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Daniel NA, Liu X, Thomas ET, Eraneva-Dibb E, Ahmad AM, Heneghan C. Brief CBT-based psychological interventions to improve mental health outcomes in refugee populations: a systematic review and meta-analysis. Eur J Psychotraumatol 2024; 15:2389702. [PMID: 39212049 PMCID: PMC11370682 DOI: 10.1080/20008066.2024.2389702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/09/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Background: Refugees, asylum seekers, and internally displaced people experience a high burden of mental health problems owing to their experiencing traumas and stressful events.Objective: To summarise the available evidence and analyse the efficacy of brief psychological interventions (< 3 months) on improving mental health outcomes, including depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms in refugees.Method: We searched Medline, EMBASE, PsycINFO, CINAHL, and Global Index Medicus from inception to 19 December 2023. We included controlled studies using any cognitive behavioural therapy (CBT) or CBT-based therapies delivered over a short time (< 3 months), which reported mental health outcomes pre-and post-intervention. We conducted meta-analyses using random effects to derive pooled summary statistics. The quality of the evidence was assessed with the Cochrane Risk of Bias (RoB2) and ROBINS-I tools. This study is registered on the Open Science Framework, DOI 10.17605/OSF.IO/9CXU4.Results: 34 eligible studies across 37 publications were retrieved for analysis, and 33 studies with 4479 participants were included in the meta-analysis. There was an overall improvement in immediate mental health outcomes for all three domains, with analysis of 13 studies on anxiety outcomes (SMD -1.12, 95% CI -1.72 to -0.52), 20 studies on depression (SMD -1.04, 95% CI -1.97 to -0.11), and 24 studies on PTSD (SMD -0.82, 95% CI -1.20 to -0.45). At 3 to 6-month follow-up, however, analysis of mental health outcomes shows no significant change from baseline, with a SMD of 0.24 (95% CI -0.94 to 1.42) across 4 studies, -0.73 (95% CI -2.14 to 0.68) across 9 studies, and 0.29 (95% CI -0.94 to 1.53) across 12 studies for anxiety, depression, and PTSD respectively.Conclusion: Low-quality evidence shows brief psychological interventions have a positive immediate effect on refugees and internally displaced people's mental well-being. However, these effects do not persist in the short-term follow up. Heterogeneity was high, even among subgroups, impacting our findings' generalisability.
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Affiliation(s)
- Nadia A. Daniel
- Magdalen College, University of Oxford, Oxford, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Xin Liu
- Magdalen College, University of Oxford, Oxford, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Elizabeth T. Thomas
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Eraneva-Dibb
- Magdalen College, University of Oxford, Oxford, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Al-Maz Ahmad
- Department of Computing, Imperial College London, London, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hamdani SU, Huma ZE, Malik A, Tamizuddin-Nizami A, Javed H, Minhas FA, Jordans MJD, Sijbrandij M, Suleman N, Baneen UU, Bryant RA, van Ommeren M, Rahman A, Wang D. Effectiveness of a group psychological intervention to reduce psychosocial distress in adolescents in Pakistan: a single-blind, cluster randomised controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:559-570. [PMID: 39025557 PMCID: PMC11254783 DOI: 10.1016/s2352-4642(24)00101-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Emotional problems in adolescents living in low-income and middle-income countries (LMICs) remain largely unaddressed; key reasons include a scarcity of trained mental health professionals and unavailability of evidence-based, scalable psychological interventions. We aimed to evaluate the effectiveness of a non-specialist-delivered, group psychological intervention to reduce psychosocial distress in school-going adolescents in Pakistan. METHODS In a two-arm, single-blind, cluster randomised controlled trial, eligible public school clusters from a rural subdistrict of Gujar Khan, Rawalpindi, Pakistan, were randomised (1:1, stratified by sex) using permuted block randomisation into intervention (n=20) and wait-list control (n=20) groups. Adolescents aged 13-15 years who provided informed assent and caregivers' consent were screened for psychosocial distress using the youth-reported Pediatric Symptoms Checklist (PSC; total psychosocial distress scores from 0 to 70), and those scoring 28 or more and their caregivers were enrolled into the trial. Adolescents in the intervention group received seven weekly group sessions and their caregivers received three biweekly group sessions in school settings from trained non-specialists. The primary outcome was change from baseline in the total PSC scores at 3 months post-intervention. The trial was registered prospectively with the International Standard Randomised Controlled Trial Number registry, ISRCTN17755448. FINDINGS From the 40 school clusters that were included, 282 adolescents in the intervention group and 284 adolescents in the wait-list control group were enrolled between Nov 2 and Nov 30, 2021. At 3 months, adolescents in the intervention group had significantly lower mean total score on the PSC compared with adolescents in the control group (mean difference in change from baseline 3·48 [95% CI 1·66-5·29], p=0·0002, effect size 0·38 [95% CI 0·18-0·57]; adjusted mean difference 3·26 (95% CI 1·46-5·06], p=0·0004, effect size 0·35 (0·16-0·55). No adverse events were reported in either group. INTERPRETATION The group psychological intervention most likely represents a feasible and effective option for adolescents with psychosocial distress in school settings. FUNDING UK Medical Research Council, Foreign Commonwealth and Development Office, Department of Health and Social Care. TRANSLATION For the Urdu translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Syed Usman Hamdani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan.
| | - Zill-E Huma
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Aiysha Malik
- Department of Mental Health and Substance Use, WHO, Geneva, Switzerland
| | - Asad Tamizuddin-Nizami
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Hashim Javed
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Fareed Aslam Minhas
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Mark J D Jordans
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Marit Sijbrandij
- Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Nadia Suleman
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Um-Ul Baneen
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Mark van Ommeren
- Department of Mental Health and Substance Use, WHO, Geneva, Switzerland
| | - Atif Rahman
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
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Ali R, Brown FL, Stevenson K, Jordans M, Taha K, Amine ME, Steen F, Meksassi B, Elias J, Aoun M, Roberts B, Sijbrandij M, Cuijpers P, Akhtar A, Malik A, Woodward A, Fuhr DC. Implementing a Non-Specialist Delivered Psychological Intervention for Young Adolescents in a Protracted Refugee Setting: a Qualitative Process Evaluation in Lebanon. J Behav Health Serv Res 2024; 51:377-394. [PMID: 38087061 PMCID: PMC11180626 DOI: 10.1007/s11414-023-09870-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 02/12/2024]
Abstract
There has been an increase in the evaluation and implementation of non-specialist delivered psychological interventions to address unmet mental health needs in humanitarian emergencies. While randomized controlled trials (RCTs) provide important evidence about intervention impact, complementary qualitative process evaluations are essential to understand key implementation processes and inform future scaling up of the intervention. This study was conducted as part of an RCT of the Early Adolescents Skills for Emotions (EASE) psychological intervention for young adolescents with elevated psychological distress (predominantly with a Syrian refugee background) in Lebanon. Our aims were firstly to conduct a qualitative process evaluation to understand stakeholder experiences and perceived impact of the intervention and identify barriers and facilitators for implementation, and secondly to explore considerations for scaling up. Eleven key informant interviews and seven focus groups were conducted with 39 respondents including adolescent and caregiver participants, trainers, providers, outreach workers, and local stakeholders. Data were analyzed using inductive and deductive thematic analysis. Respondents perceived the intervention to be highly needed and reported improvements in adolescent mental health and wellbeing. Key implementation factors that have potential to influence engagement, adherence, and perceived impact included the socio-economic situation of families, mental health stigma, coordination within and between sectors (particularly for scaling up), embedding the intervention within existing service pathways, having clear quality and accountability processes including training and supervision for non-specialists, and sustainable funding. Our findings provide important context for understanding effectiveness outcomes of the RCT and highlights factors that need to be considered when implementing a mental health intervention on a larger scale in a complex crisis.
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Affiliation(s)
- Rayane Ali
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - Felicity L Brown
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Kerrie Stevenson
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Health Informatics, University College London, London, UK
| | - Mark Jordans
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Karine Taha
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - Mounif El Amine
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - Frederik Steen
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Bassel Meksassi
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - Joseph Elias
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - May Aoun
- Research and Development Department, War Child, Amsterdam, The Netherlands
- War Child Lebanon, Beirut, Lebanon
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marit Sijbrandij
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Aiysha Malik
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Aniek Woodward
- KIT Royal Tropical Institute, KIT Health, Mauritskade 64, 1092 AD, Amsterdam, The Netherlands
- Athena Institute, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Daniela C Fuhr
- Leibniz Institute of Prevention Research and Epidemiology, Bremen, Germany.
- Health Sciences, University of Bremen, Bremen, Germany.
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El Masri R, Chaar S, Elias J, Meksassi B, Ali R, Roberts B, Brown FL, Asmar MK, McKee M, El Chammay R, Singh NS. Barriers, facilitators and proposed solutions to equitable mental health financing and service delivery for the Lebanese populations and displaced Syrians in Lebanon: Findings from a qualitative study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003318. [PMID: 38941293 PMCID: PMC11213328 DOI: 10.1371/journal.pgph.0003318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/15/2024] [Indexed: 06/30/2024]
Abstract
Forcibly displaced populations experience an increased burden of mental illness. Scaling up mental health (MH) services places new resource demands on health systems in crises-affected settings and raises questions about how to provide equitable MH services for refugee and host populations. Our study investigates barriers, facilitators, and proposed solutions to MH financing and access for Lebanese populations and Syrian refugees in Lebanon, a protracted crisis setting. We collected qualitative data via 73 interviews and 3 focus group discussions. Participants were purposively selected from: (i) national, United Nations and NGO stakeholders; (ii) frontline MH service providers; (iii) insurance company representatives; (iv) Lebanese and Syrian adults and parents of children aged 12-17 years using MH services. Data were analysed using inductive and deductive approaches. Our results highlight challenges facing Lebanon's system of financing MH care in the face of ongoing multiple crises, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and their impact on sustainability of services. The built environment presents additional challenges to individuals trying to navigate, access and use existing MH services, and the social environment and service provider factors enable or hinder individuals accessing MH care. Registered Syrian refugees have better financial coverage to secondary MH care than Lebanese populations. However, given the economic crisis, both populations are facing similar challenges in paying for and accessing MH care at primary health care (PHC) level. Multiple crises in Lebanon have exacerbated challenges in financing MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon's health financing system, working with government and external donors to equitably and efficiently finance and scale up MH care with a focus on PHC, and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations.
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Affiliation(s)
- Rozane El Masri
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Sandy Chaar
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Joseph Elias
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Bassel Meksassi
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Rayane Ali
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Felicity L. Brown
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | | | - Martin McKee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rabih El Chammay
- Department of Psychiatry, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon
| | - Neha S. Singh
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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