DR. NG’S PREVIOUS RESEARCH
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.
DR. NG’S CURRENT RESEARCH
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.
1. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217-226.
2. Betancourt TS, Ng LC, Kirk CM, et al. Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial. AIDS. 2014;28 Suppl 3:S359-368.
3. Ng LC, Ahishakiye N, Miller DE, Meyerowitz BE. Narrative characteristics of genocide testimonies predict posttraumatic stress disorder symptoms years later. Psychol Trauma. 2015;7(3):303-311.
4. Ng LC, Ahishakiye N, Miller DE, Meyerowitz BE. Life after Genocide: Mental Health, Education, and Social Support of Orphaned Survivors. International perspectives in psychology : research, practice, consultation. 2015;4(2):83-97.
5. Ng LC, Kirk CM, Kanyanganzi F, et al. Risk and protective factors for suicidal ideation and behaviour in Rwandan children. Br J Psychiatry. 2015;207(3):262-268.
6. Ng LC, Kanyanganzi F, Munyanah M, Mushashi C, Betancourt TS. Developing and validating the Youth Conduct Problems Scale-Rwanda: a mixed methods approach. PLoS One. 2014;9(6):e100549.
7. Betancourt TS, Ng LC, Kirk CM, et al. Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial. Aids. 2014;28(Suppl 0):S1-S10.
8. Betancourt TS, Ng LC, Kirk CM, et al. Family-based promotion of mental health in children affected by HIV: a pilot randomized controlled trial. Journal of child psychology and psychiatry, and allied disciplines. 2017;58(8):922-930.
9. Ventevogel P, Ndayisaba H, van de Put W. Psychosocial assistance and decentralised mental health care in post conflict Burundi 2000–2008. Intervention. 2011;9(3):315-331.
10. Kane JC, Ventevogel P, Spiegel P, Bass JK, van Ommeren M, Tol WA. Mental, neurological, and substance use problems among refugees in primary health care: analysis of the Health Information System in 90 refugee camps. BMC Med. 2014;12:228.
11. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007;370(9590):841-850.
12. Grubaugh AL, Zinzow HM, Paul L, Egede LE, Frueh BC. Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: A critical review. Clin Psychol Rev. 2011;31(6):883-899.
13. Bajor LA, Lai Z, Goodrich DE, et al. Posttraumatic stress disorder, depression, and health-related quality of life in patients with bipolar disorder: review and new data from a multi-site community clinic sample. J Affect Disord. 2013;145(2):232-239.
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18. Duke LA, Allen DN, Ross SA, Strauss GP, Schwartz J. Neurocognitive function in schizophrenia with comorbid posttraumatic stress disorder. J Clin Exp Neuropsychol. 2010;32(7):737-751.
19. Mueser KT, Lu W, Rosenberg SD, Wolfe R. The trauma of psychosis: posttraumatic stress disorder and recent onset psychosis. Schizophr Res. 2010;116(2-3):217-227.
20. Ng LC, Petruzzi LJ, Greene MC, Mueser KT, Borba CP, Henderson DC. Posttraumatic Stress Disorder Symptoms and Social and Occupational Functioning of People With Schizophrenia. The Journal of nervous and mental disease. 2016;204(8):590-598.
21. Ng LC, Hanlon C. The Presence and Impact of Traumatic Events on the Lives of People Living with Serious Mental Illness in a Low-Resource Setting. In preparation.
22. Ng LC, Medhin G, Hanlon C, Fekadu A. Trauma Exposure, Depression, Suicidal Ideation, and Alcohol Use in People with Severe Mental Disorder. Social psychiatry and psychiatric epidemiology. 2019; Jul;54(7):835-842. doi: 10.1007/s00127-019-01673-2.
23. Frueh BC, Grubaugh AL, Cusack KJ, Kimble MO, Elhai JD, Knapp RG. Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study. J Anxiety Disord. 2009;23(5):665-675.
24. Trappler B, Newville H. Trauma healing via cognitive behavior therapy in chronically hospitalized patients. Psychiatr Q. 2007;78(4):317-325.
25. Mueser KT, Rosenberg SD, Xie H, et al. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 2008;76(2):259-271.
26. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370(9590):878-889.
27. World Health Organization. Mental health atlas. Geneva: WHO Press; 2014.
28. Federal Democratic Republic of Ethiopia Ministry of Health. National Mental Health Strategy 2012/13 – 2015/16. Addis Ababa: Federal Ministry of Health;2012.
29. WHO and Ministry of Health. WHO-AIMS report on mental health system in Ethiopia. Addis Ababa, Ethiopia: World Health Organization; 2006.
30. Beaglehole R, Epping-Jordan J, Patel V, et al. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. Lancet. 2008;372(9642):940-949.
31. Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, Unutzer J. Grand challenges: integrating mental health services into priority health care platforms. PLoS Med. 2013;10(5):e1001448.
32. Hanlon C, Wondimagegn D, Alem A. Lessons learned in developing community mental health care in Africa. World Psychiatry. 2010;9(3):185-189.
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34. Patel V, Araya R, Chatterjee S, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet. 2007;370(9591):991-1005.
35. National Institutes of Health. Global Mental Health Research Program. 2015; http://www.nimh.nih.gov/about/organization/gmh/global-mental-health-research-program.shtml. Accessed September 19, 2015.
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37. Nishith P, Mueser KT, Morse GA. A brief intervention for posttraumatic stress disorder in persons with a serious mental illness Psychiatric Rehabilitation Journal. In Press.
38. Chernomas WM, Mordoch E. Nurses’ perspectives on the care of adults with mental health problems and histories of childhood sexual abuse. Issues Ment Health Nurs. 2013;34(9):639-647.
39. Chessen CE, Comtois KA, Landes SJ. Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology. Psychiatr Serv. 2011;62(10):1201-1206.
40. Salyers MP, Evans LJ, Bond GR, Meyer PS. Barriers to assessment and treatment of posttraumatic stress disorder and other trauma-related problems in people with severe mental illness: clinician perspectives. Community Ment Health J. 2004;40(1):17-31.
41. Frueh BC, Cousins VC, Hiers TG, Cavenaugh SD, Cusack KJ, Santos AB. The need for trauma assessment and related clinical services in a state-funded mental health system. Community Ment Health J. 2002;38(4):351-356.
42. Tucker WM. How to include the trauma history in the diagnosis and treatment of psychiatric inpatients. Psychiatr Q. 2002;73(2):135-144.
43. Read J, Ross CA. Psychological trauma and psychosis: another reason why people diagnosed schizophrenic must be offered psychological therapies. J Am Acad Psychoanal Dyn Psychiatry. 2003;31(1):247-268.
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48. Cusack KJ, Grubaugh AL, Knapp RG, Frueh BC. Unrecognized trauma and PTSD among public mental health consumers with chronic and severe mental illness. Community Ment Health J. 2006;42(5):487-500.
49. Gilmoor AR, Vallath S, van den Berg D, Reeger B, Peters R, Ng LC. The cultural adaptation of the trauma history questionnaire in a population of homeless persons with severe mental illness, in Tamil Nadu, India. In Preparation.
50. Gilmoor AR, Peters R, Vallath S, Ng LC. Patient and provider perspectives on the administration and assessment of trauma inventories in an Indian population of homeless persons with severe mental illness: Reflections on a pilot of the culturally adapted trauma history questionnaire Tamil version. . In Preparation.
51. Merikangas KR, He J-p, Burstein M, et al. Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989.
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57. Gerson R, Rappaport N. Traumatic stress and posttraumatic stress disorder in youth: recent research findings on clinical impact, assessment, and treatment. J Adolesc Health. 2013;52(2):137-143.
58. Banh MK, Saxe G, Mangione T, Horton NJ. Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care. Gen Hosp Psychiatry. 2008;30(6):536-545.
59. Curran GM, Sullivan G, Mendel P, et al. Implementation of the CALM intervention for anxiety disorders: a qualitative study. Implementation science : IS. 2012;7:1-11.
60. Srivastava A, Miller A, Tai M-H, Ng LC. Development of a brief PTSD intervention for adolescent medicine primary care. In preparation. In Preparation.
61. Kahn S, Alessi E, Woolner L, Kim H, Olivieri C. Promoting the wellbeing of lesbian, gay, bisexual and transgender forced migrants in Canada: Providers’ perspectives. Culture, Health & Sexuality. 2017;19(10):1165-1179.
62. Reading R, Rubin LR. Advocacy and empowerment: Group therapy for LGBT asylum seekers. Traumatology. 2011;17(2):86-98.