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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/
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Funding, affiliations, Partners
https://www.jhsph.edu/research/centers-and-institutes/global-mental-health 2
MinistriesofHealth
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Medical studies show that….Mental health care can improve HIV treatment adherence and result in
better viral suppression!
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WhatCETAworkson?PERCEPTIONS:changingthoughts,feelingsandactionsLIFESTYLE/LIFEDECISIONSMENTALHEALTHSUBSTANCEUSEPROBLEMSOLVINGBARRIERSRISKYBEHAVIORSBEHAVIORCHANGESELFEFFICACY
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Global Mental Health….view from 30,000 feet….
Depression,Trauma,Anxiety,SubstanceUse,Violence,Communicationproblems,Poorrelationships,Poorbehaviordecisions,Negativeself-beliefs,
Suicide…etc.
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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)
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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.
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There is an Implementation GAP
Itstimetousewhatweknow–LetstalkaboutHOWwedothat!
Researchshowingsomeprogramsare
feasible,adaptableand
effective
Uptakeoftheseinterventions
bylocally-basedorganizations/
systems
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CommonelementsTreatmentApproach(CETA)
• Rationale – why CETA? • Overview of what CETA is • Evidence-base – why invest in CETA?
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Singlefocustreatments=implementationchallenge
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Depression
Trauma/violence
Anxiety
SubstanceUseViolence
Riskybehaviors
Lowadherence
BehavioralActivationmanual
InterpersonalPsychotherapy
Parentingskills
PM+
CBTforSubstanceuse
TF-CBT
Cognitiveprocessingtherapy
Comorbidity!
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WhatisCETA?
◦ CommonElementsTreatmentApproach◦ ATransdiagnosticModular,Multi-problem,FlexibleApproach
◦ Definition:WithONEapproachwecantreatmultiplecommonproblems(substanceuse,anxiety,depression,PTSD)+behaviorproblemsinyouth)
◦ Nota“new”treatment:it’sanapproachusingevidence-basedelementsfromexistingtreatments.
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What is the Evidence for CETA? EFFECTIVENESS, FEASIBILITY, ACCEPTABILITY
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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
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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
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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)
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CETA Effective for Multiple Problems
18Bolton et al., PLoS Medicine, 2014
ComparedtoTreatmentasUsual
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CETAistheONLYmodular,flexible,multi-problemapproachthathasmultiplelargetrialsinlowerresourcesettings.
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Purpose: To test the effectiveness of CETA on: • VIOENCE • ALCOHOL
MIS-USE
ZambiaCETATrial
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Interventions:
1. CETA 2. Treatment as usual with
weekly safety check-ins Delivery
• Group • Individual
WhodidweTreat?
1. Men–alcoholmis-useandviolence2. Women–reportedviolence3. Youth–recommendedbycaregivers
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Data Safety and Monitoring Board Stopped the Trial 1 year EARLY!
CETA EFFECTIVE SO NEEDED TO OFFER TO CONTROLS FINAL RESULTS CURRENTLY UNDER REVIEW
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CETAisaneffectiveinterventionfor
reducingviolenceandalcoholabuse–and
mentalhealth.
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How can CETA be integrated into HIV prevention, testing, care and
treatment??
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WhocanprovideCETA?
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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
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Apprenticeship model for a
study or program.
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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.
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WhatdoestheCETAproviderjoblooklike?
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ItsFlexible!• Time:1-2daysaweek,FullTime…
• HIVpeereducatordoescommunityoutreach2daysaweekandprovidesCETA1.5daysatthecommunitychurch
• FaithbasedworkerhasaddedCETAskillsandrollsitintotheirfull-timejob
• Supervision:2hoursperweek• Location:Inaclinicsetting,inthecommunity,inschools,underatree…whereverHIVservicesaremosteffectivelydelivered!
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WhatdoestheCETAproviderjoblooklike?
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ItsFlexible!
• Delivery:• Grouporindividualdelivery• 1element,afewelements,allelements….basedonneed
• Phoneuse:Neededforsafetycasestocallsupervisor• Payment:
• Newjoblinesforlayworkers• Existingworkersreceiveincreaseinpayforadditionalskills
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WhatdoestheCETAproviderjoblooklike?
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• Numberofsessions:• Prevention:1session• Mildproblems:~3-5sessions• Moderatetosevereproblems:~8-12sessions• Sessionscanbelongerthan1hour;orshorter
• Numberofclientsonecansee:• Dependsonhoursavailableperweekandtraveltime
• Clinicsetting:5-6clientsinaday• Communitywithtravelbetweenclients:3-4inaday.
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ExampleofCETAatPreventionStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseandriskybehavior
Use1or2elementsofCETAwithstaffto:• Helpthemdealwithstressandpressuretofindindividualsthatneedtesting
• Helpthemdealwithstressofdisclosingstatus
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ExampleofCETAatTestingStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseand
riskybehavior.• Changethoughtsandproblemsolvetoincrease
disclosure
• Use1or2elementsofCETAwithstaffto:• Helpthemdealwithpressuretofindindividualsthatneedtesting
• Helpthemdealwithstressofdisclosingstatus
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ExampleofCETAatCareandTreatmentStage
UseCETAwithHIV+orthoseatriskto:• Reduceviolence,mentalhealth,substanceuseandriskybehavior–allofwhicharelinkedtopooradherence.
Use1or2elementsofCETAwithstaffto:• Helpthemlearntoengageclientsintreatment
• Increasebuy-inforprogram
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Let’s Discuss!
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AppliedMentalHealthResearchGroup(AMHR):https://www.jhsph.edu/research/centers-and-institutes/global-mental-health
LauraMurray,Ph.D.:[email protected] !!