With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up.

To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au).

We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores.

The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262–4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434–820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394–77 399) (US$517), compared with PKR 10 705 (95% CI 7731–15 627) (US$102.93) using a local supervisor.

The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

Two large earthquakes in 2015 caused widespread destruction in Nepal. This study aimed to examine frequency of common mental health and psychosocial problems and their correlates following the earthquakes.

A stratified multi-stage cluster sampling design was employed to randomly select 513 participants (aged 16 and above) from three earthquake-affected districts in Nepal: Kathmandu, Gorkha and Sindhupalchowk, 4 months after the second earthquake. Outcomes were selected based on qualitative preparatory research and included symptoms of depression and anxiety (Hopkins Symptom Checklist-25); post-traumatic stress disorder (PTSD Checklist-Civilian); hazardous alcohol use (AUDIT-C); symptoms indicating severe psychological distress (WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS)); suicidal ideation (Composite International Diagnostic Interview); perceived needs (Humanitarian Emergency Settings Perceived Needs Scale (HESPER)); and functional impairment (locally developed scale).

A substantial percentage of participants scored above validated cut-off scores for depression (34.3%, 95% CI 28.4–40.4) and anxiety (33.8%, 95% CI 27.6–40.6). Hazardous alcohol use was reported by 20.4% (95% CI 17.1–24.3) and 10.9% (95% CI 8.8–13.5) reported suicidal ideation. Forty-two percent reported that ‘distress’ was a serious problem in their community. Anger that was out of control (symptom from the WASSS) was reported by 33.7% (95% CI 29.5–38.2). Fewer people had elevated rates of PTSD symptoms above a validated cut-off score (5.2%, 95% CI 3.9–6.8), and levels of functional impairment were also relatively low. Correlates of elevated symptom scores were female gender, lower caste and greater number of perceived needs. Residing in Gorkha and Sindhupalchowk districts and lower caste were also associated with greater perceived needs. Higher levels of impaired functioning were associated with greater odds of depression and anxiety symptoms; impaired functioning was less strongly associated with PTSD symptoms.

Four months after the earthquakes in Nepal, one out of three adults experienced symptoms of depression and distressing levels of anger, one out of five engaged in hazardous drinking, and one out of ten had suicidal thoughts. However, posttraumatic stress symptoms and functional impairment were comparatively less frequent. Taken together, the findings suggest that there were significant levels of psychological distress but likely low levels of disorder. The findings highlight the importance of indicated prevention strategies to reduce the risk of distress progressing to disorder within post-disaster mental health systems of care.