A stepped-care programme of brief psychological interventions for adults affected by adversity in Jordan: Lessons from a pilot randomised controlled trial in Jordan

Background

Stepped care frameworks comprise of the use of relatively limited resources to serve the greatest number of people.

Objective

We conducted a pilot randomised controlled trial in Jordan between September 2022 and February 2023 to evaluate the feasibility of a stepped care model of psychological care for distressed adults.

Methods

Participants were randomised to receive a stepped care intervention involving a guided self-help program ( Doing What Matters; DWM), and if still met criteria for psychological distress, followed by a more intensive group program (group Problem Management Plus ; gPM+) or a guided self-help program alone. Both intervention arms also received enhanced treatment as usual (ETAU) that comprised referral to available community support services. A mixed methods design was used to assess feasibility and acceptability and expected clinical outcomes.

Findings

One hundred and forty-five distressed adults (meeting Kessler Distress Score-10 score of ≥20) were randomised to either the stepped care or the single intervention arm (86% female) on a 1:1 allocation basis. DWM was delivered over five weeks by trained non-specialist helpers, where participants attended on average 2.6 support calls. Those randomised to gPM+ attended on average 3.3 sessions. The study demonstrated feasibility and acceptability for DWM and gPM+ interventions as delivered by trained non-specialists. Although the trial was not powered to detect clinical effectiveness, the stepped care arm relative to the single intervention arm demonstrated significantly lower depression symptoms immediately after and at 3-months following intervention delivery.

Conclusions

The study and trial procedures were acceptable to participants, non-specialists, and programme staff and demonstrated feasibility of implementing such a framework in Jordan.

Clinical implications

These findings informed a fully powered definitive RCT seeking to evaluate the clinical and cost-effectiveness of a stepped model of care in Jordan.

What is already known on this topic

• Stepped care frameworks, involving the use of relatively limited resources to serve the greatest number of people, is one avenue to address the growing burden of common mental disorders in low- and middle-income countries (LMICs).

What this study adds

• This is the first feasibility trial to demonstrate acceptability for a stepped model of scalable psychological care as delivered by trained non-specialists for distressed adults in Jordan.

• This is also the first trial to explore the feasibility and acceptability of the World Health Organization interventions involving the guided self-help intervention ( Doing What Matters ; DWM) followed Problem Management Plus (PM+) within a stepped care framework in an exemplar LMIC setting.

How this study might affect research, practice or policy

• These findings informed a fully powered trial seeking to evaluate the clinical and cost-effectiveness of delivering brief, scalable psychological interventions in Jordan.