Summary description: Step-by-Step (SbS) is a 5 session intervention proven to improve symptoms of common mental disorders, subjective well-being and self-identified personal problems. It can be offered alongside other mental health interventions, or community programming. SbS can be delivered remotely and at scale and can reach many people across a large geographical area.

Access to the intervention manual: Contact WHO at Psych_interventions@who.int

Access to training: Contact WHO at Psych_interventions@who.int

Intended users/ Implementers: Trained and supervised non-specialist provider

Therapeutic strategies: SbS provides psychoeducation and training in behavioural activation alongside other therapeutic techniques such as slow breathing, identifying strengths, positive self-talk, increasing social support and relapse prevention.

Intervention format: SbS was tested in a digital format. It uses a fictional illustrated story of people seeking help for depression, with a trusted character (e.g. a health worker) giving instructions on therapeutic techniques. By reading the story the user of the programme learns the techniques. It encourages service users to practise techniques on their own, in between modules. In the RCTs is was provided as a guided intervention, with five weekly calls of 15 minutes per week. It can also be delivered as an unguided intervention: this might make the intervention less effective, but it will reach more people.

Target population: Adults with moderate to severe depressive symptoms

Significant effects found on symptoms of: Psychological distress, depression, anxiety, dysfunctioning, post-traumatic stress, self-identified problems. While some small effects on PTSD symptoms were found, these varied between studies. This is not a trauma focused intervention and other more relevant interventions exist for PTSD.

Key innovative or differentiating features of this intervention: SbS content will be available from WHO as open access and can be added to any online platform (e.g. an e-learning platform). It could also be used in other media formats such as books or videos. It follows a narrative approach, which will make it possible to tailor it for many different populations. In the RCTs is was given as a guided intervention, with five weekly calls of 15 minutes per week. It can also be delivered as an unguided intervention: this might make the intervention less effective, but it will be able to reach more people.

Summary of Evidence: SbS has been tested through two large randomized controlled trials in Lebanon. The trials showed the intervention was effective in reducing symptoms of depression and anxiety and improving functioning and well-being, including at three-month follow-up. The trials also showed this intervention could be delivered safely, with procedures developed to ensure support to people at imminent risk of suicide. A randomized controlled trial with an adapted version of SbS with Chinese students showed it is effective in reducing depressive symptoms in the short term and improving psychological well-being in a longer term.

Different populations where the intervention has been used: Communities exposed to adversities; Refugees and asylum seekers in middle and high income settings; LMICC; student populations

Restrictions or requirements for its use: SbS is not suitable for people who have a severe impairment related to a mental, neurological or substance use disorder, or are at imminent risk of suicide (e.g. people with a plan to end their life in the near future) Supervisors and trainers are ideally mental health professionals who are competent and experienced in delivering psychological interventions or guided self-help. See the SbS manual (available on request from WHO) for more information.

Requirements / qualifications for trainers and supervisors: Ideally this should be a mental health professional thoroughly trained in cognitive behaviour therapy (CBT). See the PM+ manual for more information.

Examples of adaptations and different formats: Supervisors and trainers are ideally mental health professionals who are competent and experienced in delivering psychological interventions or guided self-help. See the SbS manual (available on request from WHO) for more information.

Examples of implementation outside of RCT contexts: Adapted SbS was also proven to be an acceptable intervention for Filipino overseas workers in China. Other versions of SbS are being piloted, such as a version dedlviered by What’s App in India. After the two RCTs, Step-by-Step was scaled up as a national service in Lebanon and made available to anyone in the country. A process evaluation interviewing key stakeholders and people who completed the programme said it was relevant, acceptable and beneficial.

Information provided by Edith van ‘t Hof on 29 March 2024. She was involved in manual development at WHO.