Stepped Care for Better Mental Health in Refugees

Principal Investigator: Richard Bryant, University of New South Wales

Research Snapshot: Stepped care improves mental health for refugees

A stepped care approach combining two World Health Organization (WHO) mental health interventions proved effective in a randomised trial in Jordan, with implications for mental health provision in low-and middle-income countries (LMICs).

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What did the study set out to achieve?

Many LMICs have high rates of untreated mental illness, due to shortages in trained professionals and systemic barriers to accessing services, particularly for refugees and displaced people. Low-intensity interventions, such as WHO’s Doing What Matters in Times of Stress (DWM), are designed to increase access. Yet not all individuals respond adequately, highlighting the need for scalable, tiered solutions like stepped care.

A single-blind, parallel, randomised controlled trial was conducted in Jordan with adults (half of whom were refugees) reporting psychological distress. They were randomly assigned to either Stepped Care (400 people) or Enhanced Usual Care (EUC) (401 people). All participants received the DWM self-help program. Participants who still had psychological distress following DWM then received either EUC, or the more intensive WHO Problem Management Plus (PM+).

What were the key findings?

The stepped care model, where individuals unresponsive to basic interventions receive more intensive support, significantly reduced anxiety and depression at 3-month follow-up compared to a single low-intensity intervention.

• At three months post-intervention, participants in the stepped care model- who received both DWM and, if needed, PM+- reported significantly greater reductions in anxiety and depression than those receiving EUC.
• Clinically meaningful improvements were seen in more stepped care participants for anxiety and depression compared to the single-intervention group.
• The 12-month follow-up indicated that Stepped Care had lasting benefits, with these participants having less anxiety than those in Single Intervention.
• Stepped Care was cost-effective in the Jordan context, despite the additional resources needed. This was determined by factoring in the overall benefits gained from implementing stepped care: improvements in quality of life and productivity for Stepped Care clients.
• Process evaluations, including interviews with 90 stakeholders, indicated policy makers should strengthen partnerships and prioritise sustainable funding for Stepped Care.

What does this mean for policymakers and practitioners?

This trial is the first of its kind in a LMIC setting to empirically validate the effectiveness of a stepped care mental health framework over a single intervention.

Stepped care models can enhance the impact of existing mental health services by reserving intensive interventions for those who need them most. Intensive process evaluations with government and non-government stakeholders indicated that displaced populations in Jordan, as well as disadvantaged Jordanians, could benefit from Stepped Care but requires substantive prioritising of mental health in current organisational systems (including budgets, programmatic integration, staff training, and partnerships) to enable this.

Humanitarian organisations and LMIC health systems can implement stepped approaches using existing WHO tools such as DWM and PM+ (which is delivered by trained lay providers) to deliver targeted, cost-effective care, reducing long-term burden from untreated anxiety and depression.