Mark J. D. Jordans

School-Based Mental Health Intervention for Children Affected by Political Violence in Indonesia: A Cluster Randomized Trial

CONTEXT Little is known about the efficacy of mental health interventions for children exposed to armed conflicts in low- and middle-income settings. Childhood mental health problems are difficult to address in situations of ongoing poverty and political instability. OBJECTIVE To assess the efficacy of a school-based intervention designed for conflict-exposed children, implemented in a low-income setting. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized trial involving 495 children (81.4% inclusion rate) who were a mean (SD) age of 9.9 (1.3) years, were attending randomly selected schools in political violence-affected communities in Poso, Indonesia, and were screened for exposure (> or = 1 events), posttraumatic stress disorder, and anxiety symptoms compared with a wait-listed control group. Nonblinded assessment took place before, 1 week after, and 6 months after treatment between March and December 2006. INTERVENTION Fifteen sessions, over 5 weeks, of a manualized, school-based group intervention, including trauma-processing activities, cooperative play, and creative-expressive elements, implemented by locally trained paraprofessionals. MAIN OUTCOME MEASURES We assessed psychiatric symptoms using the Child Posttraumatic Stress Scale, Depression Self-Rating Scale, the Self-Report for Anxiety Related Disorders 5-item version, and the Childrens Hope Scale, and assessed function impairment as treatment outcomes using standardized symptom checklists and locally developed rating scales. RESULTS Correcting for clustering of participants within schools, we found significantly more improvement in posttraumatic stress disorder symptoms (mean change difference, 2.78; 95% confidence interval [CI], 1.02 to 4.53) and maintained hope (mean change difference, -2.21; 95% CI, -3.52 to -0.91) in the treatment group than in the wait-listed group. Changes in traumatic idioms (stress-related physical symptoms) (mean change difference, 0.50; 95% CI, -0.12 to 1.11), depressive symptoms (mean change difference, 0.70; 95% CI, -0.08 to 1.49), anxiety (mean change difference, 0.12; 95% CI, -0.31 to 0.56), and functioning (mean change difference, 0.52; 95% CI, -0.43 to 1.46) were not different between the treatment and wait-listed groups. CONCLUSIONS In this study of children in violence-affected communities, a school-based intervention reduced posttraumatic stress symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN25172408.

PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-Income Countries

Crick Lund and colleagues describe their plans for the PRogramme for Improving Mental health carE (PRIME), which aims to generate evidence on implementing and scaling up integrated packages of care for priority mental disorders in primary and maternal health care contexts in Ethiopia, India, Nepal, South Africa, and Uganda.

Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal.

CONTEXT Former child soldiers are considered in need of special mental health interventions. However, there is a lack of studies investigating the mental health of child soldiers compared with civilian children in armed conflicts. OBJECTIVE To compare the mental health status of former child soldiers with that of children who have never been conscripts of armed groups. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional cohort study conducted in March and April 2007 in Nepal comparing the mental health of 141 former child soldiers and 141 never-conscripted children matched on age, sex, education, and ethnicity. MAIN OUTCOME MEASURES Depression symptoms were assessed via the Depression Self Rating Scale, anxiety symptoms via the Screen for Child Anxiety Related Emotional Disorders, symptoms of posttraumatic stress disorder (PTSD) via the Child PTSD Symptom Scale, general psychological difficulties via the Strength and Difficulties Questionnaire, daily functioning via the Function Impairment tool, and exposure to traumatic events via the PTSD Traumatic Event Checklist of the Kiddie Schedule of Affective Disorders and Schizophrenia. RESULTS Participants were a mean of 15.75 years old at the time of this study, and former child soldiers ranged in age from 5 to 16 years at the time of conscription. All participants experienced at least 1 type of trauma. The numbers of former child soldiers meeting symptom cutoff scores were 75 (53.2%) for depression, 65 (46.1%) for anxiety, 78 (55.3%) for PTSD, 55 (39.0%) for psychological difficulties, and 88 (62.4%) for function impairment. After adjusting for traumatic exposures and other covariates, former soldier status was significantly associated with depression (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.31-4.44) and PTSD among girls (OR, 6.80; 95% CI, 2.16-21.58), and PTSD among boys (OR, 3.81; 95% CI, 1.06-13.73) but was not associated with general psychological difficulties (OR, 2.08; 95% CI, 0.86-5.02), anxiety (OR, 1.63; 95% CI, 0.77-3.45), or function impairment (OR, 1.34; 95% CI, 0.84-2.14). CONCLUSION In Nepal, former child soldiers display greater severity of mental health problems compared with children never conscripted by armed groups, and this difference remains for depression and PTSD (the latter especially among girls) even after controlling for trauma exposure.

Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict – a systematic review of findings in low‐ and middle‐income countries

BACKGROUND Researchers focused on mental health of conflict-affected children are increasingly interested in the concept of resilience. Knowledge on resilience may assist in developing interventions aimed at improving positive outcomes or reducing negative outcomes, termed promotive or protective interventions. METHODS We performed a systematic review of peer-reviewed qualitative and quantitative studies focused on resilience and mental health in children and adolescents affected by armed conflict in low- and middle-income countries. RESULTS Altogether 53 studies were identified: 15 qualitative and mixed methods studies and 38 quantitative, mostly cross-sectional studies focused on school-aged children and adolescents. Qualitative studies identified variation across socio-cultural settings of relevant resilience outcomes, and report contextually unique processes contributing to such outcomes. Quantitative studies focused on promotive and protective factors at different socio-ecological levels (individual, family-, peer-, school-, and community-levels). Generally, promotive and protective factors showed gender-, symptom-, and phase of conflict-specific effects on mental health outcomes. CONCLUSIONS Although limited by its predominantly cross-sectional nature and focus on protective outcomes, this body of knowledge supports a perspective of resilience as a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk- and protective factors with known impacts on mental health. Given the complexity of findings in this population, we conclude that resilience-focused interventions will need to be highly tailored to specific contexts, rather than the application of a universal model that may be expected to have similar effects on mental health across contexts.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial

BACKGROUND In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

Background Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers

BackgroundRecent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC).Model and case presentationsThis paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors.EvaluationWe review the challenges experienced with this model, and propose some possible solutions.DiscussionWe describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature.ConclusionIn our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions.

Social ecology of child soldiers: Child, family, and community determinants of mental health, psychosocial well-being, and reintegration in Nepal

This study employed a social ecology framework to evaluate psychosocial well-being in a cross-sectional sample of 142 former child soldiers in Nepal. Outcome measures included the Depression Self Rating Scale (DSRS), Child Posttraumatic Stress Disorder Symptom Scale (CPSS), and locally developed measures of functional impairment and reintegration. Hierarchical linear modeling was used to examine the contribution of factors at multiple levels. At the child level, traumatic exposures, especially torture, predicted poor outcomes, while education improved outcomes. At the family level, conflict-related death of a relative, physical abuse in the household, and loss of wealth during the conflict predicted poor outcomes. At the community level, living in high caste Hindu communities predicted lack of reintegration supports. Ultimately, social ecology is well suited to identify intervention foci across ecological levels based on community differences in vulnerability and protective factors.

Political violence and mental health: a multi-disciplinary review of the literature on Nepal.

Implementation of current international consensus guidelines regarding mental health and psychosocial support in emergencies requires the consideration of findings from both the medical and social sciences. This paper presents a multi-disciplinary review of reported findings regarding the relations between political violence, mental health and psychosocial wellbeing in Nepal. A systematic search of six databases resulted in the identification of 572 studies, of which 44 were included in the review. These studies investigated the influence of political violence on contextual variables that shape mental health and psychosocial wellbeing, and examined psychological distress and mental disorders in the context of political violence. The majority of studies addressed the mental health of Bhutanese refugees in Nepal and the impact of the Maoist Peoples War. Based upon these results from Nepal, we discuss a number of issues of concern to international researchers and practitioners and present policy and research recommendations. Specifically, we consider (a) the need for longitudinal multi-disciplinary research into protective and risk factors, including agency, of psychological distress and mental disorders in situations of political violence, (b) the continuing controversy regarding the PTSD construct, and (c) the lack of robust findings regarding the effectiveness of mental health and psychosocial support.

Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.