Problem Management Plus (PM+) in the treatment of common mental disorders in women affected by gender-based violence and urban adversity in Kenya; study protocol for a randomized controlled trial

Gender-based violence (GBV) such as intimate partner violence or sexual violence by someone else is an increasing global topic of concern. Worldwide, the estimated lifetime prevalence of GBV is at least 30 % [1‐3] Women living in urban poverty—including slums—in low and middle income countries (LMICs) are especially vulnerable for violence and common mental disorders, since poverty poses women at risk for experiencing gender-based violence. In Kenya, 47 % of women reported having experienced physical and/or sexual violence at some point in their lives.

Women exposed to GBV are at higher risk for developing common mental disorders such as depression, anxiety disorders, and posttraumatic stress disorder (PTSD) and make more use of health services than non-abused women [2, 4, 5]. Common mental disorders are among the largest contributors to disability and functional impairment (see Patel et al. [6]). Additional consequences of GBV involve reduced social and economic development prospects for women because of unwanted pregnancy, lack of resources, limited opportunities, concurrent physical health problems, low education, and fewer social supports [7, 8]. In most communities, women affected by GBV tend to receive no or minimal mental health support [1].

Effective interventions to treat common mental disorders are available (e.g., cognitive behavioural therapy; CBT [9, 10]). However, these interventions typically require expert mental health professionals providing treatments that are usually lengthy and costly to the health service. LMICs lack sufficient numbers of specialized mental health care professionals to deliver such interventions and are unlikely to afford costs associated with scaling up intensive treatment programs in an effective but safe manner. For practically and sustainably scaling-up evidence-based mental health care interventions in LMICs, interventions should be short and relatively easy to administer, so they can be carried out by non-specialist helpers in the community, such as community health workers (cf. [11]). In addition, interventions should not target one outcome (e.g. PTSD) but address a broader range of outcomes, including general functioning and common mental and psychosocial health problems.

World Health Organization (WHO) has developed a low-intensity 5-sessions program termed Problem Management Plus (PM+) which may be delivered by trained non-specialist helpers [12]. PM+ aims to reduce symptoms of depression, anxiety, PTSD, stress in the wake of adversity and trauma and to improve functioning. It comprises evidence-based techniques: of (a) problem solving, (b) stress management, (c) behavioral activation, and (d) accessing social support.

The impetus for developing the PM+ manual came from request to the Department of Mental Health and Substance Abuse at the WHO in Geneva to develop interventions for survivors of GBV that may be delivered in such manner that they are feasible in Sub-Saharan Africa, where (a) health systems typically do not have the resources to make available proven psychological interventions on a routine basis (e.g. exposure therapy, cognitive processing therapy, Eye Movement Desensitization and Reprocessing), and (b) where social stigma against GBV can be so high that attending specific mental health care for GBV can put women at social risk (e.g., further violence, abandonment by the community). PM+ addresses these two requirements by involving relatively simple, non-intrusive techniques that do not necessarily focus on the trauma of GBV. It can thus be offered outside of the context of vertical GBV-services by briefly trained but well-supervised helpers to most women impaired by distress, irrespective of the causes of the distress. Additionally, this study aims to test the capacity of PM+ to reduce mental disorders in women affected by GBV by screening for psychological distress in women in adversity-affected community settings; because this way of case identification potentially overcomes the barrier of GBV-survivors to seek mental health assistance and reduces the risks of stigmatizing women who have suffered GBV through services that are only for GBV survivors.

By evaluating the effectiveness of PM+ in women affected by gender-based violence in Nairobi, Kenya, we seek to address the need for access to brief, effective psychological interventions that can be administered by non-professional health workers in LMICs. A second RCT on the effectiveness of individually delivered PM+ in males and females in an humanitarian setting in Peshawar, Pakistan is underway [33]. If proven effective, PM+ may not only be used in similar areas in Kenya and Pakistan, but rolled out to other affected areas in both LMIC settings and high-resource countries for further adaptation. It may be a useful intervention for humanitarian settings (e.g., conflict settings) where mental health care for GBV-survivors is often lacking. PM+ may be tested in different formats (e.g., internet-delivered, group or young adolescent version) across a variety of populations suffering from psychological distress. The PM+ manual and accompanying training materials, if proven effective, will be published by WHO and will be made available on WHO’s website, in order to enable future scaling-up.