Problem Management Plus Research Articles

Community mental health for migrant women in Barcelona (“Self-Care Among Women”): Protocol for a mixed-methods process evaluation of a pilot psychological intervention

IntroductionMigrant populations, especially women, are often more susceptible to poor mental health and they face healthcare access barriers. This study aims to develop and evaluate a community-based mental health intervention through a participative research process to promote mental health and prevent psychiatric disorders among migrant women in Barcelona city. The intervention is built upon two evidence-based guidelines: Group Problem Management Plus (Group PM+) and Self-Help Plus (SH+). Methods“Self-Care Among Women” is a mixed-methods process evaluation study for the development of a community-based psychological pilot intervention. A participatory approach will be employed to adapt the content agenda of the community mental health intervention. Process indicators on context, implementation and mechanisms of change will be assessed through an intersectionality lens to explore the way in which the intervention is developed and implemented. The contextual fit, acceptability and feasibility of the proposed psychological intervention will be examined through participants' and facilitators' perceptions of the intervention. Further, women's clinical mental health condition and wellbeing will be assessed before and after the intervention, through standardized and culturally-validated instruments. Ethics and disseminationEthical approval of the research protocol has been obtained by the Research Ethics Committees of Hospital Clínic, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol) and Parc Sanitari Sant Joan de Déu. Written informed consent will be requested from all research participants for inclusion in the study. The study results will be published in peer-reviewed journals and communicated to congresses.

Feasibility and acceptability of the Problem Management for Moms programme for improving maternal mental health in Zambia: an open-label trial

Psychological distress is common among mothers in low-income and middle-income countries, limiting their capacity to care for themselves and their children. This study aimed to test the feasibility and acceptability of an adapted psychosocial intervention for distressed mothers in low-resource settings. In this open-label trial, we enrolled women living in Lusaka, Zambia, with high mental distress (>7 score on the 20-item Self-Reporting Questionnaire [SRQ-20]) and children younger than 2 years, who had previously enrolled in the ZamCharts early childhood nutrition trial. We randomly assigned participants (1:1) to the intervention or control group using a random number draw. The intervention was a newly developed Problem Management for Moms (PM4M) programme: a ten-session treatment adapted from Problem Management Plus, which was offered by phone or in person. After randomisation, participants in the intervention group underwent pre-intervention screening, a post-intervention assessment, and a final follow-up assessment 9 months after treatment initiation (ie, final follow-up visit). The control group was assessed at the baseline of ZamCharts and at the final follow-up assessment, and these participants did not receive any intervention. The primary study outcomes were feasibility, acceptability, and participant mental distress measured using the SRQ-20. All primary and secondary outcomes were estimated in the intention-to-treat population, which included all participants who were randomised to the intervention group and attended the final follow-up assessment. Data on ethnicity were not collected. The trial is registered at ClinicalTrials.gov, NCT05627206, and has been completed. Women with lived experience of mental health symptoms were involved in this study. Between April 26, and July 14, 2021, 790 women were interviewed in the ZamCharts trial, of whom 265 had high mental distress and were randomly assigned to treatment groups in this trial (134 to the intervention group and 131 to the control group). Of the 134 women in the intervention group, 61 (46%) received the PM4M intervention and 73 (55%) were excluded; 103 in the intervention group and 106 in the control group were successfully interviewed at the final follow-up assessment. The mean age of participants was 27·6 years (SD 7·6) at ZamCharts baseline. PM4M sessions were conducted between Dec 16, 2022, and May 6, 2023. The 61 participants deemed eligible after pre-intervention screening who started the intervention completed a mean of 7·9 (SD 2·9) of ten sessions. 55 (77%) of these 61 participants were somewhat or very satisfied with the intervention. In adjusted intention-to-treat models, the intervention reduced mean SRQ-20 scores by 2·11 points (95% CI -3·50 to -0·63) at the final follow-up, and the adjusted odds ratio of having an SRQ-20 of more than 7 was 0·50 (95% CI 0·27 to 0·93). No serious adverse events were reported. The results presented here suggest that the PM4M mental health intervention is feasible and has high rates of acceptability. Further research is needed to assess the long-term efficacy of this intervention on women and their children, and its suitability for integration into routine care. The Eckenstein-Geigy Professorship.

Effectiveness, cost-effectiveness, and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): a stepped-wedge, cluster-randomised, controlled trial

In low-income and middle-income countries, individuals with major depressive disorder often do not receive screening and treatment. We assessed effectiveness and cost-effectiveness of an integrated care model for treating major depressive disorder in Malawi, accounting for two sets of positive externalities: household benefits and improvements in comorbidities. In this stepped-wedge, cluster-randomised, controlled trial, 14 health facilities in Neno District, Malawi, introduced screening, diagnosis, and treatment for people with major depressive disorder, using a stepped-care model of group Problem Management Plus and antidepressant therapy. Adults (ie, aged ≥18 years) residing in facility catchment areas, newly diagnosed with major depressive disorder, and actively enrolled in an integrated chronic care clinic were eligible for inclusion. People identified with high suicidal risk or psychotic symptoms were excluded. Health facilities were categorised into two strata (ie, health centres or secondary hospitals) and randomly allocated to one of five trial sequences, with intervention initiation staggered across sequences in 3-month periods. Participants were masked to trial sequence, data collectors were masked to treatment assignment, and the chief statistician was masked to treatment assignment until analysis. Services were delivered by counsellors and clinical officers at integrated chronic care clinics, and assessments took place at 3-month intervals over 27 months. Primary outcomes were changes in depressive symptom severity (measured with the Patient Health Questionnaire-9 [PHQ-9]), current depressive episode (PHQ-9 score of >10), and functioning (measured with the WHO Disability Assessment Schedule 2.0) over the 27-month period. Longitudinal mixed-effects regression analyses assessed outcomes from an intention-to-treat perspective. The trial was registered with ClinicalTrials.gov (NCT04777006) and is completed. Between Sept 1, 2021, and April 28, 2022, we conducted 15 562 screenings, resulting in 506 (3%) adults identified with major depressive disorder and 487 (3%) enrolled (395 [81%] women and 92 [19%] men). Assignment to IC3D corresponded to a 2·60-point (95% CI -3·35 to -1·86; d -0·61) reduction in depressive symptoms and 1·69-point (-2·73 to -0·65; -0·27) improvement in functioning, reflecting a reduced odds of depression after treatment roll-out (adjusted odds ratio 0·62, 95% CI 0·51 to 0·74). Integrated care for people with major depressive disorder and chronic health conditions is effective at reducing depressive symptoms, improving functioning, and reducing the odds of depression, and facilitates expansion of services through existing infrastructure. National Institute of Mental Health.

Peer‐provided problem management plus (PM+) and case management for Arabic‐speaking and Farsi‐speaking refugees and asylum seekers in Greece

AbstractAn increasingly common response to the lack of specialist mental health services for refugees and asylum seekers in European host countries is peer‐supported services. This study examined the association between a peer‐provided psychosocial intervention and psychological symptom reduction among refugees and asylum seekers in Greece. The intervention consisted of Problem Management Plus (PM+) and peer case management sessions delivered by a team of Community Psychosocial Workers (trained refugees). The sample consisted of 173 participants, comprising Arabic and Farsi speakers, male and female participants, recognized refugees and asylum seekers. Anxiety, depression, and psychological distress were measured before and after the intervention using the Patient Health Questionnaire‐9, Generalized Anxiety Disorder‐7, and Psychological Outcome Profiles scales, respectively. Repeated measures analysis of variance was adopted to evaluate the difference in the degree of change across patient characteristics over the follow‐up period. The level of statistical significance was set at p < .05, and analyses were conducted using SPSS statistical software (version 26.0). Significant decreases were found in all postintervention scores, indicating significant decreases in anxiety and depression symptoms as well as in psychological distress following the peer‐provided psychosocial intervention, which included emotional support and social care. Large effect sizes were found at all scales. The findings support the notion that there is an association between the implemented intervention and symptom reduction in refugees. For future research, a randomized controlled trial is proposed as a study protocol.

Syrian refugee young adults as community mental health workers implementing problem management plus: Protocol for a pilot randomized controlled trial to measure the mechanisms of effect on their own wellbeing, stress and coping

This pilot randomized controlled trial protocol aims to (1) assess the impact on the wellbeing of Syrian refugee young adults (18–24 years) of being a community mental health worker (CMHW) implementing WHO's evidence-based psychosocial intervention - Problem Management Plus (PM+) - with adults in their community, and (2) identify the mechanisms associated with the outcomes of enhanced wellbeing and coping, and reduced stress among these CMHWs. Over 108 million people have been forcibly displaced as of the end of 2022. Mental health consequences of these displacements are significant, yet human resources for health are not sufficient to meet the needs. A large proportion of refugee populations are youth and young adults (YA). Evidence indicates their engagement in supporting their communities leads to their own enhanced wellbeing and that of their community. This trial trains Syrian refugees to serve their communities as CMHW (n=19) or tutors (n=19) and compare wellbeing, stress and coping outcomes between these two groups and a control group (n = 40). We will also assess 7 mechanisms as potential pathways for the interventions to influence outcomes. Surveys will assess outcomes and mechanisms, hair samples will measure stress cortisol. The primary analysis will use a Bayesian Hierarchical Model approach to model the trajectories of the mechanisms and primary study endpoints over time for individuals in each of the arms. Our results will elucidate critical mechanisms in which engagement of young adults to support their community enhances their own wellbeing. Trial registrationNational Institutes of Mental Health, NCT05265611, Registered prospectively in 2021. Lebanon clinical trials registry #LBCTR2023015206, Registered in 2023.

Comparing Mediators and Moderators of Mental Health Outcomes from the Implementation of Group Problem Management Plus (PM+) among Venezuelan Refugees and Migrants and Colombian Returnees in Northern Colombia.

Colombia hosts the largest number of refugees and migrants fleeing the humanitarian emergency in Venezuela, many of whom experience high levels of displacement-related trauma and adversity. Yet, Colombian mental health services do not meet the needs of this population. Scalable, task-sharing interventions, such as Group Problem Management Plus (Group PM+), have the potential to bridge this gap by utilizing lay workers to provide the intervention. However, the current literature lacks a comprehensive understanding of how and for whom Group PM+ is most effective. This mixed methods study utilized data from a randomized effectiveness-implementation trial to examine the mediators and moderators of Group PM+ on mental health outcomes. One hundred twenty-eight migrant and refugee women in northern Colombia participated in Group PM+ delivered by trained community members. Patterns in moderation effects showed that participants in more stable, less marginalized positions improved the most. Results from linear regression models showed that Group PM+-related skill acquisition was not a significant mediator of the association between session attendance and mental health outcomes. Participants and facilitators reported additional possible mediators and community-level moderators that warrant future research. Further studies are needed to examine mediators and moderators contributing to the effectiveness of task-shared, scalable, psychological interventions in diverse contexts.

A scoping review of the literature on the application and usefulness of the Problem Management Plus (PM+) intervention around the world.

Given the high rates of common mental disorders and limited resources, task-shifting psychosocial interventions are needed to provide adequate care. One such intervention developed by the World Health Organization is Problem Management Plus (PM+). This review maps the evidence regarding the extent of application and usefulness of the PM+ intervention, i.e. adaptability, feasibility, effectiveness and scalability, since it was introduced in 2016. We conducted a scoping review of seven literature databases and grey literature from January 2015 to February 2024, to identify peer-reviewed and grey literature on PM+ around the world. Out of 6739 potential records, 42 met the inclusion criteria. About 60% of the included studies were from low- and middle-income countries. Findings from pilot/feasibility trials demonstrated that PM+ is feasible, acceptable and safe. Results from definitive randomised controlled trials at short-term follow-up also suggested that PM+ is effective, with overall moderate-to-large effect sizes, in improving symptoms of common mental health problems. Although PM+ was more effective in reducing symptoms of common mental disorders, it was found to be costlier compared to usual care in the only study that evaluated its cost-effectiveness. Our findings indicate that PM+, in its individual and group formats, can be adapted and effectively delivered by trained helpers to target a wide range of common mental health concerns. More effectiveness and implementation evidence is required to understand the long-term impact of PM+, its cost-effectiveness and scalability, and moderators of treatment outcomes such as gender and delivery formats.

Evaluation of a scalable psychosocial intervention for refugees in Greece

IntroductionThe world of the third millennium is witnessing the highest levels of displacement on record. To meet the specific needs of this vulnerable population, a task-shifting approach is developed, where individuals with refugee background and lived experience are trained and supervised my mental health professionals to provide emotional and practical support to members of their communities.ObjectivesThe evaluation of a scalable psychosocial intervention for refugees based on the task-shifting approach.MethodsThe intervention consisted of sessions of Problem Management Plus (PM+) and peer case management delivered by a team of community psychosocial workers (trained refugees). The sample consisted of 173 participants, Arabic- and Farsi-speakers male and female, recognized refugees, and asylum seekers. Anxiety, depression, and psychological distress were measured before and after the intervention using the Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire - 9 (PHQ-9), and Psychological Outcome Profiles (Psychlops) scales respectively. Repeated measures analysis of variance (ANOVA) was adopted to evaluate the difference in the degree of change across patients’ characteristics over the follow up period. Statistical significance was set at p<0.05 and analyses were conducted using SPSS statistical software (version 26.0).ResultsSignificant decreases were found in all post-test scales, indicating diminution of anxiety, depression symptoms, and psychological distress. Large effects sizes were found in all scales.ConclusionsThe findings support that task-shifting approach incorporating PM+ and case management is effective for the mental health of refugees. Peer support could be included in a stepped care model for refugee mental health and well-being in high-income countries. For future research a randomized controlled trial is proposed as a study protocol.Disclosure of InterestNone Declared

A qualitative evaluation of the use of Problem Management Plus (PM+) among Arabic-speaking migrants with psychological distress in France - The APEX study.

ABSTRACTBackground: Feasibility studies with non-French speaking migrants in France are needed to inform appropriate adaptation of psychosocial intervention procedures.Objective: To test the WHO Problem Management Plus (PM+) intervention protocol for Arabic-speaking migrants in the Paris metropolitan region.Methods: Between 2019 and 2021 we recruited participants from three accommodation centres receiving asylum seekers or migrants experiencing social and economic difficulties. Participants experiencing psychological distress underwent five PM + sessions with trained helpers. Feasibility was evaluated through 15 interviews with 8 participants, 4 helpers, and 3 study supervisors. Interview topics covered PM + implementation in general and for each component. We also sought to understand problems with delivery and gathered suggestions for improvement. Data were analysed thematically using a deductive approach.Results: We found implementation of PM + to be feasible, with predominantly positive reactions from participants, helpers and study staff. All intervention components were considered beneficial, with breathing exercises considered easy to implement and often sustained. Selection of problems and strategies to address them were described as challenging to execute. Psychosocial support from and rapport with helpers and the use of the native language were considered key strengths of the programme. However, we observed the need for complementary or higher intensity psychological support in some cases. Findings also highlighted the importance of addressing distress among non-specialist helpers delivering PM + . Finally, local guidance to social resources were suggested to be added in the protocol.Conclusion: PM + was well-liked and feasible, with cultural adjustments and increased access to community resources for migrants needed.

AB003. Implementation of Group Problem Management Plus among displaced women in Colombia: a qualitative examination of a community-delivered mental health intervention

AB003. Implementation of Group Problem Management Plus among displaced women in Colombia: a qualitative examination of a community-delivered mental health intervention

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda

BackgroundThe war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent.MethodsA parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat.DiscussionCHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery.Trial registrationISRCTN ISRCTN10360385. Registered on 30 January 2023.

Evaluating a stepped care model of psychological support for adults affected by adversity: study protocol for a randomised controlled trial in Jordan

BackgroundThe burden of common mental disorders in low and middle-income countries (LMICs) is growing with little known about how to allocate limited resources to reach the greatest number of people...

Addressing challenges faced by young refugees in the Netherlands: Adapting problem management plus (PM+) with an emotional processing module.

Young refugees face numerous challenges before, during, and after their journey, leading to higher rates of mental health issues such as depression, anxiety, and posttraumatic stress disorder. These problems often remain untreated due to barriers like limited services, stigma, and varied distress expressions. One effective scalable intervention that bridges this treatment gap is problem management plus (PM+), a transdiagnostic program delivered by trained nonspecialists. However, PM+ lacks a module directly targeting posttraumatic stress, which is a common problem in young refugees. This study presents the cultural and contextual adaptation process of PM+ for young refugees in the Netherlands that includes a newly developed emotional processing module. Qualitative data collection included free list interviews with youngsters (n = 33), key informant interviews with professionals (n = 9), policymakers (n = 5), key people from communities (n = 10), focus group discussions (n = 11) and one focused interview. A new module targeting distressing memories was developed and reviewed by experts (n = 14). Results supported protocol adaptations, including culturally and age-appropriate language, examples, illustrations and length. This research aims to develop feasible, culturally sensitive mental health interventions tailored to the unique needs of young refugees.

Enhancing mental health and well-being in adults from lower-resource settings: A mixed-method evaluation of the impact of problem management plus.

Mental health conditions, recognised as a global crisis, were further exacerbated by the COVID-19 pandemic. Access to mental health services remains limited, particularly in low-income regions. Task-sharing interventions, exemplified by Problem Management Plus (PM+), have emerged as potential solutions to bridge this treatment gap. This study presents an evaluation of the PM+ scale-up in Sub-Saharan Africa (Ethiopia and Benin) and Eastern Europe (Croatia and Bosnia and Herzegovina) as part of a mental health and psychosocial support programming including 87 adult participants. A mixed-method approach assesses the impact of the intervention. Quantitative analyses reveal significant reductions in self-reported problems, depression, anxiety and improved functioning. Qualitative data highlight four main themes: general health, family relationships, psychosocial problems and daily activities. These thematic areas demonstrate consistent improvements across clients, irrespective of the region. The findings underscore the impact of PM+ in addressing a broad spectrum of client issues, demonstrating its potential as a valuable tool for mitigating mental health challenges in diverse settings. This study contributes to the burgeoning body of evidence supporting PM+ and highlights its promise in enhancing mental health outcomes on a global scale, particularly for vulnerable populations.

The effectiveness of Problem Management Plus at 1-year follow-up for Syrian refugees in a high-income setting.

Problem Management Plus (PM+) has been effective in reducing mental health problems among refugees at three-month follow-up, but there is a lack of research on its long-term effectiveness. This study examined the effectiveness of PM+ in reducing symptoms of common mental disorders at 12-month follow-up among Syrian refugees in the Netherlands. This single-blind, parallel, controlled trial randomised 206 adult Syrians who screened positive for psychological distress and impaired functioning to either PM+ in addition to care as usual (PM+/CAU) or CAU alone. Assessments were at baseline, 1 week and 3 months after the intervention and 12 months after baseline. Outcomes were psychological distress (Hopkins Symptom Checklist [HSCL-25]), depression (HSCL-25 subscale), anxiety (HSCL-25 subscale), posttraumatic stress disorder symptoms (PCL-5), functional impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS). In March 2019-December 2022, 103 participants were assigned to PM+/CAU and 103 to CAU of which 169 (82.0%) were retained at 12 months. Intention-to-treat analyses showed greater reductions in psychological distress at 12 months for PM+/CAU compared to CAU (adjusted mean difference -0.17, 95% CI -0.310 to -0.027; p = 0.01, Cohen's d = 0.28). Relative to CAU, PM+/CAU participants also showed significant reductions on anxiety (-0.19, 95% CI -0.344 to -0.047; p = 0.01, d = 0.31) but not on any of the other outcomes. PM+ is effective in reducing psychological distress and symptoms of anxiety over a period up to 1 year. Additional support such as booster sessions or additional (trauma-focused) modules may be required to prolong and consolidate benefits gained through PM+ on other mental health and psychosocial outcomes.

Comparing implementation strategies for training and supervising nonspecialists in Group Problem Management Plus: A hybrid effectiveness-implementation trial in Colombia.

Migrants and refugees face elevated risks for mental health problems but have limited access to services. This study compared two strategies for training and supervising nonspecialists to deliver a scalable psychological intervention, Group Problem Management Plus (gPM+), in northern Colombia. Adult women who reported elevated psychological distress and functional impairment were randomized to receive gPM+ delivered by nonspecialists who received training and supervision by: 1) a psychologist (specialized technical support); or 2) a nonspecialist who had been trained as a trainer/supervisor (nonspecialized technical support). We examined effectiveness and implementation outcomes using a mixed-methods approach. Thirteen nonspecialists were trained as gPM+ facilitators and three were trained-as-trainers. We enrolled 128 women to participate in gPM+ across the two conditions. Intervention attendance was higher in the specialized technical support condition. The nonspecialized technical support condition demonstrated higher fidelity to gPM+ and lower cost of implementation. Other indicators of effectiveness, adoption and implementation were comparable between the two implementation strategies. These results suggest it is feasible to implement mental health interventions, like gPM+, using lower-resource, community-embedded task sharing models, while maintaining safety and fidelity. Further evidence from fully powered trials is needed to make definitive conclusions about the relative cost of these implementation strategies.

Effectiveness of group problem management plus in distressed Syrian refugees in Türkiye: a randomized controlled trial.

Despite high levels of psychological distress, mental health service use among Syrian refugees in urban settings is low. To address the mental healthcare gap, the World Health Organization developed group problem management plus (gPM+), a scalable psychological intervention delivered by non-specialist peer facilitators. The study aimed to evaluate the effectiveness of gPM+ in reducing symptoms of depression and anxiety among Syrian refugees in Istanbul, Türkiye. A randomized controlled trial was conducted among 368 distressed (Kessler Psychological Distress Scale, K10 > 15) adult Syrian refugees with impaired functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16). Participants were recruited between August 2019 and September 2020 through a non-governmental organization providing services to refugees. Participants were randomly allocated to gPM+ and enhanced care as usual (gPM+/E-CAU) (184 participants) or E-CAU only (184 participants). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist (HSCL-25)) at 3-month follow-up. Secondary outcomes were post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5; PCL-5), functional impairment (WHODAS 2.0), and self-identified problems (psychological outcome profiles). Intent-to-treat analyses showed no significant effect of gPM+ on symptoms of anxiety, depression, PTSD and self-identified problems. Yet, there was a significant reduction in functional impairment in gPM+/E-CAU compared to E-CAU at 3-month follow-up (adjusted mean difference 1.66, 95 % CI 0.04, 3.27, p = 0.045, d = 0.19). Post-hoc subgroup analyses among participants with probable baseline depression or anxiety showed that there was a small but significant reduction in depression (adjusted mean difference -0.17, 95 % CI -0.32, -0.02, p = 0.028, d = 0.27) and anxiety (adjusted mean difference -0.21, 95 % CI -0.37, -0.05, p = 0.009, d = 0.30) symptoms comparing gPM+/E-CAU to E-CAU only at 1-week post assessment, but not at 3-month follow-up. There was a significant difference between conditions on functional impairment at 3-month follow-up, favouring gPM+/E-CAU condition (adjusted mean difference -1.98, 95 % CI -3.93, -0.02, p = 0.048, d = 0.26). In this study in an urban setting in Türkiye, gPM+ did not alleviate symptoms of depression and anxiety among Syrian refugees experiencing psychological distress and daily living difficulties. However, participants with higher distress at baseline seemed to benefit from gPM+, but treatment gains disappeared in the long term. Current findings highlight the potential benefit of tailored psychosocial interventions for highly distressed refugees in volatile low-resource settings.

Beyond effectiveness in eHealth trials: Process evaluation of a stepped-care programme to support healthcare workers with psychological distress (RESPOND-HCWs).

This study presents the process evaluation of an effective stepped-care programme of eHealth interventions (Doing What Matters in Times of Stress [DWM] and Problem Management Plus [PM+]) for healthcare workers (HCWs) with psychological distress (RESPOND-HCWs trial) conducted in Spain. The aim is to analyse the context in which the programme was delivered, assess key implementation outcomes and explore mechanisms of action. We used mixed methods. Quantitative data came from routine randomised control trial monitoring and structured observation, and qualitative data were collected using semi-structured, in-depth interviews with trial participants (n = 12) and decision-makers (n = 7) and a focus group discussion with intervention providers (n = 7). We conducted a descriptive analysis of quantitative data using R software and a thematic analysis of qualitative data using NVivo. Context analysis revealed implementation barriers, including unrealistic expectations of participants about the programme and mental health-related stigma. The flexibility of interventions and the opportunity for mental health actions were enabling factors. Implementation outcomes showed that the trial was feasible, appropriate and timely, and that the intervention was delivered with minimal protocol deviations and good acceptance among participants. Mechanisms of action included confidence in the positive effect of the intervention, a good therapeutic relationship and specific intervention components. These results supplement the outcome evaluation and can help inform large-scale implementation in similar settings. Specific recommendations include increasing mental health awareness and reducing stigma in the implementation setting, including a short orientation session and ensuring flexibility in schedules and peer support. NCT04980326.

Programmatic implementation of depression screening and remote mental health support sessions for persons recently diagnosed with TB in Lima, Peru during the COVID-19 pandemic.

Few studies have explored a stepped care model for delivering mental health care to persons with tuberculosis (TB). Here, we evaluated depression screening and remote low-intensity mental health interventions for persons initiating TB treatment in Lima, Peru during the COVID-19 pandemic. We used the Patient Health Questionnaire 9 (PHQ-9) to screen participants for depressive symptoms (PHQ-9≥5). Participants with PHQ-9, 5-14 received remote Psychological First Aid (PFA) or Problem Management Plus (PM+). Participants were reevaluated 6months after intervention completion. We then compared the change in median PHQ-9 scores before and after intervention completion. Those with PHQ-9≥15 were referred to higher-level care. We found that 62 (45.9%) of the 135 participants had PHQ-9≥5 at baseline. Then, 54 individuals with PHQ-9, 5-9 received PFA, of which 44 (81.5%) were reevaluated. We observed significant reductions in median PHQ-9 scores from 6 to 2 (r=0.98; p<0.001). Four participants with PHQ-9, 10-14 received PM+ but were unable to be reevaluated. Four participants with PHQ-9≥15 were referred to higher-level care. Depressive symptoms were common among persons recently diagnosed with TB. We observed improvements in depressive symptoms 6months later for most participants who received remote sessions of PFA.

Addressing mental health problems among persons without stable housing in the context of the COVID-19 pandemic: study protocol for a randomised trial. RESPOND – France

BackgroundThe COVID-19 pandemic has had an impact on population-wide mental health and well-being. Although people experiencing socioeconomic disadvantage may be especially vulnerable, they experience barriers in accessing mental health care. To overcome these barriers, the World Health Organization (WHO) designed two scalable psychosocial interventions, namely the web-based Doing What Matters in Times of Stress (DWM) and the face-to-face Problem Management Plus (PM+), to help people manage stressful situations. Our study aims to test the effectiveness of a stepped-care program using DWM and PM + among individuals experiencing unstable housing in France – a majority of whom are migrant or have sought asylum.MethodsThis is a randomised controlled trial to evaluate the effectiveness and cost effectiveness of a stepped-care program using DWM and PM + among persons with psychological distress and experiencing unstable housing, in comparison to enhanced care as usual (eCAU). Participants (N = 210) will be randomised to two parallel groups: eCAU or eCAU plus the stepped-care program. The main study outcomes are symptoms of depression and anxiety measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS).DiscussionThis randomised controlled trial will contribute to a better understanding of effective community-based scalable strategies that can help address the mental health needs of persons experiencing socioeconomic disadvantage, whose needs are high yet who frequently have limited access to mental health care services.Trial registrationthis randomised trial has been registered at ClinicalTrials.gov under the number NCT05033210.