Cognitive-behavioral group therapy for youths with anxiety disorders in the community: effectiveness in low and middle income countries

Availability of screening and treatment for common mental disorders in HIV clinic settings: data from the global International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium, 2016-2017 and 2020

INTRODUCTION

Common mental disorders (CMDs) are highly prevalent among people with HIV. Integrating mental healthcare into HIV care may improve mental health and HIV treatment outcomes. We describe the reported availability of screening and treatment for depression, anxiety and post-traumatic stress disorder (PTSD) at global HIV treatment centres participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium in 2020 and changes in availability at sites in low- or middle-income countries (LMICs) between 2016/2017 and 2020.

METHODS

In 2020, 238 sites contributing individual-level data to the IeDEA Consortium and in 2016/2017 a stratified random sample of IeDEA sites in LMICs were eligible to participate in site surveys on the availability of screening and treatment for CMDs. We assessed trends over time for 68 sites across 27 LMICs that participated in both surveys.

RESULTS

Among the 238 sites eligible to participate in the 2020 site survey, 227 (95%) participated, and mental health screening and treatment data were available for 223 (98%) sites across 41 countries. A total of 95 sites across 29 LMICs completed the 2016/2017 survey. In 2020, 68% of sites were in urban settings, and 77% were in LMICs. Overall, 50%, 14% and 12% of sites reported screening with a validated instrument for depression, anxiety and PTSD, respectively. Screening plus treatment in the form of counselling was available for depression, anxiety and PTSD at 46%, 13% and 11% of sites, respectively. Screening plus treatment in the form of medication was available for depression, anxiety and PTSD at 36%, 11% and 8% of sites, respectively. Among sites that participated in both surveys, screening for depression was more commonly available in 2020 than 2016/2017 (75% vs. 59%, respectively, p = 0.048).

CONCLUSIONS

Reported availability of screening for depression increased among this group of IeDEA sites in LMICs between 2016/2017 and 2020. However, substantial gaps persist in the availability of mental healthcare at HIV treatment sites across global settings, particularly in resource-constrained settings. Implementation of sustainable strategies to integrate mental health services into HIV care is needed.

Overview of Ten Child Mental Health Clinical Outcome Measures: Testing of Psychometric Properties with Diverse Client Populations in the U.S

While many standardized assessment measures exist to track child mental health treatment outcomes, the degree to which such tools have been adequately tested for reliability and validity across race, ethnicity, and class is uneven. This paper examines the corpus of published tests of psychometric properties for the ten standardized measures used in U.S. child outpatient care, with focus on breadth of testing across these domains. Our goal is to assist care providers, researchers, and legislators in understanding how cultural mismatch impacts measurement accuracy and how to select tools appropriate to the characteristics of their client populations. We also highlight avenues of needed research for measures that are in common use. The list of measures was compiled from (1) U.S. state Department of Mental Health websites; (2) a survey of California county behavioral health agency directors; and (3) exploratory literature scans of published research. Ten measures met inclusion criteria; for each one a systematic review of psychometrics literature was conducted. Diversity of participant research samples was examined as well as differences in reliability and validity by gender, race or ethnicity, and socio-economic class. All measures showed adequate reliability and validity, however half lacked diverse testing across all three domains and all lacked testing with Asian American/Pacific Islander and Native American children. ASEBA, PSC, and SDQ had the broadest testing.

Pilot Randomized Control Trial: Efficacy of a Group-Based Psychosocial Program for Youth with PTSD in the Brazilian Favelas

The study aimed to evaluate Teaching Recovery Techniques (TRT) delivered to Brazilian youth who experienced drug violence in one Favela. Thirty children, 8 to 14 years, were randomly assigned to TRT (n = 14) or to a treatment as usual group (n = 16) involving boxing/martial arts. Youth received five 90-min sessions over successive weeks. Standardized measures assessed Posttraumatic Stress and Depression at 2 weeks pre and post-test. An exploratory assessment of posttraumatic growth was also utilized. An interview with group leaders explored perceptions of delivering TRT within the favela. Medium effect sizes were found for PTSD and Depression, and a small effect size for posttraumatic growth. Group leaders emphasized understanding the favela context for program adaptation. In conclusion, TRT was found to be effective for children with PTSD and Depression who experienced drug violence in a Brazilian favela. TRT is recommended for future delivery. Larger scale RCTs are needed in Brazilian favelas.

Cultural adaptations of cognitive behavioural therapy for Latin American patients: unexpected findings from a systematic review

The current literature extensively recommends making cultural adaptations to psychological therapies, in order to address the differences in values, beliefs and attitudes that patients from different ethnic groups might hold. Although this approach has shown positive outcomes in some settings, it is not well established yet whether such adaptations are needed for all therapies and in all cultures. Therefore, the main aim of this study was to systematically review the literature regarding culturally adapted and ‘conventional’ cognitive behavioural therapy (CBT) for Latin American patients, within Latin American and non-Latin American countries. Sixty empirical studies regarding the effectiveness of culturally adapted and conventional CBT were included in this review. The included studies were carried out in Latin American and non-Latin American countries. The information from all studies was synthesized and assessed, including intervention effect sizes, patient retention rates, methodological quality of the papers, and the type of cultural adaptation made to the therapy. There were no differences between the sets of studies in terms of effectiveness, retention rates, methodological quality, or proportion of statistically significant interventions. Most of the cultural adaptations were peripheral or unspecified. The evidence to date indicates that both conventional and culturally adapted CBT offer the same benefits for Latin American patients in terms of effectiveness and retention rates. Rather than focusing on cultural adaptations, clinicians are encouraged to improve the way they deliver CBT through training and supervision.

Key learning aims

(1)

Systematic review on the use and description of measures to evaluate psychotherapeutic interventions with children and adolescents in Brazil

INTRODUCTION

Psychotherapeutic interventions in childhood and adolescence are recognized as a mental treatment and as a tool to reduce psychological disorders in youth and adulthood. Therefore, there is an increasing concern about evidence of effectiveness of mental disorder interventions and adequacy of measurement. The objectives of this systematic review were to investigate predominant research designs and instruments used in Brazilian studies describing psychotherapeutic interventions with children and adolescents and to examine how these instruments are described regarding evidence of validity and reliability.

METHOD

Five databases were surveyed, and for each one two independent judges performed the selection of records and applied the inclusion and exclusion criteria.

RESULTS

The final database comprised 28 papers, in which 92 instruments were referred. Fifty-seven instruments cited did not have descriptions of evidence of validity for the Brazilian population; for 31 instruments, validity evidence was mentioned, but the study did not detail which validity parameter was used; three studies described content validity evidence for their instruments. Furthermore, information about reliability was described for only two instruments.

CONCLUSION

A lack of studies in the field of child and adolescent psychotherapy was found in Brazil. There is a significant need for the field to attend both the psychometric properties and the quality of description of research instruments. The scientific production of studies focused on the evaluation of psychotherapeutic interventions may promote evidence-based psychotherapy and justify the offer of mental treatment in different contexts.

Group Cognitive Behavioral Therapy and Attention Bias Modification for Childhood Anxiety Disorders: A Factorial Randomized Trial of Efficacy

BACKGROUND

The objective of this study is to assess group differences in symptom reduction between individuals receiving group cognitive behavioral therapy (G-CBT) and attention bias modification (ABM) compared to their respective control interventions, control therapy (CT), and attention control training (ACT), in a 2 × 2 factorial design.

METHODS

A total of 310 treatment-naive children (7-11 years of age) were assessed for eligibility and 79 children with generalized, separation or social anxiety disorder were randomized and received G-CBT (n = 42) or CT (n = 37). Within each psychotherapy group, participants were again randomized to ABM (n = 38) or ACT (n = 41) in a 2 × 2 factorial design resulting in four groups: G-CBT + ABM (n = 21), G-CBT + ACT (n = 21), CT + ABM (n = 17), and CT + ACT (n = 20). Primary outcomes were responder designation as defined by Clinical Global Impression-Improvement (CGI-I) scale (≤2) and change on the Pediatric Anxiety Rating Scale (PARS).

RESULTS

There were significant improvements of symptoms in all groups. No differences in response rates or mean differences in PARS scores were found among groups: G-CBT + ABM group (23.8% response; 3.9 points, 95% confidence interval [CI] -0.3 to 8.1), G-CBT + ACT (42.9% response; 5.6 points, 95% CI 2.2-9.0), CT + ABM (47.1% response; 4.8 points 95% CI 1.08-8.57), and CT + ACT (30% response; 0.8 points, 95% CI -3.0 to 4.7). No evidence or synergic or antagonistic effects were found, but the combination of G-CBT and ABM was found to increase dropout rate.

CONCLUSIONS

We found no effect of G-CBT or ABM beyond the effects of comparison groups. Results reveal no benefit from combining G-CBT and ABM for anxiety disorders in children and suggest potential deleterious effects of the combination on treatment acceptability.

Family-based youth mental health interventions delivered by nonspecialist providers in low- and middle-income countries: A systematic review

INTRODUCTION

Youth in low- and middle-income countries (LMICs) are at increased risk for poor mental health due to economic and social disadvantage. Interventions that strengthen families may equip children and adolescents with the supports and resources to fulfill their potential and buffer them from future stressors and adversity. Due to human resource constraints, task-sharing-delivery of interventions by nonspecialists-may be an effective strategy to facilitate the dissemination of mental health interventions in low resource contexts. To this end, we conducted a systematic review of the literature on family-based interventions delivered in LMICs by nonspecialist providers (NSPs) targeting youth mental health and family related outcomes.

METHOD

Cochrane and PRISMA procedures guided this review. Searches were conducted in PsychInfo, PubMed, and Web of Science, with additional articles pulled from reference lists.

RESULTS

This search yielded 10 studies. Four studies were developed specifically for the delivery context using formative qualitative research; the remaining interventions underwent adaptation for use in the context. All interventions employed a period of structured training; nine studies additionally provided ongoing supervision to counselors. Interventions noted widespread acceptance of program material and delivery by NSPs. They also noted the need for ongoing supervision of NSPs to increase treatment fidelity.

DISCUSSION

Usage of NSPs is quite consistently proving feasible, acceptable, and efficacious and is almost certainly a valuable component within approaches to scaling up mental health programs. A clear next step is to establish and evaluate sustainable models of training and supervision to further inform scalability. (PsycINFO Database Record

Mental health challenges among adolescents living with HIV

INTRODUCTION

Mental health is a critical and neglected global health challenge for adolescents infected with HIV. The prevalence of mental and behavioural health issues among HIV-infected adolescents may not be well understood or addressed as the world scales up HIV prevention and treatment for adolescents. The objective of this narrative review is to assess the current literature related to mental health challenges faced by adolescents living with HIV, including access to mental health services, the role of mental health challenges during transition from paediatric to adult care services and responsibilities, and the impact of mental health interventions.

METHODS

For each of the topics included in this review, individual searches were run using Medline and PubMed, accompanied by scans of bibliographies of relevant articles. The topics on which searches were conducted for HIV-infected adolescents include depression and anxiety, transition from paediatric to adult HIV care and its impact on adherence and mental health, HIV-related, mental health services and interventions, and the measurement of mental health problems. Articles were included if the focus was consistent with one of the identified topics, involved HIV-infected adolescents, and was published in English.

RESULTS AND DISCUSSION

Mental and behavioural health challenges are prevalent in HIV-infected adolescents, including in resource-limited settings where most of them live, and they impact all aspects of HIV prevention and treatment. Too little has been done to measure the impact of mental health challenges for adolescents living with HIV, to evaluate interventions to best sustain or improve the mental health of this population, or to create healthcare systems with personnel or resources to promote mental health.

CONCLUSIONS

Mental health issues should be addressed proactively during adolescence for all HIV-infected youth. In addition, care systems need to pay greater attention to how mental health support is integrated into the care management for HIV, particularly throughout lifespan changes from childhood to adolescence to adulthood. The lack of research and support for mental health needs in resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed.

A systematic review of mental health outcome measures for young people aged 12 to 25 years

BACKGROUND

Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.

METHODS

MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.

RESULTS

A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.

CONCLUSIONS

With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.

Group cognitive behavioural treatment of youth anxiety in community based clinical practice: Clinical significance and benchmarking against efficacy

The efficacy of a group cognitive behavioural therapy (CBT) programme (Cool Kids) of youth anxiety has been demonstrated at university clinics in Australia and Denmark and similar CBT programmes have been found effective within community settings in other countries. However, most effectiveness studies of CBT for youth anxiety have either used a mixture of CBT guidelines, or translated protocols not previous tested in an efficacy trial. This study used a benchmarking strategy to compare outcomes from the same CBT programme used at a university research clinic (N=87) and community centres (N=82). There was a significant reduction on both clinical and self-report measures of youth anxiety over time with medium to large effect sizes within both samples. Treatment effects on self-report measures of youth anxiety were significantly larger within the university sample, while changes in clinical measures of youth anxiety were similar in the two samples. Overall these findings suggest that an efficacious CBT group treatment programme developed within research contexts is transportable to community centres. Despite being effective within the community, the results indicate that the treatment may lose some of its efficacy when disseminated to the community.

Dissemination of Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder in the Southern Region of Brazil: Challenges and Future Directions

Pediatric obsessive-compulsive disorder (OCD) is a prevalent condition that responds well to specialized treatment including cognitive behavioral therapy (CBT) or serotonin reuptake inhibitors or their combination. In Brazil, the dissemination of evidence-based treatment for pediatric OCD is hindered because of the peculiarities of the health system. The presence of a multitiered health system (public, insured, and private) with insufficient investment in public mental health and relative inaccessibility of insured/private care for most of the Brazilian population make the implementation of specialized OCD treatment centers largely unavailable in Brazil. Furthermore, lack of appropriate training in child mental health, CBT, and evidence-based approaches to OCD in current psychiatry and psychology training programs further impede improvement in diagnosis and treatment. The challenges faced in the current system in Brazil will be discussed and also strategies and programs that are currently being implemented in the south of Brazil to help address the gaps in treatment for pediatric patients with OCD.