Much of my previous research focused on identifying modifiable risk and protective factors for PTSD and common mental disorders in survivors of war and armed conflict, particularly the Rwandan genocide.2-6 I extended my research to intervention development during my National Institute of Mental Health (NIMH) funded postdoctoral fellowship at the Harvard T.H. Chan School of Public Health, where I used mixed-methods to develop and evaluate culturally-relevant measures of child mental health symptoms and conducted a pilot efficacy trial of a family-based resiliency intervention to prevent mental health problems in children affected by HIV/AIDS in Rwanda. Results indicated that participants were very satisfied with the culturally-adapted intervention and that children in the family resiliency intervention reported less depression compared to children in treatment as usual.7,8 Despite the favorable results, the intervention was not continued after the trial ended because of barriers to sustainability and lack of integration within the existing Rwandan health care system. Since that time I have dedicated myself to using hybrid effectiveness-implementation science methods1 to develop interventions that may be more sustainable and scalable in diverse settings.


PTSD and Severe Mental Illness in Low- and Middle-Income Countries

One way to make interventions more sustainable is to develop them for patients who are already presenting for care, in the settings where they present. In most low- and middle-income countries (LMICs), severe mental illness (SMI) including psychotic, bipolar, and persistent major depressive disorder, is the most common form of mental illness seen in primary care clinics.9-11 In high-income countries, 25-50% of people with SMI are thought to have PTSD;12,13 more than seven times the rate in the general population.14 For people with SMI, comorbid PTSD is associated with more severe SMI symptoms, greater functional impairment, and worse treatment outcomes.15-19 Research that I conducted at Massachusetts General Hospital found that among people with schizophrenia, PTSD symptoms, rather than psychosis or depression symptoms, were the primary predictors of participant-rated occupational and social functioning.20

My research in Ethiopia with collaborators at Addis Ababa University has similarly found that traumatic events are associated with poor outcomes. Quantitative results from a cohort of 300 people with SMI in rural Ethiopia, found that almost 50% had been restrained and more than one-third experienced traumatic events including assault or rape. Being restrained was associated with increased risk of suicidal ideation and exposure to traumatic events was associated with increased risk of hazardous drinking.22

In the US, evidence-based interventions (EBIs) for PTSD in patients with SMI improve PTSD, anxiety, and depression symptoms.23-25 However, no intervention data on comorbid PTSD and SMI is available from any LMIC. Moreover, many LMICs have extremely limited mental health services making implementation of EBIs challenging.26,27 Ethiopia has only one psychiatrist per two million people,28 and although 80% of the population lives in rural areas, the psychiatrists work in the capital,29 making regular care impossible for most. Given the dearth of mental health specialists and the chronic nature of mental disorders, primary care may be best positioned to address mental health in low- and middle-income countries (LMICs) such as Ethiopia.30,31 However little is known about factors that influence real-world service delivery, effectiveness, implementation or sustainability of mental health interventions in LMIC primary care clinics. Researching whether and how mental health services can be feasibly and effectively delivered in LMIC primary-care has been identified as a critical research need32 and a NIMH grand challenge in global mental health.33-35

In September 2016 I was awarded a five year K23 Mentored Career Development Award (K23MH110601) by the NIMH to use mixed methods to adapt and assess the feasibility, effectiveness and implementation of the Brief Relaxation, Education And Trauma HEaling (BREATHE) intervention,36,37 a US evidence-based intervention for PTSD in patients with SMI, in Ethiopian primary care clinics. Successful implementation of a psychotherapy intervention in Ethiopian primary care may provide support and a framework for interventions in other low-resource primary care settings, including those in the US, where comorbid PTSD and SMI is still usually overlooked, and integration of evidence-based interventions remains minimal.38-48

To develop a PTSD intervention that may be effective and sustainable in rural Ethiopian primary care, my research team conducted 48 semi-structured interviews with patients, caregivers, primary health care providers, community leaders, and community based rehabilitation providers in Sodo District. Interviews sought to (1) identify clinically and culturally relevant characteristics of population; (2) characterize barriers and facilitators to adoption, implementation and sustainability of the intervention; and (3) assess the cultural fit of the intervention. We have used the data to adapt the BREATHE treatment manual. We are preparing to pilot test the intervention to assess its effectiveness and implementation.

In addition to my own research developing an intervention for PTSD among people with SMI in Ethiopia, I am mentoring three PhD students who are applying the same approach to develop or adapt measures and interventions for PTSD in people with comorbid SMI in three different LMICs: Andrew Gilmoor (India), Vuyokzai Ntlantsana (South Africa), and Keneilwe Molebatsi (Botswana).

PTSD Screening and Treatment in US Adolescent Medicine Primary Care

While translational global mental health research often focuses on how to address barriers to care in LMICs, people with PTSD also face many challenges in accessing care in high-income countries such as the US. By age 18, approximately 7% of US adolescents will have had diagnosable PTSD.51 Patients who attend urban safety net hospitals with high rates of patients coping with poverty and community violence are at particularly high risk.52-54 This is concerning given that PTSD is associated with school failure, high-risk sexual behaviors, depression, suicide attempts, substance abuse, relationship problems, arrests, and health service utilization.54-56 Unfortunately, PTSD is routinely undiagnosed in US adolescent primary care.57 Those patients who are diagnosed are typically referred for specialized mental health services,58 but the rate of follow through is very low.58 Providing universal screening in primary care may improve detection. Similarly, providing interventions in primary care may increase treatment uptake since patients prefer it to specialized mental health services due to ease of access and less stigma.59 However, despite the increase in integrated care and the use of embedded mental health clinic staff in primary care, no interventions or screeners for PTSD have been developed for use in this setting.

To address this gap, I was awarded two pilot grants to adapt and validate an adult primary care PTSD screener and to adapt and test the BREATHE intervention36,37 for use in The Adolescent Center at Boston Medical Center. The Adolescent Center provides multidisciplinary primary care to over 2000 patients ranging in age from 12-22 years old, from diverse cultural, racial, and socioeconomic backgrounds and from a number of countries.

To adapt the intervention, semi-structured qualitative interviews were conducted with Adolescent Center patients at elevated risk of PTSD, parents, and clinic providers. Results indicated that the psychoeducation in the BREATHE intervention needed to be more tailored to individual patient symptom presentations, coping strategies should be included, and that psychoeducational videos of the original intervention which featured white middle-aged patients were not well received by the racially and ethnically diverse adolescent patients. In order to tailor the intervention to the primary care settings, sessions needed to be very brief, the total number of sessions needed to be fewer than five, and there needed to be flexibility in the modules to allow for the wide diversity of patient experiences seen in primary care. We adapted the treatment manual in response to the qualitative data and have recently completed an open trial to refine the manual and assess feasibility.

Factors Moderating PTSD Treatment Effectiveness in Sexual Minority Asylum Seekers

I am investigating factors that moderate mental health outcomes of asylum seekers in the US. Annually, Boston Medical Center (BMC) serves more than 400 asylum seekers who have been persecuted and tortured in their home countries. In 2017, patients came from 42 different countries, and represented over 100 different ethnicities. Prior to 2010 few BMC patients sought asylum due to being a sexual minority, but since that time approximately 20% of the asylum seeking patients report that they were persecuted because they are lesbian, gay, or bisexual. Very limited empirical literature has been published on the mental health needs of the this population,61,62 but clinical observation suggests that patients persecuted for their sexual minority status remain more isolated and experience more distress during and after treatment compared to patients persecuted for other reasons. I am currently conducting quantitative and qualitative studies to understand possible moderators and mediators of these potential discrepancies in treatment outcomes. Results may inform services and provide insight into the ways that multiple identities and experiences impact trauma treatments and outcomes.




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