Academic journal article Journal of Cognitive Psychotherapy

Implementing Evidence-Based Mental Health Care in Low-Resource Settings: A Focus on Safety Planning Procedures

Academic journal article Journal of Cognitive Psychotherapy

Implementing Evidence-Based Mental Health Care in Low-Resource Settings: A Focus on Safety Planning Procedures

Article excerpt

Despite advances in global mental health evidence and policy recommendations, the uptake of evidence-based practices (EBP) in low- and middle-income countries has been slow. Lower resource settings have several challenges, such as limited trained personnel, lack of government resources set aside for mental health, poorly developed mental health systems, and inadequate child protection services. Given these inherent challenges, a possible barrier to implementation of EBP is how to handle safety risks such as suicide, intimate partner violence (IPV), and/or abuse. Safety issues are prevalent in populations with mental health problems and often overlooked and/or underreported. This article briefly reviews common safety issues such as suicide, IPV, and child abuse and proposes the use of certain implementation strategies which could be helpful in creating locally appropriate safety protocols. This article lays out steps and examples of how to create a safety protocol and describes and presents data on safety cases from three different studies. Discussion includes specific challenges and future directions, focusing on implementation.

Keywords: global mental health; suicide; abuse; implementation; low-resource settings

Global mental health has seen significant advances over the past decade. Researchers have validated assessment tools creating evidence-based measures for use in several low- and middle-income countries (LMIC; e.g., Bass, Ryder, Lammers, Mukaba, & Bolton, 2008; Jordans, Komproe, Tol, & De Jong, 2009; Kohrt et al., 2011; Murray et al., 2011a). The effectiveness and feasibility of implementing evidence-based treatments (EBT) for mental health problems in LMIC have been shown through multiple randomized controlled trials (RCTs), including cognitive-behavioral interventions for depression in primary health care (Rahman, Malik, Sikander, Roberts, & Creed, 2008), Interpersonal psychotherapy for depression for adults and adolescents (IPT & IPT-A; Bolton et al., 2003; Patel et al., 2010; Bolton et al., 2007), Cognitive Processing Therapy (CPT) for posttraumatic stress disorder (PTSD; Bass et al., 2013), and a common elements treatment approach for multiple common mental health problems (Bolton et al., 2014; Murray et al., 2013). The research evidence has resulted in the World Health Organization (WHO) recommending EBT in their Mental Health Gap Action Programme (mhGAP; WHO, 2010). However, despite research evidence and policy recommendations, the uptake of EBT in LMIC is low. Although the sluggish uptake of EBT is not unique to LMIC or mental health (e.g., Proctor et al., 2009; Rudan, El Arifeen, Black, & Campbell, 2007), it is important to identify barriers and possible ways to facilitate their implementation.

The implementation of mental health interventions in LMIC is wrought with challenges, such as limited trained personnel and turnover, lack of government resources set aside for mental health, poorly developed mental health systems, and inadequate child protection services (Patel, 2009; Saxena, Thornicroft, Knapp, & Whiteford, 2007). One result of these challenges is that service providers may not be equipped to adequately respond to suicidal ideation or behaviors, domestic or intimate partner violence, and/or child abuse. Few clinical domains are as programmatically, clinically, and emotionally challenging as managing suicide, intimate partner violence, and child abuse. These "safety" challenges may deter organizations from including mental health services in their packages of care, thus serving as a significant barrier to uptake of evidence-based mental health assessments and treatments. Practical strategies to address serious safety issues in LMIC are a current gap in the literature as well as a barrier to implementation. This article will provide example strategies for developing local safety protocols in LMIC which could assist with the management, and hopefully prevention, of suicide, intimate partner violence, and abuse/ neglect. …

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