Archive for the 'evidence based treatment' Category

Cognitive processing therapy for rape survivors in the Democratic Republic of Congo: Setting a new standard for post-conflict psychosocial care

Last week saw the publication of an important randomized control trial of cognitive processing therapy (CPT) for Congolese survivors of sexual assault in the New England Journal of Medicine (NEJM — and thanks, NEJM, for making the article available in full online). The fruit of intensive work by Judy Bass of Johns Hopkins, Jeannie Annan of the International Rescue Committee, Debra Kaysen of the University of Washington, and a host of others, this publication sets a new standard in the field of post-conflict mental health research and is welcome news for those affected by rape and other forms of sexual assault in low and middle-income (or, “LMIC”) war-affected settings.

The study involved almost 500 female survivors of rape in the eastern provinces of the Democratic Republic of Congo (DRC), an area of the world infamous for the absence of state control and an ongoing epidemic of sexual violence. Half were randomly assigned to a group-based version of CPT led by trained local counselors, half to generalized, patient-directed individual support and case management. Those attending CPT improved far more than those in the control group (although the latter also improved somewhat).

CPT has been shown to be effective for sexual assault survivors in several Northern, high-income countries, so that it was effective in the DRC may seem unsurprising. However, debates have raged in the past decade or so about the efficacy and effectiveness of doing psychotherapy in post-conflict settings that are not technically “post”-conflict and in populations with low-levels of education.

Prior research has suggested that short-term therapies may not be effective for populations exposed to ongoing trauma or multiple severe traumas. In our study, all villages reported at least one major security incident during the trial, including attacks, displacement due to fighting, and robbery by armed groups. In addition, there was concern that providing therapy to illiterate persons would be challenging. Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.

This study shows that, with sufficient technical support, psychotherapy targeting trauma-related emotional problems can be delivered effectively in violence-affected LMICs as part of comprehensive psychosocial programs.

For a brief summary of the study and some commentary, see the related New York Times article from last Wednesday.

A “daily stressors & trauma” debate & the temptation of mental health evaluation for everything

In a special issue on “Conflict, violence and health” earlier this year, Social Science and Medicine published an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid that Ken Miller and I wrote (see my blog post from June 29th, 2010 for related material). This week the second October 2010 issue of the same journal includes a critique of our editorial from the accomplished refugee trauma researcher Frank Neuner and our response to this critique. Lest you think that publishing a second October issue in mid-September is the sign of general silliness, let me inform you that (1) the virtual world resides somewhere in the future, and (2) Social Science and Medicine consistently publishes high-quality health research and — notably — debates (like ours) in subfields that could use a healthy does of academic energy.

Our debate primarily concerns how best to provide “psychosocial” and “trauma-related” mental health services to displaced populations (i.e., refugees). The three articles are a somewhat academic read (all of us are, after all, academics), but I would not say that the topic is purely academic. Psychosocial aid and trauma interventions are hot topics in humanitarian aid, and agencies’ perspectives on these issues has direct relevance for the design of programs in the field.

I won’t repeat the detailed back-and-forth here, as you can read the articles yourselves (if you have trouble accessing the links above please let me know). I do, however, want to highlight one important point of agreement. Even though we reiterate this point in our response, I think Neuner says it better in his critique of the editorial:

Reducing hardship and daily stress is without a doubt a key objective of humanitarian assistance. No one would disagree that increasing security in refugee camps, improving child protection and medical care, reducing violence and poverty, increasing awareness of gender issues, and reducing discrimination should be high priority goals that deserve much attention by humanitarian agencies. The respective programs should clearly state their goals and be evaluated according to their specific aims. However, it is premature to claim that such programs heal psychological disorders or foster mental health. The increasing tendency to justify widespread programs on the basis of mental health is worrisome and seems to reflect the tendency to comply with donors’ fashions. Why must a program that aims at reducing discrimination of former child soldiers also improve mental health? Reducing discrimination, just like improving development and reducing violence is a worthy objective on its own right.

The increasing tendency to judge interventions in refugee camps — even interventions with the label “psychosocial” — solely by examining rates of psychiatric diagnoses pre- and post-intervention is indeed a problem. Having participated in such evaluations, I can attest that apart from the considerable cross-cultural assessment issues and challenging diagnostic environment, these efforts leave me with the sinking feeling that many in humanitarian aid have succumbed to the temptation of scientific — or perhaps better put, “scientistic” — validation. In other words, evaluations that were specific to specific programs (e.g., measuring change in social and economic indicators in order to judge child soldier reintegration programs) became mental health evaluations (measuring reductions in anxiety in order to judge child soldier reintegration programs), thereby getting the stamp of approval of medical science. This curious turn of events has meant that many programs (at least those not directly tied to food, water, and other basic needs) are now “sold” to donors in the language of mental health, even though they may working towards some other — also worthy — objective.

Article addendum: Stressors during wartime

The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.

The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).

Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.

1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.

2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.

3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).

4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).

5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).

It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).

Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.

Randomista 2: Medical marijuana for veterans with PTSD?

Only moments after writing this morning’s entry about randomized control trials, a friend sends me a link to the following, from this morning’s Morning Edition on NPR:

The arguments around marijuana and PTSD start running in circles at a certain point. Scientists say more research is needed. Activists counter that the federal government has blocked research because marijuana is illegal. The American Medical Association has called for controlled studies to settle this and other questions about the effectiveness of marijuana.

Meanwhile, policymakers in states with medical marijuana programs have to make decisions now, and they’re reaching different conclusions. While New Mexico found there’s enough evidence to approve marijuana use for PTSD, next door in Colorado lawmakers recently rejected a similar proposal.

Pot for posttraumatic stress disorder? This is a good example of how randomized control trials can help. Everybody knows that pot makes people “feel good” (or so I hear), but to decide that doctors should be prescribing it to patients with PTSD — and whether health insurance should cover costs associated with medical marijuana — we’d have to know that for more people than not it reduces symptoms over a certain period of time more than the counseling and medication the patient is already using.

Incidentally, I’ve always suspected that the medical marijuana movement was a little bit of a backdoor to legalization, for the following reason: most people in the movement seem to think that smoking it is medically necessary. If smoking a drug is the most efficient delivery system, why don’t we smoke Paxil or Zoloft? Cannabinoid pills seem to make more sense. In the NPR story, the young man mixes his cannabis into hot chocolate in order to better control the dosage. I suppose we could randomly assign medical marijuana users to “smoking” and “hot chocolate” conditions to get to the bottom of this.

Read/listen to the entire story on a young New Mexican veteran’s use of marijuana to control his PTSD symptoms by linking to the article here. If what I’ve written isn’t enough to get you there yet, consider the following: his wife says, “Medical cannabis saved our marriage.”

Randomistas, development economics, and the poetry of evaluation

Last week’s New Yorker featured an engaging portrait by Ian Parker of MIT development economist Esther Duflo, perhaps the leading light among that field’s “randomistas.” These (mostly) young economists have made their mark on their profession by applying randomized control trials (borrowed from medicine) to development strategies. This really shouldn’t surprise anyone — randomized control trials have been used for other types social programs (e.g., delinquency prevention) for years now, and given that economics is about human behavior it’s surprising that economists haven’t embraced this earlier.

Also familiar to behavioral scientists are the objections to assigning participants at random to experimental and control groups.

“You shouldn’t be experimenting on people.” O.K., so you have no idea whether [your programs] work–that’s not experimental?

The former is met far to infrequently with the latter. Someone comes up with an idea for some intervention, they announce their intentions and put that idea into practice, and all of a sudden it is accepted as the right thing to do… and to test whether it works better than doing nothing (which really means “better than engaging the variety of things people do that you don’t know about”) thus becomes the wrong thing to do. That’s some sloppy ethics, at best.

The one objection to randomized control trials mentioned in the article that might hold water is that an intervention shown to be empirically supported in one context might not be empirically supported in another due to variation in ecological and temporal phenomena. Of course, the logical solution is more experimentation, not less. In their psychosocial programs in the Democratic Republic of Congo, the Center for Victims of Torture has instituted what Research Director Jon Hubbard calls “rolling control groups” to address the problem of changing context. The situation in conflict zones is often very fluid, and so if a program is shown to be better than doing nothing during one intervention period (6 weeks for CVT’s program) that doesn’t mean that it will be better during the next. So Hubbard came up with the rolling control: at the beginning of each intervention period, the program accepts and screens 125% of their capacity, then randomly assigns 25% to a wait list control; after the intervention period they give post-tests for each group, viola! They have a small-scale randomized control trial that shows their funders that they are monitoring the effectiveness of their programs for each cohort.

The article on Duflo ends with a couple paragraphs on the art of the evaluator’s profession that I found particularly striking — but admittedly, maybe only a data nerd like myself would love:

“It can’t only be the data,” Duflo said, showing a rare willingness to generalize. “Even to understand what data means, and what data I need, I need to form an intuition about things. And that process is as ad hoc and impressionistic as anybody’s

It can’t only be the data, but there must be data. “There is a lot of noise in the world,” Duflo said. “And there is a lot of idiosyncrasy. But there are also regularities and phenomena. And what the data is going to be able to do–if there’s enough of it–is uncover, in the mess and noise of the world, some lines of music that may actually have harmony. It’s there, somewhere.”

Vikram Patel at NYU, and a genuine global mental health agenda

Last Friday, March 6, the good folks at NYU’s program in Global Public Health hosted a lecture and discussion with global mental health luminary Vikram Patel. Dr. Patel is one of the forces (perhaps the driving force) behind the field of global mental health, and one of the architects of the Lancet’s series on the subject in 2007. This relatively new field combines public health, cross-cultural psychology, and human rights, and seeks to expand concern for mental health disability from it’s purview as a Northern luxury into a worldwide movement. For more general information on the topic, visit www.globalmentalhealth.org.

Dr. Patel’s talk at NYU was largely a call to action, as opposed to an empirical evaluation of the field’s successes and failures to this point. This is not to his discredit; Dr. Patel knows of what he speaks. From his groud-breaking work on Shona idioms of distress in his native Zimbabwe to his more recent clinical trials of community health workers’ delivery of mental health services in his family’s homeland India, Dr. Patel is well-steeped in several of the field’s parent disciplines. But Friday’s purpose was to spread the word. Lauding the success of the HIV/AIDS public health movement, Dr. Patel called on public health workers — or at least the public health trainees present — to take up similar strategies to convince public officials and other healthcare workers that mental health must be a priority in the developing South as well as developed North.

As for research, Dr. Patel noted that 90% of mental health research is done in the developed North (and within that, most in the US), and insisted that that must change. Research must guide practice in order to avoid the mistake of simply applying US or European models elsewhere. Along these lines, he pointed to recent funding interest in global mental health, even by the US’s NIMH (specifically, a recent blog post by director Thomas Insel titled “Disorders without Borders” — good grief!), a research body not known to fund many international projects.

This brought a question from the crowd (well, actually a question from me): If 90% of the mental health research is done in the developed North — the place where academics have the technology, funding, and financial interests to do research — and more research needs to be done in the less developed South, how should this be accomplished without running roughshod over local explanatory models of mental distress and local service models that may do some good? Dr. Patel acknowledged that this was a major concern, and provided the following solution: work with and teach local practitioners to do the research.

This simple-sounding solution is actually a tall order. The money and research technology (and here I’m talking about specialized research training as well as computer software) is in the North. The academic motivation for high-quality research is also largely Northern — “publish or perish.” It’s hard to see how NIMH-funded research would not evince a preference for US-led projects. So at the moment, beyond projects that hire locals to collect data, it’s hard to find projects that really substantively involve local ideas and researchers and people schooled and based in the research-resourced North (like the students at NYU last Friday). But there are a few — although very few — projects that fit the bill.

The first is Patel’s own work. Although he holds several professorships throughout the Europe and North America, he is based in Goa, India, and his research is there, and includes local staff. However, until more Vikram Patels arise (which won’t be too long, I think), his remains a special case of a culture-spanning researcher, trained in Northern/Western models and adapting, applying and distributing them throughout the developing world.

The best example of a US-led project is a USAID-funded program out of the Center for Victims of Torture (CVT) in Minneapolis, the International Program Evaluation Collaborative, or IRPEC. The brainchild of Jon Hubbard, the Research director at CVT, IRPEC aims to transfer the technology of empirical research to NGO’s working in mental health and human rights around the world in order better collect and analyze data to improve their services (and, of course, to get grants from Northern foundations which require such information). At this point I should probably disclose that I was an evaluator for IRPEC this past summer (see entries on Cambodia and Peru for related material), and that I was pretty impressed.

During this evaluation Jon told me a story of meeting a researcher who evaluates such programs who asked him, “Okay, but where’s your data?” Jon replied, “It’s not my data. It’s their data.” Until we can take up Hubbard’s example, those of us in the North who work in global mental health will always be in danger of “getting it wrong” — both ethically as well as empirically — in our quest to answer Vikram Patel’s call.

NPR puts mental health after buildings in Haiti; now we’re getting it

This morning, bleary eyed and half asleep, I turned on National Public Radio’s Morning Edition, as I do pretty much every morning of the week. Following a feature on structural instability of buildings in Port Au Prince, Haiti, Alix Spiegel reported on the field of disaster mental health. Usually popular depictions of my field make me cringe — stories of mass trauma, generations of psychological damage, and heroic psychologists healing the unthinkable are everywhere these days — but today I was delightfully surprised.

They came after the Oklahoma City bombing, and flooded Sri Lanka in the wake of the South Asian tsunami. They came in droves to New York after 9/11. And according to Richard Mollica, a professor at Harvard who’s spent his life researching mental health responses to natural and man-made disasters, mental health professionals will soon come to Haiti as well.

“There’s going to be many, many, many, many hundreds of organization—– big, little and small—– doing mental health work in Haiti, “ Mollica says. “ And they will all have their own agenda, and their own donors, and their own goals.”

All will come with the best of intentions, says Mollica, but the work of a mental health professional in the aftermath of a major disaster like Haiti’s isn’t always clear. The science of how to treat psychological trauma is still very much evolving.

“Mental health has had a hard time figuring out how to fit in with the medical response,” says Mollica. Apparently while mending a broken leg is a straight forward process, mending a broken heart is much more fraught.

Okay, so “broken heart” is not what psychologists treat (usually), but other than that, the story’s pretty good. Why? First, as you can read above, the primary issue is coordination of services, as outlined by Richard Mollica (Harvard luminary in disaster mental health). Second, the piece provides a healthy dose of criticism of how our field’s embrace of PTSD as the main trauma-related problem led us to limit our thinking for what we should do (from Sandro Galea, PTSD research wunderkind). Third (and related to the second), there’s a good discussion of critical incident stress debriefing (mistakenly referred to as simply “debriefing”), which may have resulted in more people developing PTSD than would have if they had simply been left alone. Finally, as Dr. Mollica points out, psychological first aid is really more like social work 101:

The funny thing about “psychological first aid” though, is that there’s very little that’s particularly “psychological” about it. Mollica says it’s mostly very practical, basic social work.

“You can’t find your son? Well, this is who you need to talk to at the Red Cross to find your son. You don’t have enough water for tonight? This is who you need to talk to to get water for yourself.”

A couple weeks ago, I wrote in these blog pages that we really haven’t gotten much further than this. This is still true, but there is, according to Charles Marmar in an NYU Psychiatry Grand Rounds a few weeks ago, work afoot to test a behavioral treatment for the acute phase of trauma reactions (disclosure: Dr. Marmar is one of my bosses, and I like the guy). Based on  cognitive behavioral treatment for panic attacks, this treatment would involve anxiety reduction through brief education about reactions to trauma, breathing control, muscle relaxation, and thought stopping (a basic CBT technique). It would not involve reviewing or processing the trauma expereince, contraindicated in the acute posttrauma phase (the problem with critical incident stress debriefing).

In his talk, Marmar emphasized what Mollica alluded to this morning: “Mental health intervention the absence of basic needs is generally not effective.” So let’s make extra sure that mental health relief provided to Haiti follows material relief (as it did on NPR this morning).


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