making psychosocial interventions accessible - startts · 2018-09-27 · making psychosocial...
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Making Psychosocial Interventions Accessible to 100,000’s of Refugees
Richard Bryant
University of New South Wales
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Highest number of people affected by emergencies since WW2
– Worldwide
• 67 million people displaced, including 40.8 million internally displaced, 21.3 million refugees, and 3.2 million asylum-seekers
• > 125 million people in need of mental health assistance
Sources: OCHA, 2016; UNHCR 2016
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Common Mental Disorders
0
2
4
6
8
10
12
14
16
18
Depression Anxiety/PTSD
Global
Violence-Affected
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Society impact: Global burden of depression and anxiety (% of years lived with disability; GBD study)
Source: GBD 2010 study (Institute of Health Metrics and Evaluation; Vos et al, Lancet 2012)
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What do we advise agencies with limited resources to help 1,000,000s of refugees?
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KEY QUESTIONS
• What should agencies try to achieve in meeting the needs of 100,000s of people affected by trauma?
– Helping everybody severely distressed?
– Helping everybody at risk of a mental disorder?
– Helping everybody with a mental disorder?
– Helping everybody with a severe mental disorder?
– Helping people with priority disorders only (psychosis, suicidal, etc)
– Helping everybody who seeks help?
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DECISION POINTS
Do we resource a few clinics/centres very well?
Do we help just people in a few communities very well?
Do we spend a lot of resources on helping a few 100 people with maximum clinical effectiveness
How does one set priorities?
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Treating PTSD
Overwhelming evidence indicates trauma-focused psychotherapy is the treatment of choice for PTSD
Meta-analyses indicates this effectively reduces post-trauma depression
Meta-analyses indicate that these also effective in LMICs after trauma
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Limitations of Traditional Approach
Disorder-specific
Lengthy duration (10+ sessions)
Rely on complex and intensive strategies
Typically provided by qualified practitioners
Requires considerable (and costly) training
These factors preclude implementation in LMICs because of inadequate infrastructure and limited budgets
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Mental Health Treatment in LMICs
The limitations of evidence-based treatments result in most people in LMICs not receiving help
Estimated that 93% of those in LMICs who need treatment do not receive it (Chisholm et al., 2016)
Estimated that 90% of those in China and India who need treatment do not receive it (Patel et al., 2016)
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Current Priority for Scalable Interventions
Feasibile, affordable and cost-effective interventions that can be implemented on a large scale, especially in settings in which health systems are stretched and have inadequate resources
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Towards scalable psychological interventions
Conventional psychological interventions
•By specialists
•One treatment manual per problem
•Often many sessions
•Often require diagnostic assessment
More scalable psychological interventions•Innovative delivery : reduced reliance on specialists (rather: lay people, IT, self-help guides etc.)
•One treatment for multiple problems (where possible)
•May not require diagnostic assessment
•Fewer sessions
•Focus on skills for self-management
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Low Intensity Interventions Must:
Be scalable:
Be easily trained to local para-professionals
Understandable to local health providers
Be cost-effective & feasible:
Be affordable to LMIC governments
Be amenable to local capacity development
Be reasonably short to enhance engagement, attendance and completion
AND EFFECTIVELY REDUCE DISTRESS
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Can Lay Helpers Be Effective?
Major shift in recent years is training lay people to deliver psychological interventions
Meta-analysis of 27 studies using lay people to treat anxiety/depression found effect size of 0.49 (Singla et al., 2017)
Suggests ‘task-shifting’ can play an important role in alleviating common mental disorders
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Current Goal of WHO
Publish a range of different scalable psychological interventions with focus on increasing access to effective care as part of mhGAP program
All tested through partnerships (minimally in 2 countries)
WHO Press as publisher to put manuals and resources online as a public good (serving free dissemination and quality control of any translation)
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Five phase model for new intervention testing (for each intervention at 2 sites)
Phase 1
• Adaptation of intervention for local sociocultural context (qualitative research) and, sometimes, an uncontrolled pilot run
Phase 2
• Small, feasibility randomized controlled trial (RCT) to explore (a) feasibility, safety and delivery of intervention in a RCT and (b) feasibility of high quality evaluation (n = 40 – 120)
Phase 3
• Process evaluation (qualitative research) of administering and trailing the intervention to finalize intervention and prepare for Phase 4 (n = 25)
Phase 4• Large, definitive, state-of-art RTC (n = 350-550)
Phase 5
• Process evaluation (qualitative research) of administering the intervention to prepare for scaling up (n = 25)
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Problem Management Plus
UNSW collaborated with World Health Organization to develop PM+
Aimed to be driven by current evidence for best interventions to impact common mental disorders
Yet be simple enough to be delivered by local lay providers
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What Does Evidence Suggest?
• Anxiety management
• Problem solving
• Behavioural activation
• Accessing social supports
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Problem Management Plus (PM+)• For whom
– Adults, transdiagnostic (stress, depression, anxiety) – Inclusion criterion : must have high distress and impaired
functioning
• What– Problem-solving counselling (problem management) plus
behavioural strategies stress management, behavioural activation, strengthening social supports
• Formats – 5 sessions individual face-to-face (released already)– 5 sessions group face-to-face– 7 sessions group for young adolescents
• Large RCTs– Kenya – Pakistan (x 3) – Nepal– plus more planned
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PM+
• Psychoeducation (Session 1)
• Managing stress (slow breathing) (S 1)
• Managing problems (S2)
• Keep Going, Keep Doing (S2)
• Promote Social Support (S3)
• Relapse Prevention (S5)
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Peshawar• Near the border with Afghanistan - capital
of KP
• Study in PHC in peri-urban area
• 60% of study participants have experienced conflict
• 20% of study participants have natural disaster
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Informed Consent
Baseline Assessment
PM+
N = 172
Screening in PHC
Enhanced TAU
N = 174
1-Week Assessment
3-Month Assessment
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Results from mixed model analysis of primary outcomes
**Effect size is calculated by the difference in LS mean by standard deviation
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HADS-Anxiety
0
2
4
6
8
10
12
14
16
Pre Post Follow Up
PM+
EUC
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HADS-Depression
0
2
4
6
8
10
12
Pre Post Follow Up
PM+
EUC
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Informed Consent
Baseline Assessment
PM+
N = 209
Screening in PHC
Enhanced TAU
N = 212
1-Week Assessment
3-Month Assessment
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General Health Questionnaire
19
.5
11
8
18
.5
14
11
0.00
25.00
PRE POST FOLLOW -UP
PM+ TAU
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Group PM+
Scalable interventions need to be delivered in groups
Also suits many collectivist cultures
We adapted PM+ to be conducted in groups
Initial trial conducted in Swat valley in Pakistan
Rahman et al., in press, Lancet
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Informed Consent
Baseline Assessment
gPM+ (17 clusters)
N = 306
34 clusters randomized
EUC (17 clusters)
N = 306
Post assessment
N = 301
3-Month Assessment
N = 288
Post assessment
N = 300
3-Month Assessment
N = 288
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HADS-Anxiety
0
2
4
6
8
10
12
14
Pre Post Follow Up
gPM+
EUC
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HADS-Depression
0
2
4
6
8
10
12
Pre Post Follow Up
gPM+
EUC
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What About Refugees?
It is one thing to demonstrate an intervention works
BUT can it can rolled out in a local health system?
This was always the goal of WHO’s agenda
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Faculteit der Psychologie en Pedagogiek
Unprecedented increase in refugees
Over 4.8 million Syrian refugees registered by UNHCR
50% children, often unaccompanied
2.8 mln
1.0 mln
655.496
230.836
116.013
Source: http://data.unhcr.org/syrianrefugees/regional.php; Jan 22, 2017
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Faculteit der Psychologie en Pedagogiek
Asylum applications by Syrians in Europe
(April 2011-Oct. 2016)
Germany:456.023
Sweden:109.970
Netherlands:32.720
Hungary:76.592
Switzerland:13.713
Source: http://data.unhcr.org/syrianrefugees/asylum.php; Jan 22, 2017
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Studies
Individual PM+ for adult Syrians (Netherlands, Switzerland)
Group PM+ for adult Syrians (Jordan, Turkey)
Early Adolescents Skills for Emotions (EASE) (Lebanon, Jordan)
E-PM+ (app-based version) (Germany, Egypt, Sweden)
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Subsequent Steps
Once trials are complete, implementation phase will complete
Ramp up training of lay workers across agencies throughout countries and evaluate outcomes
Aim to lead to increase in evidence-based interventions for refugees in country