Abstract
Abstract Aims Common mental disorders are highly prevalent among Syrian refugees. Problem Management Plus (PM+) is a brief, transdiagnostic, non-specialist helper delivered, psychological intervention targeting psychological distress. This single-blind pilot randomised controlled trial (RCT) on PM+ delivered by peer-refugees examined trial procedures in advance of a definitive RCT, evaluated PM+ 's acceptability and feasibility, and investigated its likely effectiveness and cost-effectiveness among Syrian refugees in the Netherlands. Methods Adult Syrian refugees (N = 60) with elevated psychological distress (Kessler Psychological Distress Scale (K10) score >15) and reduced pychosocial functioning (WHO Disability Assessment Schedule 2.0 (WHODAS) score >16) were randomised into PM+ in addition to care as usual (CAU) (PM+/CAU; n = 30) or CAU alone (n = 30). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes were pychosocial functioning (WHO Disability Assessment Schedule; WHODAS 2.0), symptoms of posttraumatic stress disorder (PTSD) (PTSD Checklist for DSM 5; PCL-5) and self-identified problems (Psychological Outcomes Profiles; PSYCHLOPS). Changes in service utilisation and time out of employment and/or adult education were estimated (adapted version of the Client Service Receipt Inventory; CSRI). Semi-structured interviews on the implementation of PM+ were conducted with stakeholders (i.e. six PM+ participants, five non-specialist helpers and five key informants). Results Recruitment, randomization and blinding procedures were successful. PM+ was generally perceived positively by stakeholders, especially regarding the intervention strategies, accommodation of the intervention and the helpers. Two serious adverse events not attributable to the trial were reported. At 3-month follow-up, the HSCL-25 total score was significantly lower for the PM+/CAU group (n = 30) than CAU group (n = 30) (p = 0.004; d = 0.58). Significant differences in favour of PM+/CAU were also found for WHODAS psychosocial functioning (p = 0.009, d = 0.73), PCL-5 symptoms of PTSD (p = 0.006, d = 0.66) and PSYCHLOPS self-identified problems (p = 0.005, d = 0.81). There were no significant differences in mean health service costs (p = 0.191) and the mean costs of lost productive time (p = 0.141). This suggests PM+ may potentially be cost-effective with an incremental cost from a health system perspective of €5047 (95% CI €0–€19 773) per additional recovery achieved. Conclusions Trial procedures and PM+ delivered by non-specialist peer-refugee helpers seemed acceptable, feasible and safe. Analyses indicate that PM+ may be effective in improving mental health outcomes and psychosocial functioning, and potentially cost-effective. These results support the development of a definitive RCT with a larger sample of refugees and a longer follow-up period.
Highlights
Recent years have witnessed a dramatic increase in the number of asylum seekers and refugees worldwide, largely accounted for by refugees fleeing from the war in Syria to its neighbouring countries and Europe (UNHCR, 2018)
Post-hoc tests showed PM+/care as usual (CAU) relative to the CAU had lower scores 1 week (mean [standard deviation] 1.86 [0.58] v. 2.38 [0.65]; adjusted mean difference (AMD), 0.45; 95% CI 0.29–0.61, p = 0.005) and 3 months after the intervention (1.92 [0.62] v. 2.42 [0.59]; AMD 0.48; 95% CI 0.32– 0.65, p = 0.004)
We found a significant effect of time for HSCL-25 depression, moderated by condition (χ2(2) = 8.58; p = 0.013)
Summary
Recent years have witnessed a dramatic increase in the number of asylum seekers and refugees worldwide, largely accounted for by refugees fleeing from the war in Syria to its neighbouring countries and Europe (UNHCR, 2018). The steep increase in refugees carries significant public health implications (Priebe et al, 2016). Since the outbreak of the Syrian war, there has been an increase in studies evaluating mental health and psychosocial support programmes for Syrian refugees in Europe High-income countries such as the Netherlands have specialised mental health staff and programmes available for refugees, the treatment gap is large. Studies among refugees/migrants found that a large proportion did not receive adequate mental health care (Lamkaddem et al, 2014; Priebe et al, 2016).
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