Practical and evidence-based

interventions for NGOs/PVOs to

address mental health issues in

children

Judith Bass, PhD, MPH

Department of Mental Health

Bill Weiss, DrPH MA

Department of International Health

Johns Hopkins University School of Public Health

Applied Mental Health Research Group (AMHR)

GLOBAL MENTAL HEALTH

Low and Middle Income Countries

Risks for Mental Health Problems in LMIC

• Armed conflict and past trauma can result in serious

mental health problems

• Poverty, HIV and other chronic conditions increase risk

for mental health problems

• There are 14.8 million youth orphaned by AIDS in sub-

Saharan Africa, with numbers predicted to increase.

– HIV-related stressors, abuse, lack of social

support, neglect leads to mental health problems

and risky sexual behavior.

Global mental health

treatment GAP

• MH disorders account for approximately 1/3 of years lived with disability (WHO, 2008).

• Depression 3rd on global burden of disease

• Despite this – 90% of those in need do not receive treatment.

Treatment Gap: Children

For each child with need…

.16% receive treatment

Saraceno et al., 2007

Global Mental Health and Psychosocial

Support (MHPSS)

Most commonly reported activities are:• Provision of child-friendly spaces• Support of community-initiated social

supports• Non-specific counseling for

individuals and family• Lack of empirically supported

activities

Rarely are MHPSS programs comprehensively evaluated

Specialized

services

Focused non-

specialized

supports

Strengthening community

and family supports

Social considerations in basic

services and security

WHAT DO WE KNOW

ABOUT WHAT WORKS

Evidence-Based Treatments

• Conditions set by APA, 1996

– Manual-based

– Sample characteristics detailed

– Tested in a randomized clinical trial

– At least two different investigatory teams

must demonstrate intervention effects

Current Research in Evidence-Based

Treatments for Adults in LMIC

RCTs demonstrate that EBTs can be implemented in

LMIC with positive clinical outcomes

• (e.g. Bolton et al., 2007; Patel et al., 2010, Rahmen et al., 2008)

WHO mhGAP recommended EBTs

**But does not address HOW to do this!

Evidence-Based Treatments for

Children/Adolescents based on

Research from the West

• Anxiety (GAD, OCD, SAD)– Cognitive-Behavioral Therapy

– Psychodynamic – may be effective after 2+ years

• Depression (MDD)– Cognitive-Behavioral Therapy

– Medication

– Interpersonal Therapy For Depression (IPT-A)

• Conduct Problems (ODD, CD)– Parent Training

– Behavioral Programs

– Multi-level, intensive (primarily for adolescents)

Evidence-Based Treatment Research

for Child-Adolescents in LMIC

• Trauma-Focused Cognitive Behavioral therapy

(TF-CBT)

– Completed Feasibility studies:• Cambodia

• Zambia

– Completed RCT in Congo

– Ongoing RCTs (2) in Zambia

– Ongoing RCT in Tanzania (for traumatic grief)

Our DIME Approach

DIME:

– Design

– Implementation

– Monitoring

– Evaluation

– **Uses empirically

Based assessments

And treatment

To provide a single logical approach to the measurement and evaluation

needs of programs, to result in effective and accessible services

Comparison with “Typical” CS Project

• More emphasis on qualitative research at the start

– Learn local mental health concepts and local priority issues

– Use this information to develop the quantitative tools

– Use this information to identify appropriate interventions

• More emphasis of development/validation of instruments

– Often have to design new sections/items

– Adapt/validate concepts from Western instruments

• More emphasis on randomized trials

– Many interventions without an evidence base

– Few proven interventions with „local‟ evidence base

• More emphasis on learning about unintended results

– Positive and negative results

– Qualitative followed by quantitative methods

IMPLEMENTATION

STRATEGIES IN GLOBAL

MENTAL HEALTH

1. Apprenticeship Model of Training and Supervision

2. Common Elements Treatment Approach (CETA)

3. Implementation with safety for suicide

APPRENTICESHIP MODEL

OF TRAINING AND

SUPERVISION

Implementation Barrier to

Addressing Treatment Gap

in LMIC

Mental

health

professionals

“Task Sharing Approach”

Lay Counselors—Little or No Mental Health Training with Supervisors And more Highly TrainedPersonnel Overseeing

Patel, 2009

Apprenticeship Model

Based on Research in US

One-off trainings ineffective for behavior change.

“Train and hope” approach does not work (e.g., Kelly et

al., 2000)

Ongoing supervision with on-the-job coaching critical (Beidas &

Kendall, 2010)

Thanks to Mary McKay for the cartoon

Apprenticeship Model of

Training and Supervision

A detailed implementation process that can be used for task-sharing

MURRAY et al., 2011

Apprenticeship Model

Smallest Part

Apprenticeship Model

• Continuous feedback cycles

• Regular cross-cultural adaptations (by LOCAL counselors)

– Balancing Fidelity (expert) and Flexibility (counselors)

COMMON ELEMENTS

TREATMENT APPROACH

(CETA)

• Most target specific syndrome (i.e. depression, anxiety, PTSD)

• Training in multiple EBTs is unfeasible given resources (financial, personnel.. etc.)

• Requires larger referral system• Comborbidity is common

Evidence-Based Practices – Single Disorder

focus

Common Elements Treatment Approach

(CETA)

• A manual-based treatment built from common

elements of EBTs

• Includes components for multiple common mental

disorders (anxiety, depression, PTSD + behavior

problems in children)

• Selection of components to add specific to client‟s

needs based on symptom presentation at intake

CETA Common Components in our current

trials

• Engagement– Encourages participation, works with client to identify and manage

barriers to participation, brings in family as appropriate

• Psychoeducation– Provides information about the program (# sessions, expectations)

– Normalizes and validates current symptoms and problems

• Cognitive coping/restructuring– Helps client understand associations between thoughts, feelings and

behavior

– Teaches client to evaluate and restructure thinking to be more accurate and/or helpful

• Imaginal gradual exposure– Helps client to face memories that evoke fear and avoidance through

talking about details of the memories and the associated thoughts and feelings

– Going through this process results in gradual desensitization to the memories

CETA Selective Components

• Behavioral activation (for depressive symptoms)

– Helps client identify and engage in pleasurable, mood-boosting, or

functionality-increasing activities

• Relaxation (for anxiety symptoms)

– Teaches strategies to reduce tension, uses local practices as well as

suggesting new options when appropriate.

• In Vivo exposure (for trauma symptoms when safety ok)

– Works with client to directly face innocuous triggers/reminders in the

clients environment

– Going through this process results in gradual desensitization to the

triggers/reminders

CETA assessments and planning/services

• Suicide/homicide/danger assessment and planning

– Assessing client risk for danger to self/others

– Developing a focused plan with the client and client‟s family (when

appropriate) to keep client safe

– Additional referral when needed

• Alcohol misuse assessment and brief intervention

– Assessing client misuse of alcohol

– Utilizes concepts of motivational interviewing to get client buy-in to

change substance misuse behavior

SAFETY: SUICIDE

IDEATION MANAGEMENT

– Qualitative research shows critical reason for NOT implementing Mental Health programs in LMIC….

identification of a serious problem

(e.g., suicidal thoughts/behaviors)

with no where to refer and no training

in how to manage.

Implementation Barrier

Safety

A detailed process of how to develop safety plans in LMIC

No MH SYSTEMS

Individualized for setting

Appropriate for lay counselors

Safety protocol

Initial responses by the counselor

· The counselor finishes the checklist of symptoms form, and the follow-up form. Asks

questions directly to the client with suicidal or homicidal ideation, who is victim of

domestic violence or with psychosis or is abusing substances.

· If the client indicates suicidal ideas….

Further evaluate:

a. “Have you ever tried to end your life?”

b. “Are you thinking about ending your life?”

c. “Do you have a plan to end your life?”

d. “Do you have access to that plan, in other words, do you have the means to execute your

plan?”

If the client answers YES to any of these questions, please move on to the following steps:-

· Say to the client: "Can we agree together that if you have thoughts of killing yourself,

you will speak to me personally before carrying out a plan to harm yourself?" “How can

we be sure that you be able to speak with me?”

· If the person says "yes" or "I don't know," to the questions c and d, Say: "What I am

hearing is that you are in a lot of pain right now and thinking of ending your life, so I

want you to come with me to SHARPZ offices right now and get some help to feel better

right away. I will make sure you get there safely. Is there a family member or someone I

can call to go with you?" Or tell the person you will go with them yourself.

· Arrange for the person to be accompanied to SHARPZ, and call ahead to tell Sr Roda

that you are coming.

· If the person refuses, then ask the person to wait there with someone while you call Sr.

Roda in another room to report that the person has threatened suicide. Ask Sr Roda to

come and accompany the person to the SHARPZ offices.

Talk to your supervisor while the client is still working with you. Decide, or agree on a plan

BEFORE the client leaves.

RESULTS FROM SELECT

AMHR TRIALS

2 AMHR Trials:

1. Apprenticeship Model

2. Safety

Karbala

Mae Sot

Southern Iraq CETA Counselors

• N=12 counselors

• Medics or nurses

• No formal mental

health training

• In MoH clinics

• Task sharing

– Supervisors

were

psychiatrists at

torture

treatment

centers

Training involved active participation

Use of Apprenticeship Model

S. Iraq CETA Study Results

Implementation Challenges

During RCT

• Cultural

– Females not allowed to travel or meet with male clients alone

– Female clients not allowed to meet alone, and needed “permission” to participate

• Client mobility and security

– Consistent bombings throughout trial

– Inability to travel, or increased time at checkpoints

CETA Trial: Mae Sot Thailand

Mae Sot

PRIOR RESEARCHElevated symptoms of depression, anxiety and PTSD among Karennirefugees (Cardoza et al., 2004)

High rates of reported traumatic events and related symptoms among Burmese dissidents in Thailand (Allden et al., 1996)

Mae Sot, Thailand CETA counselors

(Burmese refugees)

N=20 counselors

Identified by one of three local partner organizations

4 had past counseling experience

Req to be able to work part-time.

• Task sharing– Supervisors were

staff from NGOs: 1 medical doctor and 2 with supervisory experience – none had MH experience

0

0.2

0.4

0.6

0.8

1

1.2

1.4

baseline follow-up

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Dep

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Sym

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Depression Symptoms

CETA

Control

0

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Trauma-related symptoms

CETA

Control

0

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Female Function

CETA

Control

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Ave

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Imp

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Male Function

CETA

Control

Thailand Implementation Outcomes

• Feasibility

– Training:

• All but 1 counselor was able to learn CETA

• 3 (out of 4) local supervisors able to teach, coach

• 2 counselors needed to take additional practice case

– Study:

• All counselors continued onto study

• Fidelity

– Local supervisors‟ and trainers‟ notes suggest good fidelity to the model, as evidenced by moving from one component to the next and completing most of each component‟s steps.

• Acceptability

– Counselors and supervisors liked the model, found it helpful and effective

– Clients referred others in community

Implementation Challenges

During RCT

• Community understanding of mental health and research

– “I‟m not crazy”

– Randomization

• Client mobility and security

– Scheduling counseling sessions

– Drop out

– Inability to travel

• Organizational– “Turf issues”

– Lack of support/leadership from organizations

Acknowledgements

JHU team:

• Laura Murray, PhD (developed from her slides!)

• Paul Bolton, Bill Weiss, Courtland Robinson, Cate Lee, Emily

Haroz, Zayan Mahmooth

• Applied Mental Health Research Group:

• http://www.jhsph.edu/refugee/response_service/AMHR/

Iraq/Thailand-Burma project:

• Heartland Alliance,

Funder:

• USAID Victims of Torture Fund

Thank you!