title: Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial.
abstract: 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.
  
  
  
  To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings.
  
  
  
  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).
  
  
  
  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.
  
  
  
  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).
  
  
  
  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 to 0.89). 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).
  
  
  
  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.
  
  
  
  anzctr.org.au Identifier: ANZCTR12614001235695.
authors.affiliation: University of Liverpool, Liverpool, England.
authors.forename: Atif
authors.initials: A
authors.lastname: Rahman
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Syed Usman
authors.initials: SU
authors.lastname: Hamdani
authors.affiliation: Lady Reading Hospital, Peshawar, Pakistan.
authors.forename: Naila Riaz
authors.initials: NR
authors.lastname: Awan
authors.affiliation: University of New South Wales, Sydney, Australia.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Bryant
authors.affiliation: University of New South Wales, Sydney, Australia.
authors.forename: Katie S
authors.initials: KS
authors.lastname: Dawson
authors.affiliation: Lady Reading Hospital, Peshawar, Pakistan.
authors.forename: Muhammad Firaz
authors.initials: MF
authors.lastname: Khan
authors.affiliation: Lady Reading Hospital, Peshawar, Pakistan.
authors.forename: Mian Mukhtar-Ul-Haq
authors.initials: MM
authors.lastname: Azeemi
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Parveen
authors.initials: P
authors.lastname: Akhtar
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Huma
authors.initials: H
authors.lastname: Nazir
authors.affiliation: University of Liverpool, Liverpool, England.
authors.forename: Anna
authors.initials: A
authors.lastname: Chiumento
authors.affiliation: VU University Amsterdam, Amsterdam, the Netherlands.
authors.forename: Marit
authors.initials: M
authors.lastname: Sijbrandij
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, England.
authors.forename: Duolao
authors.initials: D
authors.lastname: Wang
authors.affiliation: Lady Reading Hospital, Peshawar, Pakistan7Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, England.
authors.forename: Saeed
authors.initials: S
authors.lastname: Farooq
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Mark
authors.initials: M
authors.lastname: van Ommeren
mesh_terms: D000328:Adult; D001007:Anxiety / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D001521:Behavior Therapy / Q000379:methods; D003150:Community Health Workers / Q000191:economics*; D003863:Depression / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003866:Depressive Disorder / Q000175:diagnosis / Q000453:epidemiology; D000069581:Exposure to Violence / Q000523:psychology*; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D062405:Motivational Interviewing / Q000379:methods; D017063:Outcome Assessment, Health Care; D010154:Pakistan / Q000453:epidemiology; D011614:Psychotherapy, Brief; D016037:Single-Blind Method; D012959:Socioeconomic Factors; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000453:epidemiology; D013315:Stress, Psychological / Q000628:therapy*; D013997:Time Factors; D000067453:War Exposure