Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial
Open accessAbstract
Background: Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting. Methods and findings: We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, “heart–mind” problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment’s mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N= 611) had a median age of 45 years (range 18–91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7,p< 0.001), with standardized mean difference (SMD) of −0.4 (95% CI: −0.5, −0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5,p= 0.014), with SMD of −0.2 (95% CI: −0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4,p= 0.002). Fewer participants in the Group PM+ arm continued to have “heart–mind” problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0,p= 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information. Conclusions: In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants. Trial registration: ClinicalTrials.govNCT03747055.
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The long-term effectiveness of some interventions cannot be assessed because ten completed studies on these interventions did not report follow-up measurements.
“Furthermore, the long-term effectiveness of some interventions cannot be assessed because ten completed studies on these interventions did not report follow-up measurements [21,27,35,36,37,40,41,47,53,57].”
From Promoting Recovery from Disasters, Pandemics, and Trauma: A Systematic Review of Brief Psychological Interventions to Reduce Distress in Adults, Children, and Adolescents (2023) · cites this paper as [36]
The Results (Mediation analyses; page unavailable) state that endline was approximately three months after the intervention ended, so this study did report a post-treatment follow-up measurement. The Discussion calls for future research on longer-term benefits, such as at 12 months; that does not support saying the study had no follow-up measurements. This paper cannot establish the citing sentence’s count of ten studies. (LLM, conf=0.89)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredProblem Management Plus (PM+) has been shown to be effective and cost-effective in various countries globally.
“Problem Management Plus, a World Health Organization–endorsed brief psychological intervention for mental health disorders, has been shown to be effective and cost-effective in various countries globally”
From A Digital Tool (Technology-Assisted Problem Management Plus) for Lay Health Workers to Address Common Mental Health Disorders: Co-production and Usability Study in Pakistan (2025) · cites this paper as [14]
The Introduction (page unavailable) reports benefits of PM+ in Pakistan and Kenya, and the Discussion reports benefits of Group PM+ in Nepal. These passages support effectiveness in several countries, but the paper does not establish that PM+ is cost-effective. (LLM, conf=0.87)
Experimental — accuracy not yet measuredA cluster-randomized controlled trial investigated an adapted PM+ program with six to eight participants per group compared to enhanced usual care in N = 611 adults from disaster-prone regions in Nepal who received 5 weekly sessions of approximately 2.5 hours.
“A cRCT [36] investigated an adapted PM+ program with six to eight participants per group, which was compared to enhanced usual care (psychoeducation and a referral option to primary care providers trained in mental healthcare). N = 611 adults from disaster-prone regions in Nepal received 5 weekly sessions of approximately 2.5 h.”
From Promoting Recovery from Disasters, Pandemics, and Trauma: A Systematic Review of Brief Psychological Interventions to Reduce Distress in Adults, Children, and Adolescents (2023) · cites this paper as [36]
The Abstract (Methods and findings; page not provided) describes a cluster-randomized trial in disaster-prone regions of Nepal comparing five weekly Group PM+ sessions with enhanced usual care. Methods (Intervention; page not provided) specifies approximately 2.5 hours per session, and Results (Participant flow and recruitment; page not provided) reports 611 participants across both arms. The claim overstates treatment exposure: only 305 were in the Group PM+ arm, and Results (Treatment exposure and enhanced usual care; page not provided) says 166 attended all five sessions. The retrieved passages do not establish six to eight participants per group. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPM+ is a low-intensity brief psychological and transdiagnostic intervention for common mental health disorders.
“PM+ is a low-intensity brief psychological and transdiagnostic intervention for common mental health disorders. It is an evidence-based intervention that can address various mental health issues and address the limitations posed by scarce specialized treatments in low-resource settings [8-14].”
The PM+ group showed lower psychological distress and depression symptoms and had fewer "heart-mind" problems compared to the control group at 3 months post-treatment.
“The PM+ group showed lower psychological distress and depression symptoms, and had fewer “heart-mind” problems compared to the control group at 3-months post-treatment.”
The PM+ group did not show an improvement in functional impairment and PTSD symptoms.
“However, the PM+ group did not show an improvement in functional impairment and PTSD symptoms.”
Two cRCTs indicated that PM+ applied in a group significantly reduced psychological distress and depressive symptoms post-intervention.
“The results of two cRCTs [35,36] indicated that PM+ applied in a group significantly reduced psychological distress and depressive symptoms post-intervention.”
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Self-citationDecision: Scalable interventions for refugees — R0/PR7
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr7
Review: Scalable interventions for refugees — R1/PR9
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr9
Recommendation: Scalable interventions for refugees — R0/PR5
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr5
Author comment: Scalable interventions for refugees — R0/PR1
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr1
Self-citationReview: Scalable interventions for refugees — R0/PR4
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr4
Review: Scalable interventions for refugees — R0/PR3
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr3
Recommendation: Scalable interventions for refugees — R1/PR12
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr12
Review: Scalable interventions for refugees — R1/PR11
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr11
Decision: Scalable interventions for refugees — R0/PR6
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr6
Decision: Scalable interventions for refugees — R1/PR13
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr13
Review: Scalable interventions for refugees — R0/PR2
Bryant, R. A. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2022.59.pr2
Mental Health and Social Support Interventions
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- Authors
- Jordans, M. J. D., Kohrt, B. A., Sangraula, M., Turner, E. L., Wang, X., Shrestha, P., Ghimire, R., van’t Hof, E., Bryant, R. A., Dawson, K. S., Marahatta, K., Luitel, N. P., & van Ommeren, M.
- Affiliations
- King's College London (GB)
- George Washington University (US)
- Duke University (US)
- UNSW Sydney (AU)
- World Health Organization (CH)
- Corresponding author
- Kohrt, Brandon A.
- ORCID
- Venue
- PLOS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2021-06-17
- Volume
- 18
- Issue
- 6
- Pages
- e1003621
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC8211182
- OpenAlex
- W3167611877
- Cited by
- 120
- References
- 46
- Citations by year
- 2026: 22 · 2025: 27 · 2024: 21 · 2023: 26 · 2022: 21 · 2021: 3
- FWCI
- 12.09
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (submittedVersion, cc-by-nc-sa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Minerva Access (University of Melbourne) (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- USAID
- National Institute of Mental Health (K01MH104310, R01MH120649)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Keywords
- group psychological intervention, humanitarian crisis, disaster mental health, psychological distress, depression, post-traumatic stress disorder, functional disability, social support, somatic symptoms, community mental health workers, skill utilization, Nepal, natural disasters, mental health treatment gap, family psychoeducation, enhanced usual care, treatment effectiveness
- MeSH terms
- Natural Disasters, Functional Status, Adaptation, Psychological, Adolescent, Adult, Aged, Aged, 80 and over, Depression, Female, Humans, Male, Mental Health, Middle Aged, Nepal, Problem Solving, Psychotherapy, Brief, Psychotherapy, Group, Relief Work, Stress Disorders, Post-Traumatic, Stress, Psychological, Time Factors, Treatment Outcome, Young Adult
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