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Meffert SM, Neylan TC, McCulloch CE, Blum K, Cohen CR, Bukusi EA, Verdeli H, Markowitz JC, Kahn JG, Bukusi D, Thirumurthy H, Rota G, Rota R, Oketch G, Opiyo E, Ongeri L. Interpersonal psychotherapy delivered by nonspecialists for depression and posttraumatic stress disorder among Kenyan HIV-positive women affected by gender-based violence: Randomized controlled trial. PLoS Med 2021; 18:e1003468. [PMID: 33428625 PMCID: PMC7799784 DOI: 10.1371/journal.pmed.1003468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/03/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND HIV-positive women suffer a high burden of mental disorders due in part to gender-based violence (GBV). Comorbid depression and posttraumatic stress disorder (PTSD) are typical psychiatric consequences of GBV. Despite attention to the HIV-GBV syndemic, few HIV clinics offer formal mental healthcare. This problem is acute in sub-Saharan Africa, where the world's majority of HIV-positive women live and prevalence of GBV is high. METHODS AND FINDINGS We conducted a randomized controlled trial at an HIV clinic in Kisumu, Kenya. GBV-affected HIV-positive women with both major depressive disorder (MDD) and PTSD were randomized to 12 sessions of interpersonal psychotherapy (IPT) plus treatment as usual (TAU) or Wait List+TAU. Nonspecialists were trained to deliver IPT inside the clinic. After 3 months, participants were reassessed, and those assigned to Wait List+TAU were given IPT. The primary outcomes were diagnosis of MDD and PTSD (Mini International Neuropsychiatric Interview) at 3 months. Secondary outcomes included symptom measures of depression and PTSD, intimate partner violence (IPV), and disability. A total of 256 participants enrolled between May 2015 and July 2016. At baseline, the mean age of the women in this study was 37 years; 61% reported physical IPV in the past week; 91% reported 2 or more lifetime traumatic events and monthly income was 18USD. Multilevel mixed-effects logistic regression showed that participants randomized to IPT+TAU had lower odds of MDD (odds ratio [OR] 0.26, 95% CI [0.11 to 0.60], p = 0.002) and lower odds of PTSD (OR 0.35, [0.14 to 0.86], p = 0.02) than controls. IPT+TAU participants had lower odds of MDD-PTSD comorbidity than controls (OR 0.36, 95% CI [0.15 to 0.90], p = 0.03). Linear mixed models were used to assess secondary outcomes: IPT+TAU participants had reduced disability (-6.9 [-12.2, -1.5], p = 0.01), and nonsignificantly reduced work absenteeism (-3.35 [-6.83, 0.14], p = 0.06); partnered IPT+TAU participants had a reduction of IPV (-2.79 [-5.42, -0.16], p = 0.04). Gains were maintained across 6-month follow-up. Treatment group differences were observed only at month 3, the time point at which the groups differed in IPT status (before cross over). Study limitations included 35% attrition inclusive of follow-up assessments, generalizability to populations not in HIV care, and data not collected on TAU resources accessed. CONCLUSIONS IPT for MDD and PTSD delivered by nonspecialists in the context of HIV care yielded significant improvements in HIV-positive women's mental health, functioning, and GBV (IPV) exposure, compared to controls. TRIAL REGISTRATION Clinical Trials Identifier NCT02320799.
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Affiliation(s)
- Susan M. Meffert
- Department of Psychiatry, University of California, San Francisco (UCSF), San Francisco, California, United States of America
| | - Thomas C. Neylan
- Department of Psychiatry, University of California, San Francisco (UCSF), San Francisco, California, United States of America
- Mental Health Service, San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
| | - Charles E. McCulloch
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, California, United States of America
| | - Kelly Blum
- Department of Psychiatry, University of California, San Francisco (UCSF), San Francisco, California, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, UCSF, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
| | - Helen Verdeli
- Teachers College, Columbia University, New York, New York, United States of America
| | - John C. Markowitz
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, Global Health Sciences, and Global Health Economics Consortium, UCSF, San Francisco, California, United States of America
| | - David Bukusi
- Department of Psychiatry, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Harsha Thirumurthy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | | | - Ray Rota
- University of Nairobi, Nairobi, Kenya
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Levy R, Mathai M, Chatterjee P, Ongeri L, Njuguna S, Onyango D, Akena D, Rota G, Otieno A, Neylan TC, Lukwata H, Kahn JG, Cohen CR, Bukusi D, Aarons GA, Burger R, Blum K, Nahum-Shani I, McCulloch CE, Meffert SM. Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya. BMC Psychiatry 2019; 19:424. [PMID: 31883526 PMCID: PMC6935499 DOI: 10.1186/s12888-019-2395-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS/DESIGN We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up. DISCUSSION The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability. TRIAL REGISTRATION ClinicalTrials.gov NCT03466346, registered March 15, 2018.
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MESH Headings
- Adult
- Ambulatory Care/methods
- Ambulatory Care/trends
- Ambulatory Care Facilities/trends
- Antidepressive Agents, Second-Generation/administration & dosage
- Combined Modality Therapy/methods
- Combined Modality Therapy/trends
- Delivery of Health Care, Integrated/methods
- Delivery of Health Care, Integrated/trends
- Depressive Disorder, Major/epidemiology
- Depressive Disorder, Major/psychology
- Depressive Disorder, Major/therapy
- Female
- Fluoxetine/administration & dosage
- Hospitals, County/trends
- Humans
- Kenya/epidemiology
- Male
- Mental Health Services/trends
- Psychotherapy/methods
- Public Sector/trends
- Stress Disorders, Post-Traumatic/epidemiology
- Stress Disorders, Post-Traumatic/psychology
- Stress Disorders, Post-Traumatic/therapy
- Treatment Outcome
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Affiliation(s)
- Rachel Levy
- Medical School, University of California, San Francisco, CA, USA
| | - Muthoni Mathai
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Purba Chatterjee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Linnet Ongeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Simon Njuguna
- Director of Mental Health, Kenyan Ministry of Health, Nairobi, Kenya
| | | | - Dickens Akena
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | | | | | - Thomas C Neylan
- Departments of Psychiatry and Neurology, University of California, San Francisco, CA, USA
| | - Hafsa Lukwata
- Division of Mental Health and Control of Substance Abuse, Ministry of Health -, Kampala, Uganda
| | - James G Kahn
- Department of Epidemiology and Biostatistics, Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, UC Global Health Institute, San Francisco, CA, USA
| | - David Bukusi
- Department of Psychiatry, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Gregory A Aarons
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Rachel Burger
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Kelly Blum
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles E McCulloch
- Division of Mental Health and Control of Substance Abuse, Ministry of Health -, Kampala, Uganda
| | - Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, CA, USA.
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Meffert SM, Shome S, Neylan TC, Musalo K, Fineberg HV, Cooke MM, Volberding PA, Goosby EP. Health impact of human rights testimony: harming the most vulnerable? BMJ Glob Health 2017; 1:e000001. [PMID: 28588904 PMCID: PMC5321303 DOI: 10.1136/bmjgh-2015-000001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 11/18/2022] Open
Abstract
Background Current legal efforts to document human rights violations typically include interviews in which survivors are asked to provide detailed descriptions of their traumatic experiences during a single meeting. Research on similar interview techniques used as part of a mental health treatment (eg, debriefing) has raised concerns that they might worsen mental health—more than doubling the risk of post-traumatic stress disorder in some studies. While controversy over the mental health impact of debriefing continues, debriefing treatments have been discontinued in most clinics nearly 2 decades ago. The purpose of this article is to promote the development and integration of preventative measures to limit potential mental health damage associated with legal endeavours to address human rights violations and international crimes. Methods and findings Given the recent growth of the field of global mental health and its current capacity to provide feasible, acceptable, effective care in low-resource settings, we propose a research agenda to identify the mental health impact of current human rights legal practices and test a model of scalable medicolegal care that minimises risk by integrating mental health monitoring and applying up-to-date models of trauma treatment, including multiple meeting sessions, as indicated. Conclusions As the fields of global health, human rights law, international criminal law and transitional justice increasingly overlap in their efforts to assist communities affected by grave violence, we propose that synchronising efforts may offer important opportunities to improve mental health for survivors.
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Affiliation(s)
- Susan M Meffert
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Shonali Shome
- Legal and Gender Advisor, AIDS, Uniondale, New York, USA
| | - Thomas C Neylan
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Karen Musalo
- Center for Gender and Refugee Studies, UC Hastings College of the Law, San Francisco, California, USA
| | | | - Molly M Cooke
- Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Paul A Volberding
- Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Eric P Goosby
- Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, USA
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Onu C, Ongeri L, Bukusi E, Cohen CR, Neylan TC, Oyaro P, Rota G, Otewa F, Delucchi KL, Meffert SM. Erratum to: 'Interpersonal psychotherapy for depression and posttraumatic stress disorder among HIV-positive women in Kisumu, Kenya: study protocol for a randomized controlled trial'. Trials 2016; 17:151. [PMID: 27000080 PMCID: PMC4802826 DOI: 10.1186/s13063-016-1289-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 11/21/2022] Open
Affiliation(s)
- Chinwe Onu
- School of Medicine, University of California, San Francisco, USA
| | - Linnet Ongeri
- Kenya Medical Research Institute, Nairobi city, Kenya
| | - Elizabeth Bukusi
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics and Gynecology, University of California, San Francisco, USA
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, USA
| | - Patrick Oyaro
- Family AIDS Care Education and Services, Kisumu, Kenya
| | - Grace Rota
- Family AIDS Care Education and Services, Kisumu, Kenya
| | - Faith Otewa
- Family AIDS Care Education and Services, Kisumu, Kenya
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, USA
| | - Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, USA.
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Meffert SM, Neylan TC, Chambers DA, Verdeli H. Novel implementation research designs for scaling up global mental health care: overcoming translational challenges to address the world's leading cause of disability. Int J Ment Health Syst 2016; 10:19. [PMID: 26958075 PMCID: PMC4782517 DOI: 10.1186/s13033-016-0049-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 11/10/2022] Open
Abstract
Despite established knowledge that Low and Middle Income Countries (LMICs) bear the majority of the world's burden of mental disorders, and more than a decade of efficacy research showing that the most common disorders, such as depression and anxiety, can be treated using readily available local personnel in LMICs to apply evidence-based treatments, there remains a massive mental health treatment gap, such that 75 % of those in LMICs never receive care. Here, we discuss the use of a new type of implementation science study design, the effectiveness-implementation hybrids, to speed the translation and scale up of mental health care in LMICs. We use our current study of Interpersonal Psychotherapy (IPT) delivered by local personnel for depression and trauma-related disorders among HIV+ women in Kenya as an example of effectiveness-implementation hybrid design for mental health services research in LMICs.
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Affiliation(s)
- Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94127 USA
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121 USA
| | - David A Chambers
- National Cancer Institute, National Institutes of Health, BG 9609 MSC 9760, 9609 Medical Center Drive, Bethesda, MD 20892-9760 USA
| | - Helen Verdeli
- Teachers College, Columbia University, 325 HMann 525 West 120th Street, New York, NY 10027 USA
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Onu C, Ongeri L, Bukusi E, Cohen CR, Neylan TC, Oyaro P, Rota G, Otewa F, Delucchi KL, Meffert SM. Interpersonal psychotherapy for depression and posttraumatic stress disorder among HIV-positive women in Kisumu, Kenya: study protocol for a randomized controlled trial. Trials 2016; 17:64. [PMID: 26841875 PMCID: PMC4738764 DOI: 10.1186/s13063-016-1187-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 01/20/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Mental disorders are the leading global cause of years lived with disability; the majority of this burden exists in low and middle income countries (LMICs). Over half of mental illness is attributable to depression and anxiety disorders, both of which have known treatments. While the scarcity of mental health care providers is recognized as a major contributor to the magnitude of untreated disorders in LMICs, studies in LMICs find that evidence-based treatments for depression and anxiety disorders, such as brief, structured psychotherapies, are feasible, acceptable and have strong efficacy when delivered by local non-specialist personnel. However, most mental health treatment studies using non-specialist providers in LMICs deploy traditional efficacy designs (T1) without the benefit of integrated mental health treatment models shown to succeed over vertical interventions or methods derived from new implementation science to speed policy change. Here, we describe an effectiveness-implementation hybrid study that evaluates non-specialist delivery of mental health treatment within an HIV clinic for HIV-positive (HIV+) women affected by gender- based violence (GBV) (HIV+ GBV+) in the Nyanza region of Kenya. METHODS/DESIGN In this effectiveness-implementation hybrid type I design, 200 HIV+ women with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) who are receiving care at a Family AIDS Care Education and Services (FACES)-supported clinic in Kisumu, Kenya will be randomized to: (1) interpersonal psychotherapy (IPT) + treatment as usual (TAU) or (2) TAU, both delivered within the HIV clinic. IPT will consist of 12 weekly 60-minute individual IPT sessions, delivered by non-specialists trained to provide IPT. Primary effectiveness outcomes will include MDD and PTSD diagnosis on the Mini International Diagnostic Interview (MINI). Primary implementation outcomes will include treatment cost-benefit, acceptability, appropriateness, feasibility and fidelity of the IPT delivery within an HIV clinic. DISCUSSION This trial leverages newly defined effectiveness-implementation hybrid designs to gather data on mental health treatment implementation within an HIV care clinic, while testing the effectiveness of an evidence-based treatment for use with a large underserved population (HIV+ GBV+ women) in Kenya. TRIAL REGISTRATION CLINICAL TRIALS IDENTIFIER NCT02320799, registered on 9 September 2014.
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Affiliation(s)
- Chinwe Onu
- School of Medicine, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94121, USA.
| | - Linnet Ongeri
- Kenya Medical Research Institute, PO Box 54840, 00200, Nairobi, Kenya.
| | - Elizabeth Bukusi
- Department of Psychiatry, University of Nairobi, Kenya, PO Box 19676, Nairobi, Kenya.
- Department of Obstetrics and Gynecology, University of Nairobi, Kenya, PO Box 19676, Nairobi, Kenya.
| | - Craig R Cohen
- Department of Obstetrics and Gynecology, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, 4150 Clement Street, San Francisco, CA, 94121, USA.
| | - Patrick Oyaro
- Family AIDS Care Education and Services, Kenya, PO Box 614-40100, Kisumu, Kenya.
| | - Grace Rota
- Family AIDS Care Education and Services, Kenya, PO Box 614-40100, Kisumu, Kenya.
| | - Faith Otewa
- Family AIDS Care Education and Services, Kenya, PO Box 614-40100, Kisumu, Kenya.
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus avenue, San Francisco, CA, 94143, USA.
| | - Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus avenue, San Francisco, CA, 94143, USA.
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Zunner B, Dworkin SL, Neylan TC, Bukusi EA, Oyaro P, Cohen CR, Abwok M, Meffert SM. HIV, violence and women: unmet mental health care needs. J Affect Disord 2015; 174:619-26. [PMID: 25574781 PMCID: PMC4340747 DOI: 10.1016/j.jad.2014.12.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 11/24/2014] [Accepted: 12/04/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND HIV-infected (HIV+) women have high rates of Gender Based Violence (GBV). Studies of GBV find that approximately 50-90% of survivors develop mood and anxiety disorders. Given that women in sub-Saharan African constitute the largest population of HIV+ individuals in the world and the region׳s high GBV prevalence, mental health research with HIV+ women affected by GBV (HIV+GBV+) in this region is urgently needed. METHODS Qualitative methods were used to evaluate the mental health care needs of HIV+GBV+ female patients at an HIV clinic in the Kisumu County, Kenya. Thirty in-depth interviews and four focus groups were conducted with patients, healthcare providers and community leaders. Interviews were transcribed, translated and analyzed using qualitative data software. RESULTS Respondents stated that physical, sexual and emotional violence against HIV+ women was widely prevalent and perpetrated primarily by untested husbands accusing a wife of marital infidelity following her positive HIV test result. Mental health problems among HIV+GBV+ women included depressive, anxiety, traumatic stress symptoms and suicidal thoughts. Participants opined that emotional distress from GBV not only caused HIV treatment default, but also led to poor HIV health even if adherent. Respondents agreed that mental health treatment was needed for HIV+GBV+ women; most agreed that the best treatment modality was individual counseling delivered weekly at the HIV clinic. LIMITATIONS Emotional distress may be higher and/or more varied among HIV+GBV+ women who are not engaged in HIV care. CONCLUSIONS Mental health care is needed and desired by HIV+GBV+ women in Kisumu County, Kenya.
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Affiliation(s)
- Brian Zunner
- School of Nursing, University of California, San Francisco, California, USA
| | - Shari L. Dworkin
- Department of Social and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Thomas C. Neylan
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Elizabeth A. Bukusi
- Kenya Medical Research Institute; Department of Obstetrics and Gynecology, University of Nairobi, Kenya, Family AIDS Care Education & Services, Kenya
| | | | - Craig R. Cohen
- Family AIDS Care Education & Services, Kenya, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, USA
| | | | - Susan M. Meffert
- Department of Psychiatry, University of California, San Francisco, California, USA,Corresponding author: 401 Parnassus Avenue, San Francisco, California USA 94143; 415-476-7000(t); 415-476-7404 (f);
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Jiang RF, Tong HQ, Delucchi KL, Neylan TC, Shi Q, Meffert SM. Interpersonal psychotherapy versus treatment as usual for PTSD and depression among Sichuan earthquake survivors: a randomized clinical trial. Confl Health 2014; 8:14. [PMID: 25254070 PMCID: PMC4172897 DOI: 10.1186/1752-1505-8-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 07/17/2014] [Indexed: 01/10/2023] Open
Abstract
Background Without effective treatment, PTSD and depression can cause persistent disability in disaster-affected populations. Methods Our objective was to test the efficacy of Interpersonal Psychotherapy (IPT) delivered by trained local personnel compared with treatment as usual (TAU) for Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) among adults affected by the Sichuan 2008 earthquake. A small randomized controlled trial of IPT + TAU versus TAU alone was delivered by local mental health personnel in Shifang, China. Between July 2011 and January 2012, 49 adults ≥ 18 years with PTSD, MDD or both were enrolled and randomized to 12 weekly sessions of IPT + TAU (27) or TAU (22) alone x 12 weeks. IPT was then offered to the TAU group. Unblinded follow up assessments were conducted at three and six months. IPT was a 12 session, weekly one hour treatment delivered by local personnel who were trained and supervised in IPT. TAU was continuation of prescribed psychotropic medication (if applicable) and crisis counseling, as needed. Main Outcome(s) and Measures (s): Clinician Administered PTSD Scale (CAPS) PTSD diagnosis; Structured Clinical Interview for DSM-IV (SCID) for MDD diagnosis. Secondary measures included PTSD/depression symptoms, interpersonal conflict/anger, social support, self-efficacy and functioning. Results Using an intent-to-treat analysis, 22 IPT + TAU and 19 TAU participants were compared at three months post-baseline. A significantly greater reduction of PTSD and MDD diagnoses was found in the IPT group (51.9%, 30.1%, respectively) versus the TAU group (3.4%, 3.4%, respectively). Despite the small sample, the estimates for time-by-condition analyses of target outcomes (2.37 for PTSD (p = .018) and 1.91 for MDD (p = .056)) indicate the improvement was better in the IPT + TAU condition versus the TAU group. Treatment gains were maintained at 6 months for the IPT group. A similar treatment response was observed in the TAU group upon receipt of IPT. Conclusions This initial study shows that IPT is a promising treatment for reducing PTSD and depression, the two major mental health disorders affecting populations surviving natural disaster, using a design that builds local mental health care capacity. Trial Registration ClinicalTrials.Gov number, NCT01624935.
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Affiliation(s)
- Rui Fang Jiang
- Wuhan Hospital for Psychotherapy, Wuhan Mental Health Center, Tongji Medical College Huazhong University of Science and Technology, Kaiming Road 44#, Wuhan 430019, China
| | - Hui Qi Tong
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Qijia Shi
- Wuhan Hospital for Psychotherapy, Wuhan Mental Health Center, Tongji Medical College Huazhong University of Science and Technology, Kaiming Road 44#, Wuhan 430019, China
| | - Susan M Meffert
- Wuhan Hospital for Psychotherapy, Wuhan Mental Health Center, Tongji Medical College Huazhong University of Science and Technology, Kaiming Road 44#, Wuhan 430019, China
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Meffert SM, Henn-Haase C, Metzler TJ, Qian M, Best S, Hirschfeld A, McCaslin S, Inslicht S, Neylan TC, Marmar CR. Prospective study of police officer spouse/partners: a new pathway to secondary trauma and relationship violence? PLoS One 2014; 9:e100663. [PMID: 24987848 PMCID: PMC4079247 DOI: 10.1371/journal.pone.0100663] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 05/29/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION It has been reported that posttraumatic stress disorder (PTSD) is associated with secondary spouse/partner (S/P) emotional distress and relationship violence. OBJECTIVE To investigate the relationships between PTSD, S/P emotional distress and relationship violence among police recruits using a prospective design. METHODS Two hypotheses were tested in 71 S/Ps: (1) Police officer reports of greater PTSD symptoms after 12 months of police service will be associated with greater secondary trauma symptoms among S/Ps; (2) Greater secondary trauma symptoms among S/Ps at 12 months will be associated with S/P reports of greater relationship violence. METHODS 71 police recruits and their S/Ps were assessed at baseline and 12 months after the start of police officer duty. Using linear and logistic regression, we analyzed explanatory variables for 12 month S/P secondary traumatic stress symptoms and couple violence, including baseline S/P variables and couple violence, as well as exposure and PTSD reports from both S/P and officer. RESULTS S/P perception of officer PTSD symptoms predicted S/P secondary traumatic stress. OS/P secondary trauma was significantly associated with both total couple violence (.34, p = .004) and S/P to officer violence (.35, p = .003). CONCLUSIONS Although results from this relatively small study of young police officers and their S/Ps must be confirmed by larger studies in general populations, findings suggest that S/P perception of PTSD symptoms may play a key role in the spread of traumatic stress symptoms across intimate partner relationships and intimate partner violence in the context of PTSD.
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Affiliation(s)
- Susan M. Meffert
- Department of Psychiatry, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Clare Henn-Haase
- Department of Psychiatry, New York University, New York, New York, United States of America
| | - Thomas J. Metzler
- Mental Health Service, San Francisco Veterans Administration Medical Center, San Francisco, California, United States of America
| | - Meng Qian
- Department of Psychiatry, New York University, New York, New York, United States of America
| | - Suzanne Best
- Graduate School of Education and Counseling, Lewis and Clark College, Portland, Oregon, United States of America
| | - Ayelet Hirschfeld
- Mental Health Service, San Francisco Veterans Administration Medical Center, San Francisco, California, United States of America
| | - Shannon McCaslin
- Dissemination and Training Division, National Center for PTSD, Palo Alto, California, United States of America
| | - Sabra Inslicht
- Department of Psychiatry, University of California San Francisco, San Francisco, California, United States of America
- Mental Health Service, San Francisco Veterans Administration Medical Center, San Francisco, California, United States of America
| | - Thomas C. Neylan
- Department of Psychiatry, University of California San Francisco, San Francisco, California, United States of America
- Mental Health Service, San Francisco Veterans Administration Medical Center, San Francisco, California, United States of America
| | - Charles R. Marmar
- Department of Psychiatry, New York University, New York, New York, United States of America
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Meffert SM, Abdo AO, Alla OAA, Elmakki YOM, Omer AA, Yousif S, Metzler TJ, Marmar CR. A pilot randomized controlled trial of interpersonal psychotherapy for Sudanese refugees in Cairo, Egypt. ACTA ACUST UNITED AC 2014. [DOI: 10.1037/a0023540] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Meffert SM, Musalo K, Abdo AO, Alla OAA, Elmakki YOM, Omer AA, Yousif S, Metzler TJ, Marmar CR. Feelings of betrayal by the United Nations High Commissioner for Refugees and emotionally distressed Sudanese refugees in Cairo. Med Confl Surviv 2010; 26:160-72. [PMID: 20718287 DOI: 10.1080/13623699.2010.491395] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Thousands of Sudanese refugees have fled to Cairo, Egypt in the wake of Sudanese civil conflicts. Sudanese refugees were evaluated with respect to symptoms of depression, post-traumatic stress disorder (PTSD) and social stress. Four respondents (22%) indicated that their interactions with the United Nations High Commissioner for Refugees (UNHCR) in Cairo, Egypt were the worst experiences since war-related atrocities. Fourteen participants (63.6%) felt 'extremely' betrayed by the UNHCR on a four point scale. Greater feelings of betrayal by the UNHCR were associated with greater avoidance and arousal symptoms of PTSD, symptoms of depression and trait anger. This is the first study of which we are aware that examines the relationship between sense of betrayal by the UNHCR and symptoms of PTSD, depression and anger among asylum seekers.
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Affiliation(s)
- Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, California, USA.
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Meffert SM, Musalo K, McNiel DE, Binder RL. The role of mental health professionals in political asylum processing. J Am Acad Psychiatry Law 2010; 38:479-489. [PMID: 21156906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Applying for asylum in the United States can be a strenuous process for both applicants and immigration attorneys. Mental health professionals with expertise in asylum law and refugee trauma can make important contributions to such cases. Not only can mental health professionals provide diagnostic information that may support applicants' claims, but they can evaluate how culture and mental health symptoms relate to perceived deficits in credibility or delays in asylum application. They can define mental health treatment needs and estimate the possible effects of repatriation on mental health. Mental health professionals can also provide supportive functions for clients as they prepare for testimony. Finally, in a consultative role, mental health experts can help immigration attorneys to improve their ability to elicit trauma narratives from asylum applicants safely and efficiently and to enhance their resilience in response to vicarious trauma and burnout symptoms arising from work with asylum seekers.
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Abstract
Hundreds of thousands of Darfur people affected by the Sudanese genocide have fled to Cairo, Egypt, in search of assistance. Collaborating with Africa and Middle East Refugee Assistance (AMERA), the authors conducted a mental health care needs assessment among Darfur refugees in Cairo. Information was collected using individual and focus group interviews to identify gaps in mental health care and develop understandings of emotional and relationship problems. The refugee mental health care system has a piecemeal structure with gaps in outpatient services. There is moderate to severe emotional distress among many Darfur refugees, including symptoms of depression and trauma, and interpersonal conflict, both domestic violence and broader community conflict, elevated relative to pregenocide levels. Given the established relationships between symptoms of depression/traumatic stress and interpersonal violence, improving mental health is important for both preventing mental health decompensation and stemming future cycles of intra- and intergroup conflict.
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Affiliation(s)
- Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA 94143, USA.
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Abstract
It is unknown whether anger is a risk factor for the development of posttraumatic stress disorder ( PTSD) symptoms, arises as a consequence of PTSD, or both. Two hypotheses were tested in 180 police recruits: Greater trait anger during training will predict greater PTSD symptoms at one year; greater PTSD symptoms at one year will predict greater state anger at one year. Both hypotheses were confirmed, suggesting that trait anger is a risk factor for PTSD symptoms, but that PTSD symptoms are also associated with an increase of state anger. Increased anger is important not only because of the impact it has on individual distress and physical health, but also because of its potential public health impact.
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Affiliation(s)
- Susan M Meffert
- Department of Psychiatry, University of California, San Francisco, CA 94143, USA.
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