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Bosqui T, Mayya A, Farah S, Shaito Z, Jordans MJD, Pedersen G, Betancourt TS, Carr A, Donnelly M, Brown FL. Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review. Compr Psychiatry 2024; 132:152483. [PMID: 38631272 DOI: 10.1016/j.comppsych.2024.152483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/31/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential. METHOD This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes. MAIN FINDINGS We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs. PRELIMINARY CONCLUSIONS Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.
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Affiliation(s)
- Tania Bosqui
- Department of Psychology, American University of Beirut, Beirut, Lebanon; Trinity Centre for Global Health, Trinity College Dublin, Republic of Ireland.
| | - Anas Mayya
- Department of Psychology, American University of Beirut, Beirut, Lebanon.
| | - Sally Farah
- Department of Psychology, American University of Beirut, Beirut, Lebanon.
| | - Zahraa Shaito
- Department of Psychology, American University of Beirut, Beirut, Lebanon.
| | - Mark J D Jordans
- War Child Alliance, Amsterdam, The Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.
| | - Gloria Pedersen
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, the George Washington University School of Medicine and Health Sciences, Washington D.C., United States
| | | | - Alan Carr
- University College Dublin, Dublin, Republic of Ireland.
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom.
| | - Felicity L Brown
- War Child Alliance, Amsterdam, The Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.
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Prina E, Bano B, Singh R, Albanese E, Trujillo D, Dedios Sanguineti MC, Sorsdahl K, Luitel NP, Garman EC, Purgato M, Barbui C, Jordans MJD, Lund C. Effectiveness of combining prevention psychological interventions with interventions that address the social determinants of mental health in low and middle-income countries: protocol of a systematic review and meta-analysis. BMJ Open 2024; 14:e083261. [PMID: 38760028 DOI: 10.1136/bmjopen-2023-083261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Common mental health conditions (CMHCs), including depression, anxiety and post-traumatic stress disorder (PTSD), are highly prevalent in low and middle-income countries (LMICs). Preventive strategies combining psychological interventions with interventions addressing the social determinants of mental health may represent a key strategy for effectively preventing CMHCs. However, no systematic reviews have evaluated the effectiveness of these combined intervention strategies for preventing CMHCs. METHODS AND ANALYSIS This systematic review will include randomised controlled trials (RCTs) focused on the effectiveness of interventions that combine preventive psychological interventions with interventions that address the social determinants of mental health in LMICs. Primary outcome is the frequency of depression, anxiety or PTSD at postintervention as determined by a formal diagnostic tool or any other standardised criteria. We will search Epistemonikos, Cochrane Controlled Trials Register (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Global Index Medicus, ClinicalTrials.gov (Ctgov), International Clinical Trials Registry Platform (ICTRP). Two reviewers will independently extract the data and evaluate the risk of bias of included studies using the Cochrane risk of bias tool 2. Random-effects meta-analyses will be performed, and certainty of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This study uses data from published studies; therefore, ethical review is not required. Findings will be presented in a published manuscript. TRIAL REGISTRATION NUMBER CRD42023451072.
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Affiliation(s)
- Eleonora Prina
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Beatrice Bano
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera Italiana, Lugano, Switzerland
| | - Rakesh Singh
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Bagmati, Nepal
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Emiliano Albanese
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Psychiatry, University of Geneva, Geneve, Switzerland
| | | | | | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Bagmati, Nepal
| | - Emily C Garman
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Veneto, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Veneto, Italy
| | - Mark J D Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Luitel NP, Lamichhane B, Pokhrel P, Upadhyay R, Taylor Salisbury T, Akerke M, Gautam K, Jordans MJD, Thornicroft G, Kohrt BA. Prevalence of depression and associated symptoms among patients attending primary healthcare facilities: a cross-sectional study in Nepal. BMC Psychiatry 2024; 24:356. [PMID: 38745133 PMCID: PMC11092057 DOI: 10.1186/s12888-024-05794-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Depression is a prevalent mental health condition worldwide but there is limited data on its presentation and associated symptoms in primary care settings in low- and middle-income countries like Nepal. This study aims to assess the prevalence of depression, its hallmark and other associated symptoms that meet the Diagnostic and Statistical Manual (DSM-5) criteria in primary healthcare facilities in Nepal. The collected information will be used to determine the content of a mobile app-based clinical guidelines for better detection and management of depression in primary care. METHODS A total of 1,897 adult patients aged 18-91 (63.1% women) attending ten primary healthcare facilities in Jhapa, a district in eastern Nepal, were recruited for the study between August 2, 2021, and March 25, 2022. Trained research assistants conducted face-to-face interviews in private spaces before the consultation with healthcare providers. Depression symptoms, including hallmark symptoms, was assessed using the validated Nepali version of the Patient Health Questionnaire (PHQ-9). RESULTS One in seven (14.5%) individuals attending primary health care facilities in Jhapa met the threshold for depression based on a validated cut-off score ( > = 10) on the PHQ-9. The most commonly reported depressive symptoms were loss of energy and sleep difficulties. Approximately 25.4% of women and 18.9% of men endorsed at least one of the two hallmark symptoms on the PHQ-9. Using a DSM-5 algorithm (at least one hallmark symptom and five or more total symptoms) to score the PHQ-9, 6.3% of women and 4.3% of men met the criteria for depression. The intra-class correlation coefficient for PHQ-9 total scores by health facility as the unit of clustering was 0.01 (95% confidence interval, 0.00-0.04). CONCLUSION Depression symptoms are common among people attending primary healthcare facilities in Nepal. However, the most common symptoms are not the two hallmark criteria. Use of total scores on a screening tool such as the PHQ-9 risks overestimating the prevalence and generating false positive diagnoses. Compared to using cut off scores on screening tools, training health workers to first screen for hallmark criteria may increase the accuracy of identification and lead to better allocation of treatment resources.
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Affiliation(s)
- Nagendra P Luitel
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal.
- Center for Global Mental Health Equity, Department of Psychiatry and Behavioural Health, George Washington University, Washington, D.C, USA.
| | - Bishnu Lamichhane
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Pooja Pokhrel
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Rudrayani Upadhyay
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Tatiana Taylor Salisbury
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK
| | - Makhmud Akerke
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK
| | - Kamal Gautam
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Center for Global Mental Health Equity, Department of Psychiatry and Behavioural Health, George Washington University, Washington, D.C, USA
| | - Mark J D Jordans
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK
| | - Graham Thornicroft
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, UK
| | - Brandon A Kohrt
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Center for Global Mental Health Equity, Department of Psychiatry and Behavioural Health, George Washington University, Washington, D.C, USA
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Subba P, Petersen Williams P, Luitel NP, Jordans MJD, Breuer E. A qualitative study on the adaptation of community programmes for the promotion of early detection and health-seeking of perinatal depression in Nepal. BMC Womens Health 2024; 24:273. [PMID: 38704570 PMCID: PMC11069154 DOI: 10.1186/s12905-024-03122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 04/30/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Despite the high burden of perinatal depression in Nepal, the detection rate is low. Community-based strategies such as sensitization programmes and the Community Informant Detection Tool (CIDT) have been found to be effective in raising awareness and thus promoting the identification of mental health problems. This study aims to adapt these community strategies for perinatal depression in the Nepalese context. METHODS We followed a four-step process to adapt the existing community sensitization program manual and CIDT. Step 1 included in-depth interviews with women identified with perinatal depression (n=36), and focus group discussions were conducted with health workers trained in community mental health (n=13), female community health volunteers (FCHVs), cadre of Nepal government for the prevention and promotion of community maternal and child health (n=16), and psychosocial counsellors (n=5). We explored idioms and understanding of depression, perceived causes, and possible intervention. Step 2 included draft preparation based on the qualitative study. Step 3 included a one-day workshop with the psychosocial counsellors (n=2) and health workers (n=12) to assess the understandability and comprehensiveness of the draft and to refine the content. A review of the CIDT and community sensitization program manual by a psychiatrist was performed in Step 4. RESULTS The first step led to the content development for the CIDT and community sensitization manual. Multiple stakeholders and experts reviewed and refined the content from the second to fourth steps. Idioms of depression and commonly cited risk factors were incorporated in the CIDT. Additionally, myths of perinatal depression and the importance of the role of family were added to the community sensitization manual. CONCLUSION Both the CIDT and community sensitization manual are grounded in the local context and are simple, clear, and easy to understand.
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Affiliation(s)
- Prasansa Subba
- Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.
| | - Petal Petersen Williams
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | | | - Mark J D Jordans
- Centre for Global Mental Health, King's College London, London, United Kingdom
| | - Erica Breuer
- Department of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia
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Bleile ACE, Koppenol-Gonzalez GV, Orech B, Verreault K, Jordans MJD. Evaluating a Movement-Based Mental Health Promotion Intervention for Refugee Children in Uganda: A Quasi-Experimental Study. J Clin Child Adolesc Psychol 2024:1-16. [PMID: 38564186 DOI: 10.1080/15374416.2024.2330073] [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] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Mental health promotion interventions are widely implemented in humanitarian settings and low- and middle-income contexts (LMICs), yet evidence on effectiveness is scarce and mixed. This study evaluated the movement-based mental health promotion intervention "TeamUp" in Bidibidi refugee settlement, in Northern Uganda. METHOD A quasi-experimental study including four schools (two per arm) assessed the outcomes of 10- to 15-year-old South Sudanese and Ugandan children (n = 549). Randomly allocated, they either participated in up to 11 TeamUp sessions (n = 265) provided by trained facilitators; or belonged to a control group, which continued care as usual (n = 284). Primary outcomes measured psychosocial wellbeing, friendships and attitude to school; secondary outcomes included traumatic distress, depressive symptoms, quality of life, physical health, bullying, interoceptive awareness, and irritability. Data were collected at baseline and endline. RESULTS Children joining TeamUp, showed significantly more improvements on primary outcomes: emotional and psychosocial wellbeing (Mdiff = -1.49, SE = 0.6, p = .01), satisfaction with and attitude toward school (-0.57, SE = 0.2, p = .004); and secondary outcomes: traumatic stress (2.64, SE = 0.8, p < .001), health-related quality of life (-1.56, SE = 0.4, p = .001), physical health (-0.78, SE = 0.3, p = .014) and the TeamUp mechanisms of action scale (-3.34, SE = 0.9, p < .001), specifically the subscales social connectedness (-0.74, SE = 0.3, p = .007) and sense of agency (-0.91, SE = 0.3, p = .005), compared to the control group. No significant differences were found on bullying, interoceptive awareness, irritability and depressive symptoms. CONCLUSION The results are promising for TeamUp as a mental health promotion intervention for children affected by armed-conflict, displacement and on-going adversity. Further research will need to assess the intervention's effectiveness.
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Affiliation(s)
- Alexandra C E Bleile
- Research and Development Department, War Child
- Amsterdam Institute of Social Science Research, University of Amsterdam
| | | | - Bruce Orech
- Research and Development Department, War Child
| | | | - Mark J D Jordans
- Research and Development Department, War Child
- Amsterdam Institute of Social Science Research, University of Amsterdam
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Purgato M, Cadorin C, Prina E, Cabral Ferreira M, Del Piccolo L, Gerber M, Jordans MJD, Ostuzzi G, Richards J, Rudi D, Vitali F, Cortese S, Schena F, Barbui C. Umbrella Systematic Review and Meta-Analysis: Physical Activity as an Effective Therapeutic Strategy for Improving Psychosocial Outcomes in Children and Adolescents. J Am Acad Child Adolesc Psychiatry 2024; 63:172-183. [PMID: 37331468 DOI: 10.1016/j.jaac.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/21/2023] [Accepted: 05/31/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Physical activity (PA) interventions are part of many interdisciplinary programs for the management of children and adolescents with or without physical or psychological conditions or disabilities. Aiming to summarize the available evidence, we conducted an umbrella review of meta-analyses of PA interventions that included psychosocial outcomes in populations of children and adolescents. METHOD Literature searches were conducted in PubMed, Cochrane Central, Web of Science, Medline, SPORTDiscus, and PsychInfo from January 1, 2010, to May 6, 2022. Meta-analyses of randomized and quasi-randomized studies investigating the efficacy of PA interventions for psychosocial outcomes in children and adolescents were included. Summary effects were recalculated using common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small study effects, and whether the results of the observed positive studies were greater than expected due to chance. On the basis of these calculations, strength of associations was assessed using quantitative umbrella review criteria, and credibility of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Quality was assessed using the AMSTAR 2 tool. This study is registered with the Open Science Framework, https://osf.io/ap8qu. RESULTS A total of 112 studies from 18 meta-analyses generating 12 new meta-analyses comprising 21,232 children and adolescents in population groups including attention-deficit/hyperactivity disorder, cancer, cerebral palsy, chronic respiratory diseases, depression, neuromotor impairment, and obesity and in general populations were included. PA interventions were efficacious in reducing psychological symptoms in all meta-analyses across the different population groups using random-effects models. However, umbrella review criteria suggested a weak strength of association for this outcome, and GRADE credibility of evidence ranged from moderate to very low. For psychological well-being, 3 out of 5 meta-analyses identified significant effects, but the strength of these associations was weak, and GRADE credibility of evidence ranged from moderate to very low. Similarly, for social outcomes, meta-analyses reported a significant summary effect, but the strength of association was weak, and GRADE credibility of evidence ranged from moderate to very low. For self-esteem, one meta-analysis in children with obesity failed to show any effect. CONCLUSION Even though existing meta-analyses suggested a beneficial effect of PA interventions on psychosocial outcomes across different population groups, the strength of associations was weak, and the credibility of evidence was variable depending on the target population, outcome, and condition or disability. Randomized studies of PA interventions in children and adolescents with and without different physical and psychological conditions or disabilities should always include psychosocial outcomes as an important dimension of social and mental health. STUDY PREREGISTRATION INFORMATION Prenatal Maternal Infection and Adverse Neurodevelopment: A Structural Equation Modelling Approach to Downstream Environmental Hits; https://osf.io/; ap8qu.
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Affiliation(s)
- Marianna Purgato
- University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy.
| | | | | | | | | | | | | | - Giovanni Ostuzzi
- University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy
| | | | | | | | - Samuele Cortese
- University of Southampton, Solent NHS Trust, Southampton, United Kingdom, the University of Nottingham, Nottingham, United Kingdom, and New York University Grossman School of Medicine, New York
| | | | - Corrado Barbui
- University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy
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Ceccarelli C, Prina E, Alkasaby M, Cadorin C, Gandhi Y, Cristofalo D, Abujamei Y, Muneghina O, Barbui C, Jordans MJD, Purgato M. Implementation outcomes in psychosocial intervention studies for children and adolescents living in low- and middle-income countries: A systematic review. Clin Psychol Rev 2024; 107:102371. [PMID: 38118259 DOI: 10.1016/j.cpr.2023.102371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/16/2023] [Accepted: 12/01/2023] [Indexed: 12/22/2023]
Abstract
Psychosocial interventions play a key role in addressing mental health and substance use needs for children and adolescents living in low- and middle-income countries (LMICs). While research efforts have primarily focused on their effectiveness, implementation outcomes also require examining. We conducted a systematic review of qualitative, quantitative, and mixed-methods studies (PROSPERO: CRD42022335997) to synthesize the literature on implementation outcomes for psychosocial interventions for children and adolescents in LMICs. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Web of Science, PsychINFO, and Global Health through April 2023. Data were extracted and quality appraised through the Mixed Methods Appraisal Tool (MMAT) independently by two reviewers. A total of 13,380 records were screened, and 87 studies met inclusion criteria. Feasibility was the most reported implementation outcome (69, 79%), followed by acceptability (60, 69%), and fidelity (32, 37%). Appropriateness was assessed in 11 studies (13%), implementation costs in 10 (11%), and sustainability in one (1%). None of the included studies reported on penetration or adoption. Despite a growing body of evidence for implementation research in child and adolescent global mental health, most research focused on earlier-stage implementation outcomes, assessing them in research-controlled settings. To overcome this, future efforts should focus on assessing interventions in routine care, assessing later-stage implementation outcomes through standardized tools.
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Affiliation(s)
- Caterina Ceccarelli
- Global Program Expert Group on Mental Health and Psychosocial Support, SOS Children's Villages, Milan, Italy.
| | - Eleonora Prina
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Muhammad Alkasaby
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Camilla Cadorin
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Yashi Gandhi
- Addictions and related-Research Group, Sangath, Goa, India
| | - Doriana Cristofalo
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Yasser Abujamei
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Orso Muneghina
- Global Program Expert Group on Mental Health and Psychosocial Support, SOS Children's Villages, Milan, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Mark J D Jordans
- War Child, Amsterdam, the Netherlands; University of Amsterdam, Amsterdam, the Netherlands; IoPPN, King's College London, London, UK
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy
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Lund C, Jordans MJD, Garman E, Araya R, Avendano M, Bauer A, Bahure V, Dua T, Eleftheriou G, Evans-Lacko S, García Rodríguez JF, Gautam K, Gevonden M, Hessel P, Kohrt BA, Krabbendam L, Luitel NP, Roy S, Seifert Bonifaz M, Singh R, Sinichi M, Sorsdahl K, Thornicroft G, Tol WA, Trujillo D, van der Merwe N, Wahid SS, Yarrow P. Strengthening self-regulation and reducing poverty to prevent adolescent depression and anxiety: Rationale, approach and methods of the ALIVE interdisciplinary research collaboration in Colombia, Nepal and South Africa. Epidemiol Psychiatr Sci 2023; 32:e69. [PMID: 38088153 PMCID: PMC10803189 DOI: 10.1017/s2045796023000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/20/2023] [Accepted: 10/29/2023] [Indexed: 12/18/2023] Open
Abstract
AIMS Depression and anxiety are the leading contributors to the global burden of disease among young people, accounting for over a third (34.8%) of years lived with disability. Yet there is limited evidence for interventions that prevent adolescent depression and anxiety in low- and middle-income countries (LMICs), where 90% of adolescents live. This article introduces the 'Improving Adolescent mentaL health by reducing the Impact of poVErty (ALIVE)' study, its conceptual framework, objectives, methods and expected outcomes. The aim of the ALIVE study is to develop and pilot-test an intervention that combines poverty reduction with strengthening self-regulation to prevent depression and anxiety among adolescents living in urban poverty in Colombia, Nepal and South Africa. METHODS This aim will be achieved by addressing four objectives: (1) develop a conceptual framework that identifies the causal mechanisms linking poverty, self-regulation and depression and anxiety; (2) develop a multi-component selective prevention intervention targeting self-regulation and poverty among adolescents at high risk of developing depression or anxiety; (3) adapt and validate instruments to measure incidence of depression and anxiety, mediators and implementation parameters of the prevention intervention; and (4) undertake a four-arm pilot cluster randomised controlled trial to assess the feasibility, acceptability and cost of the selective prevention intervention in the three study sites. RESULTS The contributions of this study include the active engagement and participation of adolescents in the research process; a focus on the causal mechanisms of the intervention; building an evidence base for prevention interventions in LMICs; and the use of an interdisciplinary approach. CONCLUSIONS By developing and evaluating an intervention that addresses multidimensional poverty and self-regulation, ALIVE can make contributions to evidence on the integration of mental health into broader development policy and practice.
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Affiliation(s)
- Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, King’s College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Mark J. D. Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, King’s College London, London, UK
- WarChild, Amsterdam, Netherlands
| | - Emily Garman
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Ricardo Araya
- Centre for Global Mental Health and Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London, UK
| | - Mauricio Avendano
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Annette Bauer
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Vikram Bahure
- Department of International Development, King’s College London, London, UK
| | - Tarun Dua
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Georgia Eleftheriou
- Center for Global Mental Health Equity, Department of Psychiatry, George Washington University, Washington, DC, USA
| | - Sara Evans-Lacko
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | | | - Kamal Gautam
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Baluwatar, Kathmandu, Nepal
| | - Martin Gevonden
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Philipp Hessel
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, Colombia
| | - Brandon A. Kohrt
- Center for Global Mental Health Equity, Department of Psychiatry, George Washington University, Washington, DC, USA
| | - Lydia Krabbendam
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Nagendra P. Luitel
- Research Department, Transcultural Psychosocial Organization Nepal (TPO Nepal), Baluwatar, Kathmandu, Nepal
| | - Sanchari Roy
- Department of International Development, King’s College London, London, UK
| | - Manuel Seifert Bonifaz
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rakesh Singh
- Research Department, Transcultural Psychosocial Organization Nepal (TPO Nepal), Baluwatar, Kathmandu, Nepal
| | - Mohammadamin Sinichi
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London, UK
| | - Wietse A. Tol
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Athena Research Institute, Vrije University Amsterdam, Amsterdam, the Netherlands
| | | | | | - Syed Shabab Wahid
- Department of Global Health, Georgetown University, Washington, DC, USA
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Miller KE, Rasmussen A, Jordans MJD. Strategies to improve the quality and usefulness of mental health trials in humanitarian settings. Lancet Psychiatry 2023; 10:974-980. [PMID: 37879349 DOI: 10.1016/s2215-0366(23)00273-0] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/20/2023] [Accepted: 08/03/2023] [Indexed: 10/27/2023]
Abstract
A striking rise in the number of people affected by humanitarian crises has led to an increase in mental health and psychosocial support interventions to reduce the psychological effects of such crises. In a parallel trend, researchers have brought increased methodological rigour to their evaluation of these interventions. However, several methodological issues still constrain the quality and real-world relevance of the existing evidence base. We examine five core challenges in randomised controlled trials of mental health and psychosocial support interventions with conflict-affected and disaster-affected populations. These challenges are: translating intervention effects into metrics of real-world significance; giving adequate consideration to the selection and monitoring of control conditions; following rigorous processes to ensure outcome measures are culturally appropriate and psychometrically sound; ensuring and monitoring implementation variables, including fidelity, exposure, participant engagement, and the competence of implementation staff; and assessing mechanisms of change.
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Affiliation(s)
- Kenneth E Miller
- Department of Educational and Counselling Psychology, and Special Education, Faculty of Education, University of British Columbia, Vancouver, BC, Canada.
| | - Andrew Rasmussen
- Department of Psychology, Fordham University, New York City, NY, USA
| | - Mark J D Jordans
- Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
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10
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Jordans MJD, Brown FL, Kane J, Taha K, Steen F, Ali R, Elias J, Meksassi B, Aoun M, Greene CM, Malik A, Akhtar A, van Ommeren M, Sijbrandij M, Bryant R. Evaluation of the Early Adolescent Skills for Emotions (EASE) intervention in Lebanon: A randomized controlled trial. Compr Psychiatry 2023; 127:152424. [PMID: 37748283 DOI: 10.1016/j.comppsych.2023.152424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 07/21/2023] [Accepted: 09/08/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND There is a need for scalable evidence-based psychological interventions for young adolescents experiencing high levels of psychological distress in humanitarian settings and low- and middle-income countries. Poor mental health during adolescence presents a serious public health concern as it is a known predictor of persistent mental disorders in adulthood. This study evaluates the effectiveness of a new group-based intervention developed by the World Health Organization (Early Adolescent Skills for Emotions; EASE), implemented by non-specialists, to reduce young adolescents' psychological distress among mostly Syrian refugees in Lebanon. METHODS We conducted a two-arm, single-blind, individually randomized group treatment trial. Adolescents aged 10 to 14 years who screened positive for psychological distress using the Pediatric Symptom Checklist (PSC) were randomly allocated to EASE or enhanced treatment as usual (ETAU) (1:1.6). ETAU consisted of a single scripted psycho-education home-visit session with the adolescent and their caregivers. EASE consists of seven group sessions with adolescents and three sessions with caregivers. The primary outcome was adolescent-reported psychological distress as measured with the PSC (internalizing, externalizing, and attentional symptoms). Secondary outcomes included depression, posttraumatic stress, well-being, functioning, and caregivers' parenting and distress. All outcomes were assessed at baseline, endline, and 3 months (primary time point) and 12 months follow-up. RESULTS Due to the COVID-19 pandemic and other adversities in Lebanon at the time of this research, the study was prematurely terminated, resulting in an under-powered trial sample (n = 198 enrolled compared to n = 445 targeted). We screened 604 children for eligibility. The 198 enrolled adolescents were assigned to EASE (n = 80) and ETAU (n = 118), with retention rates between 76.1 and 88.4% across all timepoints. Intent-to-treat analyses demonstrated no between-group differences on any of the outcome measures between the EASE and ETAU. We did observe a significant improvement on the primary outcome equally in the EASE and ETAU groups (-0.90, 95% CI: -3.6, 1.8; p = .52), - a trend that was sustained at three months follow-up. Sub-group analyses, for those with higher depression symptoms at baseline, showed ETAU outperformed EASE on reducing depression symptoms (difference in mean change = 2.7, 95% CI: 0.1, 5.3; p = .04; d = 0.59) and internalizing problems (difference in mean change 1.0, 95% CI: 0.08, 1.9; p = .03; d = 0.56) . CONCLUSION No conclusions can be drawn about the comparative effectiveness of the intervention given that the sample was underpowered as a result of early termination. Both EASE and single session psycho-education home visits resulted in meaningful improvements in reducing psychological distress. We did not identify any indications in the data suggesting that EASE was more effective than a single session family intervention in the context of the COVID-19 pandemic and other crises in Lebanon. Fully powered research is needed to evaluate the effectiveness of EASE.
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Affiliation(s)
- Mark J D Jordans
- War Child, Research and Development Department, Amsterdam, the Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands.
| | - Felicity L Brown
- War Child, Research and Development Department, Amsterdam, the Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands.
| | - Jeremy Kane
- Department of Epidemiology, Columbia University, New York, USA.
| | - Karine Taha
- War Child, Lebanon Country Office, Beirut, Lebanon
| | - Frederik Steen
- War Child, Research and Development Department, Amsterdam, the Netherlands.
| | - Rayane Ali
- War Child, Lebanon Country Office, Beirut, Lebanon.
| | - Joseph Elias
- War Child, Lebanon Country Office, Beirut, Lebanon.
| | | | - May Aoun
- War Child, Lebanon Country Office, Beirut, Lebanon.
| | - Claire M Greene
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, USA.
| | | | - Aemal Akhtar
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Sweden; School of Psychology, University of New South Wales, Australia.
| | | | - Marit Sijbrandij
- VU University, Department of Clinical, Neuro- and Developmental Psychology, WHO Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam, the Netherlands.
| | - Richard Bryant
- School of Psychology, University of New South Wales, Australia.
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11
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Hartog K, Peters RMH, Tukahiirwa RK, Jordans MJD. Reducing stigma impacting children and adolescents in low- and middle-income countries: The development of a common multi-component stigma reduction intervention. PLoS One 2023; 18:e0292064. [PMID: 37906579 PMCID: PMC10617710 DOI: 10.1371/journal.pone.0292064] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 09/12/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Stigmatisation impedes health and quality of life. Evidence regarding stigma reduction interventions is, albeit growing, limited. There is a gap in the availability and evidence of interventions for reducing stigma among children and adolescents, especially in low- and middle-income countries. This paper describes the process that led to a stigma reduction intervention impacting children and adolescents in low- and middle-income countries, following previously conducted formative research. METHODS In this study, we conducted (i) online stakeholder consultations (FGD) (n = 43), including a survey assessing intervention acceptability, appropriateness, feasibility and scalability (n = 16); and (ii) preliminary field-testing of intervention content online and in a refugee settlement in Uganda. FINDINGS Stakeholder consultation showed the initial version of STRETCH (Stigma Reduction to Trigger Change for Children), albeit positively received, required adaptations. We made adjustments to i) take into account implementation duration, intervention flexibility and intersectionality; (ii) strengthen the involvement of individuals, including adolescents/youth, with lived stigma experience; (iii) target people close to individuals with lived stigma experience; and (iv) address feasibility and sustainability concerns. Preliminary field-testing simplified STRETCH while adding a community outreach component and revisiting the intervention setup, to ensure STRETCH can also be applied from a modular perspective. CONCLUSION We conducted a process to develop a child-focused multi-component stigma reduction intervention, with intended applicability across stigmas and settings. This paper provides an overview of the intervention development process, generating intervention-specific learnings with generic value. STRETCH aims to reduce stigmatisation at the implementing organisation, create community-wide reflection and stigma reduction demand, and reduce stigmatisation among various target groups.
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Affiliation(s)
- Kim Hartog
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, The Netherlands
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Ruth M. H. Peters
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Mark J. D. Jordans
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, The Netherlands
- Research and Development Department, War Child, Amsterdam, The Netherlands
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12
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van den Broek M, Gandhi Y, Sureshkumar DS, Prina M, Bhatia U, Patel V, Singla DR, Velleman R, Weiss HA, Garg A, Sequeira M, Pusdekar V, Jordans MJD, Nadkarni A. Interventions to increase help-seeking for mental health care in low- and middle-income countries: A systematic review. PLOS Glob Public Health 2023; 3:e0002302. [PMID: 37703225 PMCID: PMC10499262 DOI: 10.1371/journal.pgph.0002302] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Abstract
Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: 'mental health/illness' AND 'help-seeking' AND 'LMICs'; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.
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Affiliation(s)
- Myrthe van den Broek
- Research and Development, War Child, Amsterdam, The Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Yashi Gandhi
- Addictions and related-Research Group, Sangath, Goa, India
| | - Diliniya Stanislaus Sureshkumar
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Matthew Prina
- Social Epidemiology Research Group, Kings College London, London, United Kingdom
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Urvita Bhatia
- Addictions and related-Research Group, Sangath, Goa, India
- Department of Psychology, Health and Professional Development at Oxford Brookes University, Oxford, United Kingdom
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts, United States of America
| | - Daisy R. Singla
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
| | - Richard Velleman
- Addictions and related-Research Group, Sangath, Goa, India
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Helen A. Weiss
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ankur Garg
- Addictions and related-Research Group, Sangath, Goa, India
| | | | - Veera Pusdekar
- Addictions and related-Research Group, Sangath, Goa, India
| | - Mark J. D. Jordans
- Research and Development, War Child, Amsterdam, The Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Abhijit Nadkarni
- Addictions and related-Research Group, Sangath, Goa, India
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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13
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Jordans MJD, Bakolis I, Arnous M, Koppenol-Gonzalez GV, Tossyeh F, Chen A, Miller KE. Effectiveness of the caregiver support intervention on child psychosocial wellbeing among Syrian refugees in Lebanon: Mediation and secondary analysis of a Randomized Controlled Trial. Child Abuse Negl 2023:106335. [PMID: 37400323 DOI: 10.1016/j.chiabu.2023.106335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/07/2023] [Accepted: 06/24/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND War and violence have a serious negative impact on the wellbeing and mental health of many children. Caregivers play an important role in mitigating or exacerbating this impact. OBJECTIVE This study evaluates the impact of the nine session Caregiver Support Intervention on improving children's wellbeing and examines putative mediators of changes in children's psychosocial wellbeing. PARTICIPANTS AND SETTING 240 female caregivers were randomly allocated (1:1) to the CSI or a waitlist control comparison condition. The study was implemented in Lebanon, in an area characterized by high levels of poverty and a high number of the Syrian refugees. METHODS A parallel group Randomized Controlled Trial reporting on caregiver-reported child-level wellbeing. We used a combination of the Kid- and Kiddy-KINDL (parent version) for index children ages three to 12. Putative mediators of the CSI on children's psychosocial wellbeing included harsh parenting, caregiver psychological distress, caregiver wellbeing. Measurements were conducted at baseline, post-intervention and 3-months follow-up. RESULTS We demonstrated a statistically significant change in caregiver reported children's psychosocial wellbeing at post-intervention (Mdiff =4.39, 95 % CI = 1.12, 7.65, p < 0.01, d = 0.28) but not at follow-up (Mdiff = -0.97, 95 % CI = -4.27, 2.32, p > 0.05). The proportion of the total effect of the CSI intervention on child psychosocial wellbeing mediated by caregiver distress, caregiver wellbeing and harsh parenting was 77 %. CONCLUSION The CSI holds potential for down-stream short-term effect on improving children's psychosocial wellbeing, beyond the previously reported positive caregiver outcomes. This effect was not sustained three months post intervention. The study confirms caregiver wellbeing and parenting support as dual pathways mediating child psychosocial wellbeing. Prospective trial registration: ISRCTN22321773.
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Affiliation(s)
- M J D Jordans
- Research and Development, War Child Holland, Amsterdam, the Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, the Netherlands; Health Service and Population Research Department & Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - I Bakolis
- Health Service and Population Research Department & Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | | | | | - A Chen
- Department of Psychology, Harvard University, United States of America
| | - K E Miller
- Research and Development, War Child Holland, Amsterdam, the Netherlands; Faculty of Education, University of British Columbia, Canada
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14
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Tol WA, Le PD, Harrison SL, Galappatti A, Annan J, Baingana FK, Betancourt TS, Bizouerne C, Eaton J, Engels M, Hijazi Z, Horn RR, Jordans MJD, Kohrt BA, Koyiet P, Panter-Brick C, Pluess M, Rahman A, Silove D, Tomlinson M, Uribe-Restrepo JM, Ventevogel P, Weissbecker I, Ager A, van Ommeren M. Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30. Lancet Glob Health 2023; 11:e969-e975. [PMID: 37116530 PMCID: PMC10188364 DOI: 10.1016/s2214-109x(23)00128-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/23/2023] [Accepted: 03/02/2023] [Indexed: 04/30/2023]
Abstract
We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.
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Affiliation(s)
- Wietse A Tol
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Peter C Alderman Program for Global Mental Health, HealthRight International, New York, NY, USA; Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
| | - PhuongThao D Le
- Peter C Alderman Program for Global Mental Health, HealthRight International, New York, NY, USA; School of Global Public Health, New York University, New York, NY, USA
| | - Sarah L Harrison
- International Federation of Red Cross Red Crescent Societies Reference Centre for Psychosocial Support, Copenhagen, Denmark
| | - Ananda Galappatti
- Mental Health and Psychosocial Support Network (MHPSS.net), Colombo, Sri Lanka
| | - Jeannie Annan
- Airbel Impact Lab, The International Rescue Committee, New York, NY, USA
| | | | - Theresa S Betancourt
- Boston College, School of Social Work, Research Program on Children and Adversity, Chestnut Hill, MA, USA
| | - Cecile Bizouerne
- Mental Health, PsychoSocial Support and Protection Sector, Action Contre la Faim, Paris, France
| | - Julian Eaton
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK; CBM Global, Amstelveen, Netherlands
| | | | - Zeinab Hijazi
- Mental Health Unit, Programme Division, UNICEF, New York, NY, USA
| | - Rebecca R Horn
- Institute for Global Health & Development, Queen Margaret University, Edinburgh, UK
| | - Mark J D Jordans
- Centre for Global Mental Health, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK; Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA
| | | | - Catherine Panter-Brick
- Department of Anthropology and Jackson School of Global Affairs, Yale University, New Haven, CT, USA
| | - Michael Pluess
- Department of Biological and Experimental Psychology, Queen Mary University of London, London, UK
| | - Atif Rahman
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa; School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | | | - Peter Ventevogel
- Public Health Section, Division of Resilience and Solutions, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Inka Weissbecker
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Alastair Ager
- Institute for Global Health & Development, Queen Margaret University, Edinburgh, UK; Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
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15
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Brown FL, Taha K, Steen F, Kane J, Gillman A, Aoun M, Malik A, Bryant R, Sijbrandij M, El Chammay R, Servili C, van Ommeren M, Akhtar A, Zoghbi E, Jordans MJD. Feasibility randomised controlled trial of the Early Adolescent Skills for Emotions psychological intervention with young adolescents in Lebanon. BMC Psychiatry 2023; 23:131. [PMID: 36858980 PMCID: PMC9979451 DOI: 10.1186/s12888-023-04571-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/27/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Globally, there is a vast mental health treatment gap, whereby the majority of adolescents living in low- and middle-income countries requiring mental health services, do not have access to adequate care. To improve access, the World Health Organization (WHO) developed a range of interventions, designed to be low-cost and delivered by non-specialists. We conducted a two-arm, individually randomised group treatment feasibility trial of a new WHO group intervention for young adolescents with emotional distress ('Early Adolescent Skills for Emotions'; EASE) in Lebanon. METHOD The aim of this study was to determine the feasibility of the intervention and study procedures. Adolescents aged 10 to 14 years were eligible to take part if they scored above a validated cut-off on the Child Psychosocial Distress Screener. Participants were randomized to EASE or enhanced treatment as usual (ETAU) control using a 1:1 ratio. EASE consisted of seven group sessions with adolescents and three sessions with caregivers. ETAU consisted of a single brief psychoeducation home visit. Child and caregiver outcomes were measured by blind assessors at baseline, endline (8 weeks post-randomisation), and three month follow-up (20 weeks post-randomisation), with the primary outcome measure being child psychological symptoms on the Pediatric Symptom Checklist. Qualitative interviews were conducted with adolescents (n = 13), caregivers (n = 17), facilitators (n = 6), trainers (n = 3), and outreach staff (n = 1) at endline to assess barriers and facilitators related to the feasibility and delivery of EASE and study procedures. RESULTS Of 154 adolescents screened, 67 (43%) were eligible, completed baseline, and were randomized. Sixty adolescents (90%) completed endline assessments (31 EASE, 29 ETAU), and fifty-nine (88%) completed three-month assessments (29 EASE, 30 ETAU). Qualitatively, participants provided overall positive feedback about the intervention. Several challenges and suggestions for improvement were raised around logistics, intervention content, and acceptability of assessment measures. Implementation data highlighted challenges with intervention uptake and attendance. Outcome measures generally had strong psychometric properties (range: α = 0.77 to α = 87), however did not demonstrate change over time in either group. CONCLUSIONS The EASE intervention and study procedures are acceptable and feasible for implementation with vulnerable adolescents in Lebanon, however several improvements are necessary prior to full-scale evaluation. TRIAL REGISTRATION #ISRCTN60799626, retrospectively registered on 04/10/2022.
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Affiliation(s)
- Felicity L Brown
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands. .,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands.
| | - Karine Taha
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands.,War Child Lebanon, Beirut, Lebanon
| | - Frederik Steen
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands
| | - Jeremy Kane
- Mailman School of Public Health, Columbia University, New York, USA
| | | | - May Aoun
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands.,War Child Lebanon, Beirut, Lebanon
| | - Aiysha Malik
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Marit Sijbrandij
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Rabih El Chammay
- Ministry of Public Health, Beirut, Lebanon.,Department of Psychiatry, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Chiara Servili
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, NSW, Australia.,Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Mark J D Jordans
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands. .,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands.
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van den Broek M, Hegazi L, Ghazal N, Hamayel L, Barrett A, Kohrt BA, Jordans MJD. Accuracy of a Proactive Case Detection Tool for Internalizing and Externalizing Problems Among Children and Adolescents. J Adolesc Health 2023; 72:S88-S95. [PMID: 36229391 PMCID: PMC9935482 DOI: 10.1016/j.jadohealth.2021.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/12/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Lack of identification and referral of children and adolescents with mental health problems contributes to the treatment gap in low- and middle-income countries, and especially in humanitarian settings. The Community Case Detection Tool (CCDT) is developed to improve community-based detection and increase help-seeking among children and adolescents in need of mental health care. The CCDT uses brief, easily understood pictorial vignettes that represent common symptoms of childhood internalizing and externalizing problems. The tool is developed for gatekeepers to support proactive detection of children in need of mental health care and to subsequently encourage help-seeking. This study evaluates the accuracy of the CCDT in detecting children and adolescents aged 6-18 years with significant mental health care needs in a conflict-affected setting: the occupied Palestinian territory. METHODS Teachers and community workers were trained to use the CCDT. Children detected using the tool were invited for a structured clinical interview with a psychologist using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version, as well as the Strengths and Difficulties Questionnaire, to test the accuracy of CCDT-based detection. RESULTS Our sample consists of 52 children positively detected as matching with one of the vignettes. Approximately three of four detected children were indicated for psychological treatment based on the clinical interview (positive predictive value = .769), and 64.6% returned 'borderline' or 'abnormal' total difficulty scores on the Strengths and Difficulties Questionnaire. CONCLUSIONS The CCDT offers a promising low-cost solution to mitigate underdetection of mental health problems in challenging settings.
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Affiliation(s)
- Myrthe van den Broek
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, The Netherlands.
| | - Lina Hegazi
- War Child Holland, Jerusalem, Occupied Palestinian Territory
| | - Nisreen Ghazal
- Clinical Unit, Palestinian Counseling Center, Jerusalem, Occupied Palestinian Territory
| | - Layaly Hamayel
- Clinical Unit, Palestinian Counseling Center, Jerusalem, Occupied Palestinian Territory
| | - Anna Barrett
- War Child Holland, Jerusalem, Occupied Palestinian Territory
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC
| | - Mark J D Jordans
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, The Netherlands
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Miller KE, Chen A, Koppenol-Gonzalez GV, Bakolis I, Arnous M, Tossyeh F, El Hassan A, Saleh A, Saade J, Nahas N, Abboud M, Jawad L, Jordans MJD. Supporting parenting among Syrian refugees in Lebanon: a randomized controlled trial of the caregiver support intervention. J Child Psychol Psychiatry 2023; 64:71-82. [PMID: 35837815 DOI: 10.1111/jcpp.13668] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Accepted: 05/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Parenting interventions in humanitarian settings have prioritized the acquisition of parenting knowledge and skills, while overlooking the adverse effects of stress and distress on parenting-a key mediator of refugee children's mental health. We evaluated the effectiveness of the Caregiver Support Intervention (CSI), which emphasizes caregiver wellbeing together with training in positive parenting. METHODS We conducted a two-arm randomized controlled trial of the CSI with Syrian refugees in Lebanon, with an intent-to-treat design, from September 2019-December 2020. A total of 480 caregivers from 240 families were randomized to the CSI or a waitlist control group (1:1). Retention from baseline to endline was 93%. Data on parenting and caregiver psychological wellbeing were collected at baseline, endline, and three-month follow-up. Prospective trial registration: ISRCTN22321773. RESULTS We did not find a significant change on overall parenting skills at endline (primary outcome endpoint) (d = .11, p = .126) or at follow-up (Cohen's d = .15, p = .054). We did find a significant effect on overall parenting skills among participants receiving the full intervention-the sub-sample not interrupted by (COVID-19) (d = 0.25, p < .05). The CSI showed beneficial effects in the full sample at endline and follow-up on harsh parenting (d = -.17, p < .05; d = .19, p < .05), parenting knowledge (d = .63, p < .001; d = .50, p < .001), and caregiver distress (d = -.33, p < .001; d = .23, p < .01). We found no effects on parental warmth and responsiveness, psychosocial wellbeing, stress, or stress management. Changes in caregiver wellbeing partially mediated the impact of the CSI on harsh parenting, accounting for 37% of the reduction in harsh parenting. CONCLUSIONS The CSI reduced harsh parenting and caregiver distress, and demonstrated the value of addressing caregiver wellbeing as a pathway to strengthening parenting in adversity. These effects were achieved despite a pandemic-related lockdown that impacted implementation, a severe economic crisis, and widespread social unrest. Replication under less extreme conditions may more accurately demonstrate the intervention's full potential.
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Affiliation(s)
- Kenneth E Miller
- Department of Educational and Counselling Psychology, and Special Education, The University of British Columbia, Vancouver, BC, Canada.,War Child, Research and Development Department, Amsterdam, The Netherlands
| | - Alexandra Chen
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | | | - Ioannis Bakolis
- Health Service and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | | | | | | | | | | | - Nayla Nahas
- Department of Psychology, University of Balamand, Tripoli, Lebanon
| | | | | | - Mark J D Jordans
- Department of Psychology, Harvard University, Cambridge, MA, USA.,Health Service and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
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18
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Kaiser BN, Gurung D, Rai S, Bhardwaj A, Dhakal M, Cafaro CL, Sikkema KJ, Lund C, Patel V, Jordans MJD, Luitel NP, Kohrt BA. Mechanisms of action for stigma reduction among primary care providers following social contact with service users and aspirational figures in Nepal: an explanatory qualitative design. Int J Ment Health Syst 2022; 16:37. [PMID: 35953839 PMCID: PMC9367153 DOI: 10.1186/s13033-022-00546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/28/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND There are increasing initiatives to reduce mental illness stigma among primary care providers (PCPs) being trained in mental health services. However, there is a gap in understanding how stigma reduction initiatives for PCPs produce changes in attitudes and clinical practices. We conducted a pilot randomized controlled trial of a stigma reduction intervention in Nepal: REducing Stigma among HealthcAre Providers (RESHAPE). In a previous analysis of this pilot, we described differences in stigmatizing attitudes and clinical behaviors between PCPs receiving a standard mental health training (mental health Gap Action Program, mhGAP) vs. those receiving an mhGAP plus RESHAPE training. The goal of this analysis is to use qualitative interview data to explain the quantitative differences in stigma outcomes identified between the trial arms. METHODS PCPs were randomized to either standard mental health training using mhGAP led by mental health specialists or the experimental condition (RESHAPE) in which service users living with mental illness shared photographic recovery narratives and participated in facilitated social contact. Qualitative interviews were conducted with PCPs five months post-training (n = 8, standard mhGAP training; n = 20, RESHAPE). Stigmatizing attitudes and clinical practices before and after training were qualitatively explored to identify mechanisms of change. RESULTS PCPs in both training arms described changes in knowledge, skills, and confidence in providing mental healthcare. PCPs in both arms described a positive feedback loop, in which discussing mental health with patients encouraged more patients to seek treatment and open up about their illness, which demonstrated for PCPs that mental illness can be treated and boosted their clinical confidence. Importantly, PCPs in the RESHAPE arm were more likely to describe a willingness to treat mental health patients and attributed this in part to social contact with service users during the training. CONCLUSIONS Our qualitative research identified testable mechanisms of action for stigma reduction and improving clinical behavior: specifically, recovery stories from service users and social engagement led to greater willingness to engage with patients about mental illness, triggering a feedback loop of more positive experiences with patients who benefit from mental healthcare, which further reinforces willingness to deliver mental healthcare. Trial registration ClinicalTrials.gov identifier, NCT02793271.
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Affiliation(s)
- Bonnie N Kaiser
- University of California San Diego, La Jolla, CA, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- King's College London, London, UK
| | - Sauharda Rai
- Duke Global Health Institute, Durham, NC, USA
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- University of Washington, Seattle, WA, USA
| | - Anvita Bhardwaj
- Duke Global Health Institute, Durham, NC, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Manoj Dhakal
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Patan Academy of Health Sciences, School of Public Health, Kathmandu, Nepal
| | - Cori L Cafaro
- Duke Global Health Institute, Durham, NC, USA
- DePaul University, Chicago, IL, USA
| | - Kathleen J Sikkema
- Duke Global Health Institute, Durham, NC, USA
- Columbia University, New York, NY, USA
| | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Cape Town, South Africa
| | - Vikram Patel
- Harvard Medical School, Cambridge, MA, USA
- Harvard T. H. Chan School of Public Health, Cambridge, MA, USA
| | - Mark J D Jordans
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- King's College London, London, UK
| | | | - Brandon A Kohrt
- Duke Global Health Institute, Durham, NC, USA
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- George Washington University, Washington, DC, USA
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19
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Bryant RA, Malik A, Aqel IS, Ghatasheh M, Habashneh R, Dawson KS, Watts S, Jordans MJD, Brown FL, van Ommeren M, Akhtar A. Effectiveness of a brief group behavioural intervention on psychological distress in young adolescent Syrian refugees: A randomised controlled trial. PLoS Med 2022; 19:e1004046. [PMID: 35960704 PMCID: PMC9374250 DOI: 10.1371/journal.pmed.1004046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 12/30/2021] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Millions of young adolescents in low- and middle-income countries (LMICs) affected by humanitarian crises experience elevated rates of poor mental health. There is a need for scalable programs that can improve the mental health of young adolescents. This study evaluated the effectiveness of a nonspecialist delivered group-based intervention (Early Adolescent Skills for Emotions (EASE)) to improve young adolescents' mental health. METHODS AND FINDINGS In this single-blind, parallel, controlled trial, Syrian refugees aged 10 to 14 years in Jordan were identified through screening of psychological distress as defined by scores ≥15 on the Paediatric Symptom Scale. Participants were randomised to either EASE or enhanced usual care (EUC) involving referral to local psychosocial services (on a 1:1.6 ratio). Participants were aware of treatment allocation but assessors were blinded. Primary outcomes were scores on the Paediatric Symptom Checklist (PSC; internalising, externalising, and attentional difficulty scales) assessed at week 0, 9 weeks, and 3 months after treatment (primary outcome time point). It was hypothesised that EASE would result in greater reductions on internalising symptoms than EUC. Secondary outcomes were depression, posttraumatic stress, well-being, functioning, school belongingness, and caregivers' parenting and mental health. Between June 2019 and January 2020, 1,842 young adolescent refugees were screened for eligibility on the basis of psychological distress. There were 520 adolescents (28.2%) who screened positive, of whom 471 (90.6%) agreed to enter the trial. Overall, 185 were assigned to EASE and 286 to EUC, and 169 and 254 were retained at 3 months for EASE and EUC, respectively. Intent-to-treat analyses indicated that at 3 months, EASE resulted in greater reduction on the PSC-internalising scale than EUC (estimated mean difference 0.69, 95% CI 0.19 to 1.19; p = 0.007; effect size, 0.38) but there were no differences for PSC-externalising (estimated mean difference 0.24, 95% CI -0.43 to 0.91; p = 0.49; effect size, -0.10), PSC-attentional problem (estimated mean difference -0.01, 95% CI -0.51 to 0.54; p = 0.97; effect size, -0.01) scores, or on depression, posttraumatic stress, well-being, functioning, or school belongingness. Relative to EUC, caregivers in EASE had less psychological distress (estimated mean difference 1.95, 95% CI 0.71 to 3.19; p = 0.002) and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < 0.001). Secondary analyses that (a) focused on adolescents with probable internalising disorders; (b) completed the 3-month assessment; and (c) controlled for trauma exposure did not alter the primary results. Mediation analysis indicated that for caregivers in the EASE condition, reduction in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) and internalising (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) problems in their children. No adverse events were attributable to the intervention. A limitation was that EUC was not matched to EASE in terms of facilitator attention or group involvement. CONCLUSIONS EASE led to reduced internalising problems in young refugee adolescents and was associated with reduced distress and less inconsistent disciplinary parenting in caregivers. This intervention has the potential as a scalable intervention to mitigate young adolescents' emotional difficulties in LMIC. TRIAL REGISTRATION Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619000341123.
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Affiliation(s)
- Richard A. Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
- Brain Dynamics Centre, Westmead Institute for Medical Research, Sydney, Australia
| | - Aiysha Malik
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | | | - Maha Ghatasheh
- Institute for Family Health, King Hussein Foundation, Amman, Jordan
| | - Rand Habashneh
- Institute for Family Health, King Hussein Foundation, Amman, Jordan
| | - Katie S. Dawson
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Sarah Watts
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Mark J. D. Jordans
- Research and Development Department, War Child Holland, Amsterdam, the Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands
| | - Felicity L. Brown
- Research and Development Department, War Child Holland, Amsterdam, the Netherlands
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, Australia
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit, Amsterdam, the Netherlands
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20
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Kohrt BA, Turner EL, Gurung D, Wang X, Neupane M, Luitel NP, Kartha MR, Poudyal A, Singh R, Rai S, Baral PP, McCutchan S, Gronholm PC, Hanlon C, Lempp H, Lund C, Thornicroft G, Gautam K, Jordans MJD. Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial. Implement Sci 2022; 17:39. [PMID: 35710491 PMCID: PMC9205129 DOI: 10.1186/s13012-022-01202-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/18/2022] [Accepted: 04/10/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services. DESIGN In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists. DISCUSSION This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness. TRIAL REGISTRATION ClinicalTrials.gov, NCT04282915 . Date of registration: February 25, 2020.
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Affiliation(s)
- Brandon A. Kohrt
- grid.253615.60000 0004 1936 9510Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington D.C., USA
| | - Elizabeth L. Turner
- grid.26009.3d0000 0004 1936 7961Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC USA
| | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Pokhara, Nepal
| | - Xueqi Wang
- grid.26009.3d0000 0004 1936 7961Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC USA
| | - Mani Neupane
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Pokhara, Nepal
| | - Nagendra P. Luitel
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal
| | - Muralikrishnan R. Kartha
- grid.13097.3c0000 0001 2322 6764King’s Health Economics, IOPPN, King’s College London, London, UK
| | - Anubhuti Poudyal
- grid.21729.3f0000000419368729Department of Sociomedical Sciences, Columbia University, New York, NY USA ,grid.253615.60000 0004 1936 9510Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, D.C., 20036 USA
| | - Ritika Singh
- grid.253615.60000 0004 1936 9510Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, D.C., 20036 USA
| | - Sauharda Rai
- grid.34477.330000000122986657Jackson School of International Studies and Department of Global Health, University of Washington, Seattle, USA
| | - Phanindra Prasad Baral
- grid.500537.4Non-communicable Disease and Mental Health Section, Epidemiology and Disease Control Division (EDCD), Department of Health Services (DoHS), Ministry of Health and Population (MoHP), Kathmandu, Nepal
| | - Sabrina McCutchan
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Petra C. Gronholm
- grid.13097.3c0000 0001 2322 6764Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Charlotte Hanlon
- grid.13097.3c0000 0001 2322 6764Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.7123.70000 0001 1250 5688Department of Psychiatry, School of Medicine and Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Heidi Lempp
- grid.13097.3c0000 0001 2322 6764Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Crick Lund
- grid.13097.3c0000 0001 2322 6764Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.7836.a0000 0004 1937 1151Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Graham Thornicroft
- grid.13097.3c0000 0001 2322 6764Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kamal Gautam
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal
| | - Mark J. D. Jordans
- grid.13097.3c0000 0001 2322 6764Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King’s College London, London, UK
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21
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Karyotaki E, Araya R, Kessler RC, Waqas A, Bhana A, Rahman A, Matsuzaka CT, Miguel C, Lund C, Garman EC, Nakimuli-Mpungu E, Petersen I, Naslund JA, Schneider M, Sikander S, Jordans MJD, Abas M, Slade P, Walters S, Brugha TS, Furukawa TA, Amanvermez Y, Mello MF, Wainberg ML, Cuijpers P, Patel V. Association of Task-Shared Psychological Interventions With Depression Outcomes in Low- and Middle-Income Countries: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry 2022; 79:430-443. [PMID: 35319740 PMCID: PMC8943620 DOI: 10.1001/jamapsychiatry.2022.0301] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/02/2022] [Indexed: 01/14/2023]
Abstract
Importance Task sharing, the training of nonspecialist workers with no formal experience in counseling, is a promising strategy for addressing the large gap in treatment for depression in low- and middle-income countries (LMICs). Objective To examine the outcomes and moderators of task-shared psychological interventions associated with depression severity, response, and remission. Data Sources Systematic literature searches in PubMed, Embase, PsycINFO, and Cochrane Library up to January 1, 2021. Study Selection Randomized clinical trials (RCTs) of task-shared psychological interventions compared with control conditions for adults with depressive symptoms in LMICs were included. Data Extraction and Synthesis Two researchers independently reviewed the titles, abstracts, and full text of articles from an existing generic meta-analytic database that includes all RCTs on psychotherapy for depression. A systematic review and individual patient data (IPD) meta-analysis was used to estimate the outcomes of task-shared psychological interventions across patient characteristics using mixed-effects models. Procedures for abstracting data and assessing data quality and validity followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Main Outcomes and Measures Primary outcome was reduction in depression symptom severity measured by the 9-item Patient Health Questionnaire (PHQ-9). Response and remission rates were also estimated. Results Of 13 eligible trials, 11 (4145 participants) contributed IPD. Task-shared psychological interventions were associated with a greater decrease in depressive symptom severity than control conditions (Hedges g, 0.32; 95% CI, -0.26 to -0.38). Participants in the intervention groups had a higher chance of responding (odds ratio, 2.11; 95% CI, 1.60 to 2.80) and remitting (odds ratio, 1.87; 95% CI, 1.20 to 1.99). The presence of psychomotor symptoms was significantly associated with the outcomes of task-shared psychological interventions (β [SE], -1.21 [0.39]; P = .002). No other significant associations were identified. Heterogeneity among the trials with IPD was 74% (95% CI, 53%-86%). Conclusions and Relevance In this meta-analysis of IPD, task-shared psychological interventions were associated with a larger reduction in depressive symptom severity and a greater chance of response and remission than control conditions. These findings show potential for the use of task-sharing of psychological interventions across different groups of patients with depression. Further research would help identify which people are most likely to benefit and strengthen larger-scale implementation of this strategy to address the burden of depression in LMICs.
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Affiliation(s)
- Eirini Karyotaki
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | - Ricardo Araya
- Center for Global Mental Health and Primary Care Research, Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ahmed Waqas
- Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Atif Rahman
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Camila T. Matsuzaka
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Clara Miguel
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | - Crick Lund
- Center for Global Mental Health and Primary Care Research, Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Emily C. Garman
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - John A. Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Marguerite Schneider
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Siham Sikander
- Human Development Research Foundation, Islamabad, Pakistan
- Health Services Academy, Islamabad, Pakistan
| | - Mark J. D. Jordans
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Melanie Abas
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Pauline Slade
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Stephen Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Traolach S. Brugha
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Toshi A. Furukawa
- Departments of Health Promotion and Human Behaviour and of Clinical Epidemiology, Kyoto University Graduate School of Medicine, School of Public Health, Kyoto, Japan
| | - Yagmur Amanvermez
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | - Marcelo F. Mello
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
- Albert Einstein Israelite Hospital, Medicine School, São Paulo, Brazil
| | - Milton L. Wainberg
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York
| | - Pim Cuijpers
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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de Graaff AM, Cuijpers P, Acarturk C, Akhtar A, Alkneme MS, Aoun M, Awwad M, Bawaneh AY, Brown FL, Bryant R, Burchert S, Carswell K, Drogendijk A, Engels M, Fuhr DC, Hansen P, van 't Hof E, Giardinelli L, Hemmo M, Hessling JM, Ilkkursun Z, Jordans MJD, Kiselev N, Knaevelsrud C, Kurt G, Martinmäki S, McDaid D, Morina N, Naser H, Park AL, Pfaltz MC, Roberts B, Schick M, Schnyder U, Spaaij J, Steen F, Taha K, Uygun E, Ventevogel P, Whitney C, Witteveen AB, Sijbrandij M. Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis. BMJ Open 2022; 12:e058101. [PMID: 35443961 PMCID: PMC9021771 DOI: 10.1136/bmjopen-2021-058101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. METHODS AND ANALYSIS Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. ETHICS AND DISSEMINATION Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.
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Affiliation(s)
- Anne M de Graaff
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ceren Acarturk
- Department of Psychology, Koç University, Istanbul, Turkey
| | - Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Mhd Salem Alkneme
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - May Aoun
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Manar Awwad
- Technical Unit, International Medical Corps, London, UK
| | | | - Felicity L Brown
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Sebastian Burchert
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Kenneth Carswell
- Department of Mental Health and Substance Abuse, World Health Organization, Geneve, Switzerland
| | | | - Michelle Engels
- International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support, Copenhagen, Denmark
| | - Daniela C Fuhr
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pernille Hansen
- International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support, Copenhagen, Denmark
| | - Edith van 't Hof
- Department of Mental Health and Substance Abuse, World Health Organization, Geneve, Switzerland
| | | | - Mahmoud Hemmo
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jonas M Hessling
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | | | - Mark J D Jordans
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Nikolai Kiselev
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christine Knaevelsrud
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Gülsah Kurt
- Department of Psychology, Koç University, Istanbul, Turkey
| | - Saara Martinmäki
- ARQ International, ARQ National Psychotrauma Centre, Amsterdam, The Netherlands
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Naser Morina
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Hadeel Naser
- Technical Unit, International Medical Corps, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Monique C Pfaltz
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Psychology and Social Work, Mid Sweden University, Sundsvall, Sweden
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthis Schick
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ulrich Schnyder
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Julia Spaaij
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Frederik Steen
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Karine Taha
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Ersin Uygun
- Trauma and Disaster Mental Health Master Programme, Istanbul Bilgi University, Istanbul, İstanbul, Turkey
| | - Peter Ventevogel
- Public Health, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | - Anke B Witteveen
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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23
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Brown FL, Bosqui T, Elias J, Farah S, Mayya A, Abo Nakkoul D, Walsh B, Chreif S, Einein A, Meksassi B, Abi Saad R, Naal H, Ghossainy ME, Donnelly M, Betancourt TS, Carr A, Puffer E, El Chammay R, Jordans MJD. Family systemic psychosocial support for at-risk adolescents in Lebanon: study protocol for a multi-site randomised controlled trial. Trials 2022; 23:327. [PMID: 35436976 PMCID: PMC9014280 DOI: 10.1186/s13063-022-06284-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Adolescents growing up in communities characterised by adversity face multiple risk factors for poor mental health and wellbeing. There is currently a scarcity of research on effective approaches for preventing and treating psychological distress in this population, particularly in humanitarian settings. The powerful impact of the home environment and family support is well known; however, approaches targeting the family are seldom developed or evaluated in such settings. We developed a brief family systemic psychosocial support intervention to be delivered through existing child protection systems with non-specialist facilitators. This paper outlines the study protocol for a randomised controlled trial of the intervention in Lebanon. Methods We will conduct a single-blind hybrid effectiveness-implementation multi-site RCT comparing the locally developed systemic family intervention to a waitlist control group for families residing in vulnerable regions in North Lebanon and Beqaa governorates (including families of Syrian, Palestinian, and Lebanese backgrounds). Outcomes on a range of family, adolescent, and caregiver measures will be assessed at baseline (T0) and post-intervention (T1), and at a 3-month follow-up for the treatment arm (T2). Families will be eligible for the trial if they are identified by implementing organisations as being medium-to-high risk for child protection concerns and have one or more adolescent aged 12–17 who demonstrates significant psychological distress on a self-report brief screening tool. Families will be randomly assigned to a treatment or a waitlist control condition. Families in the waitlist condition will receive a group version of the programme after completion of the study, to allow us to assess feasibility, acceptability, and preliminary indications of intervention effects of this modality. The primary outcome is reduction in overall adolescent-reported psychological distress over time, with post-intervention (T1) as the primary endpoint. Secondary adolescent-reported outcomes include family functioning, psychosocial wellbeing, and emotional regulation difficulties. Secondary caregiver-reported outcomes include parenting style, family functioning, psychological distress, and emotional regulation difficulties. Discussion This trial will provide the first assessment of the effectiveness of the family systemic psychosocial support intervention for use in Lebanon, with important implications for the use of systemic, low-cost, non-specialist interventions for this age range. Trial registration Local registry: National Mental Health Program, Ministry of Public Health, Lebanese Republic. Registered on 19 October 2021 Lebanese Clinical Trial Registry LBCTR2021104870. Registered on 13 October 2021 Global registry: ISRCTN ISRCTN13751677. Registered on 1 November 2021
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24
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Bryant RA, Bawaneh A, Awwad M, Al-Hayek H, Giardinelli L, Whitney C, Jordans MJD, Cuijpers P, Sijbrandij M, Ventevogel P, Dawson K, Akhtar A. Effectiveness of a brief group behavioral intervention for common mental disorders in Syrian refugees in Jordan: A randomized controlled trial. PLoS Med 2022; 19:e1003949. [PMID: 35298469 PMCID: PMC8929659 DOI: 10.1371/journal.pmed.1003949] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 04/01/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Common mental disorders are frequently experienced by refugees. This study evaluates the impact of a brief, lay provider delivered group-based psychological intervention [Group Problem Management Plus (gPM+)] on the mental health of refugees in a camp, as well as on parenting behavior and children's mental health. METHODS AND FINDINGS In this single-blind, parallel, randomized controlled trial, 410 adult Syrian refugees (300 females, 110 males) in Azraq Refugee Camp (Jordan) were identified through screening of psychological distress (≥16 on the Kessler Psychological Distress Scale) and impaired functioning (≥17 on the WHO Disability Assessment Schedule). Participants were randomly allocated to gPM+ or enhanced usual care (EUC) involving referral information for psychosocial services on a 1:1 ratio. Participants were aware of treatment allocation, but assessors were blinded to treatment condition. Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL; depression and anxiety scales) assessed at baseline, 6 weeks, and 3 months follow-up as the primary outcome time point. It was hypothesized that gPM+ would result in greater reductions of scores on the HSCL than EUC. Secondary outcomes were disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behavior, and children's mental health. Between October 15, 2019 and March 2, 2020, 624 refugees were screened for eligibility, 462 (74.0%) screened positive, of whom 204 were assigned to gPM+ and 206 to EUC. There were 168 (82.4%) participants in gPM+ and 189 (91.7%) in EUC assessed at follow-up. Intent-to-treat analyses indicated that at follow-up, participants in gPM+ showed greater reduction on HSCL depression scale than those receiving EUC (mean difference, 3.69 [95% CI 1.90 to 5.48], p = .001; effect size, 0.40). There was no difference between conditions in anxiety (mean difference -0.56, 95% CI -2.09 to 0.96; p = .47; effect size, -0.03). Relative to EUC, participants in gPM+ had greater reductions in severity of personally identified problems (mean difference 0.88, 95% CI 0.07 to 1.69; p = .03), and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < .001). There were no significant differences between conditions for changes in PTSD, disability, grief, prodromal symptoms, or childhood mental health outcomes. Mediation analysis indicated the change in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE .07; 95% CI .003 to .274) and internalizing (β = 0.08, SE .05; 95% CI .003 to 0.19) problems in children. No adverse events were attributable to the interventions or the trial. Major limitations included only one-quarter of participants being male, and measures of personally identified problems, grief, prodromal psychotic symptoms, inconsistent parenting behavior, and children's mental health have not been validated with Syrians. CONCLUSIONS In camp-based Syrian refugees, a brief group behavioral intervention led to reduced depressive symptoms, personally identified problems, and disciplinary parenting compared to usual care, and this may have indirect benefits for refugees' children. The limited capacity of the intervention to reduce PTSD, disability, or children's psychological problems points to the need for development of more effective treatments for refugees in camp settings. TRIAL REGISTRATION Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619001386123.
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Affiliation(s)
- Richard A. Bryant
- University of New South Wales, Sydney, Australia
- Westmead Institute of Medical Research, Sydney, Australia
| | - Ahmad Bawaneh
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Manar Awwad
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Hadeel Al-Hayek
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | | | - Claire Whitney
- International Medical Corps, Washington DC, United States of America
| | - Mark J. D. Jordans
- War Child, Amsterdam, the Netherlands
- University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Peter Ventevogel
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Katie Dawson
- University of New South Wales, Sydney, Australia
| | - Aemal Akhtar
- University of New South Wales, Sydney, Australia
- Vrije Universiteit, Amsterdam, the Netherlands
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25
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Pandi-Perumal SR, Kumar VM, Pandian NG, de Jong JT, Andiappan S, Corlateanu A, Mahalaksmi AM, Chidambaram SB, Kumar RR, Ramasubramanian C, Sivasubramaniam S, Bjørkum AA, Cutajar J, Berk M, Trakht I, Vrdoljak A, Meira e Cruz M, Eyre HA, Grønli J, Cardinali DP, Maercker A, van de Put WACM, Guzder J, Bjorvatn B, Tol WA, Acuña-Castroviejo D, Meudec M, Morin CM, Partinen M, Barbui C, Jordans MJD, Braakman MH, Knaevelsrud C, Pallesen S, Sijbrandij M, Golombek DA, Espie CA, Cuijpers P, Agudelo HAM, van der Velden K, van der Kolk BA, Hobfoll SE, Devillé WLJM, Gradisar M, Riemann D, Axelsson J, Benítez-King G, Macy RD, Poberezhets V, Hoole SRH, Murthy RS, Hegemann T, Heinz A, Salvage J, McFarlane AC, Keukens R, de Silva H, Oestereich C, Wilhelm J, von Cranach M, Hoffmann K, Klosinski M, Bhugra D, Seeman MV. Scientists Against War: A Plea to World Leaders for Better Governance. Sleep Vigil 2022; 6:1-6. [PMID: 35317215 PMCID: PMC8930284 DOI: 10.1007/s41782-022-00198-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Seithikurippu R. Pandi-Perumal
- Somnogen Canada Inc., College Street, Toronto, Canada
- grid.412431.10000 0004 0444 045XSaveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India
| | | | - Namasivayam Ganesh Pandian
- grid.258799.80000 0004 0372 2033Institute for Integrated Cell-Material Sciences (WPI-iCeMS), A210, Kyoto University Institute for Advanced Study, Yoshida Ushinomiya-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Joop T. de Jong
- grid.509540.d0000 0004 6880 3010Department of Cultural Psychiatry and Global Mental Health, Amsterdam UMC, Amsterdam, The Netherlands
- grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, USA
| | - Sudalaikannu Andiappan
- grid.10214.360000 0001 2186 7912Department of Gandhian Studies and Ramalingar Philosophy, School of Religions, Philosophy and Humanist Thought, Madurai Kamaraj University, Madurai, Tamil Nadu India
| | - Alexandru Corlateanu
- grid.28224.3e0000 0004 0401 2738Department of Respiratory Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
| | - Arehally Marappa Mahalaksmi
- grid.411962.90000 0004 1761 157XDepartment of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru, 570015 India
| | - Saravana Babu Chidambaram
- grid.411962.90000 0004 1761 157XDepartment of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru, 570015 India
| | - Ramasamy Rajesh Kumar
- Global Community Educational Foundation (NGCEF), 7 Peterlee Pl, Hebersham, NSW 2770 Australia
| | | | - Sudhakar Sivasubramaniam
- grid.411780.b0000 0001 0683 3327Department of Biotechnology, Manonmaniam Sundaranar University, Tirunelveli, Tamil Nadu 627012 India
| | - Alvhild Alette Bjørkum
- grid.477239.c0000 0004 1754 9964Department of Safety, Chemistry and Biomedical Laboratory Sciences, Faculty of Engineering and Science, Western Norway University of Applied Sciences, Kronstad, Bergen, Norway
| | - JosAnn Cutajar
- grid.4462.40000 0001 2176 9482Department of Gender and Sexualities, Faculty for Social Wellbeing, University of Malta, Room # 114, Guze Cassar Pullicino Building, Msida, 2080 MSD Malta
| | - Michael Berk
- grid.414257.10000 0004 0540 0062Deakin University, The Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Barwon Health, Geelong, Australia
| | - Ilya Trakht
- grid.21729.3f0000000419368729Department of Medicine, Columbia University, New York, NY USA
| | - Anton Vrdoljak
- grid.413034.10000 0001 0741 1142Faculty of Civil Engineering, Architecture and Geodesy, University of Mostar, Kampus Sveučilišta, Maticehrvatskeb. b, 88000 Mostar, Bosnia and Herzegovina
| | - Miguel Meira e Cruz
- grid.9983.b0000 0001 2181 4263Centro Cardiovascular da Universidade de Lisboa, Lisbon School of Medicine, Av. Prof. Egas Moniz, 1649–028 Lisboa, Portugal
| | - Harris A. Eyre
- grid.414257.10000 0004 0540 0062Deakin University, The Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Barwon Health, Geelong, Australia
- grid.266102.10000 0001 2297 6811Global Brain Health Institute at University of California, San Francisco (UCSF), San Francisco, CA USA
- grid.8217.c0000 0004 1936 9705Trinity College Dublin, Dublin, Ireland
- grid.39382.330000 0001 2160 926XDepartment of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX USA
- grid.36193.3e0000000121590079Neuroscience-Inspired Policy Initiative, Organisation for Economic Co-operation and Development (OECD) and the PRODEO Institute and Meadows Mental Health Policy Institute, Paris, France
- grid.267308.80000 0000 9206 2401Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center at Houston, Houston, TX USA
| | - Janne Grønli
- grid.7914.b0000 0004 1936 7443Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Dainiel P. Cardinali
- grid.412525.50000 0001 2097 3932Faculty of Medical Sciences, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
| | - Andreas Maercker
- grid.7400.30000 0004 1937 0650Psychopathology and Clinical Intervention, University of Zurich, Binzmuhlestr. 14/17, 8044 Zurich, Switzerland
| | - Willem A. C. M. van de Put
- grid.11505.300000 0001 2153 5088Section of International Health Policy, Institute for Tropical Medicine Antwerp, Antwerp, Belgium
- grid.256023.0000000008755302XInstitute of International Humanitarian Affairs (IIHA), Fordham University, Bronx, NY USA
| | - Jaswant Guzder
- Division of Social and Transcultural Psychiatry, 1033 Pine Ave, Montreal, Canada
- grid.414980.00000 0000 9401 2774Trauma and Global Health Program, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis, Jewish General Hospital, Montreal, QC Canada
| | - Bjørn Bjorvatn
- grid.7914.b0000 0004 1936 7443Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- grid.412008.f0000 0000 9753 1393Norway and Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Wietse A. Tol
- grid.5254.60000 0001 0674 042XSection of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- grid.12380.380000 0004 1754 9227Athena Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- AArq International, Amsterdam, The Netherlands
| | - Darío Acuña-Castroviejo
- grid.4489.10000000121678994Centro de Investigación Biomédica, Departamento de Fisiología, Facultad de Medicina, Instituto de Biotecnología, Parque Tecnológico de Ciencias de la Salud, Universidad de Granada, 18016 Granada, Spain
| | - Marie Meudec
- grid.11505.300000 0001 2153 5088Outbreak Research Team and Department of Public Health, Institute of Tropical Medicine (ITM), Antwerpen, Belgium
| | - Charles M. Morin
- grid.23856.3a0000 0004 1936 8390École de Psychologie, Centre d’étude des troubles du sommeil, Centrede recherche CERVO/Brain Research Center, Université Laval, Québec, Canada
| | - Markku Partinen
- Helsinki Sleep Clinic, Terveystalo Healthcare, Valimotie 21, 00380 Helsinki, Finland
- grid.7737.40000 0004 0410 2071Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland
| | - Corrado Barbui
- grid.5611.30000 0004 1763 1124WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
- grid.5611.30000 0004 1763 1124Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mark J. D. Jordans
- grid.487424.90000 0004 0414 0756Research and Development Department, War Child Holland, Amsterdam, The Netherlands
- grid.7177.60000000084992262Amsterdam Institute of Social Science Research, Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Mario H. Braakman
- grid.12295.3d0000 0001 0943 3265Department of Transcultural Forensic Psychiatry, Tilburg University, Tilburg, The Netherlands
| | - Christine Knaevelsrud
- grid.14095.390000 0000 9116 4836Psychologische Psychotherapeutin, Klinisch-Psychologische Intervention, Freie Universität Berlin, Fachbereich Erziehungswissenschaftund Psychologie, Habelschwerdter Allee 45, 14195 Berlin, Germany
| | - Ståle Pallesen
- grid.7914.b0000 0004 1936 7443Department of Psychosocial Science, University of Bergen, Christiesgt.12, 5015 Bergen, Norway
| | - Marit Sijbrandij
- Faculty of Behavioural and Movement Sciences, Clinical Psychology, World Health Organization (WHO) Collaborating Center, Van der Boechorststraat 7, 1081BT Amsterdam, Netherlands
| | - Diego Andrés Golombek
- grid.11560.330000 0001 1087 5626Universidad Nacional de Quilmes/CONICET, R.S. Peña 352, 1876 Bernal, Buenos Aires, Argentina
| | - Colin A. Espie
- grid.4991.50000 0004 1936 8948Department of Psychiatry, University of Oxford, Oxford, UK
- grid.4991.50000 0004 1936 8948Sir Jules Thorn Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, Oxford, OX1 3QU UK
| | - Pim Cuijpers
- grid.12380.380000 0004 1754 9227Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- grid.12380.380000 0004 1754 9227WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- grid.1374.10000 0001 2097 1371Faculty of Medicine, University of Turku, Turku, Finland
| | | | - Koos van der Velden
- grid.10417.330000 0004 0444 9382Department of Public Health, Radboudumc, Nijmegen, The Netherlands
| | - Bessel A. van der Kolk
- grid.189504.10000 0004 1936 7558Department of Psychiatry, Boston University School of Medicine, Boston, USA
| | | | - Walter L. J. M. Devillé
- National Knowledge and Advisory Center on Migrants, Refugees and Health (Pharos), Utrecht, The Netherlands
- grid.7177.60000000084992262Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dieter Riemann
- grid.7708.80000 0000 9428 7911Leiter der Abteilung für Klinische Psychologie and Psychophysiologie, Zentrum für Psychische Erkrankungen, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Hauptstr. 5, 79104 Freiburg, Germany
| | - John Axelsson
- grid.10548.380000 0004 1936 9377Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden
- grid.4714.60000 0004 1937 0626Department Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gloria Benítez-King
- grid.419154.c0000 0004 1776 9908Instituto Nacional de Psiquiatría Ramón de la Fuente Muñíz, Calzada México-Xochimilco No 101, Colonia San Lorenzo, Huipulco, 14370 Mexico City, CDMX México
| | - Robert D. Macy
- International Trauma Center, Beverly Farms, Beverly, MA 01915 USA
- grid.38142.3c000000041936754XHarvard Medical School-McLean Hospital Developmental Trauma, Boston, MA USA
- Boston Children’s Foundation, 850 Summer St, South Boston, MA 02127 USA
| | - Vitalii Poberezhets
- grid.446037.2Department of Propedeutics of Internal Medicine, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | | | - Rangaswamy Srinivasa Murthy
- grid.416861.c0000 0001 1516 2246Formally of Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka India
| | - Thomas Hegemann
- Bayerisches Zentrumfür Transkulturelle Medizin, Landshuter Allee 21, 80637 München, Germany
| | - Andreas Heinz
- grid.6363.00000 0001 2218 4662Department Psychiatry and Neurosciences CCM, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jane Salvage
- grid.3575.40000000121633745Midwifery Leadership Consultant, World Health Organization, Geneva, Switzerland
- grid.15538.3a0000 0001 0536 3773Kingston University, London, UK
| | - Alexander C. McFarlane
- grid.1010.00000 0004 1936 7304Department of Psychiatry, The University of Adelaide, Adelaide, 5000 Australia
| | - Rob Keukens
- GGZ Ecademy Coöperatie UA, Keltenstraat 14, 5037 KD, Tilburg, The Netherlands
- Federation Global Initiative on Psychiatry (FGIP), P.O. Box 1956, 1200 BZ Hilversum, The Netherlands
- grid.3575.40000000121633745Supervisor Capacity Building Community Mental Health Ukraine World Health Organization, Geneva, Switzerland
| | - Harendra de Silva
- grid.8065.b0000000121828067Formally of Department of Paediatrics, University of Colombo, Colombo, Sri Lanka
| | - Cornelia Oestereich
- Institut für systemische Therapie und Beratung, Leisewitzstraße 26, 30175 Hannover, Germany
| | - Jochen Wilhelm
- grid.8664.c0000 0001 2165 8627DeutschesZentrum für Lungenforschung (DZL), Justus-Liebig-Universität Gießen (JLU), Gießen, Germany
| | - Michael von Cranach
- grid.434949.70000 0001 1408 3925Hochschule München, Eggenthal, Grub 4, 87653 München, Germany
| | - Klaus Hoffmann
- Forensic Psychiatry and Psychotherapy, Feursteinstr. 55, 78479 Reichenau, Germany
- grid.9811.10000 0001 0658 7699Zentrum für Psychiatrie Reichenau, Akademisches Lehrkrankenhaus der Universität Konstanz, Rechtsfähige Anstalt des öffentlichen Rechts, Reichenau, Germany
| | - Matthias Klosinski
- grid.6936.a0000000123222966Facharzt für Kinder- und Jugendpsychiatrie und -psychotherapie Systemischer Berater (SG), Systemischer Therapeut (SG), TU München, Klinikum rechts der Isar, München, Germany
| | - Dinesh Bhugra
- grid.13097.3c0000 0001 2322 6764Professor Emeritus, Mental Health and Cultural Diversity, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, SE5 8AF UK
| | - Mary V. Seeman
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada
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Kohrt BA, Jordans MJD, Turner EL, Rai S, Gurung D, Dhakal M, Bhardwaj A, Lamichhane J, Singla DR, Lund C, Patel V, Luitel NP, Sikkema KJ. Collaboration With People With Lived Experience of Mental Illness to Reduce Stigma and Improve Primary Care Services: A Pilot Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2131475. [PMID: 34730821 PMCID: PMC8567115 DOI: 10.1001/jamanetworkopen.2021.31475] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Collaboration with people with lived experience of mental illness (PWLE), also referred to as service users, is a growing priority to reduce stigma and improve mental health care. OBJECTIVE To examine feasibility and acceptability of conducting an antistigma intervention in collaboration with PWLE during mental health training of primary care practitioners (PCPs). DESIGN, SETTING, AND PARTICIPANTS This pilot cluster randomized clinical trial was conducted from February 7, 2016, to August 10, 2018, with assessors, PCPs, and patients blinded to group assignment. The participants were PCPs and primary care patients diagnosed with depression, psychosis, or alcohol use disorder at primary care facilities (the cluster unit of randomization) in Nepal. Statistical analysis was performed from February 2020 to February 2021. INTERVENTIONS In the control group, PCPs were trained on the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). In the Reducing Stigma Among Healthcare Providers (RESHAPE) group, the mhGAP-IG trainings for PCPs were cofacilitated by PWLE who presented recovery testimonials through photographic narratives. MAIN OUTCOMES AND MEASURES Prespecified feasibility and acceptability measures were adequacy of randomization, retention rates, intervention fidelity, data missingness, and safety. Outcome measures for PCPs included the Social Distance Scale (SDS), accuracy of diagnoses of mental illness in standardized role-plays using the Enhancing Assessment of Common Therapeutic factors tool (ENACT), and accuracy of diagnosis with actual patients. The primary end point was 16 months posttraining. RESULTS Among the overall sample of 88 PCPs, 75 (85.2%) were men and 67 (76.1%) were upper caste Hindus; the mean (SD) age was 36.2 (8.8) years. Nine of the PCPs (10.2%) were physicians, whereas the remaining 79 PCPs (89.8%) were health assistants or auxiliary health workers. Thirty-four facilities were randomized to RESHAPE or the control group. All eligible PCPs participated: 43 in RESHAPE and 45 in the control group, with 76.7% (n = 33) and 73.3% (n = 33) retention at end line, respectively. Due to PCP dropout, 29 facilities (85.3%) were included in end line analysis. Of 15 PWLE trained as cofacilitators, 11 (73.3%) participated throughout the 3 months of PCP trainings. Among PCPs, mean SDS changes from pretraining to 16 months were -10.6 points (95% CI, -14.5 to -6.74 points) in RESHAPE and -2.79 points (-8.29 to 2.70 points) in the control group. Role-play-based diagnoses with ENACT were 78.1% (25 of 32) accurate in RESHAPE and 66.7% (22 of 33) in the control group. Patient diagnoses were 72.5% (29 of 40) accurate by PCPs in RESHAPE compared with 34.5% (10 of 29) by PCPs in the control group. There were no serious adverse events. CONCLUSIONS AND RELEVANCE This pilot cluster randomized clinical trial found that procedures were feasible and acceptable for PCPs to be trained by PWLE. These pilot results will help inform a full trial to evaluate benefits of collaboration with PWLE during training of PCPs to reduce stigma and improve diagnostic accuracy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02793271.
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Affiliation(s)
- Brandon A. Kohrt
- Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Mark J. D. Jordans
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Center for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- University of Amsterdam, Amsterdam, the Netherlands
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Sauharda Rai
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Jackson School of International Studies, Department of Global Health, University of Washington, Seattle
| | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Center for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Manoj Dhakal
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Anvita Bhardwaj
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Daisy R. Singla
- Campbell Family Mental Health Research Institute, Centre of Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld Tanenbaum Research Institute, Toronto, Ontario, Canada
| | - Crick Lund
- Center for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Sangath, Goa, India
| | | | - Kathleen J. Sikkema
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
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van den Broek M, Ponniah P, Jeyakumar PJR, Koppenol-Gonzalez GV, Kommu JVS, Kohrt BA, Jordans MJD. Proactive detection of people in need of mental healthcare: accuracy of the community case detection tool among children, adolescents and families in Sri Lanka. Child Adolesc Psychiatry Ment Health 2021; 15:57. [PMID: 34625116 PMCID: PMC8501662 DOI: 10.1186/s13034-021-00405-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/10/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Most children and adolescents in need of mental healthcare remain untreated even when services are available. This study evaluates the accuracy of a new tool, the Community Case Detection Tool (CCDT). The CCDT uses illustrated vignettes, two questions and a simple decision algorithm to support proactive community-level detection of children, adolescents and families in need of mental healthcare to improve help-seeking. METHODS Trusted and respected community members in the Eastern Province of Sri Lanka used the CCDT in their daily routine. Children and families detected as potentially in need of mental healthcare based on utilizing the CCDT (N = 157, aged 6-18 years) were invited for a clinical interview by a mental health counsellor using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The CCDT results were compared against the results of the clinical interview. The concurrent validity and performance of the CCDT were also evaluated by comparing the CCDT outcomes against the Strengths and Difficulties Questionnaire (SDQ). RESULTS 7 out of 10 children and families detected by community members using the CCDT were confirmed to be in need for treatment (positive predictive value [PPV] = 0.69; 0.75 when compared to the SDQ). Detections based on the family problem vignette were most accurate (PPV = 0.76), followed by the internalising problem vignette (PPV = 0.71) and the externalising problem vignette (PPV = 0.62). CONCLUSIONS The CCDT is a promising low-cost solution to overcome under-detection of children and families in need of mental healthcare. Future research should focus on evaluating the effectiveness, as well as additional strategies to improve help-seeking.
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Affiliation(s)
- Myrthe van den Broek
- Research and Development, War Child Holland, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - John Vijay Sagar Kommu
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, USA
| | - Mark J D Jordans
- Research and Development, War Child Holland, Amsterdam, The Netherlands.
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.
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Chisholm D, Docrat S, Abdulmalik J, Alem A, Gureje O, Gurung D, Hanlon C, Jordans MJD, Kangere S, Kigozi F, Mugisha J, Muke S, Olayiwola S, Shidhaye R, Thornicroft G, Lund C. Mental health financing challenges, opportunities and strategies in low- and middle-income countries: findings from the Emerald project - CORRIGENDUM. BJPsych Open 2021; 7:e117. [PMID: 34180788 PMCID: PMC8269921 DOI: 10.1192/bjo.2021.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Jordans MJD, Kohrt BA, Sangraula M, Turner EL, Wang X, Shrestha P, Ghimire R, van’t Hof E, Bryant RA, Dawson KS, Marahatta K, Luitel NP, van Ommeren M. Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial. PLoS Med 2021; 18:e1003621. [PMID: 34138875 PMCID: PMC8211182 DOI: 10.1371/journal.pmed.1003621] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 11/06/2020] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting. METHODS AND FINDINGS We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, "heart-mind" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have "heart-mind" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information. CONCLUSIONS In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants. TRIAL REGISTRATION ClinicalTrials.gov NCT03747055.
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MESH Headings
- Adaptation, Psychological
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Depression/diagnosis
- Depression/etiology
- Depression/psychology
- Depression/therapy
- Female
- Functional Status
- Humans
- Male
- Mental Health
- Middle Aged
- Natural Disasters
- Nepal
- Problem Solving
- Psychotherapy, Brief
- Psychotherapy, Group
- Relief Work
- Stress Disorders, Post-Traumatic/diagnosis
- Stress Disorders, Post-Traumatic/etiology
- Stress Disorders, Post-Traumatic/psychology
- Stress Disorders, Post-Traumatic/therapy
- Stress, Psychological/diagnosis
- Stress, Psychological/etiology
- Stress, Psychological/psychology
- Stress, Psychological/therapy
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Mark J. D. Jordans
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Brandon A. Kohrt
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
- Division of Global Mental Health, Department of Psychiatry & Behavioral Sciences, The George Washington University, Washington, DC, United States of America
| | - Manaswi Sangraula
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Elizabeth L. Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Xueqi Wang
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Pragya Shrestha
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Renasha Ghimire
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | | | | | | | - Kedar Marahatta
- World Health Organization Country Office for Nepal, Kathmandu, Nepal
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Bleile ACE, Koppenol-Gonzalez GV, Verreault K, Abeling K, Hofman E, Vriend W, Hasan A, Jordans MJD. Process evaluation of TeamUp: a movement-based psychosocial intervention for refugee children in the Netherlands. Int J Ment Health Syst 2021; 15:25. [PMID: 33741025 PMCID: PMC7977563 DOI: 10.1186/s13033-021-00450-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nearly 60,000 people applied for asylum in the Netherland in 2015, confronting the governmental structures and services with great administrative, logistical and service provision challenges. Refugee children's psychosocial needs and wellbeing are often overlooked, and post-migration support is of pivotal importance. METHODS An easy accessible movement-based psychosocial intervention, called TeamUp, was developed for children aged 6-17 living in refugee reception centres. A mixed-method process evaluation was conducted of (1) implementation process, assessing attendance (n = 2183 children, and n = 209 children); (2) implementation quality, using structured observations at two time points to evaluate facilitator's (2a) individual-level fidelity (n = 81 facilitators); (2b) team-level fidelity (n = 22 teams); (2c) facilitators' competencies (n = 81); (2d) trainee perceived self-efficacy pre-post training (n = 73); and (3) perceptions on implementation and outcomes, employing a survey (n = 99), focus group discussions and key informant interviews with children (n = 94), facilitators (n = 24) and reception centre staff (n = 10). RESULTS Attendance lists showed a mean of 8.5 children per session, and children attending 31.3% of sessions. Structured observations demonstrated 49.2% and 58.2% individual-level fidelity, 72.5% and 73.0% team-level fidelity, and 82.9% and 88.4% adequacy in competencies, each at T1 and T2 respectively. The main reported challenges included managing children's energy regulation (e.g. offering settling moments) and challenging behaviour. Training participation significantly improved perceived self-efficacy for trainees. The facilitator survey demonstrated on average, high satisfaction and self-efficacy, low experienced burden, and high perceived capacity-building support. Qualitatively, TeamUp was positively perceived by all stakeholders and was regarded as contributing to children's psychosocial outcomes. CONCLUSION (1) Attendance and group size were lower than expected. (2) The intervention's facilitator fidelity ranged from moderate to adequate-exhibiting a need for specific fidelity and capacity strengthening-while facilitator competencies were high. Trainee's perceived self-efficacy improved significantly following a 2-day training. (3) Facilitators expressed high levels of satisfaction, self-efficacy and support, and low burden. The intervention was positively perceived by all stakeholders and to have a positive impact on children's psychosocial learning and wellbeing.
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Affiliation(s)
| | | | | | | | - Elin Hofman
- War Child Holland, Amsterdam, The Netherlands
| | | | - Adnan Hasan
- War Child Holland, Amsterdam, The Netherlands
| | - Mark J D Jordans
- War Child Holland, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
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Pokhrel P, Karmacharya R, Taylor Salisbury T, Carswell K, Kohrt BA, Jordans MJD, Lempp H, Thornicroft G, Luitel NP. Perception of healthcare workers on mobile app-based clinical guideline for the detection and treatment of mental health problems in primary care: a qualitative study in Nepal. BMC Med Inform Decis Mak 2021; 21:21. [PMID: 33468120 PMCID: PMC7816321 DOI: 10.1186/s12911-021-01386-0] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In recent years, a significant change has taken place in the health care delivery systems due to the availability of smartphones and mobile software applications. The use of mobile technology can help to reduce a number of barriers for mental health care such as providers' workload, lack of qualified personnel, geographical and attitudinal barriers to seek treatment. This study assessed the perception of Nepali primary healthcare workers about the feasibility, acceptability, and benefits of using a mobile app-based clinical guideline for mental health care. METHOD A qualitative study was conducted in two districts Chitwan and Ramechhap of Nepal with purposively selected medical officers (n = 8) and prescribing primary healthcare workers (n = 35) who were trained in the World Health Organization mental health Gap Action Program Intervention Guide. Semi-structured interviews and focus group discussions were conducted in Nepali, audio recorded, transcribed and translated into English for data analysis. Data were analysed manually using a thematic analysis approach. RESULTS The majority of the healthcare workers and medical officers reported a high level of interest, motivation and positive attitudes towards the mobile app-based clinical guidelines for detection and treatment of people with mental disorders in primary care. They respondents suggested that several features and functions should be included in the app: suggestive diagnosis and treatment options; clinical data recording system; sending messages to patients to promote follow-up visits; allow offline functions; minimal typing options and content to be available in Nepali language. The study participants reported that the app could help in bringing uniformity in diagnosis and management of mental disorders across all health facilities, enabling remote supervision, helping verification of health workers' diagnosis and treatment; and increasing patients' trust in the treatment. Lack of reliable internet connection in health facilities, possibility of distracting interaction between patient and provider, and confidentiality were the key factors potentially hindering the use of the app. CONCLUSION The suggested functions and features as well as the potential risk factors highlighted by the health workers, will be considered when further developing the mobile app-based clinical guidelines, training modality and materials, and the supervision system.
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Affiliation(s)
- P Pokhrel
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - R Karmacharya
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - T Taylor Salisbury
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - K Carswell
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - B A Kohrt
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal.,Department of Psychiatry, George Washington University, Washington, DC, USA
| | - M J D Jordans
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal.,Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - H Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - G Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - N P Luitel
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal.
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Akhtar A, Giardinelli L, Bawaneh A, Awwad M, Al-Hayek H, Whitney C, Jordans MJD, Sijbrandij M, Cuijpers P, Dawson K, Bryant R. Feasibility trial of a scalable transdiagnostic group psychological intervention for Syrians residing in a refugee camp. Eur J Psychotraumatol 2021; 12:1932295. [PMID: 34262668 PMCID: PMC8253196 DOI: 10.1080/20008198.2021.1932295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Approximately 10% of Syrian refugees currently reside in camp settings, which can impose additional post-migration stressors. With elevated rates of psychological distress and few available resources, task-shifting psychosocial programmes are necessary to provide adequate care. One such programme developed by the World Health Organization (WHO) is Group Problem Management Plus (GroupPM+). Objective: This study aimed to test the safety and acceptability of GroupPM+ in a refugee camp and to identify areas for adaptation in preparation for a definitive RCT. Method: A feasibility randomized controlled trial (RCT) was conducted in Azraq refugee camp in Jordan. Inclusion criteria were: (1) Syrian adults aged ≥18 years, (2) parent of a child aged 10-16 years, (3) experiencing psychological distress as defined by a score of ≥16 on the Kessler Distress Scale, and (4) ≥17 on the WHO Disability Assessment Schedule 2.0. Following baseline assessments, participants were randomized to receive GroupPM+ or enhanced treatment-as-usual. Post-assessments were conducted one week following the last GroupPM+ session. Primary outcomes were feasibility and acceptance of GroupPM+; symptoms of anxiety, depression, PTSD, prodromal psychosis, grief, and child's self-reported psychological distress were also assessed. Results: Of the 207 persons screened, 64 (31%) screened positive for psychological distress. Of the 35 randomized into the GroupPM+ intervention, 24 (69%) completed the intervention. No adverse events were reported throughout the trial. Children whose parents received GroupPM+ had greater reductions in internalizing and externalizing symptoms at posttreatment. 55 (86%) participants completed the post-assessment follow-up. These results demonstrate both the feasibility of conducting the trial in a camp and acceptance of the GroupPM+ intervention by Syrian refugees. Conclusions: Following the feasibility trial, both the implementation procedures and intervention were safe and culturally acceptable. The results support the readiness for a definitive RCT to determine the effectiveness and cost-effectiveness of the intervention in camp settings.
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Affiliation(s)
- Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, Australia.,Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Ahmad Bawaneh
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Manar Awwad
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Hadeel Al-Hayek
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Claire Whitney
- Technical Unit, International Medical Corps, Washington, DC, USA
| | - Mark J D Jordans
- Research and Development Department, War Child, Amsterdam, The Netherlands.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Katie Dawson
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
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Akhtar A, Malik A, Ghatasheh M, Aqel IS, Habashneh R, Dawson KS, Watts S, Jordans MJD, Brown F, Sijbrandij M, Cuijpers P, Bryant R. Feasibility trial of a brief scalable psychological intervention for Syrian refugee adolescents in Jordan. Eur J Psychotraumatol 2021; 12:1901408. [PMID: 34868475 PMCID: PMC8635577 DOI: 10.1080/20008198.2021.1901408] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Most refugees are less than 18 years and at heightened risk of common mental disorders (CMDs) relative to other youth. Limited evidence exists for psychosocial programsfor youth in low-resource settings. Early Adolescent Skills for Emotions (EASE) was developed by the World Health Organization to address this gap. OBJECTIVES This study tested the safety, feasibility, and trial procedures of the EASE intervention among Syrian refugee youth in preparation for a definitive randomized controlled trial (RCT). METHODS A feasibility RCT was conducted in Amman, Jordan with Syrian children aged 10-14 years who reported psychological distress. Following community screening, youth and their caregivers were randomized to receive either the EASE intervention or enhanced treatment as usual (ETAU). EASE comprised seven group sessions teaching children coping skills, and caregivers received three group sessions to augment the youth sessions. Assessments were conducted at baseline and 1 week following the last EASE session (8 weeks following baseline). Following the trial, a qualitative process evaluation with staff and beneficiaries took place. Primary outcomes were safety and feasibility indicators, and distress was measured by the Paediatric Symptom Checklist. RESULTS In November 2018, 179 children were screened; 61 (33%) met criteria for distress (34.1%), two were excluded for suicidal risk, and 59 were randomized (EASE = 33, ETAU = 26). Of those who received EASE, 26 children (79%) completed the intervention. Group attendance was high and no adverse events were reported in either arm. Psychological distress did not show signs of abating in either group over time. CONCLUSION This feasibility trial demonstrated the safety and acceptability of the intervention. Important lessons were learnt regarding entry criteria into the study and engagement of caregivers in the intervention. A fully powered randomized controlled trial will be conducted to evaluate the efficacy of EASE.
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Affiliation(s)
- Aemal Akhtar
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Aiysha Malik
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Maha Ghatasheh
- Institute for Family Health, King Hussein Foundation, Amman, Jordan
| | | | - Rand Habashneh
- Institute for Family Health, King Hussein Foundation, Amman, Jordan
| | - Katie S Dawson
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Sarah Watts
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Mark J D Jordans
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Felicity Brown
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
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Jordans MJD, Kohrt BA. Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact. Epidemiol Psychiatr Sci 2020; 29:e189. [PMID: 33239113 PMCID: PMC7737188 DOI: 10.1017/s2045796020001018] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS Despite recent global attention to mental health and psychosocial support services and a growing body of evidence-support interventions, few mental health services have been established at a regional or national scale in low- and middle-income countries (LMIC). There are myriad challenges and barriers ranging from testing interventions that do not target priority needs of populations or policymakers to interventions that cannot achieve adequate coverage to decrease the treatment gap in LMIC. METHOD We propose a 'roadmap to impact' process that guides planning for interventions to move from the research space to the implementation space. RESULTS We establish four criteria and nine associated indicators that can be evaluated in low-resource settings to foster the greatest likelihood of successfully scaling mental health and psychosocial interventions. The criteria are relevance (indicators: population need, cultural and contextual fit), effectiveness (change in mental health outcome, change in hypothesised mechanism of action), quality (adherence, competence, attendance) and feasibility (coverage, cost). In the research space, relevance and effectiveness need to be established before moving into the implementation space. In the implementation space, ongoing monitoring of quality and feasibility is required to achieve and maintain a positive public health impact. Ultimately, a database or repository needs to be developed with these criteria and indicators to help researchers establish and monitor minimum benchmarks for the indicators, and for policymakers and practitioners to be able to select what interventions will be most likely to succeed in their settings. CONCLUSION A practicable roadmap with a sequence of measurable indicators is an important step to delivering interventions at scale and reducing the mental health treatment gap around the world.
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Affiliation(s)
- Mark J. D. Jordans
- Research & Development, War Child Holland, Amsterdam, the Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands
| | - Brandon A. Kohrt
- Division of Global Mental Health, Department of Psychiatry & Behavioral Sciences, The George Washington University
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Purgato M, Tedeschi F, Bonetto C, de Jong J, Jordans MJD, Tol WA, Barbui C. Trajectories of psychological symptoms and resilience in conflict-affected children in low- and middle-income countries. Clin Psychol Rev 2020; 82:101935. [PMID: 33126036 DOI: 10.1016/j.cpr.2020.101935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/17/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022]
Abstract
Longitudinal studies on children's and adolescents' psychological reactions to conflict-related traumatic events in low- and middle-income countries are scarce. The present study aimed to analyze children's and adolescents' responses to conflict-related potentially traumatic events (PTEs) and the impact of the number of different types of PTEs on psychological symptoms and resilience over time. We investigated the presence of psychological symptoms and resilience, defined as low levels of symptoms and high levels of hope, in a sample of 597 conflict-affected children and adolescents allocated to a waiting list condition in four randomized trials conducted in Burundi, Indonesia, Nepal and Sri Lanka. A decrease in functional impairment (p < 0.001), symptoms of PTSD (p < 0.001), anxiety (p < 0.001), depression (p = 0.052), and an increase in social support (p < 0.001), was observed over a six-month follow-up. More than one third of children and adolescents (34.6%) exposed to conflict-related traumatic events improved at follow-up. Levels of hope did not significantly change. Improvement in psychological symptoms and resilience were significantly associated with the number of different types of PTEs experienced before study entry. This study showed that children and adolescents have the capacity to react to multiple traumatic events, and that the number of different types of traumatic events has an impact on resilience mechanisms. This will help differentiate the choice and focus of psychosocial interventions according to the amount of traumatic events experienced by children and adolescents, and will inform the development and testing of new psychosocial interventions.
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Affiliation(s)
- Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy.
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Chiara Bonetto
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Joop de Jong
- Amsterdam University Medical Center, The Netherlands; Boston University School of Medicine, Boston, MA, USA
| | - Mark J D Jordans
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands; Research and Development Department, War Child Holland, Amsterdam, The Netherlands
| | - Wietse A Tol
- Department of Public Health, University of Copenhagen, Denmark; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy; Cochrane Global Mental Health, University of Verona, Verona, Italy
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Luitel NP, Jordans MJD, Subba P, Komproe IH. Perception of service users and their caregivers on primary care-based mental health services: a qualitative study in Nepal. BMC Fam Pract 2020; 21:202. [PMID: 32988367 PMCID: PMC7523041 DOI: 10.1186/s12875-020-01266-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/10/2020] [Indexed: 11/13/2022]
Abstract
Background Integration of mental health services into primary health care systems has been advocated as a strategy to minimize the tremendous mental health treatment gap, particularly in low- and middle-income countries. Barriers to integration of mental health into primary health care have been widely documented; however, very little is known about the perception of service users and their caregivers on primary care-based mental health services. This study assessed service users’ and caregivers’ perceptions of mental health services provided by trained primary health care workers in Nepal. Methods A qualitative study was conducted among people with depression, psychosis, alcohol use disorder and epilepsy, and their caregivers in Chitwan, a district in southern Nepal. Semi-structured interviews were conducted with 43 service users and 38 caregivers to assess their perceptions about the accessibility of the services, types of services they received, skills and competencies of health care providers, satisfaction and barriers to receiving services. Results Overall, both service users and caregivers were satisfied with the mental health services provided by primary health care providers. They also perceived health workers to be competent and skillful because the services they received were effective in reducing their mental health problems. Both psychological and pharmacological services were made available free of cost, however, they considered psychological services more effective than pharmacological treatment. Major challenges and difficulties accessing services were associated with frequent transfer of trained health workers, non-availability of the same health care provider at follow-ups, frequent stock-out of medicines or non-availability of required medicines, lack of a confidential space for consultation in health facilities, and stigmatizing and negative behavior of some health workers. Conclusion The results demonstrated that both service users and caregivers perceived primary care-based mental health services to be accessible, acceptable and effective. The key recommendations emerging from this study for improving mental health services in primary care include the provision of a separate cadre of psychosocial workers to provide psychological interventions, developing quick and efficient mechanisms for the procurement and supply of psychotropic medicines, establishing a confidential place within health facilities for consultation, and further training of health workers to reduce stigma.
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Affiliation(s)
- N P Luitel
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal.
| | - M J D Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Faculty of Social and Behavioural Sciences; Department of Anthropology, University of Amsterdam, Armsterdam, the Netherlands
| | - P Subba
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - I H Komproe
- Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, the Netherlands
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Fuhr DC, Acarturk C, Sijbrandij M, Brown FL, Jordans MJD, Woodward A, McGrath M, Sondorp E, Ventevogel P, Ikkursun Z, El Chammay R, Cuijpers P, Roberts B. Planning the scale up of brief psychological interventions using theory of change. BMC Health Serv Res 2020; 20:801. [PMID: 32847580 PMCID: PMC7449040 DOI: 10.1186/s12913-020-05677-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization's Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees. METHODS We conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15-24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up. RESULTS A cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established. CONCLUSION ToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly.
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Affiliation(s)
- Daniela C Fuhr
- London School of Hygiene and Tropical Medicine; Public Health and Policy, Department of Health Services Research and Policy, 15-17 Tavistock Place, London, UK.
| | - Ceren Acarturk
- Department of Psychology, Koc University, Rumelifeneri, Sarıyer Rumeli Feneri Yolu, Sarıyer/İstanbul, Turkey
| | - Marit Sijbrandij
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081, Amsterdam, BT, Netherlands
| | - Felicity L Brown
- Research and Development Department, War Child Holland, Helmholtzstraat 61, -G, Amsterdam, Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Nieuwe Achtergracht, 166, Amsterdam, Netherlands
| | - Mark J D Jordans
- Research and Development Department, War Child Holland, Helmholtzstraat 61, -G, Amsterdam, Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Nieuwe Achtergracht, 166, Amsterdam, Netherlands
| | - Aniek Woodward
- KIT Royal Tropical Institute, Mauritskade 63, 1092, Amsterdam, Netherlands
| | - Michael McGrath
- London School of Hygiene and Tropical Medicine; Public Health and Policy, Department of Health Services Research and Policy, 15-17 Tavistock Place, London, UK
- KIT Royal Tropical Institute, Mauritskade 63, 1092, Amsterdam, Netherlands
| | - Egbert Sondorp
- KIT Royal Tropical Institute, Mauritskade 63, 1092, Amsterdam, Netherlands
| | - Peter Ventevogel
- Public Health Section, Division of Resilience and Solutions, United Nations High Commissioner for Refugees, Rue de Montbrillant 94, 1201, Genève, Switzerland
| | - Zeynep Ikkursun
- Department of Psychology, Koc University, Rumelifeneri, Sarıyer Rumeli Feneri Yolu, Sarıyer/İstanbul, Turkey
| | - Rabih El Chammay
- National Mental Health Programme, Ministry of Health, Bir Hassan, Beirut, Lebanon
- Department of Psychiatry, Faculty of Medicine, Saint Joseph University Beirut, Rue de Damas, B.P.17-5208 Mar Mikhael, Beirut, Lebanon
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081, Amsterdam, BT, Netherlands
| | - Bayard Roberts
- London School of Hygiene and Tropical Medicine; Public Health and Policy, Department of Health Services Research and Policy, 15-17 Tavistock Place, London, UK
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Rose-Clarke K, Pradhan I, Shrestha P, B K P, Magar J, Luitel NP, Devakumar D, Rafaeli AK, Clougherty K, Kohrt BA, Jordans MJD, Verdeli H. Culturally and developmentally adapting group interpersonal therapy for adolescents with depression in rural Nepal. BMC Psychol 2020; 8:83. [PMID: 32787932 PMCID: PMC7425581 DOI: 10.1186/s40359-020-00452-y] [Citation(s) in RCA: 12] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evidence-based interventions are needed to reduce depression among adolescents in low- and middle-income countries (LMICs). One approach could be cultural adaptation of psychological therapies developed in high-income countries. We aimed to adapt the World Health Organization's Group Interpersonal Therapy (IPT) Manual for adolescents with depression in rural Nepal. METHODS We used a participatory, multi-stage adaptation process involving: translation and clinical review of the WHO Manual; desk reviews of adaptations of IPT in LMICs, and literature on child and adolescent mental health interventions and interpersonal problems in Nepal; a qualitative study to understand experiences of adolescent depression and preferences for a community-based psychological intervention including 25 interviews with adolescent boys and girls aged 13-18 with depression, four focus group discussions with adolescents, four with parents/caregivers and two with teachers, six interviews with community health workers and one with a representative from a local non-governmental organisation (total of 126 participants); training of IPT trainers and facilitators and practice IPT groups; and consultation with a youth mental health advisory board. We used the Ecological Validity Framework to guide the adaptation process. RESULTS We made adaptations to optimise treatment delivery and emphasise developmental and cultural aspects of depression. Key adaptations were: integrating therapy into secondary schools for delivery by school nurses and lay community members; adding components to promote parental engagement including a pre-group session with the adolescent and parent to mobilise parental support; using locally acceptable terms for mental illness such as udas-chinta (sadness and worry) and man ko samasya (heart-mind problem); framing the intervention as a training programme to de-stigmatise treatment; and including activities to strengthen relationships between group members. We did not adapt the therapeutic goals of IPT and conserved IPT-specific strategies and techniques, making edits only to the way these were described in the Manual. CONCLUSIONS Group IPT can be adapted for adolescents in Nepal and delivered through the education system. A randomised controlled trial is needed to assess the impact and costs of the intervention in this setting. Future research in LMICs to adapt IPT for adolescents could use this adapted intervention as a starting point.
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Affiliation(s)
- Kelly Rose-Clarke
- Department of Global Health and Social Medicine, King's College London, London, WC2B 4BG, UK.
| | - Indira Pradhan
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Pragya Shrestha
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Prakash B K
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Jananee Magar
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | | | - Delan Devakumar
- Institute for Global Health, University College London, London, UK
| | - Alexandra Klein Rafaeli
- Psychological Services, Ruth and Allen Ziegler Student Services Division, Tel Aviv University, Tel Aviv, Israel
| | - Kathleen Clougherty
- Global Mental Health Lab, Teachers College, Columbia University, New York, NY, USA
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, and Department of Global Health, George Washington University, Washington, DC, USA
| | - Mark J D Jordans
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Helen Verdeli
- Global Mental Health Lab, Teachers College, Columbia University, New York, NY, USA
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Miller KE, Koppenol-Gonzalez GV, Arnous M, Tossyeh F, Chen A, Nahas N, Jordans MJD. Supporting Syrian families displaced by armed conflict: A pilot randomized controlled trial of the Caregiver Support Intervention. Child Abuse Negl 2020; 106:104512. [PMID: 32408022 DOI: 10.1016/j.chiabu.2020.104512] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The impact of armed conflict and displacement on children's mental health is strongly mediated by compromised parenting stemming from persistently high caregiver stress. Parenting interventions for refugees emphasize the acquisition of parenting knowledge and skills, while overlooking the deleterious effects of chronic stress on parenting. War Child Holland's Caregiver Support Intervention (CSI) aims to strengthen parenting by lowering stress and improving psychosocial wellbeing among refugee parents, while also increasing knowledge and skill related to positive parenting. The CSI is a nine-session group intervention delivered by non-specialist providers. OBJECTIVE We describe the findings of a two-arm pilot randomized controlled trial of the CSI with Syrian refugees in Lebanon. The primary aim was to test the feasibility of our study methodology prior to conducting a definitive RCT. METHODS We recruited 78 families (151 parents), who were randomized to the CSI or a waitlist control group. Data were collected at baseline and post-intervention. RESULTS Randomization was successful, retention was high (99 %), as was intervention completion (95 % among women, 86 % among men). Implementation fidelity was excellent. Blinding was largely, though not completely effective. The CSI group showed significantly increased parental warmth and responsiveness, decreased harsh parenting, lowered stress and distress, improved psychosocial wellbeing, and improved stress management. CSI parents reported increased child psychosocial wellbeing. Control families showed no significant change on any variable. CONCLUSIONS Findings demonstrate the feasibility of our methodology for a definitive RCT, and suggest that the CSI shows promise as a scalable approach to strengthening parenting in refugee communities. Trial registration # ISRCTN33665023.
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Affiliation(s)
- Kenneth E Miller
- War Child Holland, Helmholtzstraat 61g, 1098LE Amsterdam, The Netherlands.
| | | | | | | | | | | | - Mark J D Jordans
- War Child Holland, Helmholtzstraat 61g, 1098LE Amsterdam, The Netherlands; Amsterdam Institute of Social Science Research, University of Amsterdam, The Netherlands.
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Jordans MJD, Luitel N, Lund C, Kohrt BA. Evaluation of Proactive Community Case Detection to Increase Help Seeking for Mental Health Care: A Pragmatic Randomized Controlled Trial. Psychiatr Serv 2020; 71:810-815. [PMID: 32321389 PMCID: PMC7415529 DOI: 10.1176/appi.ps.201900377] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The Community Informant Detection Tool (CIDT) is a vignette- and picture-based method of proactive case detection to promote help seeking for persons with depression, psychosis, alcohol use disorder, and epilepsy. The authors evaluated the effectiveness of the CIDT to increase help-seeking behavior in rural Nepal, where a district mental health care plan was being implemented. METHODS Twenty-four health facilities were randomly assigned to one of two methods for training their all-female cadre of community health volunteers: standard training or standard training that included the CIDT. The authors compared the number of patients with depression, psychosis, alcohol use disorder, and epilepsy who were registered in the routine health information system prior to and 6 months after the training. RESULTS At health facilities where volunteers received CIDT training, 309 patients were registered as having depression, psychosis, alcohol use disorder, or epilepsy, compared with 182 patients at facilities where volunteers received standard training. The median number of patients registered was 47% greater at facilities where CIDT training was included (24 patients) than at facilities with standard training (16 patients) (p=0.04, r=0.42). The difference in the number of registered patients remained significant when the analysis factored in the population catchment (N=18 patients [CIDT] versus N=14 [standard] per 10,000 population; p=0.05, r=0.40). CONCLUSIONS The median number of patients registered as having a mental illness was 47% greater at primary care facilities in which community health volunteers used the CIDT than at facilities where volunteers received standard training. Proactive case finding holds promise for increasing help seeking for mental health care.
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Affiliation(s)
- Mark J. D. Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK; and Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Nagendra Luitel
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
| | - Brandon A. Kohrt
- Department of Psychiatry, George Washington University, Washington, D.C., USA; and Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
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Luitel NP, Breuer E, Adhikari A, Kohrt BA, Lund C, Komproe IH, Jordans MJD. Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study. BJPsych Open 2020; 6:e77. [PMID: 32718381 PMCID: PMC7443901 DOI: 10.1192/bjo.2020.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal. AIMS To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP. METHOD A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers. RESULTS The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors. CONCLUSIONS Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
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Affiliation(s)
| | - Erica Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Department of Medicine and Public Health, University of Newcastle, Australia
| | - Anup Adhikari
- Transcultural Psychosocial Organization (TPO), Nepal
| | - Brandon A Kohrt
- Department of Psychiatry, George Washington University, USA; and Transcultural Psychosocial Organization (TPO), Nepal
| | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Ivan H Komproe
- Faculty of Social and Behavioural Sciences, Utrecht University; and Research and Development Department, HealthNet TPO, Amsterdam, the Netherlands
| | - Mark J D Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Faculty of Social and Behavioural Sciences, Department of Anthropology, University of Amsterdam, the Netherlands; and Transcultural Psychosocial Organization (TPO), Nepal
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Upadhaya N, Jordans MJD, Adhikari RP, Gurung D, Petrus R, Petersen I, Komproe IH. Evaluating the integration of chronic care elements in primary health care for people with mental illness: a longitudinal study in Nepal conducted among primary health care workers. BMC Health Serv Res 2020; 20:632. [PMID: 32646509 PMCID: PMC7346519 DOI: 10.1186/s12913-020-05491-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/22/2019] [Accepted: 07/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness. Methods A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline). Results From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support. Conclusions These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.
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Affiliation(s)
- Nawaraj Upadhaya
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
| | - Mark J D Jordans
- Department of Research and Development, War Child, Amsterdam, the Netherlands.,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Inge Petersen
- Centre for Rural Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Ivan H Komproe
- Department of Research and Development, HealthNet TPO, Amsterdam, the Netherlands.,Utrecht University, Utrecht, the Netherlands
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43
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Bhardwaj A, Subba P, Rai S, Bhat C, Ghimire R, Jordans MJD, Green E, Vasudevan L, Kohrt BA. Lessons learned through piloting a community-based SMS referral system for common mental health disorders used by female community health volunteers in rural Nepal. BMC Res Notes 2020; 13:309. [PMID: 32611435 PMCID: PMC7328268 DOI: 10.1186/s13104-020-05148-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 02/13/2020] [Accepted: 06/19/2020] [Indexed: 11/10/2022] Open
Abstract
Objective The Community Informant Detection Tool (CIDT) is a paper-based proactive case detection strategy with evidence for improving help-seeking behavior for mental healthcare. Key implementation barriers for the paper-based CIDT include delayed reporting of cases and lack of active follow up. We used mobile phones and structured text messages to improve timeliness of case reporting, encouraging follow up, and case record keeping. 36 female community health volunteers piloted this mobile phone CIDT (mCIDT) for three months in 2017 in rural Nepal. Results Only 8 cases were identified by health volunteers using mCIDT, and only two of these cases engaged with health services post-referral. Accuracy with the mCIDT was considerably lower than paper-based CIDT, especially among older health volunteers, those with lower education, and those having difficulties sending text messages. Qualitative findings revealed implementation challenges including cases not following through on referrals due to perceived lack of staff at health facilities, assumptions among health volunteers that all earthquake-related mental health needs had been met, and lack of financial incentives for use of mCIDT. Based on study findings, we provide 5 recommendations—in particular attitudinal and system preparedness changes—to effectively introduce new mental healthcare technology in low resource health systems.
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Affiliation(s)
- Anvita Bhardwaj
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Prasansa Subba
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal. .,United Mission to Nepal, Kathmandu, Nepal.
| | - Sauharda Rai
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal.,Henry M Jackson School of International Studies and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Chaya Bhat
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Renasha Ghimire
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Mark J D Jordans
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Eric Green
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Lavanya Vasudevan
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Brandon A Kohrt
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA
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Purgato M, Tedeschi F, Betancourt TS, Bolton P, Bonetto C, Gastaldon C, Gordon J, O'Callaghan P, Papola D, Peltonen K, Punamaki RL, Richards J, Staples JK, Unterhitzenberger J, de Jong J, Jordans MJD, Gross AL, Tol WA, Barbui C. Mediators of focused psychosocial support interventions for children in low-resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants. J Child Psychol Psychiatry 2020; 61:584-593. [PMID: 31701533 DOI: 10.1111/jcpp.13151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Accepted: 10/03/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways. METHODS We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review. RESULTS We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient -0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%. CONCLUSIONS Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.
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Affiliation(s)
- Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Theresa S Betancourt
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Paul Bolton
- Center for Humanitarian Health, Department of International Health and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chiara Bonetto
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - James Gordon
- The Center for Mind-Body Medicine, Washington, D.C, USA
| | | | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Kirsi Peltonen
- Department of Psychology, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Raija-Leena Punamaki
- Department of Psychology, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Justin Richards
- School of Public Health & Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | | | | | - Joop de Jong
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark J D Jordans
- Center for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wietse A Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,HealthRight International, New York, NY, USA
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
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Van't Hof E, Sangraula M, Luitel NP, Turner EL, Marahatta K, van Ommeren M, Shrestha P, Bryant R, Kohrt BA, Jordans MJD. Effectiveness of Group Problem Management Plus (Group-PM+) for adults affected by humanitarian crises in Nepal: study protocol for a cluster randomized controlled trial. Trials 2020; 21:343. [PMID: 32307009 PMCID: PMC7168994 DOI: 10.1186/s13063-020-04263-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 03/17/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Globally, the lack of availability of psychological services for people exposed to adversities has led to the development of a range of scalable psychological interventions with features that enable better scale-up. Problem Management Plus (PM+) is a brief intervention of five sessions that can be delivered by non-specialists. It is designed for people in communities in low- and middle-income countries (LMIC) affected by any kind of adversity. Two recent randomized controlled trials in Pakistan and Kenya demonstrated the effectiveness of individually delivered PM+. A group version of PM+ has been developed to make the intervention more scalable and acceptable. This paper describes the protocol for a cluster randomized controlled trial (c-RCT) on locally adapted Group PM+ in Nepal. METHODS/DESIGN This c-RCT will compare Group PM+ to enhanced usual care (EUC) in participants with high levels of psychological distress recruited from the community. The study is designed as a two-arm, single-blind c-RCT that will be conducted in a community-based setting in Morang, a flood affected district in Eastern Nepal. Randomization will occur at ward level, the smallest administrative level in Nepal, with 72 enrolled wards allocated to Group PM+ or to EUC (ratio 1:1). Group PM+ consists of five approximately 2.5-h sessions, in which participants are taught techniques to manage their stressors and problems, and is delivered by trained and supervised community psychosocial workers (CPSWs). EUC consists of a family meeting with (a) basic information on adversity and mental health, (b) benefits of getting support, (c) information on seeking services from local health facilities with mhGAP-trained staff. The primary outcome measure is levels of individual psychological distress at endline (equivalent to 20 ± 1 weeks after baseline), measured by the General Health Questionnaire (GHQ-12). Secondary outcome measures include levels of functioning, depressive symptoms, post-traumatic stress disorder symptoms, levels of social support, somatic symptoms, and ways of coping. We hypothesize that skills acquired will mediate any impact of the intervention. DISCUSSION This c-RCT will contribute to the growing evidence-base for transdiagnostic psychological interventions delivered by non-specialists for people in communities affected by adversity. If Group PM+ is proven effective, the intervention manual will be released for use, giving the opportunity for further adaptation and implementation of the intervention in diverse settings with communities that require better access to psychological interventions. TRIAL REGISTRATION ClinicalTrials.gov, NCT03747055.
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Affiliation(s)
- Edith Van't Hof
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Manaswi Sangraula
- Transcultural Psychosocial Organization Nepal, Baluwatar, Kathmandu, Nepal
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization Nepal, Baluwatar, Kathmandu, Nepal.
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Kedar Marahatta
- World Health Organization, Country Office for Nepal, Kathmandu, Nepal
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Pragya Shrestha
- Transcultural Psychosocial Organization Nepal, Baluwatar, Kathmandu, Nepal
| | | | - Brandon A Kohrt
- Transcultural Psychosocial Organization Nepal, Baluwatar, Kathmandu, Nepal
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA
| | - Mark J D Jordans
- Transcultural Psychosocial Organization Nepal, Baluwatar, Kathmandu, Nepal
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neurosciences, King's College London, London, UK
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Aldridge LR, Garman EC, Luitel NP, Jordans MJD. Impact of a district mental health care plan on suicidality among patients with depression and alcohol use disorder in Nepal. PLoS One 2020; 15:e0231158. [PMID: 32255802 PMCID: PMC7138320 DOI: 10.1371/journal.pone.0231158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/25/2019] [Accepted: 03/17/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Large scale efforts to expand access to mental healthcare in low- and middle-income countries have focused on integrating mental health services into primary care settings using a task sharing approach delivered by non-specialist health workers. Given the link between mental disorders and risk of suicide mortality, treating common mental disorders using this approach may be a key strategy to reducing suicidality. METHODS AND FINDINGS The Programme for Improving Mental Health Care (PRIME) evaluated mental health services for common mental disorders delivered by non-specialist health workers at ten primary care facilities in Chitwan, Nepal from 2014 to 2016. In this paper, we present the indirect impact of treatment on suicidality, as measured by suicidal ideation, among treatment and comparison cohorts for depression and AUD using multilevel logistic regression. Patients in the treatment cohort for depression had a greater reduction in ideation relative to those in the comparison cohort from baseline to three months (OR = 0.16, 95% CI: 0.05-0.59; p = 0.01) and twelve months (OR = 0.31, 95% CI: 0.08-1.12; p = 0.07), with a significant effect of treatment over time (p = 0.02). Among the AUD cohorts, there were no significant differences between treatment and comparison cohorts in the change in ideation from baseline to three months (OR = 0.64, 95% CI: 0.07-6.26; p = 0.70) or twelve months (OR = 0.46, 95% CI: 0.06-3.27; p = 0.44), and there was no effect of treatment over time (p = 0.72). CONCLUSION The results provide evidence integrated mental health services for depression benefit patients by accelerating the rate at which suicidal ideation naturally abates over time. Integrated services do not appear to impact ideation among people with AUD, though baseline levels of ideation were much lower than for those with depression and may have led to floor effects. The findings highlight the importance of addressing suicidality as a specific target-rather than an indirect effect-of treatment in community-based mental healthcare programs.
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Affiliation(s)
- Luke R. Aldridge
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Emily C. Garman
- Alan J F Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Mark J. D. Jordans
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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Akhtar A, Giardinelli L, Bawaneh A, Awwad M, Naser H, Whitney C, Jordans MJD, Sijbrandij M, Bryant RA. Group problem management plus (gPM+) in the treatment of common mental disorders in Syrian refugees in a Jordanian camp: study protocol for a randomized controlled trial. BMC Public Health 2020; 20:390. [PMID: 32216762 PMCID: PMC7098148 DOI: 10.1186/s12889-020-08463-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 02/03/2023] Open
Abstract
Background Accessing quality mental health care poses significant challenges for persons affected by adversity, especially in low- and middle-income countries where resources are scarce. To mitigate this, the World Health Organization has developed group problem management plus (gPM+), a low-intensity psychological intervention for adults experiencing psychological distress. gPM+ is a group-based intervention consisting of five-sessions, and can be delivered by non-specialist providers. This paper outlines the study protocol for a trial of gPM+ in Jordan. Methods We will conduct a single-blind, two-arm, randomized controlled trial in a Syrian refugee camp in Jordan. We aim to enrol 480 adults into the trial. Participants will be eligible for the trial if they screen positive for levels of psychological distress. Following screening, those eligible will be randomly assigned to receive the gPM+ intervention or enhanced treatment as usual. The primary outcome is reduction in levels of psychological distress at 3-months post-treatment. Secondary outcomes include anxiety, depression, prodromal psychotic symptoms, posttraumatic stress disorder, prolonged grief, daily functioning, economic effectiveness, and change in parenting behaviour. Secondary outcomes also include the reduction in psychological distress of the participant’s child. Discussion The trial aims to deliver a template for affordable and scalable psychosocial interventions that can readily be implemented in refugee settings, and that can benefit both the participant and their child. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12619001386123. Registered prospectively on 10/10/2019.
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Affiliation(s)
- Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, NSW, 2052, Australia.,Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | | | - Ahmad Bawaneh
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Manar Awwad
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | - Hadeel Naser
- Jordan Country Office, International Medical Corps, Amman, Jordan
| | | | - Mark J D Jordans
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, The Netherlands
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, 2052, Australia.
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Rajan S, Rathod SD, Luitel NP, Murphy A, Roberts T, Jordans MJD. Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal. BMC Health Serv Res 2020; 20:250. [PMID: 32213188 PMCID: PMC7093962 DOI: 10.1186/s12913-020-05094-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/09/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal. METHODS We analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more. RESULTS We classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7-22%, p < 0.0001) and $9 USD increase in OOP expenditures (95% CI $2-$17; p < 0.0001). People with depression sought most healthcare from pharmacists (30.1%) but reported the greatest expenditure on specialist doctors ($36 USD). CONCLUSIONS In this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.
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Affiliation(s)
- Selina Rajan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sujit D. Rathod
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nagendra P. Luitel
- Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Adrianna Murphy
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK
| | - Tessa Roberts
- Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London, SE5 8AF UK
| | - Mark J. D. Jordans
- Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London, SE5 8AF UK
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Brown FL, Aoun M, Taha K, Steen F, Hansen P, Bird M, Dawson KS, Watts S, el Chammay R, Sijbrandij M, Malik A, Jordans MJD. The Cultural and Contextual Adaptation Process of an Intervention to Reduce Psychological Distress in Young Adolescents Living in Lebanon. Front Psychiatry 2020; 11:212. [PMID: 32265759 PMCID: PMC7104812 DOI: 10.3389/fpsyt.2020.00212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/03/2020] [Indexed: 11/13/2022] Open
Abstract
Armed conflict leads to increased risk of emotional distress among children and adolescents, and increased exposure to significant daily stressors such as poverty and community and family violence. Unfortunately, these increased risks usually occur in the context of largely unavailable mental health services. There is growing empirical support that evidence-based treatment techniques can be adapted and delivered by non-specialists with high fidelity and effectiveness. However, in order to improve feasibility, applicability, and outcomes, appropriate cultural and contextual adaptation is essential when delivering in different settings and cultures. This paper reports the adaptation process conducted on a new World Health Organization psychological intervention-Early Adolescent Skills for Emotions (EASE)-for use in the north of Lebanon. Lebanon is a middle-income country that hosts the largest number of refugees per capita globally. We conducted: i) a scoping review of literature on mental health in Lebanon, with a focus on Syrian refugees; ii) a rapid qualitative assessment with adolescents, caregivers, community members, and health professionals; iii) cognitive interviews regarding the applicability of EASE materials; iv) a psychologist review to reach optimal and consistent Arabic translation of key terms; v) "mock sessions" of the intervention with field staff and clinical psychology experts; vi) gathering feedback from the Training of Trainers workshop, and subsequent implementation of practice sessions; and vii) gathering feedback from the Training of Facilitators workshop, and subsequent implementation of practice sessions. Several changes were implemented to the materials-some were Lebanon-specific cultural adaptations, while others were incorporated into original materials as they were considered relevant for all contexts of adversity. Overall, our experience with adaptation of the EASE program in Lebanon is promising and indicates the acceptability and feasibility of a brief, non-specialist delivered intervention for adolescents and caregivers. The study informs the wider field of global mental health in terms of opportunities and challenges of adapting and implementing low-intensity psychological interventions in settings of low resources and high adversity.
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Affiliation(s)
- Felicity L. Brown
- Research and Development Department, War Child Holland, Amsterdam, Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - May Aoun
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Karine Taha
- Research and Development Department, War Child Holland, Beirut, Lebanon
| | - Frederik Steen
- Research and Development Department, War Child Holland, Amsterdam, Netherlands
| | - Pernille Hansen
- The Reference Centre for Psychosocial Support, The International Federation of Red Cross and Red Crescent Societies, Copenhagen, Denmark
| | - Martha Bird
- The Reference Centre for Psychosocial Support, The International Federation of Red Cross and Red Crescent Societies, Copenhagen, Denmark
| | - Katie S. Dawson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | | | - Rabih el Chammay
- Department of Psychiatry, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon
| | - Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborative Center for Research and Dissemination of Psychological Interventions, Vrije Universiteit, Amsterdam, Netherlands
| | - Aiysha Malik
- Oxford Institute of Clinical Psychology Training, Warneford Hospital, University of Oxford, Oxford, United Kingdom
| | - Mark J. D. Jordans
- Research and Development Department, War Child Holland, Amsterdam, Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
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50
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Miller KE, Arnous M, Tossyeh F, Chen A, Bakolis I, Koppenol-Gonzalez GV, Nahas N, Jordans MJD. Protocol for a randomized control trial of the caregiver support intervention with Syrian refugees in Lebanon. Trials 2020; 21:277. [PMID: 32183862 PMCID: PMC7079443 DOI: 10.1186/s13063-020-4175-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/28/2019] [Accepted: 02/17/2020] [Indexed: 11/25/2022] Open
Abstract
Background There is evidence that chronic stress negatively impacts parenting among refugees and other war-affected communities. Persistent parental stress and distress may lead to unresponsive, anxious, or overly harsh parenting and a corresponding increase in emotional and behavior problems among children. Most parenting interventions emphasize the acquisition of knowledge and skills; however, this overlooks the deleterious effects of chronic stress on parenting. The Caregiver Support Intervention (CSI) aims to strengthen quality of parenting skills by lowering stress and improving psychosocial wellbeing among refugee caregivers of children aged 3–12 years, while also increasing knowledge and skills related to positive parenting. The CSI is a nine-session psychosocial group intervention delivered by non-specialist providers. It is intended for all adult primary caregivers of children in high-adversity communities, rather than specifically targeting caregivers already showing signs of elevated distress. Methods/design The primary objective of this study is to assess the effectiveness of the CSI through a parallel group randomized controlled study with Syrian refugee families in North Lebanon. Participants will be primary caregivers of children aged 3–12 years, with one index child per family. Families will be randomized to the CSI or a waitlist control group. A total of 240 families (480 caregivers) will be recruited into the study. Randomization will be at the family level, and CSI groups will be held separately for women and men. The study will be implemented in two waves. Outcomes for both arms will be assessed at baseline, post-intervention, and at a 3-month follow-up. The primary outcome is quality of parenting skills. Secondary outcomes include parental warmth and sensitivity, harsh parenting, parenting knowledge, and child psychosocial wellbeing. Putative mediators of the CSI on parenting are caregiver stress, distress, psychosocial wellbeing, and stress management. Discussion This trial may establish the CSI as an effective intervention for strengthening parenting in families living in settings of high adversity, particularly refugee communities. Trial registration International Society for the Registration of Clinical Trials, ISRCTN22321773. Registered on 5 August 2019
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Affiliation(s)
- Kenneth E Miller
- Research and Development, War Child Holland, Amsterdam, The Netherlands.
| | - Maguy Arnous
- War Child Holland Lebanon Offices (Beirut and Tripoli), Beirut and Tripoli, Lebanon
| | - Fadila Tossyeh
- War Child Holland Lebanon Offices (Beirut and Tripoli), Beirut and Tripoli, Lebanon
| | - Alexandra Chen
- Psychology Department, Harvard University, Cambridge, MA, USA
| | - Ioannis Bakolis
- Institute of Psychiatry, Psychology, and Neuroscience at King's College London, London, UK
| | | | | | - Mark J D Jordans
- Research and Development, War Child Holland, Amsterdam, The Netherlands.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, Netherlands
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