Policy Makers’ Tough Choices for Psychological Interventions in Global Mental Health

Kohrt, Brandon A.; Chammay, Rabih El; Dossen, S Benedict

doi:10.1001/jamapsychiatry.2019.4267

Cited by 4 publications

(4 citation statements)

References 11 publications

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“…PM+, delivered in an individual format, has shown benefit in Pakistan [ 5 ] and Kenya [ 6 ], and a group version (Group PM+), also consisting of 5 sessions, has shown benefit among women in Pakistan [ 7 ]. As PM+ is increasingly used globally, including in the United States in response to the COVID-19 pandemic [ 8 ], one of the key questions is determining the mechanisms of action by which benefits are achieved so these mechanisms can be emphasized when adapting and implementing in new settings [ 9 ]. Therefore, in addition to this being the second trial of Group PM+, it is the first trial of PM+ evaluating mechanisms of action.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

et al. 2021

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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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Section: Introductionmentioning

confidence: 99%

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

et al. 2021

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“…Yet, it is not feasible to perform extensive adaptations and run new randomised controlled trials (RCT) in every single setting where a new mental health or psychosocial intervention is going to be deployed. That said, the variability in outcomes means that one cannot assume that interventions will be effective – and what may be going wrong when they are not effective – when scaled beyond the original effectiveness RCT (Kohrt et al ., 2020 ). Unfortunately, there is not a minimum set of guidelines for what to monitor in the scale-up process to measure if and why or why not an intervention is working.…”

Section: Introductionmentioning

confidence: 99%

Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact

Jordans

Kohrt

2020

Epidemiol Psychiatr Sci

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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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“…In addition to measuring outcomes, the implementation process should be documented, as well. Without documenting implementation, it is difficult to determine if an unsuccessful intervention is due to the intervention not being effective or lack of fidelity when delivering the intervention ( Jordans & Kohrt, 2020 ; Kohrt, El Chammay, et al, 2020 ). Moreover, assessing implementation is vital to determine that the cultural adaptations were actually enacted in delivery of the intervention.…”

Section: Reporting Criteriamentioning

confidence: 99%

Reporting Cultural Adaptation in Psychological Trials – The RECAPT criteria

Heim

Mewes

Ramia

et al. 2021

Clin. Psychol. Eur.

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Background There is a lack of empirical evidence on the level of cultural adaptation required for psychological interventions developed in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups. This lack of evidence is partly due to insufficient documentation of cultural adaptation in psychological trials. Standardised documentation is needed in order to enhance empirical and meta-analytic evidence. Process A “Task force for cultural adaptation of mental health interventions for refugees” was established to harmonise and document the cultural adaptation process across several randomised controlled trials testing psychological interventions for mental health among refugee populations in Germany. Based on the collected experiences, a sub-group of the task force developed the reporting criteria presented in this paper. Thereafter, an online survey with international experts in cultural adaptation of psychological interventions was conducted, including two rounds of feedback. Results The consolidation process resulted in eleven reporting criteria to guide and document the process of cultural adaptation of psychological interventions in clinical trials. A template for documenting this process is provided. The eleven criteria are structured along A) Set-up; B) Formative research methods; C) Intervention adaptation; D) Measuring outcomes and implementation. Conclusions Reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability.

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Policy Makers’ Tough Choices for Psychological Interventions in Global Mental Health

Cited by 4 publications

References 11 publications

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact

Reporting Cultural Adaptation in Psychological Trials – The RECAPT criteria

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