The new Step-by-Step digital mental health intervention, developed by the World Health Organization (WHO) together with the National Mental Health Program (NMHP) of the Lebanese Ministry of Health and other partners, has been effective in reducing depression among Syrian refugees. in Lebanon, according to a study published in PLOS Medicine.
The study, a randomized controlled trial supported by Elrha’s Research for Health in Humanitarian Crises (R2HC), was conducted among Syrians suffering from depression and impaired functioning in Lebanon. People who underwent digital intervention under the remote guidance of trained non-specialist assistants were found to be significantly less depressed and function significantly better after the intervention compared to those who received extended conventional care in the control group. People who took Step-by-Step also showed improvements in symptoms of anxiety, post-traumatic stress, well-being and personal problems, with all improvements sustained after 3 months of follow-up. This study confirms the results of a parallel trial of the Step by Step program with Lebanese and other populations living in Lebanon, which showed similar positive results.
All 569 Syrian adults who took part in the trial, which ended in December 2020, were from Syria. The average age of the participants was 31.5 years. The majority (58.3%) were women and the majority were married (70.1%). Most of them had a primary (32.0%) or secondary education (36.7%), and the majority were unemployed (58.7%). Half of the participants received a WHO-guided Step-by-Step intervention delivered as a hybrid app for iOS, Android and web browsers, and half received only extended care as usual (consisting of basic psychological education and referral to evidence-based care) .
A format provided by trained non-specialist assistants in a digital environment.
Step-by-Step is a 5-session WHO digital intervention designed to treat depression using an internet connected device with weekly support (e.g. 15 minutes call or message) from trained non-specialist assistants. It provides psychoeducation and behavioral activation training (such as doing more pleasurable activities) through illustrated storytelling with additional therapeutic techniques such as stress management, gratitude exercise, positive self-talk, increased social support, and relapse prevention.
Step-by-Step includes 5 illustrated stories with audio recordings of the text to support accessibility. Each session is divided into 3 small parts, which on average take a total of 20 minutes. Each session opens 4 days after the completion of the previous session to allow the individual enough time to practice the skills and exercises they learned in the previous session. Users are advised to take 1 session (with all 3 parts) per week.
Potential to extend to other displaced populations with digital access
Considering the impact observed in the study on depression, functional impairment, anxiety, post-traumatic stress disorder, subjective well-being and identified problems, and that the Step by Step program can be provided by trained non-professional helpers to displaced communities with access to digital technologies, test results show that the intervention can be part of an effective strategy to improve mental health among other displaced people who have access to digital technologies. Lebanon’s National Mental Health Program aims to scale up mental health care in line with the National Mental Health Strategy, but resources are limited. Based on these results and the results of a parallel trial conducted with Lebanese and other populations living in Lebanon, Lebanon’s National Mental Health Program expanded the intervention at the national level to be available to all adults in the country.
Substantial need for mental health support among refugees
Almost 6.8 million refugees. Lebanon, with a total population of about 7 million, currently has about 840 900 displaced Syrians. After fleeing for safety, displaced people continue to experience hardships, including unmet basic needs, language barriers, uncertainty about the future, social exclusion and discrimination. As a result, they are at risk for mental disorders such as depression, anxiety, and post-traumatic stress.
It has been estimated that 22% of displaced, war-affected Syrians in Lebanon suffer from moderate to severe depressive symptoms. While depression and other common mental disorders are the leading cause of disability, the vast majority of displaced people do not receive treatment. This is especially true in low- and middle-income countries, where only 1 in 27 people with depression are likely to receive evidence-based treatment, and where fewer than 1 in 1,000 displaced people seek help from health services for common mental disorders. . This study suggests that the Step by Step program can make a significant contribution to closing this treatment gap.