Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial
Mark J. D. Jordans, Brandon A. Kohrt, Manaswi Sangraula, Elizabeth L. Turner, Xueqi Wang, Pragya Shrestha, Renasha Ghimire, Edith van't Hof, Richard A. Bryant, Katie S. Dawson, Kedar Marahatta, Nagendra P. Luitel, Mark van Ommeren
PLOS Medicine · 2021 · DOI: 10.1371/journal.pmed.1003621
Countries: Nepal
What Was Studied
This was a two-arm, single-blind cluster randomized controlled trial (cRCT) conducted in 72 wards in Morang district, eastern Nepal, from November 2018 to September 2019. Wards were randomized (36 per arm) to Group Problem Management Plus (Group PM+) — a 5-session, WHO-developed transdiagnostic group psychological treatment delivered by briefly trained nonspecialist facilitators — or to enhanced usual care (a 30-minute family psychoeducation session plus referral information for primary care providers trained in WHO's mhGAP). Eligible adults (18+) had current psychological distress, identified using the local idiom "manko samasya" (heart–mind problems), and functional impairment (WHODAS-II score above 16). A total of 611 adults were enrolled (306 control, 305 Group PM+ at baseline), 82% female, median age 45, and 50% had recently experienced a natural disaster. Outcomes were assessed at baseline, midline (7 weeks, about 1 week post-treatment), and endline (20 weeks, about 3 months post-treatment), with the primary outcome being psychological distress on the General Health Questionnaire (GHQ-12).
What They Found
At the 3-month primary endpoint, Group PM+ participants had GHQ-12 psychological distress scores 1.4 points lower than controls (95% CI 0.3–2.5, p=0.014; standardized mean difference −0.2), and the effect was larger at midline (2.7 points lower, 95% CI 1.7–3.7, p<0.001; SMD −0.4). Depression symptoms improved more in Group PM+: 29.9% of participants achieved a 50% reduction in PHQ-9 depression scores by 3 months versus 17.3% of controls (risk ratio 1.7, 95% CI 1.2–2.4, p=0.002). "Heart–mind problems" persisted in 58.8% of Group PM+ participants versus 69.4% of controls at 3 months (risk ratio 0.8, 95% CI 0.7–1.0, p=0.042). There was no statistically significant effect on PTSD symptoms or functional impairment. Mediation analysis found that 31% of the endline treatment effect was explained by participants' use of the psychosocial skills taught in Group PM+ (breathing exercises, problem-solving, behavioral activation, seeking social support). Facilitators — 12 community members with no prior mental-health training — reached a median post-training competency of 81% (range 61–100%) and median treatment fidelity of 2.8 out of 3; 78% of Group PM+ participants completed at least 4 of 5 sessions. Effects were smaller and not statistically significant among men, though men made up only 20% of the sample, limiting power to detect gender-specific effects.
What This Means for Nepal
With psychiatrist density at just 0.17–0.22 per 100,000 and a treatment gap above 90%, Nepal cannot close its mental-health access gap through specialist care alone — this trial provides direct, Nepal-based evidence that briefly trained community members (with only a high-school education and about 20 days of training) can deliver a treatment that measurably reduces distress and depression. The Ministry of Health and Population's stated 2026 reform priority of mhGAP scale-up should treat Group PM+, already adapted and tested in Nepali by TPO Nepal, as a ready-to-deploy model for expanding non-specialist mental-health care, particularly in disaster- and conflict-affected districts like Morang. Because only 31% of the treatment effect was explained by skill use and effects were smaller among men (just 20% of this sample), scale-up efforts should add booster sessions to reinforce skill practice and pilot gender-adapted delivery — both relevant as Nepal continues to address unmet psychosocial needs from the 2015 Gorkha earthquake and works to operationalize its 2020 Mental Health Strategy in the continued absence of a Mental Health Act.
Contextualisation
Nepal's mental-health treatment gap exceeds 90%, with only about 0.17–0.22 psychiatrists per 100,000 people (most clustered around Kathmandu), and no Mental Health Act has ever been enacted despite a 1996 policy and a 2020 strategy — making task-shared, non-specialist delivery models central to any realistic scale-up. This trial was conducted in Morang district, itself marked by the 1996–2006 civil war and recurring floods, and shows that community members with no prior mental-health training, and no more than a high-school education, can be trained in about 20 days to deliver a treatment that measurably reduces psychological distress and depression. That evidence speaks directly to Nepal's stalled mhGAP scale-up and to post-disaster psychosocial response, including the unresolved mental-health burden from the 2015 Gorkha earthquake, where PTSD affected an estimated 19–23% of survivors.