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, [email protected] 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 1. 2. 3. Three Questions What happens in practice? For what do we have evidence? What are the research priorities? Recommendations 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" The Sphere Project, 2011 IASC Guidelines, 2007 International consensus favours E.g. Psychiatrist/ psychologist provides specialized care Multi-layered E.g. person systems to person support, basic mental health care in PHC Care integrated across sectors E.g. facilitating culturally appropriate support Participation affected populations for mourning/ of bereavement E.g. making sure that food supplies are safely accessible for all and do not discriminate based on gender/caste/religion/ethnicity/ etc Specialized services Focused nonspecialized supports Strengthening community and family supports Social considerations in basic services and security IASC, 2010 But… what happens in practice? 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 Funding Grey literature 1 study Searched for reports of MHPSS practice 2007 – 2010 All reports mapped on the Who does What Where until When (4Ws) 1 Tol et al, Lancet In Press Specialized services Focused non-specialized supports 1. Basic counseling for individuals 39.4% 5. Basic counseling for groups families 20.0% 2. Facilitating support for vulnerable individuals 23.1% Strengthening community and 3. Child-friendly spaces 21.3% family supports 4. Supporting community-initiated supports 21.3% Social considerations in basic services and security 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 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 Population policy and administration management Landmine clearance Civilian peace-building, Primary education conflict prevention and resolution Medical services Primary education Social services Human rights STD Control & distress Other or not reported relief 1 Medical services Social/ w elfare services Emergency and distress relief STD Control (mainly HIVAIDS) 0.0% 10.0% 20.0% 30.0% 40.0% Top 10 categories MHPSS funding (together 79% of funding) 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? Evaluation of MHPSS UNICEF guide on monitoring and evaluation For evaluation, recommends: Having a baseline Having a comparison group Systematic Review and MetaAnalysis1 Inclusion criteria No language/ date limitations All ages LAMIC countries Controlled or randomized controlled 32 studies with control group identified Funding 1Tol et al, 2011 Lancet 28.1% (n=9) 62.5% (n=20) 9.4% (n=3) 0.0% 32 in total Specialized services Focused non-specialized supports 43.0% (n=9) 52.0% (n=11) Strengthening community and family supports Social considerations in basic services and security 5.0% (n=1) 0.0% 21 RCTs 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 with adults PTSD (9 comparisons) Overall significant effects of treatment Limited heterogeneity 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? In short: Better knowledge for more specialized interventions More complex results as we move down the pyramid Specialized services Focused nonspecialized supports Strengthening community and family supports Social considerations in basic services and security What are the main research priorities? MH-SET Mental Health and Psychosocial Support in Humanitarian Settings – Research Priority SETting (MH-SET) Step 1: Focus Group Discussions Step 2: Generating & scoring research questions Tol et al, PLoS Med 2011; Tol et al, Harv Rev Psychiatry In Press Funding 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 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 Outcomes: Agreement on priority themes for research Disagreement research processes Local relevance of measures Importance Implement locally immediately Relevance Reliable & valid measures Universal Time to lessons analyze fully Excellence 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 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? 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 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 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 "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 How to connect Practice and Research to strengthen MHPSS: Delphi Exercise Step 1 Split up in smaller groups (to reach group size of 10-12) Take 20 minutes to discuss: Successes and challenges: experiences of how researchers and practitioners interacted/collaborated particularly well or poorly Step 2. Take 20 minutes to make a list of strategies that you feel are the most important to strengthen the connection between research and practice Take 20 minutes to score these Describe why you scored like this E.g. Each research project should have an advisory board that includes at least two practitioners Score: 1. Not important at all 5. Not important/ not unimportant 9. Extremely important Comment: “Although we feel this is an important strategy, it may not be feasible in every setting to achieve this” 1 2 3 4 5 6 7 8 9 Step 3 Present statements and explanations (30 - 45 minutes) Step 4. Combine all statements Each individual scores again, taking into account the discussion of the group (30 minutes): 5 ‘Beans’ Each (covered) glass represents a statement Put a bean in each glass that you feel is a crucial strategy Step 5. Is there any consensus on the top 10 strategies?