A self-help psychological intervention developed by the World Health Organization, Self-Help Plus, was effective in preventing the onset of mental disorders among Syrian refugees in Turkey, according to a study published in World Psychiatry today. The study, the first randomized controlled trial on prevention of mental disorders conducted among Syrian refugees experiencing psychological distress but without a diagnosis of a mental disorder, found that the likelihood of having a mental disorder six months after the intervention was approximately half for participants receiving Self-Help Plus as compared with those in the control arm.
Almost all of the 642 adults enrolled in the trial, which was completed in June 2020, were from Syria, with others coming from Iraq, the occupied Palestinian territory and Yemen. The average age of participants was 31, with almost 63% women. Half of the participants received Self-Help Plus and Enhanced Care As Usual (ECAU, consisting of routinely delivered social support and/or care) and half received ECAU alone.
A format delivered by trained facilitators in a group setting
Self-Help Plus (SH+) is based on acceptance and commitment therapy, a form of cognitive behavioural therapy. It consists of a pre-recorded audio course, delivered by non-specialist trained facilitators in a group setting and complemented with an illustrated self-help book adapted for the target cultural group. The audio material provides information on managing stress and guides participants through individual exercises and small group discussions. The self-help book covers all essential content and concepts. In accordance with the structure of the intervention, in the trial in Turkey, the course was delivered across five 2-hour sessions.
In the trial in Turkey, supported by the European Commission, Self-Help Plus participants were significantly less likely to have any mental disorders at six-month follow-up compared to the ECAU group (22% versus 41%). The risk reduction appeared to be similar across the most common diagnoses of mental disorders – depression, post-traumatic stress disorder (PTSD) and anxiety disorders. Consistent with this, Self-Help Plus participants also showed improvements in symptoms of depression, self-identified psychological outcomes, and quality of life at six-month follow-up.
Potential for scale-up to other large refugee populations
Given the size of the effect observed in the study, and that Self-Help Plus can be provided in large groups of up to 30 participants at a time by non-specialist facilitators following a short training, the trial results suggest that the intervention could be scaled up as a public health strategy to prevent mental disorders in large refugee populations exposed to ongoing adversity. Since the intervention does not address the determinants of the refugees’ mental health problems, however, it should be applied together with strong advocacy for protection of those who face adversity, and for services that address their social, physical and broader mental health needs.
Substantial need for mental health support among refugee populations
In 2020, the number of forcibly displaced people in the world, 80 million, was the highest since World War II. Among them, 26 million fled their countries due to violence or persecution. The largest group of refugees was from Syria, accounting for 6.6 million people. An estimated 3.6 million Syrian refugees are now living in Turkey. WHO estimates that rates of depression, PTSD and any mental disorder among people exposed to conflict in the previous 10 years are 11%, 15% and 22% respectively.