Development, feasibility, and acceptability of a one-time Problem Management Plus (PM+) booster session in the Bahamas: A pilot randomized controlled trial
● Background
○ Literature review
○ Formative research & Grand Bahama
● Aims & Hypotheses
● Methods
● References
● Acknowledgements
● Islands in the Caribbean Sea face a yearly threat from hurricanes and extreme heat, in addition to common existing stressors (job insecurity and economic instability, few MH resources, stigma)
● Climate change is well-known to have negative effects on mental health (Sanson et al., 2018, Schultz et al., 2020), yet research in the Caribbean is scarce
○ We know that after hurricanes, sxs of PTSD, anxiety, and depression have been observed to increase (FEMA, 2018; Schultz et al., 2020; United Nations, 2020)
● And capitalizing on resources is difficult because of the geographic barriers to travel between islands (Asnaani et al., 2020; Walker et al., 2022)
○ Therefore, these communities may be ideal locations for implementing task-sharing interventions
● A 5-session “task-sharing” intervention designed by the WHO to address practical and emotional problems
○ Task-sharing is a strategy used to address gaps in mental healthcare (WHO, 2016)
● Research has shown that PM+ is effective in reducing sxs of:
○ Depression and anxiety (Bryant et al., 2017; Bryant et al.,2022, de Graaff et al., 2023)
○ PTSD (Rahman et al., 2016)
● PM+ has been implemented throughout the world in many different contexts, including LMICS and HICS:
○ Kenya (Bryant et al., 2017), Pakistan (Rahman et al., 2016), Nepal (Jordans et al., 2021),with Syrian refugees in Switzerland (de Graaff et al., 2023), in NYC (Kohrt et al, 2024).
Get Going
Session 4: Strengthening Social Support Intro and Review of Managing Stress, Managing Problems and GGKD Strengthening Social Support (building trust, reaching out for help, engaging with community) Ending the session/Action
Session 5: Staying Well
Intro and Review of Managing Stress, Managing Problems, GGKD + Strengthening Social Support Staying Well (relapse prevention)
how to help others
to the future
● Northernmost populated island in the Bahamas, located in the middle of the Caribbean hurricane belt
○ Chronic, yearly period of stress during hurricane season (~June through mid-November)
● Spring 2023: TNS collaborated University of the Bahamas-North to implement a pilot program of peer-to-peer PM+
○ Results: Delivered full protocol to 2 students
■ Qualitative interviews suggested that:
● Hurricane season is a major stressor each year
● PM+ was feasible, acceptable, and well-received by the Bahamian students
● Delivery by fellow Bahamians was preferable to outside providers and helped reduce stigma
● The breathing strategy, in particular, was helpful and students reported practicing outside of sessions
● Most effectiveness studies of PM+ and group PM+ measure outcomes immediately after the intervention (~6-8 weeks after baseline)
● Many also include a three-month follow-up endline (~12-18 weeks after baseline).
● Studies that include a follow-up have tended to show reductions in mean benefit from post-intervention to follow-up (Acarturk et al., 2024; Bryant et al., 2022; Jordans et al., 2021; Greene et al., 2024),
○ Some trials maintain benefits at follow-up as well (Rahman et al., 2016).
○ Few studies have examined medium- and long-term effects of PM+.
Greene et al., (In Press)
● Even studies that continue to favor PM+ at 3-month follow-up show some waning effects over time (Bryant et al., 2017).
○ As well for studies that still show benefits at 1 year (Kananian et al., 2020)
● Some studies, however, have shown that sxs may return by 3-month follow-up (Greene et al., In Press).
● Bryant et al. (2022) conducted follow-up assessments at 12 months post PM+ and found no group differences.
● Diminished use of PM+ strategies over time (Kananian et al., 2020; Bryant et al., 2022)
○ Jordans et al. (2021) found that 31% of the observed tx effects of gPM+ at 3-month follow-up were mediated by participants’ use and practice of the PM+ strategies
● Reductions in self-efficacy
○ Q fever fatigue (QFS) pts who had previously benefited (i.e. experienced relief of fatigue sxs) from CBT showed relapse correlated with reductions in self-efficacy (Breukers et al., 2019)
● Suggested by many PM+ researchers (e.g. Jordans et al., 2021; Bryant et al, 2022) but not yet tested with PM+ or other task-sharing interventions
○ Sometimes referred to as “top-ups” (Wrapson et al., 2020), “continuation of care” (Jarrett et al., 2001), or “maintenance therapy” (Stangier et al., 2013)
● Evidence for the effectiveness of booster sessions is mixed but promising
○ Some studies show little benefit beyond maintenance of sx reduction (Baker & Wilson, 1985)
● However
○ Booster sessions after a course of CBT shown to result in significant sx improvement for panic disorder, depression and anxiety (Wesner et al., 2015)
○ A “continuation phase” (booster sessions) of cognitive therapy led to lower rates of unipolar depression relapse (10.3%) than control group (30.9%; Jarrett et al., 2001)
1. Co-create a culturally adapted protocol and manual chapter for a one-time booster session of PM+.
2. Implement RCT procedures to gather data about feasibility and acceptability of the booster session for Bahamian adults for a potential future fully-powered effectiveness trial.
3. Preliminarily evaluate the effectiveness and impact of a PM+ booster session on mental health outcomes at three and six months post PM+ compared to a control group receiving PM+ and no booster session.
1) Self reported depression and anxiety (HADS) scores will be lower for the group receiving a booster session than for the control group at six months post-PM+.
1. Self-reported depression (PHQ-9) and anxiety (GAD-7) scores will be lower for the group receiving a booster session than the control group at both three months post-PM+ and six months post-PM+.
2. Self-reported PTSD (PCL-5) and functional impairment (WHODAS 2.0) will be lower for the group receiving a booster session than the control group at both three months post-PM+ and six months post-PM+.
3. Decreases in distress related to personal problems (PSYCHLOPS) will be maintained in the intervention group from session five of PM+ to booster session.
4. Greater use and practice of PM+ skills, as measured by the RTC, will be correlated with lower depression (PHQ-9) and anxiety (GAD-7; HADS) symptoms at three- and six-month follow-up.
5. General self-efficacy (GSES) will be associated with lower rates and levels of symptom relapse at three- and six-month follow-up.
Clients
50 clients of the Grand Bahama Resilience Center
● 18 or older
● Residing in Grand Bahama
● Fluent in English
Recruitment will take place via GBRC therapist suggestion and flyers at GBRC
Providers
● Therapists from the GBRC
○ Avoids confounding variables related to helper competency
○ Avoids some potential challenges for providers (Sangraula et al., In Press)
● Screening:
○ Patient Health Questionnaire-4 (PHQ-4) (Kroenke et al., 2009)
○ Global Assessment of Functioning (GAF) (Jones et al., 1995) → 90 or lower
○ Columbia Suicide Severity Scale (Posner, 2011; Bjureberg, 2020) → excluded if “High Risk”
● Outcomes:
○ Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983)
○ Patient Health Questionnaire (PHQ-9) (Kroenke et al., 1999)
○ Generalized Anxiety Disorder Assessment (GAD-7) (Spitzer et al., 2006)
○ Psychological Outcomes Profile (PSYCHLOPS) (Ashworth et al., 2005)
○ PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013)
○ WHO Disability Assessment Schedule (WHODAS-2.0) (Ütsün, 2010)
○ General Self Efficacy Scale (GSES) (Schwartzer & Jerusalem, 1995)
○ Reducing Tension Checklist (RTC) (Jordans et al., 2021)
○ Post-hurricane Distress Scale (PHDS) (Carl et al., 2019)
● Training
○ General Self Efficacy Scale (GSES) (Schwartzer & Jerusalem, 1995)
○ Reducing Tension Checklist (RTC) (Jordans et al., 2021)
○ Fidelity Checklists
From your waitlist or walk-in, folks who are mild-moderately distressed and would like to try a 5 session intervention and be part of a research project
● Requires answering four 20-minute online surveys ($5 Amazon gift card for each) over the course of 6 months
● 5 sessions of PM+ and one follow-up call
If client is interested, ask them to complete the screener (LINK) or connect them to me via email.
I will let you know whether the client is eligible and ready for the study and you can start delivering PM+ Weeks 1-5
Half of the PM+ clients will receive a booster session of PM+ (which we will design together) Half will receive a routine follow-up call to remind them of their upcoming assessment.
I will email or text the client the link to their final assessment.
● An approach to research that addresses the core challenges of implementation research by involving community stakeholders in the research and development of interventions that are important to the community (Wallerstein & Duran, 2010)
● 10 key principals (Israel et al., 2017)
○ Community as a unit of identity
○ Build on strength and resources within the community
○ Facilitates collaborative and equitable partnerships in all phases of research,
○ Promote co-learning and capacity building among partners
○ Create a balance between research and action
○ Emphasize public health problems of local relevance
○ Involves system development through iterative processes,
○ Involves partners in the dissemination of findings
○ Requires a long term process and commitment to sustainability
○ Addresses issues of race, ethnicity, social class, and racism and “embraces cultural humility.”
● Developed to evaluate implementation of newly developed interventions
● Examines 5 dimensions of intervention efficacy:
○ R- each: rates of recruitment and retention
○ E- effectiveness: quantitative effects; qualitative feedback from participants
○ A- adoption: provider retention and fidelity; supervision attendance
○ I- implementation: provider competency, safety, and barriers to scalability
○ M- maintenance: potential for sustainability and the cost of long-term implementation of the intervention
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