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

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?