Responding to emotional distress as a result of exposure to war and displacement
Anna Chiumento is a PhD Researcher at the University of Liverpool, investigating researchers' construction and management of ethical issues in post-conflict mental health research. Anna is also concurrently working with SHARE and the WHO.
Additional details of the trial can be found on MHIN's Innovation Case Study.
Displacement and emotional distress
65.3 million people, or an average of 24 people a minute, were forced to flee their homes in 2015, four times more than a decade earlier. To put it in perspective, this number is larger than the population of the UK living in displacement.
The majority of those who have been displaced have experienced war, potentially experienced bereavement and the loss of a homeland and livelihood. Emotional distress resulting from reactions such as fear, anxiety and a sense of helplessness are expected to be more common in people living in settings that produce such chronic fear and worry. It is essential to provide effective mental health support to populations exposed to such adversities and experiencing emotional distress.
Treating emotional distress in large numbers of people is a huge challenge in settings with low numbers of mental health professionals and facilities, fragile and overburdened health and social care systems, a volatile security situation, and where there are high levels of mental health stigma. Researchers have been working to find solutions to these challenges, and have learnt that people with no mental health training or experience, known as lay health workers, can be trained and supervised to successfully deliver behavioural interventions to those in need. This approach, known as “task-sharing,” limits the burden on specialist mental health resources to provide accessible front-line mental health care to those in need.
The PM+ study
This approach has been incorporated into Problem Management Plus (PM+), one of a number of interventions being developed and tested by The World Health Organization (WHO) as part of its Mental Health Gap Action Program. In collaboration with a research team led by Professor Atif Rahman of the University of Liverpool, PM+ was tested and shown to be feasible in a randomised controlled trial (the best scientific evaluation methods we have for testing if PM+ is better than usual care), conducted in the conflict-affected city of Peshawar, Pakistan.
The trial, recently reported in the Journal of the American Medical Association (JAMA), enrolled 346 participants from three primary care centres in Peshawar. The participants had been referred to PM+ by their primary care physicians after indications they were experiencing emotional distress. Participants were allocated to either receive the intervention which involved five weekly 90-minute sessions based on established problem-solving and behavioural techniques delivered by trained and supervised lay health workers; or enhanced usual care which consisted of routine consultations with a trained primary care physician (participants in this group received between 1 and 2 routine consultations with their primary care physician).
At the beginning of the trial the intervention and control groups had similar average scores for emotional distress, assessed using the Hospital Anxiety and Depression Scale (HADS: score range 0-21) which assesses symptoms of anxiety (14.16 versus 13.64) and depression (12.67 versus 12.49). After three months, 146 participants in the intervention group and 160 in the usual care group were reassessed for emotional distress. At this assessment the intervention group participants had significantly lower average HADS scores for anxiety (7.25 versus 10.03) and depression (6.30 versus 9.27). This suggests that the PM+ programme was having a more positive impact upon the emotional distress of participants than routine care was providing.
In addition to emotional distress the study also looked at other signs of how the intervention was helping people, including post-traumatic stress, depressive disorder, functioning, and the problems for which people sought help. At the three month assessment there were significant differences in these scores also.
The research team also spoke to participants and their families, and to lay health workers about their experiences of PM+. At the end of the five PM+ sessions almost all the participants showed positive progress which was noticed by themselves and their family members.
Fazia, a participant (not her real name), commented that as a result of her participation in PM+:
“I felt as if certain burden has been lifted up from me.”
Her husband also observed:
“It feels like she is back with us after months. She talks with family members and friends now, she seems better. Also, she has started taking interest in household.”
The lay health workers spoke about their experience of delivering PM+:
“The techniques that we learnt and taught the participants were highly effective; ‘get going keep doing’, the relaxation technique and the tasks that we gave them, all were helpful. It felt great to be a contributor in making them feel better and this incentive kept us going.”
Working with local people trained and supervised to deliver PM+ was recognised to be important, enabling them to relate well to their participants lives. There were also challenges such as females requiring chaperones to attend primary healthcare centres; and many participants facing depression-like symptoms meaning they had low levels of motivation to attend weekly sessions.
According to Professor Atif Rahman:
“Being relatively brief, this intervention is more feasible for delivery in emergency settings than other mental health interventions that may require more in-depth training, or delivery by a specialist. We have shown that it is possible to train and supervise lay health workers to deliver this programme in a conflict-affected setting with all the challenges this presents.”
Furthermore, he highlighted that being designed to treat a range of common emotional problems including anxiety, depression and post-traumatic stress means PM+ has the potential to help greater numbers of people without the need for a diagnosis that may be viewed as stigmatising.
From these findings, the research team conclude that "This lay worker-administered intervention may be a practical approach for treating adults with psychological distress in conflict-affected areas". This is encouraging and offers a potentially scalable approach to addressing the many mental health needs of the millions of people displaced as a result of war around the world today.