Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan A Randomized Clinical Trial
Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan A Randomized Clinical Trial
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DOI：
10.1001/jama.2016.17165
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发表时间：
2016-12-27
影响因子：
120.7
通讯作者：
van Ommeren, Mark
中科院分区：
文献类型：
--
作者：
Rahman, Atif;Hamdani, Syed Usman;van Ommeren, Mark
重要性 冲突和暴力对心理健康造成的影响是广泛而普遍的。需要可扩展的干预措施来解决一系列心理健康问题。 目的 测试由非专业卫生工作者向初级保健机构中存在心理困扰的成年人提供的多成分行为干预措施的有效性。 设计、设置和参与者 2014 年 11 月 1 日至 2016 年 1 月 28 日，在巴基斯坦白沙瓦的 3 个初级保健中心进行了一项随机临床试验，其中包括 346 名心理和心理困扰水平较高的成人初级保健参加者。根据 12 项一般健康调查问卷和世界卫生组织残疾评估表 2.0 (WHODAS 2.0)，了解痛苦和功能障碍。 干预措施 非专业卫生工作者每周进行 5 次每次 90 分钟的单独会议，其中包括经验支持的问题解决策略、行为激活、加强社会支持和压力管理。控制是加强常规护理。 主要结果和措施 主要结果，焦虑和抑郁症状，在 3 个月时使用医院焦虑和抑郁量表 (HADS) 进行独立测量。次要结果是创伤后应激症状（DSM-5 创伤后应激障碍检查表）、功能障碍（WHODAS 2.0）、患者寻求帮助的问题进展（心理结果概况）以及抑郁症症状（9 项患者健康问卷）。 结果 346 名患者中（平均 [SD] 年龄，33.0[11.8] 岁；78.9%女性），172 名被随机分配至干预组，174 名被分配至强化常规护理；其中，分别有146人和160人完成了研究。基线时，干预组和对照组在焦虑症状（14.16 [3.17] vs 13.64 [3.20]）和抑郁症状（12.67 [3.27] vs 12.49 [3.34]；AMD，0.17）方面具有相似的平均 (SD) HADS 评分；调整后平均差 [AMD]，0.52；95% CI，-0.22 至 1.27。 95% CI，-0.54 至 0.89）。治疗3个月后，干预组的焦虑（7.25 [3.63] vs 10.03 [3.87]；AMD，-2.77；95% CI，-3.56至-1.98）和抑郁（6.30 [3.40] vs 9.27 [3.56]；AMD，-2.98；95% CI，-3.56至-1.98）平均（SD）HADS评分显着低于对照组。 -3.74 至 -2.22）。 3个月时，创伤后应激（AMD，-5.86；95% CI，-8.53至-3.19）、功能障碍（AMD，-4.17；95% CI，-5.84至-2.51）、寻求帮助的问题（AMD，-1.58；95% CI，-2.40至-0.77）以及抑郁症状的评分也存在显着差异。障碍（AMD，-3.41；95% CI，-4.49 至 -2.34）。 结论和相关性 在受冲突影响地区遭受心理困扰的成年人中，与加强常规护理相比，非专业卫生工作者根据既定行为策略进行简短的多成分干预，可在 3 个月时临床上显着减少焦虑和抑郁症状。
IMPORTANCE The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed.OBJECTIVE To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings.DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).INTERVENTIONS Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care.MAIN OUTCOMES AND MEASURES Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire).RESULTS Among 346 patients (mean [SD] age, 33.0[11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress(AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help(AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder(AMD, -3.41; 95% CI, -4.49 to -2.34).CONCLUSIONS AND RELEVANCE Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months.