Mental health app helps refugees cope with suffering

A digital, self-guided mental health self-help intervention reduces psychological distress and improves overall functioning among refugees, according to a study in Egypt.

“Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations,” the investigators said.

A two-arm pragmatic randomized controlled trial was conducted involving 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 >15) and reduced psychosocial functioning (WHO Disability Assessment Schedule [DAS] 2.0 >16). Participants were randomly allocated to receive SBS plus care as usual (CAU; n=266) or CAU only (n=272).

Psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO DAS 2.0) at 3-month follow-up were the primary outcomes. Secondary ones included symptoms of PTSD and self-identified problems.

In intention-to-treat analyses, the digital self-help intervention provided small but significantly positive effects on psychological distress (mean difference, ‒0.15, 95 percent confidence interval [CI], ‒0.28 to ‒0.02; p=0.01) and functioning (mean difference, ‒2.04, 95 percent CI, ‒3.87 to ‒0.22; p=0.02) at 3 months. [PLoS Med 2024;21:e1004460]

No significant between-group differences were seen in symptoms of PTSD and self-identified problems. Remission rates were also comparable between conditions on any of the outcomes. Notably, 9.4 percent of participants used contact-on-demand (COD) support for a median of 1 contact per person.

“Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability,” the investigators said.

These results provide further evidence for low-threshold digital mental health interventions for underserved populations in low- and middle-income countries. [Camb Prisms Glob Ment Health 2023;10;1-28; Lancet Psychiatry 2020;7:851-864]

“In the context of similar trials, [the current] study underlines the importance of balancing key components for scalability and effectiveness when implementing digital mental health solutions,” the investigators said.

COD support

This study was limited by high intervention dropout and low utilization of COD support. The latter was potentially caused by the following: (a) the technical implementation of the feature; (b) the manner in which the feature was introduced and explained within the app; (c) the topics and extent of e-helper support; or (d) characteristics of e-helpers.

“The feature’s technical implementation underwent thorough testing and was designed to mirror the functionality of messaging apps, which were identified as widely familiar to most Syrians through prior research,” the investigators said. [Front Psychiatry 2019;9:663]

To increase awareness of the e-helper contact option, this feature was introduced during study onboarding. Additionally, participants received a welcome message from their e-helper as part of the introduction session. During the intervention, reminders were also integrated into the summary at the end of each session.

Participants who initiated contact with an e-helper were tasked to select one of the following topics: question about SbS, motivation to continue the intervention, technical question, question about the research, or another topic.

“The selected topics and the overall scope of the support might not have aligned with the actual needs of the participants, as evidenced by the frequent expression of a desire to contact a mental health professional or to receive a referral for face-to-face therapy,” the investigators said.