Key message
– We did not find enough evidence in favour of interventions for promoting positive aspects of mental health in humanitarian settings. Larger, well-conducted randomised studies are needed.
Mental health during a humanitarian crisis
A humanitarian crisis is an event, or series of events, that threatens the health, safety, security, and well-being of a community or large group of people, usually over a wide area. Examples include wars and armed conflicts; famine; and disasters triggered by hazards such as earthquakes, hurricanes, and floods. People living through a humanitarian crisis may experience physical and mental distress and experience highly challenging circumstances that make them vulnerable to developing mental disorders, such as post-traumatic stress disorder, depression, and anxiety. The estimated occurrence of mental disorders during humanitarian crises is 17% for depression and anxiety, and 15% for post-traumatic stress disorder.
What are psychological and social interventions?
Psychological and social interventions (also called psychosocial) recognise the importance of the social environment for shaping mental well-being. They usually have both psychological components (related to the mental and emotional state of the person; e.g. relaxation) and social components (e.g. efforts to improve social support). They can be aimed at promoting positive aspects of mental health (e.g. strengthening hope and social support, parenting skills), or prevent and reduce psychological distress and mental disorders.
What did we want to find out?
We wanted to know if psychosocial interventions could promote positive mental health outcomes in people living through humanitarian crises in low- and middle-income countries, compared with inactive comparators such as no intervention, intervention as usual (participants are allowed to seek treatments that are available in the community), or waiting list (participants receive the psychosocial intervention after a waiting phase).
What did we do?
We searched for studies that looked at the effects of psychosocial interventions on positive aspects of people's mental health in low- and middle-income countries affected by humanitarian crises. In these studies, we selected those outcome measures representative of positive emotions, positive social engagement, good relationships, meaning, and accomplishment. This is in line with the definition of mental health given by the World Health Organization, according to which mental health is "a state of mental wellbeing that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community." We looked for randomised controlled studies in which the interventions people received were decided at random. This type of study usually gives the most reliable evidence about the effects of an intervention.
What did we find?
We found 13 studies on mental health promotion with a total of 7917 participants. Nine studies were with children and adolescents (aged seven to 18 years), and four were with adults (aged over 18 years). Four studies were carried out in Lebanon; two in India; and one study each in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The average study duration was 18 weeks (minimum 10 weeks, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. The studies measured mental well-being, functioning, and prosocial behaviour (a behaviour that benefits other people or society as a whole), at the beginning of the study, at the end of the intervention, and three or four months later. They compared the results in people who did and did not receive the intervention.
What are the results of our review?
There is not enough evidence to make firm conclusions. In children and adolescents, psychosocial interventions may have little to no effect in improving mental well-being, functioning, and prosocial behaviour, but the evidence is very uncertain. For the adult population, we found encouraging evidence that psychosocial interventions may improve mental well-being slightly, but there were no data on any other positive dimensions of mental health. Overall, for both children and adults, we are not confident that these results are reliable: the results are likely to change when further evidence is available.
What are the limitations of the evidence?
The main limitation of this review is that we cannot guarantee that the evidence we have generated is trustworthy. This is a direct consequence of the small amount of data that addressed our research question. By conducting analyses from such a small pool of data, we cannot be sure that the changes in outcomes are related to the interventions provided, rather than due to the play of chance. Furthermore, people in the studies were aware of which treatment they were getting, and not all the studies provided data about everything that we were interested in.
How up to date is this evidence?
We included evidence published up to January 2023.
To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.
Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.
To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.
We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.
Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).
We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.
We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations.
For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) −0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD −0.25, 95% CI −0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) −0.70, 95% CI −2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD −0.48, 95% CI −1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD −2.18, 95% CI −3.86 to −0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD −3.33, 95% CI −5.03 to −1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence).
Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD −0.29, 95% CI −0.44 to −0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.