Effectiveness and cost-effectiveness of simplified psychological support in conflict-affected Pakistan

Purpose

The overall objective of this research was to help improve the mental health and functioning of people in humanitarian settings. The study aimed to test the efficacy of an innovative, simplified psychological intervention named Problem Management Plus (PM+). PM+ is a short programme delivered by paraprofessionals, which is transdiagnostic (i.e. geared to a number of conditions) and designed for people in low-income communities affected by adversity. The study sought to establish the impact of the PM+ intervention on people with high levels of psychological distress and functional impairment. The impact of PM+ on people’s anxiety and depression was tested. The research also aimed to establish if the intervention could be delivered by health workers who did not have prior training in delivering psychological treatment, and evaluated the cost-effectiveness of PM+ as a treatment.

Programmes and Outcomes Achieved

The research was successfully undertaken. A randomised controlled trial was conducted in three primary care centres in Peshawar, Pakistan. 346 adult primary care attendees with high levels of both psychological distress and functional impairment were randomly assigned to either the intervention or enhanced usual care. The intervention was delivered by lay health workers, and involved 5-sessions which employed problem solving, behavioural activation, strengthening social support, and stress management strategies.

Key findings:

• In a randomised clinical trial in primary care settings in Peshawar, Pakistan, 346 adults impaired by psychological distress were randomised to the intervention or enhanced usual care. Three months after treatment, the intervention group had significantly lower anxiety and depression scores (primary outcome measures) compared with those in the enhanced usual care group.
• The study also suggested positive findings for secondary outcome measures including functioning, posttraumatic stress and outcomes defined by local participants themselves.
• Before treatment approximately 90% of participants met criteria for depression. At 3-months follow up, 30% of PM+ participants and 60% of comparison participants had depression.
• The intervention worked equally well independent of initial severity, i.e. the intervention appears to work equally well for severe as for mild presentations.
• As a result of this study and a similar study in Kenya, WHO decided to release PM+ as a public good.

Key outputs:

• PM+ manual published in English, Urdu, Kiswahili, Arabic, Chinese, Japanese and Spanish on WHO website
• Journal articles published in JAMA, World Psychiatry and BMC Psychiatry
• National workshop held in Pakistan
• Key note presentation at the International Society of Traumatic Stress Studies (ISTSS) conference
• A WHO implementation guide for psychological interventions is in preparation.

Next steps:
Multiple agencies are being trained in the use of the PM+ intervention.  The PM+ manual will be translated into further languages for widespread uptake.
 Quotes:

“My opinion is that a lot of improvement has occurred in myself. I have changed a lot. Moreover, burden from my mind is removed and I have also got control over my anxiety and fear.” Study participant.

“PM+ may be a practical approach for helping adults impaired by psychological distress in conflict-affected areas.  The research confirms that after brief training and with continuous supervision, non-specialist helpers can do much for people’s mental health in just 5 sessions. As a result, PM+ has been released by WHO as a public good. It is attracting much interest from partners who seek evidence-based scalable interventions to address psychological needs of affected populations.” Mark van Ommeren (PI), WHO.