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 Professor Director of Clinical Training Director GMHLab Doctoral Program in Clinical Psychology Teachers College, Columbia University
Acknowledgments 2 Myrna Weissman, Ph.D. Peter Ventevogel, MD, PhD Kathy Clougherty, LCSW Rabih El-Chammay, MD Paul Bolton, Ph.D. Sandra Pardi Maradian, M.Sc. Vikram Patel, MD My students Mark Van Ommeren, PhD Our patients and their families
GMHLab: Where We Work Jordan Lebanon U.S.A. Bangla Nepal desh Haiti India Ethiopia Uganda Colombia
Chronic 5-30% mild moderate severe Disruptions in normal functioning Delayed 0-15%? Recovery 15-25% modal response Resilience 35-65% PTE 1 year 2 years Bonanno (2004) American Psychologist; Galatzer-Levy, Huang, Bonanno (2018) Clinical Psychology Review
Daily Stressors in the lives of Displaced Persons 5 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.
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 1. Two Tam (no interest) 2. Kumu (no appetite) 3. Par (constant crying) Lots of thoughts Loss of appetite Lots of thoughts/worries Constant worries Pain in the heart Easily annoyed Body pain Sits with cheek in palm Wants to be alone Brain isn ’ t functioning Cries when alone Holds head Think self is of no use Does not sleep at night Loses concentration in class* Thinks about suicide Talks about problems Drinks alcohol Talks about problems Lies down all the time Thinks about suicide Doesn ’ t greet people Sits alone Has lots of worries Loses interest in school* Headaches Sits alone Headaches Feels cold Does not think straight Feels sad Weak Does not do anything to help themselves Does not care if lives or dies Does not feel like talking Does not trust Thinks of bad things Disobedient Mutters to self Doesn ’ t feel like talking Insults friends Forgetful Disobedient Weak Weak Cries continuously Cries continuously
Function Assessment Graphic
Lebanon 9 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).
Policy Level 10 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 Rabih El Chammay, MD vulnerable populations (Dir. Mental Health Unit)
Rationale for Selection of IPT by the Ministry of Public Health (MoPH) 11 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.
Policy Level 12 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
Apprenticeship Model 13 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.
Provider Level 14 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
Lebanon IPT Team Pilot 15
Lebanon IPT Team Scale-up 16
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 0 0 Profession Clinical Psychologist 30 81.1 8 88.9 Psychiatrist 3 8.1 0 0 Social Worker 2 5.4 0 0 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 0 0 Consultants and Private Practice 6 16.2 3 33.3 Volunteer 1 2.7 0 0 Part-Time and Private Practice 2 5.4 0 0 Education College Degree 5 13.5 0 0 Masters Degree 25 67.6 6 66.7 Doctorate/Ph.D 7 18.9 3 33.3
Theoretical Orientation (Trainee- Providers)
Training Goals / Milestones for IPT trainee-providers
Training Goals / Milestones for IPT trainee-supervisors 20
International Transition-to- Transition-to-Scale Medical Corps Scale (GCC) (GCC) (IMC) IPT Supervisors IPT Providers IPT Providers NGOs 4 PHC Staff CBOs (Makhzoumi)
Patient Level ةبآك 22 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)
Patient Status Screened and signed consent (n=89) Accessed IPT Screen only (n=86) (n=3) Referred to Currently IMPROVED in Dropped/Lost Higher Care continuing IPT IPT (n=65) Contact (n=9) (n=4) (n=8)
Depression, Anxiety & PTSD
WHODAS 2.0 25
Local Systems Level Integrating IPT into Primary Care in Lebanon 26 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.
Makhzoumi Care Team
Patient Screening Protocol
E υχαριστώ 29 Thank you
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