mental health following emergencies Lena Verdeli, Ph.D, MSc - - PowerPoint PPT Presentation
Mental Health Athens, Conference From Alkis Managing Argyriadis Hall emergencies to 3-4.06.2019 Sustaining Reforms Sustainable capacity-building in in mental health following emergencies Lena Verdeli, Ph.D, MSc Associate
Mental Health Conference “From Managing emergencies to Sustaining Reforms” Athens, “Alkis Argyriadis” Hall 3-4.06.2019
Associate Professor Director of Clinical Training Director GMHLab Doctoral Program in Clinical Psychology Teachers College, Columbia University
Myrna Weissman, Ph.D. Kathy Clougherty, LCSW Paul Bolton, Ph.D. Vikram Patel, MD Mark Van Ommeren, PhD
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Peter Ventevogel, MD, PhD Rabih El-Chammay, MD Sandra Pardi Maradian, M.Sc. My students Our patients and their families
Bangla desh Nepal Colombia Uganda India U.S.A. Haiti Lebanon Jordan Ethiopia
PTE Chronic 5-30% 1 year 2 years Disruptions in normal functioning
mild moderate severe
modal response Recovery 15-25% Delayed 0-15%? Resilience 35-65%
Bonanno (2004) American Psychologist; Galatzer-Levy, Huang, Bonanno (2018) Clinical Psychology Review
Daily Stressors in the lives of Displaced Persons
Studies in displaced adults and youth find high levels of daily
environmental stressors:
Struggles for survival in the face of dearth of material and emotional resources, loss of persons and old roles, increases in domestic violence, overcrowded camps, loneliness, uncertainty about future, safety concerns, etc ( Bolton et al, 2007; Riley et al, 2017).
In a recent study with Rohingya refugees (Riley et al, 2017) it was
shown that:
While there was a direct effect of trauma exposure on PTSD symptoms, daily
environmental stressors partially mediated this relationship.
Depression symptoms were associated with daily stressors, but not prior
trauma exposure. Daily stressors play a pivotal role in mental health outcomes of populations affected by collective violence and statelessness.
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Group IPT for Depressed Adolescents in Northern Uganda: A Randomized Control Trial (Bolton et al, 2007; Verdeli, et al, 2008)
Local Anxiety and Depressive Syndromes
Lots of thoughts Constant worries Body pain Brain isn’t functioning Think self is of no use Thinks about suicide Talks about problems Sits alone Loses interest in school* Headaches Feels sad Does not care if lives or dies Thinks of bad things Doesn’t feel like talking Forgetful Weak Cries continuously Loss of appetite Pain in the heart Sits with cheek in palm Cries when alone Does not sleep at night Talks about problems Lies down all the time Has lots of worries Headaches Feels cold Weak Does not feel like talking Disobedient Lots of thoughts/worries Easily annoyed Wants to be alone Holds head Loses concentration in class* Drinks alcohol Thinks about suicide Doesn’t greet people Sits alone Does not think straight Does not do anything to help themselves Does not trust Mutters to self Insults friends Disobedient Weak Cries continuously
Middle-income country, long history of war
and political unrest
Population: approximately 4 million
400 000 Palestinian refugees More than 1 million registered and half a
million unregistered refugees from Syria (UNHCR, 2018).
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2015: The Ministry of Public Health (MoPH) initiated a 5-year Mental Health Strategy (2015-2020) emphasizing human rights and evidence-based practices. Aim: provide MH care for everyone living in Lebanon: avoid creating a parallel system for refugees. Comprehensive, integrated and responsive mental health services in community-based settings, with attention to vulnerable populations
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Rabih El Chammay, MD (Dir. Mental Health Unit)
Multiple RCTs of individual and group IPT in high-, middle-, and
low-income regions for common mental illness (especially depression and growing evidence for PTSD).
Recommended and disseminated globally through WHO mhGAP
Intervention Guide 2.0
www.who.int/mental_health/mhgap/interpersonal_therapy/en/
Has been tested and used with non-specialists in primary care
settings.
Interpersonal focus deemed by stakeholders to be relevant to the
experience of the Syrian refugees and host populations (grief, role transitions, disputes, and loneliness).
Emphasis on attachment appealed to many psychoanalytic
therapists.
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Implementation best case scenario: Coordinated initiative by MoPH, Academic centers, NGOs, CBOs, and Hospitals Strategic selection of trainees (key roles in therapy training, included operations outside Beirut) Innovative accreditation standards in community and primary care (forming of community advisory boards to guide planning of services and engagement of patients) Midpoint evaluation of the policy (2018) moph.gov.lb
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Verdeli, H., Clougherty, K., Bolton, P., Speelman, L., Lincoln, N., Bass, J., Neugebauer, R., Weissman, M. (2003). Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda. World Psychiatry 2003, 2:114-20. Murray, L. K., Dorsey, S., Bolton, P., Jordans, M. J., Rahman, A., Bass, J., & Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers. International journal of mental health systems, 5(1), 30.
Target key actors in dissemination (MoPH advertised for
English-speaking therapists, 2 year commitment: 60+ applications/selected 37)
Competency based training Knowledge, attitudes, skills (supervision, not just didactic workshop) Support Continuing education model
Former providers became supervisors (dissemination champions) Professional advancement Brain-drain reduction strategies
Learning collaboratives
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Demographic Characteristics of the Trainee-Providers and Trainee-Supervisors
Trainee-Providers Trainee-Supervisors
Frequency Percent Frequency Percent
Gender
Women 30 81.1 6 66.7 Men 7 18.9 3 33.3
Nationality
Lebanese 36 97.3 9 100 Iraqi 1 2.7
Profession
Clinical Psychologist 30 81.1 8 88.9 Psychiatrist 3 8.1 Social Worker 2 5.4 Nurse 2 5.4 1 11.1
Employment
Employed Full-Time (NGOs, MOPH, hospitals) 22 59.5 6 66.7 Employed Part-Time 6 16.2 Consultants and Private Practice 6 16.2 3 33.3 Volunteer 1 2.7 Part-Time and Private Practice 2 5.4
Education
College Degree 5 13.5 Masters Degree 25 67.6 6 66.7 Doctorate/Ph.D 7 18.9 3 33.3
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Transition-to- Scale (GCC) IPT Supervisors
Transition-to-Scale (GCC) IPT Providers
NGOs CBOs 4 PHC Staff
(Makhzoumi)
International Medical Corps (IMC) IPT Providers
IPT relevant to patients’ experiences Adaptations in content and delivery
Family engagement 8-12 sessions Treat to Target (depression care pathway)
Response: 50% symptom reduction or PHQ-9<10 Remission criteria for depression PHQ-9 <5
Problems
Difficulty finding simple training cases Suicidality and comorbidity Lack of access (transportation issues)
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Screened and signed consent (n=89) Accessed IPT (n=86) Referred to Higher Care (n=4) Currently continuing IPT (n=8) IMPROVED in IPT (n=65) Dropped/Lost Contact (n=9) Screen only (n=3)
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Local Systems Level Integrating IPT into Primary Care in Lebanon
2017: Integrate Interpersonal Therapy (IPT) for depression into
primary care and other healthcare service centers, using a collaborative care approach (IMPACT).
PI: Lena Verdeli, Ph.D; C0-PI: Rabih El Chammay, M.D.
Collaborative Care focuses on defined patient populations tracked in a
registry, measurement-based practice and treatment to target.
Trained primary care providers and embedded behavioral health
professionals
They are supported by regular psychiatric case consultation and
treatment adjustment for patients who are not improving as expected.
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