Making sure the right mental health interventions are provided in humanitarian settings
The third paper in The Lancet Series on Global Mental Health examines mental health and psychosocial support (MHPSS) in humanitarian settings, and points out that most research and evidence is focused on interventions that are infrequently applied, while the most commonly used interventions have had little rigorous scrutiny. The paper is by Dr Wietse Tol, Global Health Initiative, MacMillan Center, Yale University, New Haven, CT, USA, and colleagues.
The authors did a review of 160 reports, and found that 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%). Moreover, a financial analysis showed most interventions took place and were funded outside national mental health and protection systems. With regard to evidence, a systematic review and meta-analysis of evaluation studies identified 32 controlled studies.
Overall, few studies have focused on evaluating the effectiveness of structured social activities and interventions aimed at strengthening community and family supports. In adults with symptoms of post-traumatic stress disorder, meta-analysis of seven randomised controlled trials shows beneficial effects for psychological interventions (psychotherapy and psychosocial support) compared with standard care or waiting list. In children, meta-analysis of four RCTs of school-based interventions failed to show an effect for symptoms of PTSD, but showed a beneficial effect of a wider group of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms.
A major finding of the review is the need to bridge the gap between research and practice. The authors call for more research into the most commonly implemented MHPSS, since these often lack evidence. These include interventions such as child-friendly spaces, counselling, and promotion of community supports. Further improvement of MHPSS in humanitarian settings will require a concerted effort by researchers to increase the rigour of studies, broaden outcomes beyond PTSD and internalising symptoms, and systematically integrate monitoring and evaluation of longer term outcomes in humanitarian programs.
There are many issues to address, including a need for more attention to clinical and protective interventions for people with severe mental disorders, including psychotic disorders and substance dependence. The authors highlight that most interventions are implemented and funded outside of national health, protection, and education systems, thus raising critical concerns regarding the sustainability of MHPSS when time-limited humanitarian funding ceases. Furthermore, the authors conclude: "Funding should be diversified beyond only emergency relief and should also be invested in early recovery—ie, investment in recovery from the first day of the crisis. Likewise, intervention research lacks information on cost-effectiveness, an essential source of information to plan scale-up of MHPSS."
