Effectiveness of a brief group behavioral intervention for common mental disorders in Syrian refugees in Jordan: A randomized controlled trial

Background Common mental disorders are frequently experienced by refugees. This study evaluates the impact of a brief, lay provider delivered group-based psychological intervention [Group Problem Management Plus (gPM+)] on the mental health of refugees in a camp, as well as on parenting behavior and children's mental health. Methods and findings In this single-blind, parallel, randomized controlled trial, 410 adult Syrian refugees (300 females, 110 males) in Azraq Refugee Camp (Jordan) were identified through screening of psychological distress (>= 16 on the Kessler Psychological Distress Scale) and impaired functioning (>= 17 on the WHO Disability Assessment Schedule). Participants were randomly allocated to gPM+ or enhanced usual care (EUC) involving referral information for psychosocial services on a 1:1 ratio. Participants were aware of treatment allocation, but assessors were blinded to treatment condition. Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL; depression and anxiety scales) assessed at baseline, 6 weeks, and 3 months follow-up as the primary outcome time point. It was hypothesized that gPM+ would result in greater reductions of scores on the HSCL than EUC. Secondary outcomes were disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behavior, and children's mental health. Between October 15, 2019 and March 2, 2020, 624 refugees were screened for eligibility, 462 (74.0%) screened positive, of whom 204 were assigned to gPM+ and 206 to EUC. There were 168 (82.4%) participants in gPM+ and 189 (91.7%) in EUC assessed at follow-up. Intent-to-treat analyses indicated that at follow-up, participants in gPM+ showed greater reduction on HSCL depression scale than those receiving EUC (mean difference, 3.69 [95% CI 1.90 to 5.48], p = .001; effect size, 0.40). There was no difference between conditions in anxiety (mean difference -0.56, 95% CI -2.09 to 0.96; p = .47; effect size, -0.03). Relative to EUC, participants in gPM+ had greater reductions in severity of personally identified problems (mean difference 0.88, 95% CI 0.07 to 1.69; p = .03), and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < .001). There were no significant differences between conditions for changes in PTSD, disability, grief, prodromal symptoms, or childhood mental health outcomes. Mediation analysis indicated the change in inconsistent disciplinary parenting was associated with reduced attentional (beta = 0.11, SE .07; 95% CI .003 to .274) and internalizing (beta = 0.08, SE .05; 95% CI .003 to 0.19) problems in children. No adverse events were attributable to the interventions or the trial. Major limitations included only one-quarter of participants being male, and measures of personally identified problems, grief, prodromal psychotic symptoms, inconsistent parenting behavior, and children's mental health have not been validated with Syrians. Conclusions In camp-based Syrian refugees, a brief group behavioral intervention led to reduced depressive symptoms, personally identified problems, and disciplinary parenting compared to usual care, and this may have indirect benefits for refugees' children. The limited capacity of the intervention to reduce PTSD, disability, or children's psychological problems points to the need for development of more effective treatments for refugees in camp settings. Trial registration Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619001386123. Author summary Why was this study done?There are approximately 80 million refugees and forcibly displaced people today, and they are at greater risk for common mental disorders.Most countries hosting refugees lack the health resources to address these mental health problems.In response to this situation, the World Health Organization has developed a brief psychological intervention that can be delivered by trained lay workers that aims to reduce psychological distress following adversity.To our knowledge, this study was the first to test the effectiveness of the Group Problem Management Plus (gPM+) program in distressed refugees in a refugee camp.What did the researchers do and find?This study screened adult Syrian refugees in a camp in in Jordan, and subsequently randomized 410 adult refugees who displayed distress and impaired functioning to either 5 individual sessions of gPM+ or enhanced usual care (EUC).Independent assessments indicated that 3 months following treatment, refugees who received gPM+ reported significantly less depression but not anxiety, with a moderate effect relative to EUC.gPM+ also led to greater reductions inconsistent disciplinary parenting, and this was associated with greater reductions in attentional and internalizing problems in refugees' children.What do these findings mean? This study suggests that mental health nonspecialists can be briefly trained in gPM+, and they can deliver this intervention in a way that it can improve mental health of refugees.This brief intervention has the potential to scale up mental health services for refugees in settings that lack adequate health resources, and this may have downstream benefits for refugees' children.