviews to explore causal interpretations and strategies for coping. Causal interpretations consisted of several dimensions, including life struggles and physical, psychological, and spiritual interpretations. Respondents primarily focused on life struggles in terms of socioeconomic and interpersonal problems. They described coping strategies as primarily addressing negative emotional and psychological affect through social support for relief, comfort, distraction, or advice on coping with the situation and emotions. In addition, religious coping and professional support from a social worker, psychologist, support group, or medications were mentioned. Findings illustrate that depression should be understood beyond individual suffering and be situated in its immediate social environment and larger sociopolitical setting. Interventions for depression therefore may benefit from a multilevel approach that addresses socioeconomic conditions, strengthens local resources, and fosters collaboration among locally appropriate informal and formal support structures.

Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by nodding syndrome in Uganda.

BACKGROUND: Despite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma. METHODS: A non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention. RESULTS: Caregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10-0.62] and 6 months (RR 0.33, 95% CI 0.11-0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers. CONCLUSION: IPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.

Natural Medicines for Psychotic Disorders: A Systematic Review.

Patients with psychotic disorders regularly use natural medicines, although it is unclear whether these are effective and safe. The aim of this study was to provide an overview of evidence for improved outcomes by natural medicines. A systematic literature search was performed through Medline, PsycINFO, CINAHL, and Cochrane until May 2015. In 110 randomized controlled trials, evidence was found for glycine, sarcosine, N-acetylcysteine, some Chinese and ayurvedic herbs, ginkgo biloba, estradiol, and vitamin B6 to improve psychotic symptoms when added to antipsychotics. Ginkgo biloba and vitamin B6 seemed to reduce tardive dyskinesia and akathisia. Results on other compounds were negative or inconclusive. All natural agents, except reserpine, were well tolerated. Most study samples were small, study periods were generally short, and most results need replication. However, there is some evidence for beneficial effects of certain natural medicines.

A review of mental health treatment dropout by ethnic minority youth.

A large proportion of treatments in youth mental health care are prematurely terminated by the patient. Treatment dropout can have severe consequences. Since ethnic minority youth are treated less often for mental disorders than other youth, it is important to analyse their risk for dropout and to determine if there are ethnicity-specific determinants. This review aimed to provide an overview of the findings from empirical studies on child and adolescent therapy dropout by ethnic minority and to determine if there were ethnicity-specific dropout determinants. An extensive literature search was performed to locate relevant journal articles. Identified articles were inspected for relevant references and these articles were then included in the meta-analysis. A total of 27 studies were accepted for analysis. The results showed that ethnic minority patients have a higher risk of treatment dropout than ethnic majority patients and that dropout rates are ethnically specific. Several differences in dropout predictors among the ethnic groups were found. In spite of diverse results, review limitations, and the lack of several key variables in the available research, some clinical recommendations are made. The review indicates that to prevent dropout, therapists should pay attention to variables such as ethnic background, therapist-patient ethnic match, and the quality of the therapeutic relationship.

Child mental health in Sierra Leone: a survey and exploratory qualitative study.

BACKGROUND: This study complements the growing amount of research on the psychosocial impact of war on children in Sierra Leone by examining local perceptions of child mental health, formal and informal care systems, help-seeking behaviour and stigma. METHODS: The study combined: (1) a nationwide survey of mental health care providers, with (2) exploratory qualitative research among service users and providers and other stakeholders concerned with child and adolescent mental health, with a particular emphasis on local explanations and stigma. RESULTS: Formal mental health care services are extremely limited resulting in an estimated treatment gap of over 99.8 %. Local explanations of child mental health problems in Sierra Leone are commonly spiritual or supernatural in nature, and associated with help-seeking from traditional healers or religious institutions. There is a considerable amount of stigma related to mental disorders, which affects children, their caregivers and service providers, and may lead to discrimination and abuse. CONCLUSIONS: Child and Adolescent Mental Health (CAMH) care development in Sierra Leone should cater to the long-term structural effects of war-violence and an Ebola epidemic. Priorities for development include: (1) the strengthening of legal structures and the development of relevant policies that strengthen the health system and specifically include children and adolescents, (2) a clearer local distinction between children with psychiatric, neurological, developmental or psychosocial problems and subsequent channelling into appropriate services (3) supplementary CAMH training for a range of professionals working with children across various sectors, (4) specialist training in CAMH, (5) integration of CAMH care into primary health care, education and the social welfare system, (6) further research on local explanations of child mental disorders and the effect they have on the well-being of the child, and (7) a careful consideration of the role of religious healers as care providers.

Family interventions in traumatized immigrants and refugees: A systematic review.

The importance of the family as a unit in the aftermath of trauma necessitates the use of family interventions among immigrants and refugees. While abundant clinical material suggests that family-based trauma interventions are applicable across cultures, very little is known about the extent to which family treatment modalities are effective for immigrants and refugees. We conducted a systematic review of intervention studies that have been designed or modified specifically for traumatized immigrant and refugee families. The terms "trauma," "family," and "immigrants/refugees/culture" were used along with different terms for "intervention." Studies with no research methodology were excluded. Only 6 experimental studies met our inclusion criteria; 4 of them describe school-based interventions and 2 present multifamily support groups. The shortage of research in this area does not allow clear conclusions about the effectiveness of family interventions for traumatized immigrants or refugees. The complexity of employing methodologically rigorous research in small communities is discussed. Future trials should go beyond the individualistic approach and focus on posttraumatic stress disorder to address family-level processes, such as family relationship, communication, and resilience.

A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies.

This paper describes how socio-ecological theory and a syndemic health systems and public health approach may help address the plight of youth in situations of political violence and humanitarian emergencies. We describe the treatment gap caused by discrepancies in epidemiological prevalence rates, individual and family needs, and available human and material resources. We propose four strategies to develop a participatory public health approach for these youth, based on principles of equity, feasibility, and a balance between prevention and treatment. The first strategy uses ecological and transgenerational resilience as a theoretical framework to facilitate a systems approach to the plight of youth and families. This theoretical base helps to engage health care professionals in a multisectoral analysis and a collaborative public health strategy. The second strategy is to translate pre-program assessment into mental health and psychosocial support (MHPSS) priorities. Defining priorities helps to develop programs and policies that align with preventive and curative interventions in multiple tiers of the public health system. The third is a realistic budgetary framework as a condition for the development of sustainable institutional capacity including a monitoring system. The fourth strategy is to direct research to address the knowledge gap about effective practices for youth mental health in humanitarian settings.

Medicinal plants used by traditional healers for the treatment of malaria in the Chipinge district in Zimbabwe.

ETHNOPHARMACOLOGICAL RELEVANCE: Because about 50% of the Zimbabwean population is at risk of contracting malaria each year, the majority of people, especially in rural areas, use traditional plant-based medicines to combat malaria. This explorative ethnobotanical survey was undertaken to document how malaria is conceptualized and diagnosed by traditional healers, and to record the medicinal plants used in the prevention and treatment of malaria, their mode of preparation and administration. MATERIALS AND METHODS: The research was conducted in three villages in Headman Muzite׳s area and in Chiriga village. These villages are located in the Chipinge district in the Manicaland Province in Zimbabwe.Traditional healers were selected with the assistance of the headman of the Muzite area and a representative of the Zimbabwe National Traditional Healers Association. Semi-structured interviews were conducted with 14 traditional healers from four villages in the Chipinge district in Zimbabwe. RESULTS: In total, 28 plants from 16 plant families are used by the healers who manage malaria with medicinal plants. The most cited plant is Cassia abbreviata Oliv. (Leguminosae) followed by Aristolochia albida Duch (Aristolociaceae) and Toddalia asiatica (L.) Lam. (Rutaceae). Roots (55.3%) are the most common part used. Most of the plant parts used to treat malaria are stored as dried powders in closed bottles. The powders are soaked in hot or cold water and the water extract is taken as the active medicine. The healers consider their medicinal knowledge as a spiritual family heritage. Only 25% of the healers refer the malaria patients that do not respond to their treatment to hospital - they believe evil spirits cause their remedies to failure and they would rather try a different plant or perform a cleansing ceremony. CONCLUSIONS: Local knowledge of medicinal plants in the treatment of malaria still exists in all four villages surveyed and traditional healers appear to play an important role in primary health care services in this remote rural area in Zimbabwe. This explorative survey underscores the need to preserve and document traditional healing for managing malaria and for more future scientific research on the plants to determine their efficacy and their safety. This could improve their traditional anti-malarial recipes and might contribute to a better integration of Zimbabwean traditional medicine into the national health system in the future.

Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?

BACKGROUND: The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence. AIMS: The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers. METHODS: A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments. RESULTS: The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples. CONCLUSIONS: This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed.

World Health organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead.

Wietse Tol and colleagues discuss some of the key challenges for implementation of new WHO guidelines for stress-related mental health disorders in low- and middle-income countries. Please see later in the article for the Editors' Summary.

Traditional health practitioners' perceptions, herbal treatment and management of HIV and related opportunistic infections.

BACKGROUND: In South Africa, traditional health practitioners' (THPs) explanatory frameworks concerning illness aetiologies are much researched. However there is a gap in the literature on how THPs understand HIV-related opportunistic infections (OIs), i.e. tuberculosis, candidiasis and herpes zoster. This study aimed to comprehend THPs' understandings of the aforementioned; to ascertain and better understand the treatment methods used by THPs for HIV and OIs, while also contributing to the documentation of South African medicinal plants for future conservation. METHODS: The study was conducted in two locations: Strand, Western Cape where THPs are trained and Mpoza village, Mount Frere, Eastern Cape from where medicinal plants are ordered or collected. Semi-structured interviews were conducted with 53 THPs of whom 36 were diviners (amagrirha: isangoma) and 17 herbalists (inyanga). THPs were selected through a non-probability "snowball" method. Data were analysed using a thematic content analysis approach. An ethnobotanical survey was conducted and plants used to manage HIV and OIs were collected. A complete set of voucher specimens was deposited at the University of the Western Cape Herbarium for identification. Plant names were checked and updated with Kew's online website http://www.theplantlist.org . RESULTS: THPs conceptualise the aetiology of HIV and OIs at two related levels. The first involves the immediate manifestation of the illness/condition because of a viral infection in the blood (HIV), the presence of bacteria in the lungs (tuberculosis), or weakened state of the body making it susceptible to OIs. The presence of OIs is indicative of the probable presence of HIV. The second level of causation affects the first, which includes pollution, changes in cultural sexual norms, witchcraft, environmental factors, and lack of adherence to ancestral rituals. THPs reported using 17 plants belonging to 12 families. Remedies included mixes of up to five plants. CONCLUSION: This study explored the THPs' perspectives on HIV and commonly associated OIs and their herbal treatment methods. THPs generally rely on biomedical diagnosis before treating a client. They also seek guidance from the ancestors for a particular diagnosis, the plants to use for a specific treatment, when to harvest, and how to administer herbal remedies.

Challenges of creating synergy between global mental health and cultural psychiatry.

This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.

Understanding resilience in armed conflict: social resources and mental health of children in Burundi.

Little is known about the role of cognitive social capital among war-affected youth in low- and middle-income countries. We examined the longitudinal association between cognitive social capital and mental health (depression and posttraumatic stress disorder (PTSD) symptoms), functioning, and received social support of children in Burundi. Data were obtained from face-to-face interviews with 176 children over three measurement occasions over the span of 4-months. Cognitive social capital measured the degree to which children believed their community was trustworthy and cohesive. Mental health measures included the Depression Self-Rating Scale (DSRS) (Birleson, 1981), the Child Posttraumatic Symptom Scale (Foa et al., 2001), and a locally constructed scale of functional impairment. Children reported received social support by listing whether they received different types of social support from self-selected key individuals. Cross-lagged path analytic modeling evaluated relationships between cognitive social capital, symptoms and received support separately over baseline (T1), 6-week follow-up (T2), and 4-month follow-up (T3). Each concept was treated and analyzed as a continuous score using manifest indicators. Significant associations between study variables were unidirectional. Cognitive social capital was associated with decreased depression between T1 and T2 (B = -.22, p < .001) and T2 and T3 (ß = -.25, p < .001), and with functional impairment between T1 and T2 (ß = -.15, p = .005) and T2 and T3 (ß = -.14, p = .005); no association was found for PTSD symptoms at either time point. Cognitive social capital was associated with increased social support between T1 and T2 (ß = .16, p = .002) and T2 and T3 (ß = .16, p = .002). In this longitudinal study, cognitive social capital was related to a declining trajectory of children's mental health problems and increases in social support. Interventions that improve community relations in war-affected communities may alter the trajectories of resource loss and gain with conflict-affected children.

School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial.

BACKGROUND: Armed conflicts are associated with a wide range of impacts on the mental health of children and adolescents. We evaluated the effectiveness of a school-based intervention aimed at reducing symptoms of posttraumatic stress disorder, depression, and anxiety (treatment aim); and improving a sense of hope and functioning (preventive aim). METHODS: We conducted a cluster randomized trial with 329 children in war-affected Burundi (aged 8 to 17 (mean 12.29 years, standard deviation 1.61); 48% girls). One group of children (n = 153) participated in a 15-session school-based intervention implemented by para-professionals, and the remaining 176 children formed a waitlist control condition. Outcomes were measured before, one week after, and three months after the intervention. RESULTS: No main effects of the intervention were identified. However, longitudinal growth curve analyses showed six favorable and two unfavorable differences in trajectories between study conditions in interaction with several moderators. Children in the intervention condition living in larger households showed decreases on depressive symptoms and function impairment, and those living with both parents showed decreases on posttraumatic stress disorder and depressive symptoms. The groups of children in the waitlist condition showed increases in depressive symptoms. In addition, younger children and those with low levels of exposure to traumatic events in the intervention condition showed improvements on hope. Children in the waitlist condition who lived on their original or newly bought land showed improvements in hope and function impairment, whereas children in the intervention condition showed deterioration on these outcomes. CONCLUSIONS: Given inconsistent effects across studies, findings do not support this school-based intervention as a treatment for posttraumatic stress disorder and depressive symptoms in conflict-affected children. The intervention appears to have more consistent preventive benefits, but these effects are contingent upon individual (for example, age, gender) and contextual (for example, family functioning, state of conflict, displacement) variables. Results suggest the potential benefit of school-based preventive interventions particularly in post-conflict settings. TRIAL REGISTRATION: The study was registered as ISRCTN42284825.

Psychosocial interventions for children exposed to traumatic events in low- and middle-income countries: study protocol of an individual patient data meta-analysis.

BACKGROUND: The burden of mental health and psychosocial problems in children exposed to traumatic events in humanitarian settings in low- and middle-income countries is substantial. An increasing number of randomized studies has shown promising effects of psychosocial interventions, but this evidence has shown complexity with regard to setting, conflict-phase, gender, and age. These complex findings raise the need of a detailed evaluation of the specific factors which influence size and direction of intervention effects.Individual patient data meta-analysis is a specific type of meta-analysis that allows the collection of exact information at an individual patient level, and to examine whether intervention and socio-demographic characteristics, trauma-related variables, environmental conditions, and social support may act as moderators and mediators of intervention effect.The aim of the present study is to carry out an individual patient data meta-analysis using data from all available randomized controlled trials (either published or unpublished) comparing psychosocial intervention with waiting list or no intervention arms in children exposed to traumatic events living in low- and middle-income countries. METHODS/DESIGN: All randomized trials comparing selective preventive psychosocial intervention versus waiting list or no treatment conditions in children (0-18 years) living in low- and middle-income countries will be included. Studies will be identified in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. There will be no restrictions on publication type, status, language, or date of publication. The primary outcome measures will be psychological symptoms (post-traumatic stress disorder, anxiety, depression). Secondary outcomes will be positive mental health outcomes (coping methods, social support, self-esteem), and function impairment. DISCUSSION: We are expecting that some variables, like socio-demographic characteristics, trauma-related variables, environmental conditions, and social support will act as moderators/mediators of intervention effect. The investigation of the role of these factors on the intervention effects will help in the appropriate selection, development, implementation, and dissemination of evidence-based programs in low- and middle-income countries. TRIAL REGISTRATION: This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42013006960).

Validation of the Kirundi versions of brief self-rating scales for common mental disorders among children in Burundi.

BACKGROUND: In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi. METHODS: Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external 'gold standard' criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL). RESULTS: The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90. CONCLUSIONS: The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.

Pitfalls in the assessment, analysis, and interpretation of routine outcome monitoring (ROM) Data: results from an outpatient clinic for integrative mental health.

There is considerable debate about routine outcome monitoring (ROM) for scientific or benchmarking purposes. We discuss pitfalls associated with the assessment, analysis, and interpretation of ROM data, using data of 376 patients. 206 patients (55 %) completed one or more follow-up measurements. Mixed-model analysis showed significant improvement in symptomatology, quality of life, and autonomy, and differential improvement for different subgroups. Effect sizes were small to large, depending on the outcome measure and subgroup. Subtle variations in analytic strategies influenced effect sizes substantially. We illustrate how problems inherent to design and analysis of ROM data prevent drawing conclusions about (comparative) treatment effectiveness.