A new digital mental health intervention, Step-by-Step, developed by the World Health Organization (WHO) with the National Mental Health Programme (NMHP) at the Ministry of Public Health Lebanon and other partners, was 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. It found that people who received the digital intervention with remote guidance from trained non-specialist helpers were significantly less depressed and had significantly better functioning after the intervention compared with those who received enhanced usual care in the control group. People who received Step-by-Step also showed improvements in symptoms of anxiety, post-traumatic stress, well-being and personal problems, with all improvements maintained at 3-month follow-up. This study supports results from a parallel trial of Step-by-Step with Lebanese and other populations living in Lebanon, which showed similar positive results.

All of the 569 Syrian adults enrolled in the trial, which was completed in December 2020, were from Syria. The average age of participants was 31.5. The majority (58.3%) were women, and the majority were married (70.1%). Most had primary (32.0%) or secondary education (36.7%), and the majority were unemployed (58.7%). Half of the participants received the guided WHO Step-by-Step intervention provided as a hybrid app for iOS, Android, and web browsers, and half received Enhanced Care as Usual alone (consisting of basic psychoeducation and referral to evidence based care).

A format delivered by trained non-specialist helpers in a digital setting

Step-by-Step is a 5-session WHO digital intervention designed to treat depression through an internet-connected device, with weekly support (e.g. a 15 minute call or message) from trained non-specialist helpers. It provides psychoeducation and training in behavioural activation (e.g. doing more pleasant activities) through an illustrated narrative, with additional therapeutic techniques such as stress management, a gratitude exercise, positive self-talk, strengthening social support, and relapse prevention.

Step-by-Step includes five illustrated story sessions with audio recordings of the text to support accessibility. Each session is divided into three smaller parts, which on average take a total of 20 minutes to complete. Every session unlocks after four days of completing the previous session to give enough time for the person to practice the skills and exercises they learned in the previous session. Users are recommended to complete one session (with all its three parts) per week.

Potential for scale-up to other displaced populations with digital access

Given the effect observed in the study on depression, functional impairment, anxiety, post-traumatic stress, subjective well-being, and self-identified problems, and that Step-by-Step can be provided by trained non-specialist helpers to communities of displaced populations that have digital access, the trial results suggest that the intervention can be part of an effective strategy to improve mental health among other displaced populations with digital access. Lebanon’s National Mental Health Programme aims to scale up mental health care in line with the National Mental Health Strategy but resources are limited. Based on these results and results of a parallel trial conducted with Lebanese and other populations living in Lebanon, Lebanon’s National Mental Health Programme have scaled up the intervention nationally so that it is accessible to all adults in the country.

Substantial need for mental health support among refugee populations

The number of forcibly displaced persons reached 89.3 million at the end of 2021 and is estimated to have further increased to more than 100 million, because of recent global events.

The war in Syria has involved almost 6.8 million refugees. Lebanon, with a total population of close to 7 million, currently hosts about 840 900 displaced Syrians. After fleeing for safety, displaced people experience continuing difficulties, including unmet basic needs, language barriers, uncertainty about the future, social isolation, and discrimination. As a result, they are at risk of 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. Although depression and other common mental disorders are a 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 treatments and where less than 1 per 1000 displaced people seeks help from health services for common mental disorders. This study suggests that Step-by-Step can make a considerable contribution to addressing this treatment gap.

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