Tol MHPSS Evidence Research Priorities (coments added) IASC RG 22-11-1

Mental Health and Psychosocial Support in Humanitarian Settings: 

Mental Health and Psychosocial Support in Humanitarian Settings Current Evidence & Future Research Priorities IASC MHPSS Reference Group Meeting – 22 Nov 2011 Wietse A. Tol, Ph.D. Yale University & HealthNet TPO, wietse.tol@yale.edu

Timetable: 

Timetable 11.45 – 12.30 Presentation 13.30 – 15.00 How to link practice & research – A Delphi exercise 15.00 – 15.30 Afternoon Tea 15.30 – 16.15 Delphi continued

Presentation Overview: 

Presentation Overview Three Questions What happens in practice? For what do we have evidence? What are the research priorities? Recommendations

Popular Practices: 

Popular Practices Consensus exists on best practices Mental Health and Psychosocial Support (MHPSS) is "any type of local or outside support that aims to protect or promote psychosocial wellbeing and/or prevent or treat mental disorder " IASC Guidelines , 2007 The Sphere Project, 2011

PowerPoint Presentation: 

International consensus favours Multi-layered systems Care integrated across sectors Participation of affected populations IASC, 2010 Social considerations in basic services and security Strengthening community and family supports Focused non-specialized supports Specialized services E.g. making sure that food supplies are safely accessible for all and do not discriminate based on gender/caste/religion/ethnicity/ etc E.g. facilitating culturally appropriate support for mourning/ bereavement E.g. person to person support, basic mental health care in PHC E.g. Psychiatrist/ psychologist provides specialized care

But… what happens in practice?: 

But… what happens in practice?

Acknowledgements: 

Acknowledgements Author Institution Corrado Barbui , PhD University of Verona, Italy Ananada Galappatti Good Practice Group Colombo, University of Colombo, Sri Lanka Derrick Silove University of New South Wales, Australia Theresa S. Betancourt Harvard University, USA Renato Souza International Federation of the Red Cross, Switzerland Anne Golaz UNICEF, Switzerland Mark van Ommeren World Health Organization, Switzerland

Grey literature study1: 

Grey literature study 1 Searched for reports of MHPSS practice 2007 – 2010 All reports mapped on the W ho does W hat W here until W hen (4Ws) 1 Tol et al, Lancet In Press Funding

PowerPoint Presentation: 

Social considerations in basic services and security Strengthening community and family supports Focused non-specialized supports Specialized services 1. Basic counseling for individuals 39.4% 2. Facilitating support for vulnerable individuals 23.1% 3. Child-friendly spaces 21.3% 4. Supporting community-initiated supports 21.3% 5. Basic counseling for groups families 20.0%

PowerPoint Presentation: 

Similar picture in three recent humanitarian settings (Nepal, Jordan, Haiti) Lots of attention for structured social activities and counseling Little emphasis on specialized services

Funding: 

Funding Tracking of the Financial Tracking Service and Creditor Reporting System for 2007 - 2009 MHPSS is largely funded outside of national mental health, social service or education systems Top 10 categories MHPSS funding (together 79% of funding) STD Control & distress relief Primary education Medical services Social services

PowerPoint Presentation: 

Extract from webinar ‘chat’ Amanda Melville 2: does he know what distress and relief actually means ? Ruth: that is an interesting question for the content discussion Amanda

What happens in practice?: 

What happens in practice? In short: Dominantly non-specialized and community based social supports Implemented and funded outside of national systems

And…for what do we have evidence?: 

And…for what do we have evidence?

Evaluation of MHPSS: 

Evaluation of MHPSS UNICEF guide on monitoring and evaluation For evaluation, recommends: Having a baseline Having a comparison group

PowerPoint Presentation: 

Extract from webinar ‘chat’ Ananda: http://mhpss.net/wp-content/uploads/group-documents/78/1306249255-UNICEFGuidetotheEvaluationofPsychosocialProgramming.pdf Ananda: Contained in group on MHPSS Network http://mhpss.net/resources/policy-and-good-practice-guidelines/

Systematic Review and Meta-Analysis1: 

Systematic Review and Meta-Analysis 1 Inclusion criteria No language/ date limitations All ages LAMIC countries Controlled or randomized controlled 32 studies with control group identified Funding 1 Tol et al, 2011 Lancet

PowerPoint Presentation: 

Social considerations in basic services and security Strengthening community and family supports Focused non-specialized supports Specialized services 9.4% (n=3) 0.0% 62.5% (n=20) 28.1% (n=9) 5.0% (n=1) 0.0% 52.0% (n=11) 43.0% (n=9) 21 RCTs 32 in total

Extract from Webinar ‘chat’:: 

Extract from Webinar ‘chat’: Amanda Melville 2: can they tell which types of interventions for children in school are more effective? Amanda Melville: school based are usually not designed to treat PTSD Amanda Melville: that's the problem Maria BRAY: yes this is the key question ! Amanda Melville: and the fact that we don't have standardised ways to measure PSS wellbeing

PowerPoint Presentation: 

Meta-analysis with children & adolescents PTSD (5 comparisons) No overall significant effect, high heterogeneity Internalizing symptoms (8 comparisons) Overall significant effect, but high heterogeneity

Meta-analysis: 

Meta-analysis Meta-analysis with adults PTSD (9 comparisons) Overall significant effects of treatment Limited heterogeneity

Extract from Webinar ‘chat’:: 

Extract from Webinar ‘chat’: Amanda Melville 2: Ruth another question for later Ruth: yes? Amanda Melville 2: to clarify when he says RCT does it include non-RCT that used comparison group? Ruth: noted, thanks!

PowerPoint Presentation: 

Meta-analysis with children & adolescents PTSD (5 comparisons) No overall significant effect, high heterogeneity Internalizing symptoms (8 comparisons) Overall significant effect, but high heterogeneity

For what do we have evidence?: 

For what do we have evidence? In short: Better knowledge for more specialized interventions More complex results as we move down the pyramid Social considerations in basic services and security Strengthening community and family supports Focused non-specialized supports Specialized services

Extract from Webinar ‘chat’:: 

Extract from Webinar ‘chat’: Amanda Melville: School based are usually not designed to treat PTSD. That's the problem Maria BRAY: yes this is the key question ! Amanda Melville: and the fact that we don't have standardised ways to measure PSS wellbeing…

What are the main research priorities?: 

What are the main research priorities?

MH-SET: 

MH-SET M ental Health and Psychosocial Support in H umanitarian Settings – Research Priority SET ting (MH-SET) Step 1: Focus Group Discussions Step 2: Generating & scoring research questions Funding Tol et al, PLoS Med 2011; Tol et al, Harv Rev Psychiatry In Press

Acknowledgements: 

Acknowledgements Author Institution Vikram Patel Sangath , India & LSHTM Mark Tomlinson Stellenbosch University, South Africa Florence Baingana Makerere University, Uganda Ananda Galappatti Good Practice Group Colombo, University of Colombo, Sri Lanka Catherine Panter-Brick Yale University Derrick Silove University of New South Wales, Australia Egbert Sondorp LSHTM Michael Wessells Columbia University, USA Mark van Ommeren World Health Organization, Switzerland

MH-SET Step 1: 

MH-SET Step 1 Focus Groups in Peru (n=2), Uganda (n=3), Nepal (n=4) In capitals and remote humanitarian settings; diverse participants Asking about research priorities/ barriers-facilitating factors for research

MHSET Step 1: 

MHSET Step 1 Outcomes: Agreement on priority themes for research Disagreement research processes Relevance Excellence Implement immediately Time to analyze fully Importance locally Universal lessons Reliable & valid measures Local relevance of measures

MH-SET step 2: 

MH-SET step 2 Advisory group (n=136), representative of humanitarian settings, each generated 5 research questions (total n=654) Compiled into list of 74 research questions Research questions rated by 72 people, based on 5 criteria: Significance Answerability Applicability Equity Ethics

Extract from Webinar ‘chat’:: 

Extract from Webinar ‘chat’: Maria BRAY: I also have a question for the end; what is Wietse’s opinion regarding RCT as only scientific research methodology to reach evidence based research, especially in Psychosocial and MH field ? Amanda Melville: What were the themes?

PowerPoint Presentation: 

Research Option Category Average Rating (%) 1. Stressors faced Problem Analysis 86.7 2. Assessment methods Research and Information Management 85.9 3. Local perceptions mental health and psychosocial wellbeing Problem Analysis 85.9 4. Monitoring and evaluation indicators Research and Information Management 85.4 5. Adaptation interventions to sociocultural settings MHPSS Context 85.2 6. Effectiveness of family-based interventions MHPSS Interventions 84.7 7. Protective factors Problem Analysis 84.4 8. Effectiveness of school-based interventions MHPSS Interventions 83.2 9. Addressing local needs MHPSS Context 82.5 10. Most common problems Problem Analysis 82.2

What research has top priority?: 

What research has top priority? In short: Emphasis is strongly on (a) research that can immediately benefit practice , (b) sensitivity to local perspectives and participation Major academic debates score low E.g. only 6% of original list of 733 questions is trauma-focused Distinction distress and universality of diagnostic categories in bottom 10

Conclusions: 

Conclusions Large gap between what is popular in practice and evidence for effect Researchers focus on issues that are not relevant for practitioners Person-to-person and clinical supports PTSD as outcome Growing evidence base, but interventions can not simply be assumed effective

Recommendations for practice: 

Recommendations for practice More focus on sustainability  integrate programs in national health and social service systems from early recovery onwards Better financial tracking necessary More emphasis on care for severe mental disorders " Get Evidence Into Practice " Strengthen collaboration with research partners More funding for M&E practices as part of programming Expand M&E from outputs to outcomes/ impacts Treatments that have been shown effective should be made more available, where applicable

Recommendations for research: 

Recommendations for research " Get Practice Into Evidence " Prioritize MH-SET agenda Capacity building and involvement of practitioners Evaluate care for severe mental disorders Evaluate programs at the bottom of the pyramid