Decreasing the Global Mental Health Research and Treatment an - - PowerPoint PPT Presentation

Milton L. Wainberg, MD Professor of Clinical Psychiatry Columbia University Milton.Wainberg@nyspi.columbia.edu No conflicts to report

Plen enar ary y Ses essi sion: n: Goi

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ng to

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Scal ale e in in Low Res esour

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e Se Setting ings “Decreasing the Global Mental Health Research an and Treatment eatment Gap”

Mental and substance use disorders are the leading cause of years lost to disability (YLD) globally, affecting multiple levels of health as well as economic and social systems

Whiteford et al., PLoS One. 2015

Prince, Lancet, 2007; Demyttenaere K et al, 2004; Wainberg ML et al, 2017

1:2 Million

IDEAL: 45:100,000 Switzerland 39; USA 13; Mozambique 0.052

*

The Global Mental Health Treatment Gap

The 10/90 Research Gap Global Forum for Health : Less than 10% of worldwide resources are spent in LMICs, where 90% of all preventable death occur. Mental Health: Only 6% of psychiatry journals content covers approximately 90% of the world’s population

The Global Mental Health Research Gap

Research to Practice Gap

 17 years for 14% of new discoveries to enter day-to-day clinical practice  Longer for psycho/social/behavioral interventions

• Designed to be conducted by specialists, which works against dissemination
• LMICs: Lack of specialized human resources
• Mental Illness Stigma
• Minimal budget for mental health in most countries, especially in LMICs

Green LW, et al, 2009; Brenner, R. et al. Ann Clin Psychiatry, 2010; Patel, V., Araya, R. et al. Lancet, 2007

2) Optimizing Fit: Adaptation Principles 1) Optimizing Fidelity: EBI Principles 3) Balancing Fidelity and Fit: Intervention Adaptation 4) Pilot Testing and Refining: Final Intervention 5) Efficacy Testing: RCT 6) Effectiveness, Implementation & Dissemination

Intervention Adaptation Development Model

Wainberg, ML, et al, 2007

2) Optimizing Fit: Contextual EBI Adaptation + Implementation Principles 1) Optimizing Fidelity to the EBI: EB Principles 3) Balancing Fidelity and Fit: EBI Implementation Strategy 4) Pilot of Implementation Strategy 5) Hybrid Effectiveness- Implementation/ Dissemination Studies

Fidelity to a particular intervention as developed and the need for local adaptation during scale-up

T32 Liat Helpman, PhD (Colombia: Internally Displaced & Trauma) (Faculty) Sabrina Hermosilla, PhD** (Nepal: Child friendly spaces) Karen Johnson, PhD** (NYC: Homelessness Syndemics) (Faculty) Cady Carlson, PhD (Uganda: Schools MH) Jennifer Mootz, PhD* (Uganda: IPV & ETOH) Annika Sweetland, DrPH (Brazil: TB & MH) Sara Davaasambuu, PhD (Mongolia: Adolescent Suicide) (UNICEF) K Awardees & Academic Appointments Pamela Scorza, PhD* (PR: Transgeneratio nal Stress) Kate Lovero, PhD* (Mozambique Adolescent Girls HIV&MH) *K under review ** K in preparation

Advice to Early Career Investigators Train US new investigators to help build a global mental health implementation science team NIMH – T32 MH096724 Columbia University

Global Partners: Fogarty/NIMH D43 (2014) & U19 (2017) GMH Hub

• 1. Angola,
• 2. Cape Verde,
• 3. Guinea-Bissau,
• 4. Mozambique,
• 5. Säo Tomé and

Principe, and

• 6. Equatorial Guinea.

U19

IN EACH COUNTRY: MINISTRY OF HEALTH, UNIVERSITIES, NGOS

D43

• 1. Botswana,
• 2. Malawi,
• 3. South Africa,
• 4. Zambia, and
• 5. Mozambique

PRIDE sSA: Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence Based Practices in sub Saharan Africa

Partnerships Needed To Scale-up Effective Interventions In Low-Resource Settings

Hybrid E-I Cluster Randomized Trial: Three Pathways

(Proctor’s Framework)

Goal: Determine best cost-effective pathway to expand comprehensive mental health care (Measured Based-Care, Meds, IPT, MI) Screen: ~40,000 Patients: ~14,000 Providers: ~500 36 districts diverse urbanicity

Pathway 1 – Usual Care: District Level Care: Psychiatric Technicians Pathway 2 – Clinic Level Care: CHWs* Screen, Refer to Clinic for Treatment Pathway 3 – Community & Clinic Level Care both by CHWs & Clinic Providers

*CHW: Community Health Workers

U19 – Research Capacity Building Component

“They were just a few – it was easy to supervise them. How do we grow, provide better access in rural areas, and still ensure quality of care?” Lidia Gouveia, MD – MH Director/Mozambique Ministry of Health

29 mil illio lion in inhabit itants - 70% Rural 4th

th poorest country

ry 13 Psychia iatri rists - 125 Psycholo logis ists - 0 PhDs in in MH 250 Psychia iatric ic Technic icia ians (Task-Shif iftin ing)

(G (Glo lobal* Mental Health Treatment Gap)

*Global = low resources

(FIDELITY: Tablets – Measures/EBPs)

Priority Research Questions To Be Answered In Support Of Scaling Up Interventions In Low- resource Settings

Thank you! Obrigado!

Partners

• Mozambique: Ministry of Health and their Providers;

Patients, Relatives and Communities; U. Eduardo Mondlane & MIHER

• Brazil: UNIFESP
• US: Columbia, UPenn, Vanderbilt & Oregon Social Learning

Center