A Contextual Adaptation of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Victims of the Armed Conflict in Colombia

Cultural adaptation of an evidence-based intervention to address mental health among youth affected by armed conflict in Colombia: An application of the ADAPT-ITT approach and FRAME-IS reporting protocols

Background

In Colombia, over 9 million people have been impacted by armed conflict, creating a significant need for mental health services. This study aimed to culturally adapt and pilot test the Youth Readiness Intervention (YRI), an evidence-based transdiagnostic mental health intervention, for conflict-affected Colombian youth aged 18-28 years.

Methods

The eight phases of the Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, and Testing (ADAPT-ITT) framework were used to culturally adapt the YRI for conflict-affected Colombian youth. The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) was used to track the adaptations made. Qualitative and quantitative data were gathered and analyzed throughout the adaptation process.

Results

Data from the Assessment phase demonstrated a high need for mental health interventions among conflict-affected youth. The Testing phase revealed significant improvements in emotion regulation and functional impairment, suggesting the YRI is a promising intervention among conflict-affected Colombian youth. Qualitative data confirmed the intervention's acceptability among youth and mental health providers.

Conclusions

The YRI was successfully adapted for conflict-affected Colombian youth. Future studies using randomized designs are needed to test the effectiveness of the YRI for improving mental health among larger samples of Colombian conflict-affected youth.

State of the Science: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

Before the development of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP), evidence-based treatment options for commonly co-occurring anxiety, mood, and related disorders consisted of numerous single-disorder protocols that shared many similarities, reflecting the overlap among these disorders themselves. The UP distilled common elements of cognitive behavioral protocols into a unified intervention directly targeting core temperamental features underlying these disorders of emotion, namely neuroticism and associated emotion dysregulation. The UP has since become a leading "transdiagnostic" treatment for emotional disorders, which is now available in several formats (e.g., individual, group, digital) and has accumulated a strong evidence base, leading to international implementation. There is now also research evidence that the UP can be flexibly applied to a range of clinical presentations, including borderline personality disorder, trauma- and stressor-related disorders, eating disorders, alcohol use disorder, and comorbid chronic physical health conditions. Yet additional research is needed to evaluate the UP in routine clinical settings, with more heterogeneous patient populations, and under circumstances that mirror actual clinical practice. Thus, we must also continue to explore the benefits of large-scale UP training initiatives and implementation in major healthcare systems.

Adaptation of unified protocol treatment for transdiagnostic disorders in Pakistan: A heuristic framework

The access to evidence-based treatments for mental health problems is limited in low-resource settings. Transdiagnostic approaches, such as the Unified Protocol (UP), are a potential solution for these settings because they are multi-problem focused, modular, flexible, and have low complexity. This study aimed to adapt UP to the mental health context of an urban speciality clinic in Pakistan using a four-step process of heuristic framework. The study employed an iterative and stakeholder-based approach to align the protocol with local values, language, and needs. Primarily, the proposed modifications focus on language use, matching literacy level, graphical illustrations, and relevance of examples. A multi-method approach including expert review, cognitive interviewing, and adaptation testing ensured cultural equivalence. Participants diagnosed with depression and anxiety were provided culturally adapted treatment (N = 15) at the testing phase. Findings indicated that the participants not only experienced significant reductions in symptoms of depression and anxiety but also found the culturally adapted UP to be easy to understand, culturally relevant, and engaging. This study provides evidence that the UP can be culturally adapted and used in the mental health context of Pakistan. The findings suggest that the UP is a promising intervention for individuals with depression and anxiety in low-resource settings.

Multidimensional Emotional Disorder Inventory: reliability and validity in a Colombian non-clinical sample

BACKGROUND

Contemporary diagnostic frameworks in the realm of mental health have garnered criticism due to their categorical paradigm. Given the propensity of emotional disorders to manifest overlapping features, these frameworks fall short in comprehensively encapsulating their intricate nature. As a strategic response, Brown and Barlow introduced an innovative composite approach, amalgamating dimensions and categorical classifications, to adress this concern. Their strategic implementation hinged on the Multidimensional Emotional Disorder Inventory (MEDI), a transdiagnostic self-report instrument.

OBJECTIVE

this study undertakes the task of refining and validating the applicability of the MEDI within a non-clinical sample of Colombian university students (n = 808).

METHODS

This study employed Exploratory Structural Equation Modeling (ESEM) to explore the structure of the measure.

RESULTS

ESEM suggested that the 8-dimension model with 48 items was the best-fitting solution, aligning with most dimensions identified by the original MEDI validation. Reliability was adequate for almost all dimensions (α: 0.69 - 0.92). An 8-dimension model with 48 items emerged as the most fitting solution, aligning with most dimensions identified by the original MEDI validation.

CONCLUSION

The ensuing validation and contextual adaptation of the MEDI for use in the Colombian population augments the transdiagnostic evaluation of emotional disorders, with potential implications for enhanced stratification of targeted therapeutic interventions. By optimizing the assessment of both dimensional and cross-diagnostic paradigms, the MEDI portends a noteworthy impact in realms encompassing both academic inquiry and clinical practice.

Barriers and Facilitators to Implementing a Community-Based Psychosocial Support Intervention Conducted In-Person and Remotely: A Qualitative Study in Quibdó, Colombia

Community-based psychosocial support group (CB-PSS) interventions using task-shifting approaches are well suited to provide culturally appropriate services in low- and middle-income countries. However, contextual barriers and facilitators must be considered to tailor interventions effectively, particularly considering the challenges introduced by the COVID-19 pandemic. We explore the barriers, facilitators, and psychosocial changes associated with implementing a CB-PSS group intervention delivered by local lay providers to conflict-affected adults in Quibdó, Colombia, using both in-person and remote modalities. Data were analyzed from 25 individual interviews with participants and a focus group discussion involving staff members, including 7 community psychosocial agent facilitators and 2 mental health professional supervisors. The analysis used a thematic approach grounded in a descriptive phenomenology to explore the lived experiences of participants and staff members during implementation. Participant attendance in the in-person modality was compromised by factors such as competing work and family responsibilities and disruption caused by the COVID-19 pandemic. Participants in the remote modality faced challenges concerning unstable Internet connectivity, recurrent power outages caused by heavy rain, distractions, interruptions, and threats to confidentiality by family and coworkers. Despite these challenges, data revealed key contextual facilitators, including the community-based knowledge of facilitators and integration of traditional practices, such as the comadreo (informal talks and gatherings). Respondents shared that the CB-PSS groups promoted stronger community relationships and created opportunities for participants to exchange peer support, practice leadership skills, develop problem-solving skills based on peers' experiences, and enhance emotional regulation skills. Differences and similarities across in-person and remote modalities are discussed, as are key considerations for practitioners and policymakers.

Piloting a community-based psychosocial group intervention designed to reduce distress among conflict-affected adults in Colombia: a mixed-method study of remote, hybrid, and in-person modalities during the COVID-19 pandemic

BACKGROUND

Community members in Quibdó (Choco, Colombia) are highly vulnerable to psychosocial problems associated with the internal armed conflict, poverty, and insufficient public services, and exacerbated by the COVID-19 pandemic. A pilot study was conducted with conflict-affected adults in Quibdó to assess feasibility and outcomes of a community-based psychosocial support group intervention using three different intervention modalities: in-person, remote (conducted online), and hybrid (half of sessions in-person, half-remote). This group model integrated problem-solving and culturally based expressive activities and was facilitated by local community members with supervision by mental health professionals.

METHODS

This study utilized a mixed-explanatory sequential design (a quantitative phase deriving in a qualitative phase) with 39 participants and 8 staff members. Participants completed quantitative interviews before and after an eight-week group intervention. A subset of 17 participants also completed in-depth qualitative interviews and a focus group discussion was conducted with staff at post-intervention.

RESULTS

From pre- to post-intervention, participants in all modalities demonstrated improved wellbeing and reduced symptoms of generalized distress, anxiety, depression, and posttraumatic stress. Use of coping skills varied across modalities, with remote groups associated with a decrease in some forms of coping, including use of social support. In qualitative interviews and the focus group discussion, participants and staff described logistical challenges and successes, as well as facilitators of change such as problem resolution, emotional regulation and social support with variations across modalities, such that remote groups provided fewer opportunities for social support and cohesion.

CONCLUSIONS

Results offer preliminary evidence that this model can address psychosocial difficulties across the three modalities, while also identifying potential risks and challenges, therefore providing useful guidance for service delivery in conflict-affected settings during the COVID-19 pandemic and other challenging contexts. Implications of this study for subsequent implementation of a Randomized Control Trial (RCT) are discussed.

Effects of a Contextual Adaptation of the Unified Protocol in Multiple Emotional Disorders in Individuals Exposed to Armed Conflict in Colombia: A Randomized Clinical Trial

Importance

A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied.

Objective

To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia.

Design, Setting, and Participants

From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded.

Intervention

CXA-UP or waitlist.

Main Outcomes and Measures

Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5.

Results

Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04).

Conclusions and Relevance

In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts.

Trial Registration

ClinicalTrials.gov Identifier: NCT03127982.

Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW's mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW's health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study's findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW's diverse gender identities and expressions; (2) focusing on SMW's nonbinary stressors; (3) formulating SMW's gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW's lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

Medición de indicadores de salud mental de población en contexto de conflicto armado en Colombia: revisión de alcance

El conflicto armado ha marcado las diferentes dimensiones de vida de la población colombiana por lo que ha sido objeto de diversos estudios, generando la necesidad de evaluar el abordaje e instrumentos utilizados para medir indicadores de salud mental de población en contexto de conflicto armado. Esta investigación pretende analizar artículos científicos que aborden dichos indicadores y que utilicen instrumentos psicométricos para tal fin. Se realizó una revisión de alcance siguiendo la metodología PRISMA y utilizando el software CADIMA. La búsqueda bibliográfica se hizo en las bases de datos Web of Science, Scielo y Scopus, usando términos claves en inglés y español. Se analizaron 21 artículos en los que se identifica el uso de 53 instrumentos, siendo los más aplicados el AUDIT y la CIDI-CAPI. La mayoría de los artículos reportaron afectaciones relacionadas con estrés postraumático, ansiedad, depresión y consumo de sustancias. Se encontraron pocos estudios de validación o construcción de instrumentos. Es necesario fortalecer el trabajo en el desarrollo y validación de pruebas para evaluar indicadores de salud mental en poblaciones víctimas del conflicto armado colombiano, con las que se posibilite una mejor valoración de las afectaciones.

Reporting Cultural Adaptation in Psychological Trials - The RECAPT criteria

Background

There is a lack of empirical evidence on the level of cultural adaptation required for psychological interventions developed in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups. This lack of evidence is partly due to insufficient documentation of cultural adaptation in psychological trials. Standardised documentation is needed in order to enhance empirical and meta-analytic evidence.

Process

A "Task force for cultural adaptation of mental health interventions for refugees" was established to harmonise and document the cultural adaptation process across several randomised controlled trials testing psychological interventions for mental health among refugee populations in Germany. Based on the collected experiences, a sub-group of the task force developed the reporting criteria presented in this paper. Thereafter, an online survey with international experts in cultural adaptation of psychological interventions was conducted, including two rounds of feedback.

Results

The consolidation process resulted in eleven reporting criteria to guide and document the process of cultural adaptation of psychological interventions in clinical trials. A template for documenting this process is provided. The eleven criteria are structured along A) Set-up; B) Formative research methods; C) Intervention adaptation; D) Measuring outcomes and implementation.

Conclusions

Reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability.