The Common Elements Treatment Approach
(CETA) LAURA MURRAY, PHD ([email protected])
JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH
DEPARTMENT OF MENTAL HEALTH & INTERNATIONAL HEALTH
HT TPS://WWW.JHSPH.EDU/RESEARCH/CENTERS-AND-INSTITUTES/GLOBAL-MENTAL-HEALTH/
1
Funding, affiliations, Partners
https://www.jhsph.edu/research/centers-and-institutes/global-mental-health 2
MinistriesofHealth
3
Medical studies show that….Mental health care can improve HIV treatment adherence and result in
better viral suppression!
4
5
WhatCETAworkson?PERCEPTIONS:changingthoughts,feelingsandactionsLIFESTYLE/LIFEDECISIONSMENTALHEALTHSUBSTANCEUSEPROBLEMSOLVINGBARRIERSRISKYBEHAVIORSBEHAVIORCHANGESELFEFFICACY
Global Mental Health….view from 30,000 feet….
Depression,Trauma,Anxiety,SubstanceUse,Violence,Communicationproblems,Poorrelationships,Poorbehaviordecisions,Negativeself-beliefs,
Suicide…etc.
TrialsofMentalHealthInterventions• InterpersonalPsychotherapyforDepression(IPT)
• S.Ugandawithadults;HIVaffected(Boltonetal.,2007)• N.UgandawithyouthinIDPcamp;conflictandHIV(Boltonetal.2009)
• CognitiveProcessingTherapy(CPT)• DRC;Adultsurvivorsofsexualviolence;HIV(Bassetal.2013)• N.andS.Iraq:Adulttorturesurvivors(Boltonetal.,2014;Weissetal.,2015)
• BehavioralActivation(BA)• N.Iraq:Adulttorturesurvivors(Boltonetal.,2014)
• TraumaFocusedCognitiveBehavioralTherapy(TF-CBT)• Zambia:OVC;HIV-affected(Murrayetal.,2015)
• CommonElementsTreatmentApproach(CETA)• SouthernIraq(Weiss,Murrayetal.,2015)• Thailand/Myanmarborder(Boltonetal.,2014)• Ethiopiarefugeeyouth(Murrayetal.,2017)• Zambiaviolenceandsubstanceuse(Murrayetal.,underreview)
Effective Treatment for HIV-affected OVC
*Effect of treatment is statistically significant (p<.0001)
Cohen’s d = 2.39
TRAUMA
Trauma-FocusedCognitiveBehavioralTherapy
MurrayLK,SkavenskiS,KaneJC,MayeyaJ,DorseyS,CohenJA,MichalopoulosLT,ImasikuM,BoltonPA.EffectivenessofTrauma-FocusedCognitiveBehavioralTherapyamongTrauma-AffectedChildreninLusaka,Zambia;ARandomizedClinicalTrial.JAMAPediatrics.2015Aug1;169(8):761-9.
There is an Implementation GAP
Itstimetousewhatweknow–LetstalkaboutHOWwedothat!
Researchshowingsomeprogramsare
feasible,adaptableand
effective
Uptakeoftheseinterventions
bylocally-basedorganizations/
systems
9
CommonelementsTreatmentApproach(CETA)
• Rationale – why CETA? • Overview of what CETA is • Evidence-base – why invest in CETA?
Singlefocustreatments=implementationchallenge
11
Depression
Trauma/violence
Anxiety
SubstanceUseViolence
Riskybehaviors
Lowadherence
BehavioralActivationmanual
InterpersonalPsychotherapy
Parentingskills
PM+
CBTforSubstanceuse
TF-CBT
Cognitiveprocessingtherapy
Comorbidity!
WhatisCETA?
◦ CommonElementsTreatmentApproach◦ ATransdiagnosticModular,Multi-problem,FlexibleApproach
◦ Definition:WithONEapproachwecantreatmultiplecommonproblems(substanceuse,anxiety,depression,PTSD)+behaviorproblemsinyouth)
◦ Nota“new”treatment:it’sanapproachusingevidence-basedelementsfromexistingtreatments.
13
What is the Evidence for CETA? EFFECTIVENESS, FEASIBILITY, ACCEPTABILITY
15
Data on CETA
UkraineIDPsandvets:Hybrid,shortCETAmodel,DImeasurement Lebanon–Syrianrefugees:Telephone,Training/supervisionmethodsandcompetencyrating Zambia–Familyandcommunityfocus,IPVandSU,Train-the-trainertechnologystrategies
Citation Site Population N Impact(Effectsizes)
Boltonetal.(2014)
MaeSot,Thailand
Adult;BurmeseRefugees
CETA:182Wait-list:165
CETAvs.Wait-list
Depression:1.16PTS:1.19ImpairedFunction:0.63Anxiety:0.79Aggression:-0.58
Weiss,Murrayetal.(2015)
SouthernIraq Adult;Survivorsofsystematicviolence
CPT:99Wait-list:50
CETAvs.Wait-list
PTS:2.40Depression:1.82Dysfunction:0.88
Murrayetal.,(2018)
Ethiopia Somalirefugeesincamps;Youth
CETA:37 Opentrial Internalizing1.37Externalizing0.85Posttraumaticstress1.71Improvementsinwell-being0.7
CETA Effectively Decreased Depression and Trauma Depression Effect Size = 1.82
Trauma Effect Size = 2.40
Weiss, Murray, Zangana, Mahmooth, Kaysen, Dorsey, Lindgren, et al. BMC Psychiatry
Depression Scale (HSCL-25) Harvard Trauma Questionnaire
CETA is more Effective than Single Focused Treatments
0.87
1.78
2.38
1.56
0.63
0.44
0.61
0.59
0.79
0.84
0.56
0.48
0.07
0.4
0.43
0.27
0.54
0.55
0.34
0.41
0 0.5 1 1.5 2 2.5
Dysfunction
Depression
PTS
Anxiety
NonspecificCounseling
CognitiveProcellingTherapy-SouthIraq
BehavioralActivationtreatment-NorthIraq
CognitiveProcessingTherapy-NorthIraq
CETA
(Weiss,Murray,etal.2015;Boltonetal.,2014)
CETA Effective for Multiple Problems
18Bolton et al., PLoS Medicine, 2014
ComparedtoTreatmentasUsual
CETAistheONLYmodular,flexible,multi-problemapproachthathasmultiplelargetrialsinlowerresourcesettings.
Purpose: To test the effectiveness of CETA on: • VIOENCE • ALCOHOL
MIS-USE
ZambiaCETATrial
Interventions:
1. CETA 2. Treatment as usual with
weekly safety check-ins Delivery
• Group • Individual
WhodidweTreat?
1. Men–alcoholmis-useandviolence2. Women–reportedviolence3. Youth–recommendedbycaregivers
Data Safety and Monitoring Board Stopped the Trial 1 year EARLY!
CETA EFFECTIVE SO NEEDED TO OFFER TO CONTROLS FINAL RESULTS CURRENTLY UNDER REVIEW
22
CETAisaneffectiveinterventionfor
reducingviolenceandalcoholabuse–and
mentalhealth.
24
How can CETA be integrated into HIV prevention, testing, care and
treatment??
WhocanprovideCETA?
25
Mental
healthprofessionals
“TaskShifting/SharingApproach”
LAYPROVIDERS!• Noadvancededucationneeded(e.g.,4thgrade)• Speakslocallanguage(s)• Passiontohelpreach95.95.95goals• Goodwithpeople/adolescents• Peoplewhoknowthecommunities• PeopleatallstagesofHIVcare:prevention,testing,treatment,ARTmanagement
• ThosewithTIME• Thosethathaveorganizationskills,Responsibility
Apprenticeship model for a
study or program.
CETA Builds Capacity
► CETAelements
► Weeklysymptommonitoring(tool,use,monitoring)
► Supervisionskills● Localsupervisorschosenoutofthelayproviderstrained
► Safetyprotocols(suicide,homicide,abuse,violence)
► ImplementationofCETAintoexistingprograms
● E.g.,choiceofproviders,communityrecruitment,M&E,forms,buy-infrom
stakeholders…etc.
WhatdoestheCETAproviderjoblooklike?
28
ItsFlexible!• Time:1-2daysaweek,FullTime…
• HIVpeereducatordoescommunityoutreach2daysaweekandprovidesCETA1.5daysatthecommunitychurch
• FaithbasedworkerhasaddedCETAskillsandrollsitintotheirfull-timejob
• Supervision:2hoursperweek• Location:Inaclinicsetting,inthecommunity,inschools,underatree…whereverHIVservicesaremosteffectivelydelivered!
WhatdoestheCETAproviderjoblooklike?
29
ItsFlexible!
• Delivery:• Grouporindividualdelivery• 1element,afewelements,allelements….basedonneed
• Phoneuse:Neededforsafetycasestocallsupervisor• Payment:
• Newjoblinesforlayworkers• Existingworkersreceiveincreaseinpayforadditionalskills
WhatdoestheCETAproviderjoblooklike?
30
• Numberofsessions:• Prevention:1session• Mildproblems:~3-5sessions• Moderatetosevereproblems:~8-12sessions• Sessionscanbelongerthan1hour;orshorter
• Numberofclientsonecansee:• Dependsonhoursavailableperweekandtraveltime
• Clinicsetting:5-6clientsinaday• Communitywithtravelbetweenclients:3-4inaday.
31
ExampleofCETAatPreventionStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseandriskybehavior
Use1or2elementsofCETAwithstaffto:• Helpthemdealwithstressandpressuretofindindividualsthatneedtesting
• Helpthemdealwithstressofdisclosingstatus
32
ExampleofCETAatTestingStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseand
riskybehavior.• Changethoughtsandproblemsolvetoincrease
disclosure
• Use1or2elementsofCETAwithstaffto:• Helpthemdealwithpressuretofindindividualsthatneedtesting
• Helpthemdealwithstressofdisclosingstatus
33
ExampleofCETAatCareandTreatmentStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseandriskybehavior–allofwhicharelinkedtopooradherence.
Use1or2elementsofCETAwithstaffto:• Helpthemlearntoengageclientsintreatment
• Increasebuy-inforprogram
Let’s Discuss!
34
AppliedMentalHealthResearchGroup(AMHR):https://www.jhsph.edu/research/centers-and-institutes/global-mental-health
LauraMurray,Ph.D.:[email protected]!!
