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- Title
Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial.
- 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
- Abstract
<bold>Importance: </bold>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.<bold>Objective: </bold>To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings.<bold>Design, Setting, and Participants: </bold>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).<bold>Interventions: </bold>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.<bold>Main Outcomes and Measures: </bold>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).<bold>Results: </bold>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).<bold>Conclusions and Relevance: </bold>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.<bold>Trial Registration: </bold>anzctr.org.au Identifier: ANZCTR12614001235695.
- Subjects
PESHAWAR (Pakistan); PAKISTAN; MENTAL health services; PSYCHOLOGICAL distress; PUBLIC health; CLINICAL trials; PSYCHOLOGY; WAR; SOCIAL history; ANXIETY diagnosis; ANXIETY treatment; DIAGNOSIS of mental depression; THERAPEUTICS; DIAGNOSIS of post-traumatic stress disorder; TREATMENT of psychological stress; ANXIETY; BEHAVIOR therapy; BRIEF psychotherapy; COMMUNITY health workers; COMPARATIVE studies; MENTAL depression; RESEARCH methodology; MEDICAL cooperation; HEALTH outcome assessment; POST-traumatic stress disorder; PSYCHOLOGICAL tests; QUESTIONNAIRES; RESEARCH; RESEARCH funding; TIME; SOCIOECONOMIC factors; EVALUATION research; RANDOMIZED controlled trials; MOTIVATIONAL interviewing; BLIND experiment
- Publication
JAMA: Journal of the American Medical Association, 2016, Vol 316, Issue 24, p2609
- ISSN
0098-7484
- Publication type
journal article
- DOI
10.1001/jama.2016.17165