WHO digital mental health intervention effective in reducing depression among Syrian refugees in Lebanon – Lebanon

A new digital mental health intervention, Step-by-Step, developed by the World Health Organization (WHO) with the National Mental Health Program (NMHP) of Lebanon’s Ministry of Public Health and other partners, was effective in reducing depression among Syrian refugees in Lebanon, study finds published in PLOS Medicine.

The study, a randomized controlled trial, supported by Elrha Research for Health in Humanitarian Crises (R2HC), was conducted among Syrians with depression and functional disorders in Lebanon. It found that people who received the digital intervention with remote guidance from trained lay assistants were significantly less depressed and had significantly better functioning after the intervention compared to those who received enhanced usual care in the control group. People who received Step-by-Step also showed improvements in symptoms of anxiety, post-traumatic stress, well-being, and personal issues, with all improvements maintained at 3-month follow-up. This study confirms the results of a parallel trial of Step-by-Step with Lebanese and other populations living in Lebanon, which showed similar positive results.

All of the 569 Syrian adults enrolled in the trial, which concluded in December 2020, were from Syria. The average age of the participants was 31.5 years. The majority (58.3%) were women and the majority were married (70.1%). Most had primary (32.0%) or secondary (36.7%) education and the majority were unemployed (58.7%). Half of the participants received the WHO step-by-step guided intervention delivered as a hybrid app for iOS, Android and web browsers, and the other half received enhanced care as usual alone (including basic psychoeducation and referral to evidence-based care).

A format delivered by non-specialist helpers trained in a digital framework

Step-by-Step is a WHO 5-session digital intervention designed to treat depression via an internet-connected device, with weekly support (e.g. a 15-minute call or message) by lay assistants trained. It provides psychoeducation and behavioral activation training (e.g. making activities more pleasurable) through an illustrated narrative, with additional therapeutic techniques such as stress management, gratitude exercise, positive self-talk, building social support and preventing relapse.

Step by Step includes 5 illustrated story sessions with audio recordings of the text for easy accessibility. Each session is divided into 3 smaller parts, which take an average of 20 minutes in total. Each session unlocks after 4 days of the previous session ending to give the person enough time to practice the skills and drills they learned in the previous session. Users are recommended to follow 1 session (with all 3 parts) per week.

Potential to expand to other displaced populations with digital access

Given the effect observed in the study on depression, functional impairment, anxiety, post-traumatic stress, subjective well-being and self-identified problems, and that the step-by-step can be delivered by trained lay helpers to communities of displaced populations with digital access, the trial results suggest that the intervention can be part of an effective strategy to improve the mental health of other displaced populations with digital access. Lebanon’s national mental health program aims to expand mental health care in line with the national mental health strategy, but resources are limited. Based on these results and the results of a parallel trial with Lebanese and other populations living in Lebanon, Lebanon’s National Mental Health Program scaled up the intervention nationwide to be accessible to all adults in the country.

Substantial need for mental health support among refugee populations

The number of forcibly displaced persons reached 89.3 million by the end of 2021 and is expected to have increased further to more than 100 milliondue to recent world events.

The war in Syria involved almost 6.8 million refugees. Lebanon, with a total population of nearly 7 million, is currently home to approximately 840 900 displaced Syrians. After fleeing for security reasons, displaced people face persistent challenges, including unmet basic needs, language barriers, uncertainty about the future, social isolation and discrimination. As a result, they are at risk for mental disorders, such as depression, anxiety, and post-traumatic stress.

An estimated 22% of displaced and war-affected Syrians in Lebanon suffer from moderate to severe depressive symptoms. Although depression and other common mental disorders are a major cause of disability, the vast majority of displaced people do not receive treatment. This is especially true in low- and middle-income countries where only 1 in 27 people with depression are likely to receive evidence-based treatments and less than 1 in 1,000 displaced people seek help from health services. for common mental disorders. This study suggests that Step-by-Step can make a significant contribution to filling this treatment gap.

Julio V. Miller