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
Graduate Student Lead: Christine Bird
This project is investigating factors that moderate mental health outcomes of asylum seekers in the US across two studies. The first study, is using quantitative and qualitative data from intake assessments and narrative interviews with persecuted asylum seekers who sought services at Boston Medical Center. Since 2010, approximately 20% of the asylum seeking patients report that they were persecuted because they are lesbian, gay, or bisexual, yet very limited empirical literature has been published on the mental health needs of the this population. 61,62 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. We are currently conducting these quantitative and qualitative analyses to understand possible moderators and mediators of these potential discrepancies in mental health outcomes, particularly regarding the identity of the perpetrator, specifically the closeness of the relationship between the perpetrator and the victim, as well as levels of rejection and support received by the victim.
The second study uses qualitative narratives obtained from Boston Medical Center clinicians who have provided treatment to both LGBT and non-LGBT asylum seekers to analyze and determine differences in treatment outcomes for sexual minority asylum seekers. Results from these analyses may inform services and provide insight into the ways that multiple identities and experiences impact trauma treatments and outcomes.
Understanding the relationship between initial and subsequent trauma exposure
Graduate Student Lead: Rddhi Moodliar
This project aims to elucidate the relationship between an initial traumatic event and the risk for future trauma exposure. In this study, we will be primarily examining the cognitive sequelae of trauma exposure (e.g. attention, memory, concentration, problem solving, risk-taking behaviors, etc.). We hope that this study would better inform the field’s understanding of the cycle of trauma.
Developing and implementing a brief trauma intervention for individuals experiencing homelessness
Graduate Student Lead: Rddhi Moodliar
In this project, we plan to work alongside community partners who serve individuals experiencing homelessness in order to develop and implement an effective trauma-informed intervention which aims to reduce PTSD symptoms and future trauma exposure. One of the goals of this project is to meet the participants where they are at. That is, we will utilize a pragmatic approach which prioritizes flexibility and adaptation of traditional interventions so that they can be more effectively implemented in real-world settings.
Increasing the demand for and engagement in trauma treatment: Implementing direct-to-consumer strategies for youth of color and immigrant youth
Graduate Student Lead: Yesenia Aguilar Silvan
This study will use an experimental design to test direct-to-consumer (DTC) strategies to improve mental health service engagement of trauma exposed youth of color and immigrant youth. This study will consist of a qualitative analysis of effective engagement strategies and a quantitative analysis of consumer engagement with a real-world psychological service webpage and mental health services.
Health service disparities among youth who have experienced traumatic events: The role of intersectional identities
Graduate Student Lead: Yesenia Aguilar Silvan
This study will use medical record data to address the following aims on traumatic events and intersectional identity: 1) identify rates of traumatic events that are reported to health care providers pre and post California ACEs mandate, 2) identify rates of health service referrals when traumatic events are disclosed pre and post California ACEs mandate, and 3) examine trauma exposure identification rates and health service referral rates disparities by youths’ intersecting minority identities (i.e., age, gender identity, sex, race/ethnicity, education, country of origin, and socio-economic status).
Intersectional Minority Identity and PTSD Research Projects
Graduate Student Lead: Gia Chodzen
Gia’s research interests center around intersectional minority identity and PTSD. The overarching goal of Gia’s research is to identify strategies to make trauma-focused mental health interventions more effective for intersectional minority populations. She is pursuing three projects within the TRUST Lab with this goal in mind. First, she is conducting a systematic review to understand the scope of the academic literature that has been written about PTSD within intersectional minority groups. The goal of the review is to understand the extent to which intersectional minority identity impacts risk for the development and maintenance of PTSD, and whether there are identified variables that mediate or moderate this relationship.
Second, Gia is conducting a secondary analysis of data from the TRUST Lab’s PTSD Screening and Treatment in US Adolescent Medicine Primary Care project. She is analyzing taped PTSD therapy sessions, qualitative interviews, and medical charts to identify themes related to the participants’ identities and examine whether these themes are related to treatment outcome or engagement. Third, Gia will be collecting data within an upcoming TRUST Lab study to test several hypothesized mechanisms of PTSD treatment outcome, engagement, and satisfaction.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
- Mueser KT, Salyers MP, Rosenberg SD, et al. Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates. Schizophr Bull. 2004;30(1):45-57.=
- Mueser KT, Essock SM, Haines M, Wolfe R, Xie H. Posttraumatic stress disorder, supported employment, and outcomes in people with severe mental illness. CNS Spectr. 2004;9(12):913-925.
- Lysaker PH, Larocco VA. The prevalence and correlates of trauma-related symptoms in schizophrenia spectrum disorder. Compr Psychiatry. 2008;49(4):330-334.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Trappler B, Newville H. Trauma healing via cognitive behavior therapy in chronically hospitalized patients. Psychiatr Q. 2007;78(4):317-325.
- 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.
- Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370(9590):878-889.
- World Health Organization. Mental health atlas. Geneva: WHO Press; 2014.
- Federal Democratic Republic of Ethiopia Ministry of Health. National Mental Health Strategy 2012/13 – 2015/16. Addis Ababa: Federal Ministry of Health;2012.
- WHO and Ministry of Health. WHO-AIMS report on mental health system in Ethiopia. Addis Ababa, Ethiopia: World Health Organization; 2006.
- 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.
- 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.
- Hanlon C, Wondimagegn D, Alem A. Lessons learned in developing community mental health care in Africa. World Psychiatry. 2010;9(3):185-189.
- Collins PY, Patel V, Joestl SS, et al. Grand challenges in global mental health. Nature. 2011;475(7354):27-30.
- 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.
- 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.
- Mueser KT, Gottlieb JD, Xie H, et al. Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness. Br J Psychiatry. 2015;206(6):501-508.
- 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.
- 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.
- 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.
- 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.
- 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.
- Tucker WM. How to include the trauma history in the diagnosis and treatment of psychiatric inpatients. Psychiatr Q. 2002;73(2):135-144.
- 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.
- Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998;66(3):493-499.
- Cascardi M, Mueser KT, DeGiralomo J, Murrin M. Physical aggression against psychiatric inpatients by family members and partners. Psychiatr Serv. 1996;47(5):531-533.
- Craine LS, Henson CE, Colliver JA, MacLean DG. Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hosp Community Psychiatry. 1988;39(3):300-304.
- Lommen MJ, Restifo K. Trauma and posttraumatic stress disorder (PTSD) in patients with schizophrenia or schizoaffective disorder. Community Ment Health J. 2009;45(6):485-496.
- 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.
- 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.
- 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.
- 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.
- Liebschutz J, Saitz R, Brower V, et al. PTSD in Urban Primary Care: High Prevalence and Low Physician Recognition. J Gen Intern Med. 2007;22(6):719-726.
- Alim TN, Graves E, Mellman TA, et al. Trauma exposure, posttraumatic stress disorder and depression in an African-American primary care population. J Natl Med Assoc. 2006;98(10):1630-1636.
- Lipschitz DS, Rasmusson AM, Anyan W, Cromwell P, Southwick SM. Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic. J Am Acad Child Adolesc Psychiatry. 2000;39(9):1104-1111.
- Cohen JA, Bukstein O, Walter H, et al. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-430.
- Kartha A, Brower V, Saitz R, Samet JH, Keane TM, Liebschutz J. The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients. Med Care. 2008;46(4):388-393.
- 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.
- 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.
- 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.
- Srivastava A, Miller A, Tai M-H, Ng LC. Development of a brief PTSD intervention for adolescent medicine primary care. In preparation. In Preparation.
- 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.
- Reading R, Rubin LR. Advocacy and empowerment: Group therapy for LGBT asylum seekers. Traumatology. 2011;17(2):86-98.