Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial.
Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial.
复制标题
群体问题管理的有效性，对尼泊尔受人道主义灾难影响的成年人进行简短的心理干预：一项随机分组对照试验。
DOI：
10.1371/journal.pmed.1003621
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发表时间：
2021-06
期刊：
影响因子：
15.8
通讯作者：
van Ommeren M
中科院分区：
文献类型：
--
作者：
Jordans MJD;Kohrt BA;Sangraula M;Turner EL;Wang X;Shrestha P;Ghimire R;Van't Hof E;Bryant RA;Dawson KS;Marahatta K;Luitel NP;van Ommeren M
在全球范围内，有2.35亿人受到人道主义紧急情况的影响，患精神障碍的风险增加。我们的目标是测试在容易发生灾害的环境中，由训练有素的辅导员在没有事先接受过专业心理健康培训的情况下提供的简短小组心理治疗的有效性。我们于2018年11月25日至2019年9月30日进行了一项聚类随机对照试验（cRCT）。两组参与者分别在基线、中线（基线后7周，实验组治疗后约1周）和终线（基线后20周，治疗后约3个月）进行评估。干预措施是群体问题管理+ (PM+)，这是一种每周5次的心理治疗，与强化常规护理（EUC）进行比较，后者由家庭心理教育会议组成，并可选择转介给接受过心理保健培训的初级保健提供者。设置为尼泊尔东部的72个病房（地理聚类单位），治疗组每个病房1个PM+组。如果他们在灾害多发地区，并且居民说尼泊尔语，他们就有资格。病房被分配到基于协变量约束随机化的研究组。符合条件的参与者是年龄在18岁及以上的成年男女，他们符合心理困扰和功能障碍的筛查标准。在参与者水平上测量结果，评估者对小组分配不知情。主要结局是用一般健康问卷（GHQ-12）评估心理困扰。次要结局包括抑郁症状、创伤后应激障碍（PTSD）症状、“心灵”问题、社会支持、躯体症状和功能障碍。假设的中介是与治疗作用机制一致的技能使用。共有324名参与者入组对照组（36个病房），319名入组PM+组（36个病房）。总体样本（N = 611）的中位年龄为45岁（范围为18-91岁），82%的参与者是女性，50%最近经历过自然灾害，31%患有慢性身体疾病。对照组302名参与者（36个病房）和PM+组303名参与者（36个病房）完成了终点评估。在中线评估时（实验组PM+后立即），PM+组GHQ-12平均总分比对照组低2.7个单位（95% CI: 1.7, 3.7, p < 0.001），标准化平均差（SMD）为- 0.4 （95% CI: - 0.5, - 0.2）。在治疗后3个月（主要终点），PM+组GHQ-12平均总分比对照组低1.4个单位（95% CI: 0.3, 2.5, p = 0.014）， SMD为- 0.2 （95% CI: - 0.4, 0.0）。在次要结局中，PM+组抑郁症状减轻50%以上的比例更大（PM+组为29.9%，对照组为17.3%，风险比为1.7,95% CI: 1.2, 2.4, p = 0.002）。与对照组（69.4%）相比，PM+组在终末仍有“心脏-精神”问题的参与者较少（58.8%），风险比= 0.8 （95% CI, 0.7, 1.0, p = 0.042）。PM+组与较低的PTSD症状或功能障碍无关。在中线使用心理社会技能估计可以解释31%的PM+对终线GHQ-12分数的影响。对照组的不良事件包括1例自杀死亡和1例可报告的家庭暴力事件；PM+组有1例因身体疾病死亡。研究的局限性包括缺乏评估性别效应的能力，缺乏长期结果（如治疗后12个月），以及缺乏成本效益信息。在这项研究中，我们发现，在一个容易发生人道主义紧急情况的环境中，由非专业人员提供的5次小组心理治疗适度地减少了心理困扰和抑郁症状。在日常生活中使用心理社会技能的程度部分解释了这些好处。为了提高治疗效益，未来的实施应侧重于提高PM+参与者技能使用的方法。ClinicalTrials.gov NCT03747055。Mark Jordans和他的同事在尼泊尔评估了一项针对受心理困扰的成年人的团体治疗干预。全世界有数百万人受到战争、环境灾害和流行病等人道主义紧急情况的影响。这些环境中的大多数人口缺乏获得精神卫生服务的机会。在之前的研究中，不是心理健康专家的人经过培训，可以有效地提供心理治疗，包括问题管理+ (PM+)，这是一个简短的5次干预。然而，在此之前只有一项关于由非专业人员交付的基于小组的PM+形式的研究。随着非专业人员的使用增加，出现了新的问题，即当这些心理干预由非心理健康专业人员提供时，这些干预是如何起作用的。研究潜在的作用机制（即干预如何起作用）可能有助于在扩大规模时提高有效性。研究人员评估了PM+小组在容易发生人道主义紧急情况的情况下的有效性，并通过简单训练的非专业人员进行干预，研究人员评估了减少心理困扰的潜在作用机制。与接受转诊服务的成年人相比，接受社区非专业人员提供的PM+小组治疗的成年人在干预后3个月的心理困扰程度有所降低。在干预3个月后，PM+组中大约有1 / 3的成年人抑郁症状减轻了50%，而对照组中有1 / 6的人接受了转诊服务。至于干预是如何产生变化的，研究小组之间三分之一的差异可以解释为参与者使用PM+小组教授的社会心理技能，如呼吸练习，解决问题的技巧和寻求社会支持。在缺乏精神卫生专家的人道主义紧急情况下，可采用由非专业人员提供的5次小组心理治疗，以适度减轻心理困扰和抑郁症状。小组PM+的好处部分可以通过干预促进社会心理技能的使用程度来解释。因此，未来的干预应该探索如何在日常生活中加强这些技能的练习。需要进一步的研究来评估小组PM+的影响如何因性别而异，因为研究指出，与女性相比，男性的益处可能更少。
Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting. We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, “heart–mind” problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment’s mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18–91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of −0.4 (95% CI: −0.5, −0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of −0.2 (95% CI: −0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have “heart–mind” problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information. In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants. ClinicalTrials.gov NCT03747055. Mark Jordans and co-workers evaluate a group therapy intervention in adults affected by psychological distress in Nepal. Millions of people worldwide are affected by humanitarian emergencies such as war, environmental disasters, and pandemics. Most populations in these settings lack access to mental health services. In prior studies, people who are not mental health specialists have been trained to effectively deliver psychological treatments, including Problem Management Plus (PM+), which is a brief 5-session intervention. However, there has only been one prior study of a group-based format of PM+ delivered by nonspecialists. As the use of nonspecialists increases, there are new questions about how these psychological interventions work when delivered by someone who is not a mental health professional. Studying potential mechanisms of action (i.e., how the intervention works) could be instrumental to increasing effectiveness when scaling up. The researchers evaluated the effectiveness of Group PM+ in a setting prone to humanitarian emergencies with delivery of the intervention by briefly trained nonspecialists, and the researchers evaluated a potential mechanism of action involved in reducing psychological distress. Adults who received Group PM+ delivered by nonspecialists in their communities showed greater reduction in psychological distress at 3 months after the intervention compared to adults who had been offered referral options for services. At 3 months after the intervention, approximately 1 out of 3 adults in Group PM+ had a 50% reduction in depression symptoms compared to 1 out of 6 who were in the control arm receiving referral options for services. Regarding how the intervention produced changes, a third of the differences between study arms was explained by participants’ use of psychosocial skills taught in Group PM+, such as breathing exercises, problem-solving techniques, and seeking social support. In humanitarian emergencies with a lack of mental health specialists, a 5-session group psychological treatment delivered by nonspecialists can be used to modestly reduce psychological distress and depression symptoms. The benefits of Group PM+ are partly explained by the degree of psychosocial skill use being promoted through the intervention. Therefore, future use of the intervention should explore how to enhance practice of these skills in daily life. Further research is needed to evaluate how the impact of Group PM+ differs by gender because the study points toward potentially less benefit among men compared to women.
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影响因子：
15.8
作者：
Jordans, Mark J. D.;Luitel, Nagendra P.;Lund, Crick
通讯作者：
Lund, Crick
影响因子：
4.4
作者：
Kohrt, Brandon A.;Luitel, Nagendra P.;Jordans, Mark J. D.
通讯作者：
Jordans, Mark J. D.
影响因子：
105.7
作者：
Campbell, Marion K.;Piaggio, Gilda;Altman, Douglas G.
通讯作者：
Altman, Douglas G.
影响因子：
3.6
作者：
Luitel NP;Jordans MJ;Adhikari A;Upadhaya N;Hanlon C;Lund C;Komproe IH
通讯作者：
Komproe IH
影响因子：
8.1
作者：
Jordans MJD;Kohrt BA
通讯作者：
Kohrt BA