Effectiveness of a WHO self‐help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial

Abstract

Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self‐help psychological intervention developed by the World Health Organization, called Self‐Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two‐arm, assessor‐masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self‐Help Plus arm (consisting of Self‐Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self‐Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six‐month follow‐up. Secondary outcome measures were the presence of mental disorders at post‐intervention, and psychological distress, symptoms of post‐traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well‐being, and quality of life at post‐intervention and six‐month follow‐up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty‐four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self‐Help Plus (N=322) or ECAU (N=320). Self‐Help Plus participants were significantly less likely to have any mental disorders at six‐month follow‐up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408‐0.696). Analysis of secondary outcomes suggested that Self‐Help Plus was not effective immediately post‐intervention, but was associated with beneficial effects at six‐month follow‐up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self‐Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low‐intensity self‐help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities.

Long-term effectiveness of Self-Help Plus in refugees and asylum seekers resettled in Western Europe: 12-month outcomes of a randomised controlled trial

“…Psychological distress poses risk for subsequent mental disorders and causes marked impairment, so a beneficial effect of SH + on psychological distress represents an important finding. A trial with a design similar to the present study conducted with refugees in Turkey found that participants allocated to SH + were significantly less likely to have any mental disorders after 6 months of follow-up compared to the control group (Acarturk et al ., 2022). Considering that both this study and the Turkish SH + study observed effects on key measures several months after the intervention, we hypothesise these findings may be related to the main SH + components which were delivered over the five weekly sessions.…”

“…The effect was much more pronounced for the Turkey study where efficacy (i.e. reducing the frequency of any mental disorder) was observed at 6 months (Acarturk et al, 2022), compared to the Western European study where a preventative effect was only found immediate postintervention and not after 6 months (Purgato et al, 2021). In both studies, we planned a long-term follow-up at 12 months, but data at 12 months are only available for the Western European study due to logistic and administrative problems occurred in Turkey.…”

Mental healthcare in primary and community-based settings: evidence beyond the WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide

“…Clinical interventions focused on psychoeducation, psychosocial support and brief psychological therapies (including recent innovations, such as self-help plus40 41 and problem-management plus),42–46 all of which are recommended by the mhGAP-IG and associated resources. Similarly, interventions targeted depression, substance use and child and adolescent mental health conditions: all mhGAP-IG modules.…”

Preventing the mental health consequences of war in refugee populations

“…Notably, a preventative effect on the development of mental disorders has recently been demonstrated for Self Help Plus (SH+), a WHO self-help psychological intervention that can be delivered to up to 30 people at once by briefly trained non-specialist facilitators (Epping-Jordan et al ., 2016; WHO, 2021 a ). Two randomised trials, one conducted in Western Europe and another in Turkey, have recently assessed the preventative effect of SH+ in refugee populations (Purgato et al ., 2021; Acarturk et al ., 2022), while a trial in Uganda showed its beneficial effects for reducing psychological distress (Tol et al ., 2020). Both the Western European and Turkey studies showed evidence of an effect of SH+ in preventing the onset of mental disorders and reducing stress, but differences were observed between the studies.…”

“…The effect was much more pronounced for the Turkey study where efficacy (i.e. reducing the frequency of any mental disorder) was observed at 6 months, compared to the Western European study where beneficial effects were only found immediate post-intervention and not after six months (Purgato et al ., 2021; Acarturk et al ., 2022). As SH+ is a low-intensity, brief intervention, it cannot deal with the full range of difficulties that refugees and asylum seekers may experience following war-related traumatic events.…”