Mental health and psychosocial support in humanitarian settings: linking practice and research

doi:10.1016/S0140-6736(11)61094-5

The Lancet

Volume 378, Issue 9802, 29 October–4 November 2011, Pages 1581-1591

https://doi.org/10.1016/S0140-6736(11)61094-5 Get rights and content

Summary

This review links practice, funding, and evidence for interventions for mental health and psychosocial wellbeing in humanitarian settings. We studied practice by reviewing reports of mental health and psychosocial support activities (2007–10); funding by analysis of the financial tracking service and the creditor reporting system (2007–09); and interventions by systematic review and meta-analysis. In 160 reports, the five most commonly reported activities were basic counselling for individuals (39%); facilitation of community support of vulnerable individuals (23%); provision of child-friendly spaces (21%); support of community-initiated social support (21%); and basic counselling for groups and families (20%). Most interventions took place and were funded outside national mental health and protection systems. 32 controlled studies of interventions were identified, 13 of which were randomised controlled trials (RCTs) that met the criteria for meta-analysis. Two studies showed promising effects for strengthening community and family supports. Psychosocial wellbeing was not included as an outcome in the meta-analysis, because its definition varied across studies. In adults with symptoms of post-traumatic stress disorder (PTSD), meta-analysis of seven RCTs showed beneficial effects for several interventions (psychotherapy and psychosocial supports) compared with usual care or waiting list (standardised mean difference [SMD] −0·38, 95% CI −0·55 to −0·20). In children, meta-analysis of four RCTs failed to show an effect for symptoms of PTSD (–0·36, −0·83 to 0·10), but showed a beneficial effect of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms (six RCTs; SMD −0·24, −0·40 to −0·09). Overall, research and evidence focuses on interventions that are infrequently implemented, whereas the most commonly used interventions have had little rigorous scrutiny.

Section snippets

MHPSS practices

To assess which MHPSS practices are common, we reviewed documents disseminated on the internet, within organisations, or to donors, to identify reports of implemented programmes (webappendix p 3). We selected countries that had had a humanitarian crisis (including natural or technological disasters, and armed conflicts) between Jan 1, 2007, and Sept 20, 2010, using four databases: the Uppsala Conflict Data Program,19, 20, 21 the annual Conflict Barometer,22, 23, 24 the Central Emergency Relief

Financial tracking

We searched the Financial Tracking Service and Creditor Reporting System databases, in accordance with the approach used in other financial tracking efforts (for global health,²⁹ reproductive health in conflict-affected settings,³⁰ and maternal, newborn, and child health³¹). The databases provide specific codes for some health specialties (eg, reproductive health) but not for mental health. Using the list of countries affected by humanitarian crises identified in the grey literature review, we

The evidence for MHPSS

To identify studies assessing MHPSS in humanitarian settings, we did a systematic review and meta-analysis separate from our review of the grey literature (panel). Studies were identified in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.⁴⁶ For the systematic review, randomised controlled trials (RCTs) or controlled clinical trials were included (ie, studies that compared any mental health or psychosocial support practice with either

Study selection

Figure 1 shows the selection criteria for the systematic review and meta-analysis (for selected characteristics of included studies see webappendix pp 8–15). All identified studies were categorised according to intervention goals (figure 2) as described in the intervention pyramid of the IASC MHPSS and Sphere guidelines.⁷³ We did not identify studies that assessed MHPSS at the lowest level of the IASC pyramid—social considerations in basic services and security (eg, promotion of participation

Meta-analysis of RCTs

In total, 13 studies met the inclusion criteria: six in children and adolescents, and seven in adults (figure 1). The studies in children and adolescents focused mainly on two school-based interventions (ERASE Stress⁶² and the classroom-based intervention57, 58, 59, 60) that had PTSD as one of the primary outcomes. Other studies were of a parenting intervention and basic medical support for young children in Bosnia and Herzegovina (including both outcomes for parents and children)⁵⁶ and

Conclusion

The main strength of this review is that it provides a comprehensive overview of implemented practice, funding, and synthesis of evidence for psychological interventions with rigorous standards of systematic review and meta-analysis. Our findings had the following limitations. First, our grey literature search included only reports in English. Second, the financial tracking might provide an incomplete account of funding for MHPSS. No dedicated code for MHPSS funding exists in the relevant

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Randomized controlled trial: Comparing the effectiveness of brief group cognitive behavioural therapy and group eye movement desensitisation and reprocessing interventions for PTSD in internally displaced persons, administered by paraprofessionals in Northern Iraq
2023, European Journal of Trauma and Dissociation
In 2023, 339 million people need humanitarian assistance due to emergencies. In those contexts, prevention and treatment of Post-Traumatic Stress Disorder (PTSD) are extremely important. Trauma Focussed Cognitive Behavioural Therapy (TF-CBT) and Eye Movement Desensitisation and Reprocessing (EMDR) are recommended treatments but their deployment comes up against various obstacles, especially in Low- and Middle-Income Countries (LMIC) where mental health professionals are rare. Developing evidence-based, brief, group interventions by paraprofessionals might be an option for scaling up.
The research has been conducted in northern Iraq, in a complex on-going emergency setting. After one psycho-education session on trauma, adults over 18 years of age, willing to participate to the program and with IES-R (Impact Event Scale-Revised, Weiss & Marmar, 1997) score superior or equal to 33 were randomly assigned to TF-CBT or EMDR Group-Traumatic Episode Protocol (G-TEP) interventions. Eighty-six men and women, internally displaced, living in camps, received six sessions of either TF-CBT (n = 46) or EMDR G-TEP (n = 40) in groups settings. Measures included IES-R, Hospital Depression Scales (HADS, (Zigmond & Snaith, 1983)) at admission and after six sessions. Statistical analysis has been done on participants that have attended at least sessions one and six of the protocols. For each group (TF-CBT and G-TEP), results between pre-treatment and post-treatment were compared using Student's t-test paired for quantitative variables and chi-square paired for qualitative variables to measure the effectiveness of each treatment. All tests were bilateral and were considered significant at p < 0.05.
Results in the TF-CBT group showed a significant reduction in IES-R (t = 7.38; p = 0.001; Effect Size= 1.088), HAD-Depression (t = 6.03; p = 0.001; Effect Size= 0.889) and HAD-Anxiety (t = 6.34; p = 0.001; Effect Size=0.934). Results in the EMDR- G-TEP group showed a significant reduction in IES-R (t = 4.63; p< 0.001; Effect Size= 0.732), HAD-Depression (t = 3.12; p = 0.003; Effect Size=0.494) and HAD-Anxiety (t = 3.01; p = 0.005; Effect Size=0.475). Both populations remained clinical, despite a significant treatment effect. There was no statistical difference between the two treatments.
Findings open the possibility to scale up EMDR G-TEP or TF-CBT interventions in groups conducted by paraprofessionals for reducing PTSD symptomatology within humanitarian programs.
Mental health and psychosocial support in humanitarian settings: research priorities for 2021–30
2023, The Lancet Global Health
We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021–30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.
Psychosocial support interventions in the context of forced displacement: A systematic review and meta-analysis
2023, Journal of Migration and Health
Forced displacement is associated with elevated risk for poor psychosocial wellbeing, yet there remains a lack of clarity around the effectiveness of commonly implemented psychosocial support interventions focused on preventing disorder and promoting wellbeing. This study aimed to synthesize the literature on evaluations of psychosocial support interventions for populations affected by forced displacement.
We searched for peer reviewed and gray literature in seven databases (PubMed, Embase, Global Health, CINAHL, SocIndex, PsychInfo, PILOTS), fifteen organizational websites, and via solicitation through multiple networks. Various study designs were included, with the criteria that they report an evaluation of a psychosocial intervention delivered to populations affected by forced displacement, and included quantitative or qualitative data on psychosocial outcomes. Records were screened independently by two reviewers at both title/abstract and full-text review; data was double-extracted and study quality assessed, with discrepancies resolved by consensus. Meta-analyses for seven outcomes were conducted on a subset of 33 studies.
We identified 162 reports. Over half (55%) used a single-group study design, with fewer using non-random (19%) or randomized (21%) comparisons. Study designs incorporating comparison conditions were less likely to report positive findings than single-group studies. In the meta-analyses, a moderately strong overall effect was found for psychosocial wellbeing (ES: -0.534, 95% CI: [-0.870, -0.197], p=.005); small effects on both internalizing (ES: -0.152, 95% CI: [-0.310, 0.005], p= .057) and externalizing (ES: -0.249, 95% CI: [-0.515, 0.016], p=.064) problems were promising but not conclusive. Subgroup analysis suggested differential impacts on internalizing problems for adults (improvement; ES: -0.289, 95% CI: [-0.435, -0.143], p=.001) and children (worsening; ES: 0.129, 95% CI: [.054, 0.204], p=.002). Other subgroup analyses showed little meaningful variation by context, population, or intervention characteristics.
Pragmatic, field-driven program evaluations are dominated by single-group designs with significant risk of bias. Findings from controlled studies are promising but highlight a need for more rigorous research to support causal inference, align outcomes with theories of change, improve measurement of more positive or wellbeing-focused outcomes, examine subgroup differences, and report potentially negative impacts.
The social outcomes of psychosocial support: A grey literature scoping review
2022, SSM - Mental Health
Policymakers, practitioners and academics expect mental health and psychosocial support (MHPSS) interventions to have social outcomes. Surprisingly, the existing academic literature on the effectiveness of MHPSS has focused almost exclusively on clinical outcomes. The evidence base of MHPSS interventions is in that way limited. To feed the research agenda on MHPSS (i.e., MHPSS-SET2), this scoping review analyses the presence and understanding of social outcomes in the grey literature. Open-access documents were systematically searched from various online grey literature databases and websites of organisations. Documents which describe psychosocial programming in low- and middle-income countries for people affected by humanitarian emergencies were included. Data characteristics were extracted, such as the type of document, intervention and outcome. A textual analysis of social outcomes was conducted to categorise the descriptions of these outcomes.
A total number of 95 grey literature documents were included in the review. It was found that in the vast majority of the reviewed documents, social outcomes are being described. However, social outcomes have been poorly conceptualised both theoretically and methodologically, meaning that most documents lack definitions of theoretical concepts and measurement instruments. Mechanisms relating interventions to social outcomes have remained implicit. These findings are interpreted in light of key developments in the field of MHPSS, in particular the introduction of the Inter-Agency Standing Committee (IASC) guidelines, and the review traces the underexposed position of social outcomes back to the clinical historical roots of the field.
In conclusion, those who develop and evaluate interventions should focus more structural attention on social outcomes to fully understand the possible impact of psychosocial interventions. Further harmonisation between academic research and practice is necessary, by drawing from practice-based insights on social outcomes as found in the grey literature, and using methods and measurement instruments from social sciences in MHPSS research.
Web-Based Psychosocial Interventions for Disaster-Related Distress: What Has Been Trialed in the Past, and What Can We Learn from This?
2023, Disaster Medicine and Public Health Preparedness
Macro level system mapping of the provision of mental health services to young people living in a conflict context in Colombia
2024, BMC Health Services Research

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SeriesMental health and psychosocial support in humanitarian settings: linking practice and research

Summary

Section snippets

MHPSS practices

Financial tracking

The evidence for MHPSS

Study selection

Meta-analysis of RCTs

Conclusion

Lancet

Soc Sci Med

Soc Sci Med

Am J Prev Med

Soc Sci Med

Soc Sci Med

Lancet

Lancet

Lancet

Clin Psychol Rev

Clin Psychol Rev

Behav Res Ther

Behav Res Ther

J Adolesc Health

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement

JAMA

Post-traumatic stress disorder following disasters: a systematic review

Psychol Med

60,000 disaster victims speak: part I. An empirical review of the empirical literature, 1981–2001

Psychiatry

Estimating clinically relevant mental disorders in a rural and an urban setting in postconflict Timor Leste

Arch Gen Psychiatry

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

JAMA

Post-disaster mental health need assessment surveys – the challenge of improved future research

Int J Methods Psychiatr Res

Psychiatric effects of traumatic brain injury events in Cambodian survivors of mass violence

Br J Psychiatry

Humanitarian charter and minimum standards in disaster response—2011 edition

IASC guidelines on mental health and psychosocial support in emergency settings

Mental health in complex emergencies

Lancet

Mental health in the aftermath of disasters: consensus and controversy

J Nerv Ment Dis

Dyadic dimensions of armed conflict, 1946–2007

J Peace Res

Armed conflicts, 1946–2008

J Peace Res

Armed conflicts, 1946–2009

J Peace Res

Conflict barometer 2007

Conflict barometer 2008

Conflict barometer 2009

Central emergency relief fund

Consolidated appeals process

Country and lending groups

Who does What Where and until When (4Ws)

Tracking official development assistance for reproductive health in conflict-affected countries

PLoS Med

Preventive interventions among children exposed to trauma of armed conflict: a literature review

Aggress Behav

The psychosocial aspects of children exposed to war: practice and policy initiatives

J Child Psychol Psychiatry

Systematic review of evidence and treatment approaches: psychosocial and mental health care for children in war

Child Adolesc Ment Health

School-based interventions for minors in war-exposed countries: a review of targeted and general programmes

Torture

Psychological impact of disasters on children: review of assessment and interventions

World J Pediatr

Series
Mental health and psychosocial support in humanitarian settings: linking practice and research