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Freeman JA, Farrar JC, Placencio-Castro M, Desrosiers A, Brennan RT, Hansen NB, Akinsulure-Smith AM, Su S, Bangura J, Betancourt TS. Integrating Youth Readiness Intervention and Entrepreneurship in Sierra Leone: A Hybrid Type II Cluster Randomized Trial. J Am Acad Child Adolesc Psychiatry 2024; 63:708-719. [PMID: 38143022 DOI: 10.1016/j.jaac.2023.09.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 09/03/2023] [Accepted: 09/14/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE Conflict-affected youth are at risk for poor psychological and social outcomes, yet few receive mental health services. Strategies to expand access and sustain evidence-based interventions (EBIs) across novel delivery platforms must be tested. The present study was a hybrid type II implementation-effectiveness trial using a cluster randomized design. The primary goal was to evaluate feasibility and impact of using the collaborative team approach to deliver the Youth Readiness Intervention (YRI), an EBI, integrated into a youth entrepreneurship program (ENTR) with quality control in post-conflict Sierra Leone. METHOD Youth were screened and randomly assigned to control, ENTR, or combined YRI and ENTR (YRI+ENTR). Implementation outcomes were dissemination and implementation indicators, competence, and fidelity. Effectiveness outcomes were emotion regulation, psychological distress, and interpersonal functioning. Secondary outcomes were third-party reporter assessments of youth functioning and behavior. RESULTS Data were collected and analyzed from 1,151 youth participants and 528 third-party reporters. Scores on implementation constructs, competence, and fidelity demonstrated acceptable intervention response and quality. YRI+ENTR participants showed overall improvements in depression (β = -.081, 95% CI -0.124 to -0.038, d = -0.154) and anxiety (β = -.043, 95% CI -0.091 to -0.005, d = 0.082) symptoms compared with control participants. Community leaders indicated that YRI+ENTR participants demonstrated improvements in overall work or training performance compared with control participants (β = -.114, 95% CI 0.004 to 0.232, d = 0.374). CONCLUSION Integration of EBIs such as the YRI into youth employment programs has the potential to address limited reach of EBIs in conflict and post-conflict settings. A collaborative team implementation approach can facilitate integration and fidelity. PLAIN LANGUAGE SUMMARY In a Hybrid Type-II Implementation-Effectiveness trial conducted in Sierra Leone, researchers tested a Collaborative Team Approach (CTA) for delivering an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), within a youth entrepreneurship program. A total of 1,151 youth participated in the study, with outcomes measured on youth mental health indicators of emotional regulation, psychological distress, and interpersonal functioning, as well as implementation indicators, competence, and fidelity. Results demonstrated that the integrated YRI and entrepreneurship program led to significant improvements in depression and anxiety symptoms compared to the control group. Community leaders also noted enhanced overall performance in YRI participants, suggesting that integrating evidence-based interventions into youth employment programs can effectively address mental health challenges in low-resource regions. DIVERSITY & INCLUSION STATEMENT We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science. CLINICAL TRIAL REGISTRATION INFORMATION Youth FORWARD Phase 2 YRI and EPP Study; https://clinicaltrials.gov/; NCT03542500. STUDY PREREGISTRATION INFORMATION Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol; https://doi.org/10.1176/appi.ps.202000009.
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Affiliation(s)
| | | | | | | | - Robert T Brennan
- National Initiative on Gender, Culture and Leadership in Medicine: C - Change, Women's Study Research Center, Brandeis University, Waltham, Massachusetts
| | | | | | - Shaobing Su
- Boston College, Chestnut Hill, Massachusetts
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2
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Kane JC, Figge C, Paniagua-Avila A, Michaels-Strasser S, Akiba C, Mwenge M, Munthali S, Bolton P, Skavenski S, Paul R, Simenda F, Whetten K, Cohen J, Metz K, Murray LK. Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial. AIDS Behav 2024; 28:245-263. [PMID: 37812272 DOI: 10.1007/s10461-023-04179-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/10/2023]
Abstract
Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.
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Affiliation(s)
- Jeremy C Kane
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Caleb Figge
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alejandra Paniagua-Avila
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Susan Michaels-Strasser
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- ICAP, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Christopher Akiba
- Department of Health Behavior, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA
| | - Mwamba Mwenge
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Saphira Munthali
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Bolton
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephanie Skavenski
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ravi Paul
- School of Medicine, University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | | | - Kathryn Whetten
- Duke Global Health Instittute, Durham, NC, USA
- Duke Sanford School of Public Policy, Durham, NC, USA
- Center for Health Policy and Inequalities Research, Durham, NC, USA
| | - Judith Cohen
- Drexel University College of Medicine, Allegheny Health Network/Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kristina Metz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Stockton MA, Mazinyo EW, Mlanjeni L, Nogemane K, Ngcelwane N, Sweetland AC, Basaraba CN, Bezuidenhout C, Sansbury G, Lovero KL, Olivier D, Grobler C, Wall MM, Medina-Marino A, Nobatyi P, Wainberg ML. Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa. Glob Ment Health (Camb) 2023; 11:e4. [PMID: 38283876 PMCID: PMC10808975 DOI: 10.1017/gmh.2023.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/29/2023] [Accepted: 12/13/2023] [Indexed: 01/30/2024] Open
Abstract
In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool's performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.
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Affiliation(s)
- Melissa Ann Stockton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ernesha Webb Mazinyo
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
- University of California Global Health Institute, University of California, San Francisco, USA
| | - Lungelwa Mlanjeni
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Kwanda Nogemane
- Buffalo City Metro Health District, Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Nondumiso Ngcelwane
- Buffalo City Metro Health District, Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Annika C. Sweetland
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
- New York State Psychiatric Institute, New York, USA
| | - Cale Neil Basaraba
- Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Charl Bezuidenhout
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Kathryn L. Lovero
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA
| | - David Olivier
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Christoffel Grobler
- Faculty of Medicine, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Melanie M. Wall
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
- New York State Psychiatric Institute, New York, USA
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Phumza Nobatyi
- Buffalo City Metro Health District, Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Milton L. Wainberg
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
- New York State Psychiatric Institute, New York, USA
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Heltne UM, Sarkadi A, Lien L, Dybdahl R. Training non-specialists in teaching recovery techniques (TRT) to help traumatised children in humanitarian settings: a qualitative analysis of experiences gained from 20 years of practice. Int J Equity Health 2023; 22:187. [PMID: 37697272 PMCID: PMC10494337 DOI: 10.1186/s12939-023-01999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/25/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Although several manuals and guidelines have been developed to enhance the quality of task-sharing interventions, it remains challenging to train non-professional personnel in mental health and psychosocial support. Practitioners must translate general recommendations into practical applications to make them relevant in demanding contexts. However, limited research exists on practical experiences with standardised programmes in the field. AIM To explore how experiences gained from the training of first-line health providers in a low-threshold intervention for children with trauma symptoms may guide implementation of such interventions in local communities in low-income countries. METHOD We summarise 20 years of experience in the training of first-line health providers, teachers, and school counsellors in providing a low-threshold intervention. The intervention is called teaching recovery techniques (TRT), developed by the Children and War Foundation (CAW). Field notes containing notes from trainings and oral, informal feedback from participants are analysed using thematic analysis, a method well-suited for identifying, analysing, and reporting patterns, or themes, within data in qualitative research. FINDINGS The analysis showed three main themes/ challenges: (1) Who can conduct the TRT intervention? (2) What form and content should the training take? (3) How can the intervention be used in a responsible way to follow the 'do no harm' principle? We discuss the implications of the findings for trainings in scalable interventions and further research.
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Affiliation(s)
| | | | - Lars Lien
- National Competence Services for Concurrent Addiction and Mental Disorders, Brummundal, Norway
| | - Ragnhild Dybdahl
- Centre for Crisis Psychology, University of Bergen, Bergen, Norway
- Norwegian Institute of Public Health, Oslo, Norway
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Nguyen AJ, Russell T, Skavenski S, Bogdanov S, Lomakina K, Ivaniuk I, Aldridge LR, Bolton P, Murray L, Bass J. Development and Piloting of a Mental Health Prevention and Referral Program for Veterans and Their Families in Ukraine. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200488. [PMID: 37348936 DOI: 10.9745/ghsp-d-22-00488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/18/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND While growing evidence exists for the effectiveness of mental health interventions in global mental health, the evidence base for psychosocial supports is lacking despite the need for a broader range of supports that span the prevention-treatment continuum and can be integrated into other service systems. Following rigorous evaluation of the Common Elements Treatment Approach (CETA) in Ukraine, this article describes the development and feasibility testing of CETA Psychosocial Support (CPSS), a brief psychosocial prevention and referral program for Ukrainian veterans and their families. CPSS DEVELOPMENT CPSS development used evidence-based CETA intervention components and was informed by a stakeholder needs analysis incorporating feedback from veterans and their families, literature review, and expert consultations. The program includes psychoeducation, cognitive coping skill development, and a self-assessment tool that identifies participants for potential referral. After initial development of the program, the intervention underwent: (1) initial implementation by skilled providers focused on iterative refinement; (2) additional field-testing of the refined intervention by newly trained providers in real-world conditions; and (3) a formal pilot evaluation with collection of pre-post mental health assessments and implementation ratings using locally validated instruments. RESULTS Fifteen CPSS providers delivered 14 group sessions to 109 participants (55 veterans, 39 family members, and 15 providers from veterans' service organizations). After incorporating changes related to content, process, and group dynamics, data from the pilot evaluation suggest the refined CPSS program is an acceptable and potentially effective brief psychosocial prevention and promotion program that can be implemented by trained veteran providers. Forty percent of participants required safety or referral follow-ups. CONCLUSION The iterative, inclusive development process resulted in an appropriate program with content and implementation strategies tailored to Ukrainian veterans and their families. Brief psychosocial programs can fit within a larger multitiered mental health and psychosocial continuum of care that supports further referral.
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Affiliation(s)
- Amanda J Nguyen
- School of Education and Human Development, University of Virginia, Charlottesville, VA, USA.
| | | | | | | | - Kira Lomakina
- National University of Kyiv-Mohyla Academy, Kyiv, Ukraine
| | - Iryna Ivaniuk
- National University of Kyiv-Mohyla Academy, Kyiv, Ukraine
| | - Luke R Aldridge
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paul Bolton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura Murray
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Judy Bass
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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6
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Mavragani A, Goud BR, Kalidindi B, Ruben JP, Devadass D, Waghmare A, Collins PY, Raj T, Srinivasan K. Mobile Mental Health in Women's Community-Based Organizations: Protocol for a Pilot Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e42919. [PMID: 36753310 PMCID: PMC9947759 DOI: 10.2196/42919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Of every 10 women in rural India, 1 suffers from a common mental disorder such as depression, and untreated depression is associated with significant morbidity and mortality. Several factors lead to a large treatment gap, specifically for women in rural India, including stigma, lack of provider mental health workforce, and travel times. There is an urgent need to improve the rates of detection and treatment of depression among women in rural India without overburdening the scarce mental health resources. OBJECTIVE We propose to develop, test, and deploy a mental health app, MITHRA (Multiuser Interactive Health Response Application), for depression screening and brief intervention, designed for use in women's self-help groups (SHGs) in rural India. METHODS We will use focus groups with SHG members and community health workers to guide the initial development of the app, followed by iterative modification based on input from a participatory design group consisting of proposed end users of the app (SHG members). The final version of the app will then be deployed for testing in a pilot cluster randomized trial, with 3 SHGs randomized to receive the app and 3 to receive enhanced care as usual. RESULTS This study was funded in June 2021. As of September 2022, we have completed both focus groups, 1 participatory design group, and app development. CONCLUSIONS Delivering app-based depression screening and treatment in community settings such as SHGs can address stigma and transportation-related barriers to access to depression care and overcome cultural and contextual barriers to mobile health use. It can also address the mental health workforce shortage. If we find that the MITHRA approach is feasible, we will test the implementation and effectiveness of MITHRA in multiple SHGs across India in a larger randomized controlled trial. This approach of leveraging community-based organizations to improve the reach of depression screening and treatment is applicable in rural and underserved areas across the globe. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42919.
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Affiliation(s)
| | | | | | - Johnson Pradeep Ruben
- St John's Medical College, Bengaluru, India.,St John's Research Institute, Bengaluru, India
| | | | | | - Pamela Y Collins
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Tony Raj
- St John's Research Institute, Bengaluru, India
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Venturo-Conerly KE, Wasil AR, Osborn TL, Puffer ES, Weisz JR, Wasanga CM. Designing Culturally and Contextually Sensitive Protocols for Suicide Risk in Global Mental Health: Lessons From Research With Adolescents in Kenya. J Am Acad Child Adolesc Psychiatry 2022; 61:1074-1077. [PMID: 35217169 DOI: 10.1016/j.jaac.2022.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
In cross-cultural psychological treatment research, investigators must ensure that protocols for addressing risk are culturally tailored and feasible, while also protecting against harm. Guidelines including the Belmont Report1 and the Declaration of Helsinki2 emphasize respecting participants' autonomy and right to equitable treatment, minimizing harm and maximizing benefit, while considering unique circumstances, local laws and regulations, and cultures. They highlight the importance of supervision from qualified health professionals,2 and special protections for children.1 Suicide risk poses distinctive challenges for cross-cultural research; actions that protect participants in one cultural context may harm participants in another. For example, because suicide attempts are illegal in many countries (eg, Kenya, Gambia, Nigeria), involving law enforcement, or others who may report to them, can generate penalties and incriminate those at risk. Upholding the Belmont and Helsinki principles can therefore require adapting strategies for different cultural contexts. This Commentary outlines strategies for applying principles of ethical risk management3,4 that prioritize sensitivity to context. We focus on addressing participant suicide risk during clinical research in low-resource and high-stigma settings, presenting the example of risk among adolescents in Kenya.5,6.
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Affiliation(s)
- Katherine E Venturo-Conerly
- Harvard University, Cambridge, Massachusetts; Shamiri Institute, Nairobi, Kenya, and Pittsfield, Massachusetts.
| | | | - Tom Lee Osborn
- Shamiri Institute, Nairobi, Kenya, and Pittsfield, Massachusetts
| | | | | | - Christine M Wasanga
- Shamiri Institute, Nairobi, Kenya, and Pittsfield, Massachusetts; Kenyatta University, Nairobi, Kenya
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Alzaghoul AF, McKinlay AR, Archer M. Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review. BJPsych Open 2022; 8:e153. [PMID: 35938530 PMCID: PMC9380009 DOI: 10.1192/bjo.2022.552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Millions of children and adolescents are exposed to wars, affecting their psychological well-being. This review focuses on psychosocial interventions in low and middle-income countries (LMICs) in the Middle East, where mental health services are limited. AIMS Our primary aim was to evaluate the effectiveness of trial-assessed psychosocial interventions in reducing post-traumatic stress disorder (PTSD) symptoms in children and adolescents aged ≤18 years who were exposed to war in LMICs in the Middle East. Changes in other psychological conditions and symptoms were evaluated where reported. METHOD PubMed, Cochrane Library and Ovid were searched without year restriction, in December 2021. Previous review reference lists were also checked. Only studies published in English were included. Each study was evaluated for risk of bias and results are presented as a narrative synthesis. RESULTS Three group-based interventions were identified and evaluated across six studies: 'Teaching Recovery Techniques', 'Writing for Recovery' and 'Advancing Adolescents'. Two studies took place in post-war settings, and four in a context of ongoing conflict. Positive experiences and improved social skills were indicated following most interventions, but Teaching Recovery Techniques was the only programme associated with a statistically significant reduction in PTSD score. Differences in follow-up interval limited comparability of outcomes. CONCLUSIONS This review highlights a paucity of evidence for effective treatment options for children and adolescents affected by war from LMICs in the Middle East. Promising indications of reductions in PTSD symptoms, specifically from Teaching Recovery Techniques, require further rigorous evaluation and long-term follow-up.
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Affiliation(s)
- Aseel F Alzaghoul
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Alison R McKinlay
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, UK
| | - Marc Archer
- Centre for Mental Health and Wellbeing, Department of Psychology, Faculty of Behavioural Sciences, HELP University, Malaysia
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Patel AR, Kovacevic M, Hinton D, Newman E. "I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence. Transcult Psychiatry 2022; 59:522-538. [PMID: 34860626 DOI: 10.1177/13634615211055003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.
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Affiliation(s)
| | | | - Devon Hinton
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Morena AL, Gaias LM, Larkin C. Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms. FRONTIERS IN HEALTH SERVICES 2022; 2:896885. [PMID: 36925794 PMCID: PMC10012807 DOI: 10.3389/frhs.2022.896885] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022]
Abstract
Background The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms. Methods The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers. Results Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship. Conclusion Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.
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Affiliation(s)
- Alexandra L. Morena
- Department of Psychology, University of Massachusetts, Lowell, MA, United States
| | - Larissa M. Gaias
- Department of Psychology, University of Massachusetts, Lowell, MA, United States
| | - Celine Larkin
- University of Massachusetts Chan Medical School, Worcester, MA, United States
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Merrill KG, Mwansa JK, Miti S, Burke VM, Abrams EA, Frimpong C, Decker MR, Campbell JC, Denison JA. Experiences with a violence and mental health safety protocol for a randomized controlled trial to support youth living with HIV. Glob Health Res Policy 2021; 6:40. [PMID: 34654487 PMCID: PMC8518229 DOI: 10.1186/s41256-021-00224-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Safety protocols are an essential component of studies addressing violence and mental health but are rarely described in the published literature from Sub-Saharan Africa. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15-24 years) in a randomized controlled trial of a peer-mentoring intervention across four HIV clinics in Ndola, Zambia. METHODS Youth who reported severe violence and/or suicidal thoughts on research surveys or during meetings with youth peer mentors (YPM) were referred to designated healthcare providers (HCP). We explored experiences with the safety protocol using: a) monitoring data of referrals, and b) in-depth interviews with youth (n = 82), HCP (n = 10), YPM (n = 8), and staff (n = 6). Descriptive statistics were generated and thematic analysis of coded transcripts and written memos performed. RESULTS Nearly half of youth enrolled (48% of females, 41% of males) were referred to a HCP at least once. The first referral was most often for sexual violence (35%) and/or suicidal ideation/depression (29%). All referred youth aged 15-17 years and over 80% of referred youth aged 18 + agreed to see a HCP. HCP referred 15% for additional services outside the clinic. Twenty-nine youth, all HCP, all YPM, and all staff interviewed discussed the safety protocol. Most youth felt "encouraged," "helped," "unburdened," and "relieved" by their meetings with HCP; some expressed concerns about meeting with HCP. The safety protocol helped HCP recognize the need to integrate care for violence and mental health with medication adherence support. HCP, YPM, and study staff raised implementation challenges, including youth choosing not to open up to HCP, time and resource constraints, deficiencies in HCP training, and stigma and cultural norms inhibiting referrals outside the clinic for emotional trauma and mental health. CONCLUSIONS Implementing a safety protocol within an HIV clinic-based research study is possible and beneficial for youth and HCP alike. Implementation challenges underscore that HCP in Zambia work in over-stretched healthcare systems. Innovative strategies must address deficiencies in training and resources within HIV clinics and gaps in coordination across services to meet the overwhelming need for violence and mental health services among youth living with HIV.
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Affiliation(s)
- Katherine G Merrill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA.
| | | | - Sam Miti
- Arthur Davison Children's Hospital, Ndola, Zambia
| | - Virginia M Burke
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Elizabeth A Abrams
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | | | - Michele R Decker
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jacquelyn C Campbell
- Department of Community-Public Health, Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Rajabzadeh V, Burn E, Sajun SZ, Suzuki M, Bird VJ, Priebe S. Understanding global mental health: a conceptual review. BMJ Glob Health 2021; 6:bmjgh-2020-004631. [PMID: 33758013 PMCID: PMC7993328 DOI: 10.1136/bmjgh-2020-004631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/14/2022] Open
Abstract
Background Mental health disorders are viewed as a global concern requiring globally led approaches to address them. Since the publication of the 2007 Lancet series on global mental health (GMH), the term has become widespread. Over the last two decades, GMH has become increasingly affiliated with policy reform, academic courses, funding bodies and research. However, it is not always obvious how those working in the field of GMH are using the term, resulting in a lack of clarity. Therefore, work is needed to synthesise the current understanding(s) of GMH to help characterise its meaning. Aim To synthesise the literature and identify the different ways GMH is understood. Method A conceptual review, using a systematic search and a content analysis, was conducted to develop a conceptual framework of the different conceptual understandings of GMH. Results We developed a conceptual framework of four understandings of GMH. These understandings of GMH are as follows: an area of research generating findings to establish a GMH evidence-base; implementation of research into practice; improving the mental health environment; learning from and supporting low-and-middle-income countries (LMICs). Conclusion Our review proposes a simple framework, clarifying the key characteristics of the GMH landscape. The findings highlight the diversity of usage of the term in the literature, as well as present the wide scope that comprises the field of GMH. Referring to this framework may help those engaged with GMH to be more specific with which aspect of the field they are concerned with.
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Affiliation(s)
- Vian Rajabzadeh
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Erin Burn
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Sana Z Sajun
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Mimi Suzuki
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Victoria Jane Bird
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
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Readiness of Allied Professionals to Join the Mental Health Workforce: A Qualitative Evaluation of Trained Lay Trauma Counsellors' Experiences When Refugee Youth Disclose Suicidal Ideation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041486. [PMID: 33557361 PMCID: PMC7914504 DOI: 10.3390/ijerph18041486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 12/17/2022]
Abstract
The recent refugee crisis presented a huge challenge for the Swedish mental health workforce. Hence, innovative mental health workforce solutions were needed. Unaccompanied refugee minors (URM) are a particularly vulnerable refugee group. Teaching Recovery Techniques (TRT) was introduced as a community-based intervention utilising trained lay counsellors in a stepped model of care for refugee youth experiencing trauma symptoms. Professionals (e.g., teachers, social workers) can deliver the Cognitive Behavioural Therapy-based intervention after a brief training. A point of debate in this workforce solution is the readiness of trained lay counsellors to deal with potentially demanding situations like disclosure of suicidal ideation. This study aimed to explore the TRT trained lay counsellors’ experiences of procedures upon URM’s disclosure of suicidal ideation. Individual semi-structured interviews with TRT trained lay counsellors were conducted, then analysed using systemic text condensation. The analysis revealed four themes: “Importance of safety structures”, “Collaboration is key”, “Let sleeping dogs lie” and “Going the extra mile”. Dealing with suicidal ideation is challenging and feelings of helplessness occur. Adding adequate supervision and specific training on suicidal ideation using role play is recommended. Collaboration between agencies and key stakeholders is essential when targeting refugee mental health in a stepped care model.
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A randomized-controlled trial of community-based transdiagnostic psychotherapy for veterans and internally displaced persons in Ukraine. Glob Ment Health (Camb) 2021; 8:e32. [PMID: 34513001 PMCID: PMC8392687 DOI: 10.1017/gmh.2021.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND There is limited research on community-based mental health interventions in former Soviet countries despite different contextual factors from where most research has been conducted. Ongoing military conflict has resulted in many displaced persons and veterans and their families with high burdens of mental health problems. Lack of community-based services and poor uptake of existing psychiatric services led to the current trial to determine the effectiveness of the common elements treatment approach (CETA) on anxiety, depression, and posttraumatic stress symptoms (PTS) among conflict affected adults in Ukraine. METHODS We conducted a three-armed randomized-controlled trial of CETA delivered in its standard form (8-12 sessions), a brief form (five-sessions), and a wait-control condition. Eligible participants were displaced adults, army veterans and their adult family members with elevated depression and/or PTS and impaired functioning. Treatment was delivered by community-based providers trained in both standard and brief CETA. Outcome data were collected monthly. RESULTS There were 302 trial participants (n = 117 brief CETA, n = 129 standard CETA, n = 56 wait-controls). Compared with wait-controls, participants in standard and brief CETA experienced clinically and statistically significant reductions in depression, anxiety, and PTS and dysfunction (effect sizes d = 0.46-1.0-6). Comparing those who received standard CETA with brief CETA, the former reported fewer symptoms and less dysfunction with small-to-medium effect sized (d = 0.20-0.55). CONCLUSIONS Standard CETA is more effective than brief CETA, but brief CETA also had significant effects compared with wait-controls. Given demonstrated effectiveness, CETA could be scaled up as an effective community-based approach.
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Bellairs-Walsh I, Perry Y, Krysinska K, Byrne SJ, Boland A, Michail M, Lamblin M, Gibson KL, Lin A, Li TY, Hetrick S, Robinson J. Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people's perspectives. BMJ Open 2020; 10:e038855. [PMID: 33115897 PMCID: PMC7594366 DOI: 10.1136/bmjopen-2020-038855] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES General practitioners (GPs) have a key role in supporting young people who present with suicidal behaviour/self-harm. However, little is known about young people's opinions and experiences related to GPs' practices for such presentations, and their decisions to disclose suicidal behaviour/self-harm to GPs. Additionally, existing guidelines for the management of suicide risk and/or self-harm have not incorporated young people's perspectives. This study aimed to explore young people's views and experiences related to the identification, assessment and care of suicidal behaviour and self-harm in primary care settings with GPs. DESIGN, SETTING AND PARTICIPANTS Two qualitative focus groups were conducted in Perth, Western Australia, with 10 young people in total (Mage = 20.67 years; range: 16-24). Data were collected using a semistructured, open-ended interview schedule and analysed using thematic analysis. RESULTS Five major themes were identified from the focus groups. (1) Young people wanted a collaborative dialogue with GPs, which included being asked about suicidal behaviour/self-harm, informed of treatment processes and having autonomy in decision making; (2) young people were concerned with a loss of privacy when disclosing suicidal behaviour/self-harm; (3) young people viewed labels and assessments as problematic and reductionist-disliking the terms 'risk' and 'risk assessment', and assessment approaches that are binary and non-holistic; (4) young people highlighted the importance of GPs' attitudes, with a genuine connection, attentiveness and a non-judgemental demeanour seen as paramount; and (5) young people wanted to be provided with practical support and resources, followed-up, and for GPs to be competent when working with suicidal behaviour/self-harm presentations. CONCLUSIONS Our study identified several concerns and recommendations young people have regarding the identification, assessment and care of suicidal behaviour/self-harm in primary care settings. Taken together, these findings may inform the development of resources for GPs, and support progress in youth-oriented best practice.
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Affiliation(s)
- India Bellairs-Walsh
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Yael Perry
- Telethon Kids Institute, The University of Western Australia, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Karolina Krysinska
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sadhbh J Byrne
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Alexandra Boland
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Maria Michail
- School of Psychology, Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Michelle Lamblin
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Kerry L Gibson
- School of Psychology, Faculty of Science, The University of Auckland, Auckland, New Zealand
| | - Ashleigh Lin
- Telethon Kids Institute, The University of Western Australia, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Tina Yutong Li
- Orygen, Parkville, Victoria, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Sarah Hetrick
- Orygen, Parkville, Victoria, Australia
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jo Robinson
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
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16
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Pedersen GA, Lakshmin P, Schafer A, Watts S, Carswell K, Willhoite A, Ottman K, van 't Hof E, Kohrt BA. Common factors in psychological treatments delivered by non-specialists in low- and middle-income countries: Manual review of competencies. ACTA ACUST UNITED AC 2020; 30:165-186. [PMID: 34308387 DOI: 10.1016/j.jbct.2020.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Delivery of psychological and psychosocial treatments by non-specialists in low-and middle-income countries (LMIC) is a growing strategy to address the global mental health treatment gap. However, little is known about which competencies are essential for non-specialists to effectively deliver treatment. Psychotherapy research in high-income countries suggests that effective treatment requires competency in common factors. Therefore, our objective was to identify how common factors are described in evidence-supported non-specialist interventions in LMICs. To meet this objective, we identified and coded common factors by reviewing 16 evidence-supported manuals for psychological treatments delivered by non-specialists in LMICs. World Health Organization (WHO) manuals and other non-proprietary manuals, with positive randomized control outcomes, were included in the review. Fifteen common factors were identified and described in most manuals: 'promoting hope and realistic expectancy of change' and 'confidentiality' were described in 15 manuals (94%), followed by 'giving praise' and 'psychoeducation' (88% of manuals), and 'rapport building' (81% of manuals). Descriptions of common factors were similar across manuals, suggesting that training and competency evaluation approaches can be harmonized across interventions. Compiling these descriptions from the manuals can inform foundational training in common factors for diverse cadres of non-specialists around the world.
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Affiliation(s)
- Gloria A Pedersen
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L St NW, Suite 600, Washington, D.C. 20037, USA
| | - Pooja Lakshmin
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L St NW, Suite 600, Washington, D.C. 20037, USA
| | - Alison Schafer
- World Health Organization, Department of Mental Health and Substance Use, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Sarah Watts
- World Health Organization, Department of Mental Health and Substance Use, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Kenneth Carswell
- World Health Organization, Department of Mental Health and Substance Use, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Ann Willhoite
- United States Agency for International Development, DCHA/DRG, Empowerment & Inclusion Division, Washington, D.C., USA.,Child Protection in Emergencies, Child Protection, Programme Division, UNICEF Headquarters, 3 UN Plaza, 10017 New York, NY, USA
| | - Katherine Ottman
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L St NW, Suite 600, Washington, D.C. 20037, USA
| | - Edith van 't Hof
- World Health Organization, Department of Mental Health and Substance Use, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L St NW, Suite 600, Washington, D.C. 20037, USA
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17
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Dorsey S, Lucid L, Martin P, King KM, O’Donnell K, Murray LK, Wasonga AI, Itemba DK, Cohen JA, Manongi R, Whetten K. Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial. JAMA Psychiatry 2020; 77:464-473. [PMID: 31968059 PMCID: PMC6990668 DOI: 10.1001/jamapsychiatry.2019.4475] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low- and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population. OBJECTIVES To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis. INTERVENTIONS In the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population. MAIN OUTCOMES AND MEASURES The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured. RESULTS A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): rural Kenya (Cohen d = 1.04 [95% CI, 0.72-1.36]), urban Kenya (Cohen d = 0.56 [95% CI, 0.29-0.83]), and urban Tanzania (Cohen d = 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC in both rural (Cohen d = 0.86 [95% CI, 0.64-1.07]) and urban (Cohen d = 0.99 [95% CI, 0.75-1.23]) Kenya. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohen d = 0.09 [95% CI, -0.08 to 0.26]; urban Tanzania, Cohen d = 0.11 [95% CI, -0.09 to 0.31]). A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events). CONCLUSIONS AND RELEVANCE This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01822366.
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Affiliation(s)
- Shannon Dorsey
- Department of Psychology, University of
Washington, Seattle
| | - Leah Lucid
- Department of Psychology, University of
Washington, Seattle
| | - Prerna Martin
- Department of Psychology, University of
Washington, Seattle
| | - Kevin M. King
- Department of Psychology, University of
Washington, Seattle
| | - Karen O’Donnell
- Center for Child and Family Health, Duke
University, Durham, North Carolina
| | - Laura K. Murray
- Department of Mental Health and International
Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Judith A. Cohen
- Department of Psychiatry, Allegheny Health
Network, Drexel University College of Medicine, Pittsburgh, Pennsylvania
| | - Rachel Manongi
- Institute of Public Health, Kilimanjaro
Christian Medical University College, Moshi, Tanzania
| | - Kathryn Whetten
- Center for Health Policy and Inequalities
Research, Sanford School of Public Policy and Duke Global Health Institute, Duke
University, Durham, North Carolina
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Murray LK, Kane JC, Glass N, Skavenski van Wyk S, Melendez F, Paul R, Kmett Danielson C, Murray SM, Mayeya J, Simenda F, Bolton P. Effectiveness of the Common Elements Treatment Approach (CETA) in reducing intimate partner violence and hazardous alcohol use in Zambia (VATU): A randomized controlled trial. PLoS Med 2020; 17:e1003056. [PMID: 32302308 PMCID: PMC7164585 DOI: 10.1371/journal.pmed.1003056] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 03/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Both intimate partner violence (IPV) and alcohol misuse are highly prevalent, and partner alcohol misuse is a significant contributor to women's risk for IPV. There are few evidence-based interventions to address these problems in low- and middle-income countries (LMICs). We evaluated the effectiveness of an evidence-based, multi-problem, flexible, transdiagnostic intervention, the Common Elements Treatment Approach (CETA) in reducing (a) women's experience of IPV and (b) their male partner's alcohol misuse among couples in urban Zambia. METHODS AND FINDINGS This was a single-blind, parallel-assignment randomized controlled trial in Lusaka, Zambia. Women who reported moderate or higher levels of IPV and their male partners with hazardous alcohol use were enrolled as a couple and randomized to CETA or treatment as usual plus safety checks (TAU-Plus). The primary outcome, IPV, was assessed by the Severity of Violence Against Women Scale (SVAWS) physical/sexual violence subscale, and the secondary outcome, male alcohol misuse, by the Alcohol Use Disorders Identification Test (AUDIT). Assessors were blinded. Analyses were intent-to-treat. Primary outcome assessments were planned at post-treatment, 12 months post-baseline, and 24 months post-baseline. Enrollment was conducted between May 23, 2016, and December 17, 2016. In total, 123 couples were randomized to CETA, 125 to TAU-Plus. The majority of female (66%) and a plurality of male (48%) participants were between 18 and 35 years of age. Mean reduction in IPV (via SVAWS subscale score) at 12 months post-baseline was statistically significantly greater among women who received CETA compared to women who received TAU-Plus (-8.2, 95% CI -14.9 to -1.5, p = 0.02, Cohen's d effect size = 0.49). Similarly, mean reduction in AUDIT score at 12 months post-baseline was statistically significantly greater among men who received CETA compared to men who received TAU (-4.5, 95% CI -6.9 to -2.2, p < 0.001, Cohen's d effect size = 0.43). The Data and Safety Monitoring Board recommended the trial be stopped early due to treatment effectiveness following the 12-month post-baseline assessment, and CETA was offered to control participants. Limitations of the trial included the lack of a true control condition (i.e., that received no intervention), self-reported outcomes that may be subject to social desirability bias, and low statistical power for secondary IPV outcomes. CONCLUSIONS Results showed that CETA was more effective than TAU-Plus in reducing IPV and hazardous alcohol use among high-risk couples in Zambia. Future research and programming should include tertiary prevention approaches to IPV, such as CETA, rather than offering only community mobilization and primary prevention. TRIAL REGISTRATION The trial was registered on ClinicalTrials.gov (NCT02790827).
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Affiliation(s)
- Laura K. Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Jeremy C. Kane
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Nancy Glass
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Stephanie Skavenski van Wyk
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Flor Melendez
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ravi Paul
- Department of Psychiatry, School of Medicine, University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Carla Kmett Danielson
- National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Sarah M. Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - John Mayeya
- Ministry of Health–Zambia, Chainama Hills College Hospital, Lusaka, Zambia
| | | | - Paul Bolton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Patel AR, Weobong B, Patel VH, Singla DR. Psychological treatments for depression among women experiencing intimate partner violence: findings from a randomized controlled trial for behavioral activation in Goa, India. Arch Womens Ment Health 2019; 22:779-789. [PMID: 31363925 PMCID: PMC6841649 DOI: 10.1007/s00737-019-00992-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/11/2019] [Indexed: 12/03/2022]
Abstract
Intimate partner violence (IPV) strongly predicts depression, but it is unknown if women experiencing IPV can benefit from depression treatments in contexts where depression and IPV are prevalent. This study explored whether women experiencing IPV in Goa, India, can benefit from the Healthy Activity Program (HAP), a culturally adapted behavioral activation treatment, compared with enhanced usual care (EUC). Cross-sectional and longitudinal analyses were performed on data from a clinical trial. Measures assessed at baseline and 3 and 12 months included depressive symptoms. Measures assessed at 3 and 12 months included activation and IPV. Independent t tests were conducted to assess if participants experiencing IPV had higher depressive symptoms and lower activation at 3 and 12 months; hierarchical linear regression was conducted to determine if 3-month IPV predicted 12-month depressive symptoms across trial arms (Hypothesis 1). Hierarchical linear regression was then conducted to examine if the relationship between 3-month activation and 12-month depressive symptoms was moderated by 3-month IPV within each trial arm (Hypothesis 2). As expected, participants experiencing IPV had significantly lower activation levels and higher depressive symptoms compared with participants who did not experience IPV at 3 and 12 months in cross-sectional analyses. Similarly, IPV endorsed at 3 months significantly predicted depressive symptoms at 12 months. However, activation was significantly associated with less severe depressive symptoms at 12 months, irrespective of IPV endorsement among HAP participants. For EUC participants, IPV remained the only significant predictor of depressive symptoms at 12 months. Results suggest that women experiencing IPV can still benefit from behavioral activation.
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Affiliation(s)
- Anushka Rajesh Patel
- Department of Psychology, The University of Tulsa, 800 S. Tucker Drive, Tulsa, OK, 74104, USA
| | - Benedict Weobong
- School of Public Health, Department of Social and Behavioural Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Vikram Harshad Patel
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Sangath, H No 451 (168), Bhatkar Waddo, Socorro, Bardez, Porvorim, Goa, 403501, India
| | - Daisy Radha Singla
- Department of Psychiatry, University of Toronto and Sinai Health System, 600 University Ave, Rm914A, Toronto, Ontario, M5T 1R8, Canada.
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Mootz JJ, Muhanguzi FK, Panko P, Mangen PO, Wainberg ML, Pinsky I, Khoshnood K. Armed conflict, alcohol misuse, decision-making, and intimate partner violence among women in Northeastern Uganda: a population level study. Confl Health 2018; 12:37. [PMID: 30127845 PMCID: PMC6091151 DOI: 10.1186/s13031-018-0173-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 07/20/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Relations among and interactions between exposure to armed conflict, alcohol misuse, low socioeconomic status, gender (in)equitable decision-making, and intimate partner violence (IPV) represent serious global health concerns. Our objective was to determine extent of exposure to these variables and test pathways between these indicators of interest. METHODS We surveyed 605 women aged 13 to 49 who were randomly selected via multistage sampling across three districts in Northeastern Uganda in 2016. We used Mplus 7.4 to estimate a moderated structural equation model of indirect pathways between armed conflict and intimate partner violence for currently partnered women (n = 558) to evaluate the strength of the relationships between the latent factors and determine the goodness-of-fit of the proposed model with the population data. RESULTS Most respondents (88.8%) experienced conflict-related violence. The lifetime/ past 12 month prevalence of experiencing intimate partner violence was 65.3%/ 50.9% (psychological) and 59.9%/ 43.8% (physical). One-third (30.7%) of women's partners reportedly consumed alcohol daily. The relative fit of the structural model was superior (CFI = 0.989; TLI = 0.989). The absolute fit (RMSEA = 0.029) closely matched the population data. The partner and joint decision-making groups significantly differed on the indirect effect through partner alcohol use (a1b1 = 0.209 [0.017: 0.467]). CONCLUSIONS This study demonstrates that male partner alcohol misuse is associated with exposure to armed conflict and intimate partner violence-a relationship moderated by healthcare decision-making. These findings encourage the extension of integrated alcohol misuse and intimate partner violence policy and emergency humanitarian programming to include exposure to armed conflict and gendered decision-making practices.
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Affiliation(s)
- Jennifer J. Mootz
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032 USA
- New York State Psychiatric Institute, 1051 Riverside Drive, Kolb 171, New York, NY 10032 USA
| | | | - Pavel Panko
- Department of Educational Psychology and Leadership, Texas Tech University, 3008 18th Street, Lubbock, TX 79409 USA
| | - Patrick Onyango Mangen
- Transcultural Psychosocial Organization Uganda, Plot 3271 Kansanga off Ggaba Road, P.O.Box 21646, Kampala, Uganda
| | - Milton L. Wainberg
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032 USA
- New York State Psychiatric Institute, 1051 Riverside Drive, Kolb 171, New York, NY 10032 USA
| | - Ilana Pinsky
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032 USA
- New York State Psychiatric Institute, 1051 Riverside Drive, Kolb 171, New York, NY 10032 USA
| | - Kaveh Khoshnood
- School of Public Health, Yale University, 60 College St, New Haven, CT 06510 USA
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Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJD, Mutamba BB, Nadkarni A, Pedersen GA, Singla DR, Patel V. The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1279. [PMID: 29914185 PMCID: PMC6025474 DOI: 10.3390/ijerph15061279] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022]
Abstract
Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.
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Affiliation(s)
- Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Laura Asher
- Division of Epidemiology and Public Health, University of Nottingham, NG7 2RD, UK.
| | - Anvita Bhardwaj
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Mina Fazel
- Department of Psychiatry, University of Oxford, Warneford Lane, OX1 2JD, UK.
| | - Mark J D Jordans
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
- War Child, Research and Development, 1098 LE, Amsterdam, The Netherlands.
| | - Byamah B Mutamba
- Butabika National Mental Hospital, 2 Kirombe-Butabika Road, P.O. Box 7017 Kampala, Uganda.
- YouBelong, P.O. Box 36510 Kampala, Uganda.
| | - Abhijit Nadkarni
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
- Sangath, Socorro, Porvorim, Goa 403501, India.
| | - Gloria A Pedersen
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Daisy R Singla
- Department of Psychiatry, Sinai Health System & University of Toronto, Toronto, ON M5G 1X5, Canada.
| | - Vikram Patel
- Sangath, Socorro, Porvorim, Goa 403501, India.
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA 02115, USA.
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA.
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22
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Murray LK, Hall BJ, Dorsey S, Ugueto AM, Puffer ES, Sim A, Ismael A, Bass J, Akiba C, Lucid L, Harrison J, Erikson A, Bolton PA. An evaluation of a common elements treatment approach for youth in Somali refugee camps. Glob Ment Health (Camb) 2018; 5:e16. [PMID: 29868236 PMCID: PMC5981655 DOI: 10.1017/gmh.2018.7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 11/04/2017] [Accepted: 01/24/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention. METHODS This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors. RESULTS Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d = 1.37), externalizing (d = 0.85), and posttraumatic stress (d = 1.71), and improvements in well-being (d = 0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility. CONCLUSIONS This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.
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Affiliation(s)
- L. K. Murray
- Department of Mental Health and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - B. J. Hall
- Global Community Mental Health Research Group, Department of Psychology, Faculty of Social Science, University of Macau, Macau (SAR), People's Republic of China
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - S. Dorsey
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - A. M. Ugueto
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - E. S. Puffer
- Department of Psychology and Neuroscience and Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - A. Sim
- Department of Social Policy and Intervention, Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK
| | - A. Ismael
- International Rescue Committee, IRC, Addis Ababa, Ethiopia
| | - J. Bass
- Department of Mental Health and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C. Akiba
- Department of Mental Health and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - L. Lucid
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - J. Harrison
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - A. Erikson
- Senior Technical Advisor, International Rescue Committee, New York, New York, USA
| | - P. A. Bolton
- Department of Mental Health and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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23
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Murray SM, Kass N, Mendelson T, Bass J. The ethics of mental health survey research in low- and middle- income countries. Glob Ment Health (Camb) 2016; 3:e12. [PMID: 28596881 PMCID: PMC5314948 DOI: 10.1017/gmh.2016.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/21/2015] [Accepted: 01/27/2016] [Indexed: 11/06/2022] Open
Affiliation(s)
- S. M. Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - N. Kass
- Department of Health Policy and Management, Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - T. Mendelson
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J. Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kohrt BA, Ramaiya MK, Rai S, Bhardwaj A, Jordans MJD. Development of a scoring system for non-specialist ratings of clinical competence in global mental health: a qualitative process evaluation of the Enhancing Assessment of Common Therapeutic Factors (ENACT) scale. Glob Ment Health (Camb) 2015; 2:e23. [PMID: 28593049 PMCID: PMC5269630 DOI: 10.1017/gmh.2015.21] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 10/16/2015] [Accepted: 10/25/2015] [Indexed: 11/25/2022] Open
Abstract
Task-sharing is the involvement of non-specialist providers to deliver mental health services. A challenge for task-sharing programs is to achieve and maintain clinical competence of non-specialists, including primary care workers, paraprofessionals, and lay providers. We developed a tool for non-specialist peer ratings of common factors clinical competency to evaluate and optimize competence during training and supervision in global mental health task-sharing initiatives. The 18-item ENhancing Assessment of Common Therapeutic factors (ENACT) tool was pilot-tested with non-specialists participating in mental health Gap Action Programme trainings in Nepal. Qualitative process evaluation was used to document development of the peer rating scoring system. Qualitative data included interviews with trainers and raters as well as transcripts of pre- and post-training observed structured clinical evaluations. Five challenges for non-specialist peer ratings were identified through the process evaluation: (1) balance of training and supervision objectives with research objectives; (2) burden for peer raters due to number of scale items, number of response options, and use of behavioral counts; (3) capturing hierarchy of clinical skills; (4) objective v. subjective aspects of rating; and (5) social desirability when rating peers. The process culminated in five recommendations based on the key findings for the development of scales to be used by non-specialists for peer ratings in low-resource settings. Further research is needed to determine the ability of ENACT to capture the relationship of clinical competence with client outcomes and to explore the relevance of these recommendations for non-specialist peer ratings in high-resource settings.
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Affiliation(s)
- B. A. Kohrt
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, USA
- Duke Global Health Institute, Duke University, Durham, USA
| | - M. K. Ramaiya
- Duke Global Health Institute, Duke University, Durham, USA
- Department of Psychology, University of Nevada, Reno, USA
| | - S. Rai
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
- Duke Global Health Institute, Duke University, Durham, USA
| | - A. Bhardwaj
- Duke Global Health Institute, Duke University, Durham, USA
| | - M. J. D Jordans
- HealthNetTPO, Amsterdam, the Netherlands
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
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25
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Weiss WM, Murray LK, Zangana GAS, Mahmooth Z, Kaysen D, Dorsey S, Lindgren K, Gross A, Murray SM, Bass JK, Bolton P. Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry 2015; 15:249. [PMID: 26467303 PMCID: PMC4605204 DOI: 10.1186/s12888-015-0622-7] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq. METHODS This was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12. RESULTS The CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively. CONCLUSIONS Both CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings. TRIAL REGISTRATION AND PROTOCOL This trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq. The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol . In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.
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Affiliation(s)
- William M Weiss
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA.
| | | | - Zayan Mahmooth
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Debra Kaysen
- Department of Psychology, University of Washington, 335 Guthrie Hall, Seattle, WA, 98195, USA.
| | - Shannon Dorsey
- Department of Psychology, University of Washington, 335 Guthrie Hall, Seattle, WA, 98195, USA.
| | - Kristen Lindgren
- Center for the Study of Health and Risk Behaviors, University of Washington, 1100 NE 45th, Suite 300, Seattle, WA, 98105, USA.
| | - Alden Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Sarah McIvor Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA.
| | - Judith K Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Baltimore, MD, 21205, USA.
| | - Paul Bolton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
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26
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Murray LK, Skavenski S, Kane JC, Mayeya J, Dorsey S, Cohen JA, Michalopoulos LTM, Imasiku M, Bolton PA. Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial. JAMA Pediatr 2015; 169:761-9. [PMID: 26111066 PMCID: PMC9067900 DOI: 10.1001/jamapediatrics.2015.0580] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings. OBJECTIVE To evaluate the effectiveness of lay counselor-provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat. INTERVENTIONS The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. MAIN OUTCOMES AND MEASURES The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. RESULTS At follow-up, the mean item change in trauma symptom score was -1.54 (95% CI, -1.81 to -1.27), a reduction of 81.9%, for the TF-CBT group and -0.37 (95% CI, -0.57 to -0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was -0.76 (95% CI, -0.98 to -0.54), a reduction of 89.4%, and -0.54 (95% CI, -0.80 to -0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. CONCLUSIONS AND RELEVANCE The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01624298.
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Affiliation(s)
- Laura K. Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephanie Skavenski
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeremy C. Kane
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle
| | - Judy A. Cohen
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | | | - Paul A. Bolton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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