Background: Low- and middle-income countries (LMICs) have very few mental health professionals. Given the chronic nature of mental disorders, primary care clinics may be best positioned to address mental health in LMICs. However, little is known about factors that influence real-world service delivery, access, quality, and sustainability of mental health interventions in LMIC primary care. Researching whether and how mental health services can be feasibly and effectively delivered in LMIC primary care is a NIMH priority and a grand challenge in global mental health. Severe mental illness (SMI) is the most common form of mental illness seen in primary care clinics in LMICs, and is a top contributor to the burden of disease. People with SMI are at high risk of developing posttraumatic stress disorder (PTSD), which is associated with more severe psychiatric symptoms, functional impairment, and worse treatment outcomes.
Specific aims : The current study proposes to develop and assess the feasibility, effectiveness and implementation of a psychotherapy intervention to treat PTSD in patients with SMI in primary care clinics in rural Ethiopia.
Aim 1 : To conduct semi-structured qualitative interviews with patients, caregivers, providers and community members (n=60) and one community advisory board (n=17) to identify clinically and culturally relevant characteristics of the population and characterize barriers and facilitators to intervention adoption, implementation and sustainability. Results will be used to assess the fit and development of the intervention;
Aim 2 : To conduct a mixed methods open trial to refine the intervention and explore initial treatment effects (n=20 patients, 20 caregivers);
Aim 3 : To conduct a mixed methods multi-stakeholder process evaluation to assess intervention implementation as measured by the RE-AIM implementation framework (n=20 patients, 20 caregivers, 7 providers). Candidate: This Mentored Patient-Oriented Research Career Development Award (K23) builds upon the candidate's experience in trauma-focused global mental health research in low-income countries. The candidate's long-term career goal is to be an independent investigator of evidence-based interventions for PTSD and SMI in LMICs. Training objectives: The K23 provides training and mentorship in (1) the course, prevalence and treatment of comorbid PTSD and SMI; (2) health services research, including methods to evaluate how healthcare is delivered and accessed in Ethiopian primary care, and factors that might influence delivery of a psychosocial intervention for PTSD; and (3) implementation science methods to decrease ?science-to-service? gaps in providing mental health care in LMIC primary care, including hybrid effectiveness-implementation trials. Training activities. Training will be achieved through mentorship by experts (Drs. David Henderson, Abebaw Fekadu, Charlotte Hanlon, Kim Mueser, and Graham Thornicroft), field-based experience in Ethiopia, formal coursework at Harvard and Boston Universities, and seminars, trainings, and conference and workshop attendance.

Public Health Relevance

Mental and substance use disorders are leading causes of disability worldwide. Although 85% of the world's population lives in low- and middle-income countries (LMICs), less than 10% of research on mental health interventions has been conducted in LMICs. Implementation of a psychotherapy intervention in Ethiopian primary care may provide support and a framework for interventions in other low-resource primary care settings, improving equity and access to care, and reducing the burden of mental illness.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Mentored Patient-Oriented Research Career Development Award (K23)
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Mental Health Services Research Committee (SERV)
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Horvath Marques, Andrea de Fatima
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University of California Los Angeles
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Los Angeles
United States
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Koenen, K C; Ratanatharathorn, A; Ng, L et al. (2017) Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med 47:2260-2274
Ng, Lauren C; López, Belkys; Pritchard, Matthew et al. (2017) Posttraumatic stress disorder, trauma, and reconciliation in South Sudan. Soc Psychiatry Psychiatr Epidemiol 52:705-714