which focuses on changing mindsets (that is, <mark>developing positive outlook and resilience, and improving decision‐making abilities), may be incremental over time. It also implies t</mark> hat the impact of psychosocial interventions, in general, on mental health and well‐being may take a while to manifest, and impact evaluations need to factor that in.

Since this is one of the first studies looking at the impact of such an intervention on a non‐clinical population, a proper benchmark for comparison does not yet exist. For instance, it was not possible to answer how a reduced odds ratio of 0.46 of encountering depression and anxiety compares to other interventions for entrepreneurs. However, consultations with clinical psychologists in Pakistan and at the University of Liverpool who have conducted PM+ RCTs suggest that a reduction of this magnitude in the prevalence and intensity of depression and anxiety symptoms is meaningful for a non‐clinical population such as entrepreneurs. That the PM+E curriculum was able to move people across categories of depression and anxiety is also a test of clinical meaningfulness.

Given the challenging implementation environment, attrition levels were higher than anticipated which reduced the power to detect statistically significant impact with greater confidence. At the same time, with the existing sample size, the results show (clinically) meaningful and directionally expected results. Three months after the intervention, based on analysis of pooled data across two follow‐up rounds, entrepreneurs in the treatment group experienced statistically significant reduction in the intensity and prevalence of depression and anxiety symptoms and higher levels of well‐being compared with the control group. This implies that with a larger sample in future studies, these effects could be determined with greater confidence.

# 7. Conclusion

The project demonstrates that empirical research, including RCTs, can be conducted in challenging, FCV settings through appropriate rapid training of local researchers and NSPs. The ERKF project provided a unique setting for researchers to test the hypothesis that financial assistance, coupled with the 5‐week PM+E training intervention, can be more effective at reducing psychological stressors of SME entrepreneurs in FCV contexts, such as symptoms of depression and anxiety — the most common manifestations of psychosocial distress.

The results of this study are encouraging for a few reasons.

First, it confirms that even non‐clinical populations suffer from clinically significant levels of mental health issues such as depression and anxiety. The baseline data indicates that 1 of every 3 to 4 SME entrepreneurs in KPK experiences symptoms of depression and anxiety. This is new data and provides a sense of the gravity of the situation. It would help to make a case for mental health services to be made available for not only clinical populations, but also for populations at‐ risk, as per the Lancet Commission recommendations.<sup>11</sup> As such, it can also help to prevent burgeoning healthcare costs in the future, ensuring a decent quality of life for all.

> 11 According to the Lancet Commission report on Global Mental Health (2018), policy makers and practitioners need to “broaden the global mental health agenda from a focus on reducing the treatment gap for people affected by mental disorders to the improvement of mental health for whole populations.”

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