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Globally, populations affected by humanitarian crisis are in need of accessible, scalable and effective mental health and psychosocial support (MHPSS) programs. However, in such crisis-affected areas there is generally a lack of resources for services and the routine human and financial resource allocation for MHPSS is dramatically lacking given the scope of the problem. Psychological interventions are one form of MHPSS along with a range of other interventions. Psychological interventions rank currently high on international research agendas.

To address the global demand of accessible, scalable and effective psychological interventions, the World Health Organization has developed a simplified psychological intervention, Problem Management Plus(PM+) to support those affected by devastating disasters, humanitarian emergencies and chronic adversities. With support from R2HC, PM+ was evaluated in primary health care in conflict-affected, peri-urban Peshawar, Pakistan, through a randomized controlled trial (RCT). The team of researchers at Lady Reading Hospital, Peshawar – in close collaboration with a range of partners – enrolled 346 participants, suffering from disabling psychological distress in the research. Among these, 306 participants completed the study. Sixty percent of the participants reported exposure to conflict and 20% reported having experienced natural disaster.

The PM+ providers had no previous mental health training or experience and received an 8-day training in PM+. There was additional training for local supervisors/future trainers. The PM+ providers received weekly supervision while the supervisors received fortnightly to monthly supervision by the master trainer.

Upon enrollment in the study, the PM+ group and comparison group (who did not receive the PM+ but received enhanced usual care in the primary healthcare dispensary) had similar average scores (score range 0-21) on the primary outcome measure of this study, the Hospital Anxiety and Depression Scale (HADS), for anxiety (14.16 versus 13.64) and depression (12.67 versus 12.49).

At three months, the PM+ therapy group participants had significantly lower average HADS scores for anxiety (7.25 versus 10.03) and depression (6.30 versus 9.27). Also, there were significant differences in scores of posttraumatic stress, functional impairment, and problems for which the person sought help.

At baseline, about 90% of intervention and comparison participants met the PHQ-9 criteria for depression. At follow-up, the rates were close to 30% and 60%, respectively.
Importantly, analyses showed that initial severity of emotional problems did not predict treatment outcome. This is further evidence to show that scalable psychological interventions can address both mild and severe emotional problems.

Cost-effectiveness analyses of the data are in progress and look promising.
The findings – confirmed in a second RCT (forthcoming) – proved PM+ to be a practical, evidence-based approach for helping adults with disabling psychological distress in areas affected by adversity. On the basis of these results, WHO decided to make the PM+ manual publicly available on its website. The results of the evaluation were published in the Journal of the American Medical Association (JAMA) and shared in a plenary session at the International Society of Traumatic Stress Studies in 2016.

In Rawalpindi, Pakistan a dissemination meeting was hosted by the WHO Collaborating Center for Mental Health Research and Training. The stakeholders at the meeting represented national, regional and global policy partners, development sector partners working in the disaster relief and humanitarian emergencies and public health practitioners, and local partners including the implementers and technical support organizations.

The stakeholders appreciated the usefulness and appropriateness of the program to the humanitarian context. Disaster management policies, curriculum of undergraduate and postgraduate programs and pre-service training for public sector employees were suggested as the suitable platforms to scale-up psychosocial support through the PM+ program in low resource settings by the stakeholders.

Authors:
Syed Usman Hamdani, Human Development Research Foundation, Islamabad, Pakistan
Parveen Akhtar, Human Development Research Foundation, Islamabad, Pakistan
Atif Rahman, University of Liverpool, Liverpool, UK
Anna Chiumento, University of Liverpool, Liverpool, UK
Saeed Farooq, Lady Reading Hospital, Peshawar, Pakistan
Mark van Ommeren, World Health Organization, Geneva, Switzerland.

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