Anna Chiumento

Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial

Importance The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. Objective To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. Design, Setting, and Participants A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Interventions Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. Main Outcomes and Measures Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). Results Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help (AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder (AMD, -3.41; 95% CI, -4.49 to -2.34). Conclusions and Relevance Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. Trial Registration anzctr.org.au Identifier: ANZCTR12614001235695.

Managing Ethical Challenges to Mental Health Research in Post-Conflict Settings.

Abstract Recently the World Health Organization (WHO) has highlighted the need to strengthen mental health systems following emergencies, including natural and manmade disasters. Mental health services need to be informed by culturally attuned evidence that is developed through research. Therefore, there is an urgent need to establish rigorous ethical research practice to underpin the evidence‐base for mental health services delivered during and following emergencies.

Problem Management Plus (PM+): pilot trial of a WHO transdiagnostic psychological intervention in conflict‐affected Pakistan

The mental health consequences of conflict and natural disaster are substantial and wide‐ranging1, 2. There is an urgent need for interventions by non‐specialist workers that can address a range of mental health problems3. The World Health Organization (WHO)s Problem Management Plus (PM+) is a brief transdiagnostic psychological intervention employing evidence‐based strategies of problem solving, behavioural activation, strengthening social support, and stress management4. We adapted the individual treatment format of this intervention for conflict‐affected Peshawar in Pakistan. It consisted of five face‐to‐face sessions, with a key feature of being affordable in most settings, because it can be offered not only by specialists but also by supervised non‐specialists with no prior training or experience in mental health care delivery. We used an apprenticeship (on‐the‐job learning) model for training and supervising the non‐specialists5, which involved an initial 6‐day training programme by a master trainer to local mental health specialists, who in turn provided an 8‐day training programme to six non‐specialists. Training of both supervisors and non‐specialists was followed by four weeks of practice under supervision of the local trainers. The local trainers themselves were supervised 3‐weekly through audio calls by the master trainer, building skills in the intervention as well as in training and supervision. All non‐specialists were evaluated for their competency by independent assessors using a competency rating tool evaluating basic helping skills and use of PM+ strategies through observation of specially designed role plays. Competency was rated using a 5‐point scale. In total, four out of six achieved scores indicating competency in all basic helping skills and five out of six achieved all competency scores on PM+ strategies. Following additional training and supervision, all non‐specialists demonstrated adequate proficiency in requisite skills. We conducted a single‐blind pilot randomized controlled trial (RCT) to explore the feasibility and acceptability of the intervention in Peshawar. PM+ was compared to enhanced treatment as usual, consisting of management by primary care physician who received one day of basic training in treatment of common mental disorders. The study was conducted from March to May 2014 in two primary care centres in Gulbahar Union Council, a low‐income peri‐urban locality in Peshawar district. Participants were primary care attenders aged 18 or above, referred for screening by the primary care physician. Screening was conducted by trained members of the research team following informed consent to recruit persons with both marked distress and impairment. Invited participants scored: a) 2 or above on the General Health Questionnaire (GHQ‐12)6, a 12 item questionnaire of general psychological distress with a 4‐point scale ranging from 0 to 3 scored bi‐modally when used as a screener (possible range 0‐12), and b) 17 or above on the WHO Disability Assessment Schedule (WHODAS 2.0)7, a screener for functional impairment with 12 items measured on a scale ranging from 1 to 5 (possible range 12‐60). We excluded individuals with imminent suicide risk, severe cognitive impairment (e.g., severe intellectual disability or dementia) or with expressed acute needs/protection risks (e.g., recent abandonment by husband and his family). We also excluded individuals who reported having experienced a major traumatic event during the past month and individuals with severe mental disorder (psychotic disorders, substance dependence). Individuals meeting the exclusion criteria were referred to specialist centres depending upon their needs. Ethical approvals were obtained from the Ethics Review Board at the Lady Reading Hospital, Peshawar, and WHOs Ethical Review Committee. Approval was also obtained from the district primary care administration. Participants were interviewed after voluntary written consent. Out of 1,286 people seen by a physician during the study period, 94 were referred for screening, 85 met study criteria, 81 were accessible, and 60 consented to participate in the trial. Randomization to the PM+ intervention or enhanced treatment as usual was performed by an independent researcher not involved in the project using computerized software on a 1:1 basis, stratified for gender. Nine out of 60 (15%) – five from the intervention arm and four from the control arm – were lost to follow‐up. The groups were well‐balanced at baseline for demographic and clinical variables. The primary outcome, assessed by independent raters, was psychological distress, measured by GHQ‐12 with scores being the total sum across 12 items (possible range 0‐36). Other outcomes included: functioning, measured using the 12‐item interviewer‐administered screener version of the WHODAS 2.0; and post‐traumatic stress symptoms, measured using the PTSD Checklist for DSM‐5 (PCL‐5)8, which is a 20‐item checklist corresponding to the twenty DSM‐5 PTSD symptoms in the last week, with items rated on a 0‐4 scale (possible range 0‐80). The intervention had high uptake, with 22/30 (73%) completing all sessions. The intervention arm showed improvement in functioning (mean WHODAS 2.0 scores reduced from 17.7 ± 9.2 to 6.6 ± 6.1 vs. 17.0 ± 10.5 to 11.3 ± 10.4 in controls) and in post‐traumatic stress symptoms (mean PCL‐5 scores reduced from 34.2 ± 20.1 to 9.8 ± 9.1 vs. 32.3 ± 17.1 to 19.5 ± 18.5 in controls). Due to skewed distribution and variance heterogeneity of the outcome variable, log‐linear regression was carried out. After adjustment of baseline scores, the results showed a reduction of 90% in geometric mean within the intervention group (95% CI: 90.4%‐91.7%, p=0.04) in WHODAS 2.0 scores and a reduction of 92% (95% CI: 91.2%‐92.3%, p=0.02) in post‐traumatic stress symptoms. There was no significant change in GHQ‐12 scores. On qualitative evaluation of a sub‐sample of participants and primary care staff, we found that the intervention was perceived as useful, and was successfully integrated into primary care centres. As this was a pilot study with a small sample size, recruited through primary care physician referral, and no power calculations were carried out, the findings and their generalizability warrant a cautious interpretation. However, a successful conduction in challenging settings, with adequate enrolment rate, a low drop‐out, and balanced randomization provides evidence that RCTs are feasible in such settings. The intervention delivery through non‐specialists with no prior mental health care experience and the encouraging results demonstrate the feasibility of the task shifting approach, and are consistent with previous reports9, 10. The results of this pilot study should encourage further adaptation and large‐scale fully‐powered RCTs of this new, transdiagnostic psychological intervention4. Atif Rahman1,2, Naila Riaz3, Katie S. Dawson4, Syed Usman Hamdani2, Anna Chiumento1, Marit Sijbrandij5, Fareed Minhas6, Richard A. Bryant4, Khalid Saeed7, Mark van Ommeren8, Saeed Farooq3 1University of Liverpool, Liverpool, UK; 2Human Development Research Foundation, Islamabad, Pakistan; 3Lady Reading Hospital, Peshawar, Pakistan; 4University of New South Wales, Sydney, Australia; 5VU University Amsterdam, Amsterdam, The Netherlands; 6Institute of Psychiatry, Rawalpindi, Pakistan; 7Mental Health and Substance Abuse Unit, Regional Office for the Eastern Mediterranean Region, World Health Organization, Cairo, Egypt; 8Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland

Ethical standards for mental health and psychosocial support research in emergencies: Review of literature and current debates

BackgroundResearch in emergencies is needed to understand the prevalence of mental health and psychosocial problems and strengthen the evidence base for interventions. All research - including operational needs assessments, programme monitoring and evaluation, and formal academic research - must be conducted ethically. While there is broad consensus on fundamental principles codified in research ethics guidelines, these do not address the ethical specificities of conducting mental health and psychosocial support (MHPSS) research with adults in emergencies. To address this gap, this paper presents a review of multidisciplinary literature to identify specific ethical principles applicable to MHPSS research in emergencies.DiscussionFifty-nine sources meeting the literature review inclusion criteria were analysed following a thematic synthesis approach. There was consensus on the relevance of universal ethical research principles to MHPSS research in emergencies, including norms of participant informed consent and protection; ensuring benefit arises from research participation; researcher neutrality, accountability, and safety; and the duty to ensure research is well designed and accounts for contextual factors in emergency settings.We go onto discuss unresolved issues by highlighting six current debates relating to the application of ethics in emergency settings: (1) what constitutes fair benefits?; (2) how should informed consent be operationalised?; (3) is there a role for decision making capacity assessments?; (4) how do risk management approaches impact upon the construction of ethical research?; (5) how can ethical reflection best be achieved?, and (6) are ethical review boards sufficiently representative and equipped to judge the ethical and scientific merit of emergency MHPSS research? Underlying these debates is a systemic tension between procedural ethics and ethics in practice.Summary and recommendationsIn summary, underpinning the literature is a desire to ensure the protection of participants exposed to emergencies and in need of evidence-based MHPSS. However, there is a lack of agreement on how to contextualise guidelines and procedures to effectively maximise the perspectives of researchers, participants and ethical review boards. This is a tension that the field must address to strengthen ethical MHPSS research in emergencies.

School‐based mental health service for refugee and asylum seeking children: multi‐agency working, lessons for good practice

Purpose – Following a description of the Haven Project: a school based Child and Adolescent Mental Health Service (CAMHS) for refugee children in Liverpool, this paper aims to raise awareness of a multiagency model for replication across community mental health services.Design/methodology/approach – Using semi‐structured interviews with school head teachers and outcome measures of group therapeutic sessions, a short service review has been conducted, set against background literature, identifying refugee statistics and highlighting mental health policy imperatives that advocate multi‐agency working.Findings – The findings illustrate that refugee children are more likely and prefer to access a school based mental health service than a CAMH clinic. Links between schools and CAMHS facilitate mutual understanding of different agencies working in the interests of all children and, using outcome measures and quotes, the evidence indicates that the service achieves its aim: improvement in refugee childrens ment...

Evaluating feasibility and acceptability of a group WHO trans-diagnostic intervention for women with common mental disorders in rural Pakistan: a cluster randomised controlled feasibility trial.

AIMS The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan. METHODS This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews. RESULTS The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention. CONCLUSION This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.

Mediated research encounters: methodological considerations in cross-language qualitative interviews

Given increasing globalisation, the continuing prevalence of emergencies, and the importance of rigorous research to ensure the mental health needs of populations exposed to emergencies are effectively met, cross-language research will continue to arise. Drawing upon the lead author’s experience of conducting a cross-language qualitative study in three post-conflict settings in South Asia, this article discusses methodological considerations raised when interviewing with interpreters. These include considering interpreter positionality and matching; the approach to cross-language mediation during interviews; and assessing the quality of interpreter facilitated interviews. Drawing upon approaches taken in this study, the important choices researchers face about how these are managed are examined, considering the roles of researcher and interpreter positionality, the research context, and the epistemological underpinnings of the research. The discussion further illuminates the interrelated methodological, practical and ethical considerations for other researchers embarking upon similar research.

Addressing culture and context in humanitarian response: preparing desk reviews to inform mental health and psychosocial support.

Delivery of effective mental health and psychosocial support programs requires knowledge of existing health systems and socio-cultural context. To respond rapidly to humanitarian emergencies, international organizations often seek to design programs according to international guidelines and mobilize external human resources to manage and deliver programs. Familiarizing international humanitarian practitioners with local culture and contextualizing programs is essential to minimize risk of harm, maximize benefit, and optimize efficient use of resources. Timely literature reviews on traditional health practices, cultural beliefs and attitudes toward mental health and illness, local health care systems and previous experiences with humanitarian interventions can provide international practitioners with crucial background information to improve their capacity to work efficiently and with maximum benefit. In this paper, we draw on experience implementing desk review guidance from the World Health Organization (WHO) and UNHCR, the United Nations Refugee Agency (2012) in four diverse humanitarian crises (earthquakes in Haiti and Nepal; forced displacement among Syrians and Congolese). We discuss critical parameters for the design and implementation of desk reviews, and discuss current challenges and future directions to improve mental health care and psychosocial support in humanitarian emergencies.

Online interviewing with interpreters in humanitarian contexts

ABSTRACT Purpose: Recognising that one way to address the logistical and safety considerations of research conducted in humanitarian emergencies is to use internet communication technologies to facilitate interviews online, this article explores some practical and methodological considerations inherent to qualitative online interviewing. Method: Reflections from a case study of a multi-site research project conducted in post-conflict countries are presented. Synchronous online cross-language qualitative interviews were conducted in one country. Although only a small proportion of interviews were conducted online (six out of 35), it remains important to critically consider the impact upon data produced in this way. Results: A range of practical and methodological considerations are discussed, illustrated with examples. Results suggest that whilst online interviewing has methodological and ethical potential and versatility, there are inherent practical challenges in settings with poor internet and electricity infrastructure. Notable methodological limitations include barriers to building rapport due to partial visual and non-visual cues, and difficulties interpreting pauses or silences. Conclusions: Drawing upon experiences in this case study, strategies for managing the practical and methodological limitations of online interviewing are suggested, alongside recommendations for supporting future research practice. These are intended to act as a springboard for further reflection, and operate alongside other conceptual frameworks for online interviewing.

A qualitative evaluation of a brief multicomponent intervention provided by lay health workers for women affected by adversity in urban Kenya

Background: Problem Management Plus (PM+) is a brief multicomponent intervention incorporating behavioral strategies delivered by lay health workers. The effectiveness of PM+ has been evaluated in randomized controlled trials in Kenya and Pakistan. When developing interventions for large-scale implementation it is considered essential to evaluate their feasibility and acceptability in addition to their efficacy. This paper discusses a qualitative evaluation of PM+ for women affected by adversity in Kenya. Methods: Qualitative interviews were conducted with 27 key informants from peri-urban Nairobi, Kenya, where PM+ was tested. Interview participants included six women who completed PM+, six community health volunteers (CHVs) who delivered the intervention, seven people with local decision making power, and eight project staff involved in the PM+ trial. Results: Key informants generally noted positive experiences with PM+. Participants and CHVs reported the positive impact PM+ had made on their lives. Nonetheless, potential structural and psychological barriers to scale up were identified. The sustainability of CHVs as unsalaried, volunteer providers was mentioned by most interviewees as the main barrier to scaling up the intervention. Conclusions: The findings across diverse stakeholders show that PM+ is largely acceptable in this Kenyan setting. The results indicated that when further implemented, PM+ could be of great value to people in communities exposed to adversities such as interpersonal violence and chronic poverty. Barriers to large-scale implementation were identified, of which the sustainability of the non-specialist health workforce was the most important one.