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Effects of a WHO-guided digital health intervention for depression in Syrian refugees in Lebanon: A randomized controlled trial
Open accessAbstract
BACKGROUND: Most displaced people with mental disorders in low- and middle-income countries do not receive effective care, and their access to care has deteriorated during the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health interventions are scalable when digital access is adequate, and they can be safely delivered during the COVID-19 pandemic. We examined whether a new WHO-guided digital mental health intervention, Step-by-Step, in which participants were supported by a nonspecialist helper, was effective in reducing depression among displaced people in Lebanon. METHODS AND FINDINGS: We conducted a single-blind, 2-arm pragmatic randomized clinical trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among displaced Syrians suffering from depression and impaired functioning in Lebanon. Primary outcomes were depression (Patient Health Questionnaire, PHQ-9) and impaired functioning (WHO Disability Assessment Schedule-12, WHODAS) at posttreatment. Secondary outcomes included subjective well-being, anxiety, post-traumatic stress, and self-described problems. A total of 569 displaced people from Syria with depression (PHQ-9 ≥ 10) and impaired functioning (WHODAS > 16) were randomized to Step-by-Step (N = 283; lost to follow-up: N = 167) or ECAU (N = 286; lost to follow-up: 133). Participants were considered to be lost to follow-up when they did not fill in the outcome measures at posttest or follow-up. Recruitment started on December 9, 2019 and was completed on July 9, 2020. The last follow-up assessments were collected in December 2020. The study team had access to the online platform, where they could see treatment arm assignment for each participant. All questionnaires were completed by participants online. Intention-to-treat (ITT) analyses showed intervention effects on depression (standardized mean differences [SMDs]: 0.48; 95% CI: 0.26; 0.70; p < 0.001), impaired functioning (SMD: 0.35; 95% CI: 0.14; 0.56; p < 0.001), post-traumatic stress (SMD: 0.36; 95% CI: 0.16; 0.56; p < 0.001), anxiety (SMD: 0.46; 95% CI: 0.24; 0.68; p < 0.001), subjective well-being (SMD: 0.47; 95% CI: 0.26; 0.68; p < 0.001), and self-identified personal problems (SMD: 0.49; 95% CI 0.28; 0.70; p < 0.001). Significant effects on all outcomes were maintained at 3 months follow-up. During the trial, one serious adverse event occurred, unrelated to the intervention. The main limitation of the current trial is the high dropout rate. CONCLUSIONS: In this study, we found that a guided, digital intervention was effective in reducing depression in displaced people in Lebanon. The guided WHO Step-by-Step intervention we examined should be made available to communities of displaced people that have digital access. TRIAL REGISTRATION: ClinicalTrials.gov NCT03720769.
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“Initial studies on a guided self-help version of SbS with weekly phone contacts in Lebanon found positive treatment effects on indicators of psychological distress and functioning in Syrian refugees and Lebanese local populations [23,37,38].”
From Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial (2024) · cites this paper as [23]
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“Our trial is the first to implement SbS using a COD guidance model, as opposed to the regular (typically weekly) guidance of previous trials via phone or messaging [23].”
From Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial (2024) · cites this paper as [23]
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“For Syrian refugees, there is only a small number of studies on digital interventions that find a range from small, nonsignificant effects [21,22] to medium effects [23] on mental health outcomes.”
From Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial (2024) · cites this paper as [23]
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“In a previous trial using SbS among Syrian refugees, which used the same version of the SbS digital app [23], significant effects were found on symptoms of depression (g = 0.61), anxiety (g = 0.41), and PTSD (g = 0.39) as well as on functioning (g = 0.45), well-being (g = 0.51), and self-defined problems (g = 0.40).”
From Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial (2024) · cites this paper as [23]
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“Recently published data on guided versions are promising (Cuijpers et al., 2022).”
From Smartphone-delivered mental health care interventions for refugees: A systematic review of the literature (2023) · cites this paper as Cuijpers et al., 2022
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Citations
Cites
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“Satisfaction with the intervention was measured with the Client Satisfaction Questionnaire (CSQ-3), a measure of client satisfaction with mental health services [30].”
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Cited by
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Keyan, D., Habashneh, R., El-Dardery, H., Faroun, M., Al-Johary, F., Abualhaija, A., Aqel, I. S., Akhtar, A., Dardas, L. A., & Bryant, R. A. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-098188 · Cited by 1
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Bacelo, S. R., do Nascimento, V. F., de Sousa, A. R., Borchhardt, S. V. B., & Lourenção, L. G. (2026) · COVID · doi:10.3390/covid6010018
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“Digital interventions have been researched in Iraq [9] and Lebanon [10], as have lay counselor–led interventions in Iraq [11].”
Papola, D., Patania, F., Pedersen, G. A., Patel, A., Cristofalo, D., Purgato, M., Patel, V., & Barbui, C. (2026) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2026.100590
McGrath, M., El-Vecih, A., Kurt, G., Lekkeh, S. A., Yasaki, W., Beetar, A., Rosenbaum, S., & Wells, R. (2026) · BJPsych Open · doi:10.1192/bjo.2026.11013
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Digital Mental Health in Trauma and Migration: Opportunities and Challenges
Orsolini, L., Nuzzo, G. L., Pompili, S., Longo, G., & Volpe, U. (2026) · Springer eBooks · doi:10.1007/978-3-032-21028-9_16
Nasith, A., Anwar, D. F. F., Hibatulloh, M. F., Salma, Z. N., & Pambudi, M. F. N. (2025) · Mental Health Religion & Culture · doi:10.1080/13674676.2025.2585327
“Longer durations, as seen in Cuijpers et al. (2022) and Nygren et al. (2019), tended to yield more durable and significant effects compared to shorter interventions like Rohr et al. (2021).”
Kenbubpha, K., Polrak, A., Tongyonk, C., Pathike, W., & Juengsiragulwit, D. (2026) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-026-00668-6
Bashmi, L., Silove, D. M., Brayne, C., Kuhn, I. L., & Boyd-MacMillan, E. (2026) · BMJ Global Health · doi:10.1136/bmjgh-2025-021128 · Cited by 1
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“Evidence indicates that “Step-by-Step” can effectively reduce depressive symptoms in both adults and university students, with effects maintained for up to a 3-month follow-up period [31,32].”
Song, M. J., & Krausz, M. (2026) · Springer eBooks · doi:10.1007/978-3-319-70134-9_161-1
System-Level Tensions in Scaling Digital Mental Health: A Qualitative Study of STARS in Jordan
Dardas, L. A., de Graaff, A. M., Al‐Khayat, A., Ali, A., Saleh, R., Habashneh, R., Keyan, D., Fanatseh, S., Akhtar, A., Abualhaija, A., et al. (2026) · Healthcare · doi:10.3390/healthcare14182986
“…Doing What Matters–based stepped-care programs, now detailed in the WHO manual for implementing psychological self-help interventions [25], have demonstrated effectiveness in reducing psychological distress across diverse populations, including refugees, migrants, and healthcare workers [26,27].”
Yan, Y.-L., Li, Q.-Q., & Xu, M. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1967813
“This human-supported, locally adapted model has empirical support: a culturally adapted WHO digital program guided by nonspecialist helpers yielded moderate, sustained reductions in depression and impairment among displaced Syrians in a randomized trial (49).”
Pereira, H., & Torre, R. D. (2026) · Psychology International · doi:10.3390/psycholint8040068
Metadata
- Authors
- Cuijpers, P., Heim, E., Abi Ramia, J., Burchert, S., Carswell, K., Cornelisz, I., Knaevelsrud, C., Noun, P., van Klaveren, C., van’t Hof, E., Zoghbi, E., van Ommeren, M., & El Chammay, R.
- Affiliations
- Babeș-Bolyai University (RO)
- University of Zurich (CH)
- Freie Universität Berlin (DE)
- World Health Organization (CH)
- Vrije Universiteit Amsterdam (NL)
- University of Lausanne (CH)
- Corresponding author
- Cuijpers, Pim
- ORCID
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2022-06-23
- Volume
- 19
- Issue
- 6
- Pages
- e1004025
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC9223343
- OpenAlex
- W4283376471
- Cited by
- 118
- References
- 38
- Citations by year
- 2026: 20 · 2025: 32 · 2024: 28 · 2023: 26 · 2022: 12
- FWCI
- 21.64
- Type
- journal article
- Language
- en
- Update notices
- correction (2023-04-14)
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, cc-by)
- IRIS (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Refubium (Universitätsbibliothek der Freien Universität Berlin) (submittedVersion, cc-by)
- VU Research Portal (submittedVersion, other-oa)
- SERVAL (Université de Lausanne) (submittedVersion, other-oa)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Universitätsbibliothek der FU Berlin Hochschulschriftenstelle u. Dokumentenserver (cc-by)
- Funders
- Research for Health in Humanitarian Crises
- Horizon 2020 Framework Programme (733337)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- depression, Syrian refugees, digital mental health interventions, WHO STEPwise approach, impaired functioning, post-traumatic stress, anxiety, subjective well-being, COVID-19 pandemic, displaced persons, Lebanon, access to mental health care, WHODAS, PHQ-9
- MeSH terms
- Internet-Based Intervention, COVID-19, Depression, Humans, Lebanon, Refugees, Syria, World Health Organization, Single-Blind Method, Treatment Outcome, Pandemics
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