Mental Health Implementation Research in Low- and Middle- Income Countries

1. Mental Health Implementation Research in Low- and Middle- Income Countries Laura Murray, Ph.D., Paul Bolton, MBBS MPH; Judith Bass, Ph.D. Johns Hopkins University School of Public Health Applied Mental Health Research Group (AMHR) Departments of International Health and Mental Health

2. Global Mental Health Action Plan: A Focus on IMPLEMENTATION • Keywords to begin discussion: • Universal access – reducing treatment gap • Task-shifting or Task-sharing • Evidence-based practice • Suicide prevention • Strengthen information systems – evidence and research for mental health

3. How are we really going to do all this so that those without access would have access?

4. Two specific implementation strategies addressing the following topics: Universal access: reducing treatment gap. Task Shifting or sharing to reduce the treatment gap Use of Evidence-based Practices

5. Tool #1: • The Apprenticeship Model of Training and Supervision • A detailed implementation process that can be used for task-shifting - and more likely to result in behavior change. The essence of implementation is behavior change (Fixsen et al., 2005)…..

6. Apprenticeship Model of Training and Supervision • Based on research on training: • Implementation research shows that one-off trainings are ineffective for behavior change. • “Train and hope” approach to implementation does not work (e.g., Kelly et al., 2000) • Ongoing supervision with on-the-job coaching critical

7. Training outcomes • Joyce & Showers, 2002; Adapted from Fixsen et al., 2005

8. Apprenticeship Model of Training and Supervision • Based on Research showing ongoing supervision is critical • Spouse (2001): 4 main roles • Supervision • Teaching while engaged in practice activities • Assessment and feedback • Provision of emotional support • Experience with lay workers internationally • Multiple trainers utilize this process

9. What is the Apprenticeship Model? • 3 Groups • Trainers – experts in intervention/program • Supervisors – locally based, trained to be in this role • Counselors – those delivering the intervention/program

11. Tool #2: • Common Elements Transdiagnostic Approach (CETA) • A manualized treatment built from common elements of EBTs • Can treat all common mental disorders (anxiety, depression, PTSD) + behavior problems in children) Quality MH services requires use of Evidence-based practices (Global Action Plan)

12. Why this type of approach? • Recent research shows that EBTs are feasible, acceptable and effective in LMIC – and recommended by mhGAP. • However, singular focused MH treatments are a challenge to Implementation goals in LMIC • Support and resources for trainings to address all disorders is unlikely • If a provider trained only in 1, we would need extensive referral resources. (And difficult to master multiple.) • Comorbidity is common

13. CETA • Common elements, or transdiagnostic intervention approaches, are increasingly receiving attention (e.g., Chorpita, Daleiden, & Weisz, 2005; Weisz, Ugueto, Herren, Afienko & Rutt, 2011). • This approach teaches a set of common practice elements that can be delivered in varying combinations to address a range of problems. • Decision rules based on research evidence guide selection and sequencing of elements, but allow for flexibility in individual symptom presentation (Chorpita & Daleiden, 2009).

17. How would CETA help? • These approaches are viewed favorably due to their flexibility and focus on handling comorbidity. • In LMIC, if effective, they have the potential to offer a flexible approach to treating varied common mental health conditions. • One provider could be trained/supervised in ONE model to treat a range of disorders….thus reducing the treatment gap.

18. One specific implementation strategy addressing the following topic: Suicide Prevention

19. Tool #3: • Active Suicide Prevention and Planning • A detailed process of how to develop safety plans in LMIC • Individualized for setting • Appropriate for lay counselors Our biggest fear: identification of a serious problem (e.g., suicidal thoughts/behaviors) with no where to refer and no training in how to manage.

20. Summary The challenges and complexities of implementation far outweigh the efforts of developing the practices and programs themselves. The evaluation is messy – it occurs on multiple levels on moving variables. We DO have some tools and lessons learned – but need to put those into action on a wider scale. We need to work together to better understand implementation factors and how we can be more successful. We should talk more specifically about the HOW!

21. Thoughts for Discussion: • What does task shifting really mean? • How will it actually be IMPLEMENTED? • Does it need to be professionalized? • What are other examples of tools besides these mentioned? • What are ways to get more joint work between technical agencies and non-governmental organizations to develop and TEST such implementation tools? • Does the Action Plan have enough details/resources on HOW to implement?

22. Thank You!Merci beaucoup! Laura Murray, Ph.D. Johns Hopkins School of Public Health Email: lamurray@jhsph.edu