There is a growing body of research demonstrating the effectiveness of psychological therapies for refugees and asylum seekers. However, psychological treatments require extensive training and supervision, and sufficient time to be delivered in full. Additionally, most interventions targeted the symptoms of mental disorders, without a specific focus on prevention.
Recently, the World Health Organization (WHO) has developed a novel, low-intensity five-session self-help intervention for managing stress and coping with adversity. This psychosocial intervention, called Self-Help Plus (SH+), is intended to help and support people with and without mental disorders to cope with distress stemming from diverse types of adversity.
RE-DEFINE was developed to test the effectiveness and cost-effectiveness of using SH+ to prevent the onset of mental disorders in refugees and asylum seekers with psychological distress in Western Europe and Turkey. Two prospective, multi-centred, randomized controlled trials took place in seven sites in five Western European countries and Turkey. RE-DEFINE included a total of 1,101 asylum seekers and refugees (Syrians, Afghans, Pakistanis, Iraqis, Nigerians), aged 18+ years old experiencing psychological distress but without a diagnosis of a mental disorder. SH+ was delivered by briefly trained, non-specialist facilitators with refugee or other migrant backgrounds. The trials measured the development of mental disorders, symptoms of psychological distress, functioning, mental well-being, intervention acceptability and economical outcomes.
Main results of REDEFINE research include the following:
• Both the Western European and Turkey studies have shown evidence of an impact of SH+ on preventing mental disorders and reducing stress, but differences were observed between the studies.
• In Turkey providing the SH+ intervention in addition to usual care was found to be highly cost-effective, while in Western European countries there were no differences found in cost-effectiveness.
• RE-DEFINE has shown that SH+ can be effectively delivered in a range of different settings, with groups of different sizes and to people from diverse cultures.
• RE-DEFINE has shown, for the first time, that it is possible to prevent the onset of mental disorders in distressed refugees and asylum seekers.
• RE-DEFINE has shown that it is possible to complete state-of-art randomized controlled trials on preventive mental health interventions.
• Preventive value of RE-DEFINE: Both the Western European and Turkey studies showed evidence of an impact of SH+ on preventing mental disorders and reducing stress. This effect was much more pronounced for the Turkey study where substantial effects were observed at 6 months follow up, compared to the Western European study where effects were only found immediate post-intervention and not at six months follow up. This difference may be explained by differences in context as the participants in Turkey faced many more stressors during the study than the participants in Western Europe.
The RE-DEFINE research has led to the following recommendations for populations affected by adversity, including refugees and asylum seekers:
1. Invest in evidence-based mental health and psychosocial support interventions, such as SH+, along with interventions that support integration and contribute to wider economic benefits.
2. Implement SH+ as intervention for populations exposed to adversity to reduce psychological distress and prevent onset of serious mental illness.
3. Implement SH+ as part of a whole of society approach that also addresses social and economic challenges. SH+ is part of the solution, but it cannot be the only solution.
4. Integrate SH+ and the other low resource intensity interventions, within health and community services to increase accessibility, scalability and sustainability. The best results are likely to be achieved if SH+ is part of an integrated approach with educational, financial legal and social supports.
5. Invest in implementation science to understand the pathways, barriers and facilitating factors to scale up low resource-intensity psychological interventions. Research is needed on implementation; combining SH+ with other key interventions; exploring different delivery approaches; identifying subgroups who will benefit from SH+; and delivering SH+ to groups of people from different cultures together at scale.
