Law enforcement and mental health clinician partnerships in global mental health: outcomes for the Crisis Intervention Team (CIT) model adaptation in Liberia, West Africa.

BACKGROUND: The Crisis Intervention Team (CIT) model is a law enforcement strategy that aims to build alliances between the law enforcement and mental health communities. Despite its success in the United States, CIT has not been used in low- and middle-income countries. This study assesses the immediate and 9-month outcomes of CIT training on trainee knowledge and attitudes. METHODS: Twenty-two CIT trainees (14 law enforcement officers and eight mental health clinicians) were evaluated using pre-developed measures assessing knowledge and attitudes related to mental illness. Evaluations were conducted prior to, immediately after, and 9 months post training. RESULTS: The CIT training produced improvements both immediately and 9 months post training in knowledge and attitudes, suggesting that CIT can benefit law enforcement officers even in extremely low-resource settings with limited specialized mental health service infrastructure. CONCLUSION: These findings support further exploration of the benefits of CIT in highly under-resourced settings.

Law Enforcement and Clinician Partnerships: Training of Trainers for CIT Teams in Liberia, West Africa.

The crisis intervention team (CIT) model was developed in the United States to align law enforcement goals with those of mental health advocates and service users. Liberia is the first low-income country where CIT has been implemented. After preliminary training of law enforcement officers and mental health clinicians by U.S. CIT experts, the program is now entirely implemented by Liberian personnel. In this column, the authors describe topics addressed in the 5-day training-of-trainers process to prepare Liberian mental health clinicians and law enforcement officers to conduct the program, along with feedback received from participants. They hope that this model can guide future initiatives aimed at fostering collaboration of law enforcement and mental health services in global mental health.

The myth of the 1-day training: the effectiveness of psychosocial support capacity-building during the Ebola outbreak in West Africa.

BACKGROUND: In emergencies and resource-poor settings, non-specialists are increasingly being trained to provide psychosocial support to people in distress, with Psychological First Aid (PFA) one of the most widely-used approaches. This paper considers the effectiveness of short training programmes to equip volunteers to provide psychosocial support in emergencies, focusing particularly on whether the PFA training provided during the Ebola outbreak enabled non-specialists to incorporate the key principles into their practice. METHODS: Semi-structured interviews were conducted in Sierra Leone and Liberia with 24 PFA trainers; 36 individuals who participated in PFA training; and 12 key informants involved in planning and implementing the PFA roll-out. RESULTS: Findings indicate that many PFA training-of-trainers were short and rarely included content designed to develop training skills. As a result, the PFA training delivered was of variable quality. PFA providers had a good understanding of active listening, but responses to a person in distress were less consistent with the guidance in the PFA training or with the principles of effective interventions outlined by Hobfoll et al. CONCLUSIONS: There are advantages to training non-specialists to provide psychosocial support during emergencies, and PFA has all the elements of an effective approach. However, the very short training programmes which have been used to train non-specialists in PFA might be appropriate for participants who already bring a set of relevant skills to the training, but for others it is insufficient. Government/NGO standardisation of PFA training and integration in national emergency response structures and systems could strengthen in-country capacity.

How competent are non-specialists trained to integrate mental health services in primary care? Global health perspectives from Uganda, Liberia, and Nepal.

Evaluations to objectively assess minimum competency are not routinely implemented for training and supervision in global mental health. Addressing this gap in competency assessment is crucial for safe and effective mental health service integration in primary care. To explore competency, this study describes a training and supervision program for 206 health workers in Uganda, Liberia, and Nepal in humanitarian settings impacted by political violence, Ebola, and natural disasters. Health workers were trained in the World Health Organization's mental health Gap Action Programme (mhGAP). Health workers demonstrated changes in knowledge (mhGAP knowledge, effect size, d = 1.14), stigma (Mental Illness: Clinicians' Attitudes, d = -0.64; Social Distance Scale, d = -0.31), and competence (ENhancing Assessment of Common Therapeutic factors, ENACT, d = 1.68). However, health workers were only competent in 65% of skills. Although the majority were competent in communication skills and empathy, they were not competent in assessing physical and mental health, addressing confidentiality, involving family members in care, and assessing suicide risk. Higher competency was associated with lower stigma (social distance), but competency was not associated with knowledge. To promote competency, this study recommends (1) structured role-plays as a standard evaluation practice; (2) standardized reporting of competency, knowledge, attitudes, and clinical outcomes; and (3) shifting the field toward competency-based approaches to training and supervision.

Health system preparedness for integration of mental health services in rural Liberia.

BACKGROUND: There are increasing efforts and attention focused on the delivery of mental health services in primary care in low resource settings (e.g., mental health Gap Action Programme, mhGAP). However, less attention is devoted to systematic approaches that identify and address barriers to the development and uptake of mental health services within primary care in low-resource settings. Our objective was to prepare for optimal uptake by identifying barriers in rural Liberia. The country's need for mental health services is compounded by a 14-year history of political violence and the largest Ebola virus disease outbreak in history. Both events have immediate and lasting mental health effects. METHODS: A mixed-methods approach was employed, consisting of qualitative interviews with 22 key informants and six focus group discussions. Additional qualitative data as well as quantitative data were collected through semi-structured assessments of 19 rural primary care health facilities. Data were collected from March 2013 to March 2014. RESULTS: Potential barriers to development and uptake of mental health services included lack of mental health knowledge among primary health care staff; high workload for primary health care workers precluding addition of mental health responsibilities; lack of mental health drugs; poor physical infrastructure of health facilities including lack of space for confidential consultation; poor communication support including lack of electricity and mobile phone networks that prevent referrals and phone consultation with supervisors; absence of transportation for patients to facilitate referrals; negative attitudes and stigma towards people with severe mental disorders and their family members; and stigma against mental health workers. CONCLUSIONS: To develop and facilitate effective primary care mental health services in a post-conflict, low resource setting will require (1) addressing the knowledge and clinical skills gap in the primary care workforce; (2) improving physical infrastructure of health facilities at care delivery points; and (3) implementing concurrent interventions designed to improve attitudes towards people with mental illness, their family members and mental health care providers.

Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study.

BACKGROUND: Access to mental health care services for patients with neuropsychiatric disorders remains low especially in post-conflict, low and middle income countries. Persons with mental health conditions and epilepsy take many different paths when they access formal and informal care for their conditions. This study conducted across three countries sought to provide preliminary data to inform program development on access to care. It thus sought to assess the different pathways persons with severe mental disorders and epilepsy take when accessing care. It also sought to identify the barriers to accessing care that patients face. METHODS: Six in depth interviews, 27 focus group discussions and 77 key informants' interviews were conducted on a purposively selected sample of health care workers, policy makers, service users and care takers in Uganda, Liberia and Nepal. Data collected along predetermined themes was analysed using Atlas ti software in Uganda and QSR Nvivo 10 in Liberia and Nepal RESULTS: Individual's beliefs guide the paths they take when accessing care. Unlike other studies done in this area, majority of the study participants reported the hospital as their main source of care. Whereas traditional healers lie last in the hierarchy in Liberia and Nepal, they come after the hospital as a care option in Uganda. Systemic barriers such as: lack of psychotropic medicines, inadequate mental health specialists and services and negative attitudes of health care workers, family related and community related barriers were reported. CONCLUSION: Access to mental health care services by persons living with severe mental disorders and epilepsy remains low in these three post conflict countries. The reasons contributing to it are multi-faceted ranging from systemic, familial, community and individual. It is imperative that policies and programming address: negative attitudes and stigma from health care workers and community, regular provision of medicines and other supplies, enhancement of health care workers skills. Ultimately reducing the accessibility gap will also require use of expert clients and families to strengthen the treatment coalition.