Background.Lebanon has a need for innovative approaches to increase access to mental health care to meet the country's current high demand. E-mental health has been included in its national mental health strategy while in parallel the World Health Organization has produced an online intervention called ‘Step-by-Step’ to treat symptoms of depression that is being tested in Lebanon over the coming years.Aim.The primary aim of this study is to conduct bottom-up, community-driven qualitative cognitive interviewing from a multi-stakeholder perspective to inform the cultural adaptation of an Internet-delivered mental health intervention based on behavioural activation in Lebanon.Methods.National Mental Health Programme staff conducted a total of 11 key informant interviews with three mental health professionals, six front-line workers in primary health care centres (PHCCs) and two community members. Also, eight focus group discussions, one with seven front-line workers and seven others with a total of 66 community members (Lebanese, Syrians and Palestinians) were conducted in several PHCCs to inform the adaptation of Step-by-Step. Results were transcribed and analysed thematically by the project coordinator and two research assistants.Results.Feedback generated from the cognitive interviewing mainly revolved around amending the story, illustrations and the delivery methods to ensure relevance and sensitivity to the local context. The results obtained have informed major edits to the content of Step-by-Step and also to the model of provision. Notably, the intervention was made approximately 30% shorter; it includes additional videos of content alongside the originally proposed comic book-style delivery; there is less emphasis on total inactivity as a symptom of low mood and more focus on enjoyable activities to lift mood; the story and ways to contact participants to provide support were updated in line with local gender norms; and many of the suggested or featured activities have been revised in line with suggestions from community members.Conclusions.These findings promote and advocate the use of community-driven adaptation of evidence-based psychological interventions. Some of the phenomena recorded mirror findings from other research about barriers to care seeking in the region and so changes made to the intervention should be useful in improving utility and uptake of ‘Step-by-Step’.

Background: E-mental health is an established mode of delivering treatment for common mental disorders in many high income countries. However, evidence of its effectiveness in lower income countries is lacking. This mixed methods study presents lessons learned and preliminary data on the feasibility of a minimally guided e-mental health intervention in Lebanon. The aim was to pilot test Step-by-Step, a WHO guided e-mental health intervention, and research methods prior to future, controlled testing.Methods: Participants were recruited using social media and advertisements in primary care clinics. Participants completed baseline and post-intervention questionnaires on depression symptoms (primary outcome, PHQ-8), anxiety symptoms, well-being, disability and self-perceived problem severity, and a client satisfaction questionnaire. In addition, seven completers, four drop-outs, 11 study staff, and four clinic managers were interviewed with responses thematically analyzed. Website analytics were used to understand participant behavior when using the website.Results: A total of 129 participants signed up via the Step-by-Step website. Seventy-four participants started session 1 after completing pre-test questionnaires and 26 completed both baseline and post-intervention data. Among those who completed postassessments, depression symptoms improved (PHQ-8 scores (t=5.62, p < 0.001 twotailed, df = 25). Wilcoxon signed ranks tests showed a significant difference between baseline and post-Step-by-Step scores on all secondary outcome measures. Client satisfaction data was positive. Interview responses suggested that the intervention could be made more appropriate for younger, single people, more motivating, and easier to use. Those who utilized the support element of the intervention were happy with their relationship with the non-specialist support person (e-helper), though some participants would have preferred specialist support. E-helpers would have liked more training on complex cases. Website analytics showed that many users dropped out

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Background: Mental health services in Lebanon are weakly integrated in the health system due to a huge political unrest, cultural and societal stigma, and more importantly, due to the inappropriate planning of human resources. A shift of the mental health services in Lebanon from hospital-based care into community-based care and efficient planning of human resources became a priority given the increasing burden of mental health disorders as a consequence of socio-political and economic crises: the bordering Syrian war, the massive influx of refugees, the huge inflation rate and above all the Beirut explosion. Methods: The WHO-ATLAS was conducted in 2019 as well as the WHO-AIMS in 2015 to map mental health services in Lebanon. Data from those two reports was plugged into the service needs calculator; an economic tool including epidemiology of eight priority mental health packages and target population, outpatient service use/needs and inpatient service use/needs. Total full-time equivalents (FTE) were calculated for psychiatrists, nurses and psychosocial care providers. All formulas were extracted from the WHO “Planning and Budgeting to deliver mental health services” module of the Mental Health Policy and Service Guidance Package. Results: For an effective community-based mental health system in Lebanon, there is additional need for 182 (+16%) psychiatrists, 762 (+68%) nurses and 184 (+16%) psychosocial care providers; a total increase of 1,128 mental health workforce. Conclusions: A proper workforce skill mix for an optimal utilization of the existing staff is recommended. New models will need to account for task shifting to attempt to close the gap between what is needed and what is available.