Mental health

WHO behavioural intervention shows promise for treating depression and anxiety in conflict-affected areas

November 2016 – Problem Management Plus (PM+), a WHO behavioural intervention delivered by lay health workers, showed significant reductions in depression, anxiety, and post-traumatic stress as well as improved functioning in adults living in a conflict-affected area of Pakistan, according to a study published online in the Journal of the American Medical Association (JAMA) on 12 November. The study, a randomized controlled trial of the intervention in a conflict-affected setting, paves the way for introduction of the intervention in conflict-affected areas.

Peshawar, Pakistan
Peshawar, Pakistan
WHO/H. Bower

PM+ is one of a series of materials on psychological interventions that can be delivered by lay workers, produced through the World Health Organization’s mental health Gap Action Programme (mhGAP).

The randomized controlled trial, conducted between 2014 and 2016, was conducted in 3 primary care centres in Peshawar, Pakistan. Of the 346 participating in the trial, nearly 80% were female and nearly 60% uneducated. Just over 60% had witnessed or experienced armed conflict or war and over 20% had experienced a natural disaster.

How the intervention works

In the study, the 346 adults participating, each suffering from disabling psychological distress, were randomly assigned to receive 5 weekly 90-minute sessions or enhanced care. Session 1 of PM+ oriented participants to the intervention with motivational interviewing techniques to improve engagement, provided information about common reactions to adversity, and taught participants how to manage stress through slow breathing. Session 2 addressed a participant-selected problem using problem-solving techniques, and introduced activities to help participants reengage with pleasant and task-oriented activities. Sessions 3 and 4 introduced strategies to strengthen social support networks. In session 5, education about retaining treatment gains was provided. Post-treatment assessments were carried out 1 week and 3 months after treatment.

Adults in the control group were given enhanced care by primary care physicians who had received a 5-day training on mental health and a 1-day refresher on treating anxiety and depression. They also received the opportunity of a repeated consultation.

The training and supervision model

A master trainer conducted a 6-day training with local mental health specialists, who in turn provided an 8-day training programme to 9 lay health workers, recruited from the local population. Both training programmes comprised education about common mental disorders, basic counselling skills, delivery of intervention strategies, and self-care. Supervisors received additional training in training and supervision skills. The lay health workers were supervised in 2 groups on a weekly basis for 2 hours by the in-country supervisors, who in turn were supervised for 1-2 hours a month by Skype by the master trainer.

Study results

After 3 months, the intervention group showed lower levels of anxiety and depression than the control group. At the same point, there were also significant differences in scores of posttraumatic stress, functional impairment, and problems for which the person sought help, with the intervention showing more positive results than enhanced care. Post hoc analysis showed that at baseline, 94% of participants in the intervention group and 90% of participants in the control group met criteria for depression. At 3 months, the rates were 27% and 59%, respectively. The study shows that PM+ may be a practical approach for helping adults with disabling psychological distress in conflict-affected areas.


Note: The above-mentioned study was supported by Elrha's Research for Health in Humanitarian Crises (R2HC) initiative funded by the UK Department for International Development and the Wellcome Trust.