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

Abstract

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 self­help psychological intervention developed by the World Health Organization, called Self­Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two­arm, assessor­masked 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 Self­Help Plus arm (consisting of Self­Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self­Help 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 six­month follow­up. Secondary outcome measures were the pres­ence of mental disorders at post­intervention, and psychological distress, symptoms of post­traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well­being, and quality of life at post­intervention and six­month follow­up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty­four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self­Help Plus (N=322) or ECAU (N=320). Self­Help Plus participants were sig­nificantly less likely to have any mental disorders at six­month follow­up compared to the ECAU group (21.69% vs. 40.73%; Cramer’s V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408­0.696). Analysis of secondary outcomes suggested that Self­Help Plus was not effective immediately post­intervention, but was associated with beneficial effects at six­month follow­up 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. Self­Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low­intensity self­help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities