Alvin Kuowei Tay

Problem Management Plus (PM+): a WHO transdiagnostic psychological intervention for common mental health problems

Mental disorders are significant contributors to the global burden of disease (1). While they occur across all levels of socio-economic status, the majority of populations in low- and middle-income countries (LMICs) do not have access to effective psychological and pharmacological interventions (2). Key barriers to sustainable delivery of psychological therapies in LMICs include limited mental health funding and infrastructure, chronic shortage of mental health professionals, lack of treatments adapted to the local context, and challenges associated with training and supervision. Implementation of low-intensity psychological interventions by trained para-professionals is one potential solution to this problem (3,4) which is receiving significant attention as part of global mental health research agendas (e.g.,(5)). A number of low-intensity interventions have demonstrated clinical benefit and utility in high-income settings. For example, early analyses of the UK’s Improving Access to Psychological Therapies programme (IAPT,(6)) found a substantial reduction in depression and anxiety in people who attended at least two sessions of low-intensity interventions. Additionally, a recent meta-analysis challenged conventional thinking and provided support for low-intensity interventions as an effective treatment even for individuals with symptoms of severe depression (7). Evidence for the applicability of psychological interventions by non-specialists in LMICs is mounting (8,9). For instance, group interpersonal psychotherapy facilitated by local para-professionals has been shown to be effective in rural Uganda among depressed adults compared to usual care at six month follow-up (10). In rural Pakistan, Rahman et al (11) found that local community health workers could effectively deliver a locally adapted cognitive-behavioural intervention for perinatal depression. Mothers receiving the treatment demonstrated significant clinical improvement on depression symptoms, showed less disability and better overall and social functioning. Finally, a comparatively more intensive transdiagnostic intervention, the Common Elements Treatment Approach (CETA), has shown promising results for the treatment of symptoms of depression, anxiety and post-traumatic stress in Burmese refugees when delivered by para-professionals (12). To fill the gap between mental health needs and access to quality care, and extend the current research on low-intensity interventions in LMICs, the World Health Organization (WHO) – as part of its Mental Health Gap Action Programme (mhGAP) – has begun to develop and test low-intensity psychological interventions. The current paper focuses on one such intervention, named Problem Management Plus (PM+).

The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees

BackgroundThe validity of applying the construct of post-traumatic stress disorder (PTSD) across cultures has been the subject of contention. Although PTSD symptoms have been identified across multiple cultures, questions remain whether the constellation represents a coherent construct with an interpretable factor structure across diverse populations, especially those naïve to western notions of mental disorder. An important additional question is whether a constellation of Complex-PTSD (C-PTSD) can be identified and if so, whether there are distinctions between that disorder and core PTSD in patterns of antecedent traumatic events. Our study amongst West Papuan refugees in Papua New Guinea (PNG) aimed to examine the factorial structure of PTSD based on the DSM-IV, DSM-5, ICD-10 and ICD-11 definitions, and C-PTSD according to proposed ICD-11 criteria. We also investigated domains of traumatic events (TEs) and broader psychosocial effects of conflict (sense of safety and injustice) associated with the factorial structures identified.MethodsCulturally adapted measures were applied to assess exposure to conflict-related traumatic events (TEs), refugees’ sense of safety and justice, and symptoms of PTSD and C-PTSD amongst 230 West Papuan refugees residing in Port Morseby, PNG.ResultsConfirmatory factor analysis (CFA) supported a unitary construct of both ICD-10 and ICD-11 PTSD, comprising the conventional symptom subdomains of intrusion, avoidance, and hyperarousal. In contrast, CFA did not identify a unitary construct underlying C-PTSD. The interaction of witnessing murders and sense of injustice was associated with both the intrusion and avoidance domains of PTSD, but not with the unique symptom clusters characterizing C-PTSD.ConclusionsOur findings support the ICD PTSD construct and its three-factor structure in this transcultural refugee population. Traumatic experiences of witnessing murder associated with a sense of injustice were specifically related to the intrusion and avoidance domains of PTSD. The unitary nature of C-PTSD across cultures remains in question.

Associations of Conflict-Related Trauma and Ongoing Stressors with the Mental Health and Functioning of West Papuan Refugees in Port Moresby, Papua New Guinea (PNG)

Documentation is limited in relation to the mental health of the people of West Papua, a territory that has been exposed to decades-long political persecution. We examined associations of traumatic events (TEs) and current stressors with mental disorder and functioning, amongst 230 West Papuan refugees residing in six settlements in Port Morseby, Papua New Guinea (PNG). We used culturally adapted modules to assess exposure to TEs and mental disorders. Current stressors and functioning were assessed using modifications of measures developed by the World Health Organization (WHO). 129 of 230 respondents (56%) reported exposure to at least one traumatic event (TE), including: political upheaval (36.5%), witnessing or hearing about family members tortured and murdered (33.9%), and not being able to access medical care for family members (33%). One fifth of respondents (47, 20.4%) experienced exposure to high levels of TEs (16 to 23). 211 (91.7%) endorsed at least one or more ongoing stressors, including: exposure to illicit substance use in the community (91.7%), problems with safety and the protection of women (89.6%), no access to legal rights and citizenship (88.3%), and lack of adequate shelter and facilities (85.2%). A quarter (26.9%) met criteria for one or more current mental disorder, and 69.1% reported functional impairment ranging from mild to extreme. Mental disorder was associated with being male (adjusted odds ratio=2.00; 95% CI=1.01-3.97), and exposure to the highest category of ongoing stressors (AOR=2.89; 95% CI=1.08-7.72). The TE count showed a dose-response pattern in its relationship with functional impairment, the greatest risk (AOR=11.47; 95% CI=2.11-62.37) being for those experiencing the highest level of TE exposure (16-23 events). West Papuans living in settlements in Port Moresby reported a range of TEs, ongoing stressors and associated mental disorders characteristic of populations exposed to mass conflict and persecution, prolonged displacement, and ongoing conditions of extreme hardship.

Associations of mental distress with residency in conflict zones, ethnic minority status, and potentially modifiable social factors following conflict in Sri Lanka: a nationwide cross-sectional study

BACKGROUND The subject of post-conflict mental health lacks studies that are nationally representative or large enough to allow robust examination of levels of distress according to residency in geographical zones of conflict and ethnic minority status. We undertook a nationwide study in Sri Lanka to address these issues. METHODS We used tablet devices to survey 20,632 people across 18 of 25 districts in Sri Lanka, of which nine were purposefully selected and nine randomly selected districts. Based on their exposure to war and levels of population displacement, these districts were classified as being in the severe, moderate, or minimal conflict zones. Trained local fieldworkers did private interviews with the participants in the local language; responses were entered directly into the tablet devices. The questions assessed exposure to a wide range of stresses, including ongoing adversities, threat or protection issues, and service access factors, and respondents provided categorical responses (yes/no) to a list of items. We used the 25-item Hopkins Symptom Checklist to measure depression and anxiety in participants. We used multivariate analysis and calculated population-attributable fractions to estimate potential improvement in mental distress if modifiable factors were addressed. FINDINGS Our results showed a stepwise increase in symptoms of depression (10%, 33%, 40%) and anxiety (13%, 23%, 23%) across minimal, moderate, and severe conflict zones, respectively. Membership of an ethnic minority group was associated with depression (Tamil odds ratio [OR] 2·4 [95% CI 1·8-3·1], other ethnic minority OR 2·7 [2·1-3·6]) and anxiety (Tamil OR 1·5 [1·1-2·0], other ethnic minority OR 1·5 [1·2-1·8]). Other fixed characteristics associated with depression and anxiety were older age (both depression and anxiety; OR 2·7 [95% CI 2·0-3·7] for anxiety and 2·3 [1·7-3·0] for depression), being married (anxiety only; OR 1·5 [95% CI 1·1-2·1]), and time spent in camps for internally displaced people (anxiety only; OR 1·4 [95% CI 1·0-1·9]). Modifiable characteristics were threat or protection issues (depression OR 1·8 [95% CI 1·2-2·8], anxiety OR 1·8 [1·3-2·6]) and scarcity of food (depression OR 1·4 [1·2-1·6], anxiety OR 1·4 [1·2-2·7]), loss of job (OR 1·2 [95% CI 1·2-1·4] for anxiety), and proximity to army camps (OR 1·6 [95% CI 1·2-2·2] for depression). Allaying of safety concerns had the potential to reduce depression by 53% and anxiety by 57%, with other factors (removal of army camps from proximity and addressing food scarcity, loss of jobs and threat/protection issues) making smaller contributions to a reduction in depression and anxiety. INTERPRETATION Our findings offer a basis for detecting high-risk groups and provide directions in devising policies and programmes aimed at alleviating psychological distress in Sri Lanka. Restoration of safety seems to be crucial to mental health recovery. FUNDING Australian National University-Department of Immigration Border Protection Collaborative Research Program.

The coherence and correlates of intermittent explosive disorder amongst West Papuan refugees displaced to Papua New Guinea.

Questions remain about the nosological status of intermittent explosive disorder (IED) as a universal diagnosis. Cross-cultural studies are needed to establish whether IED symptoms form a coherent pattern and are distinguishable from other related symptom constellations. A study amongst a refugee population also allows further inquiry of the relationship between exposure to potentially traumatic events (PTEs) and other adversities with the IED constellation. In the present study amongst West Papuan refugees residing in Port Moresby, Papua New Guinea, we apply culturally adapted interview modules to assess symptoms of IED, post-traumatic stress disorder (PTSD), and depression, as well as the potentially traumatic events (PTEs) of conflict and ongoing adversity in the post-migration environment. Latent class analysis yielded a PTSD class (23%), a posttraumatic depressive class (14%), an IED class (12%), and a low/no symptom class (49%). Compared to the low/no-symptom class, the PTSD class had high levels of exposure to all PTE domains including childhood-related adversities, witnessing murder, human rights trauma, and traumatic losses, as well as ongoing adversity relating to displacement and separation from families, safety concerns, and lack of access to basic needs and health care. The posttraumatic depression class had greater exposure to traumatic losses and childhood-related adversities, higher levels of stress relating to material loss and deprivation, as well as to displacement and separation from families. In contrast, the IED class was distinguished only by the ongoing stress of displacement and separation from families in the homeland. Our findings provide support for the phenomenological distinctiveness of IED symptoms in this transcultural setting. Although not exclusive to IED, conditions of long-term displacement and separation appear to be a source of ongoing anger and explosive aggression amongst this population.

A high-risk group of pregnant women with elevated levels of conflict-related trauma, intimate partner violence, symptoms of depression and other forms of mental distress in post-conflict Timor-Leste

Women in post-conflict, low-income, post-conflict (LI-PC) countries are at risk of exposure to the traumatic events (TEs) of war and intimate partner violence (IPV), forms of stress that are known to lead to depression and other adverse mental health outcomes. We aimed to assess an index of exposure to these two forms of trauma to identify pregnant women attending antenatal clinics in conflict-affected Timor-Leste at high risk of depression and other forms of stress. A large, cross-sectional study of women in the second trimester of pregnancy was conducted in the four main government antenatal clinics in Dili district of Timor-Leste, between May 2014, and January 2015. The sample consisted of 1672 consecutive women, 3 to 6 months pregnant, with a response rate of 96%. We applied the Edinburgh Postnatal Depression Scale, the Kessler-10 psychological distress scale and the Harvard Trauma Questionnaire. IPV was assessed by the World Health Organisation measure. Composite categories of conflict-related TEs and severity of IPV showed a dose–response relationship with depressive symptoms: for exposure to four or more conflict-related TEs and severe psychological IPV, the adjusted odds ratio (AOR) was 3.95 (95% confidence interval (CI) 2.10–7.40); for four or more TEs and physical abuse, AOR 8.16 (95% CI 3.53–18.85); and for four or more TEs and severe psychological and physical abuse, AOR 9.78 (95% CI 5.31–18.02). For any mental distress, the AOR for four or more TEs and severe psychological abuse was 3.60 (95% CI 2.08–6.23); for four or more TEs and physical abuse 7.03 (95% CI 3.23–15.29); and for four or more TEs and severe psychological and physical abuse the AOR was 10.45 (95% CI 6.06–18.01). Of 184 women (11% of the sample) who reported ⩾4 TEs and either physical abuse alone or in combination with severe psychological abuse, 78 (42%) reached threshold for depressive symptoms and 93 (51%) for any mental distress, a 10-fold increase in depressive and other mental health symptoms. Priority should be directed to providing urgent mental health and social interventions for this group of women. Our findings offer a framework for a tiered approach to detection, guiding prevention and intervention strategies for IPV and associated mental health problems in low-income post-conflict countries.

Pathways to perinatal depressive symptoms after mass conflict in Timor-Leste: a modelling analysis using cross-sectional data

BACKGROUND The contributions of potentially traumatic events (PTEs) of mass conflict and post-traumatic stress disorder (PTSD) symptoms to perinatal depression in women living in low-income, post-conflict countries are unclear. We tested a model including these factors, intimate partner violence (IPV), and continuing adversity in women in Timor-Leste. METHODS Our modelling study used cross-sectional data from a sample of women living in two districts in Timor-Leste, identified through service registers, clinic records, village chiefs, and a door-to-door survey between June, 2012, and June, 2013. Eligible women were 3-6 months pregnant or 3-6 months postpartum. We assessed conflict-related PTEs, IPV, continuing adversity (poverty and insecurity), PTSD symptoms (the Harvard Trauma Questionnaire), and maternal depressive symptoms (the Edinburgh Postnatal Depression Scale [EPDS]) to develop a theoretical model to examine pathways leading directly and indirectly to depressive symptoms. FINDINGS We assessed 427 eligible women, of whom 258 (60%) were pregnant and 169 (40%) were postnatal. 87 (22%) of 387 women who were given the EPDS to complete were above the threshold used to define depression, and 40 (9%) of 427 were regarded as having PTSD. Our most comprehensive model showed that IPV and conflict-related deprivations led directly to depressive symptoms as well as to continuing adversity. Human rights-related trauma, witnessing murder, and a further path from IPV led to PTSD symptoms. Human rights-related trauma also led to continuing adversity. Paths from continuing adversity led to depressive symptoms, and PTSD symptoms, which was the predominant path. We noted a strong and unidirectional path from PTSD symptoms to depressive symptoms. INTERPRETATION Protection of women from human rights abuses, prevention of IPV, reduction in insecurity and poverty in the post-conflict period, and identification of and treatment for PTSD symptoms might reduce the risk of perinatal depression in post-conflict, low-income countries. Longitudinal studies are needed to confirm these findings. FUNDING Australian National Health and Medical Research Council.

Prevalence and correlates of explosive anger among pregnant and post-partum women in post-conflict Timor-Leste

Background Little is known about explosive anger as a response pattern among pregnant and post-partum women in conflict-affected societies. Aims To investigate the prevalence and correlates of explosive anger among this population in Timor-Leste. Method We assessed traumatic events, intimate partner violence, an index of adversity, explosive anger, psychological distress and post-traumatic stress disorder among 427 women (257 in the second trimester of pregnancy, 170 who were 3–6 months post-partum) residing in two districts of Timor-Leste (response >99%). Results Two-fifths (43.6%) had explosive anger. Levels of functional impairment were related to frequency of explosive anger episodes. Explosive anger was associated with age (>35 years), being married, low levels of education, being employed, traumatic event count, ongoing adversity and intimate partner violence. Conclusions A combination of social programmes and novel psychological therapies may assist in reducing severe anger among pregnant and post-partum women in conflict-affected countries such as Timor-Leste. Declaration of interest None. Copyright and usage

Symptoms of post-traumatic stress disorder, severe psychological distress, explosive anger and grief amongst partners of survivors of high levels of trauma in post-conflict Timor-Leste.

BACKGROUND Little is known about the mental health of partners of survivors of high levels of trauma in post-conflict countries. METHOD We studied 677 spouse dyads (n = 1354) drawn from a community survey (response 82.4%) in post-conflict Timor-Leste. We used culturally adapted measures of post-traumatic stress disorder (PTSD), psychological distress, explosive anger and grief. RESULTS Latent class analysis identified three classes of couples: class 1, comprising women with higher trauma events (TEs), men with intermediate TEs (19%); class 2, including men with higher TEs, women with lower TEs (23%); and class 3, comprising couples in which men and women had lower TE exposure (58%) (the reference group). Men and women partners of survivors of higher TE exposure (classes 1 and 2) had increased symptoms of explosive anger and grief compared with the reference class (class 3). Women partners of survivors of higher TE exposure (class 2) had a 20-fold increased rate of PTSD symptoms compared with the reference class, a pattern that was not evident for men living with women exposed to higher levels of trauma (class 1). CONCLUSIONS Men and women living with survivors of higher levels of trauma showed an increase in symptoms of grief and explosive anger. The manifold higher rate of PTSD symptoms amongst women living with men exposed to high levels of trauma requires replication. It is important to assess the mental health of partners when treating survivors of high levels of trauma in post-conflict settings.

The Relationship of Complex Post-traumatic Stress Disorder and Post-traumatic Stress Disorder in a Culturally Distinct, Conflict-Affected Population: A Study among West Papuan Refugees Displaced to Papua New Guinea

Background Controversy continues about the validity of the construct of complex post-traumatic stress disorder (C-PTSD). In particular, questions remain whether C-PTSD can be differentiated from post-traumatic stress disorder (PTSD) and, secondarily, other common mental disorders. The examination of these issues needs to be expanded to populations of diverse cultural backgrounds exposed to prolonged persecution. We undertake such an inquiry among a community sample of West Papuan refugees exposed to extensive persecution and trauma. Methods We interviewed over 300 West Papuan refugees using the Refugee-Mental Health Assessment Package to record symptoms of PTSD, C-PTSD, major depressive disorder (MDD), and complex grief (CG). We used first- and second-order confirmatory factor analysis (CFA) to test aspects of the convergent and discriminant validity of C-PTSD. Results The CFA analysis supported both a one-factor and two-factor model of PTSD and C-PTSD. Nested model comparison tests provide support for the parsimonious one-factor model solution. A second-order CFA model of PTSD and C-PTSD produced a poor fit. The modified three-factor multi-disorder solution combining a traumatic stress (TS) factor (amalgamating PTSD and C-PTSD), MDD, and CG yielded a good fit only after removing three CG domains (estrangement, yearning, and behavioral change), a model that produced large standardized residuals (>0.20). Conclusion The most parsimonious model yielded a single TS factor combining symptom domains of C-PTSD and PTSD in this culturally distinct community exposed to extensive persecution and conflict-related trauma. There may be grounds for expanding the scope of psychological treatments for refugees to encompass this wider TS response. Our findings are consistent with theoretical frameworks focusing on the wider TS reaction of refugees exposed to human rights-related traumas of mass conflict, persecution, and displacement.