Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial

• Published in: JAMA : the journal of the American Medical Association Vol. 316; no. 24; pp. 2609 - 2617
• Main Authors: Rahman, Atif, Hamdani, Syed Usman, Awan, Naila Riaz, Bryant, Richard A, Dawson, Katie S, Khan, Muhammad Firaz, Azeemi, Mian Mukhtar-ul-Haq, Akhtar, Parveen, Nazir, Huma, Chiumento, Anna, Sijbrandij, Marit, Wang, Duolao, Farooq, Saeed, van Ommeren, Mark
• Format: Journal Article
• Language: English
• Published: United States American Medical Association 27-12-2016
• Subjects: Adult; Anxiety - diagnosis; Anxiety - epidemiology; Anxiety - therapy; Behavior Therapy - methods; Community Health Workers - economics; Depression - diagnosis; Depression - epidemiology; Depression - therapy; Depressive Disorder - diagnosis; Depressive Disorder - epidemiology; Exposure to Violence - psychology; Female; Humans; Intention to Treat Analysis; Male; Motivational Interviewing - methods; Outcome Assessment, Health Care; Pakistan - epidemiology; Psychotherapy, Brief; Single-Blind Method; Socioeconomic Factors; Stress Disorders, Post-Traumatic - diagnosis; Stress Disorders, Post-Traumatic - epidemiology; Stress, Psychological - therapy; Time Factors; War Exposure; Pakistan
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2016.17165

IMPORTANCE: The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. OBJECTIVE: To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). INTERVENTIONS: Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. MAIN OUTCOMES AND MEASURES: Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). RESULTS: Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, −0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, −0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, −2.77; 95% CI, −3.56 to −1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, −2.98; 95% CI, −3.74 to −2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, −5.86; 95% CI, −8.53 to −3.19), functional impairment (AMD, −4.17; 95% CI, −5.84 to −2.51), problems for which the person sought help (AMD, −1.58; 95% CI, −2.40 to −0.77), and symptoms of depressive disorder (AMD, −3.41; 95% CI, −4.49 to −2.34). CONCLUSIONS AND RELEVANCE: Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12614001235695