Step-by-Step, an E-Mental Health Intervention for Depression: A Mixed Methods Pilot Study From Lebanon

Abstract

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

The state of psychiatric research in the Asia Pacific region

“…The latter group has been of particular interest, with many studies assessing the mental health needs of Syrians and other refugees who fled their nations to Lebanon (E. Karam et al, 2016; Kerbage et al, 2020; Yassin, Taha, Ghantous, Atoui, & Forgione, 2018). Lastly, many mental health interventional activities are being studied in these groups (Dirani, Raad, & Akoury‐Dirani, 2018; Harper Shehadeh et al, 2020; Kaplan, El Khoury, Lize, Wehbe, & Mokhbat, 2019; Noubani et al, 2020).…”

Cultural adaptation of Hap-pas-Hapi, an internet and mobile-based intervention for the treatment of psychological distress among Albanian migrants in Switzerland and Germany

“…Internet and mobile-based interventions appear to be promising for potential scalability and may therefore contribute to narrow the worldwide treatment gap, particularly among “hard-to-reach populations” such as culturally diverse populations (e.g., Abi Ramia et al, 2018 ; Atallah et al, 2018 ; Burchert et al, 2019 ; Carswell et al, 2018 ; Cuijpers et al, 2008 ; Garabiles et al, 2019 ; Hedman et al, 2012 ; Kayrouz et al, 2018 ; Muñoz, 2010 ; Sijbrandij et al, 2017 ; Wang et al, 2013 ). Through large randomized controlled trials (RCTs) and pilot studies, several research groups seek to examine the effectiveness of culturally adapted online-interventions for treating common mental disorders such as depression, anxiety or post-traumatic stress disorder (PTSD) and culturally shaped concepts of distress in different indigenes cultures and their diaspora ( Harper Shehadeh et al, 2020 ; Kayrouz et al, 2015a , Kayrouz et al, 2016b ; Reich et al, 2019 ; Salamanca-Sanabria et al, 2018 , Salamanca-Sanabria et al, 2020 ; Sidani et al, 2018 ; Slobodin et al, 2018 ; Ünlü Ince et al, 2013 ; van't Hof et al, 2020 ).…”

“…However, due to small sample sizes and high attrition rates in the pilot studies ( Harper Shehadeh et al, 2020 ; Kayrouz et al, 2016b , Kayrouz et al, 2016a ; Salamanca-Sanabria et al, 2020 ), only cautious assumptions can be made concerning statistically substantial effects on the reduction of distressing symptoms. However, the largely positive results on feasibility and acceptability of the mentioned studies seem promising, emphasizing the need for culturally adapted interventions.…”

A digital mental health intervention to reduce depressive symptoms among overseas Filipino workers: protocol for a pilot hybrid type 1 effectiveness-implementation randomized controlled trial

“…The SbS program with minimal guidance has been piloted among Syrian refugees and local population in Lebanon [ 23 ]. A qualitative evaluation of the SbS program in Germany found that the Syrian refugees accepted the digital intervention and perceived the potential impact of the intervention on their mental health [ 24 ].…”

“…In order to utilize this trial design, the intervention should be supported by at least indirect effectiveness evidence and pose minimal risk to participants [ 29 ]. These characteristics are found in the WHO SbS program, since it was trialed on Syrian refugees, who share similar background as immigrants with OFWs in Macao, and showed no perceived risks for its application [ 23 ], and the evidence from the cultural adaptation and initial feasibility study conducted among OFWs in Macao.…”