A Pilot Randomised Controlled Trial of Delivering Mental Health Care by Telephone in Humanitarian Settings

Background

Refugee children face staggering mental health challenges, yet most never receive intervention.

Across the globe, more than 108 million individuals have been forcibly displaced, with approximately 40% being children. For those uprooted by war, the psychological impact is profound. Research indicates that up to half of refugee children suffer from post-traumatic stress disorder (PTSD), depression or anxiety. However, in low- and middle-income countries (LMICs), where the majority of refugees reside, access to mental health care remains severely limited. Clinics are often geographically distant, transportation is costly, and there is a chronic shortage of trained professionals. Consequently, many refugee families are unable to access therapeutic support.

Within this context, we posed a critical question: could telephone-delivered therapy help bridge this treatment gap.

What were the aims of this study?

Could therapy over the telephone work for children in a humanitarian setting?

The study set out to examine whether a telephone-delivered version of the evidence-based Common Elements Treatment Approach (CETA) could reduce mental health symptoms in Syrian refugee children in Lebanon and whether it could overcome the barriers that so often block access to care.

How was this study carried out?

Refugee children, local lay counsellors and a new approach to therapy

The Common Elements Treatment Approach (CETA), a transdiagnostic intervention ground in cognitive behavioural therapy, was adapted for delivery via telephone (t-CETA).

The pilot randomised controlled trial enrolled 20 Syrian refugee children between the ages of 9 and 17 years, all residing in informal tented settlements in Lebanon, who met diagnostic criteria for mental health conditions including PTSD, depression, anxiety disorders or conduct/oppositional defiant disorder. Participants were randomly allocated to either the t-CETA intervention, delivered by trained lay counsellors under close clinical supervision, or to a treatment-as-usual condition, consisting of standard face-to-face care provided by Medecins du Monde.

Pre- and post-intervention assessments of mental health symptoms were conducted using validated measures for PTSD, depression, anxiety and externalising problems. In addition, symptom trajectories were monitored on a session-by-session basis to evaluate patterns of improvement across the course of treatment.

What we the key findings?

Therapy by telephone reduced symptoms and improved access

Children who received t-CETA demonstrated a consistent reduction in self-reported symptoms over the course of treatment. Relative to the treatment-as-usual condition, t-CETA was associated with greater improvements in overall emotional and behavioural functioning, with particularly promising effects observed for depressive symptoms. Notably, treatment adherence differed markedly between groups: 60% of participants in the t-CETA condition completed a full course of therapy, whereas none of those allocated to treatment as usual did so.

Contextual barriers were central to this discrepancy. Face-to-face sessions were frequently interrupted by Lebanon’s political instability and road closure whereas telephone sessions were able to continue without disruption. Moreover, families highlighted the value of flexible scheduling, including evening and weekend appointments. As a result, the number of t-CETA sessions delivered exceeded in-person sessions by a factor of five.

While not all outcomes favoured t-CETA, there were no significant group differences in global disability scores, the intervention was at least as effective as standard care and substantially more accessible. Although the small sample size means these findings must be interpreted cautiously, the evidence nonetheless points to a promising and scalable model of care in humanitarian contexts.

What are the implications of this research?

Remote therapy could transform access to mental health care in humanitarian settings

The pilot trial demonstrates that mental health treatment can be adapted to meet the realities of life in refugee camps.

By using lay counsellors with supervision, the model addresses the severe shortage of professionals in LMICs. Delivering therapy by telephone sidesteps barriers like transport, cost and scheduling, making it far easier for families to participate.

For policymakers and humanitarian organisations, the implications are profound. Scaling up phone-based therapies like t-CETA could bring care to children who would otherwise go untreated. It also shows that interventions do not need to be “high-tech”: a simple telephone call can be enough to make a real difference.

Challenges however remain. Recruitment for the study was difficult highlighting issues of stigma and limited awareness of mental health services. Addressing these barriers will require community-level education alongside service delivery.

Ultimately, this study suggests that even in the most unstable settings, therapy can reach those who need it. If confirmed in larger trials, t-CETA could become a cornerstone of global mental health strategies, ensuring that the youngest victims of conflict are not left to face their struggles alone.

About the study team

Our multidisciplinary research team comprises experts in psychology including Michael Pluess (University of Surrey); Fiona S. McEwen (Queen May University of London, Kings College London); Claudinei Biazoli (Queen Marry University of London, Universidade Federal du ABC); Nicolas Chehade (Medecins du Monde); Tania Bosqui (American University of Beirut; Trinity College Dublin); Stephanie Skavenski (Medical School Hamburg); Laura Murray (John Hopkins Bloomberg School of Public Health); Roland Weierstall-Pust (Medical School of Hamburg); Paul Bolton (John Hopkins Bloomberg School of Public Health)and Elie Karam (University of Beirut).