GOOD MORNING.
MY NAME IS CHRISTINA BORBA THE
DIRECTOR OF THE NIMH OFFICE ON
DISPARITIES RESEARCH AND
WORKFORCE DIVERSITY.
A LITTLE BIT ABOUT OUR OFFICE.
WE COORDINATE TWO SIGNIFICANT
PRIORITIES AT NIMH.
FIRST, REDUCE MENTAL HEALTH
DISPARITIES AND PROMOTE EQUITY
IN THE UNITED STATES AND
DIVERSIFY THE MENTAL HEALTH
RESEARCH WORKFORCE.
THE OFFICE COMBINE FOCUS ALLOWS
NIMH TO SUPPORT ADVANCE
PRACTICES WITH EQUITY AND MENTAL
HEALTH RESEARCH.
THE OFFICE WORKS CLOSELY WITH
THE CENTER FOR GLOBAL MENTAL
HEALTH RESEARCH TO ADDRESS
DISPARITIES IN LOW AND MIDDLE
INCOME COUNTRIES.
IT GIVES ME GREAT PLEASURE TO
INTRODUCE DR. PETER KILMARX OF
THE FOGARTY CENTER AND ACTING
DIRECTOR FOR THE NATIONAL
RESEARCH AT THE NIH.
HE JOINED FOGARTY IN JULY OF
2015 AND ASSUMED HIS CURRENT
ROLE IN JANUARY 2023.
DR. KILMARX IS AN EXPERT ON
INFECTIOUS DISEASE RESEARCH AND
HIV/AIDS RESEARCH AND REPRESENT
THE CENTER AT NIH AT NATIONAL
AND INTERNATIONAL FORUMS.
HE CO-LED AN INITIATIVE TO
TRANSFORM AFRICAN HEALTH
PROFESSIONAL EDUCATION IN
RESEARCH RESULTING IN THE
FORMATION OF THE AFRICAN
ASSOCIATION FOR HEALTH
PROFESSIONS, EDUCATION AND
RESEARCH.
HE ALSO FOCUSSED ON EFFORTS TO
INCREASE EQUITY IN GLOBAL HEALTH
RESEARCH AND BUILD GLOBAL
CAPACITY FOR PANDEMIC
PREPAREDNESS.
IT'S A VERY IMPRESSIVE BIO.
AFTER EARNING HIS M.D. HE
COMPLETED HIS INTERNAL MEDICAL
RESIDENCY IN INFECTIOUS DISEASE
FELLOWSHIP AT JOHNS HOPKINS
HOSPITAL AND REMAINED BORT BOARD
CERTIFIED AND PART OF THE
INFECTIOUS DISEASE SOCIETY OF
AMERICA AND PUBLISHED
PEER-REVIEWED ARTICLES AND BOOK
CHAPTERS AND SERVED ON THE OF
SEXUALLY TRANSMITTED DISEASES.
HE BEGAN AS A PEACE CORPS
VOLUNTEER HELPING DEVELOP
FISHERIES WHICH ARE STILL
PRODUCTIVE TODAY.
HE RECEIVED NUMEROUS AWARDS
INCLUDING THE NIH DIRECTOR'S
GROUP AWARD FOR PILOTING AN
NIH-CHINA OFFICE AND
U.S. EMBASSY IN BEIJING TO
SUPPORT INVESTMENT IN CHINA AND
THE DISTINGUISHED SERVICE METAL
FOR CAREER RESPONDING TO
HIV/AIDS AND OTHER INFECTIOUS
DISEASE THREATS IN BUILDING
CAPACITY WORLDWIDE AND THE
PRESIDENTIAL UNIT CITATION FOR
COURAGE IN PERFORMS AND ACTION
TO THE EBOLA OUTBREAK.
THE FOG ARTY INTERNATIONAL
CENTER SUPPORTS AND FACILITATES
GLOBAL HEALTH RESEARCH CONDUCTED
BY U.S. AND INTERNATIONAL
INVESTIGATORS, BUILDING
PARTNERSHIPS BETWEEN HEALTH
RESEARCH INSTITUTIONS IN THE
U.S. AND ABROAD AND TRAINING THE
NEXT GENERATION OF SCIENTISTS TO
ADVANCE GLOBAL HEALTH NEEDS.
PLEASE JOIN ME IN WELCOMING
DR. PETER KILMARX.
>> THANK YOU, CHRISTINA FOR THAT
GENEROUS INTRODUCTION AND THANKS
TO LEO FOR INVITING ME TO SPEAK
THIS MORNING.
I HOPE EVERYONE'S GOOD AND
MENTALLY HEALTHY AND IT WAS
GREAT TO GET TOGETHER LAST
NIGHT.
I'M SURE THOSE ARE HERE ENJOY
BEING TOGETHER AND IN PERSON AND
I UNDERSTAND THERE'S MANY PEOPLE
ONLINE IN SECURITY AND I'M
DELIGHTED TO BE HERE.
NIH IS A GLOBAL INSTITUTION AND
FOGARTY IS VERY DEDICATED TO
MENTAL HEALTH RESEARCH AND
RESEARCH TRAINING.
THOSE ARE MY TWO MAIN MESSAGES
THIS MORNING.
IN SUPPORTING DATA ABOUT NIH
BEING A GLOBAL INSTITUTION.
A FEW YEARS AGO WE LOOKED AT ALL
PUBLICATION INS PUB MED THAT
CITE NIH FUNDING AND HOW MANY
HAVE A NON-U.S. AFFILIATED
CO-AUTHOR AND IT'S 35% OF ALL
NIH FUNDED PUBLICATIONS HAVE A
NON-U.S. AFFILIATED CO-AUTHOR SO
IT'S A GLOBAL ACTIVITY.
THOSE PAPERS THAT HAD A U.S. AND
NON-U.S. CO-AUTHOR HAD A HIGHER
SCIENTIFIC IMPACT THAN THE
PUBLICATIONS THAT HAD
U.S. AUTHORS ONLY.
SO THERE'S A LOT OF GLOBAL
COLLABORATION IN SCIENCE.
YOU CAN SEE ON THE LEFT THE
COUNTRIES MOST REPRESENTED MAYBE
NO SURPRISE, CHINA WAS NUMBER
ONE IN 2017.
THE OTHERS, U.K., CANADA,
GERMANY, ETCETERA, HIGH-INCOME
COUNTRIES AND ON THE RIGHT THE
LOWER INCOME COUNTRIES FUNDED BY
THE NIH INCLUDING BRAZIL, INDIA
AND SOUTH AFRICA.
THEN ANOTHER POINT IS THE GLOBAL
COLLABORATION IS VERY DIVERSE.
INFECTIOUS DISEASE IS NUMBER ONE
AND IF YOU LOOK AT THE NIH
RECORDS THERE'S AN IMPORTANT
WEBSITE WORLD REPORT.NIH.gov
THAT CATALOGS THIS.
THERE'S NEARLY 20,000 IN 2022.
AND NEARLY 20,000 RECORDS OF
FOREIGN COLLABORATIONS FUNDED BY
THE NIH AND NIAD AND HEART,
LUNG, DISEASE AND STROKE AND
NIMH IS A GLOBAL PLAYER IN TERMS
OF THE GLOBAL ACTIVITIES OF NIH.
THIS IS -- THERE'S 24 INSTITUTES
AND CENTERS THAT FUND EXTRAMURAL
COLLABORATION AND EVERY ONE OF
THEM HAS SOME ROLE IN SUPPORTING
GLOBAL COLLABORATION AT NIH.
NOW, LET ME TURN TO THE FOGARTY.
WE HAVE BASICALLY TWO MAIN
MISSIONS.
ONE IS TO SUPPORT ALL THE OTHER
I.C.s AND INSTITUTES AND CENTERS
IN THEIR GLOBAL ACTIVITIES.
WE HAD A RICH AND PRODUCTIVE
PARTNERSHIP WITH NIMH I'LL SAY
MORE ABOUT.
WITH OUR RESOURCES WE FOCUSSED
PRIMARILY ON LOWER-INCOME
COUNTRIES AND I'LL SAY MORE
ABOUT THAT ALSO.
THIS IS OUR NAMESAKE JOHN
FOGARTY A CONGRESSMAN FROM RHODE
ISLAND, ALSO MY HOME STATE AND
HAD A NICE INSPIRATIONAL QUOTE
IN THE '60s SAYING EXPANDED
RESEARCH IS ONE PERHAPS THE ONE
TRULY GLOBAL EFFORT IN WHICH ALL
NATIONS CAN AND WILL JOIN AS
REAL PARTNERS.
SO WE REALLY TAKE THIS
COLLABORATION AND SOCIAL JUSTICE
MESSAGE AS PART OF OUR FOUNDING
ETHOS.
THIS IS THE MONEY SLIDE.
KEY INFORMATION TO CONVEY FIRST
OF ALL TO SAY MANY DIVERSE AREAS
WHERE FOGARTY SUPPORTS GLOBAL
MENTAL HEALTH RESEARCH AND
RESEARCH TRAINING AND ALSO THE
STRONG SUPPORT IN PARTNERSHIP
WITH NIMH THAT'S PART OF THAT
EFFORT.
THIS IS A TOTAL OF $2.7 MILLION
OF CO-FUNDING FROM NIMH FOR
FOGARTY IN THE LAST FISCAL YEAR.
THAT'S IMPORTANT FOR THE
FINANCIAL CONTRIBUTION AND ALSO
PROBABLY MORE IMPORTANT IS JUST
THAT PARTNERSHIP AND PUTTING
TOGETHER OUR NETWORKS OF
INVESTIGATORS AND KEY PART OF
HAVING THIS MEETING IS TO LINK
TOGETHER THE NETWORKS OF FUNDERS
AND INVESTIGATORS TO HAVE EVEN
MORE EFFECTIVE RESEARCH RESEARCH
TRAINING.
BE THE RESEARCH SIDE THE GLOBAL
BRAND DISORDERS RESEARCH PROGRAM
WHICH STARTS AS AN R21 AND ALSO
THERE'S R01 AWARDS PART OF THAT
COLLABORATION.
AND OUR HIV NCD RESEARCH PROGRAM
THAT INCLUDES A LOT OF MENTAL
HEALTH RESEARCH AS PART OF THAT.
THE MOBILE HEALTH RESEARCH HAS
BEEN VERY PRODUCTIVE AND ACTIVE.
AN R21 AND FOR THOSE ACTIVITIES
THAT MEET THEIR MILESTONES
CONVERTS TO AN R33 FOR MORE
YEARS OF FUNDING TO BE ABLE TO
IMPLEMENT THESE GLOBAL HEALTH
INTERVENTIONS AND TECHNOLOGIES.
THERE'S A BIG COMMON FOUND DATA
SIGN IN AFRICA NIMH IS PART OF.
WE ALSO HAVE A RESEARCH PROGRAM
ON STIGMA REDUCTION IN HIV/AIDS
PREVENTION, TREATMENT AND CARE
AND ON THE TRAINING AND CAREER
DEVELOPMENT SIDE WE HAVE OUR NCD
RESEARCH TRAINING PROGRAM, D43
PROGRAM.
HIV RESEARCH TRAINING PROGRAM
WHICH IS QUITE DIVERSE AND
INCLUDES A LOT OF MENTAL HEALTH
RESEARCH TRAINING AS PART OF
THAT.
THE FELLOWS AND SCHOLARS
PROGRAM.
THIS IS A ONE-YEAR MENTORED
RESEARCH OPPORTUNITY FOR STUNTHS
AND DOCTORAL STUDENTS, MEDICAL
OR Ph.D. OR OTHER DOCTORAL
STUDENTS OR FOR POSTDOCS TO HAVE
A ONE-YEAR MENTORED RESEARCH
ACTIVITY AND MEETING WITH A LOT
OF PEOPLE AT THE RECEPTION LAST
NIGHT THEY TOLD ME THEY WERE
FORMER TRAINEES UNDER THE
PROGRAM AND I THINK IT WILL BE
INTERESTING TO THE AUDIENCE THE
EMERGING GLOBAL LEADER PROGRAM
AND THE DOMESTIC K AWARD.
THE ONLY ONE FOR NIH SCIENTISTS
FROM LOW AND MIDDLE INCOME
COUNTRIES ARE ELIGIBLE.
SO IT'S FIVE YEARS OF MENTORED
CAREER DEVELOPMENT SUPPORT FOR
PEOPLE IN LOW AND MIDDLE INCOME
COUNTRIES INCLUDING SOME WITH
MENTAL HEALTH RESEARCH
ACTIVITIES THAT NIMH SUPPORTS.
A FEW EXAMPLES OF SOME OF THESE
ACTIVITIES.
THIS IS ABOUT ADDRESSING MENTAL
HEALTH IN THE U.S. COMMUNITIES.
THESE RESEARCHERS WERE LOOKING
AT MENTAL HEALTH RESEARCH IN
LIBRARY TO SUPPORT DEVELOPMENT
OF THE LIBERIA STRATEGIC HEALTH
PLAN AND SUPPORTING MENTAL
HEALTH EDUCATION AND MENTAL
HEALTH ACTIVITY FOR AFRICANS IN
LOWELL, MASSACHUSETTS UNDER
SCORING THE RECIPROCAL
INNOVATION AND BRIDGING LESSONS
LEARNED FROM AROUND THE WORLD
AND BRINGING THEM BACK TO THE
U.S. WITH OTHER HIGHER INCOME
COUNTRIES.
THIS WAS SUPPORTED THROUGH A K01
AWARD.
SO DR. CORP IS A RESEARCHER WITH
THE K AWARD SUPPORTED BY FOGARTY
AND NIMH.
THIS IS A SCHOLAR.
HER U.S. INSTITUTION WAS
VANDERBILT AND WAS RESEARCHING
MENTAL HEALTH DELIVERY IN KENYA
IN LMICs GENERALLY AND HEAD OF
THE DEPARTMENT OF MENTAL HEALTH
AT THE TEACHING HOSPITAL.
OPPORTUNITIES FOR FOREIGN EARLY
CAREER RESEARCHERS AND THEN
DR. MASNARI IS ONE OF OUR
GRANTEES WORKING IN UKRAINE AND
ALSO SUPPORTED BY JOHNS HOPKINS
AND WAS LOOKING AT THE LANDSCAPE
FOR MENTAL DISORDERS IN UKRAINE
AND EVIDENCE-BASED DIAGNOSTIC
APPROACHES FOR MENTAL DISORDERS
IN UKRAINE AND WITH THE START OF
THE WAR PIVOTED TO LOOK AT THE
CAPACITY FOR SCALING UP MENTAL
HEALTH PROVIDERS IN UKRAINE FUND
FOGARTY AND NIMH AND HER
INSPIRATIONAL QUOTE AND A
TRAVELED TO WARSAW IN JUNE AND
MET WITH ALL OF OUR GRANTEES IN
UKRAINE AND SHE CAPTURED THEIR
SENTIMENT SAYING TO CONTINUE ON
WITH THE WORK IS THE FORM OF
RESISTANCE AND RESILIENCE NOT
SOMETHING INHERITED AND
SOMETHING EARNED BY EXISTING
DURING A TIME WHEN WE SIMPLY
MUST ENDURE.
REMARKABLE WORK LANA AND OTHER
TRAINEES ARE CARRYING IN
UKRAINE.
THERE'S EQUITY IN RESEARCH AND
THERE'S BEEN DISCUSSION ABOUT
DECOLONIZATION AND WE HAVE A
WORKING GROUP FOCUSSED ON
PROMOTING EQUITY IN GLOBAL
HEALTH RESEARCH AND NORTH-SOUTH
PARTNERSHIPS.
WE HAD A REQUEST FOR INFORMATION
LAST YEAR AND HAD 186 RESPONSES
WE TOOK AS A ROBUST RESPONSE
FROM THE COMMUNITY FROM
HIGH-INCOME COUNTRIES AND
LOWER-INCOME COUNTRIES SOME
CRITICAL THEMES EMERGED OUT OF
THAT.
I THINK A KEY ONE WE TALK ABOUT
THE GOLDEN RULE AND HE WHO HAS
THE GOLD MAKES THE RULES AND THE
PARADIGM WE NEED TO GET AWAY
FROM IS FUNDING HIGH-INCOME
COUNTRIES RESEARCHERS AND GO TO
LOW-INCOME COUNTRIES AND SAY
HERE'S MY PROTOCOL DO YOU WANT
TO PARTICIPATE YES OR NO.
THAT'S A DISEM POWERING
RELATIONSHIP VERSUS FUNDING
DIRECTLY RESEARCHERS IN
LOW-INCOME COUNTRIES AND LET
THEM BE IN THE DRIVER'S SEAT IN
MANAGING THE RESOURCES.
THESE NINE INSTITUTES AND
CENTERS WHICH ARE THE MOST
ACTIVE GLOBALLY AT NIH ARE
COMMITTED AND ACTIVE IN TAKING
FINDINGS FORWARD IN
IMPLEMENTATION.
IN SUMMARY, THERE'S A STRONG
COLLABORATION AND SUPPORT
BETWEEN FOGARTY AND NIMH FOR
GLOBAL MENTAL HEALTH RESEARCH
AND RESEARCH AND TRAINING AND
SUPPORTING EQUITY IN THE
RESEARCH PARTNERSHIPS IS GOING
TO BE KEY TO RESILIENCE AND TO
GLOBAL HEALTH RESEARCH AND TO
SOLVING THE MANY CHALLENGES,
HEALTH CHALLENGES THAT WE HAVE
GOING FORWARD.
BIG CONGRATULATIONS TO NIMH AND
PARTNERS FOR THIS MEETING.
IT'S REALLY IMPORTANT TO ADDRESS
THIS GLOBAL AREA AND BRING
PEOPLE TOGETHER THE FUNDERS AND
RESEARCHERS AND TRAINEES.
HAPPY TO PARTICIPATE AND
UNFORTUNATELY I HAVE TO SCOOT TO
ANOTHER SET OF ALL-DAY MEETINGS
BUT HAPPY TO HAVE THIS CHANCE TO
BE HERE.
THANK YOU.
>> GOOD MORNING AND THANK YOU
EVERYONE.
I'LL REQUEST THE PANELISTS TO
PLEASE TAKE THEIR SEATS.
I THINK IT'S A GREAT MORNING
ESPECIALLY IN THE CONTEXT OF
THIS CONFERENCE TAKING PLACE AND
ALSO ABOUT 10 OR 12 YEARS OF
SUCCESSION IN TERMS OF THE
GLOBAL MENTAL HEALTH.
THE CURRENT PANEL WE'RE GOING TO
BE TALKING ABOUT IS ON
STRATIFICATION IN MENTAL HEALTH
AND WHAT PROMISE DOES IT HOLD
FOR GLOBAL MENTAL HEALTH
RESEARCH.
I TAKE A MOMENT TO REFLECT ON
THE JOURNEY THAT GLOBAL MENTAL
HEALTH FIELD HAS TAKEN AND HOW
RELEVANT IS STRATIFICATION IN
MENTAL HEALTH RESEARCH AT THIS
POINT IN TIME.
IF YOU REALIZE THAT THE GLOBAL
HUBS THAT NIMH SUPPORTED THE
SCALE-UP RESEARCH SUPPORTED AND
THE COMMUNITY THAT HAS
CONTRIBUTED TO IT HAS LED US TO
THE POINT WHERE WE KNOW WHAT ARE
THE EFFECTIVE INTERVENTIONS IN
GLOBAL MENTAL HEALTH.
WE DON'T KNOW WHAT WORKS FOR
WHOM, UNDER WHAT CONDITIONS WE
LOOK AT SCALABILITY AND THE
IMPACT OF THOSE INTERVENTIONS.
STRATIFICATION COULD BE ONE OF
THE WAYS THAT CAN HELP US PAY
FORWARD THE AGENDA OF GLOBAL
MENTAL HEALTH RESEARCH.
I'M PRIVILEGED TO HAVE
DISTINGUISHED SPEAKERS WHO ARE
GOING TO BE TALKING ABOUT WHAT
THE FIELD OF MACHINE LEARNING
AND STRATIFICATION TRIALS HAVE
TO OFFER TO THE FIELD OF GLOBAL
MENTAL HEALTH AND PRIVILEGED TO
HAVE THESE DISTINGUISHED GUESTS
WHO HAVE FLOWN IN AND TOOK TIME
FOR THE MEETING BECAUSE THEY
REALIZE HOW IMPORTANT IT IS FOR
THEIR WORK AND THE FIELD OF
GLOBAL MENTAL HEALTH.
I'D LIKE TO INVITE THE CHAIR OF
THE SESSION, PROFESSOR NIKOLAOS
KOUTSOULERIS TO FORMALLY START
THE SESSION.
>> THANK YOU.
THANKS TO THE WELCOME TRUST AND
THE NIH COLLEAGUES FOR MAKING
THIS SESSION POSSIBLE GOOD
MORNING TO ALL OF YOU,
COLLEAGUES TO THE SESSION.
I THINK WE HAVE A NICE ROSTER OF
SPEAKERS AND ALSO ONE COLLEAGUE
ONLINE AND MUNMUN DE CHOUDHURY
AND INTERVENTIONS HAVE
DIFFICULTY WITH THEIR EFFICACY
AND EFFICIENCY AND ONE BIG
CHALLENGE IS HETEROGENEITY OF
THE POPULATIONS OF PATIENTS WITH
DEPRESSION, PATIENTS WITH
PSYCHOSIS AND INDIVIDUALS
USUALLY YOUNG PEOPLE AND I THINK
THIS IS RELEVANT FOR COUNTRIES
AND GLOBAL SOUTH WHERE THE
BIGGEST CHUNK OF THE POPULATION
ARE YOUNG PEOPLE AND THE
CONDITIONS BLEED INTO EACH
OTHER.
THERE'S A GREAT DEAL OF
COMORBIDITIES AND CLINICAL
PHENOTYPES AND DISTINGUISH THOSE
FROM A MENTAL HEALTH CRISIS
WHICH MAY RESOLVE PLACE FOR
NORMAL DEVELOPMENT.
THE HETEROGENEITY, WHERE DOES IT
COME FROM.
ONE KEY ASPECT IS THAT THE
CURRENT SYSTEM THAT HAS BEEN
DEVELOPED WAS DEVELOPED BY
EXPERTS MOST OF THOSE EXPERTS
BEING MALE, WHITE COLLEAGUES
SITTING OR WORKING IN THE
INDUSTRIALALIZED WORLD.
THESE CATEGORIES DO NOT RESPECT
NOT ONLY YOUR GRAPHIC JOURNEY OF
THESE PERSONS THAT SUFFER FROM
MENTAL ILLNESS FROM A LIFESTYLE
PERSPECTIVE BUT ALSO DISREGARD
THE BIOLOGY AND SOCIAL CONTEMPT
IN WHICH THESE JOURNEYS DEVELOP.
PRECISION MEDICINE MAY BE ONE
PRINCIPLE WAY TO OVERCOME THE
CHALLENGE AND WOULD BE USEFUL TO
BECOME A COMPONENT IN THE GLOBAL
MENTAL HEALTH MOVEMENT.
THIS IS WHERE I THINK IT COULD
BE MOST USEFUL IN MENTAL HEALTH
CARE SYSTEMS THAT STRIVE TO
BECOME MORE EFFICIENT TO WORK TO
BE CLINICALLY SCALABLE.
THIS IS WHERE STRATIFICATION OF
PRECISION MEDICINE IS ANOTHER
WORD FOR I THINK IS A SIMILAR
APPROACH COULD PLAY OUT ITS
STRENGTHS PARTICULARLY IN A TIME
WHERE WE HAVE INCREDIBLY GROWING
DENSITY OF INFORMATION BEING
AVAILABLE THAT DESCRIBE THE
INDIVIDUAL.
THINK ABOUT DIGITAL PHENOTYPES
BASED ON SMART PHONES AND
WEARABLES OR ELECTRONIC MEDICAL
RECORDS OR SOCIAL MEDIA AND ALSO
BIOLOGICAL DATA BECOMES MORE
COMMONPLACE THOUGH NOT AT THE
SAME PACE WITH THE SAME LEVEL OF
EQUAL ACCESS.
AND FROM THIS GROWING DENSITY OF
DATA AVAILABLE WE CAN EXTRACT
PREDICTIVE MODELS USING MACHINE
LEARNING OR ARTIFICIAL
INTELLIGENCE.
FOR THE UPCOMING MINUTES I WOULD
LIKE TO INVITE YOU TO CRITICALLY
APPRAISE WHAT THE OPPORTUNITIES
ARE OF THESE THREE POINTS SO
THAT BASICALLY THE DATA ACCESS,
THE MULTI-MODAL POSSIBILITY TO
DESCRIBE INDIVIDUAL AND USING
MACHINE LEARNING TO ANALYZE DATA
OR PREDICTIVE MODEL IN GENERAL.
WHAT ARE THE POTENTIAL BENEFITS
AND WHAT ARE ALSO THE CHALLENGES
IN TERMS OF SUCCESS OF EQUITABLE
CARE.
WITH THAT I'D LIKE TO CLOSE MY
SHORT INTRODUCTION AND HAND OVER
TO MUNMUN.
I HOPE SHE IS ONLINE.
YES.
MUNMUN, HI, GREAT TO SEE YOU.
YOU CAN START.
>> ALL RIGHT.
>> COULD I GET AN OKAY FROM
SOMEONE IF YOU SEE THE SLIDE
SHOW OKAY ON THE ZOOM.
>> YES.
>> THANK YOU VERY MUCH.
AND THANK YOU PROFESSOR.
IT'S MY PLEASURE TO JOIN THIS
MORNING AND APOLOGIES I COULDN'T
BE THERE IN PERSON AND PLEASED
TO REPRESENT THE WORK RELEVANT
TO THE PANEL.
MY TALK OVER THE NEXT FEW
MINUTES WILL COVER SOME BENEFITS
AS WELL AS HARMS AND CHALLENGES
WE HAVE SEEN ARTIFICIAL
INTELLIGENCE BROADLY SPEAKING TO
OFFER IN THE CONTEXT OF MENTAL
HEALTH.
SO IN MANY WAYS THE FIELD OF
MENTAL HEALTH OVER THE PAST
DECADE OR SO HAS BEEN UNDERGOING
WHAT I WOULD SAY A DIGITAL
TRANSFORMATION.
WE HAVE A LOT OF -- WE HAVE SEEN
A LOT OF POTENTIAL OF A.I. IN
GENERAL AND ALSO APPROACHES LIKE
MACHINE LEARNING IN HOW IT IS
TRANSFORMING -- HOW WE DO MENTAL
HEALTH CARE AND HOW IT'S
AVAILABLE TO PEOPLE.
FOR INSTANCE, NOW WE HAVE RICH
BODIES OF RESEARCH APPLIED.
THINGS LIKE ANALYSIS AND NATURAL
LANGUAGE PROCESS TO DETECT TEXT
IN SPEECH AND SOCIAL MEDIA AND
SO ON AND THESE STUDIES HAVE
SHOWN COMPUTATIONAL ANALYSIS OF
DIGITAL DATA CAN ACCURATELY
DETECT MOOD AND EMOTION, SOCIAL
DISENGAGEMENT, COGNITIVE
PROCESSING.
THE IMPLICATIONS OF THESE
STUDIES HAVE BASICALLY RANGE
FROM THE POTENTIAL TO PROVIDE A
VARIETY OF INSIGHTS FOR
APPLICATIONS IN SITUATIONS LIKE
MONITORING PATIENTS TO PAVING
THE WAY FOR EARLY INTERVENTIONS
AMONG PEOPLE AND THE
PERSONALIZED TREATMENT PLANS.
I'LL TALK ABOUT ONLINE TOOLS IN
THIS PRESENTATION.
THAT COULD INCLUDE THINGS LIKE
SOCIAL MEDIA OR OTHER TOOLS THAT
ALLOW PEOPLE TO EXPRESS AND LOOK
FOR INFORMATION AND TAKE A
MOMENT TO INTRODUCE TO YOU SOME
OF THESE BEFORE WE TALK ABOUT
SOME OF THE CHALLENGES THAT WE
HAVE SEEN TO EMERGE HERE.
AND THE REASON I'M TALKING ABOUT
ONLINE TOOLS AND THE USE HAVE
SKRS
SKYROCKETED OVER THE LAST FEW
YEARS WITH OVER 80% OF
U.S. ADULTS USING SOME FORM OF
SOCIAL MEDIA PLATFORM IN THEIR
LIVES PRETTY FREQUENTLY.
I'LL START BY HIGHLIGHTING THE
RESEARCH THAT MY COLLABORATORS
AND MYSELF CONDUCTED ALMOST A
DECADE BACK NOW THAT LAID THE
FOUNDATION FOR RESEARCH AND WE
EXPLORED ONLINE MEDIA AND IF IT
CAN SUPPORT IDENTIFYING
PHENOTYPES AND IF IT COULD BE
ASSOCIATED OR BE PREDICTIVE OF
THE CLINICAL DIAGNOSIS.
WE RECRUITED INDIVIDUALS WHO
CONSENTED TO GIVE US ACCESS TO
THEIR FEEDS AND ALSO TO A MAJOR
DEPRESSION SCREENING
QUESTIONNAIRE WHICH GAVE US
INFORMATION ABOUT THEIR CLINICAL
MAJOR DEPRESSION.
AND UNDERSTAND WHAT KINDS OF
BEHAVIORS AND ENGAGEMENTS AND
ACTIVITIES ON TWITTER COULD BE
INDICATIVE OF THEIR MENTAL
HEALTH CONDITION AND BUILDS TO
PREDICT THE ONSET OF THE ILLNESS
IN THESE INDIVIDUALS AND FOUND
WE COULD BE QUITE SUCCESSFUL IN
PREDICTING THESE KINDS OF
OUTCOMES.
WE ALSO LOOKED AT THE COMMUNITY
LEVEL AND WE LOOKED AT TO WHAT
EXTENT ONLINE ACTIVITIES AGAIN
IN THE CONTEXT OF SOCIAL MEDIA
COULD TELL US THINGS ABOUT
SITUATED COMMUNITIES.
IN THIS CASE BEING COLLEGE
CAMPUSES.
AND ONE APPLICATION WE LOOKED AT
WHERE THIS KIND OF COMMUNITY
LEVEL ASSESSMENT OF MENTAL
HEALTH CAN BE PARTICULARLY
HELPFUL IN THE CONTEXT OF
COMMUNITIES EXPERIENCING CRISIS
EVENTS.
WE LOOKED AT 12 INCIDENTS OF GUN
VIOLENCE AT 12 UNIVERSITIES IN
THE U.S. EXPERIENCED OVER THE
PERIOD OF FIVE YEARS AND EXPLORE
HOW STRESS AND ANXIETY EVOLVES
AROUND THESE EVENTS AND CAN WE
GET AN ASSESSMENT OF THE DRIVERS
OR STRESSORS THAT UNFOLD IN THE
COMMUNITIES AFTER THE EVENTS AND
SOCIAL MEDIA CAN BE A GREAT WAY
TO UNDERSTAND WHAT THE STRESSORS
COULD BE AND HOW DIFFERENT
INCIDENTS OF CRISIS IMPACT THE
MEMBERS OF THE COMMUNITY.
FINALLY, WE ALSO LOOKED AT THE
POPULATION CONTEXT AND THIS WAS
IN THE CONTEXT OF THE COVID-19
PANDEMIC.
OVER THE FIRST 18 MONTHS OF THE
PANDEMIC WE WANTED TO SEE TO
WHAT EXTENT WE CAN UNDERSTAND
THE PSYCHOSOCIAL CONCERNS PEOPLE
WERE EXPERIENCING AT THAT POINT
IN TIME AND THE KINDS OF MENTAL
HEALTH CHALLENGES THEY WERE
UNDERGOING AT THAT MOMENT.
AND WE FOUND THAT IN THESE 18
MONTHS OF THE PANDEMIC WE
OBSERVED HEIGHTENED LEVELS OF A
VARIETY OF MENTAL HEALTH
CONCERNS WHETHER IT'S
DEPRESSION, ANXIETY, STRESS OR
SUICIDAL IDEATION AND
IMPORTANTLY A LOT OF THESE WERE
SIGNIFICANTLY HIGHER THAN THE
LEVELS THAT THE SAME POPULATIONS
EXPERIENCE THE YEAR BEFORE THE
PANDEMIC IN 2019.
BUT NOT JUST THAT SOCIAL MEDIA
AND THE ONLINE PLATFORMS WERE
ALSO PLACES AND TALK ABOUT
MENTAL HEALTH STRUGGLES.
WE SAW HOW SOCIAL MEDIA BECAME
THE PLATFORM WHERE WE WERE
BEGINNING TO SEE NORMALIZATION
OF MENTAL HEALTH ISSUES THAT
CAME WITH THE PANDEMIC AND
PEOPLE LOOKED FOR EMOTIONAL AND
INFORMATIONAL SUPPORT ON THE
RIGHT SIDE OF THE SLIDE.
IN FACT, THOSE SUPPORT-SEEKING
BEHAVIORS ALSO WERE MUCH HIGHER
THAN IN A SIMILAR AMOUNT OF TIME
BEFORE THE PANDEMIC.
SO I WANT TO TURN TO THE
CHALLENGE.
THIS SEEMS PROMISING AND IF
THESE ARE SO PROMISING WHY ARE
WE NOT SEEING THE A.I.-BASED
APPROACHES?
I'LL BE REFLECTING ON THE
IMPEDIMENTS IN THE FORM OF
BIASES AND HARMS SEVERAL
SCHOLARS INCLUDING MYSELF HAVE
SEEN TO EMERGE AND THAT IS A
SIGNIFICANT BARRIER THAT WE HAVE
TO OVERCOME IN ORDER FOR A.I. TO
BE SUCCESSFUL IN THE CONTEXT OF
STRATIFIED PSYCHIATRIC.
LET'S TALK ABOUT VALIDITY OF THE
A.I.-BASED ASSESSMENTS.
WE WANTED TO EXPLORE HOW IS IT
THESE MODELS THESE A.I.
APPROACHES HAVE BEEN BUILT ON
SOCIAL MEDIA DATA?
WHAT KINDS OF SIGNALS HAVE BEEN
LEARNED FROM AND WE FOUND A LOT
OF THE WORK ACTUALLY OFTEN
DOESN'T USE CLINICAL ASSESSMENTS
AS A SOURCE OF INFORMATION TO
BUILD THE MODELS ON BUT RATHER
RELY ON A SET OF PROXIES.
SO WHAT ARE SOME OF THESE
PROXIES?
THEY COULD BE THINGS LIKE PEOPLE
FOLLOW A SUDDEN MENTAL HEALTH
ACCOUNT ON SOCIAL MEDIA OR
LOOKING FOR SUPPORT ON AN ONLINE
COMMUNITY AND SO ON.
AND RELYING ON PROXY COMES AT A
COST.
WE SHOWED COMPARED TO MODELS
THAT ARE TRAINED ON PATIENT
POPULATIONS IN THIS CASE
PATIENTS DIAGNOSED WITH
SCHIZOPHRENIA SPECTRUM DISORDER,
WHEN WE LOOK AT THE PROXIES AND
BUILD A.I. MODELS WITH PROXIES
AS A SOURCE OF GROUND TRUTH, WE
DO PRETTY POORLY WHEN IT COMES
TO THE VID TI.
IT MEANS A LOT OF THESE PROXYIE
BUT MAY NOT BE MEASURING WHAT
THEY INTEND TO MEASURE.
IN THIS CASE THE DIAGNOSIS OF A
SERIOUS MENTAL ILLNESS LIKE
SCHIZOPHRENIA.
SO THERE'S A PROBLEM.
IF YOU WANT THESE MODELS TO BE
SUCCESSFUL AND IMPLEMENTED IN
THE REAL WORLD WE HAVE TO PAY
ATTENTION TO THESE VALIDITY
ISSUES.
THE NEXT CENTER AROUND EFFICACY.
THIS IS EQUALLY IMPORTANT.
WE WANT THE WANT THEM TO WORK
WELL WHEN IMPLEMENTS IN THE
REAL WORLD.
TO UNDERSTAND HOW EFFICACY CAN
BE A PROBLEM IN THE A.I. MODELS
WE HAVE TO UNDERSTAND THE
STRUCTURE AND THE WAY THESE
MODELS WORK.
NORMALLY WHAMZ IS THERE'S AN
INDIVIDUAL.
WE OBTAIN DATA ABOUT THE
INDIVIDUAL AND MAYBE ONLINE DATA
THEY CONSENT TO SHARE WITH THE
TEAM AND HAVE INFORMATION AN
INDIVIDUAL SHARES ABOUT THEIR
MENTAL HEALTH.
AND THAT SHOULD HAVE GOOD
EFFICACY.
WHAT'S THE PROBLEM?
THE PROBLEM IS THAT A LOT OF
THESE ONLINE LANGUAGES ARE NOT
ACTUALLY LEARNING THINGS ABOUT
THE MENTAL HEALTH OF THE PERSON
BUT LEARNING A REPRESENTATION OF
THAT MENTAL HEALTH.
WHAT'S THAT MEAN?
IT MEANS THE REALITY IS THAT
MANY MENTAL HEALTH STATES THEY
HAVE DIFFERENT REPRESENTATIONS
IN OUR MIND.
IF I ASK SOMEONE A QUESTION,
THEY COULD SELF-REPORT WHICH
WOULD BE THEIR PSYCHOLOGICAL
EVALUATION OF THEIR EXPERIENCE,
THEIR STRESS OR ANXIETY OR COULD
BE A PHYSICAL REPRESENTATION OF
THE MENTAL HEALTH STATE WHICH
COULD BE AGAIN FOR THE
EXPERIENCE OF STRESS OR ANXIETY
COULD BE THEIR HEART RATE.
IN MANY WAYS A LOT OF THE MODEL
LEARNING THAT REPRESENTATION AND
THAT CREATES WHAT WE CALL A
SEMANTIC GAP WHEN THERE'S A
SEMANTIC GAP CERTAIN KINDS OF
DATA ARE ONLY GOOD AT LEARNING
CERTAIN KINDS OF ASPECTS OR
REPRESENTATIONS OF THE MENTAL
HEALTH EXPERIENCE IF WE LOOK AT
THE LANGUAGE AND BUILD THE
MODELS WE COULD BE PRETTY GOOD
AT ASSESSING THE MENTAL HEALTH
STATE.
THE PSYCHOLOGICAL NATURE THE
SELF-REPORT OF STRESS OR ANXIETY
BUT NOT SO GOOD IN MEASURING THE
PHYSICAL MANIFESTATION OF MENTAL
HEALTH CHALLENGE.
AS WE THINK ABOUT WE HAVE TO PAY
ATTENTION WHAT IS BEING LEARNED
FROM AND THE REPRESENTATION OF
MENTAL HEALTH WE ARE LEARNING.
THAT'S BECAUSE WE NEED NEED TO
ACCOUNT FOR THE SEMANTIC GAP.
THAT'S TRUE FOR ANY A.I. MODEL
WE BUILD ON DATA.
NEXT ISSUE IS AROUND
GENERALIZABILITY.
THIS SAY QUESTION WE OFTEN ASK
AS RESEARCHERS IN MANY DOMAINS.
IT'S STATED WHEN WE TALK ABOUT
MENTAL HEALTH AND THE
APPLICATION OF A.I. FOR
STRATIFIED PSYCHIATRY.
ONLINE LANGUAGE NOT A MONOLITH.
WE EXPRESS OURSELVES IN
DIFFERENT WAYS ON DIFFERENT
PLATFORMS ON THE INTERNET.
OUR DIFFERENT FACETS ARE
REPRESENTED IN EACH OF THOSE
PLATFORMS AND THEY COULD BE
QUITE DISTINCT FOR EACH OTHER.
IF YOU ARE A LOT OF ARE LINKED
IN AND USE FOR PROFESSIONAL
PURPOSES BUT FACEBOOK MAY BE FOR
PERSONAL PURPOSES AND SO ON.
THE SUM OF THOSE FRAGMENTS IS
WHAT MAKES US THE PERSON WE ARE.
THE CHALLENGE IS IF YOU LOOK AT
EXISTING MODELS OF WORK WE BUILD
THESE ON A SINGLE SOURCE OF DATA
WHICH COULD BE A SINGLE SOURCE
OF ONLINE LANGUAGE THAT COMES
FROM ONE PLATFORM.
AND THAT CREATES A PROBLEM IF
YOU WANT TO GENERALIZE TO OTHER
CONTEXT.
WE COULD BE GENERALIZING TO
OTHER POPULATIONS WHO HAY NOT
USE THE SAME PLATFORM.
WE COULD BE GENERALIZING TO
CONTEXT WHERE OTHER PLATFORMS
MIGHT BE POPULAR OR MIGHT BE
INTERESTED IN GENERALIZING TO
FIVE OR SEVEN YEARS LATER WHERE
THE PERSON HAS MOVED ON FROM THE
PLATFORM AND NO LONGER USES IT.
THIS CREATES CHALLENGE IN
ENSURING THE GENERALIZABILITY OF
THE A.I. MODELS WE BUILT OFTEN
IT'S TIED TO SPECIFIC DATA AT
POINT IN TIME AND FOR THESE TO
WORK MOVING FORWARD WE HAVE TO
THINK HOW WE PULLED TOGETHER THE
FRAGMENTS OF THE INDIVIDUAL THAT
LIE ACROSS THESE DIFFERENT
DIGITAL PLATFORMS IN ORDER TO
GET A WHOLISTIC SENSE OF WHO
THEY ARE AND TO BOLSTER THE
GENERALIZE OF THE ASSESSMENTS
THAT WE MAKE.
FINALLY, I WOULD LIKE TO TALK
ABOUT CREDIBILITY OF THESE A.I.
MODELS OVER THE LAST YEAR OR SO
WE HAVE GOTTEN FAMILIAR WITH
LANGUAGE MODELS.
NOT BECAUSE IT'S A NEW
TECHNOLOGY THAT'S BEEN AROUND
THE LAST FIVE, SEVEN YEARS BUT
WE NOW HAVE A SIMPLE TO USE,
USER-FRIENDLY INTERFACE IN TERMS
OF A TOOL KNOWN AS CHAT GPT.
IT HAS PUT LARGE LANGUAGE MODELS
A TYPE OF GENERATIVE A.I. INTO
THE HANDS OF THE REGULAR PERSON.
THIS HAS CREATED A LOT OF
CONFERENCE LIKE CAN THESE BE A
CHATBOT OR MEET THE TREATMENT
AND CARE GAPS WE SEE IN RESOURCE
CONSTRAINED AREAS AND IS THE
INFORMATION PROVIDED BY THESE
MODELS ACCURATE NORT.
WE FIND IT TURNS OUT THEY MAY
NOT BE AND THE ADVOCATE FOR
LARGE LANGUAGE MODELS TO WORK WE
HAVE INDIVIDUALS FOR WHOM THE
PRIMARY LANGUAGE IS NOT ENGLISH.
HOW WILL THEY BE PERFORMED WHEN
WE INTEND TUESDAY THEM IN
NON-ENGLISH CONTEXT.
WE SEE FOR SPANISH, CHINESE AND
HINDI THE RESPONSES PROVIDED BY
STATE OF THE ART LARGE LANGUAGE
MODELS ARE LESS CORRECT AND LESS
THAN VERIFIABLE WITH
COUNTERPARTS.
WE SEE AN 18% DECREASE IN THE
COMPREHENSIVENESS OF THE ANSWERS
PROVIDED BY LARGE LANGUAGE
MODELS TO TYPICAL HEALTH
QUERIES.
WE FIND THEY'RE LESS CONSISTENT
ACROSS DIFFERENT RUNGS WHEN YOU
ASK THE CHATBOT THE SAME
QUESTI
QUESTIONS AND LESS VERY FINALLY
AND WE LOOKED AT THE QUALITY OF
NON-ENGLISH RESPONSES BY LARGE
LANGUAGE MODELS AND THERE WAS A
SIGNIFICANT DROP IN EVALUATION
WHEN IT COMES TO THE QUALITY AND
CREDIBILITY OF THE INFORMATION
PROVIDED BY THE LARGE LANGUAGE
MODELS.
TO WRAP IT UP I REFLECTED OVER
THE LAST FEW MINUTES THE
QUESTIONS WE SEE AND THE
DIFFERENT BIASES AND HARMS WE'D
NEED TO COVER COME.
A.I. PROVIDES A LOT OF POTENTIAL
FOR STRATIFIED PSYCHIATRY BUT
IT'S NOT A PLACE WHERE WE SHOULD
RUSH TO IMPLEMENTATION BUT
PAUSE, REFLECT, UNDERSTAND AND
WORK ON FIXING SOME OF THE
ISSUES THAT ARE TURNING OUT TO
BE AN IMPEDIMENT TO THE USE OF
A.I. IN THE REAL WORLD.
THANK YOU VERY MUCH.
THAT'S ALL I HAVE FOR YOU.
.
THANK YOU.
SHE'S AN ASSOCIATE PROFESSOR AT
GEORGIA TECH AND ANALYZES SOCIAL
MEDIA DATA WITH MACHINE LEARNING
AND REFLECTIVE ON THE PROS AND
CONS OF THIS COMBINATION.
LET US QUICKLY MOVE ON.
THE NEXT SPEAKER IS A PROFESSOR
FOR PSYCHIATRY AT THE KINGS
COLLEGE LONDON AND NEUROSCIENCE.
ONE OF THE MOST PROLIFIC
RESEARCHERS IN THE FIELD OF
EARLY DETECTION AND RECOGNITION
OF PSYCHOSIS AND HAS ALSO DONE
TERRIFIC WORK IN BRINGING OR
DEVELOPING MODELS THAT COULD
ALLOW US TO SCALE EARLY
DETECTION IN DIFFERENT
POPULATIONS.
PAOLO THE STAGE IS YOURS.
>> I'VE BEEN ASKED TO TALK ABOUT
IMPLEMENTATION OF THE GLOBAL
STRATEGY TO SCREEN AND DETECT
EMERGING MENTAL DISORDERS.
I WILL FOCUS ON PSYCHOSIS BUT IT
CAN BE EXTENDED TO OTHER MENTAL
DISORDERS.
I'D LIKE START AND CONCLUDE MY
LECTURE WITH THE PRESENTATION
WITH THE PERSPECTIVE OF THE
EXPERIENCE.
WHAT IS PSYCHOSIS?
WE RECENTLY PRODUCED AN ARTICLE
WITH THE EXPERIENCE OF PSYCHOSIS
AND PSYCHOSIS IS ONE OF THE MOST
PAINFUL AND UPSETTING
EXISTENTIAL EXPERIENCE.
ALIEN TO OUR PATTERNS OF LIFE,
AT THE SAME TIME ENIGMATIC AND
HUMAN.
BECAUSE IT'S ASSOCIATED WITH
HIGH SUBJECTIVE AND PERSONAL
BURDEN IT'S CLEAR WE NEED TO
INTERVENE AND TRY TO IMPROVE
OUTCOMES AND PREVENT PSYCHOSIS
AND THE FIRST STEP IS TO DETECT
AND SCREEN YOUNG PEOPLE WHO MAY
BE ACTUALLY DEVELOPING THE
DISORDER.
FOR 80% OF THE CASES, PSYCHOSIS
TYPICALLY DEVELOPS FROM A
CLINICAL STAGING MODEL AND
EVOLVES AS THE SYMPTOMS
INTENSIFY UNTIL THE FIRST
EPISODE OF THE DISORDER.
TO DATE, WE CAN IDENTIFY YOUNG
PEOPLE WITH THE SO-CALLED
CLINICAL HIGH-RISK STATE FOR
PSYCHOSIS.
IT'S THE STAGE OF THE
DEVELOPMENT AND DEVELOPED THE
FIRST EPISODE OF PSYCHOSIS IF
THEY DON'T INTERVENE YOU DON'T
DETECT THEM.
TYPICALLY THESE PEOPLE PRESENT
WITH PSYCHOTIC SYMPTOMS.
THESE ARE THE PATIENTS I TAKE
CARE OF IN LONDON WITH CLINICAL
PSYCHOSIS AND HAVE THOUGHTS THAT
ARE UNUSUAL AND DISCONNECTED
FROM THE WORLD.
HOW DO WE DETECT AND SCREEN
THOSE PROBLEMS IN YOUNG PEOPLE?
WHAT'S THE MOST EFFICIENT WAY
AND IN DIFFERENT CLINICAL
SETTINGS.
THE DETECTION IS THE FIRST STEP
FOR EFFECTIVE PREVENTION OF
PSYCHOSIS.
ONCE WE ARE ABLE TO DETECT
FUNCTIONAL IMPAIRMENT AND
PSYCHOTIC SYSTEMS WE CAN ASSESS
THEM AND PREDICT THEIR
LIKELIHOOD OF DEVELOPING
PSYCHOUS AND THE THIRD COMPONENT
IS IMPLEMENT PREVENTATIVE
TREATMENT AND I'LL FOCUS ON
PEOPLE WITH HIGH RISK FOR
PSYCHOSIS.
THE PREVALENCE OF CONDITION IS
1.7% IN THE GENERAL POPULATION
AND ABOUT 20% IN CLINICAL
SAMPLES.
CLINICAL LIKE YOUNG PEOPLE
ACCESSING EMERGENCY DEPARTMENTS
AND VISITING PRIMARY CARE, SO
FORTH.
IT'S CLEAR WE NEED TO HAVE TWO
DIFFERENT COMPLIMENTARY
APPROACHES TO SCREEN FOR
EMERGING PSYCH OWES --
PSYCHOSIS IN CLINICAL SAMPLES
AND WHAT I'LL BRIEFLY DISCUSS.
IN THE COMMUNITY IN OUR CLINIC
IN LONDON WE HAVE A WEBSITE
YOUNG PEOPLE CAN ACCESS THE
WEBSITE AND SELF-REFER FOR
ASSESSMENT.
IT'S GOOD BUT NOT VERY EFFICIENT
AND WE HAVE IMPLEMENTED
SCREENING FOR YOUNG PEOPLE AND
THERE'S A GRANT ONGOING AND
PROJECT CALLED E-DETECTION TOOL
FOR EMERGING MENTAL DISORDER AND
FUNDED BY THE TRUST AND WE'RE
PLANNING TO EXPAND THOSE IN
OTHER PARTS.
THIS SCREENING APPROACH IS QUITE
SIMPLE.
WE FIRST ADVERTISED ON SOCIAL
MEDIA AND TARGET YOUNG PEOPLE
AND TALKED ABOUT MENTAL HEALTH,
RISK OF DEVELOPING SEVERE MENTAL
DISORDERS AND WE ADVERTISE ON
DIFFERENT CHANNELS LIKE
INSTAGRAM AND COLLEGES AND
UNIVERSITIES AND TRIED TO INVITE
PEOPLE TO ACCESS THE PROGRAM.
AND LOOKING AT THE DEMOGRAPHIC
RISK FACTORS AND THOSE ARE VALID
GLOBALLY NOT JUST IN LONDON.
THEY WERE SET TO COMPLETE A
SHORT COGNITIVE ASSESSMENT AND
SHORT SPEECH ACQUISITION AND
ANALYZING THE DATA AND
ESTIMATING WHETHER THE RISK OF
DEVELOPING OR POSSIBLY BEING
VULNERABLE FOR DEVELOPING
PSYCHOSIS IS ABOVE A CERTAINLY
THRESHOLD.
IF THAT'S THE CASE AN ALERT IS
BEING GENERATED TO THE RESEARCH
TEAM AND THE RESEARCH TEAM
INVITES YOUNG PERSONS TO
COMPLETE THE FULL CLINICAL
ASSESSMENT TO CHECK WHETHER
THEY'RE AT RISK OF DEVELOPING
PSYCHOSIS.
AND THERE'S A GAP BETWEEN
DIGITAL DATA ONLINE AND THE
CLINICAL ASSESSMENTS PERFORMED
BY THE GOLD STANDARD AND THAT'S
WHY WE'RE RUNNING AT A TWO-STAGE
ASSESSMENT AND ALSO A WAY OF
MAXIMIZING EFFICIENCY.
THEN IF THE INDIVIDUAL IS AT THE
CLINICAL ASSESSMENT STAGE 2 IS
STILL TESTING FOR BEING AT RISK
FOR PSYCHOSIS AND THEY'RE
REFERRED TO THE LOCAL CLINIC.
IN LONDON AND MOVE ON WITH THE
PREVENTIVE CARE.
THIS IS THE APPROACH WE ARE
IMPLEMENTING FOR DIGITAL SCREENS
FOR EMERGING VULNERABILITY IN
THE COMMUNITY AND WHAT'S THE
COMPLIMENTARY APPROACH FOR
HEALTH CARE SYSTEM FOR THE
CLINICAL SAMPLES FOR PEOPLE ALL
RIGHT UNDER MENTAL HEALTH CARE
IN SOME WAY.
WE DEVELOPED A RISK
STRATIFICATION ALGORITHM WHICH
IS QUITE FLEXIBLE.
THE DIFFERENT VERSIONS AND
FLEXIBILITY IS IMPORTANT IN LOW
AND MIDDLE INCOME COUNTRIES AND
THERE'S SOCIO DEMOGRAPHIC
PREDICTORS AND DIAGNOSIS LIKE
PRESENTING WITH DEPRESSION AND
ANXIETY AND THERE'S ALSO MORE
REFINED AND THERE'S PATHOLOGICAL
SYMPTOMS.
THE SYMPTOMS CAN BE ENTERED BY
THE CLINICIAN WITH AN ONLINE
WEBSITE OR EXTRACTED
AUTOMATICALLY FROM THE
ELECTRONIC HEALTH RECORD IF
AVAILABLE AND THE ALGORITHM
PREDICTS DEVELOPING PSYCHOSIS
OVER TIME WHICH IS FOR EXAMPLE
UP TO SIX YEARS AND IF IT'S
ABOVE A CERTAIN THRESHOLD
CLINICIANS MAY BE PROMPTED TO
OFFER FURTHER ASSESSMENT AND
OFFER PREVENTIVE CARE.
THIS IS ALL GOOD BUT WE HAVE
LEARNED THAT THE CRUCIAL THING
IS TO BE ABLE TO IMPLEMENT,
CERTIFIED AND SCREENING METHODS
IN REAL-WORLD PRACTICE FOR THE
BENEFITS OF THE PATIENTS AND THE
FIRST STEP IS TO DEMONSTRATE THE
ALGORITHM ARE TRANSPORTABLE AND
SURVIVE OUTSIDE THE SCREENING
AND THIS IS REPLICATIONS OF THIS
PREDICTION MODEL WHICH
DEMONSTRATED IN THE MORE REFINED
VERSION AND THE CHALLENGE IS TO
IMPLEMENT THE MODEL IN
REAL-WORLD CLINICAL PRACTICE.
IF WE LOOK AT THE NUMBER OF
PRECISION MEDICINE ALGORITHM
ONLY 5% TYPICALLY ARE EXTERNALLY
VALIDATED AND ONLY A FEW ARE
REALLY PUTTING INTO PRACTICE.
SOME OF OF THE CORE PROBLEMS
SOME OF THE CORE LOGISTIC ISSUES
NOT ADDRESSED PROPERLY AND
ETHICAL CHALLENGES OF BRINGING
PRECISION PSYCHIATRY TO
REAL-WORLD SCREENING.
THIS IS SCREENING OF COMMUNITY
OR HEALTH CARE TRUST IS CRUCIAL.
THAT'S WHY WE CONNECTED WITH THE
GLOBAL NETWORK OF PATIENT
EXPERIENCES THROUGH ANOTHER
INITIATIVE FUNDED BY THE VETERAN
COLLEGE OF NEUROPSYCHIC
PHARMACOLOGY AND COLLABORATED
WITH THEM A SUSTAINABLE ETHICAL
GUIDE LANE FOR PSYCHIATRY IN
CLINICAL PRACTICE AND REWARDING
EXPERIENCES FROM THE MODEL
DEVELOPMENT IS CRUCIAL.
WE THEN CONTINUED WITH THIS WORK
AND WE WANTED TO IMPLEMENT THE
ALGORITHM IN CLINICAL CARE IN
OUR TRUST IN LONDON.
WE DEVELOPED AN INTERFACE OF
SCREENING DEVICE FILTERING AND
CHECK THE PRE INDICATORS
RECORDED IN THE LOCAL REGISTRY
AND PLOTTING THE LIKELY HEADLINE
OF DEVELOPING PSYCHOSIS AND
DEMONSTRATING CHA WAS FEASIBLE
TO USE IT PROSPECTIVELY.
AND THE OUTCOMES OF THE
IMPLEMENT STUDY WAS WE DEVELOPED
AND DEPLOYED A GOVERNANCE
PATHWAY.
WE HAD ADHERENCE OF CLINICIANS
AND 77% OF THE CLINICIANS HAD
RECOMMENDATIONS FROM THE DIGITAL
SCREENING IN HEALTH CARE AND
WITH OUTREACH IT WAS CLOSE TO
85%.
THIS WAS A PRIMARY OUTCOME OF
THE STUDY FOR HEALTH CARE TO
SCREEN AND DETECT AND STRATIFY
PEOPLE FOR RISK WITH EXPANDING
THE APPROACH IN OTHER COUNTRIES
OUTSIDE THE U.K.
THE OASIS HAS BEEN AWARDED ABOUT
1,000 APPLICATIONS FOR
INNOVATION IN COMMUNITY MENTAL
HEALTH DEMONSTRATING IT'S
POSSIBLE TO BRING PRECISION
PSYCHIATRY AND RISK
STRATIFICATION AND DIGITAL
SCREENING INTO REAL WORLD
CLINICAL PRACTICE FOR THE
BENEFIT OF MANY YOUNG PERSONS.
THANK YOU VERY MUCH.
WE'LL KEEP THE QUESTIONS FOR THE
END AND WOULD LIKE TO INTRODUCE
VICE PRESIDENT OF RESEARCH AND
HEADS AN EXCELLENT RESEARCH UNIT
AT THE CENTER FOR ADDICTION AND
MENTAL HEALTH RESEARCH IN
TORONTO.
HE FOCUSES IN HIS RESEARCH AND
GROUP ON UNDERSTANDING HOW
DIFFERENT DATA DOMAINS INTERACT
WITH EACH OTHER TO PRODUCE
BASICALLY MENTAL ILLNESSES FROM
A LIFE SPAN PERSPECTIVE.
I THINK HE'LL SHOW US WORK ALONG
THESE LINES AND I'M LOOKING
FORWARD TO YOUR TALK.
>> THANK YOU.
THERE'S STRAIGHTFORWARD FOR
IMPORTANT CONCEPTUALIZATION HOW
TO MAKE A DIFFERENCE FOR
PATIENTS.
THOUGH THE FOCUS IS ON PRECISION
MEDICINE IT DOESN'T SIT IN
ITESLATION.
WE HEARD ABOUT THE CONNECTION
BETWEEN PRECISION MEDICINE AND
HEALTH CARE SYSTEM DEDICATED TO
IMPROVEMENT THROUGH DATA AND
CONTINUOUS IMPROVEMENT CYCLES.
I WANT TO SHOW YOU A COUPLE
THINGS THAT KEEP ME HONEST.
THIS IS BUSY SLIDE BUT THE TALKS
WITH PRECISION MEDICINE AND ANY
EXPERIENCE HAS BEEN THROUGH
IMPLEMENTING A MODEL OF CARE OF
PSYCHOSIS IN SMALLER
COMMUNITIES.
AND IMPLEMENTING A MODEL OF CARE
KNOWN AS NAVIGATE AND SHOWN TO
BE SUPERIOR FOR THOSE IN THE
U.S. AND A CLUSTER RANDOMIZED
EFFECTIVENESS STYLE AND THE
CHALLENGE IN PSYCHOSIS CARE ARE
LESS THE INITIAL DECISIONS IN
THE ACUTE CARE BUT MORE THE
ELEMENTS OF CARE.
THERE'S A LOT OF INCONSISTENCY
IN HOW ELEMENTS OF CARE ARE
DELIVERED AND THE OUTCOME
MEASURE IS IMPROVING FIDELITY TO
THE STANDARD OF CARE AND AFTER
DOING THIS IN AN ONGOING WAY AND
SPREAD TO MANY MORE SITES WE
IMPROVED THE KEY RECOVERY
ORIENTED ELEMENTS AND SUPPORTING
EDUCATION AND SUPPORT.
THOUGH IT'S NOT AN RCT WE HAVE
THE DATA THE RAISED TRIAL TO
LOOK AT THE PATIENT-LEVEL
OUTCOMES AND IMPROVEMENTS IN
FUNCTIONING OF THE PATIENTS IN
THE SIX CLINICS.
WERE IDENTICAL TO THE ACTIVE
INTERVENTION AND RAISE TRIAL
SUGGESTING IN A MESSIER PROJECT
IN THE MIDDLE OF THE PANDEMIC
PEOPLE WERE ABLE TO IMPROVE WITH
THE TEAM-BASED CARE DONE IN A
CONSISTENT WAY AND WHATEVER WE
DEVELOP IN PRECISION MEDICINE
HAS TO FOLLOW THIS CONCEPT.
IT HAS TO BE MANUALIZED AND HAS
TO BE STANDARDIZED TRAINING AND
FIDELITY TO THE MODEL AND A LOT
OF THE WORK WAS INFORMED BY
PATIENTS AND FAMILIES WITH THE
WORK WE DO.
AND LOOKING AT ANTI-PSYCHOTIC
TREATMENT WHICH IS STILL THE
MAIN TREATMENT FOR PSYCHOSIS AND
WE HAVE A MEDICINE WHICH IS
CRITICAL FOR THE PATIENTS THAT
DON'T RESPOND AND IT'S BEEN
ASSOCIATED OVER AND OVER WITH
REDUCED SUICIDALITY AND DEATH BY
SUICIDE AND LESS HOSPITALIZATION
AND BETTER FUNCTIONAL OUTCOMES
FOR PATIENTS.
ONE OF THE THINGS WE NEED TO
CONSIDER AS WE START TO IDENTIFY
MARKERS THAT MAY BE ASSOCIATED
WITH TREATMENT RESPONSE OR OTHER
KINDS OF CLINICAL OUTCOMES IS TO
EVALUATE THE MARKERS IN CLINICAL
TRIALS.
ONE CHALLENGE IN OUR FIELD HAS
BEEN WHEN WE HAVE THE BIOLOGICAL
SCIENCES AND IMPLEMENTATION
HEALTH SCIENCES OVER THERE BUT
THEY'RE NEVER CONNECTED.
EVEN THE SCIENTISTS WHO WORK IN
BOTH AREAS DON'T TYPICALLY WORK
TOGETHER AND HAVE TO CONNECT THE
TWO AREAS MUCH BETTER.
AS WE DEVELOP THINGS IN THE
PRECISION MEDICINE FIELD LET'S
TEST THEM AND TRY THEM OUT.
THEY MAY NOT WORK BUT IF YOU
HAVE THE BIOMARKER AND IT GUIDES
YOUR DECISION MAKING IS THAT
BETTER THAN USUAL CARE?
IT'S AN EMPIRICAL QUESTION THAT
DESERVES TESTING, THEN A STUDY
COULD FOLLOW TO EVALUATE WHETHER
IT CAN CHANGE CLINICAL PRACTICE.
HERE'S THE HEART OF THE TALK AND
IT'S ABOUT THINKING ABOUT MENTAL
ILLNESS FROM A LIFE SPAN
PERSPECTIVE AND ALSO
ACKNOWLEDGING AND YOU MAY HAVE
SEEN AN ARTICLE RECENTLY IN
PSYCHIATRY AND IF YOU DIDN'T
IT'S WORTH TAKING A LOOK AT A
BUNCH OF PSYCHIATRISTS AND SAID
YOUTH MENTAL HEALTH IS MENTAL
HEALTH AND LOOKED AT THE ONSET
OF MOST OF OUR MENTAL DISORDERS.
THEY'RE ALMOST ALL IN
ADOLESCENTS OR EARLY ADULTHOOD
AND THE BURDEN OF DISEASE FROM
THE MENTAL DISORDERS IS VERY
HIGH AT THIS TIME OF LIFE.
AND CERTAINLY IN MANY COUNTRIES
NOT ALL COUNTRIES WHERE
INFECTIOUS DISEASE IS A REAL
CHALLENGE BUT MANY COUNTRIES IS
THE TOP CAUSE OF DISABILITY IN
YOUNG PEOPLE, MENTAL DISORDERS.
BUT WHAT'S INTERESTING ABOUT
MENTAL ILLNESS IS THERE'S PEAK
WINDOWS OF ONSET AT DIFFERENT
POINTS IN THE LIFE SPAN AND THIS
MAY ARTICULATE THAT.
THERE'S ALSO WINDOWS WHERE EARLY
INTERVENTION MAY BE PARTICULARLY
HELPFUL.
WHAT WE'RE ALSO LEARNING THAT
REQUIRES A DIFFERENT PERSPECTIVE
IS HAVING A MENTAL ILLNESS AT
ONE TIME POINT IN THE LIFE SPAN
MAY INCREASE DEVELOPING MENTAL
ILLNESS AT ANOTHER TIME SPAN AND
THIS SHOWS PEOPLE WITH AUTISM
HAVE AN ODDS RATIO FIVE SO SIX
OF DEVELOPING SCHIZOPHRENIA OR
ANOTHER DISORDER.
THIS IS FROM THE PHILADELPHIA
DEVELOPMENT COHORT LOOKING AT
THE SYMPTOMS.
A NICE DESCRIPTION OF WHAT
PSYCHOSIS MAY BE LIKE.
IT'S NOT A PSYCHOTIC DISORDER
BUT A PARANOID IDEA OR SOME
DISORDERED THINKING OR
EXPERIENCING A VOICE BUT NOT A
FULL-BLOWN ILLNESS.
WHAT'S FASCINATING THOUGH IS
THAT CHILDREN AND YOUTH WHO
ALREADY HAD A MENTAL ILLNESS
WERE MORE LIKELY TO HAVE THOSE
IMPAIRMENTS INCLUDING THOSE WHO
DID NOT HAVE A MENTAL ILLNESS
SUGGESTING THE PRESENCE OF
MENTAL DISORDER IN YOUNG PEOPLE
IN AND OF ITSELF CREATES RISK
FOR NEW PROBLEMS AND THESE ARE
NOT BENIGN THINGS.
THEY'RE ASSOCIATED WITH POOR
COGNITION AND SUICIDALITY.
HAVING DIMENSIONAL THINGS THERE
WHICH MAY OR MAY NOT BE EARLY
INDICATE INDICATORS OF RISK FOR
PSYCHOTIC DISORDER ARE HIGHLY
PROBLEMATIC AND CAUSE DISTRESS
IN CHILDREN AND YOUTH.
CONG CONCEPTS OF PREVENTION AND
I'M NOT A CHILD PSYCHOLOGIST BUT
A CONVERTED ONE BECAUSE OF THE
DATA AND WORK WE'RE TRAINING
TOWARD.
I WAS TRAINED IN GERIATRICS
ORIGINALLY.
HERE'S SYSTEMS DATA THE KAISER
SYSTEM AND WE HAVE DATA FROM THE
ONTARIO SYSTEM AND I CAN TELL
YOU THE DATA ARE IDENTICAL BUT
OURS ARE UNDER REVIEW.
IN CALIFORNIA, 74% OF PEOPLE WHO
HAD A FIRST PSYCHOTIC EPISODE
HAD ALREADY PRESENTED FOR MENTAL
HEALTH PROBLEMS.
THAT'S A BIG NUMBER.
THAT'S THREE-QUARTERS OF PEOPLE
ALREADY ASKING FOR PEOPLE BUT
NOT FOR PSYCHOSIS.
WE LOOK AT THE PIECE BELOW THE
HIGHLIGHTED AREA AND ASKING FOR
HELP FOR DEPRESSION, ANXIETY,
ADHD AND OTHER PROBLEMS.
THESE ARE WHAT ARE CALLED
HETEROTIPIC CHANGES.
KIDS WITH ONE DISORDER WHO THEN
DEVELOP ANOTHER DISORDER.
AND ONE OF THE CHALLENGES IN I
THINK SOME OF THE CURRENT
PARADIGMS AROUND PREVENTION
WHERE THERE'S BEEN A BIG FOCUS
IN CLINICAL HIGH RISK AND
HOPEFU
HOPEFULLY THIS WILL PROVOKE TALK
BECAUSE THERE'S BEEN
COMMUNITY-BASED SAMPLING AND
MADE IT HARD TO ASCERTAIN A LOT
OF THE CASES.
AND THERE WERE RECRUITS AND THEY
WORKED SO HARD TO RECRUIT THE
HIGH-RISK PATIENTS AND SHE'S
LIKE WHERE ARE ALL THE PEOPLE.
MAYBE THEY'RE IN YOUTH MENTAL
HEALTH CLINICS OR PRESENTING TO
THEIR COUNSELOR ALL ALONG.
SO I THINK THIS MOTION THAT THE
PREMORBID PHASE IS A NEWER
SYMPTOM PHASE MAY BE TRUE WHEN
YOU THINK OF PSYCHOTIC DISORDERS
BUT NOT WHEN YOU THINK OF
ILLNESS WITH 74% OF THOSE
PATIENTS OR PEOPLE WITH A
PSYCHOTIC EPISODE ARE
EXPERIENCING OTHER FORMS OF
MENTAL ILLNESS AND OPENS UP ALL
SORTS OF FASCINATING QUESTIONS.
WHAT ARE THE TRAJECTORIES AND
PATHWAYS TO PSYCHOSIS FOR PEOPLE
WHO YOUNGER PEOPLE WITH AUTISM
OR DEPRESSION OR OTHER PROBLEMS.
WHAT ABOUT THIS IS LIKE A REAL
AMBITIOUS THING AND ASPIRATIONAL
IDEA, WHAT IF YOU EFFECTIVELY
TREATED THAT IN A 13-YEAR-OLD
WOULD NOT NOT ONLY HELP THEM IN
THE MOMENT BUT PREVENT THEIR
PSYCHOSIS LATER?
THESE ARE FASCINATING QUESTIONS
WHEN YOU THINK OF STRATIFICATION
ARE ONES WE SHOULD EXAMINE AND
THINK ABOUT AND ONE WAY TO
ADDRESS THIS IN TORONTO ONE OF
THE MULTICULTURAL CITIES IS
THROUGH THE TORONTO YOUTH COHORT
STUDY.
WE'LL TALK ABOUT THE DESIGN AND
PROTOCOL BECAUSE WE JUST
STARTED.
THIS IS REALLY A RESPONSE TO THE
ISSUE WHICH IS THAT THERE'S MANY
MANY AMAZING POPULATION COHORTS
LIKE THE PNC AND COGNITIVE
DEVELOPMENT COHORT THAT'S
HAPPENING AND OTHER COHORTS
AROUND THE WORLD OF CHILDREN AND
YOUTH LEGENDARY AND FAMOUS BUT
STILL IN THE POPULATION
COMMUNITY SPHERE.
THEY'RE NOT NECESSARILY SAMPLES
AND THE DATA I SHOWED YOU THAT
IS SHOWING YOU AGAIN WHAT THE
RISK PROFILES MAYBE AND WHAT
ABOUT A PROSPECTIVE STUDY OF
CHILDREN AND YOUTH ALREADY
RECEIVING MENTAL HEALTH SERVICE
TO TRY TO STRATIFY THEIR RISK
PATHWAYS AND STRATIFY AND
PROVIDE CLINICAL TRIALS HOW TO
MODERATE OR PREVENT WORSE
OUTCOMES OVER TIME.
HERE'S THE DESIGN OF OUR STUDY.
WE WORKED HARD TO TRY TO MIRROR
OUR ASSESSMENT SCHEDULES AND THE
ASSESSMENTS WE CHOSE ARE
COMPLICATED.
YOU CAN IMAGINE WITH A TEAM OF
OVER 100 SCIENTISTS EVERYONE HAS
THEIR WAY OF DOING THINGS AND WE
WERE TRYING TO BE DISCIPLINED TO
MIRROR OUR ASSESSMENT IN THE
CLINICAL POPULATION TO OTHER
POPULATION-BASED COHORTS SUCH AS
THE ABCD STUDY.
THE OTHER THING WE PAY ATTENTION
TO IS THE THIRD LINE AND WE HAVE
ENVIRONMENTAL DATA LIKE POSTAL
CODES TO UNDERSTAND NEIGHBORHOOD
DEVELOP.
AN THERE'S A RICH PIPELINE AND
THERE'S A CORE ISSUE FOR MANY
FOLKS HERE.
NOT JUST IN OUR OWN HOSPITAL
FROM OUR OWN ELECTRONIC HEALTH
RECORD BUT IF A PATIENT GETS
SICK AND GETS HOSPITALIZED THREE
HOURS AWAY, WE WON'T KNOW THAT
IN REAL TIME BUT WHEN WE LOOK AT
THE DATA AS SOON AS PEOPLE
CONSENT TO HAVE THEIR DATA
LINKED THAT WAY AND WE'LL BE
ABLE TO KNOW THAT INFORMATION
TOO.
SCIENTIFICALLY SPEAKING, THERE'S
FIVE DIFFERENT SCIENTIFIC
CONCEPTS WE FRAME THEM AS
PROJECTS BUT IT'S ALL ONE BIG
STUDY.
ONE TEAM IS REALLY FOCUSSED ON
THE CLINICAL RESEARCH OUTCOMES
OF PSYCHOSIS.
OTHER KINDS OF SYSTEM --
SYMPTOM-RELATED DATA.
THESE ARE COMING TO OUR CLINIC
FOR ANY REASON.
YOU'LL SEE A LITTLE BIT ABOUT
THEM IN A MOMENT.
COGNITION, AND GETTING REPORT
CARDS FROM SCHOOL TO THE EXTENT
POSSIBLE AND SCHOOL PERFORMS IS
A CRITICAL OUTCOME MEASURE.
PROJECT THREE IS OUR BIOLOGICAL
DATA PROJECT.
PROJECT 4 IS SERVICE USE AND
COST TO THE SYSTEM.
IF YOU HAVE PROFILE A WHAT ARE
THE HEALTH CARE COSTS ASSOCIATED
WITH YOUR PROFILE AND 5 IS A
DATA INTEGRATION PROJECT WHICH
IS HOW DO WE INTEGRATE DIFFERENT
LEVELS OF ANALYSIS TO CREATE
PERSON-CENTERED MODELS OF
OUTCOME?
AND THIS IS SORT OF LIKE A
SIMPLE GRAPHIC AND THIS COULD
GIVE PSYCHOSIS RISK BUT COULD BE
ABOUT BRAIN DEVELOPMENT, HEALTH
CARE COSTS AND LOOKING AT THE
DIFFERENT TRAJECTORIES.
SO FAR WITH RECRUITED A LITTLE
OVER 600 PEOPLE.
I DIDN'T MENTION THE AGE RANGE
IS 11 TO 24 TO TRY TO CAPTURE
THE CRITICAL WINDOW OF TIME THAT
RELATES TO THE HIGHEST BURDEN OF
MENTAL DISORDER IN THE LIFE SPAN
AND ALSO AT LEAST ACROSS THE
FIVE YEARS OF THE PROJECT OR
MORE WHAT THE WINDOW IS FOR
PSYCHOSIS.
IT'S SPLIT IN TERMS OF AGE
DISTRIBUTION.
WE HAVE THREE PAPERS THAT
DESCRIBE THE PROTOCOL TO THIS
WORK AND A SNAPSHOT CROSS
SECTIONALLY.
WE DID A STOP TO THE DATA
CLEANING IN FEBRUARY FIRST AND
WE WANTED TO GET A SNAPSHOT OF
WHAT WAS GOING ON AND TO GIVE US
A REALITY CHECK OF WHAT WE WERE
UP TO.
ONE OF THE STRIKING THINGS IS
THE MEDIAN NUMBER OF DIAGNOSIS
WAS 3.5.
PEOPLE ARE NOT SEEKING MENTAL
HEALTH CARE FOR FUN.
THEY'RE COMING IN AND THERE'S
ALREADY SIGNIFICANT BURDEN OF
DISEASE.
80% HAVE ANXIETY OR A MOOD
DISORDER AND WHEN YOUNG PEOPLE
COME IN TO THE EMERGENCY ROOM
THAT'S WHAT'S PROBLEMATIC FOR
THEM.
I'LL FEELING LOW, DISTRESS,
ANXIOUS, DYSREGULATED.
THEY COULD HAVE A
NEURODEVELOPMENTAL DISORDER OR
ANOTHER PROBLEM.
45% REPORTED SUICIDAL THINKING
AND OTHER KINDS OF SUICIDAL RISK
AND ALMOST 50% SO IN THE
POPULATION-BASED COHORTS IN THIS
TIME OF LIFE IT'S STRIKING
BECAUSE IT'S QUITE HIGH.
USUALL
USUALLY 10% TO 20% REPORT
DYNAMICS AND IN THIS POMP ALMOST
AUTO -- 50% REPORTED A DISORDER
AND MANY ARE EXPERIENCING IS
SOME CHALLENGE IN THEIR THINKING
AND PERCEPTION AND ETHNIC
DIVERSITY AS WELL.
THE OTHER THING THAT WAS
STRIKING WAS IN A CLINICAL
SAMPLING AND WE WORKED WITH THE
POPULATION-BASED SAMPLE THERE'S
CONCERN ABOUT THE BIOLOGICAL
DATA AND THE QUALITY OF THE DATA
FROM PEOPLE WHO HAVE EXPERIENCED
MORE MENTAL ILLNESS IN AN MRI.
WE'RE NOT FINDING THIS IN OUR
DATA AND PEOPLE ARE JUST AS
LIKELY TO AGREE TO DO OTHER
PROCEDURES WHICH IS REALLY
IMPORTANT.
IT'S SURPRISING IN A GOOD WAY
AND ONE BIG REASON IS WE ENGAGED
YOUNG PEOPLE IN THEIR CAREGIVERS
AS PARTNERS IN THE RESEARCH FROM
THE BEGINNING AND MANY DO THE
WORK IN THE SERVICES SPACE.
IT'S MUCH LESS TYPICAL AS WE
MOVE UPSTREAM BRIDGING THE
BIOMEDICAL SPACE WITH THE
SERVICE SPACE.
WE'VE BEEN PLEASANTLY SURPRISED
AND IT'S BEEN A RICH EXPERIENCE
AND IT'S ALLOWED US TO PUSH AND
CHANGE OUR PROTOCOL AND CHANGE
LANGUAGE THAT PEOPLE DIDN'T LIKE
THAT MAY BE OTHER RESEARCHERS
THOUGHT WAS OKAY AND MAKING
SITUATIONS MORE COMFORTABLE OR
DOABLE.
FOR INSTANCE, ONE OF THE THINGS
WE DID WAS TO GET A T-SHIRT WITH
A PICTURE OF THEIR OWN BRAIN FOR
THOSE GETTING A SCAN AND THEY
LOVED THAT.
ONE OF THE MOST HEARTWARMING
THINGS IS SOME KIDS COME INTO
CLINIC WITH THEIR T-SHIRT ON.
IT'S PRETTY AMAZING.
THAT'S THEIR IDEA NOT THE ERS.
IN A FIVE-YEAR STUDY AND SOME
KIDS WILL GET QUITE ILL IT WILL
BE CRITICAL TO THINK OF
RETENTION.
WE DON'T WANT TO LOSE EVERYONE
BECAUSE WE'RE NOT BEING THOUGHT.
IN OUR INTENTION.
WE HOPE TO GET AT DIFFERENT
YOUTH EXPERIENCING MENTAL
ILLNESS AND IDENTIFY RISK, WHO
IS AT HIGHEST RISK FOR PSYCHOSIS
AND OTHER PROBLEMS.
RUN CLINICAL TRIALS TO ADDRESS
THESE ISSUES PARTICULARLY FROM A
PREVEN
PREVENTION-BASED PERSPECTIVE AND
NOT PRESENTING A PROBLEM BUT
PREVENTION OF FUTURE PROBLEMS
AND WE'VE ENGAGED YOUNG PEOPLE
WITH LIVED EXPERIENCE AND
FAMILIES AND SERVICE PROVIDERS.
AND THE FINAL SLIDE IS THIS
INITIAL COHORT IS SUPPORTIVE OF
ADDITIONAL FUNDING TO DO THIS
OTHER CENTERS IN OUR
JURISDICTION AND BUILD WHAT'S
CALLED A MASTER OBSERVATIONAL
TRIAL A CONCEPT FROM CANCER AND
THE STRATIFICATION BY RECRUIT
COHORT OF PEOPLE AND GIVING US
THE OPPORTUNITY TO STRATIFY
DIFFERENT PATIENTS OR PEOPLE IN
THE COHORT INTO DIFFERENT
CLINICAL TRIALS AS ARE NEEDED
FOR THEIR PRESENTING PROBLEM.
THAT'S WHAT THE PURPOSE OF THIS
FOLLOW-UP PROJECT IS GOING TO BE
AS ONE PROJECT GROWS IT WILL
FEED INTO ANOTHER PROJECT FROM A
CLINICAL TRIAL POINT OF VIEW.
THERE'S MANY PEOPLE INVOLVED IN
THE PROJECT AND I JUST WANTED TO
ACKNOWLEDGE THEM ALL.
THANK YOU.
>> THE SPEAKER FOR TODAY, MARK
VAN OMMEREN WANTED TO SHARE HIS
THOUGHTS ON THE STRATIFICATION
APPROACH.
>> HEAD OF THE MENTAL HEALTH
UNIT NOT THE DIRECT BUT HONORED
TO SOMETIMES BE CONFUSED.
I'M PLEASED TO SPEAK WITH QUA
ALL PRESENTED AND THE COLLEAGUES
ONLINE THANK YOU SO MUCH.
WHEN YOU THINK OF MANY OF US
HAVE BEEN INVOLVED IN RESEARCH
PRIORITY EXERCISES AND A KEY
QUESTION IN RESEARCH WHEN YOU
ARE A PARTICIPANT IN SUCH AN
EXERCISE, THERE'S USUALLY THE
MOMENT THINK OF THE RESEARCH
QUESTION THAT CAN BE ANSWERED IN
THE UPCOMING YEARS IN THE NEXT
MONTHS OR HOWEVER, LONG.
THE RESEARCH QUESTION YOU CAN
ANSWER IN SIX MONTHS IS
DIFFERENT YOU CAN ANSWER IN FIVE
YEARS.
AND THERE'S A CURE FOR
SCHIZOPHRENIA.
THAT WOULD BE SURPRISING FOR
PEOPLE TO THINK IT'S A
REASONABLE RESEARCH QUESTION.
THERE'S OTHER RESEARCH QUESTIONS
AND SO WHEN OBSERVE THE
DISCUSSION ON MORE BASIC SCIENCE
MECHANISMS THIS IS WHAT ALWAYS
COMES TO MY MIND.
WHAT HOW WILL IT TAKE TO HAVE AN
ANSWER.
YOU'RE GOVERNED BY COUNTRIES AND
ASKING QUESTIONS THE KINDS OF
QUESTIONS WE GET FROM COUNTRIES
ARE WHAT CAN WE DO NOW?
WHAT KNOWLEDGE DO WE HAVE NOW
THAT WE CAN IMPLEMENT?
THE KIND OF RESEARCH WE PROMOTE
IS IMPLEMENTATION SCIENCE AND
W.H.O. TELLS US A LOT OF THINGS
WORK.
HOW DO WE MAKE IT WORK?
IT'S A SHORTER AGENDA.
AND SHOULD HAVE THE APPLIED
IMPLEMENTATION.
THERE'S AN ISSUE WITH THEM.
THE QUESTION OF THE PANEL IS
WHAT IS PRECISION MEDICINE AND
TRANSLATION PSYCHIATRY WITH
GLOBAL HEALTH.
FIRST, IF WE'RE TALKING ABOUT
STRATIFICATION WE'RE TALKING
ABOUT POPULATIONS WORLDWIDE.
AND THE WORLD IS MORE AND MORE A
GLOBAL PLACE.
PEOPLE IN ONE COUNTRY ARE ALSO
OFTEN IN OTHER COUNTRIES.
SECOND IS A QUESTION OF MORE
MORAL QUESTION OF CAPACITY
BUILDING.
CAPACITIES SHOULD BE BUILT
EVERYWHERE.
THERE'S A QUESTION OF COST AND
RESEARCH QUESTIONS AND YOU CAN
GO FURTHER WITH YOUR RESEARCH
DOLLAR OR POUND IN CERTAIN
HIGH-INCOME COUNTRIES AND OVER
ALL I WOULD ARGUE IT'S EXTREMELY
IMPORTANT TO HAVE THE RESEARCH
YOU'RE DOING AND HAVE IT
OCCURRING AROUND THE WORLD.
AT THE W.H.O. WE DO
INTERVENTIONS AND WE CALL TRANS
DIAGNOSTIC AND ALMOST
ADIAGNOSTIC.
WE HAVE THEM DISTRESSED AND HOPE
AS MANY PEOPLE WE SEE HOW MANY
PEOPLE CAN BENEFIT FROM THAT AND
FOR RIGHT NOW WHAT WE SHOULD
HELP PEOPLE WITH NEXT COUPLE
YEARS IS ABSOLUTELY DERIVED
THROUGH WHAT PEOPLE NEED TO
HAVE.
THINK OF THE DATA AND WE DID A
WORLD MENTAL HEALTH AND LOOKED
AT THE COVERAGE AND TREATMENT
GAP.
TWO OF THREE PEOPLE AROUND THE
WORLD ARE IN NEED DUE TO
PSYCHOSIS.
AND CLEARLY THE DIAGNOSTIC IS
APPROACH IS NOT ENOUGH.
WE CAN DO MUCH BETTER.
THANK YOU.
>> EXCELLENT, MARK.
THANK YOU FOR YOUR CONTRIBUTION
AND CRITICAL THOUGHTS ON THIS.
I THINK WE HAVE TIME FOR A FEW
QUESTIONS.
NOT TOO MANY BUT ARE THERE
COMMENTS OR QUESTIONS FROM THE
AUDIENCE?
IF YOU CAN GO TO THE MICROPHONES
IN BOTH CORRIDORS.
>> I'M FROM HOLLAND.
I HAVE A QUESTION FOR YOU.
PAOLO, YOU TALKED ABOUT CHILDREN
ARE AT RISK FOR PSYCHOSIS AND
ALSO IN THE PAST AT RISK FOR
DEPRESSION AND THERE'S SOME
RELATION THERE OVER TIME.
DO YOU BELIEVE THE SECOND
DISORDER THE RISK IS RAISED BY
THE FIRST DISORDER OR IS THERE
AN UNDERLYING CAUSE THAT LEADS
TO BOTH?
PERHAPS SOCIAL DETERMINATE OR
SOMETHING YOU'VE SEEN IN
PATIENTS?
>> I THINK WE LEARNED PSYCHOSIS
CAN EMERGE FROM DIFFERENT
PSYCHOLOGICAL DIMENSIONS AND NOT
PSYCHOSIS SEPARATE FROM EARLY
STAGE OF NEURODEVELOPMENT
DISORDER AND THINGS CAN GET
BLURRED AND OVERLAPPING AND IF
WE WANT TO BE PRAGMATIC AND TRY
TO PREVENT SCHIZOPHRENIA IN ANY
SCENARIO WE WANT TO MAXIMIZE OUR
ABILITY TO DO THAT TO THE VAST
MAJORITY OF YOUNG PEOPLE AT
RISK.
SOME MAY HAVE COMMON MENTAL
DISORDER, DEPRESSION, SUBSTANCE
MISUSE.
AND THERE'S A COMBINATION OF
RISK FACTORS AND THE MORE THE
RISK AND WILL DEVELOP PSYCHOTIC
CONDITIONS.
THE EMERGING DISORDERS ACROSS
THE STATES AND MENTAL HEALTH
SERVICES AND EMERGENCY
DEPARTMENTS PRIMARY CARE IS A
WAY OF BOOSTING OUR ABILITY TO
DIAGNOSIS INDIVIDUALS AND IF YOU
WANT TO LOOK AT SPECIFIC NUMBERS
THERE'S META-ANALYSIS AND
REPORTING ON SPECIFIC RISK, FOR
EXAMPLE, OF THE LIKELY OF
DEVELOPING PSYCHOSIS FROM A
PRECEDING DEPRESSION OR BIPOLAR
DISORDER.
>> I THINK LIKE LET'S TAKE A
YOUNG PERSON WITH ADHD IT'S
ASSOCIATED WITH A FOUR-FOLD
INCREASE OF DEVELOPING PSYCHOSIS
AS AN ADULT.
WE ALSO HAVE GENETIC STUDIES
THERE'S SOME SHARED RISK GENES
BETWEEN ADHD AND SCHIZOPHRENIA.
SOME PEOPLE MAY BE UNLUCKY AND
HAVE ADHD AND DEVELOP PSYCHOSIS
LATER.
ON THE OTHER HAND IF YOU THINK
OF SOMEONE WITH ADHD WHO MAY BE
IMPULSIVE OR RISK TAKE AND MAY
GO OUT AND DECIDE TO USE
CANNABIS OR COCAINE BECAUSE IT'S
FUN AND THEN YOU'RE POURING
GASOLINE ON A VULNERABLE BRAIN.
MAYBE THEY WOULDN'T HAVE GOTTEN
PSYCHOSIS BUT YOU THROW THAT IN
THE MIX.
I THINK THERE'S DIFFERENT
PATHWAYS TO GET THERE AND
SOMETIMES IT'S PRE DETERMINED
AND OTHERS TIMES NOT AND OTHER
SOCIAL DETERMINATES OF HEALTH
AND RISK FACTORS ON TOP OF A
VULNERABLE KID THAT LEADS THEM
TO PSYCHOSIS.
>> ANY QUESTION IS FOR EVERYBODY
ON THE PANEL, I'M A CLINICIAN
AND A WONDER IF FOR YOU GUYS IN
DETERMINING THESE FACTORS FOR
PSYCHOSIS IF YOU DO
INTERDISCIPLINARY WORK BECAUSE I
HAVE CLIENTS THAT HAVE GOTTEN
INDUCED FROM PSYCHOSIS FROM
NUTRITIONAL IMBALANCES AND HAVE
CLIENTS WITH PSYCHOSIS DUE TO
DRUGS AND OTHER THEORIES PLAY A
ROLE IN THE AUTONOMIC SYMPTOMS
AND THERE'S SO MANY FACTORS THAT
CAN CONTRIBUTE TO PSYCHOSIS
SPECIFICALLY.
>> RESEARCH AND EVIDENCE SHOWS
THERE'S SUB TYPES OF THE
CONUNDRUM THAT CAN CAUSE
PSYCHOSIS.
I TAKE MARK'S VIEW SERIOUSLY.
THIS IS SCIENCE AT THE MOMENT.
SCIENCE FROM THE INDUSTRIALIZED
WORLD.
WE HAVE POOR INSIGHT INTO HOW
THE COMPLEXITY MAPS INTO OTHER
MIDDLE INCOME COUNTRIES BECAUSE
THERE'S A SCARCITY OF EVIDENCE
OF LONGITUDINAL STUDIES
CONDUCTED IN THE SETTINGS.
IT'S SCIENCE IT'S STILL NOT
ACTIONABLE BUT THERE'S AS PAOLO
SHOWED GOOD WAYS OF DOING
STRATIFICATION WITH WHAT WE
ALREADY HAVE.
DETECTING DESPITE ALL THE
COMPLEXITY AND SIGNAL OF RISK
EARLY ON BUT TO CONTINUE ALONG
TO THE LINES YOU RAISED
BASICALLY.
HAVE YOU SHOWN THERE'S AN
ALGORITHM THAT PREDICTS LY WELL
THE INDIVIDUAL RISK.
WHAT DO YOU DO WITH THAT?
IF IT'S SENSITIVE IT WILL PICK
UP RISK ACROSS SWATHS OF THE
POPULATION.
WHAT DO YOU ED FOR A LOW AND
MIDDLE INCOME SETTING TO DO WITH
THAT SIGNAL IF THERE'S SCARCITY
OF RESOURCES?
>> YES, THIS KIND OF DIGITAL
SCREENING APPROACHES THAT
CAPTURE THE FACTORS AND THE
CAUSES FOR PSYCHOSIS ARE ALL
FACTORS.
IT'S A PRAGMATIC SYSTEM SYSTEMIC
APPROACH TO DETECT VULNERABILITY
INCLUDING THE RISK FACTORS.
THERE'S A BALANCE BETWEEN
SENSITIVITY AND SPECIFICITY
AROUND 90% SO IT'S OKAY WE'RE
TRYING TO IMPROVE THAT WE'RE NOT
BEING INUNDATED BY TOO MANY
CASES AND IT'S USEFUL TO BE USED
IN THE COMMUNITY.
AND THE RISK IS WITHOUT
SCREENING THERE WILL BE CASES
WITH YOUNG PEOPLE DEVELOPING
PSYCHOSIS WITHOUT PROPER
DIAGNOSIS AND TREATMENT AND THE
DURATION OF UNTREATED PSYCHOSIS
IF YOU LOOK AT BIPOLAR DISORDER
IT TAKES 10 YEARS TO GET A
DIAGNOSIS IN THE U.K.
AND CAPTURING EMERGING
DISORDERS.
AND THAT'S THE APPROACH AND
STRAIGHT BETWEEN POST POSITIVES
AND NEGATIVES.
>> CAN I FOLLOW-UP?
YOU HAVE A WIDE RANGE OF MENTAL
DISORDERS, BIPOLAR AND PTSD
INCLUDING HALLUCINATIONS AND
PSYCHOSIS.
MY QUESTION WOULD BE IS THERE'S
RESEARCH TO SHOW MISDIAGNOSIS
BECAUSE OF THE EFFECTS OF TRAUMA
ON THE BODY.
I'M WONDERING HOW YOU GUYS ARE
IMPLEMENTING DIFFERENT FIELD OF
OF PEOPLE DOING SPECIFIC STUDIES
TO COME UP WITH MORE ACCURATE
TOOLS AND ASSESSMENTS FOR THAT.
>> THE FIRST SLIDE I PRESENT WAS
THE TEAM-BASED MODEL OF CARE FOR
PEOPLE WITH PSYCHOSIS.
WHEN YOU HAVE THAT YOU NEED A
TEAM IF YOU HAVE THE RESOURCES.
ONE OF THE CONSIDERATIONS IS
STEP-CARE MODEL IN TERMS OF LESS
SPECIFIC TO THE DIAGNOSIS AND
MORE THE INTENSIVITY OF ME.
THE NAVIGATE MODEL THAT SUPPORTS
EDUCATION AND EMPLOYMENT, FAMILY
SUPPORT AND INDIVIDUAL
RESILIENCE AND MEDICATION.
ANY SEVERELY ILL 16, 17-YEAR-OLD
WOULD BENEFIT AND WE'RE TRYING
TO ADOPT THAT BUT ADAPT IT IN A
STEPPED WAY BECAUSE WE DON'T
HAVE THE RESOURCES TO DO IT FOR
EVERYONE BUT I THINK FOR THAT
BOTTOM 20% YOU'RE DESCRIBING
COULD BENEFIT FROM A TEAM-BASED
MODEL LIKE THAT AND HAVE YOU
LIGHTER TOUCHES AS YOU GO UP.
AND WE HAVE TO BUILD A SYSTEM
DESIGN IF WE'RE GOING TO TAKE
CARE OF EVERYONE.
>> THANK YOU, ARISTOTLE.
I THINK WE'RE END AT THE
SESSION.
CLOSING WORDS FROM MUSMUN.
>> WE KNOW THE FIELD OF GLOBAL
MENTAL HEALTH IS AT THE POINT WE
WANT TO REFINE AND NOW THE
STRATIFICATIONS.
WHEN WE THINK OF THIS IT'S NOT
FOR GLOBAL MENTAL HEALTH BUT
FROM THE PRESENTATIONS WE CAN
SEE IT'S CROSS-DISCIPLINARY AND
SCALABLE AND THE IMPLEMENTATION
RESEARCH STUDIES THE MENTAL
HEALTH FOLKS ARE ENGAGED IN LEND
TO THE METHODOLOGIES AND TOOLS
AND TACTICS CERTIFICATION HAS TO
OFFER AND OPEN NEW DOORS FOR THE
INTERVENTIONS THAT WE NEED IN
GLOBAL MENTAL HEALTH.
A BIG ROUND OF APPLAUSE FOR THE
PANELISTS.
I AM VERY HONORED TO WELCOME
THE STAGE, PROFESSORS.
WHEN I WAS TRAINED IN MEDICINE E
90s, I USED TO THINK THAT
RANDOMIZED CONTROL TRIALS AND TS
OVERALL, WERE EXCLUSIVELY DONE N
MEDICINE AND MENTAL HEALTH.
OVER TIME, THAT HAS CHANGED.
-- TO ALLEVIATE POVERTY.
SHE RECEIVED [ INAUDIBLE ]
AND MICHAEL KRAMER.
PROFESSOR DEFLOW IS PROFESSOR AE
MASSACHUSETTS INSTITUTE OF TECHY
IN POVERTY ALLEVIATION AND
DEVELOPMENTAL ECONOMICS.
OUR HOST OF THE SECOND GLOBAL ML
HEALTH CONVERSATIONS IS PROFESSR
BENJAMIN COOK.
PROFESSOR COOK WAS RECENTLY PROD
TO FULL PROFESSOR AT THE DEPARTT
OF PSYCHIATRY AT HARVARD MEDICAL
SCHOOL.
HE HOLDS A PH.D. IN HEALTH POLIY
FROM HARVARD AS WELL AND HE DIRS
THE CENTER FOR EQUITY RESEARCH N
BOSTON.
HE IS A HEALTH SERVICES RESEARCR
WHO WORKS PRIMARILY IN HEALTH
DISPARITIES USING A MIX OF
QUALITATIVE AND QUANTITATIVE MES
AND EMPLOYS A LOT OF BIG DATA.
SO, I WILL LET YOU, BENJAMIN, TT
AWAY.
THANK YOU VERY MUCH FOR BEING H.
AND THANK YOU PROFESSOR, FOR BEG
HERE.
>> I HAVE TO REALLY GET INTO ITE
A LEAD SINGER OF A ROCK BAND.
OKAY.
GREAT TO BE HERE.
SO NICE TO HAVE THE TIME TO TALH
YOU.
SO, WE HAVE BEEN ASKED TO DO A
FIRESIDE CHAT.
THIS IS GOING TO BE A LITTLE MOE
INFORMAL.
I WAS TOLD THAT THIS SHOULD LOOA
LITTLE BIT LIKE THE SHOW, INSIDE
ACTOR'S STUDIO.
THIS GUY, JAMES LIPTON.
SO I WENT ON LINE BECAUSE I HAVT
SEEN THE SHOW.
AND HE INTERVIEWS PEOPLE LIKE
MICHELLE PHEIFFER AND ROBERT DEO
AND SO -- THAT'S HOW THIS IS GOO
GO.
WE'RE GOING TO DO SOMETHING LIKE
INSIDE THE ACTOR'S STUDIO AND IL
PLAY JAMES LIPTON.
WHY DON'T WE START.
I'M GOING ASK QUESTIONS AND WE'L
HAVE ABOUT 10 MINUTES AT THE ENF
THIS TO ASK SOME MORE QUESTIONSF
ESTER.
SO I WANTED TO START TO ASK A
QUESTION A LITTLE BIT ABOUT YOUR
BACKGROUND.
YOU'RE AN ECONOMIST.
AND I DON'T THINK THERE ARE GOIO
BE MANY ECONOMISTS IN THE ROOM,E
SOME WHO TRAINED IN HEALTH ECONS
AND SOME ECONOMISTS ARE HERE.
YES.
AND SO I WANTED TO MAKE SURE THE
ARE KIND OF ON THE SAME PAGE ABT
YOUR BACKGROUND AND TO MERGE THT
WITH SOME OF THE EXPERIENCE HERF
THE CLINICIANS AND THE
EPIDEMIOLOGISTS AND WILL MENTAL
HEALTH SERVICES RESEARCHERS THAE
COMING.
AND I THOUGHT I'D START BY READG
SOMETHING FROM THE RECENT BOOK T
YOU PUBLISHED ON GOOD ECONOMICSN
BAD PLACES.
AND WHAT YOU SAID WAS, ECONOMISE
MORE LIKE PLUMBERS THAN PHYSICI.
WE SOLVE PROBLEMS WITH A COMBINN
OF IN TUITION GROUNDED IN SCIEN,
SOME GUESSWORK AIDED BY EXPERIEE
AND A BUNCH OF PURE TRIAL AND E.
SO I'M NO PLUMBER BUT I PLUMBEDW
SINKS AND TOILETS IN MY DAY, ANI
KNOW THAT IT'S A LOT OF WORK.
IT'S VERY REWARDING, ALSO.
SO I WONDER IF WE COULD START T.
WHY IS AN ECONOMIST LIKE A PLUMR
AND TELL US, MAYBE, ABOUT YOUR
EDUCATIONAL BACKGROUND AND HOW I
DON'T THINK MOST TRADITIONAL
ECONOMISTS WOULD CALL THEMSELVES
PLUMBERS, OR MAYBE THEY WOULD.
IF YOU'LL TRACK US THROUGH THAT.
>> THANK YOU VERY MUCH.
THANK YOU FOR HAVING ME HERE.
SO I THINK THE PLUMBING -- A LOF
PEOPLE I DO NOT THINK WANT TO TK
OF THEMSELVES AS PLUMBERS.
SO I THINK THAT'S A GOOD THING.
SO I BECAME AN ECONOMIST BECAUSE
MOMENT THAT I REALIZED THAT IT D
BE A WAY TO REALLY MAKE A MEANIL
CHANGE FOR THE BETTER IN THE LIF
VERY MANY PEOPLE.
SO I DID BECOME AN ECONOMIST WIE
HOPE AND THE AMBITION OF IMPROVG
PROGRAMS AND POLICIES THAT AFFEE
POOR IN THE WORLD.
AND BEFORE THAT, I WAS NOT PLANG
TO BE AN ECONOMIST.
WHEN YOU REALIZED IT COULD BE AY
TO DO THAT, THAT'S WHEN I BECAME
INTERESTED.
SO IN I A SENSE, I WAS ALWAYS IS
PROFESSION, SO I STARTED IN THIS
PROFESSION IN ORDER TO GET TO AE
OF BEING USEFUL AND DEVELOPING L
INTERVENTIONS AND HELPING OTHERS
DEVELOPING AND IMPLEMENTING USEL
INTERVENTIONS.
AND WHEN YOU DO THAT, YOU REALIE
THAT THERE IS -- THAT THE WORLDG
A -- PLACE, THERE IS SO MUCH WET
UNDERSTAND ABOUT THE CIRCUMSTANS
ABOUT WHICH PEOPLE LIVES AND ABT
WHAT MOTIVATES THEIR ACTIONS ORE
ACTIONS OF OTHERS AROUND THEM AW
IT INTERACTS WITH THE ENVIRONME,
PHYSICALLY OR SOCIALLY.
THE ONLY THING YOU CAN DO -- THT
THEORY IS ONLY GOING TO TAKE YOO
FAR.
AND THE ONLY THING YOU CAN DO AN
GOVERNMENT OR NGOS TO TO PUT YOR
BEST FOOT FORWARD IN DESIGNING A
PROGRAM AND THEN HOPE THAT IT'SG
TO LEAD TO A GOOD OUTCOME.
BUT YOU CAN'T POSSIBLY HAVE FIGD
OUT EVERYTHING.
AND SO THAT'S WHERE THE PLUMBIND
ENERGY COMES FROM, WHICH IS WHEA
PLUMBER COMES TO YOUR HOUSE ANDY
LOOK AT THE PROBLEM, THEY HAVE N
TUITION FOR WHAT THE PROBLEM MIT
BE.
THAT IN TUITION IS NOT RANDOM.
IT'S GROUNDED IN THEORY, THEY MY
HAVE LEARNED IN PAST EXPERIENCER
SCHOOL.
BUT ULTIMATELY IT'S UNLIKELY TOR
ALL THE POSSIBLE CONTINGENCIES.
THEY ARE GOING TO TRY SOMETHINGD
THEN SEE IF IT WORKS.
AND IF IT DOESN'T WORK, THEY ARE
GOING TO TRY SOMETHING ELSE.
AND I THINK THAT'S THE ATTITUDET
A LOT EVER ECONOMISTS SHOULD HAD
THAT'S THE ATTITUDE THAT I HAVEN
ECONOMIST, WHICH IS WHY I KIND Y
TO START FROM THE BEST POSSIBLE
UNDERSTANDING OF WHAT MIGHT WORO
SOLVE A PARTICULAR PROBLEM.
IT COULD BE A MENTAL HEALTH PROM
SINCE WE ARE IN THIS ROOM T COUE
AN ECONOMIC ISSUE.
IT COULD BE AN EDUCATION ISSUE R
ANYTHING.
AND THEN ALWAYS I LEARN FROM THE
POSSIBILITY THAT YOU HAVE MISSEE
DETAIL WHICH TURNS OUT TO BE CRL
AND THEREFORE THE INTERVENTION D
HAVE TO BE RE-THOUGHT.
>> AND IT'S A GREAT ANALOGY AND
REALLY WORKS, I THINK.
IS THERE SOMETHING ABOUT ECONOMC
THEORY AND THE TRAINING THAT YOU
RECEIVED IN ECONOMIC THEORY THAT
HELPS US TO UNDERSTAND MENTAL HH
AND THINKING ABOUT APPLYING THE
DIFFERENT WAYS THAT THE PRODUCTN
FUNCTIONS AND THINGS LIKE THAT.
WHERE DOES MENTAL HEALTH FIT INH
THAT AND IN YOUR TRAINING, HOW D
A TRADITIONAL ECONOMIST FIT MENL
HEALTH INTO THEIR FRAMEWORKS ANN
WHAT WAYS HAVE YOU KIND OF LEARD
ABOUT MENTAL HEALTH GIVEN YOUR
TRAINING?
>> SO I THINK IT'S ONLY RELATIVY
RECENTLY THAT ECONOMISTS HAVE SD
TO BECOME INTERESTED IN MENTAL
HEALTH.
AND IT'S BEEN A LONG TIME SINCE
ECONOMISTS HAVE BEEN INTERESTEDN
WORKING WITH PSYCHOLOGISTS AND
INCORPORATING SOME FUNDAMENTAL
LIMITATION OF THE HUMAN PSYCHE O
UNDERSTAND BETTER BEHAVIORS.
IT'S BEEN A LONG TIME SINCE
ECONOMISTS HAVE NOT NECESSARILY
ASSUMING PERFECTLY RATIONAL BEHR
AND SO ON AND SO FORTH.
BUT I THINK IT WAS MAYBE THE PLE
THAT WAS GIVEN TO PSYCHOLOGY AND
ECONOMICS FOR A WHILE, WAS MORET
THIS -- THE HUMAN BEINGS ARE SUH
THAT, FOR EXAMPLE, THEY GIVE MOE
IMPORTANCE TO THE PRESENT THAN E
FUTURE IN A WAY THAT IS NOT COHT
OF OUR TIME.
WE NEED TO TAKE THAT INTO ACCOU.
HUMAN BEINGS ARE SUCH THAT THERS
ONLY SO MANY PIECES IN THEIR BRT
ANY GIVEN TIME AND THAT WILL LED
THEM TO FORGET IMPORTANT DETAIL.
SO IN A SENSE, THE INCORPORATIOF
PSYCHOLOGY WAS MORE INSTRUMENTAO
UNDERSTAND THE BEHAVIOR BETTER,E
ECONOMIC BEHAVIOR BETTER.
BUT WHAT I THINK HAS HAPPENED OS
IN THE PROCESS OF HAPPENING, ISO
THINGS.
NUMBER 1 SILENT RELATION THAT ML
HEALTH -- IS THE RELATE THAT MEL
HEALTH IS VALUABLE IN ITSELF.
WE THINK OF UTILITY BUT MENTAL H
IS NOT A GO TO AN END BUT IT ISO
THE END.
MORE AND MORE PEOPLE ARE REALIZG
HAVING SATISFIED TO USE OUTCOMES
RELATED TO MENTAL HEALTH AS THE
DEFINED OUTCOME.
NOT AS SOMETHING ELSE.
THAT'S ONE PART OF IT.
AND IN THE PROCESS OF DOING THA,
REALIZING FROM MY CORNER OF THE
SPACE, THANKS TO WORK LIKE -- FR
EXAMPLE, THOSE IN THE ROOM, THAN
POORER COUNTRIES, MENTAL HEALTH
PROBLEMS ARE SO MUCH WORSE.
AND IN PARTICULAR, BEING POOR, S
PEOPLE MISERABLE.
AND IN AND OF ITSELF, THAT'S BA.
AND THEREFORE WHEN WE THINK ABOT
INTERVENTION THAT ARE MEANT TO
ALLEVIATE THE CONDITIONS OF POV,
WE CAN THINK OF MENTAL HEALTH AS
SOMETHING THAT IS DESIRABLE OUTE
TO ACHIEVE.
REGARDLESS OF WHETHER IT THEN LS
TO MORE ECONOMIC WELL-BEING.
THAT'S THE FIRST THING.
AND THE SECOND THING THAT IS ALO
HAPPENING IS REALIZING THE FUNCL
IMPACT OF MENTAL HEALTH POTENTIY
ON PEOPLE'S ABILITY TO BE IN THE
WORLD.
THAT IS THE FIRST KIND OF WALK E
LIMITATION OF PSYCHOLOGY AND HOW
PEOPLE BEHAVE.
WITH THE FOCUS ON THE MENTAL HEH
ASPECT AND NOT JUST -- SO WHAT S
SOMEONE WITH DEPRESSION, HOW DOS
THAT AFFECT THEIR ABILITY TO BEN
THE WORLD AND GO ABOUT THEIR RER
BUSINESS, EARN MONEY AND SO ON.
HOW ANXIETY, DEPRESSION, STRESSD
SO ON.
SO THESE TWO THINGS, I THINK, BE
OF MUCH GREATER INTEREST IN ASSG
IN PART OF THE -- AND IN MY OWNK
IN THE LAST LET'S SAY 5-10 YEAR.
SO IT IS VERY YOUNG.
>> I APPRECIATE THAT BEING ON TE
LEFT AND RIGHT-HAND SIDE OF THE
PRODUCTION FUNCTION OF MENTAL H.
I WANTED TO MAKE SURE WE TALK AT
JAY POWELL, THE POVERTY ACTION .
THIS IS AN INCREDIBLY IMPORTANTB
IN THE FIELD FOR GROUNDING ECONC
THEORY AND RIGOROUS FIELD WORK D
EXTREMELY INFLUENTIAL IN PUSHING
PUBLIC POLICY AROUND THE WORLD D
ABROAD.
CAN YOU TALK ABOUT THE GENESIS Y
POWELL AND MAYBE A LITTLE BIT AT
THE MISSION AND WHY IT'S SO GOOT
CHANGING -- WHY IT'S BEEN SUCCEL
AT CHANGING POLICY AS OPPOSED TT
MAKING STUDIES?
>> YES, SO JAY POWELL, YOU CAN
CHARACTERIZE IT AS A LAB BUT --H
YOU MIGHT -- [ INAUDIBLE ]
ACTION LAB SO YOU MIGHT THINK IA
LAB.
IT IS IN SOME WAYS BUT IN OTHERS
IT'S MORE LIKE A NETWORK OR A
MOVEMENT.
SO IT'S REALLY A NETWORK OF
RESEARCHERS WHO ARE USING RANDOD
CONTROL TRIALS TO STUDY QUESTIOS
RELATEDDED TO POVERTY AROU AROUE
WORLD IN THE U.S. AND ELSE WEAR.
I'M SAYING REALITY TO POVERTY AE
WELCOME THE ENVIRONMENT AND WE
WELCOME PURE HEALTH QUESTIONS TT
CAN AFFECT PEOPLE WHO ARE NOT TT
POOR.
BUT MOSTLY IT'S ABOUT IMPROVINGE
LIFE OF THE POOR.
WHY IT'S BEEN SUCCESSFUL?
I THINK THE MAIN REASON WHY IS S
NOTION OF MOVEMENT, WHICH IT WAS
NEVER ABOUT THE RESEARCH OF SOME
IN PARTICULAR.
IT WAS ALWAYS AND STILL IS TO TS
DAY REALLY FOCUSED ON EMPOWERING
PEOPLE TO CONDUCT THEIR OWN WOR.
AND IN THIS WAY, IT HAS A MUSHRG
CAPACITY BECAUSE THE ONLY CLARIF
VISION THAT I EVER HAD WITH REST
TO THIS IS WE ARE ABOUT ON THE -
CONTROL TRIALS AND WE ARE ABOUT
POVERTY.
AND OTHER THAN THAT, PEOPLE SHOE
ABLE TO DO WHATEVER IT IS THEY .
AND THIS IS THE WORK TO BRANCH N
ANY NUMBER OF DIRECTIONS.
AND TO WORK WITH MANY PARTNERS O
ARE DOING WORK ACROSS-THE-BOARD.
FOR EXAMPLE, IF WE TAKE THIS MEL
HEALTH SPACE, HAVING THE
INFRASTRUCTURE, WE HAVE A VERY E
PRESENCE IN INDIA AND THE
INFRASTRUCTURE OF INDIA IS ALLOO
TAKE THE WORK OF OTHERS TO KIND-
HOW WOULD I SAY?
EXPAND ON IT.
SO FOLLOW LONGER-TERM IMPACT OF
INTERVENTION THAT HAVE BEEN DONN
THE PAST LIKE WORK -- OF TAKING
INTERVENTION AND THEN TRYING THN
ANOTHER PLACE AND WHAT WE ARE TG
TO DO -- WHICH IS TAKING A COGNE
BEHAVIOR THERAPY INTERVENTION AD
KIND OF TRY TO MAKE IT -- EMBEDT
INTO A GOVERNMENT PROGRAM, WHICU
COULDN'T DO WITHOUT HAVING 10 YS
OF RELATIONSHIP WITH THE GOVERNT
THAT WE KNOW EVERYONE UP AND DON
WITHOUT PAYING A LOT OF PHYSICAL
PRESENCE, WITHOUT HAVING BEEN
STUDYING MORE PEOPLE FOR MANY Y.
AND WITHOUT HAVING OF COURSE THE
INTELLECTUAL RIGOR AND CAPACITYF
THE RESEARCHERS.
SO THAT'S AN EXAMPLE OF THE
NETWORKING.
YOU HAVE THE GOVERNMENT PIECE.
YOU HAVE THE INFRASTRUCTURE IN E
AND YOU HAVE THE INTELLECTUAL I.
>> THAT'S GREAT.
IT'S BEEN EXTREMELY SUCCESSFUL.
I WAS THINKING ABOUT HOW TO BUID
NETWORKS LIKE THAT AND HOW OFTEN
THERE ARE DISINCENT I WAS TO DOT
IN ACADEMIA, GIVEN WE ARE OFTEN
JUDGED BY OUR INDIRECTS AND THEY
THAT WE BRING INTO OUR INSTITUT.
YOU HAVE DONE SO WELL IN CREATIG
THESE NETWORKS IN BLOWING UP THD
ACADEMIC SYSTEM.
LOTS OF PEOPLE NOW GO ON TO HAVE
INDETECTIVES ACROSS MULTIPLE
INSTITUTIONS AND NOT TO MENTIONE
RESEARCH THAT YOU HAVE ACROSS TE
WORLD.
DO YOU HAVE SOME ADVICE ABOUT T,
ABOUT HOW, WHEN WE ARE IN OUR S,
HOW DO WE CREATE NETWORKS AND HW
HAVE YOU BEEN SO SUCCESSFUL IN G
THAT?
>> I THINK THAT IS WHAT WE THIN.
THAT IF WE ARE GOING TO -- WE HO
DEVELOP OUR OWN RESEARCH WORK BR
OUR OWN GOOD.
BUT IT'S NOT TRUE.
THE REASON WHY WE HAVE A NETWORM
THE BEGINNING AND OUR INITIAL NK
WAS 8 PEOPLE AND OUR INITIAL FUG
WAS 300,000 DOLLARS OVER THREE .
SO IT STARTED SMALL.
BUT I THINK IT'S TRUE THAT THE
INSTINCT WOULD HAVE BEEN -- [
INAUDIBLE ]
LAB MANAGER AND RUN MORE OF MY
EXPERIMENTS.
THAT'S NOT WHAT WE WANTED TO DO
BECAUSE WE, BEING ME AND OTHERSN
WE STARTED WE DIDN'T HAVE THE --
THAT'S NOT WHAT WE WANTED TO DO
BECAUSE WE FELT WE WERE AT THE T
WHERE WE CAN HAVE ONE OR MORE OO
MORE EXPERIMENTS BUT WHAT WOULDE
THE POINT FROM THE POINT OF WHAS
LIMITING US, IMPROVING THE LIVEF
VERY MANY PEOPLE.
IT IS ALWAYS GOING TO BE SO LIM.
AND WHAT WE NEED TO DO IS TO CRE
INFRASTRUCTURE TO BRING IN SO MY
MORE PEOPLE BECAUSE CLEARLY WE D
SEE THAT THERE WAS INTEREST IN G
THIS WORK BUT ALSO A LOT OF APP
REHENSION AND LIMITATION BECAUSS
COMPLICATED AND COSTS MONEY ANDS
TIME.
AND A LOT OF THE YOUNG RESEARCHT
THE TIME, THEY WERE WONDERING WR
IT WAS SOMETHING WISE TO DO FOR
TENURE AND SO ON.
SO WE THOUGHT IF WE COULD HELP
ALLEVIATING THOSE PRACTICAL PROS
THAT THEY HAVE AT THE SCALE THAE
CAN, WITH THE MONEY WE HAVE FOR,
IT'S GOING TO BUILD ON EACH OTHD
IT'S GOING TO CREATE -- I DON'TT
TO TELL YOU, WE ARE EXACTLY 20.
SO I DON'T WANT TO SAY THAT 20 S
AGO I HAD THE VISION OF THE SCAE
THAT WE WOULD HAVE TODAY.
BUT AT LEAST I HAD THE VISION TT
NOTHING I CAN DO IF IN MY OWN WS
GOING TO BE GOOD ENOUGH FOR THEE
OF THE PROBLEM THAT IS IN FRONTF
ME.
BUT IF WE CAN -- IF I CAN EMPOWR
OTHER PEOPLE TO DO IT WHO IN TUN
WILL EMPOWER OTHER PEOPLE TO DOT
AND SO ON, THEN MAYBE WE CAN MAA
DENT IN THE PROBLEM.
AND THE TRUTH IS THAT I'VE DONE
PRETTY WELL FOR MYSELF.
SO IT'S NOT THAT IT WAS A BAD -S
NOT THAT IT WAS A BAD SELFISH
DECISION.
SO SOMETIMES I WANT TO HOPE THAT
WAS NOT THE IMPETUS BUT I THINKU
SEE THAT AGAIN AND AGAIN IS THAT
SOMETIMES THINKING ABOUT NOT THE
IMAGE, THAT LINE OF TOMORROW ORE
IMMEDIATE VALUE OF DOING SOMETHG
FOR YOUR OWN PURPOSE, PUBLISH WB
PAPER OR JUST THIS ONE FIELD.
IT WILL HELP EVEN IN YOUR OWN CR
TOO, STEP BACK AND SEE HOW CAN U
BRING MORE PEOPLE?
HOW CAN YOU CREATE EXCITEMENT AD
WHAT YOU'RE DOING AND SO ON?
>> VERY INSPIRATIONAL.
THAT'S GOOD FOR FOLKS LIKE US WN
BE WRAPPED UP IN OUR OWN SILOS.
THAT'S THE RIGHT MESSAGE.
I WANTED TO GET BACK TO THINKING
ABOUT RANDOMIZED TRIALS AND
RANDOMIZED CONTROL TRIALS.
IN THE BOOK THAT YOU JUST WROTED
ECONOMICS FOR HARD TIMES, YOU TL
SOME OF THE HISTORY OF THE EARLH
TRANSFER RANDOMIZED TRIALS IN NW
JERSEY AND SOME OF THE OTHERS TT
HAPPENED IN THE U.S. AND IT'S JT
VERY COMPELLING.
THE IDEA THAT YOU CAN TAKE A
RANDOMIZED CONTROL TRIAL, THE GD
STANDARD IN CLINICAL TRIALS, INO
SOCIAL SITUATIONS.
I WONDER IF YOU TALK TO US SOMEE
ABOUT THE STRENGTH AND WHAT THAT
MEANS IN SOCIAL INNOVATION
SITUATIONS, BUT ALSO THE WEAKNE.
I THINK A LOT OF PEOPLE WILL SA,
WELL, THERE IS GOING TO BE COMMY
RESISTANCE TO RANDOMIZATION.
THERE WILL BE -- IT WILL TAKE AG
TIME TO GET COMMUNITY BUY IN FON
RCT.
YOU GAIN TRUST DEALING WITH POL,
THE FUNDING OF IT.
SO I WONDERED IF YOU WOULD TALKT
SOME OF THOSE -- WHAT PEOPLE MIT
THINK OF AS LIMITATIONS WHEN DOG
THESE BROADER RCTs.
BUT ALSO THE STRENGTHS OF THE R.
>> SO I THINK THE STRENGTHS RELO
THE QUESTION THAT IS WE STARTED.
IF YOU LIVE IN A WORLD WHERE YOE
NO IDEA -- WHEN YOU PUT YOUR BET
FOOT FORWARD, YOU BEING A POLICR
OR ANYONE WITH A POSSIBLE
INTERVENTION, ACADEMIC, POLICYM,
SOMEONE FROM AN NGO.
IF YOU LIVE IN A WORLD WHERE YOW
THAT THERE IS SO MANY THINGS THU
DON'T CONTROL AND DON'T EVEN
UNDERSTAND AND HAVEN'T EVEN BEEN
TRAINED TO PAY ATTENTION TO THA-
IN INTERVENTION, THAT SEEMS TO E
REALLY HYPE FOR RANDOMIZED CONTL
TRIALS BECAUSE -- YOU HAVE NO IA
MOST OF THE THINGS THAT YOU'RE G
WHETHER IT MIGHT WORK OR NOT WO.
SO THEN, YOU WANT TO TRY THEM OD
THEN USUALLY IT'S NOT POSSIBLE Y
TO SCALE THE INTERVENTION
IMMEDIATELY, NOR DESIRABLE.
SO USUALLY YOU NEED A PILOT ANY.
SO, IT'S KIND OF DOESN'T ADD MUN
TERMS OF COMPLEXITY TO DO IT INY
THAT YOU CAN LEARN FROM IT AND N
MOVE ON FROM THAT.
SO THAT'S THE KIND OF RATIONAL.
AND WE WERE WORKING A LOT IN HEH
AND EDUCATION BECAUSE I THINK IS
THE CLOSEST ANALOGY TO UNDERSTAD
THEN PROGRESSIVELY, IT APPEARED
THANKS TO THIS NETWORK STRUCTURT
YOU CAN -- STUFF WE DIDN'T THINK
ABOUT, GIVING CASH TO PEOPLE IN
RANDOMIZED FASHION.
DIDN'T THINK YOU COULD REALLY DE
20 YEARS AGO I THOUGHT THERE WOE
ISSUES OF OTHER PEOPLE BEING UPT
AND SO ON.
SO THAT'S THE RATIONAL.
THE RESISTANCE.
SO YOU SPOKE ABOUT LIMITATIONS T
YOU -- AND NOW BOTH LIMITATIONSD
RESISTANCE.
SO THE RESISTANCE ARE MUCH LESSN
YOU MIGHT IMAGINE.
BECAUSE ONCE YOU EXPLAIN WHAT IT
EXPLAINED AND PEOPLE UNDERSTAND.
PEOPLE IN COMMUNITIES PERFECTLY
UNDERSTAND THAT THERE ARE SO MAY
THINGS THAT THEY GET OR DON'T GD
USUALLY IT'S FOR NOT VERY GOOD
REASONS.
AND IF YOU'RE GOING TO BE NOT CD
BY A PILOT, MAYBE IT'S BETTER YT
COVER UP NOW BECAUSE WE ARE TRYO
FIND OUT IF IT WORKS.
THEN YOU'RE NOT COVERED NOW BECE
YOU'RE NOT THE NEPHEW OF THE RIT
UNCLE.
I'VE NEVER SEEN ANYBODY IN THE
COMMUNITIES NOT LIKING THE POSI.
WE HAVE A PROGRAM WHERE WE GIVEH
[ INAUDIBLE ]
VERY VALUABLE.
AND -- SCHOLARSHIP (?) WE IDENTY
THE KIDS WHO HAVE QUALIFIED FOR
SECONDARY SCHOOL AND NOT ABLE TO
ATTEND AND WE RANDOMLY SELECTED.
AND SOME OF THEM WE GIVE THEM FL
SCHOLARSHIP TO GO TO SCHOOL.
YOU THINK THERE WOULD BE RESISTS
IN THE CONTROL GROUP.
WE STARTED IN 2008.
WE ARE STILL SERVING THEM.
THEY ARE OKAY WITH BEING PART O
THIS.
AND THEY UNDERSTAND THAT PART OE
PLANNING WENT INTO MAKING INTO E
RATIONAL FOR EXPANDING -- IF THS
A REASON FOR YOUR EXPERIMENT, IN
PASS AN IRB, YOU SHOULD BE ABLEO
EXPLAIN IT TO THE PEOPLE AND IFU
CAN NOT, THEN MAYBE THERE IS A
PROBLEM WITH THE EXPERIMENT.
THERE ARE ALSO LIMITATIONS, HARO
RANDOMIZE THAN OTHERS.
THERE ARE ALWAYS PROBLEMS SO
PARTICULARLY PROBLEMS SO LARGE T
YOU HAVE -- YOU DON'T HAVE -- TE
IS A LONG WAY BETWEEN WHAT YOU
INTENDED TO DO AND WHAT HAPPENSN
REALITY.
SO IT MAKES INTERPRETATION MORE
COMPLICATED.
SOMETIMES THERE ARE SPILL OVERSO
IT'S DIFFICULT TO INTERPRET THE.
BUT ALSO OF THIS WE THINK WE HAE
LEARNED AND ALSO TO KIND OF TAKN
THIS PART OF WHAT IT IS IN THE .
SO THE BIG DIFFERENCE BETWEEN AT
OF THE TRIALS THAT SOME OF YOU E
MIGHT DO WHICH ARE VERY CONTROL,
VERY SMALL, WELL UNDERSTOOD ANDT
WE MIGHT DO, WHICH IS VERY
LARGE-SCALE, GOVERNMENT PARTNERS
THAT WE DON'T GET THE PURITY OFA
MECHANISM BUT WE GET SOMETHING -
WHAT WOULD HAPPEN IN THE -- ANDN
YOU HAVE LESS MAYBE THEORETICAL
LESSONS TO DERIVE BUT THEY ARE L
IMMEDIATE APPLICATION OF THE RE.
AND REALLY PEOPLE ARE ALL OVER E
RANGE OF DOING THINGS VERY, VERY
CONTROLLED THAT MIGHT NOT BE SUR
VALIDATED OR NOT VERY, VERY
CONTROLLED AND HAVE MORE EXTENDD
VALIDATION -- [ INAUDIBLE ]
MU COMBINE THE EXPERIMENT WITH
QUALITATIVE WORK TO KNOW WHAT
HAPPENED.
>> IT'S INTERESTING.
IT'S SO INTERESTING TO HEAR YOU.
I THINK WE HAVE ENCOUNTERED A LF
RESISTANCE TRYING TO DO RANDOMID
CONTROL TRIALS WITH NARROW SCOPN
UNDER RESOURCED COMMUNITIES.
COMMUNITY MEMBERS WOULD SAY YOUE
GOING TO DENY HALF OF THESE THEE
RESOURCES THAT HAVE YOU BUT IT S
LIKE THERE IS A COMMUNICATION, Y
GOOD COMMUNICATION ABOUT WHAT
EQUIPOISE IS, WHAT ARE THE END S
FOR THE COMMUNITY AND THOSE TYPF
THINGS THAT REALLY HELP.
>> WHAT WE PROVIDE IS LESS,
OBVIOUSLY -- THEY FEEL IT'S [
INAUDIBLE ]
>> AND IT SOUNDS LIKE YOU MAINTN
THAT CONTROL GROUP.
IT'S NOT LIKE YOU'RE GIVING THEM
NOTHING BUT YOU CONTINUE TO STAN
TOUCH WITH THEM.
>> YES, SO FOR EXAMPLE IN THE GA
EXAMPLE, WE GIVE THEM A CELL PHE
BECAUSE WE WANT TO STAY IN TOUCH
THEM AND WE KEEP IN TOUCH WITH M
AND TALK TO THEM.
WE RE-UP -- IT'S REALLY NOT A LT
THEY ARE KIND OF PART OF THE PR.
WHICH SHAPES THE RESULTS.
>> RECENTLY PUBLISHED PAPER WE E
TALKING ABOUT THE PAPER THAT YOD
OTHERS PUBLISHED ABOUT LOOKING E
EFFECTS OF COGNITIVE BEHAVIORAL
THERAPY, CBT, AND CASH TRANSFERN
OLDER PERSONS LIVING ALONE IN I.
I WONDER, AS YOU WERE SAYING, YW
MADE MENTAL HEALTH KIND OF AN OE
HERE.
I WONDER IF THERE ARE SOME OTHER
LESSONS?
IS THERE SOMETHING UNIQUE ABOUT
MENTAL HEALTH AS AB OUTCOME?
SOMETHING ABOUT THE CONTEXT OR R
CONSIDERATIONS RELATED TO NOW HG
MENTAL HEALTH AS AN OUTCOME THAT
SURPRISED YOU?
OR WAS NEW?
ANYTHING LIKE THAT?
>> SO THIS PARTICULAR PROJECT CE
OUT OF THIS WORK I HAVE BEEN DOG
FOR A WHILE, JUST STAYED IN THEH
OF INDIA, QUITE WEALTHY BY INDIN
STATES, WHICH HAS ALSO BEEN VERT
DEMOGRAPHIC TRANSITION SEVERAL S
AGO NOW.
AND WE STARTED COLLECTING A PANF
OLDER PEOPLE SIMILAR TO THE
RETIREMENT SURVEY.
THE WE DID A CENSUS TO FIND OUTO
ARE THE OLD PEOPLE, WHERE THEY O
SAMPLE FROM THEM.
AND WE HAD IN THE CENSUS, 1-6 OR
PERSON IN THE STATE LIVE ENTIREY
ALONE.
AND MOST OF THE PEOPLE WILL LIVE
ENTIRELY ALONE ARE WOMEN.
AND THEN THAT SURPRISED OUR
GOVERNMENT PARTNER A LOT BECAUSY
HAD THIS VIEW THAT NO ONE IN INA
LIVES ALONE.
BECAUSE YOU SHOULD LIVE WITH YOR
EXTENDED FAMILY.
YOU SHOULD EXCEPT IF YOU DON'T,E
A LOT OF PEOPLE DO NOT.
WOMEN, MAYBE HAD VERY FEW KIDS,E
ONLY ONE AND THEY MY GREATED ORT
HAD A SON AND THEY CANNOT -- ORA
DAUGHTER AND THEY CAN'T LIVE WIE
DAUGHTER BECAUSE YOU DON'T LIVEH
YOUR SON ANYMORE OR SOME SUCH.
SO WE STARTED FOLLOWING THIS GRP
PURPOSEFULLY OF THESE OLDER PEOE
LIVING ALONE AND WE REALIZED IN
COLLECTING MENTAL HEALTH DATA --
INITIALLY WE WERE GOING TO DO A-
PENSION BECAUSE A LOT OF THESE E
ARE ELIGIBLE FOR A PENSION THATY
DON'T GET BAUDS THEY DON'T KNOWW
TO APPLY AND -- BECAUSE -- PAYRL
CUTS AND NOT GIVING THE PENSION.
SO ULTIMATELY IT WAS GOING TO BA
PENSION PAPER.
BUT THEN WE REALIZED WHEN WE WEE
DOING SURVEY AFTER SURVEY, HOW
MISERABLE THESE PEOPLE LIVING AE
WERE.
VERY POOR MENTAL HEALTH.
THEIR MENTAL HEALTH DECLINED ASY
AGE, FASTER THAN OTHER PEOPLE TE
SAME AGE AND HEALTH CONDITIONS.
THEIR PHYSICAL DECLINE IS FASTED
THEIR COGNITIVE DECLINE IS FAST.
AND THEY ALSO ARE EXTREMELY ISO.
YOU TALK ABOUT LONELINESS IN TH.
SOME OF THESE PEOPLE HAVEN'T SPN
TO ANYONE IN WEEKS.
AND SO THE FACT THAT THE GOVERNT
DIDN'T EVEN KNOW ABOUT THEM IN Y
THAT THEY DON'T HAVE SPACE IN TE
POLICY SPACE.
SO WE DECIDED WE BETTER DO SOMEG
AND BEFORE COVID, JUST BEFORE C,
WE HAD DECIDED WE WOULD HIRE --E
COLLEGE STUDENTS WHO WOULD GO AD
TALK TO THESE OLD PEOPLE AND CRE
LIKE A SOCIAL LINKS.
WE WERE ABOUT TO START THIS THE
PROJECT IN FEBRUARY OF 2020 ANDE
THING WE DIDN'T SEE WAS COVID H.
MY ONE MOMENT OF LOU SIDDITY IS
BEFORE THE WHOLE WORLD SHUT DOW,
MAYBE WAS THAT THING INSIDE US T
A VERY GOOD IDEA TO SEND PEOPLE
FROMVILLAGE TOVILLAGE GOING TO D
PEOPLE TO OLD PEOPLE AND WE SHOT
DO THIS PROJECT.
SO WE SCUTTLED IT BEFORE WE HAD.
AND THE NICE ADVANTAGE OF THAT E
SHIFTED AND WE DECIDED TO SHIFTN
BECAUSE WE GOT MORE WORRIED ABOE
MENTAL HEALTH OF THESE PEOPLE NN
ADDITION, THEY ARE KIND OF
OPPORTUNITY FOR DISEASE.
WE SHIFTED IT TO THIS COGNITIVE
THERAPY.
WE WERE WORKING WITH A PSYCHOLOT
WHO WAS KIND OF BUILDING THE WHE
INTERVENTION WITH COLLEGE STUDEO
SHE SHIFTED GEARS AND STARTED
WRITING, ADAPTING MODULES THAT D
WE LAUNCHED THAT INTERVENTION.
ONE OF THE SAME, WE DID LEARN AT
MENTAL HEALTH AS AN OUTCOME IS S
VERY DIFFICULT TO MEASURE VERY
RELIABLY.
AND IN PARTICULAR WITH MEN.
SO WHAT WE HAD A BASELINE IS THR
MEN WERE SO HAPPY.
THEY WERE JUMPING FOR JOY AND HO
PROBLEM.
AND WHAT IS INTERESTING IS THATE
COGNITIVE BEHAVIORAL -- FOR WOMD
HARMFUL FOR MEN AND WOMEN.
WHAT I SUSPECT ALTHOUGH I DON'TW
FOR A FACT, IS THEY WENT FROM HG
NO PROBLEM WHATSOEVER, THANK YOY
MUCH, TO KIND OF REALIZING WHATR
ISSUES MIGHT BE AND ONE OF THE S
I LEARNED ABOUT MENTAL HEALTH IM
NOT VERY SURE WE ARE COMPLETELYD
OF PERFECT WITH THE PHQ9 AND OTR
SELF-REPORTED MEASURES, PARTICUY
IN THIS POPULATION.
SO NOW WE HAVE TO DO SOMETHING
IN-PERSON WITH THE GOVERNMENT, H
THE FRONT LINE WORKER BEING TRA.
PILOTING THIS AT THE MOMENT.
AND FORTUNATELY WE DECIDED NOT O
WORK WITH THE MEN BECAUSE THIS
MEASUREMENT IS VERY DIFFICULT TO
SURMOUNT AND WE HAVE WOMEN IN --
DEPARTMENT.
AND THE OTHER THING IS WE ARE GG
TO SEND PSYCHOLOGIST FOR LONG
ASSESSMENTS TO SEE WHETHER THER
IS -- HOW -- THIS IS SOMETHING M
SURE YOU KNOW MUCH BETTER THAN ,
BUT KIND OF A COUNTER SETTING.
>> WE WERE TALKING EARLIER ABOUW
THE CASH TRANSFERS WERE PART OFT
SO CBT, SHOULD WE BE CONSIDERINH
TRANSFERS AS MENTAL HEALTH
INTERVENTIONS?
>> DEFINITELY.
IT'S WHAT I WAS TALKING -- POOR
PEOPLE AND WE HAVE DONE A DESCRE
STUDY FROM SEVERAL COUNTRIES WIH
SURVEYS AND IN THE U.S. AS PEOPE
BECOME OLDER, THEIR MENTAL HEALH
SITUATION STABILIZES OR IMPROVE.
BUT WE FOUND IN THE LOWER NEW ED
COUNTRIES, IT GOES DOWN AND DOWD
DOWN.
AND SO AS PEOPLE AGE AND RESOURS
DWINDLE, THEIR MENTAL HEALTH BES
SO BAD.
AND SIMPLY IT'S VERY OLD-FASHIOD
BUT SIMPLY RELAXING SOME OF THE
REAL -- THAT THEY FACE IN SITUAS
WHERE THERE IS NO PENSIONS AND E
IS NO HEALTH INSURANCE AND SO O.
REALLY SHOULD BE EXPECTED TO HED
I THINK IN GENERAL, IT'S BEEN FD
THAT CASH OR ECONOMIC INTERVENTF
VALUES CAN HELP PEOPLE'S MENTAL
HEALTH AND THE CBT PAPER WE FOUD
CASH TO BE MORE EFFECTIVE THAN T
BECAUSE IT'S CHEAPER TO DO CASHN
TO DO CBT.
SO AS A RESULT OF THIS ONE, IT D
BE MADE MORE CHEAPER AND SO ON.
I DON'T SEE THIS AS WE SHOULD JO
CASH AND FORGET ABOUT ANYTHING E
AT ALL BUT IT DOES SUGGEST THATE
CAN THINK ABOUT ECONOMIC
INTERVENTIONS AS MENTAL HEALTH
INTERVENTION AS WELL.
I WORKED A LOT FOR PEOPLE WHO AE
EXTREMELY POOR AND FOR THAT THES
A PROGRAM THAT WAS INITIATED IN
BANGLADESH ON PROVIDING ASSETS D
SOME TRAINING IN THE ASSETS TO Y
KIND OF INTENSE INTERVENTIONS.
BUT IT HAS LONG TERM IMPACTS.
WE HAVE BEEN FIGURING NOW FOR 15
YEARS AND THEY ARE STILL DOING H
BETTER IF THEY HAVE THE INTERVE.
AND ONE OF THE CHANNEL I'M VERYE
IS THE FACT THAT YOU TAKE PEOPLO
ARE LIVING IN HOPELESS SITUATIOD
YOU ARE GIVING THEM HOPE.
IN THE FORM OF ASSET AND HELP YU
TAKE CARE OF THIS ASSET AND ASSG
YOU YOU CAN DO IT.
THIS IS SOMETHING YOU DON'T HAVO
LIVE IN THIS -- ON THE EDGE OF S
EXTREME POVERTY.
YOU CAN RUN A BUSINESS.
A LOT OF PEOPLE THINK THAT NO, Y
CANNOT.
WHATEVER HAPPENS IN THEIR LIFE S
MADE THEM INCAPABLE OF DOING TH.
AND IT'S JUST NOT TRUTHFUL AT A.
SO I THINK THAT'S ALL THAT MAKE-
ECONOMIC INTERVENTION, CASH OR R
CONCEPTS AND PROGRAMS AND SHOULE
PART OF THE MENTAL HEALTH TOOLK.
AND ONE QUESTION THAT I THINK IN
IS HOW DOES IT INTERACT WITH EXT
MENTAL HEALTH INTERVENTIONS SUCS
ACTIVE BEHAVIOR INTERVENTION --
DEPENDS FROM STUDY TO STUDY.
IN GHANA, [ INAUDIBLE ]
ARE DOING GROUP SESSION OF COGNE
BEHAVIORAL INTERVENTION IN
COMBINATION WITH CASH INTERVENTN
AND THEY ARE SPECTACULARLY POSIE
EFFECT AT VERY LOW COST BECAUSES
A GROUP.
SO I THINK THIS IS POTENTIAL.
THERE IS A LOT OF INTERESTING NS
TO FOLLOW.
>> I WANT TO GIVE SOME TIME FORS
TO ASK QUESTIONS.
FOR YOU ALL AS WELL, I WANTED TK
ONE MORE QUESTION BEFORE WE OPET
UP.
AND THINKING ABOUT THE FUTURE AY
POWELL AND YOUR WORK GOING FORWD
AND THE THING THAT WAS ON MY MIN
READING THE CHAPTER ON IMMIGRATN
YOUR BOOK WAS THINKING ABOUT CLE
CHANGE AND THE LESSONS THAT WE E
LEARNED FROM THE RCTs THAT YOU L
HAVE DONE AND WHETHER CLIMATE CE
WILL CHANGE SOME OF THAT.
AS AN EXAMPLE, I THINK A LOT OFE
DATA SHOWS THAT IMMIGRATION FOR
REASONS -- I FORGET THE TERM --E
SHARK'S TEETH ARE BEING IN THE H
OF THE SHARK IS WHAT DRIVES PEOO
LEAVE, NOT JUST HIGHER WAGES
SOMEWHERE ELSE.
BUT THERE IS THE POSSIBILITY OFS
MIGRATION BECAUSE OF CLIMATE CH.
AND I WONDER IF YOU ANTICIPATE E
OF THESE LESSONS NOT WORKING ASL
IN THE FUTURE BECAUSE OF CLIMATE
CHANGE OR OTHER THINGS WE SHOULE
CANNING ABOUT AS SCIENTISTS THAU
HAVE BEEN FORECASTING OR THINKIG
ABOUT AS CLIMATE CHANGE STARTS O
IMPACT ALL OF THE SOCIAL PROGRAD
THE WAYS WE ARE GOING TO BE LIVN
THE WORLD.
>> SO THAT'S A VERY GOOD TIME TK
THIS QUESTION BECAUSE AS I SAIDI
HAVE BEEN THINKING ABOUT WHERE L
WE BE BEYOND.
SO I THINK YOU ARE CORRECT THAT
CLIMATE CHANGE IS A BIG ELEPHANN
THE ROOM.
I THINK CLIMATE CHANGE DOESN'T T
AFFECT THE RESULTS OF THE RESEAH
THAT WILL BE A SMALL ISSUE.
I THINK IT AFFECTS -- IT'S GOOD-
THE VERY CONSIDERABLE GAINS THAE
BEEN EXPERIENCED IN POVERTY IN E
LAST FEW YEARS.
SO IN THE LAST 20 YEARS, A LOT -
IN THE WORLD THE LIFE OF THE POS
NOT -- GENERALLY THINGS HAVE
IMPROVED.
MORTALITY HAS BEEN DIVIDED INTO
ALMOST EVERY SCHOOL.
POVERTY REALLY DECLINED A LOT UR
COVID.
THAT DECLINED STOPPED AFTER COV.
BUT MOVING -- SO COVID AND THENE
FOLLOWING CRISIS HAVE STOPPED TT
PROGRESS BUT THERE ARE TIMES VEY
GOOD.
CLIMATE CHANGE COULD CHANGE ALLF
THAT BECAUSE IT TURNS OUT THAT E
COUNTRIES IN WHICH A LOT OF THER
PEOPLE LIVE ARE IN PLACES THAT E
ALREADY HOT AND THAT THE AFFECTF
WARMER CLIMATE IS NOT LINEAR.
AND THOSE PLACES WHERE A LOT OF
PEOPLE LIVE, IN AFRICA, SOUTH A,
IN THE NORTH OF LATIN AMERICA, S
IS EXPERIENCING MORE AND MORE OE
DAYS NOT CONDUCIVE TO HUMAN LIF.
AND EVEN IN THE ABSENCE OF
CATASTROPHES, HEAT IS GOING TO L
PEOPLE.
IT'S ESTIMATED THAT THE INCREASN
MORTALITY BY 2100 IS GOING TO GS
73 400,000 JUST FROM ONE -- WHIS
MORE THAN ALL OF THE INFECTIOUS
DISEASE TO TODAY COMBINED.
THIS THE IS ALL GOING TO BE IN R
COUNTRIES.
NONE OF THE -- CLIMATE CHANGE IT
GOING TO KILL ANYBODY IN THE --O
THAT'S REALLY CHANGING THE LANDE
AND WE DON'T HAVE ENOUGH.
WE DON'T KNOW ENOUGH.
WE DON'T KNOW NEARLY ENOUGH OF T
WILL HELP PEOPLE TO ADAPT AND BE
RESILIENT.
HOW WE CAN MITIGATE IN THE POOR
COUNTRIES MOSTLY AND SO ON.
SO I THINK THAT IS HUGE, HUGE H.
AND OF COURSE THE POLICY AGENDAS
WELL.
THE OTHER THING I WOULD SAY IN S
OF WHERE I SEE AND WHERE I WOULE
TO SEE BY 2030, I WOULD LIKE --E
LESS IMPORTANT IN 30 THAN IT ISW
IN PROPORTION TO THE AMOUNT OF K
THAT IS BEING DONE.
LET ME EXPLAIN HOW I MEAN THAT.
FROM THE BEGINNING WE WERE ABOUT
CREATING A NETWORK, CREATING A
MOVEMENT AND SO WE STARTED FRIDY
EXPANDING FROM -- RIGHT NOW MOSF
THE EXPANSION HAS BEEN IN -- BUO
BE ABLE TO DO THIS WILL, WE NEED
RESEARCHERS MORE EQUIPPED AND
CONNECTED SO THEY CAN DO THEIR N
RESEARCH AND POLICYMAKERS AS WE.
THE BIG -- I SEE THE BIG CAPACIY
POTENTIAL FOR EXPANSION TODAY IO
CREATE MUCH MORE -- IN WORKING H
UNIVERSITIES AND NETWORKING THEN
THE SAME WAY WE NETWORKED WITH
RESEARCHERS TAKING ONE STEP FURR
AT THE UNIVERSITY LEVEL AND WITY
MORE PARTNERS.
AND THEN KIND OF BUILDING ON THO
CREATE A CONNECTION OF OPPORTUNS
AND I THINK THAT CAN HELP IN CRG
A HUGE AMOUNT OF WORK THAT IS GG
TO BE NEEDED TO THINK ABOUT CLIE
CHANGE AND ALL THE OTHER ISSUESL
WITH US.
>> THANK YOU.
JUST THE RIGHT VISION FOR WHAT'O
COME.
WHY DON'T I OPEN IT UP AND PLEAE
FIND YOUR WAY TO THE MICROPHONEF
YOU HAVE A QUESTION.
YES, IF YOU WOULDN'T MIND COMINO
THE MIC AND ASKING YOUR QUESTION
THERE.
GO AHEAD.
>> A COMMENT AND A QUESTION.
SO THE COMMENT IS -- MY NAME ISA
AND I'M WITH PSYCHIATRY AND ALSO
PATIENT RESEARCHER AMONG OTHER
THINGS.
THIS IS A BIT OF AN ELEPHANT INE
ROOM, WE KEEP TALKING ABOUT SOCL
DETERMINANTS AND MAYBE IT RELATS
WELL AS WHEN TALKING BELL CASH
TRANSFERS.
ISN'T THE REAL QUESTION NOT SOCL
DETERMINANTS BUT POLITICAL
DETERMINANTS?
AND PEOPLE ARE NOT POOR OUT OF
DESIGN.
THEY ARE POOR BECAUSE OF THE DEN
OF POLITICS.
SO MAYBE WE NEED STOP TALKING AT
SOCIAL DETERMINANTS BUT THE POLL
DECISIONS WHICH ARE MADE ON BEHF
PEOPLE WHICH HAVE AN IMPACT ON
PEOPLE.
AND THAT'S AN ECONOMY QUESTION M
MY PERSPECTIVE AS A LAYPERSON.
MY QUESTION IS ALSO, THIS HAS TO
WITH THE DESIGN OF YOUR RCTs.
AND I WAS WONDERING IN ORDER TO
COUNTER ACT THE FACT WITH DEALIG
WITH VERY LARGE SAMPLES, WHICH E
NATURE OF RCTs, DO YOU INVOLVE
PEOPLE SO PATIENTS NOTICE THE PC
IN THE DESIGN OF YOUR RCTs?
BECAUSE THAT WOULD HELP.
THANK YOU.
>> YOU WANT TO TAKE A COUPLE OTR
QUESTIONS?
I THINK WE PROBABLY ONLY HAVE TE
FOR THREE TOTAL.
MAYBE GO TO THIS SIDE AND THIS .
YOU'RE KEEPING TRACK OF ALL OF ?
OKAY.
GO AHEAD.
>> THANK YOU MY NAME IS LAUREN D
I'M A DOCTORAL STUDENT AT JOHNS
HOPKINS.
I WAS CURIOUS TO ASK ABOUT YOUR
APPROACH TO RCS IN PARTICULAR WH
JAY POWELL.
I CERTAINLY APPRECIATED THE
FOUNDATIONAL WORK YOU HAVE DONED
THE GRADUATION APPROACH.
WE ARE LOOKING AT THAT IN
HUMANITARIAN CONTEXT AND RECOGNG
THE VALUE OF THAT.
I'M CURIOUS ABOUT YOUR PERSPECTN
USING OTHER KINDS OF COMPLEX CAL
INFERENCE APPROACHES USING
OBSERVATIONAL DATA TO ASSESS OTR
TYPES OF INTERVENTIONS AND PERHS
POLICIES IN PARTICULAR.
SO IF IT'S NOT FEASIBLE TO RANDE
AT A CERTAIN LEVEL OR PERHAPS IN
ORDER TO TAKE ADVANTAGE OF EXISG
DATA THAT WEREN'T COLLECTED WITN
ARE.
CT FRAMEWORK, I WAS CURIOUS IF E
WAS TAKING THAT APPROACH IN THEY
POWELL?
THANK YOU.
>> THANK YOU FOR A GREAT TALK.
I'M AT THE UNIVERSITY OF ZIMM BY
AND HARVARD MEDICAL SCHOOL.
I WAS WONDERING IF YOU COULD TAK
MORE BROADLY ABOUT UNIVERSAL BAC
INCOME AS A POSSIBILITY AND THEN
MICROFINANCE AND HOW YOU THINK T
THE DIFFERENCE BETWEEN THOSE TYF
INTERVENTIONS WITHIN THE POVERTY
SPACE AS THEY RELATE TO MENTAL
HEALTH.
>> I'LL TAKE THE THREE QUESTIOND
MAYBE THE FIRST TWO ARE RELATED.
SO THE POLITICAL DETERMINANTS, ,
TRUE.
POLITICS IS IMPORTANT.
A LOT OF HARD WORK, SOMETIMES PE
SAY ALL OF THESE DETAILS BECAUSL
OF THAT MATTERS IS POLITICAL
STRUCTURE AND EVEN THOUGH POLITS
INVOLVED I AGREE WITH THE SECOND
COMMENT IN TWO WAYS.
FIRST THERE IS A LOT THAT GOES N
PRETTY GOOD POLITICAL ENVIRONME.
SO EVEN THERE YOU HAVE - EVEN OE
POLITICS IS OKAY, YOU HAVE SO MH
THAT GOES WRONG BECAUSE OF OTHER
THINGS LIKE IGNORANCE, BECAUSE T
BEING CLOSE TO THE FIELD, BECAUE
DESPITE THE BEST INTENTION, JUST
FINDING THE BEST POLICIES.
SO THERE IS A TON OF SCOPE WITHN
POLITICS.
AND EVEN THE POLITICS ITSELF, IS
IS USEFUL TO SEE IT AS 10,000 FT
LEVEL BUT SOMETIMES IT'S USEFULO
SEE AT A VERY LOCAL LEVEL, WHICS
POLITICS BECOME, HOW DO YOU RUN
ELECTIONS?
WHO GETS TO VOTE?
WHO GETS TO -- WHO GETS TO BE A
CANDIDATE?
WHO WANTS TO BE A CANDIDATE?
CAN WE GET MORE PEOPLE?
SO POLITICS BECOME A SUBJECT OF
INQUIRY IN A WAY THAT IS PROTEC.
IF YOU SEE IT FROM THE SMALLER .
THE QUESTION -- [ INAUDIBLE ]
NON-RANDOMIZED WORK FROM TIME T
TIME.
JAY POWELL ITSELF IS ABOUT
RANDOMIZATION BECAUSE IT'S VERY
USEFUL TO HAVE A MISSION.
BUT THERE IS PLENTY OF SCOPE FOS
NON RANDOMIZED METHODS AS WELL.
THE HISTORY, TO STUDY THINGS YON
NOT RANDOMIZE, MONETARY POLICY D
LARGE INSTITUTIONAL QUESTIONS.
SO BE MY GUEST.
I DO THINK THAT THE EXISTENCE OF
RANDOMIZED CONTROL TRIALS HAS FA
VERY HUGE DISCIPLINING DEVICE ON
THESE OTHER METHODS BECAUSE NOWU
CAN ALWAYS ASK YOURSELF IF I CAN
RANDOMIZE, WHAT WOULD I DO?
THAT DOES HELP IN CANDIDATES.
IN TERMS OF THE -- INVOLVING
COMMUNITIES IN THE TRIAL.
FOR US IT'S VERY, VERY MUCH THEY
IN WHICH WE WORK WITH NGOs SO IS
ACTIVISTS.
SO IT'S NOT NECESSARILY THE LOW-
THE POOR PEOPLE THEMSELVES ALTHH
THEY OFTEN GET INVOLVED IN THE
DEFINITION OF PROGRAMS, BUT IT'S
DEFINITELY THE TYPE OF WORK WITH
THEM.
I SHOULD SAY THAT WE HAVE -- WEE
DOING THIS.
FOR THE MORNING PANEL SESSION I
REALLY WANTED POOR PEOPLE TO BEN
THE SEAT AND NOT RESEARCHERS.
AND I'M NOT FULLY SUCCEEDED BECE
GETTING THERE HAS BEEN A NIGHTME
BUT I PARTLY SUCCEEDED.
AND THIS IS VERY MUCH WITH THISN
MIND.
WE SHOULD DO MORE OF THAT AND KF
LEARN FROM PEOPLE AND HOW CAN WE
LEARN FROM PEOPLE?
SO THAT'S A FIRST STEP IN GOINGN
THIS DIRECTION.
AND ON UBI, SO WE TOOK ABOUT --T
WE PROPOSED IS UNIVERSAL VERY BC
INCOME SO THERE SHOULD BE A FLA.
NOBODY SHOULD FIT IN THE WORLD T
THEY COULD NOT HAVE ENOUGH FOODO
FEED THEIR CHILDREN.
AND THAT IN POOR COUNTRIES THATN
BE ACHIEVED BY MAKING -- COULD E
ACHIEVED BY ASSURING PEOPLE HAVE
RIGHT EVERY MONTH TO AN ALLOCATN
FOR THAT MONTH IN A WAY THAT ISY
AND THAT IT WOULD GO A LONG WAYO
REMOVING SOME STRESS AND ANXIETR
PEOPLE'S ACTIVITIES.
IN THE RICHER COUNTRIES, I MUCHS
SEE THE POINT FOR BASIC INCOME
BECAUSE TO GIVE THE MINIMUM WILE
SO EXPENSIVE THAT IT WOULD TAKEY
A LOT OF OTHER PROGRAMS AND ON E
CONTRARY, AT THE LEVEL TIME, WEE
A LOT OF INFORMATION ON PEOPLE U
CAN TARGET YOUR -- TWO PEOPLE WO
NEED IT AS OPPOSED TO SHOWERING
EVERYONE WITH MONEY WHICH WOULDE
NOTHING FOR A LOT OF PEOPLE ANDT
ENOUGH FOR PEOPLE WHO NEED IT.
SO I WOULD SAY WE WOULD GIVE MOO
FEWER PEOPLE.
>> WE BETTER STOP THERE.
THANK YOU ESTER.
CONGRATULATIONS AND THANK YOU FL
YOUR WORK.
>> THANK YOU.
[ APPLAUSE ]
>> I SHOULD ADD IN CONCLUSION TT
THERE ARE A LOT OF PEOPLE WHO WD
WORK WITH A LOT OF YOU.
SO PLEASE BE IN TOUCH.
>> IS THIS ON?
HELLO, EVERYONE.
I HAVE THE PLEASURE OF INTRODUCG
OUR NEXT KEYNOTE SPEAKER.
SO WE'VE HAD A WONDERFUL CONFERE
FOCUSED ON SOCIAL DETERMINANTS.
YOU JUST HEARD SOME CONVERSATION
ABOUT IT.
AND IT'S VERY APPROPRIATE THAT
DR. CRICK LUND IS GOING TO SPEAN
SOCIAL DETERMINANTS OF MENTAL H.
HE IS A CLINICAL PSYCHOLOGIST WH
THE APPOINTMENTS AT KING'S COLL,
LONDON AS WELL AS THE UNIVERSITF
CAPETOWN.
HIS SCHOLARSHIP SPANS WORK ON PY
ALLEVIATION AND LMICs,
STRENGTHENING MENTAL HEALTH SERS
AND SYSTEMS AND INTEGRATION OF L
HEALTH SERVICES WITH OTHER
NON-COMMUNICABLE DISEASES AS WES
MANY OTHER TOPICS.
SO HE HAS SERVED ON NUMEROUS EXT
ADVISORY BOARDS INCLUDING ONE FE
W.H.O.'S SOCIAL DETERMINANTS OF
HEALTH.
AND ALL AROUND I THINK HE'S AN N
INCREDIBLE SCIENTIST.
SO PLEASED HE IS HERE.
SO PLEASE JOIN ME IN WELCOMING
DR. LUND.
GOOD AFTERNOON, EVERYONE.
THANK YOU VERY MUCH FOR THE
INVITATION TO SPEAK.
IT IS A GREAT HONOR TO BE HERE
AND I A TOUGH ACT TO FOLLOW.
IT WAS WONDERFUL TO HEAR ESTER.
SO IT'S BEEN SUCH A PLEASURE
THIS LAST COUPLE OF DAYS
RECONNECTING WITH SO MANY OLD
FRIENDS AND REALLY GETTING A
SENSE OF HOW VIBRANT OUR GLOBAL
MENTAL HEALTH COMMUNITY IS.
AND TODAY MY TALK, I REALLY
WANTED TO TALK ABOUT HOW WE CAN
FURTHER DIVERSIFY SOME OF THE
WORK WE DO IN THE NAME OF GLOBAL
MENTAL HEALTH TO THINK ABOUT HOW
WE DESIGN INTERVENTIONS TO
ADDRESS THE SOCIAL DETERMINANTS
OF MENTAL HEALTH.
I THINK WE HAVE JUST HEARD VERY
ELOQUENTLY FROM ESTER ON THE
ENORMOUS WORK THEY HAVE DONE IN
CASH TRANSFERS AND POVERTY
ALLEVIATION PROGRAMS AND HOW
THEY ARE STARTING TO INVESTIGATE
THE MENTAL HEALTH IMPACTS OF
SOME OF THESE PROGRAMS.
AND I THINK THERE IS AN
OPPORTUNITY TO MEET SOMEWHERE IN
THE MIDDLE HERE WHERE THOSE OF
US IN WORKING IN GLOBAL MENTAL
HEALTH CAN PERHAPS BE DOING MORE
TO EVALUATE INTERVENTIONS TO
ADDRESS THE SOCIAL AND ECONOMIC
ADVERSITIES THAT DRIVE MENTAL
HEALTH PROBLEMS IN OUR
POPULATIONS.
SO THAT IS THE FOCUS OF MY TALK
TODAY.
HERE IS AN OUTLINE.
I'M GOING TO START OFF BY
TELLING YOU A STORY OF ONE
INDIVIDUAL TO GIVE YOU A SENSE
OF HOW THESE SOCIAL AND ECONOMIC
DRIVERS INFLUENCE THE MENTAL
HEALTH OF INDIVIDUALS.
AND THEN I'LL SHARE A FRAMEWORK
THAT WE DEVELOPED FOR THE SOCIAL
DETERMINANTS OF MENTAL HEALTH AS
PART OF THE COMMISSION ON GLOBAL
MENTAL HEALTH AND SUSTAINABLE
DEVELOPMENT IN 2018.
AND THEN TALK A LITTLE BIT ABOUT
HOW WE CAN POTENTIALLY GO ABOUT
INTERVENING TO ADDRESS SOME OF
THESE SOCIAL DETERMINANTS.
I'LL TOUCH ON SOME OF THE
CHALLENGES IN THIS FIELD BUT
ALSO WHAT I THINK ARE SOME
REALLY EXCITING OPPORTUNITIES
AND POTENTIAL APPROACHES AND
I'LL ILLUSTRATE THIS WITH SOME
EXAMPLES OF CURRENT WORK WE ARE
INVOLVED IN.
AND THROUGH THE CHANCE PROJECT.
AND I'LL SHARE WITH YOU SOME
IDEAS FOR RESEARCH PRIORITIES
GOING FORWARD AND SOME OF THE
POLICY CHALLENGES THAT THIS
BROADENED RESEARCH AGENDA NOW
OPENS UP FOR US.
SO THESE PICTURES ARE TAKEN FROM
A LARGE TOWNSHIP SETTLEMENT ON
THE OUTSKIRTS OF CAPETOWN ABOUT
20 KILOMETERS FROM WHERE I LIVE
AND WORK.
AND WE CONDUCTED A RANDOMIZED
CONTROL TRIAL HERE FROM
2011-2016.
WE WERE EVALUATING THE
EFFECTIVENESS OF A TASK-SHARING
PSYCHOLOGICAL COUNSELING
INTERVENTION DELIVERED BY
COMMUNITY HEALTH WORKERS FOR
PERINATAL DEPRESSION.
NOW AS PART OF THIS WORK, WE
CONDUCTED A LOT OF FORMATIVE,
QUALITATIVE RESEARCH ASKING
ANTI-NATAL AND POSTNATAL WOMEN
ABOUT THEIR EXPERIENCE OF
DEPRESSION.
AND WE APPROACHED WOMEN LIKE
THIS WOMAN, WHO WE SHALL CALL
MANDY TO DESCRIBE WHAT THE TERMS
THEY USED TO UNDERSTAND
DEPRESSION BUT ALSO WHAT DID
THEY THINK WERE SOME OF THE MAIN
CAUSES OF DEPRESSION IN THEIR
LIVES.
THE STORIES THAT CAME OUT HAD
ILLUSTRATIONS OF A WHOLE RANGE
OF SOCIAL AND ECONOMIC
ADVERSITIES.
INADEQUATE WATER AND SANITATION.
POOR HOUSING, AS YOU CAN SEE
FROM THESE IMAGES, HIGH LEVELS
OF INEQUALITY WITH SOUTH AFRICA
BEING ONE OF THE MOST UNEQUAL
COUNTRIES IN THE WORLD.
VIOLENCE, GENDER-BASED VIOLENCE
ENDEMIC FROM THIS COMMUNITY.
HIGH LEVELS OF FOOD INSECURITY.
VERY HIGH UNEMPLOYMENT RATES.
AND ALSO MIGRATION, MANY WOMEN
HAD MIGRATED FROM THE RURALLINE
CAPE TO THE WESTERN CAPE TO
CAPETOWN IN SEARCH OF WORK AND
THINGS HAD NOT WORKED OUT FOR
THEM AS WELL AS THEY HAD HOPED
THEY MIGHT.
IT WAS VERY DIFFICULT TO
DISENTANGLE IN USING WESTERN
DIAGNOSTIC TOOLS IDENTIFY AS
DEPRESSION FROM EVERY SOCIAL AND
ECONOMIC ADVERSITY.
WHY COULDN'T BE BE DOING MORE TO
ADDRESS THE SOCIAL AND ECONOMIC
DETERMINANTS AS A WAY OF
PREVENTING AND POTENTIALLY
TREATING DEPRESSION.
AND SO, IF WE LOOK AT THE
EPIDEMIOLOGICAL EVIDENCE IT
SUPPORTS HER EXPERIENCE.
THIS IS DATA FROM A LARGE
SYSTEMATIC REVIEW WE PUBLISHED
IN 2010 LOOKING AT THE
ASSOCIATIONS BETWEEN POVERTY AND
COMMON MENTAL DISORDERS,
DEPRESSION AND ANXIETY AND
DISORDERS IN LOW AND
MIDDLE-INCOME COUNTRIES.
WE INCLUDED 115 STUDIES IN THIS
REVIEW AND THERE WAS 76
COMMUNITY-BASED STUDIES.
THE VAST MAJORITY SHOWED A
STATISTICALLY SIGNIFICANT
ASSOCIATION BETWEEN DIVERSE
MEASURES OF POVERTY AND COMMON
MENTAL DISORDERS.
POVERTY WAS STRONGLY ASSOCIATED
WITH HIGHER RATES OF COMMON
MENTAL DISORDERS ACROSS AGE
RANGES IN RURAL AND URBAN AREAS.
IT WAS ASSOCIATED WITH INCREASED
PREVALENCE, INCREASED SEVERITY,
LONGER COURSE AND WORSE OUTCOME.
REALLY QUITE A COMPELLING CASE
THAT POVERTY AND COMMON MENTAL
DISORDERS WERE VERY STRONGLY
ASSOCIATED.
AND THIS ASSOCIATION WAS EVEN
STRONGER IN THE CASE OF STUDIES
THAT DID MULTIVARIATE ANALYSIS.
SO A LOT OF THOSE EARLY DATA
WERE CROSS SECTIONAL IN NATURE
AND IT'S VERY DIFFICULT TO
DISENTANGLE WHICH COMES FIRST.
ARE PEOPLE DEPRESS BECAUSE THEY
ARE POOR OR POOR BECAUSE THEY
ARE DEPRESSED?
FROM RECENT WORK, AND THIS IS A
PAPER PUBLISHED IN SCIENCE.
MORE EVIDENCE ABOUT THESE CAUSAL
MECHANISMS LINKING POVERTY AND
MENTAL HEALTH.
AND ESSENTIALLY, THE
RELATIONSHIP IS BIDIRECTIONAL.
SO ON THE ONE HAND WE HAVE WHAT
IS OFTEN REFERRED TO AS THE
SOCIAL CAUSATION PATHWAY BY
WHICH LIVING IN CIRCUMSTANCES OF
POVERTY CAUSES MENTAL ILLNESS
THROUGH A NUMBER OF MECHANISMS.
THESE INCLUDE WORRIES AND
UNCERTAINTY, ENVIRONMENTAL
FACTORS, PHYSICAL HEALTH
PROBLEMS, WHICH ARE MORE
PREVALENT AMONG POORER
COMMUNITIES AND CO-MORBID MENTAL
HEALTH CONSEQUENCES.
EARLY LIFE CONDITIONS AND
EXPOSURES, TRAUMA, VIOLENCE AND
CRIME AND SOCIAL STATUS, SHAME
AND ISOLATION ALL DRIVE AN
INCREASED RISK FOR A RANGE OF
MENTAL HEALTH PROBLEMS, IN
PARTICULAR DEPRESSION AND
ANXIETY.
BUT THE RELATIONSHIP ALSO WORKS
IN THE OTHER DIRECTION AND THIS
IS OFTEN WHAT IS REFERRED TO AS
THE SOCIAL DRIFT PATHWAY.
SO LIVING WITH A MENTAL ILLNESS
IMPEDES ONE'S COGNITIVE
FUNCTIONING.
IT HAS AN EFFECT ON ONE'S
BELIEFS ABOUT ONE'S SELF AND THE
FUTURE.
IT HAS AN IMPACT ON YOUR
PREFERENCES ESPECIALLY YOUR
TIME-RELATED PREFERENCES.
THE DISABILITY ASSOCIATED LIVING
WITH A MENTAL ILLNESS HAS
IMPACTS ON LABOR SUPPLY AND
PRODUCTIVITY.
STIGMA OF LIVING WITH A
ILLNESS EXCLUDES YOU FROM
INCOME-GENERATING OPPORTUNITIES.
AND ONE TENDS TO SPEND MORE ON
HEALTH CARE GENERALLY, NOT JUST
MENTAL HEALTH WHEN YOU'RE LIVING
WITH A MENTAL ILLNESS.
AND WOMEN'S EMPOWERMENT IS
PARTICULARLY AFFECTED BY A
MENTAL ILLNESS AND
INTERGENERATIONAL EFFECTS.
IT'S QUITE STRONG AND EMERGING
EVIDENCE THAT LIVING WITH A
MENTAL ILLNESS HAS IMPACT ON
IMPOVERISHING THE NEXT
GENERATION.
SO THESE REALITIES OF THE SOCIAL
DETERMINANTS OF MENTAL HEALTH
ARE GETTING INCREASING
INTERNATIONAL RECOGNITION.
THERE HAVE BEEN A NUMBER OF
LANDMARK REPORTS INCLUDING
COMING OUT OF THE W.H.O.
COMMISSION ON THE SOCIAL
DETERMINANTS OF HEALTH, WHICH
INCLUDED A CHAPTER ON MENTAL
HEALTH.
THERE WAS THE W.H.O. MENTAL
HEALTH AND DEVELOPMENT REPORT IN
2010 AND THIS REPORT BY THE
FOUNDATION AND W.H.O. PUBLISHED
ON THE SOCIAL DETERMINANTS OF
MENTAL HEALTH IN 2014.
SO WHAT DO WE MEAN BY SOCIAL
DETERMINANTS?
I THINK IT'S IMPORTANT TO GET
SOME OF THE CONCEPTUAL BUILDING
BLOCKS RIGHT HERE.
THIS IS A DEFINITION THAT WE
DEVELOPED AS PART OF THE
COMMISSION ON GLOBAL MENTAL
HEALTH AND SUSTAINABLE
DEVELOPMENT IN 2018.
AND WE SAID, SOCIAL DETERMINANTS
REFER TO THE SOCIAL AND ECONOMIC
CONDITIONS THAT HAVE A DIRECT
PREVELANCE AND SEVERITY OF
MENTAL DISORDERS IN MALES AND
FEMALES ACROSS THE LIFE COURSE.
AND THREE REALLY IMPORTANT
ASPECTS.
FIRST OF ALL THE STRUCTURAL
SOCIAL AND ECONOMIC ARRANGEMENTS
WHICH CONFER ADVANTAGE OR
DISADVANTAGE ON SOME.
THE DIFFERENTIAL EXPOSURE TO
ADVERSE LIFE EVENTS, WHICH IS
OFTEN QUITE STRONGLY ASSOCIATED
WITH WHERE YOU ARE POSITIONED
SOCIALLY AND ECONOMICALLY.
AND OFTEN THE SPECIFIC
CONDITIONS OF VULNERABILITY OR
RESILIENCE THAT THE COMBINATION
OF THESE ARRANGEMENTS AND
EXPOSURES PRODUCE.
SO QUITE ROBUST EVIDENCE NOW
THAT THE EFFECTS OF SOCIAL AND
ECONOMIC ADVERSITY ON
DEPRESSION, FOR EXAMPLE, IS
EXACERBATED BY THE INCREASED
RISK FOR MORE SEVERE AND MORE
FREQUENT ADVERSE LIFE EVENTS.
THESE ARE VERY CLOSELY
INTERTWINED.
AS PART OF THIS WORK, WE
DEVELOPED A FRAMEWORK TO REALLY
TRY TO MAKE SENSE OF THE COMPLEX
ARRAY OF SOCIAL AND ECONOMIC
FACTORS THAT HAVE A BEARING ON
THE MENTAL HEALTH OF
POPULATIONS.
WHAT WE DID WAS, WE CONDUCTED A
LARGE SYSTEMATIC VIEW OF
REVIEWS.
AND THERE WERE 289 VIEWS
INCLUDED IN OUR REVIEW.
AND WE TOOK THE DATA AND WE
TRIED TO MAKE SENSE OF IT IN
TERMS OF FIVE MAIN DOMAINS.
SO THERE IS THE DEMOGRAPHIC
DOMAIN, THE ECONOMIC DOMAIN, THE
NEIGHBORHOOD DOMAIN WHICH REFERS
TO THE CHARACTERISTICS OF THE
NEIGHBORHOOD OR THE COMMUNITY IN
WHICH YOU LIVE OVER AND ABOVE
THE CHARACTERISTICS OF THE
INDIVIDUALS WHO LIVE IN THAT
NEIGHBORHOOD.
THE ENVIRONMENTAL EVENTS DOMAIN,
WHICH INCLUDES THE NATURAL
DISASTERS, WAR AND CONFLICT,
CLIMATE CHANGE AND SO ON.
AND THEN THE SOCIAL AND CULTURAL
DOMAIN.
AND EACH OF THESE DOMAINS SOCIAL
DETERMINANTS EXERT INFLUENCE ON
MENTAL HEALTH THROUGHOUT THE
LIFE COURSE THROUGH A
COMBINATION OF DISTAL AND MORE
PROXIMAL FACTORS.
SO FOR EXAMPLE, IF WE TAKE THE
ECONOMIC DOMAIN, THE EFFECT OF
ECONOMIC RECESSIONS SUCH AS THAT
ASSOCIATED WITH COVID, EXERTS
INFLUENCE ON THE MENTAL HEALTH
OF INDIVIDUALS THROUGH THEIR
EXPERIENCE OF REDUCED INCOME OR
UNPREDICTABLE INCOME, INCREASED
DEBT, ERODED ASSETS, FINANCIAL
STRAIN AND SO ON.
AND VERY IMPORTANTLY, THESE
SOCIAL AND ECONOMIC FACTORS
INTERACT WITH A RANGE OF GENETIC
RISK FACTORS TO PRODUCE MENTAL
HEALTH RESILIENCE OR MENTAL
HEALTH CONDITIONS OVER THE LIFE
COURSE.
AND CRITICALLY, THERE ARE
IMPORTANT DEVELOPMENTAL LIFE
STAGES, FOR EXAMPLE, DURING THE
PERINATAL PERIOD, EARLY INFANCY,
ADOLESCENCE AND OLD AGE.
IN WHICH THESE EFFECTS OF THESE
SOCIAL DETERMINANTS BECOME
PARTICULARLY EXAGGERATED.
AND ALL OF THIS IS EVEN MORE
RELEVANT IN THE COVID ERA.
WE HAVE SEEN 71 TO 100 MILLION
PEOPLE DRIVEN INTO EXTREME
POVERTY ACCORDING TO WORLD BANK
ESTIMATES.
WIDENING INCOME AND INEQUALITY
WITH INCREASING RESOURCES
CONCENTRATED IN THE HANDS OF A
SMALLER AND SMALLER MINORITY OF
THE WORLD'S POPULATION.
INCREASED FOOD INSECURITY AND
INCREASED GENDER-BASED VIOLENCE.
THESE ARE KNOWN RISK FACTORS.
COVID ACTED LIKE A PRESSURE
COOKER TO EXACERBATE THE EFFECTS
OF THESE SOCIAL DETERMINANTS ON
MENTAL HEALTH.
AND ONE CONSEQUENCE WAS, WE SAW
DURING THE PANDEMIC A 25%
INCREASE IN THE GLOBAL
PREVALENCE OF ANXIETY DISORDERS
DURING THE PANDEMIC.
SO IT'S CLEAR THIS IS A COMPLEX
PICTURE AS YOU CAN SEE, THERE IS
A LOT OF HETEROGENEITY ACROSS
COUNTRIES AROUND THE WORLD BUT
THE SOCIAL AND ECONOMIC DRIVERS
ARE ALREADY VERY, VERY IMPORTANT
IN THIS PICTURE.
SO THIS THEN BRINGS OR BEGS THE
QUESTION AND BRINGS ME TO THE
MAIN FOCUS OF MY TALK TODAY
WHICH IS REALLY HOW DO WE GO
ABOUT INTERVENING TO ADDRESS
THESE SOCIAL DETERMINANTS?
ISN'T THERE MORE WE COULD BE
DOING TO TRY TO ADDRESS SOME OF
THESE UPSTREAM DRIVERS AND
EXAMINE THEIR MENTAL HEALTH
IMPACTS?
JUST BEFORE THE COVID PANDEMIC
BROKE IN 2020, EARLY 2020, THERE
WAS A MEETING CONVENED BY THE
ACADEMY OF MEDICAL SCIENCES AND
THE INTERACADEMY PARTNERSHIP ON
THE SOCIAL DETERMINANTS OF
MENTAL HEALTH.
WE MENTIONED LONDON IN
OCTOBER/NOVEMBER OF 2019.
AND THE TASK THAT WE PUT TO THE
GROUP WAS REPRESENTING AROUND 21
LOW AND MIDDLE-INCOME COUNTRIES
RECRUITED THROUGH THE ECONOMIES
OF SCIENCE AND NETWORKS.
IT WAS TO TRY TO COME UP WITH
IDEAS AROUND POTENTIAL
INTERVENTIONS AND WE USED THE
SAME FRAMEWORK.
WE USED THE FIVE DOMAINS,
DEMOGRAPHIC, ECONOMIC,
NEIGHBORHOOD, ENVIRONMENTAL
EVENTS AND SOCIAL AND CULTURAL
DOMAINS.
AND WE ASKED THE GROUP TO COME
UP WITH IDEAS AROUND FIRST OF
ALL, RESEARCH PRIORITIES FOR
EACH OF THESE DOMAINS, AND
PARTICULARLY WHAT ARE THE
POTENTIAL CANDIDATE
INTERVENTIONS BASED ON THE
EVIDENCE THAT WE CURRENTLY HAVE,
WHICH COULD HAVE A SUBSTANTIAL
POPULATION IMPACT.
AND THESE ARE SOME OF THE IDEAS
THAT THE GROUP CAME UP WITH.
IN THE DEMOGRAPHIC DOMAIN,
REDUCED GENDER-BASED VIOLENCE IS
AN OBVIOUS CANDIDATE.
REDUCED CHILD MILD TREATMENT IS
LONG HANGING FRUIT TO HAVE
SUBSTANTIAL POPULATION LEVEL
IMPACTS.
IN THE ECONOMIC DOMAIN, SOCIAL
PROTECTION PROGRAMS LIKE CASH
TRANSFERS.
IN THE NEIGHBORHOOD DOMAIN,
URBAN RENEWAL PROGRAMS.
IN THE ENVIRONMENTAL AND EVENTS
DOMAIN, IMPROVE DISASTER
RESPONSIVENESS AND MITIGATING
THE EFFECTS OF CLIMATE CHANGE
AND IN THE SOCIAL AND CULTURAL
DOMAIN, INTERVENTIONS THAT BUILD
SOCIAL CAPITAL AND TRUST AND
STRENGTHEN EDUCATION.
EDUCATION IS A MAJOR PREDICTOR
OF LIFELONG MENTAL HEALTH.
AND SO FAR THERE SEEMS TO BE
QUITE ENCOURAGING EVIDENCE THAT
SOME OF THESE INTERVENTIONS
REALLY DO WORK AND DO HAVE
MENTAL HEALTH BENEFITS.
IT WAS INTERESTING TO HEAR ESTER
SPEAKING ABOUT THIS EARLIER ON.
THIS IS A LARGE SYSTEMATIC
REVIEW OF META-ANALYSIS THAT WAS
PUBLISHED IN NATURE HUMAN
BEHAVIOR JUST A YEAR AGO BY JOHN
McGUIRE AND COLLEAGUES.
AND THEY SHOWED REALLY QUITE A
COMPELLING PICTURE THAT CASH
TRANSFERS IN LOW AND
MIDDLE-INCOME COUNTRIES HAD AN
EFFECT SIZE OF .13 ON SUBJECT
WELL-BEING OUTCOMES AND .07 ON
MENTAL HEALTH OUTCOMES.
SO THESE MAY NOT BE BIG EFFECT
SIZES THAT WE ARE THINKING ABOUT
CLINICAL TRIALS BUT IF WE THINK
ABOUT THE POTENTIAL FOR
POPULATION-LEVEL IMPACT, IT
REALLY IS MASSIVE.
AND THERE IS A LOT THAT COULD BE
DONE TO THINK ABOUT HOW THESE
COULD BE POTENTIATED TO TRY TO
IMPROVE MENTAL HEALTH OUTCOMES.
SO FAR SO GOOD.
WE KNOW A LOT ABOUT THE SOCIAL
AND ECONOMIC DRIVERS OF MENTAL
HEALTH.
WE THINK THERE IS SOMETHING WE
COULD POTENTIALLY BE DOING TO
DEVELOP INTERVENTIONS TO ADDRESS
THOSE SOCIAL DETERMINANTS.
BUT WHEN WE START TO THINK ABOUT
HOW WE COULD DESIGN AND EVALUATE
THESE INTERVENTIONS, SOME QUITE
MAJOR CHALLENGES EMERGE.
THE FIRST IS THAT THE
INTERVENTIONS THAT WE TRY TO
MOUNT ARE OFTEN QUITE DISTAL TO
THE MENTAL HEALTH OUTCOME.
IF WE WERE TO LAUNCH URBAN
RENEWAL PROGRAM TO IMPROVE
HOUSING IN INFORMAL SETTLEMENTS,
THERE ARE A NUMBER OF VARIABLES
MAY IMPACT ON THE OUTCOME AND
THAT WE HOPE TO ACHIEVE.
SECONDLY AND RELATED TO THIS,
THE MECHANISMS BY WHICH THESE
SOCIAL INTERVENTIONS INFLUENCE
MENTAL HEALTH ARE ALREADY POORLY
UNDERSTOOD.
WE DON'T REALLY KNOW HOW CASH
TRANSFERS GET INTO THE
NEUROPATHWAYS OF THE BRAIN TO
REDUCE DEPRESSION AND ANXIETY
AMONG PEOPLE.
THIRDLY, AND I'M GLAD SOMEONE
RAISED THIS IN THE PREVIOUS
SESSION.
THESE ARE OFTEN COMPLEX
POLITICAL AND STRUCTURAL
CHALLENGES.
IT'S OFTEN VERY DIFFICULT TO
BRING ABOUT SUBSTANTIAL CHANGES.
FOURTH, WE OFTEN WILL NEED
INTERDISCIPLINARY APPROACHES.
OFTEN WITHIN MENTAL HEALTH WE
WORK WITHIN OUR OWN SILOS.
IF WE WANT TO DESIGN EFFECTIVE
SOCIAL POLICY INTERVENTIONS WE
NEED TO WORK ACROSS A NUMBER OF
DIFFERENT SECTORS INCLUDING A
VERY PROACTIVE WAY AND LIVED
EXPERIENCE.
THE EVALUATION OF THE MENTAL
HEALTH OUTCOMES AND VALIDATION
OF MENTAL HEALTH OUTCOME
MEASURES HASN'T REALLY KEPT PACE
AND THERE IS A BIG GAP THERE.
THERE ARE REALLY IMPORTANT
CHALLENGES AROUND WHO GETS TO BE
IN THE CONTROL GROUP AND HOW DO
YOU DENY PEOPLE IN THE CONTROL
GROUP AND INTERVENTION WHERE
THERE IS A CLEAR NEED FOR THAT?
FOR EXAMPLE IN THE CASE OF CASH
TRANSFERS OR FOOD SECURITY
INTERVENTIONS.
AND FINALLY, THIS FIELD REALLY
PRESENTS A NUMBER OF NEW
CHALLENGES TO RESEARCH FUNDERS.
IT REQUIRES FUNDERS TO GET OUT
OF THEIR DISCIPLINARY SILOS TO
THINK IN A MUCH MORE
INTERDISCIPLINARY WAY AND TO
CONVENE INTERDISCIPLINARY REVIEW
PANELS TO BE ABLE TO ASSIST
FUNDING APPLICATIONS.
HAVING SAID ALL OF THAT, I THINK
THERE ARE A NUMBER OF QUITE
EXCITING POTENTIAL APPROACHES,
AND I WANT TO RUN YOU THROUGH
SOME INITIAL IDEAS.
I PUT THESE TOGETHER IN A PAPER
WHICH WE JUST RECENTLY PUBLISHED
IN BEHAVIORAL RESEARCH THERAPY.
IF YOU WANT TO READ MORE, PLEASE
HAVE A LOOK AT THAT PAPER AND I
WOULD BE INTERESTED TO HEAR YOUR
THOUGHTS.
I THINK THE FIRST STEP IS TO TRY
AND BUILD MORE ROBUST
THEORETICAL MODELS OF HOW WE
THINK PARTICULAR SOCIAL AND
ECONOMIC ADVERSITIES LEAD TO
PARTICULAR MENTAL HEALTH
OUTCOMES.
AND TO REALLY TRY AND DEVELOP
VERY CLEARLY IDENTIFIED CAUSAL
MECHANISMS.
THE SECOND STEP IS THEN TO TEST
THESE SPECIFIC MECHANISMS IN
THESE HYPOTHESIZED CAUSAL
PATHWAYS AND TO INCLUDE THESE
MEDIATION ANALYSIS IN THE DESIGN
OF OUR TRIALS.
AND THE THIRD IS TO POOL DATA
ACROSS MULTIPLE SITES BECAUSE
CONTEXT REALLY MATTERS AND HAS
HUGE IMPACT ON THESE KINDS OF
INTERVENTIONS ON HOW WE DELIVER
THEM AND MEASURE THEIR IMPACTS.
SO LET ME TRY TO UNPACK THIS A
THE CURRENT PROJECT I'M GOING TL
YOU MORE ABOUT IN A MOMENT.
THIS IS ABOUT THE LINKS BETWEEN
POVERTY AND SELF-REGULATION.
SO ELIAS AND HANSON GO THROUGH A
PROCESS OF REVIEWING THE LITERAE
IN SELF-REGULATION, INCLUDING
REACTIONIVE SIGNALS AND SAILIANT
EVALUATION, INTERPRETATION, STIS
GENERALIZATION AND CONTEXTURAL
PROCESSING AS WELL AS MORE TOP-N
ELEMENTS OF CONTROL FOR EXAMPLE
DECISION-MAKING, EMOTIONAL REGUN
AND EXECUTIVE ATTENTION.
AND THEN MAP SOME OF THE
NEUROCORRELATES OF THESE PATHWAD
ALSO MAPPED THE WAY IN WHICH THE
DIFFERENT TOP-DOWN AND BOTTOM-UP
MECHANISMS ARE IMPACTED BY POVEY
AND IN TURN HOW THEY PREDICT VAS
FORMS OF PSYCHOPATHOLOGY.
THIS IS HELPFUL FOR US TO THINKT
HOW TO TEST THESE MECHANISMS.
SO IF FOR EXAMPLE, WE WERE TO DN
AN INTERVENTION TO DELIVER CASH
TRANSFERS FOR REFUGEE YOUTH, ANE
WANTED TO ACHIEVE AN OUTCOME OF
PREVENTING DEPRESSION, WE COULD
POTENTIALLY HYPOTHESIZED THAT
NEUROPSYCHOLOGICAL MECHANISMS OF
SELF-REGULATION ARE LYING ALONGS
CAUSAL PATHWAY.
BUT IF WE REALLY WANTED TO TEST
WHETHER THERE ARE INVOLVED
MECHANISTICALLY, WE NEED TO INCE
THIS KIND OF MEDIATION ANALYSISN
THE TRIALS THAT WE CONDUCT.
FOR EXAMPLE, IN SOME OF THESE PS
COME FROM WORK THAT WAS DONE ON
PSYCHOTHERAPY TRIALS.
WE NEED TO FIRST OF ALL HAVE A
TEMPORAL RELATIONSHIP BETWEEN TE
MEDIATOR AND THE OUTCOME AND BEN
THE EXPOSURE AND THE MEDIATOR.
THERE NEEDS TO BE A CLEAR DOSE
RESPONSE ASSOCIATION BETWEEN THE
MEDIATOR AND THE OUTCOME THAT WE
MEASURING.
WE NEED TO CONTROL FOR THIRD
VARIABLES IN THE RELATIONSHIP BH
BETWEEN THE INTERVENTION AND THE
MEDIATOR AND IN TURN BETWEEN THE
MEDIATOR AND THE OUTCOME.
AND WE NEED TO HAVE ROBUST
EXPERIMENTAL DESIGNS.
WE NEED TO BE ADEQUATELY POWEREO
BE ABLE TO MEASURE THESE EFFECTD
FINALLY, WE NEED TO HAVE A STROG
THEORETICAL FRAMEWORK WHICH UNDS
ALL OF THIS.
SO THIS GIVES US SOME POTENTIALS
ABOUT WHERE WE CAN DEVELOP TARGO
STRENGTHEN THE IMPACTS OF
INTERVENTIONS THAT ARE ADDRESSED
UPSTREAM SOCIAL AND ECONOMIC
DETERMINANTS.
AND THEN OF COURSE IT'S REALLY
IMPORTANT THAT WE POOL AND SHARA
AS FAR AS POSSIBLE.
IT REQUIRES A HIGH LEVEL OF CONS
BETWEEN RESEARCH GROUPS ON PLAUE
PATHWAYS AND MEASURES.
REALLY INSPIRING TO HEAR ESTER
SPEAKING ABOUT THE NETWORK.
I THINK THERE IS ENORMOUS POTENL
FOR US TO DEVELOP NETWORKS WITHR
GLOBAL MENTAL HEALTH GROUPS AROD
POOLING DATA ON INTERVENTIONS TO
ADDRESS SOCIAL DETERMINANTS.
AND THE THIS MEANS ALSO A HIGH L
OF COOPERATION ACROSS SCIENCE
INTERNATIONALLY.
CONTEXT REALLY MATTERS AND
INTERDISCIPLINARY IS REALLY
IMPORTANT.
THIS THEN RAISES THE QUESTION, H
SOCIAL DETERMINANTS SHOULD I TAT
IF I'M THINKING ABOUT THE WHOLE
PLETHORA OF POTENTIAL TARGET
INTERVENTIONS?
HERE ARE SOME POTENTIAL CRITERIR
CONSIDERATION.
FIRST OF ALL IT'S REALLY IMPORTT
THAT THERE IS A PLAUSIBLE MECHA.
WE NEED TO BE ABLE TO HAVE A ROT
CASE FOR WHY WE THINK A PARTICUR
INTERVENTION MIGHT YIELD A PARTR
MENTAL HEALTH OUTCOME.
SECONDLY, IT NEEDS TO BE FEASIBO
INTERVENE AND WE NEED GOOD COMMY
PARTICIPATION AND BUY IN FROM PY
STAKEHOLDERS TO MAKE THAT POSSI.
THIRD THERE SHOULD BE A MEASURAE
OUTCOME AND THE OUTCOME SHOULD E
VALID, CULTURALLY VALID AND REL.
AND THERE NEEDS TO BE THE POTENL
FOR SUBSTANTIAL POPULATION IMPA.
OUR FINDINGS SHOULD BE GENERALIE
AND SUSTAINABLE.
I WANT TO SHARE WITH YOU A COUPF
EXAMPLES OF STUDIES WE ARE INVOD
IN AT THE MOMENT WHICH I HOPE WL
ILLUSTRATE SOME OF THESE POTENTL
APPROACHES.
THE FIRST IS THE CHANCE OF 6 ST.
THIS IS LED BY SARAH EVANS VAS T
THE LONDON SCHOOL OF ECONOMICS.
AND WE HAVE BEEN EXPLORING THE
EFFECTS OF CASH TRANSFERS ON MEL
HEALTH AND LIFE CHANCES OF YOUNG
PEOPLE IN SIX LOW AND MIDDLE-INE
COUNTRIES.
SO BRAZIL, COLUMBIA, MEXICO, LI,
MALAWI AND SOUTH AFRICA.
AND WE ARE USING EXISTING COHORT
DATASETS.
NOT ALL ARE RANDOMIZED CONTROL
TRIALS.
WE TRIED TO USE OTHER METHODS LE
INSTRUMENTAL VARIABLE ANALYSIS D
REGRESSION CONTINUOUS DESIGNS TY
TO CONTROL FOR CONFOUNDING.
AND OUR APPROACH WAS TO REALLY A
COMBINATION OF QUALITATIVE WORKE
CONDUCTED INTERVIEWS AND FOCUS P
DISCUSSIONS WITH YOUNG PEOPLE, H
FAMILIES IN RECEIPT OF CASH TRAR
PROGRAMS, WITH PROFESSIONALS IND
IN ADMINISTERING THESE CASH TRAR
PROGRAMS.
WE DID QUANTITATIVE ANALYSIS ASI
MENTIONED, OF EXISTING LONGITUDL
DATASETS.
AND WE CONDUCTED STAKEHOLDER
WORKSHOPS WITH POLICYMAKERS IN E
OF THE COUNTRIES TO GET A SENSEF
SOME OF THE POLICY OPTIONS AND E
APPETITE FOR ASSESSING MENTAL HH
OUTCOMES OF CASH TRANSFER PROGRS
AND WHETHER THESE COULD BE ENHAD
IN SOME WAY.
AND THE WORK IS ONGOING.
WE HAVEN'T PUBLISHED ALL THE FIS
YET.
WHAT WE TRIED TO DO IS IDENTIFYE
POTENTIAL MECHANISMS BY WHICH CH
TRANSFERS AS FAR AS THESE PROGRS
ARE CONCERNED, YIELD MENTAL HEAH
OUTCOMES AND HOW THE EFFECTS OFE
CASH TRANSFER PROGRAMS COULD BE
POTENTIATED TO IMPROVE THE MENTL
HEALTH AND LIFE CHANCES OF YOUNG
PEOPLE IN THESE SETTINGS.
THE SECOND EXAMPLE I WANT TO THE
SHARE WITH IS A WELCOME TRUST FD
COLLABORATIVE AWARD, CALLED ALI.
IMPROVING ADOLESCENT MENTAL HEAY
REDUCING THE IMPACT OF POVERTY.
AND WE ARE WORKING IN COLUMBIA D
SOUTH AFRICA AND IN NEPAL.
AND WE CONCENTRATING IN CIRCUMSS
OF URBAN POVERTY.
SO WORKING IN BOGOTA AND COLUMB,
CAPETOWN IN SOUTH AFRICA AND
KATHMANDU IN NEPAL.
MARK JORDANS IS CO-PI OF THIS PT
TOGETHER WITH MYSELF.
AND OUR MAIN HYPOTHESIS IS
MULTIDIMENSIONAL POVERTY INCREAS
THE INCIDENCE OF DEPRESSION AND
ANXIETY AMONG ADOLESCENTS DIRECY
AND MEDIATED THROUGH SELF-REGUL.
AND BY SELF-REGULATION, WE MEANE
CAPACITY TO SET GOALS AND TO MAN
GOAL-DIRECTED BEHAVIOR DESPITE
EMOTIONALLY SALIENT AND CHALLENG
ENVIRONMENT.
SO WE DESIGNED AN INTERVENTION H
HAS AN ANTIPOVERTY COMPONENT TOR
WITH INTERVENTION WHICH HAS A
COMPONENT TO STRENGTHEN
SELF-REGULATION SKILLS AMONG
ADOLESCENTS.
AND THIS IS A ROUGH ILLUSTRATIOF
THE OVERALL STUDY DESIGN.
SO IMPORTANTLY HOOTS A PILOT
RANDOMIZED CONTROL TRIAL.
WE ARE NOT GOING TO BE ADEQUATEY
POWERED TO ASSIST THE IMPACT OFE
INTERVENTION.
THERE ARE ONLY 240 ADOLESCENTS N
EACH COUNTRY.
THE IDEA IS TO TEST THE FEASIBIY
AND ACCEPTABILITY OF THE INTERVN
AND THE FEASIBILITY AND ACCESSIY
OF THE INSTRUMENTATION WITH A VO
APPLY FOR A FULLY-POWERED RANDOD
CONTROL TRIAL.
SO LET ME JUST SEE IF I CAN WALU
THROUGH THE DESIGN HERE.
FROM LEFT TO RIGHT, WE ARE ASSEG
ADOLESCENTS FOR INCLUSION BASEDN
FIRST OF ALL, LIVING IN CIRCUMSS
OF MULTIDIMENSIONAL POVERTY IN H
OF THE THREE COUNTRIES.
AND SECONDLY, SCORING HIGH RISKN
THE IDEA RISK SCORE WHICH IS A
COMPOSITE RISK INDEX TO IDENTIFK
FOR DEPRESSION IN ADOLESCENTS.
WE WILL EXCLUDE ADOLESCENTS WHOE
ABOVE CATEGORICAL THRESHOLD ON E
PHQA OR GAD 7, IN OTHER WORDS TE
WHO ARE DEPRESSED OR ANXIOUS AT
BASELINE WILL BE EXCLUDED BECAUE
ARE INTERESTED IN INCIDENTS.
WE WANT TO MEASURE THE NUMBER OW
CASES OVER TIME.
AND WE ALSO EXCLUDE ADOLESCENTSO
ARE LOW RISK.
SO THE ONES WE ARE INTERESTED IE
THE GREEN FIGURES AND THEN WE WL
RANDOMIZE THEM TO ONE OF FOUR AS
AND IT'S A CLUSTER TRIAL SO THE
RANDOMIZATION IS SCHOOLS.
THE FIRST ARM WILL RECEIVE AN
ANTIPOVERTY INTERVENTION WHICH
INCLUDES CASH TRANSFERS, TWO-THS
OF WHICH WILL GO TO THE HOUSEHOD
1/3 OF WHICH WILL GO TO THE
ADOLESCENT THEMSELVES.
AND TOGETHER WITH THE CASH TRANS
WE ARE PROVIDING FINANCIAL EDUC,
INFORMATION ON NEGOTIATION SKILD
ALSO INFORMATION ON YOUR EARNINF
YOU STAY IN SCHOOL FOR LONGER
COMPARED TO IF YOU DROP OUT EAR.
SO THAT'S THE ANTIPOVERTY
INTERVENTION.
THE SECOND ARM IS A SELF-REGULAN
INTERVENTION WHICH IS A GROUP-BD
INTERVENTION.
ALL INTERVENTIONS ARE GROUP-BAS.
AND IT'S FACILITATED BY A YOUTH
COACH, SOMEONE BETWEEN THE AGE 8
AND 30 FROM THE SAME COMMUNITY T
THE ADOLESCENTS ARE LIVING IN.
IT STARTS WITH REALLY TRYING TOD
A CULTURE OF TRUST WITHIN THE G.
THE GROUPS ARE AROUND 15 ADOLESS
EACH.
AND THEN BASED ON EXPERIENCES OF
BUILDING TRUST AND DEVELOPING SL
COMMUNICATION SKILLS, WE ARE
INCLUDING SKILLS AROUND EMOTIONL
REGULATION AND PROBLEM-SOLVING.
AND THEN THE THIRD ARM IS TO COE
THE ANTIPOVERTY AND THE
SELF-REGULATION INTERVENTIONS.
AND THE FOURTH ARM IS A CONTROL.
SO AS I MENTIONED, PRIMARY OUTCS
THE INCIDENTS OF DEPRESSION OR
ANXIETY ACROSS THE STUDY ARMS AI
JUST WANTED TO GIVE YOU A SENSEF
THE MEASURES WE ARE USING BECAUT
GOES BACK TO MY POINT EARLIER AT
MEDIATORS.
THE PRIMARY OUTCOMES ARE DEPRESN
AND ANXIETY.
BUT WE'VE DEVELOPED A WHOLE LOTF
MEDIATOR MEASURES OR ADAPTED TH,
INCLUDING THE WHO THAT?
THE DIFFICULT IN EMOTION REGULAN
SCALE SHORT FORM, CHILD HOPE SC,
AND THEN SOME NEUROPSYCHOLOGICAL
TESTS.
THE BALLOON ANALOGUE RISK TAKING
TASK, THE EMOTION GO-NO-GO, ANDY
GRATIFICATION TASK.
WE ARE ALSO MEASURING HEART RATE
VARIABILITY AS A BIOMARKER.
AND THEN THERE ARE A NUMBER OF
SECONDARY OUTCOMES RELATED TO SP
AND SOCIAL AND ECONOMIC OUTCOMER
THE CHILDREN AND FOR THEIR PARE.
AND THIS IS THE WONDERFUL ALIVE.
THIS THE IS OUR MOST RECENT ANNL
MEETING IN BOGOTA IN MARCH OF TS
YEAR.
VERY MUCH ALIVE.
AND IT'S JUST -- THE OTHER REALY
EXCITING THING ABOUT THIS PROJES
BEEN THE VERY ACTIVE INVOLVEMENF
ADOLESCENTS IN THE PROCESS.
SO WE HAVE AN ADOLESCENT ADVISOY
GROUP IN EACH COUNTRY AND AS PAF
THE PROJECT, WE ARE EVALUATING E
PROCESS OF ADOLESCENTS BEING END
IN THE STUDY THEMSELVES AND
INFLUENCING THE DESIGN.
WE RUN THESE ADD LES ONLY ADVISY
GROUPS APPROXIMATELY EVERY TWO S
AND INCREDIBLY ENERGIZING AND
INFORMATIVE BOTH IN DESIGNING TE
INTERVENTION AND ALSO IN DESIGNG
OUR EVALUATION APPROACH.
SO, WHERE COULD THIS POTENTIALLD
IF WE WERE TO, AS A FIELD OF GLL
MENTAL HEALTH PRACTITIONERS DO E
WORK IN DESIGNING INTERVENTIONSO
ADDRESS SOCIAL DETERMINANTS?
WHAT ARE THE KINDS OF RESEARCH
QUESTIONS WE COULD BE POTENTIALY
EXPLORING?
I THINK THERE IS A LOT OF POTENL
TO DO MORE LONGITUDINAL
EPIDEMIOLOGICAL WORK.
THERE HAS BEEN VERY INTERESTING
WELCOME TRUST FUNDED LANDSCAPINF
LONGITUDINAL DATASETS RECENTLY I
THINK THERE IS A RICH DATA SOURE
THERE BUT THERE IS MORE WE COULE
DOING TO MEASURE THE
INTERGENERATIONAL TRANSMISSION F
POVERTY AND MENTAL ILLNESS TO EE
THE MECHANISMS OF POVERTY AND ML
HEALTH OVER TIME, AND ALSO VERY
IMPORTANTLY THE LINKS BETWEEN G,
POVERTY AND MENTAL HEALTH ACROSE
LIFE COURSE, INCLUDING GENETIC,
BIOLOGICAL AND SOCIOECONOMIC RIK
FACTORS BRINGING PEOPLE TOGETHEM
MULTIPLE DISCIPLINES.
SO THAT'S ON THE DESCRIPTIVE SI.
I ALSO THINK THERE IS ENORMOUS
POTENTIAL FOR US TO BE DOING MOE
INTERVENTION RESEARCH TO ADDRESS
PROXIMAL MECHANISMS LIKE CASH
TRANSFERS AND THINKING MORE ABOW
THEY CAN BE DESIGNED TO IMPROVEE
MENTAL HEALTH OUTCOMES OF PEOPLO
RECEIVE THEM.
BUT ALSO TARGETING MORE DISTAL
MECHANISM.
FOR EXAMPLE THE IMPACT OF LIVING
ENVIRONMENTS.
WE HAVE BEEN HEARING A LOT ABOUT
CLIMATE CHANGE AND MIGRATION.
WE ARE ALREADY ON THE THRESHOLDA
NEW ERA FOR US IN TERMS OF RISKA
RANGE OF SOCIAL AND ECONOMIC DRS
IN THE CONTEXT OF CLIMATE CHANGD
MIGRATION.
AND I THINK THERE IS A LOT MOREE
COULD BE DOING TO TRY AND IMPROR
RESILIENCE AND RESPONSIVENESS TO
THESE CIRCUMSTANCES.
AND THEN IN TERMS OF A POLICY A,
I THINK THIS DOES POTENTIALLY RA
WHOLE LOT OF NEW COMPLICATIONS R
US.
I THINK FOR MANY OF US, WE HAVEN
INVOLVED IN ADVOCATING FOR THE
SCALING UP OF MENTAL HEALTH SERS
BY GOVERNMENTS ESPECIALLY IN LOR
AND MIDDLE-INCOME COUNTRIES.
DONE A LOT OF WORK OF IMPROVINGE
EFFECTIVENESS OF THESE INTERVEN,
ESPECIALLY IN LOW-RESOURCE SETT.
IF WE ARE THINKING ABOUT THE BRR
AGENDA OF THE SOCIAL AND ECONOMC
DETERMINANTS, THIS MAKES IT A BR
POLICY AGENDA AS WELL.
SO, IT'S VERY EXCITING THAT GOAF
THE SUSTAINABLE DEVELOPMENT GOA,
MENTAL HEALTH IS NOT INCLUDED BF
WE ARE TAKING A SOCIAL DETERMINS
PERSPECTIVE, MANY OF THESE OTHEE
ALSO POTENTIALLY RELEVANT FOR ML
HEALTH.
AND THIS COMPLICATES THE POLICY
MESSAGE.
NOT JUST SIMPLE POLICY MESSAGE F
ADVOCATING FOR BETTER TREATMENTR
SCALING UP TREATMENTS.
IT'S ALSO POLICY MESSAGE OF HOWN
WE IMPROVE LIVING ENVIRONMENTS O
IMPROVE THE MENTAL HEALTH AND
WELL-BEING OF POPULATIONS AND
REDUCING INEQUITIES IN THE
DISTRIBUTION OF MENTAL HEALTH.
SO IN A SENSE, THE POLICY OPTIOS
COULD BE INVESTING IN MENTAL HEH
CARE OR INVESTING IN INTERVENTIS
THAT ARE ADDRESSED SOCIAL
DETERMINANTS OF MENTAL HEALTH AI
THINK I WOULD ARGUE VERY STRONGY
THAT WE NEED A VERY BROAD-BASEDE
OF SOCIETY APPROACH WITH
INTERVENTIONS THAT ADDRESS BOTHE
CAUSES AND THE CONSEQUENCES OF L
ILLNESS.
AND IN CASE WE NEED ANYMORE MORE
CONVINCING ABOUT THE IMPORTANCEF
MENTAL HEALTH CARE, THIS IS SOMA
FROM THE SYSTEMATIC REVIEW AND
META-ANALYSIS WE ARE HOPING TO
PUBLISH SOON.
WE LOOKED AT THE ECONOMIC IMPACF
39 RANDOMIZED CONTROL TRIALS WHE
ARE EVALUATING MENTAL HEALTH
INTERVENTIONS.
THESE INCLUDED A RANGE OF
PSYCHOSOCIAL AND PHARMACOLOGICAL
TRIALS AND WE FOUND QUITE SIGNIT
EFFECTS ON LABOR MARKET OUTCOMES
AROUND 1.6 STANDARD DEVIATION FR
PSYCHOSOCIAL INTERVENTIONS FOR N
MENTAL DISORDERS AND AROUND .3 O
STANDARD DEVIATIONS ON LABOR MAT
OUTCOMES FOR SEVERE MENTAL ILLN.
THIS THE IS COMPELLING ECONOMIC
REASONS TO INVEST MORE IN MENTAL
HEALTH.
I HOPE I'M CONVEYING, THIS IS NN
EITHER-OR SITUATION.
WE NEED TO ADDRESS SOCIAL
DETERMINANTS AND WE ALSO NEED TE
SCALING UP MENTAL HEALTH CARE AD
THAT REMAINS VERY MUCH UNFINISHD
BUSINESS.
INTERESTINGLY, ON THE RIGHT HERU
CAN SEE THIS IS SOME ANALYSIS AI
WANTED TO GIVE A SHOUT OUT TO KE
AND MARK WHO HAVE DONE SOME AMAG
HEAVY LIFTING ON THE ANALYSIS FR
THIS META-ANALYSIS.
SO, WHAT WE DID WAS LOOKED AT TE
ASSOCIATIONS BETWEEN THE EFFECTE
ON THE MENTAL HEALTH OUTCOME ANE
LABOR MARKET OUTCOME AND IT'S A
FAIRLY LINEAR ASSOCIATION, WHICH
IMPLIES THAT THE MECHANISM BY WH
THESE MENTAL HEALTH TREATMENTS D
THESE ECONOMIC BENEFITS SEEMS TE
THROUGH IMPROVED MENTAL HEALTH D
IMPROVED FUNCTIONS.
SO VERY EXCITING AND CONFIRMINGT
OF THE EVIDENCE ABOUT THE CYCLIL
BIDIRECTIONAL RELATIONSHIP BETWN
POVERTY AND MENTAL HEALTH AND TE
OPPORTUNITIES FOR INTERVENING AH
ENDS OF THAT CYCLE.
SO TO CONCLUDE, I THINK I HOPE E
BEEN ABLE TO SHOW YOU THAT SOCIL
DETERMINANTS REALLY PLAY A PROFD
ROLE IN CASE YOU DIDN'T NEED MOE
CONVINCING IN SHAPING THE MENTAL
HEALTH OF POPULATIONS AND IT'S Y
VITAL THAT WE INTERVENE EARLY TO
ADDRESS THESE SOCIAL DETERMINAN.
AND I THINK DESPITE THE MANY
CHALLENGES, I THINK THERE ARE AO
MANY OPPORTUNITIES FOR THESE KIF
INTERVENTIONS.
WE NEED TO IDENTIFY MECHANISMS D
INTERVENTION TARGETS.
IT'S NOT JUST ABOUT MOUNTING A L
PROGRAM OR A PARTICULAR ECONOMIC
INTERVENTION.
IT'S ABOUT BEING REALLY CLEAR AT
THE CAUSAL PATHWAY BY WHICH WE K
THE SOCIAL INTERVENTIONS WOULD D
A PARTICULAR MENTAL HEALTH OUTC.
AND OF COURSE THIS REQUIRES
INTERDISCIPLINARY APPROVES.
IT REQUIRES ACTIVE COMMUNITY
PARTICIPATION AND EMPOWERMENT,
INVOLVEMENT OF PEOPLE WITH LIVED
EXPERIENCE, AND COMMITMENT FROM
GOVERNMENTS, PRIVATE SECTOR AND
INTERNATIONAL DEVELOPMENT AGENC,
ALONGSIDE THIS ONGOING AGENDA OF
SCALING UP MENTAL HEALTH CARE.
SO THANK YOU VERY MUCH.
I JUST WANT TO ACKNOWLEDGE THE
COINVESTIGATORS ON THE STUDIES D
SEVERAL OF WHOM ARE IN THE ROOM
TODAY.
AND ALSO TO ACKNOWLEDGE THE FUNS
WHO HAVE SUPPORTED ALL OF THIS K
OVER THE YEARS.
THANK YOU VERY MUCH, INDEED.
[ APPLAUSE ]
I HAVE BEEN TOLD THERE IS TIME R
QUESTIONS IF ANYONE HAS ANY -- R
COMMENTS.
>> HERE WE GO.
HI, I'M RACHEL, A PH.D. STUDENTN
HEALTH SERVICES RESEARCH.
I KNOW YOU MENTIONED SELF-REGULN
A GOOD BIT AS KNOW UNDERLYING
MECHANISM FOR POTENTIALLY MEDIAG
LIKE ANXIETY, DEPRESSION, COMMON
MENTAL DISORDERS.
AND YOU LINKED THAT TO PARTICULR
SOCIAL DETERMINANTS OF HEALTH AD
OF A PATHWAY.
ARE THERE PATHWAYS OR ARE THERE
MEDIATORS OTHER THAN SELF-REGULN
THAT HAVE CAUGHT YOUR ATTENTIONS
POTENTIAL, LIKE, KIND OF CAUSAL
PATHWAYS FOR CODs?
>> I THINK THERE ARE A NUMBER OF
OTHER POTENTIAL MEDIATORS.
I MEAN, WE CAN THINK ABOUT THEMN
TERMS OF BROAD SOCIAL MEDIATORS.
SO FOR EXAMPLE, MEDIATORS AROUND
BUILDING SOCIAL TRUSTS, CREATINE
ENVIRONMENTS, BUILDING SOCIAL
CONNECTIONS AND SOCIAL SUPPORTS.
WE HAVE DONE WORK RECENTLY FROME
ORIGINAL FIRM TRIAL THAT I MENT,
LOOKING AT THE EXTENT TO WHICH E
EFFECT OF FOOD INSECURITY ON
PERINATAL DEPRESSION AND MODERAY
SOCIAL SUPPORT AND SOCIAL
CONNECTIONS.
SO SOCIAL CONNECTIONS, SOCIAL ST
CAN OFTEN PLAY A VERY IMPORTANTE
IN PROTECTING AGAINST THE EFFECF
SOCIAL AND ECONOMIC ADVERSITY.
>> GREAT.
AND TAKING THAT FURTHER, DO YOUK
MENTAL HEALTH TREATMENT -- SUPPS
THOSE THINGS AS WELL IN THAT THY
KIND OF HAVE SIMILAR MENTAL HEAH
TREATMENT AND SOCIAL DETERMINANS
WOULD HAVE SIMILAR ROLLS IN PROG
KIND OF THE SAME MECHANISMS?
OR DO YOU THINK THERE ARE
COMPLEMENTARY ROLES THEY WOULD ?
LIKE HOW DO YOU THINK THAT WOULD
INTERACT?
>> I THINK THEY HAVE THE POTENTO
DO THAT.
I THINK A LOT DEPENDS ON THE NAE
OF THE INTERVENTION AND PSYCHOSL
INTERVENTIONS INCLUDING A SOCIAL
COMPONENT HAVE THE POTENTIAL FOR
DOING THAT.
SO GROUP-BASED INTERVENTIONS FOR
EXAMPLE, PROVIDE A MEANS OF SOCL
SUPPORT IN THE CONTEXT OF WHATER
THE ACTIVE INGREDIENT OF THE
PSYCHOTHERAPY MIGHT HAPPEN TO B.
PSYCHOSOCIAL SUPPORT OR
REHABILITATION PROGRAMS AS AN AT
TO PHARMACOLOGICAL TREATMENTS HE
THAT POTENTIAL SOCIAL ROLE.
SO I THINK A LOT DEPENDS ON HOWE
INTERVENTIONS ARE DESIGNED BUT Y
ALSO DO HAVE THAT POTENTIAL.
>> THANK YOU.
>> HI, EMORY UNIVERSITY.
THANK YOU VERY MUCH FOR YOUR
PRESENTATION, DR. LUND AND I REY
APPRECIATE YOUR THOUGHTS ON CAUL
MECHANISM AND YOU ALREADY MENTID
NEUROPSYCHOLOGY AS ONE SOURCE FR
HYPOTHESES FOR THOSE CAUSAL PAT.
AND I WONDERED WHAT ARE YOUR THS
ON OTHER APPROACHES TO FIGURE OT
SUCH MECHANISMS?
FOR INSTANCE QUALITATIVE RESEARH
METHODS, INCLUDING RANDOM THEOR?
>> SO QUALITATIVE RESEARCH METHS
ARE REALLY IMPORTANT IN ALL OF S
WORK.
AND IT'S SOMETHING WE SPEND A LF
TIME DOING IN THE CONTEXT OF THE
ALLIANCE PROJECT.
IN THE FIRST PHASE WE HAVE DONET
OF QUALITATIVE INTERVIEWS WITH
ADOLESCENTS LIVING IN CIRCUMSTAS
OF POVERTY IN EACH OF THE THREE
COUNTRIES ASKING THEM QUESTIONST
DEPRESSION AND ANXIETY AND IDENY
THE KINDS OF STRATEGIES THEY USO
COPE WITH THOSE KINDS OF ADVERS.
AND THAT'S REALLY BEING INCREDIY
INFORMATIVE IN TERMS OF DESIGNIR
SELF-REGULATION INTERVENTION.
IT'S REALLY PICKED UP ON A LOT F
THOSE STRATEGIES.
>> THANK YOU.
>> HI, THANK YOU FOR YOUR TALK.
SO I'M WONDERING ABOUT - YOU'RE
TALKING ABOUT THE FACT THAT THEE
MIGHT BE SMALL EFFECT SIZES AT E
POPULATION COULD HAVE MASSIVE I.
BUT THE INTERVENTIONS WE ARE TAG
ABOUT TESTING COULD BE VERY DIFT
TO SCALE COMPARED TO OTHER SOCID
ECONOMIC POLICIES THAT MIGHT BE
INFLUENCING THINGS LIKE POVERTYD
INEQUALITY, THE STRENGTHENING OF
SOCIAL SAFETY NETS, DISABILITY
INSURANCE, THE SORT OF MECHANISS
THAT GOVERNMENTS HAVE AT THEIR
DISPOSAL.
SO I'M CURIOUS HOW YOU THINK ABT
HOW WE POSITION THIS IN TERMS OF
ADVOCATING FOR POLICY THAT COULD
INTERVENE IN SOCIAL DETERMINANT?
>> I THINK THAT IS WHAT I WAS TG
TO GET AT TOWARDS THE END WAS, I
THINK THIS PLACESINOUS A REALLY
IMPORTANT ROLE AS MENTAL HEALTH
POLICYMAKERS OR RESEARCHERS AND
ADVOCATES.
IS TO TRY AND BE MORE ACTIVE INE
POLICY SPACE, TO BE ADVOCATING E
FOR SOCIAL JUSTICE, FOR MORE FAR
REDISTRIBUTION OF WEALTH TO MAKE
THAT PEOPLE HAVE ACCESS TO HEALH
CARE THAT IS AFFORDABLE.
ALL OF THESE SOCIAL AND ECONOMIC
DRIVERS ARE REALLY IMPORTANT PAF
THE MENTAL HEALTH POLICY AGENDA.
ONE OF THE CHALLENGES IN TERMS F
MENTAL HEALTH POLICY IS WHAT MAN
REFERS TO AS DIAGONAL -- IF I'M
SITTING IN A MINISTRY OF HEALTHY
INVESTMENT IN MENTAL HEALTH WILL
OFTEN YIELD AN ECONOMIC RETURN R
ANOTHER SECTOR AT SOME POINT INE
FUTURE.
SO IT'S VERY DIFFICULT TO MAKE E
CASE TO PARTICULAR SECTORS OF
GOVERNMENT FOR THE BENEFIT OF
INVESTING IN MENTAL HEALTH WITHN
THEIR SECTOR.
AND AGAIN THIS IS WHY A WHOLE OF
SOCIETY APPROACH IS REALLY IMPO.
WE NEED TO BE ABLE TO DEMONSTRAE
IMPACT OF MENTAL HEALTH TREATMEN
LABOR MARKET PARTICIPATION, FOR
EXAMPLE.
WE NEED TO SHOW IF CASH TRANSFES
COMBINED WITH PSYCHOLOGICAL
TREATMENTS FOR PERINATAL DEPRESN
IMPROVE MOTHER INFANT DETACHMEN,
THAT HAS A WHOLE NUMBER OF OTHER
POTENTIAL HEALTH AND EDUCATIONAL
BENEFITS FURTHER DOWN THE LINE.
AND THERE ARE METHODS FOR EVALUG
THESE KINDS OF CAUSES AND EFFEC.
FOR EXAMPLE THE W.H.O. CHOICE M,
WHICH REALLY LOOKS AT THE INVEST
IN RELATION TO RETURN ON INVEST,
BUT ALSO IN RELATION TO STANDARD
UTILITY MEASURES LIKE DISABILITY
ADJUSTED LIFE YEARS, AS A RESULA
PARTICULAR INTERVENTION.
>> THANK YOU.
>> THANK YOU FOR A FASCINATING .
YOU BRING UP SEVERAL QUESTIONS Y
MIND.
DURING COVID IN THE UNITED STATE
HAD A HUGE AMOUNTED OF MENTAL HH
PROBLEMS WITH YOUNGSTERS WITH SE
AND DEPRESSION AND SO ON.
AND I WAS LOOKING AT WHAT YOU LD
AS SOCIAL DETERMINANTS THINKING
NOBODY WOULD BE IN A GREAT STATE
GIVEN THOSE CONDITIONS.
BUT THERE ARE PEOPLE WHO HAVE TE
CONDITIONS AND FUNCTION, AND YEE
HAD PEOPLE WHO HAD ALL OF THE
POSITIVE THINGS AND YET WERE
DEPRESSED ENOUGH TO COMMIT SUIC.
SO, I JUST WONDERED WHETHER YOUE
TO TAKE CULTURE INTO ACCOUNT?
AND THEN I STARTED THINKING ABOE
INTERNET.
FIRST OF ALL, IT SEEMED TO ME TE
PEOPLE WOULD BE EXPERIENCING ENS
AMOUNTS OF SHAME AND LACK OF
SELF-ESTEEM.
AND WHAT HAPPENS WHEN THESE PEOE
ARE NOW LOOKING AT FACEBOOK OR
INSTAGRAM AND GETTING ALL OF THT
PRESSURE FROM THE OUTSIDE ON WHT
THEY SHOULD HAVE OR SHOULD BE OO
ON?
I WONDERED IF YOU WOULD BE INTED
IN EXPANDING YOUR IDEA TO INCLUE
MORE CULTURAL VALUES?
>> YES, VERY MUCH.
AND I THINK CULTURAL VALUES CANE
POSITIVE OR NEGATIVE MENTAL HEAH
CONSEQUENCES.
SO A SENSE OF CULTURAL IDENTITY,
BELONGING, IS A LOT OF EVIDENCET
THESE ARE PROTECTIVE FOR THE MEL
HEALTH POPULATIONS AND IF WE HAA
SENSE OF WHO WE ARE, WHAT OUR VS
ARE, HOW OUR LIFESTYLE ALLIANCEH
OUR VALUES, THESE ARE IMPORTANT
CULTURAL FACTORS WHICH PROVIDE L
HEALTH PROTECTION.
OF COURSE THERE ARE OTHER MORE C
ELEMENTS OF SPACE ON THE INTERND
SOCIAL MEDIA WHICH HAVE BEEN SHO
HAVE NEGATIVE MENTAL HEALTH OUT,
FOR EXAMPLE, AS THE INTERNET SP.
SO IT'S A COMPLEX PICTURE AND IK
WHAT I HOPE I TRIED TO SHOW IS E
SOCIAL AND ECONOMIC ADVERSITIESE
IMPACT BUT THEY ARE OBVIOUSLY VY
HETEROGENOUS ACROSS DIFFERENT
CULTURES AROUND THE WORLD.
AND CERTAIN CULTURES CAN HAVE A
PROTECTIVE ROLE, WHICH IS IS WHT
THAT FIFTH DIMENSION OR DOMAIN I
MENTIONED.
>> THANK YOU.
EXCELLENT.
>> THANK YOU.
ANY OTHER QUESTIONS?
>> I'D LIKE TO GO BACK TO THE IE
ABOUT POLITICS BECAUSE I'M THING
IN THE U.K. WE HAVE NOW A DISCOE
AROUND IF YOU'RE UNEMPLOYED, IF
YOU'RE MENTALLYIL, THAT IN ITSES
A MENTAL ILLNESS.
THEY WANT TO ADDRESS THIS THROUH
INTERVENTIONS AND SANCTIONS.
SO AGAIN, POLITICS DO INFLUENCEE
SORT OF POLICIES THAT WILL MAKEA
DIFFERENCE SOMETIMES NEGATIVE, N
PEOPLE'S LIVES.
SO WE REALLY NEED TO ADDRESS TH.
IT REALLY IS THE ELEPHANT IN THE
ROOM.
>> ABSOLUTELY.
I REALLY AGREE AND I THINK A LOF
THESE SOCIAL INTERVENTIONS ARE
MOUNTED FROM PARTICULAR POLITICL
PROGRAMS SO IT'S REALLY IMPORTAE
ADVOCATE FOR EXAMPLE, FOR BASIC
INCOME GRANTS AND FOR BASIC FINL
SECURITY FOR PEOPLE WHO ARE LIVN
EXTREMELY VULNERABLE CIRCUMSTAN.
SO IT IS PROFOUNDLY A POLITICALE
AS WELL AS A SOCIAL AND ECONOMIC
ISSUE.
ALL RIGHT, LET'S LEAVE IT AT TH.
THANK YOU VERY MUCH, INDEED.
I THINK WE'RE GOING TO GET
STARTED.
AND THOSE WHO ARE NOT IN THE
ROOM CAN TRICKLE IN.
I THINK I SAID THIS BEFORE.
I'M HOLLY CAMPBELL-ROSEN WORKING
IN THE CENTER FOR GLOBAL HEALTH
RESEARCH AT NIMH AND I'M PLEASED
TO INTRODUCE THIS LAST PLENARY
PANEL.
AS YOU KNOW, IT'S ABOUT
IMPLEMENTATION SCIENCE AND A LOT
OF THE WORK DONE SHOWN HERE THE
LAST FEW DAYS IS USING
IMPLEMENTATION STRATEGIES AND
APPROACHES AND IS REALLY KEY TO
ADVANCING THE FIELD.
I'LL JUST BE BRIEF AND SAY,
DR. BRIAN PENCE IS THE CHAIR
HERE AND HE'S A PROFESSOR OF
EPIDEMIOLOGY AT THE UNIVERSITY
OF NORTH CAROLINA.
AND IMPLEMENTATION SCIENCE IS
JUST ONE OF THE APPROACHES HE
USES TO UNDERSTAND HOW TO TREAT
AND SCALE UP MENTAL HEALTH
INTERVENTIONS.
I'LL TURN IT OVER TO YOU AND
HAVE FUN.
>> DR. BRIAN PENCE: THANK YOU
VERY MUCH, HOLLY.
AND DELIGHTED TO BE HERE FOR
THIS CLOSING SESSION TO BE
SHARING THE STAGE WITH MY FELLOW
PANELISTS FOR A CONVERSATION
ABOUT THE ROLE OF IMPLEMENTATION
SCIENCE IN GLOBAL MENTAL HEALTH,
OPPORTUNITIES, PITFALLS AND
FUTURE DIRECTIONS.
I'LL JUST TAKE A MOMENT TO
INTRODUCE THE PEOPLE ON THE
STAGE.
WE HAVE DR. PAMELA COLLINS FROM
JOHNS HOPKINS UNIVERSITY.
DR. BILL MILLER ALSO FROM THE
UNIVERSITY OF NORTH
CAROLINA-CHAPEL HILL.
DR. VICTOR MWAPASA FROM THE
UNIVERSITY OF HEALTH SCIENCES IN
MALAWI.
DR. SOUMITRA PATHARE FROM THE
INDIANA LAW SOCIETY.
THANK YOU VERY MUCH FOR JOINING
ME FOR THIS CONVERSATION.
AND I'LL INVITE YOU IN A MOMENT
AS WE GET INTO OUR CONVERSATION
TO MAYBE START EACH OF YOUR
INITIAL RESPONSES WITH A BRIEF
DISCUSSION OF YOUR ENGAGEMENT IN
IMPLEMENTATION SCIENCE RESEARCH
IN YOUR OWN WORK JUST TO
CONTEXTUALIZE A LITTLE BIT FOR
OUR AUDIENCE MEMBERS.
HOW YOU COME TO THIS WORK.
BUT JUST TO GIVE A FRAMEWORK FOR
OUR CONVERSATION TODAY, HOPING
TO BE INFORMAL DISCUSSION AMONG
US AND ALSO TO ENGAGE OUR
AUDIENCE MEMBERS.
THE FOCUS OF THIS DISCUSSION IS
TO ADDRESS THE QUESTION, HOW CAN
IMPLEMENTATION SCIENCE MAXIMIZE
THE IMPACT OF FUNDING DOLLARS ON
GLOBAL MENTAL HEALTH?
WHICH WE CAN THINK OF WHAT IS
THE ROLE OF IMPLEMENTATION
SCIENCE IN ADVANCING GLOBAL
MENTAL HEALTH AND WHAT ARE
PITFALLS AND SPECIAL
CONSIDERATIONS FOR DOING
IMPLEMENTATION SCIENCE WELL?
SO TO UNPACK THIS OVERARCHING
QUESTION A LITTLE BIT, THE PANEL
WILL DISCUSS FOUR QUESTIONS.
WE'LL START BY TALKING ABOUT WHY
IMPLEMENTATION SCIENCE?
WHY IS THIS THE RIGHT TOOL AT
THIS POINT IN OUR RESPONSE TO
THE GLOBAL MENTAL HEALTH NEEDS?
WHAT IS THE IMPORTANCE OF
CONSIDERING CONTEXT IN DOING
IMPLEMENTATION SCIENCE RESEARCH?
WHAT ARE SPECIAL CONSIDERATIONS
IN THE DESIGN AND CONDUCT OF
IMPLEMENTATION SCIENCE STUDIES
AND HOW CAN IMPLEMENTATION
SCIENCE MAXIMIZE ITS IMPACT?
BUT BEFORE GETTING INTO THOSE
DISCUSSION QUESTIONS, I JUST
WANTED TO TAKE A MOMENT TO SET
SOME COMMON UNDERSTANDING OF
WHAT DO WE MEAN BY THE TERM,
IMPLEMENTATION SCIENCE, AN
APPROACH WHICH GOES BY DIFFERENT
NAMES AND LABELS IN DIFFERENT
PARTS OF THE WORLD.
SO FOR OUR PURPOSES HERE,
IMPLEMENTATION SCIENCE IS REFERS
TO SCIENTIFIC RESEARCH.
THE GOAL IS TO IDENTIFY THE BEST
WAYS TO SCALE UP PROVEN
INTERVENTIONS.
NOT TO ASSESS EFFICACY, BUT TO
TAKE AS GIVEN THAT THE EFFICACY
OF A PARTICULAR TREATMENT MODEL
HAS BEEN ESTABLISHED AND THE
QUESTION AT HAND IS, HOW TO
SCALE UP THAT TREATMENT MODEL IN
A GIVEN CONTEXT.
AND SO, AS A RESULT, THESE
RESEARCH STUDIES ARE TYPICALLY
NOT STUDYING PATIENT'S HEALTH OR
PATIENTS THEMSELVES AS THE
PRIMARY UNIT OF ANALYSIS,
MEASUREMENT, RANDOMIZATION; BUT
RATHER ARE TYPICALLY STUDYING
STAFF, CLINICS, HEALTH SYSTEMS,
INTERVENTIONS ON STAFF AND
CLINICS OR HEALTH SYSTEMS.
IMPLEMENTATION STRATEGIES AT
THESE LEVELS THAT WE HOPE LEAD
TO BETTER IMPLEMENTATION.
TYPICALLY, THESE RESEARCH
STUDIES ARE NOT FOCUSING ON
PATIENT HEALTH AS THE PRIMARY
OUTCOME BUT RATHER FOCUSING ON
FIDELITY OF THE EVIDENCE-BASED
TREATMENT MODEL DELIVERY OR
ADOPTION OF EVIDENCE-BASED
TREATMENT INTERVENTIONS WITHIN
THE HEALTH CONTEXT.
SO, PATIENT HEALTH OUTCOMES MAY
STILL BE MEASURED AS A
DOWNSTREAM IMPACT OF ACHIEVING
HIGHER FIDELITY, ACHIEVING
IMPLEMENTATION BUT THEY AREN'T
THE PRIMARY FOCUS.
AS A RESULT, IF WE ARE STUDYING
STAFF OR CLINICS OR HEALTH
SYSTEMS, WE ARE USUALLY
CONSTRAINED FROM THE PERSPECTIVE
OF SAMPLE SIZE THE WAY WE
USUALLY THINK ABOUT THAT
STATISTICALLY.
WE MIGHT JUST PRAGMATICALLY
REALLY ONLY BE ABLE TO WORK WITH
20 HEALTH DISTRICTS OR 12 HEALTH
FACILITIES OR A CERTAIN NUMBER
OF STAFF, RATHER THAN THE POWER
OF CALCULATION USED FOR
INDIVIDUALLY-POWERED TRIALS.
AND THIS TYPICALLY INVOLVES
SPECIALIZED STATISTICAL METHODS
TO ADDRESS CLUSTERING AND SMALL
SAMPLE SIZES.
SO, THESE ARE -- THIS IS THE
CONTEXT OF WHAT WE ARE TALKING
ABOUT IN THIS PANEL, AND IN THIS
CONTEXT, I'M GOING TO TURN TO MY
PANEL AND ASK MY OPENING
QUESTION WHICH IS, WHY
IMPLEMENTATION SCIENCE?
SO WHY IS IMPLEMENTATION SCIENCE
AN IMPORTANT TOOL FOR MOVING THE
GLOBAL MENTAL HEALTH FIELDS
FURTHER TOWARDS MAXIMIZING
IMPACT?
AND DR. COLLINS, I'LL TURN THE
QUESTION FIRST TO YOU.
IF YOU WILL JUST TAKE A MOMENT
TO TALK ABOUT YOUR ENGAGEMENT IN
IMPLEMENTATION SCIENCE RESEARCH
AS YOU LEAD INTO YOUR ANSWER.
>> THANK YOU, BRIAN.
SO MY RESEARCH TRAINING REALLY
BEGAN WITH INTERVENTION
RESEARCH.
SO, DEVELOPING INTERVENTIONS IN
MY CASE, FOCUSED ON HIV
PREVENTION AMONG PEOPLE LIVING
WITH SERIOUS MENTAL ILLNESS.
DEVELOPING INTERVENTIONS,
TESTING THOSE INTERVENTIONS,
DOING THE EFFICACY AND THEN
HOPEFULLY EFFECTIVENESS STUDIES
THAT BRIAN IS REFERRING TO.
IT REALLY WASN'T UNTIL I MOVED
OUT OF THE UNIVERSITY AND CAME
HERE TO NIMH FOR EIGHT YEARS,
THAT I BEGAN TO REALLY
UNDERSTAND IMPLEMENTATION
SCIENCE AND THE VALUE OF IT.
AND THAT BEING THE NEXT STEP
AFTER EFFECTIVENESS RESEARCH.
HOW DO WE TAKE THINGS TO SCALE?
SO, LOOKING AT IT MORE FROM THE
KIND OF SCIENCE POLICY
PERSPECTIVE THAN ACTUALLY FROM
THE RESEARCHER PERSPECTIVE,
FIRST OF ALL.
BUT SINCE THAT TIME, I'VE BEEN
INVOLVED IN -- BACK TO ACADEMIA
AND IMPLEMENTATION SCIENCE IS A
REAL PRIORITY AND NOW INVOLVED
IN IMPLEMENTATION SCIENCE
STUDIES FOCUSING ON -- WE HAVE A
STUDY FOCUSED ON ADOLESCENTS
LIVING WITH HIV AND INTEGRATING
PSYCHOLOGICAL INTERVENTIONS INTO
REAL-WORLD HIV CARE.
I THINK ONE OF MY CO-PIs IS IN
THE AUDIENCE HERE.
THAT'S MY BACKGROUND IN HOW I
COME TO THIS.
AND THE OTHER WAY I COME TO THIS
IS WHAT I'M GOING TO TALK ABOUT
NOW, WHICH IS THAT, I WAS
THINKING OF HOW TO ANSWER THIS
QUESTION AND I THOUGHT, WOW, CAN
YOU ACTUALLY IMAGINE COMMUNITIES
OF HEALTH SYSTEMS THAT CAN
SUSTAINIBLY DELIVER ACCESSIBLE,
QUALITY, PREVENTIVE AND
TREATMENT INTERVENTIONS THAT ARE
BASED ON THE BEST AVAILABLE
EVIDENCE FOR THE DIVERSITY OF
PEOPLE IN YOUR CONTEXT, WHO NEED
THE CARE?
AND IF YOU LET THAT VISION OF
WHAT THAT LOOKS LIKE SIT WITH
YOU, YOU REALIZE THAT THOSE ARE
IMPLEMENTATION SCIENCE
QUESTIONS.
HOW DO WE GET THERE?
THIS IS WHAT WE ALL ARE ASPIRING
FOR.
HOW DO WE GET THERE.
WE HAVE INTERVENTIONS THAT WORK
BUT WE STILL HAVE SIGNIFICANT
DISPARITIES AND UPTAKE IN
UTILIZATION OF MENTAL HEALTH
INTERVENTIONS AND THESE ARE
APPARENT BY AGE, BY ETHNICITY,
BY GENDER.
OTHER DOMAINS DEPENDING ON WHERE
YOU ARE.
SO IMPLEMENTATION SCIENCE SHOULD
HELP GUIDE US TO THE SMARTEST
WAYS TO TRANSLATE WHAT WE KNOW
ABOUT THE NEEDS OF POPULATIONS,
WHAT WE KNOW ABOUT SYSTEMS, TO
BE ABLE TO ACHIEVE THIS GOAL.
SO I'M GOING TO TALK ABOUT --
AND I THINK IN PARTICULAR, MAYBE
ONE OF THE BIG CHALLENGES OF
IMPLEMENTATION SCIENCE IS
FIGURING OUT HOW TO DO THAT WITH
SOME OF THE MOST VULNERABLE
POPULATIONS.
I'M GOING TO TALK ABOUT MY
EXPERIENCE WORKING WITH ONE OF
THOSE VULNERABLE POPULATIONS,
WHICH IS PEOPLE LIVING WITH HIV.
THE GOOD NEWS IS THAT THIS IS A
COMMUNITY THAT IS INCREASINGLY
RECEIVING ACCESS TO MENTAL
HEALTH SERVICES, IMPORTANT GIVEN
THE RISK THAT PEOPLE LIVING WITH
HIV HAVE FOR MENTAL HEALTH
CONDITIONS, AS A RESULT OF THE
LIVING WITH A CHRONIC DISEASE,
AS THE RESULT OF THE EFFECTS OF
THE VIRUS ON THE BRAIN, AS A
RESULT OF MANAGING THE KINDS OF
SOCIAL STRESSORS AND SOCIAL
CONTEXT THAT PUT PEOPLE AT RISK.
SO, THERE IS A CLEAR NEED.
AND FRONT LINE HIV RESEARCHERS
HAVE KNOWN FOR MANY, MANY YEARS
THAT PEOPLE WHO ARE RECEIVING
NEWS OF HIV TEST, FOR MANAGING
LIFE WITH A STIGMATIZING
CONDITION, REQUIRES STRONG
SOCIAL SUPPORT AND OFTEN SUPPORT
FOR MENTAL HEALTH.
AND THOSE FOLKS IN THESE CLINICS
AT THE FRONT LINE HAVE OFTEN
SAID, WE DON'T HAVE THE SKILLS
TO DELIVER MENTAL HEALTH
INTERVENTIONS.
WE KNOW OUR PATIENTS NEED THIS
BUT WE DON'T KNOW HOW TO DO
THIS.
OVER THE LAST DECADES WE
ACCUMULATED GOOD EVIDENCE FOR
WHY IT'S IMPORTANT TO TAKE CARE
OF PEOPLE'S MENTAL HEALTH NEEDS
AROUND HIV.
PEOPLE WHO NEED MENTAL HEALTH
SERVICES NEED MENTAL HEALTH
SERVICES.
AND PEOPLE HAVE ALSO RECOGNIZED,
WOW, WHEN YOU'RE MANAGING TWO
DIFFERENT CONDITIONS, YOU REALLY
HAVE TO TREAT BOTH BECAUSE YOU
CAN'T REALLY BE SUCCESSFUL IF
YOU DON'T TREAT BOTH.
AND DUE TO THE EVIDENCE, DUE TO
THE ROBUST ADVOCACY NEED FOR
INTEGRATING CARE, WE HAVE
ACHIEVED A VICTORY AND THAT IS
THAT FUNDERS LIKE THE
PRESIDENT'S EMERGENCY PLAN FOR
AIDES RELIEF AND MOST RECENTLY
THE GLOBAL FUND, ARE NOW FUNDING
THE IMPLEMENTATION OF MENTAL
HEALTH INTERVENTIONS IN
REAL-WORLD HIV CARE.
AND SO, THE IMPLEMENTATION IS
HAPPENING OFTEN WITHOUT THE
IMPLEMENTATION SCIENCE
ACCOMPANYING IT.
AND IMPLEMENTATION IS COMPLEX.
SO I'M GOING TO POSE SOME
QUESTIONS THAT MY COLLEAGUES AND
I HAVE CONSIDERED IN THE CONTEXT
OF REAL-WORLD IMPLEMENTATION AND
I'LL SPEAK FROM MY RECENT
EXPERIENCES AS THE FORMER
EXECUTIVE DIRECTOR OF ITECH, A
PEPFAR IMPLEMENTING PARTNER
BASED AT THE UNIVERSITY OF
WASHINGTON.
AND I HOPE THAT ALL OF YOU CAN
HELP ANSWER SOME OF THESE
QUESTIONS AS WE HAVE THIS
CONVERSATION.
BUT, WHAT HAPPENS WHEN YOU TAKE
AN INTERVENTION THAT WE KNOW
WORKS AND THEN MOVE IT INTO THE
REAL WORLD?
MANY OF YOU HAVE ANSWERS TO
THAT.
BUT IF WE JUST THINK ABOUT
PSYCHOLOGICAL INTERVENTIONS FOR
PEOPLE LIVING WITH HIV, SOME OF
THE QUESTIONS THAT COME UP ARE,
WHAT ARE THE BEST DELIVERY
MODELS FOR AN EVIDENCE-BASED
PSYCHOLOGICAL INTERVENTION IN
HIV SERVICES WHEN WEEKLY
ATTENDANCE IS NOT THE ROUTINE,
NOT OFTEN ACCEPTABLE OR FEASIBLE
FOR PEOPLE WHO ARE RECEIVING
CARE AND YET THAT'S THE WAY
PEOPLE HAVE BEEN TRAINED TO
DELIVER THE INTERVENTION.
IN REAL WORLD IMPLEMENTATION,
INTERVENTION ADAPTATION DOESN'T
ALWAYS OCCUR UNDER THE GUIDANCE
OF THE RESEARCHERS, SCIENTISTS
WHO DEVELOPED THE INTERVENTION.
SO, WHAT KIND OF GUIDANCE DO
NON-SPECIALISTS PUBLIC HEALTH
PROFESSIONALS NEED TO ADAPT SUCH
AN INTERVENTION WHILE PRESERVING
THE ACTIVE INGREDIENTS?
HOW CAN SUPERVISION THAT
MAINTAINS FIDELITY AND QUALITY
BE YOU IS STAINABLY INTEGRATED
INTO ROUTINE PRACTICE SETTINGS
IN THE CONTEXT OF A BUSY HIV
CLINIC.
AND THEN HOW DOES IMPLEMENTATION
SCIENCE TACKLE THE COMPLEXITIES
OF CONTEXT THAT EFFECTS
STRATEGIES FOR
REAL-WORLDIVEITATION.
IN A NATION WILD IMPLEMENTATION,
SOME MAY BE IN CONFLICT.
IN DECENTRALIZED GOVERNMENTS
DIFFERENT PROVINCES MAY HAVE
DIFFERENT MENTAL HEALTH BUDGETS
AND THEREFORE THIS IS GOING TO
EFFECT HOW YOU ULTIMATELY
IMPLEMENT YOUR MENTAL HEALTH
SERVICES ESPECIALLY WHEN MENTAL
HEALTH CARE OUTSIDE OF HIV CARE
MAY NOT BE AVAILABLE.
SO THESE ARE A FEW OF THE KINDS
OF QUESTIONS THAT ARISE IN
REAL-WORLD IMPLEMENTATION BUT
THAT ARE THE KINDS OF QUESTIONS
ALSO THAT IMPLEMENTATION SCIENCE
IS PREPARED TO ADDRESS.
>> THANK YOU VERY MUCH,
DR. COLLINS, FOR YOUR INITIAL
THOUGHTS AND QUESTIONS.
DR. MILLER, CAN I INVITE YOU TO
BRIEFLY DESCRIBE YOUR ENGAGEMENT
IN THIS SPACE AND WHAT ARE YOUR
THOUGHTS ON WHY IS
IMPLEMENTATION SCIENCE THE RIGHT
TOOL RIGHT NOW?
>> SURE, THANK YOU.
SO, AS BRIAN MENTIONED, I'M AN
INFECTIOUS DISEASES
EPIDEMIOLOGIST AND TRAINED AS AN
INFERS DISEASES PHYSICIAN AND
FOR MUCH OF THE EARLY PART OF MY
CAREER, I DID A LOT OF WORK WITH
LOCAL HEALTH DEPARTMENTS, STATE
HEALTH DEPARTMENTS AND THE CDC
TRYING TO DO THINGS LIKE FIGURE
OUT WAYS TO ESTIMATE THINGS LIKE
CHLAMYDIA PREVALENCE BETTER THAN
WITH THE INFORMATION THEY HAD
AVAILABLE.
AND OVER TIME, I ALSO BEGAN SORT
OF DOING MORE INTERVENTION WORK
AND I WAS FORTUNATE TO BE THE
PROTOCOL CHAIR OF A LARGE STUDY
CALLED HBTN074.
HIV PREVENTION TRIALS NETWORK.
074.
IT WAS CONDUCTED IN THREE
COUNTRIES, VIETNAM, INDONESIA
AND UKRAINE.
IT WAS A STUDY AMONG -- FOR
PEOPLE WHO INJECT DRUGS.
ESSENTIALLY THOSE WHO WERE NEWLY
DIAGNOSED OR WHO WERE NOT IN HIV
CARE.
AND IT WAS A FAIRLY SIMPLE
INTERVENTION OF SYSTEMS
NAVIGATION, WHICH WAS JUST TWO
SESSIONS, AND THEN PSYCHOSOCIAL
COUNSELING WHICH WAS ALSO TWO
SESSIONS WITH A FOCUS ON
PROBLEM-SOLVING AND ESSENTIALLY
HELPING THEM UNDERSTAND WHAT IT
WAS GOING TO TAKE TO TAKE THEIR
ANTI-RETROVIRAL THERAPY.
THAT STUDY, WHICH WAS INTENDED
ACTUALLY TO BE A GIANT PILOT
STUDY, WAS EXTREMELY SUCCESSFUL.
AND DOUBLED THE RATE OF ART USE,
REDUCED VIRAL SUPPRESSION OR
INCREASED VIRAL SUPPRESSION BY
TWO FOLD, AND SORT OF
DRAMATICALLY REDUCED DEATH BY
TWO FOLD.
AND IT WAS A STUDY THAT NIAID
DECIDED WAS SO SIGNIFICANT THAT
THEY COULDN'T -- THAT THEY
OFFERED THE INTERVENTION TO THE
REST OF THE PEOPLE THAT HADN'T
RECEIVED IT, THE CONTROL ARM.
AND SO, WE LOOKED AT THIS THE
STUDY AND WE'RE LIKE, THIS
REALLY WORKS.
WE CAN'T JUST LEAVE IT HERE.
SO WE DESIGNED AN IMPLEMENTATION
SCIENCE TRIAL IN VIETNAM.
I KNOW DIDDLEY ABOUT
IMPLEMENTATION SCIENCE.
AND I SURROUNDED MYSELF WITH
PEOPLE THAT DID.
AND WE'RE NOW IN THE MIDST OF
JUST FINISHING UP A TRIAL THAT
HAS TAKEN FIVE YEARS AND 42
CLINICS IN VIETNAM.
WE HAVEN'T BROKEN THE CODE YET.
SO I CAN'T TELL YOU THE RESULTS.
I CAN TELL THAT YOU SOMETHING
WORKED.
I DON'T KNOW WHICH ONE FOR SURE,
BUT SOMETHING WORKED QUITE WELL.
AND IT JUST WAS REALLY CLEAR TO
ME THAT WE NEED TO THINK ABOUT
WHEN WE'RE RIGHT FROM THE START
OF DESIGNING THE INTERVENTION,
HOW IS THIS ACTUALLY GOING TO
PLAY OUT IN THE REAL WORLD?
AND IT'S NOT EASY BECAUSE
DEPENDING ON THE CONTEXT AS
VICTOR WILL TALK ABOUT A LITTLE
BIT LATER, THINGS THAT WE THINK
ARE OKAY OR STRAIGHTFORWARD, ARE
NOT.
AND WE'LL TALK A LITTLE BIT MORE
ABOUT THAT WHEN WE TALK ABOUT
THE DESIGN OF IMPLEMENTATION
TRIALS.
BUT FOR ME, IT'S BECOME WHEN I
THINK ABOUT INTERVENTION, I
THINK ABOUT HOW IT'S GOING TO
WORK IN THE REAL WORLD EVERY
TIME.
>> THANK YOU.
AND DR. SOUMITRA PATHARE.
CAN YOU INTRODUCE YOURSELF
BRIEFLY AND YOUR WORK IN THIS
SPACE AND WHAT IS YOUR TAKE ON
THIS QUESTION?
WHY IS IMPLEMENTATION SCIENCE
THE RIGHT TOOL?
>> THANKS, BRIAN.
I GOT INTERESTED IN IT ONLY
BECAUSE I TALKED TO A
POLICYMAKERS.
IT'S WHEN I STARTED TALKING TO
POLICYMAKERS.
ONE OF THE THINGS THAT STRUCK ME
IS A LOT OF THESE GREAT
INNOVATIONS WE COME UP WITH ARE
NEVER REACH THE POPULATION.
AND THERE IS LIKE A 15-20 YEAR
GAP THAT IS NORMAL FOR ANY NEW
INNOVATION TO ACTUALLY REACH
SCALE AND REACH POPULATION.
AND THE QUESTION IS, CAN WE CUT
THAT SHORT?
BECAUSE 15-20 YEARS -- SO WHAT
YOU INVENT TODAY, A WHOLE
GENERATION WILL NOT GET THE
BENEFIT OF THAT INVENTION.
THERE WILL BE BE THE PEOPLE
AFTERWARDS.
WHEN YOU'RE TALKING TO
POLICYMAKERS AND I THINK A LOT
OF RESEARCHERS LIKE MYSELF WILL
DO THAT WHICH IS WHEN YOU'RE
TALKING TO POLICYMAKERS TO SCALE
UP THINGS, THE SIMPLE THING THAT
WE ALSO THINK OF IS THAT OUR
POLICYMAKERS ARE NOT INTERESTED.
THEY DON'T WANT TO DO IT.
AND I THOUGHT THE SAME.
LIKE A BUNCH OF POLICYMAKERS
DON'T UNDERSTAND WHAT THEY ARE
DOING AND DON'T -- REALLY NOT
INTERESTED IN MENTAL HEALTH.
AND THEN WHEN YOU TALK TO THEM,
YOU REALIZE AFTER A WHILE, THEY
HAVE SOME REAL CONCERNS ABOUT
WHEN YOU SCALE UP.
HOW IS IT GOING TO HAPPEN?
WHAT CAN HAPPEN?
AND SO IT'S NOT JUST A
HIT-AND-MISS AFFAIR.
THERE IS A WAY YOU CAN ANSWER
SOME OF THESE QUESTIONS FOR
THEM, FOR THEM TO BE ABLE TO
PLAN BETTER.
SO THAT'S HOW WE GOT INTO THIS
WHOLE IMPLEMENTATION SCIENCE
RESEARCH PROJECT.
AND I'LL GIVE YOU AN EXAMPLE OF
ONE WHICH IS ONGOING.
WE SPOKE TO A STATE GOVERNMENT
IN INDIA AND SAID, YOU SHOULD
IMPLEMENT GATEKEEPER TRAINING
FOR SCHOOLTEACHERS AS A SUICIDE
PREVENTION MEASURE.
AND THEY SAID, YES, WE WILL DO
THAT.
HOW?
WHAT ARE THE CHALLENGES IN DOING
IT?
AFTER A LOT OF DISCUSSION WITH
THE POLICYMAKERS, WE DESIGNED A
TRIAL WHICH HAS THREE ARMS TO
IT.
IN ONE ARM, THE GATEKEEPER
TRAINING IS PROVIDED TO
SCHOOLTEACHERS JUST AS AN ONLINE
PROGRAM AND ANOTHER ARM THEY GET
THE ONLINE PROGRAM PLUS REGULAR
REFRESHERS, THEY GET THE ONLINE
PROGRAM THE REFRESHER AND SOME
MENTORING.
THE IDEA WAS NOT TO SEE WHICH IS
MORE EFFECTIVE BUT SIMPLY THE
OUTCOME MEASURE IS WHICH OF
THOSE MODELS OF DOING IT WOULD
RESULT IN TEACHERS DOING WHAT WE
WANT THEM TO DO, WHICH IS
IDENTIFY KIDS WHO ARE AT RISK OF
SUICIDE AND MAKING THE
APPROPRIATE REFERENCE.
SO THE OUTCOME IS NOT WHETHER
SUICIDE RATES GO DOWN OR NOT.
THE OUTCOME WAS FOCUSED, ARE
WE -- WHICH MODEL BRINGS ABOUT
THE BEHAVIOR CHANGE?
AND THEN POLICYMAKERS SAID
WHICHEVER ONE WORKS, WE WILL
ADOPT IT FOR THE WHOLE STATE.
SO IT'S THOSE KINDS OF QUESTIONS
THAT I THINK VERY OFTEN
POLICYMAKERS HAVE AND WHICH I
THINK IMPLEMENTATION SCIENCE
RESEARCH CAN START TO ADDRESS.
THAT'S REALLY -- SO WE
INCREASINGLY MOVED OVER TO DOING
ON -- LOOKING AT THAT RATHER
THAN EFFICACY RESEARCH WORK.
LOOKING AT HOW WE CAN TAKE SOME
OF THESE INTERESTING MODELS OF
CARE AND SCALE THEM UP.
SO WE REALLY HAVE NOT BEEN DOING
IN OUR GROUP, NOT BEEN DOING ANY
PRIMARY EFFICACY STUDIES.
>> THAT'S A REALLY GREAT
TRANSITION INTO OUR SECOND
QUESTION THINKING ABOUT THE
CONCERNS THAT POLICY MAKERS
MIGHT BRING ABOUT THE RELEVANCE
OF CONTEXT FROM A TRANSITIONING
FROM THE RESEARCH ENVIRONMENT TO
REAL-WORLDSCALE UP.
AND BILL, WHAT YOU WERE SAYING A
MOMENT AGO HOW TO PLAN FOR
IMPLEMENTATION FROM THE START?
OUR SECOND QUESTION IS TO THINK
ABOUT -- WHILE CLASSICAL
CLINICAL RESEARCH TRIES TO
CONTROL CONTEXT AS MUCH AS
POSSIBLE TO GET THE CLEAREST
SIGNAL OF THE EFFICACY OF THE
INTERVENTION, ENGAGEMENT WITH
CONTEXT IS REALLY INESCAPABLE IN
IMPLEMENTATION SCIENCE.
SO, DR. VICTOR MWAPASA, THIS
QUESTION IS TO YOU.
WHY MUST CONTEXT BE CONSIDERED
IN DESIGNING AND CONDUCTING
IMPLEMENTATION SCIENCE RESEARCH,
HOW SHOULD RESEARCHERS ENGAGE
WITH CONTEXT TO MAXIMIZE THE
IMPACT OF THEIR WORK?
IF YOU WOULD START WITH JUST A
LITTLE BIT OF ORIENTATION TO
YOUR WORK IN THIS SPACE.
>> YES.
SO I AM A MEDICAL DOCTOR FROM
MALAWI.
AND MALAWI HASN'T GOT A LOT OF
RESOURCES.
I WAS ACTUALLY THE FIRST GROUP
OF MA LAWIAIAN DOCTORS BEFORE WE
DID NOT HAVE MEDICAL SCHOOL.
SO WE ARE TRAINED IN THE U.K.
AND THEN AFTER TRAINING WENT
BACK TO MALAWI.
THE HEALTH SYSTEM WAS BEING RAN
BY DASH DOCTORS.
MY ENGAGEMENT WITH
IMPLEMENTATION SCIENCE IS BY
DOING IT BECAUSE I HAVE BEEN AN
OFFICER FOR TWO LIFE DISTRICTS.
OFTENTIMES THE SITUATION I MEET
AS A DISTRICT HEALTH OFFICER IS
A LOT OF -- GOVERNMENT
ORGANIZATIONS WOULD COME AND
SAY, THIS WORKS.
IMPLEMENT IT TO IMPROVE THE
SITUATION IN YOUR DISTRICT.
AT THAT TIME, I WAS IN TRAINING
IMPLEMENTATION SCIENCE.
THEN I JUST GO BACK TO MY OFFICE
TO THINK ABOUT IT, DOES IT WORK
OR NOT?
AND THEN I GOT INVOLVED IN THE
MINISTER OF HEALTH ADVISING WHAT
EVIDENCE THEY SHOULD SCALE UP
AND WHAT EVIDENCE THEY
SHOULDN'T.
AND TO GIVE YOU A TYPICAL
EXAMPLE, WE HAD A MENTAL HEALTH
CONFERENCE HERE AND WE HAVE BEEN
HEARING ABOUT THE FRIENDSHIP
BENCH.
SO I WANT TO GIVE AN EXAMPLE OF
WHAT I MEANT AS ADDITIONAL.
THE FRIENDSHIP BENCH YOU KNOW
ABOUT IT.
DEVELOPED IN ZIMBABWE 2014 OR
15.
IT WAS TOUTED THAT THIS IS GOING
TO SOLVE THE MENTAL HEALTH GAP.
WHY?
BECAUSE MOST OF OUR COUNTRIES
WHO DON'T HAVE A LOT OF PEOPLE
IN THE MENTAL HEALTH SPACE.
AND THE THIS INTERVENTION
INVOLVED GIVING PROBLEM-SOLVING
THERAPY DELIVERED BY GRANDMAS,
THAT DON'T NEED A LOT OF SALARY.
AND IT INVOLVED LIKE SIX
SESSIONS OF PROBLEM-SOLVING
THERAPY.
AND THEN IN BETWEEN THE THERAPY,
THEY SENT TO THE PATIENTS AND
THEN JOIN A PEER GROUP.
IT WAS TOUTED AS AN EASY
STRAIGHTFORWARD INTERVENTION
THAT WILL HELP PEOPLE WITH
MENTAL DISORDERS.
THAT WAS 2014 OR 2015.
AND REDUCE DEPRESSION LEVELS.
PEOPLE CAME FOR THE SESSIONS.
IT WORKED BEAUTIFULLY IN
ZIMBABWE.
SO THE MALAWI GOVERNMENT SAID
THAT'S WELL AND GOOD.
ZIMBABWE -- THIS WAS IN THE
CAPITOL.
LET'S TRY TO IMPLEMENT IT IN
MALAWI WHICH IS JUST LIKE 400
KILOMETERS AWAY.
SO THE DOCTOR WITH THE TEAM WE
ALL WENT AND SAID LET'S
IMPLEMENT THIS EASY FRIENDSHIP
BENCH.
AND THAT WAS IN 2016-2017 OR
THEREABOUTS.
THEY IMPLEMENTED IT IN A TYPICAL
HEALTH FACILITY.
AND FIRST OF ALL THEY HAD TO
ADOPT IT BECAUSE THE WAY IT WAS
DESIGNED IN ZIMBABWE, IT
INCLUDED THE PROBLEM-SOLVING
THERAPY.
IT INCLUDED SENDING SMS TO THE
PARTICIPANTS, THE CLIENTS, AND
ALSO JOINING A PEER GROUP.
BUT WHEN IT LANDED IN MALAWI, A
DECISION WAS MADE THAT THE SMS
PART, SENDING A SIMPLE MESSAGE
PART IS SIMPLY NOT AFFORDABLE IN
MALAWI BECAUSE BASICALLY THE
SOCIAL ECONOMIC SITUATION, THE
HEALTH SYSTEM CANNOT AFFORD
SENDING MESSAGES TO THE
PATIENTS.
THE SECOND ASPECT IS THAT I TOLD
YOU ZIMBABWE IT WAS BEING
DELIVERED BY GRANDMAS.
THE MALAWI GOVERNMENT REALIZED
THAT YOU SEE THE EDUCATIONAL
STATUS OF GRANDMAS IN
ZIMBABWE -- THEY HAVE A GOOD
EDUCATION SYSTEM.
IF WE JUST IMPORT IT INTO MALAWI
AND USE THE GRANDMA AS IN
MALAWI, THEY ARE NOT AT THAT
LEVEL TO DELIVER THE
INTERVENTION.
SO THEY MADE A MODIFICATION AND
THEY SAID, NO, THIS IS GOING TO
BE DELIVERED BY COMMUNITY HEALTH
CENTERS TO ADJUST THAT.
SO THE LONG AND SHORT OF IT IS
THAT WHEN IT WAS TESTED IN
MALAWI, SUPPOSED TO BE JUST
TESTED RIGHT AND SCALED UP?
IT DID NOT WORK.
REDUCTION IN DEPRESSION, THE
PEOPLE DID NOT ATTEND THEIR
SESSIONS.
THEIR PROBLEM-SOLVING SESSIONS.
IT WAS IN PEOPLE'S VIEW, THIS
WONDERFUL FRIENDSHIP BENCH WHICH
WORKED BEAUTIFULLY TO DECREASE
DEPRESSION IN ZIMBABWE BY 70%,
COME TO MALAWI, IT DOESN'T WORK.
WHEN YOU FIGURE OUT WHY IT NOT
WORK, THESE ARE SIMPLE THINGS.
PEOPLE ARE NOT EXPOSED TO
INTERVENTION.
WHY?
BECAUSE THEY DID NOT ATTEMPT THE
SIX PROBLEM-SOLVING THERAPY.
THE OTHER THING THE PEOPLE WHO
WERE DELIVERING THE
PROBLEM-SOLVING THERAPY, THESE
WERE THE COMMITTEE HEALTH
CENTERS.
IN MALAWI THEY ARE DOING OTHER
THINGS BESIDES MENTAL HEALTH.
THEY ARE ALSO DELIVERING
IMMUNIZATIONS.
THEY ARE DELIVERING MALARIA
SCREENING.
SO TO ASK THEM TO SPEND 45
MINUTES PER PATIENT FOR SIX
SESSIONS, THEY SIMPLY DID NOT
HAVE THE TIME.
SO AT THAT THE TIME, IT WAS EASY
FOR THE MINISTER OF HEALTH TO
SAY, IT'S WRONG.
FRIENDSHIP BENCH DID NOT WORK.
BUT THE KEY THING WAS THAT WHY
WAS THE IMPLEMENTATION STRATEGY
THAT MALAWI WAS USING.
SO IT SHOWS THE CONTEXT OF THE
HEALTH SYSTEM IS VERY IMPORTANT.
PEOPLE SHOULD SEE THE CONTEXT.
IS THE CONTEXT OF THE HEALTH
SYSTEM IN MALAWI SIMILAR TO
ZIMBABWE?
THEY DID NOT ATTEND BECAUSE IT
IS COSTLY TO COME TO THE
FACILITIES SIX TIMES.
IT'S COSTLY.
MALAWI IS FAIRLY POOR.
SO PEOPLE WAITED OUT AND MAYBE
NOT ATTEND THESE SESSIONS.
SO WHEN YOU JUST IMPLEMENT AN
INTERVENTION, THINK ABOUT THE
HEALTH SYSTEM CONTEXT AND THINK
ABOUT THE COMMUNITY, THE SOCIAL
CONTEXT OTHERWISE YOU'RE GOING
TO BE DISAPPOINTED.
THANK YOU.
>> THANK YOU.
SO SOME VERY IMPORTANT POINTS
THERE IN TERMS OF WHAT IS
INVOLVED IN MOVING AN
EVIDENCE-BASED INTERVENTION, ONE
CONTEXT TO ANOTHER, AND WHY IT'S
SO CRITICAL TO CONSIDER THAT
CONTEXT.
WOULD YOU LIKE TO WEIGH IN ON
THIS QUESTION AS WELL ABOUT WHY
MUST CONTEXT BE CONSIDERED?
>> I WAS GOING TO GET IN THERE
AND BILL MENTIONED ABOUT CONTEXT
AND I THINK THE CONTEXT NEEDS TO
BE CONSIDERED WHEN YOU'RE
DESIGNING IT AND NOT JUST WHEN
YOU'RE TRYING TO -- I MEAN IF
YOU WERE DESIGNING FRIENDSHIP
BENCH FOR MALAWI, YOU WILL HAVE
CONSIDERED CONTEXT WHEN
DESIGNING THE INTERVENTION
ITSELF AND YOU WOULDN'T HAVE
KIND OF HEARD SOME OF THOSE
PROBLEMS YOU HAD.
LIKE LET ME GIVE YOU AN EXAMPLE
FROM WHAT WE DID IN INDIA.
IN 2013, THIS IS -- SEEMS LIKE A
LONG TIME AGO, MORE THAN A
DECADE AGO, WHEN WE WANTED TO
LOOK AT HOW YOU COULD USE WHAT
EVERYONE CALLS STAR SHIFTING OR
STAR SHARING WORK NOW TO SEE HOW
WE COULD DO THAT IN THE INDIAN
CONTEXT USING NON-HEALTH
PROFESSIONALS TO BE DOING IT.
AND ONE OF THE THINGS WE
REALIZED VERY QUICKLY AFTER WE
STARTED TALKING TO COMMUNITY
HEALTH WORKERS WAS EXACTLY WHAT
VICTOR SAID, WHICH IS THE
COMMUNITY HEALTH WORKERS ARE
VERY BUSY DOING LOTS OF THINGS
AND THEY AREN'T NECESSARILY
GOING TO FIND THE TIME.
SO WE DESIGNED AN INTERVENTION
WHICH WAS SLIGHTLY DIFFERENT.
WE SPOKE TOVILLAGE COUNCILS AND
HAD VOLUNTEERS FROM THE VILLAGE
VOLUNTEER TO DO THIS WORK.
AND THEY VOLUNTEERED FOR FIVE OR
SIX HOURS OF WORK.
THEY WERE TRAINED AND THEY WERE
MONITORED AND MENTORED TO DO IT.
SO THEY WERE NOT HEALTH WORKERS
FROM THE COMMUNITY, THEY WERE
NOT PART OF THE PUBLIC HEALTH
SYSTEM.
WE TAPPED INTO WHAT WE CALL
SOCIAL CAPITAL AND VILLAGES AND
COMMUNITIES FELT OWNERSHIP OF
THAT PROBLEM.
AND STARTING WITH 14 VILLAGES
AND 100,000 PEOPLE, TODAY THAT
PROGRAM, WHICH IS NOW EXPANDED
TO FOUR DISTRICTS, COVERAGES
ABOUT 6 MILLION PEOPLE.
WE HAVE ABOUT 1500 OF THESE
SO-CALLED CHAMPIONS WHO DO THIS
WORK AND ALONG THE WAY WE HAVE
DONE A LARGE-STEP RANDOMIZED
TRIAL ON IT TO SHOW THAT THEY
ARE AS EFFECTIVE AS ANY OTHER
COMMUNITY HEALTH WORKER.
SO THE POINT OF TELLING YOU THIS
STORY IS NOT TO SAY THAT YOU ARE
SUCCESSFUL, BUT THE POINT IS TO
SAY THAT IF YOU'RE GOING TO
SCALE UP SOME OF THESE
INTERVENTIONS LIKE FRIENDSHIP
BENCH OR MANY OF THESE MODELS
THAT PEOPLE HAVE, YOU REALLY
NEED TO DESIGN IT FOR THAT
CONTEXT.
YOU NEED TO SAY, WHAT IS MY
CONTEXT AND HOW AM I GOING TO DO
IT?
AND IT MIGHT REQUIRE TWEAKING
THE KIND OF TWEAKS YOU'RE
TALKING ABOUT, IS THE KIND OF
TWEAKS WE HAD TO MAKE AT THE
TIME OF DESIGNING IT.
AND YOU DO THAT IF YOU WERE NOT
SOMEBODY WHO IS ONLY FOCUSED ON
THE EFFICACY WORK.
IF YOU'RE FOCUSED ON EFFICACY,
YOU WILL NOT TWEAK IT AT ALL.
THE WHOLE IDEA OF THE LAW OF
EFFICACY RESEARCH IS TO NOT
TWEAK THE CONTEXT.
CONTEXT AGNOSTIC IN THAT SENSE
AND YOU'RE TRYING TO DO IT,
WHICH I DON'T THINK MAKES A LOT
OF SENSE WHEN YOU COME TO THE
IMPLEMENTATION SCIENCE END OF
IT.
SO I DO THINK IT'S SOMETHING WE
SHOULD BE LOOKING AT HOW -- AND
SO THAT IS WHY I THINK MANY OF
THESE MODELS DON'T TRAVEL VERY
WELL VERY EASILY.
THEY WILL -- THEY ARE LOCALIZED
AND FOR CONTEXT, THEY WORK IN
THAT CONTEXT.
THEY HAVE A CODE OF SIMILARITIES
BUT THE FINAL IS VERY
CONTEXTURAL.
I THINK THAT'S HOW IT SHOULD BE.
>> I WAS GOING TO SAY, I THINK
AS RESEARCHERS, WE THINK OF
IMPLEMENTATION SCIENCE AS THE
PROGRESSION.
THERE IS EFFICACY AND THERE IS
EFFECTIVENESS AND THEN
IMPLEMENTATION SCIENCE.
BUT I THINK THE EXAMPLE THAT
YOU'RE GIVING, THE EXPERIENCE
I'VE HAD IN WORKING IN FIVE
COUNTRIES THAT ARE GOING
STRAIGHT TO IMPLEMENTATION IS
THAT PEOPLE TAKE THE BEST
AVAILABLE EVIDENCE AND
IMPLEMENT.
SO THERE IS A LOT OF STUFF THAT
IS SKIPPED IN THAT PROCESS.
AND I THINK YOU END UP IN GLOBAL
MENTAL HEALTH AS IT IS TODAY,
ONE OF THE RULES OF RESEARCHERS
HAS TO BE TO SAY, HOW DO I
INFORM THESE REAL-WORLD EFFORTS
THAT ARE HAPPENING, BRING SOME
OF THESE PRINCIPLES OF SCIENCE
IN PLACES AND SITUATION THAT IS
ARE QUITE MESSY BECAUSE IT'S A
GOVERNMENT THAT IS SAYING, WE
WANT TO DO THIS.
IT'S A DONOR THAT IS SAYING WE
WANT TO DO THIS.
AND YOU DON'T HAVE THE WONDERFUL
PROGRESSION THAT HAPPENS WHEN
YOU ARE FOCUSING ON A RESEARCH
PROJECT AND NOT A LARGE
INITIATIVE AT THE COUNTRY LEVEL.
>> SO THIS CONVERSATION ABOUT
CONTEXT HAS TOUCHED ON, I THINK,
ALSO A CONVERSATION ABOUT WHAT
ARE CORE VERSUS ADAPTABLE
COMPONENTS, WHICH IS SOMETHING
THAT WE TALK ABOUT IN THE
IMPLEMENTATION SCIENCE CLASS
THAT I TEACH.
SO THREE OF YOU HAVE SPOKEN
ABOUT AN INTERVENTION THAT MAY
HAVE ELEMENTS WHICH CANNOT BE
MODIFIED WITHOUT REMOVING ITS
EFFECTIVENESS AND THEN OTHER
ELEMENTS WHICH CAN BE MODIFIED
IN ORDER TO SUIT THE CONTEXT,
AND VICTOR, YOU IDENTIFIED A FEW
ELEMENTS THAT WERE MODIFIED
ABOUT THE FRIENDSHIP BENCH
INTERVENTION IN THE TRANSITION
TO MALAWI THAT MAY THEN HAVE
UNDERCUT ITS EFFECTIVENESS.
AND BEING AT THE IMPLEMENTATION
STAGE TO DISTINGUISH WHAT ARE
THOSE CORE COMPONENTS THAT NEED
TO BE MAINTAINED VERSUS THE
ADAPTABLE COMPONENTS THAT CAN BE
MODIFIED TO FIT THE CONTEXT IS A
CRITICAL PART OF THE
CONVERSATION.
I'M GOING TO MAYBE GO OFF SCRIPT
A LITTLE BIT TO RIP-OFF OF
PAMELA'S COMMENT AND JUST SAY,
SO WHAT IS THE ROLE OF
IMPLEMENTATION SCIENCE RESEARCH
THEN?
WE TALKED ABOUT THE FACT WE HAVE
AN EVIDENCE BASE.
WE TRY TO IMPLEMENT TOO QUICKLY
OR INSUFFICIENT UNDERSTANDING
AND THINGS MIGHT GO AWRY.
WHAT IS THE LENSE THAT
IMPLEMENTATION SCIENCE RESEARCH
BRINGS TO TRY TO KEEP THAT FROM
HAPPENING?
OPEN QUESTION.
NO ONES PICTURE IS ON THE SCREEN
NOW.
[ LAUGHS ]
>> I THINK THAT PART OF THAT
QUESTION IS -- SO TO ME, THERE
IS A COUPLE OF ELEMENTS HERE.
SO IN THE CASE THAT VICTOR
PROVIDED VERY ELEGANTLY, THERE
WERE ISSUES WITH THE
INTERVENTION ITSELF IN TERMS OF
ITS SUITABILITY FOR MALAWI AS IT
WAS ORIGINALLY CONSTRUCTED.
AGAIN IT GOES BACK TO THE CORE
VERSUS ADAPTABLE COMPONENTS OF
AN INTERVENTION.
BUT WHEN YOU TAKE IT ONE STEP
FURTHER TO WHAT DOES
IMPLEMENTATION SCIENCE BRING?
TO ME IT'S A QUESTION OF IF YOU
HAVE A CLEAR UNDERSTANDING OF
THOSE CORE COMPONENTS AND THOSE
ARE SUITABLE TO A PARTICULAR
CONTEXT, THEN THE QUESTION IS,
HOW DO YOU DO IT MOST
EFFECTIVELY?
HOW DO YOU DO IT MOST
EFFICIENTLY?
HOW DO YOU DO IT IN A WAY THAT
LOSES THE LEAST EFFICACY IN A
SENSE?
BECAUSE ALMOST ALWAYS WHEN YOU
TAKE SOMETHING FROM A PEER
CLINICAL TRIAL TO THE REAL
WORLD, THERE WILL BE SOME LOSS
OF EFFECTIVENESS.
SO HOW DO YOU DO THAT IN A WAY
THAT YOU KEEP IT AS CLOSE TO THE
CLINICAL TRIAL EFFICACY AS YOU
POSSIBLY CAN?
AND TO ME, THAT'S WHAT THE
IMPLEMENTATION SCIENCE QUESTIONS
ARE.
IT'S MORE ABOUT IF WE DO IT THIS
WAY, HOW WELL DO WE DO VERSUS
THIS WAY?
AND THAT'S WHY IT GETS IN A
PRETTY MUDDY SPACE IN TERMS OF
LIKE WHO THE PARTICIPANTS ARE
AND THAT SORT OF THING, WHICH
WE'LL TALK ABOUT IN A LITTLE B
BIT.
>> WHEN YOU READ THE CLINICAL
TRIAL IN ZAMBIA, IN THE
CONCLUSION SECTION THEY WRITE,
WE WERE NOT CLEAR WHICH ELEMENT
OF THIS INTERVENTION ACTUALLY
REDUCED DEPRESSION.
REMEMBER THAT THERE WAS
COUNSELING.
THERE WAS SMS SENT TO THE
CLIENTS IN BETWEEN THE SESSIONS
AND THE JOINING OF A PEER GROUP.
SO WE HAVE THREE ELEMENTS.
BUT THE PUBLISHERS, THE
RESEARCHERS OF THE ORIGINAL DID
NOT KNOW WHICH OF THE ELEMENTS
WERE CRITICAL.
MEANING THAT IF YOU ARE ADAPTING
IT WHICH PART DO YOU DROP?
>> EXACTLY.
>> BUT I DO THINK THAT'S THE
PLACE FOR IMPLEMENTATION
SCIENCE.
SO FOR -- IF YOU COULD HAVE IN
THE MINISTRY OF HEALTH THIS
PERSON WHO IS ABLE TO TALK ABOUT
THE ADAPT OHM, HOW DO WE THINK
ABOUT ADAPTATION, SYSTEMATICALLY
AND THEN HOW DO YOU ENABLE THOSE
PEOPLE WHO ARE GOING TO BE
ULTIMATELY RESPONSIBLE FOR
ENSURING THAT THINGS ARE
IMPLEMENTED WELL TO USE THESE
SCIENTIFIC PRINCIPLES?
SO I THINK WE HAVE A ROLE OF
IDENTIFYING THE SCIENTIFIC
PRINCIPLES AND TRANSLATING THEM
FOR USE IN A PUBLIC HEALTH
CONTEXT.
>> I THINK IT'S -- I THINK IT'S
SIMPLER SOMETIMES LIKE USING OUR
SUICIDE TRAINING, GATEKEEPER
TRAINING MODEL AS AN EXAMPLE,
IT'S A SIMPLE QUESTION THAT THE
POLICYMAKER HAS, IS THAT HOW CAN
I BE SURE IF I DO THIS TRAINING
THAT SCHOOLTEACHER IS GOING TO
IDENTIFY THESE KIDS AND DO WHAT
THEY ARE SUPPOSED TO DO?
AND WHAT IS THE BEST WAY TO
TRAIN THESE SCHOOLTEACHERS?
THAT'S THE QUESTION.
THAT'S THE IMPLEMENTER'S
QUESTION WHICH YOU TAKE AND YOU
TRY AND DESIGN A WAY BY WHICH
YOU CAN ANSWER THAT QUESTION
WITH SOME DATA.
THAT'S HOW I SEE IT.
THAT'S HOW I SEE THE ROLE OF
WHAT WE DO AS IMPLEMENTATION
SCIENCE, THAT YOU HAVE A
REAL-WORLD QUESTION AND YOU TAKE
THAT REAL-WORLD QUESTION AND YOU
MAKE IT INTO A STUDY OF SOME WAY
TO TRY AND ANSWER THAT QUESTION.
SO YOU COULD DO, FOR EXAMPLE,
YOU COULD DO SOMETHING WHERE YOU
WANT TO LOOK AT REACH.
YOU WANT TO SEE IF WE TRAIN
COMMUNITY HEALTH WORKERS TO
DELIVER A MENTAL HEALTH
INTERVENTION, HOW MANY PEOPLE IN
THE COMMUNITY GET HELPED?
NOW THAT'S A DIFFERENT QUESTION
TO SAYING, IF WE TRAIN COMMUNITY
HEALTH WORKERS, HOW MANY
COMMUNITY HEALTH WORKERS WILL
ACTUALLY DELIVER THAT
INTERVENTION?
NOW THAT'S A COMPLETELY
DIFFERENT QUESTION TO THE FIRST
ONE AND YOU DO A VERY DIFFERENT
SET OF TRIALS OR STUDIES TO
ANSWER THOSE TWO QUESTIONS.
BUT BOTH OF THOSE QUESTIONS ARE
EXTREMELY IMPORTANT FOR THE
POLICYMAKER.
AND YOU NEED TO BE ABLE TO
ANSWER THOSE QUESTIONS FOR THE
POLICYMAKER BEFORE THE
POLICYMAKER FEELS CONFIDENT
ENOUGH TO COMMIT THEIR FUNDS TO
DOING WHAT YOU WANT THEM TO DO.
THEY WANT TO BE SURE THAT IF
THEY DID THAT, THEY ARE GETTING
VALUE FOR MONEY.
THEY ARE GOING TO GET BANG FOR
THE BUCK.
AND HOW DO THEY KNOW IF THEY
TRAIN LOTS OF THESE PEOPLE TO DO
MENTAL HEALTH WORK, THEY WILL GO
OUT AND DO THE MENTAL HEALTH
WORK?
THAT'S THE KIND OF QUESTIONS WE
SHOULD BE ASKING AND ANSWERING.
SO I THINK IMPLEMENTATION
SCIENCE DOES HAVE A HUGE ROLE TO
ANSWER REAL-WORLD QUESTIONS
RATHER THAN THINK ABOUT
DISCOVERY RESEARCHERS.
>> SO I THINK WE ARE GETTING
SOME CONTINUING THEMES AROUND
HOW TO USE THESE TOOLS TO
ADDRESS POLICY RELEVANT QUESTION
THAT IS HELP POLICYMAKERS
TRANSLATE EVIDENCE BASE INTO
SCALED UP SERVICE DELIVERY.
AUDIENCE MIGHT HAVE REALIZED
YOU'RE GIVING TWICE THE BENEFIT
OUT OF THIS SESSION BECAUSE THE
TOP -- THE POINTS THE SPEAKERS
DECIDE TO MAKE FROM THE STAGE
DOESN'T NECESSARILY ALIGN WITH
THE POINTS THEY INTENDED TO MAKE
WHICH ARE UP ON THE SLIDES.
SO BOTH YOU GET THEIR
REFLECTIONS IN PRINT AND THEIR
OFF THE CUFF REFLECTIONS ORALLY.
[ LAUGHS ]
BUT WITH THAT, WE WILL
TRANSITION TOPICS A LITTLE BIT
TO TALK ABOUT WHAT ARE SOME OF
THE COMPLEXITIES THAT A COMPANY
IMPLEMENTATION SCIENCE RESEARCH
SPECIFICALLY IN TERMS OF
THINKING ABOUT DESIGNING AND
CONDUCTING THESE STUDIES TO BE
ABLE TO ANSWER THESE QUESTIONS
THAT WE HAVE BEEN RAISING?
BILL?
>> BRIAN, YOU'LL BE HAPPY TO
KNOW I'M LOOKING AT --
[ LAUGHS ]
SO, DESIGNING IMPLEMENTATION
SCIENCE STUDIES IS QUITE A
CHALLENGE IN MANY WAYS.
IT'S NOT WHAT WE'RE USED TO --
INDIVIDUAL INTERVENTIONS AND WE
ARE ABSOLUTELY VIRTUALLY ALWAYS
WORKING AT SOME SORT OF CLUSTER
LEVEL, WHETHER THAT CLUSTER IS A
PHYSICIAN WHOSE TREATING MANY
PATIENTS OR WHETHER THAT CLUSTER
IS A CLINIC OR EVEN A COUNTY OR
A CITY OR SOMETHING LIKE THAT.
AND AS A RESULT, YOU HAVE MANY,
MANY FEWER PARTICIPANTS IN A
SENSE.
WHAT I MEAN BY THAT IS, YOU'LL
HAVE AN N OF 42 IS HUGE IN THE
IMPLEMENTATION SCIENCE WORLD.
SO WE WERE REALLY LUCKY IN OUR
SCALE UP OF HPTN074 TO BE ABLE
TO DO IT IN 42 CLINICS.
I JUST LOST MY THING SO I DON'T
KNOW WHAT ELSE I'M GOING TO SAY.
THERE WE GO.
AND WHEREAS IN CONTRAST, BRIAN.
[ OFF MICROPHONE ]
>> SO WE DID 10 AND WE THOUGHT
THAT TOOK A LOT OF WORK AND NOW
WE'RE DOING 12.
[ LAUGHS ]
12 DISTRICTS.
>> 12 DISTRICTS.
>> PRETTY COMPLICATED.
>> YES, EXACTLY.
>> SCALING UP SERVICES IN 12
HEALTH DISTRICTS.
>> IN OUR FOLLOW-UP IN A
DIFFERENT PROJECT, WHICH IS AN
ALCOHOL-BASED --
ALCOHOL-REDUCTION INTERVENTION
IS IN 30 CLINICS.
WE WENT FROM 42 TO THIRT BECAUSE
42 IS IMPOSSIBLE TO MANAGE --
42-30.
IF YOU THINK ABOUT WHAT YOU'RE
DOING IN EACH OF THOSE CLINICS,
YOU'RE TRAINING PEOPLE TO
DELIVER THIS INTERVENTION.
SO THE PEOPLE THAT YOU'RE
ACTUALLY TRYING TO STUDY ARE
USUALLY THE STAFF.
AND POTENTIALLY THE CLINIC
DIRECTORS.
AND THAT'S A VERY DIFFERENT
POPULATION THAN WE'RE USED TO
WORKING WITH.
AND THEY HAVE OTHER JOBS TO DO.
THEY ARE TRYING TO, YOU KNOW,
MANAGE THE REST OF THEIR
CLINICAL RESPONSIBILITIES.
TYPICALLY YOU'RE NOT -- YOU
MIGHT BE GIVING THE CLINIC A
LITTLE BIT OF FUNDING.
YOU'RE NOT NECESSARILY PAYING
THEM DIRECTLY BECAUSE YOU'RE
TRYING TO REPLICATE THE REAL
WORLD OF WHERE THE MINISTRY OF
HEALTH BASICALLY SAYS, YOU'RE
GOING TO ADD THIS TO YOUR
REPERTOIRE OF WHAT YOU DO.
AND THERE IS NO -- LIKE YOU'RE
GOING TO ADD THIS TO YOUR REP
PRIOR AND YOU'RE GOING TO GET
PAID EXTRA TO DO THAT.
AND SO, SOMETIMES SOME OF THE
LARGER AGENCIES WILL DO THAT.
THEY'LL COME IN, THEY'LL PAY
PEOPLE EXTRA TO DO IT.
THEY'LL DO IT AND THEN WHEN THE
AGENCY LEAVES, THE ACTIVITY
STOPS.
SO YOU DO HAVE TO TAKE THOSE
KINDS OF THINGS INTO ACCOUNT AS
WELL.
THE OUTCOMES ARE TOTALLY
DIFFERENT THAN WHAT WE'RE USED
TO.
THE OUTCOMES ARE THINGS LIKE
FIDELITY TO THE INTERVENTION.
SO FOR OUR STUDIES, FIDELITY IS
BEING MEASURED BY A COMPOSITE
INDEX THAT WE CREATED THAT TAKES
INTO ACCOUNT THE FREQUENCY THAT
THE NUMBER OF SESSIONS WAS
COMPLETED COUPLED WITH AN AUDIO
RECORDING REVIEW OF ESSENTIALLY
THE QUALITY OF THE COUNCILLING
SESSION.
AND WE DON'T REVIEW EVERY SINGLE
AUDIO RECORDING.
WE REVIEW A SAMPLE AND THEN YOU
PUT THAT TOGETHER TO GET A
CLINIC SCORE TO BE ABLE TO
COMPARE THE CLINICS IN THE TWO
ARMS OF THE STUDY.
IT'S QUITE A CHALLENGE TO THINK
ABOUT HOW DO YOU DESCRIBE THAT
FIDELITY OUTCOME IN A WAY THAT
EVERYONE CAN GRASP AND TAKE AWAY
IN A MEANINGFUL WAY?
HOW DO YOU DESCRIBE WHO ARE YOUR
PARTICIPANTS?
YES YOU HAVE TO CONSENT EVERY
PERSON IN ORDER TO GET THEIR
AUDIO RECORDING.
BUT THAT'S ALL YOU'RE GETTING
FROM THEM IS AN AUDIO RECORDING
THAT YOU'RE ACTUALLY NOT GRADING
THEM.
YOU'RE GRADING THE PERSON THAT
DELIVERED THE AUDIO RECORDING.
SO, ARE THEY A PARTICIPANT?
THEY ARE FROM AN IRB
PERSPECTIVE.
THEY AREN'T REALLY FROM A TRIAL
PERSPECTIVE.
BUT HOW DO YOU THINK ABOUT THAT
AND HOW DO YOU MANAGE THAT KIND
OF THING?
>> I HAVE TO LOOK UP HERE NOW.
>> THANK YOU.
>> I'LL ALSO ADD THAT THERE IS
OFTEN A QUALITATIVE ELEMENT TO
IT.
WHEN YOU'RE THINKING ABOUT
ACCESSIBILITY, SURE WE HAVE
MEASURES -- ACCEPTABILITY --
THEY ARE USUALLY GENERIC.
THEY AREN'T NECESSARILY LES.
YOU CAN TAYLOR THEM TO YOUR
PARTICULAR CIRCUMSTANCES.
BUT YOU HAVE TO TALK TO PEOPLE
AND TALK TO THE PEOPLE WHO
DELIVERED THE INTERVENTION AND
TO THE PEOPLE WHO RECEIVED THE
INTERVENTION.
THOSE ARE TWO DIFFERENT FORMS OF
ACCEPTABILITY THAT ARE REALLY
IMPORTANT.
SO WHEN YOU TAKE ALL OF THESE
THINGS INTO CONSIDERATION, IT'S
A QUITE DIFFERENT FEEL FROM A
TRADITIONAL INTERVENTION TRIAL.
AND JUST TO GIVE YOU A SENSE OF
WHAT THE ARMS MIGHT BE, SO IN
OUR - AUTO ONE I REFERRED TO
EARLIER, ONE ARM IS JUST SIMPLY
MAPPING OUT WHAT THE SORT OF
SUPPORT MECHANISMS WERE FROM A
VERY SORT OF CENTRALLY-MANAGED
PERSPECTIVE.
MUCH LIKE A MINISTRY WOULD
TYPICALLY DO.
THEY WOULD SAY YOU NEED TO
IMPLEMENT THIS.
THESE ARE YOUR RESOURCES TO
IMPLEMENT.
THE INTERVENTION ARM WAS
BASICALLY TAILORED TO THE CLINIC
WHERE WE DID SOME VERY FAIRLY
SIMPLE INTERVIEWS OF PEOPLE IN
THE CLINIC FOUND OUT WHAT THEIR
NEEDS WERE, FOUND OUT WHAT THEIR
CHALLENGES WERE AND THEN A MENU
OF THINGS THEY COULD PICK FROM
TO ADD TO THAT.
SO NOT A LOT MORE TIME AND
ENERGY BUT SOME.
AND SO OBVIOUSLY COST WILL BE
ONE OF OUR OUTCOMES IN ADDITION
TO THE ACTUAL INTERVENTION.
AND THEN IN THE OTHER CONTEXT WE
ARE DOING AN INTERVENTION THAT
IS AN EXPERIENTIAL ONE WHERE THE
INTERVENTION ARM UNDERGOES THE
INTERVENTION TO UNDERSTAND WHAT
IT FEELS LIKE TO BE THE
RECIPIENT BEFORE THEY DELIVER
IT.
SO THOSE ARE SOME OF THE -- IT'S
QUITE A DIFFERENT FEEL FROM YOUR
TYPICAL INTERVENTION AND QUITE
DIFFICULT FROM A STATISTICAL
PERSPECTIVE.
IF YOU EVER HAVE THE FORTUNE TO
BE WRITING AN IMPLEMENTATION
SCIENCE GRANT AND SEND IT TO AN
NIH STUDY SECTION, HOPE AT LEAST
ONE OR TWO OF THE PEOPLE
UNDERSTAND SOMETHING ABOUT
IMPLEMENTATION SCIENCE OTHERWISE
THEY WILL TELL YOU THAT YOU
CAN'T DO THAT WITH 30 CLINICS.
YOU CAN'T HAVE A SAMPLE SIZE OF
30.
THAT'S RIDICULOUS.
SO YOU NEED PEOPLE TO UNDERSTAND
WHAT YOU'RE TRYING TO DO.
>> IT'S A REAL CHALLENGE GETTING
REVIEWERS WHO ARE GOING TO
UNDERSTAND WHAT YOU'RE TRYING TO
DO AND YOU GET REVIEWERS WHO
LARGELY HAVE DONE EFFICACY
STANDARDS AND THINK WHAT YOU'RE
DOING IS REALLY A PROBLEM.
AND EVEN WHEN YOU HAVE PEOPLE ON
YOUR DSMB THINKING SOMETIMES
THAT THEY DON'T KNOW WHAT YOU'RE
DOING.
LIKE FOR EXAMPLE, ONE OF THE
TRIALS WE DID, AND WE HAD A VERY
INTERESTING EXPERIENCE, WAS THIS
IDEA OF RESTRICTING ACCESS TO
MEANS IS RECOMMENDED AS A WAY TO
REDUCING SUICIDE.
NOW EVERYONE SAYS, WE SHOULD BE
DOING IT.
AND SO IN INDIA IT'S PESTICIDE.
WE THOUGHT WE WOULD TRY THIS OUT
IN REAL LIFE, WHAT HAPPENS IF
YOU TRY TO RESTRICT ACCESS TO
MEANS.
SO THE METHOD WE CHOSE WAS, WE
WOULD PUT THESE BOXES, SAFE
DEPOSIT BOXES IN THE VILLAGE
COUNSEL AND ENCOURAGE FARMERS TO
USE THOSE BOXES.
NOW IN A TYPICAL RCT WHAT YOU
WOULD DO IS TRY TO GET 100%
COMPLIANCE WITH THAT.
YOU WANT TO GET EVERY FARMER
PUTTING IN THEIR -- INTO THE
BOXES AND THEN YOU WANT TO SEE
THE SUICIDE DEATHS GO DOWN.
IF YOU'RE TRYING TO DO IT IN THE
REAL WORLD, YOU WANT TO KNOW
WHAT HAPPENS IN THE REAL WORLD
WHICH IS THAT HALF OF THE
FARMERS WILL USE IT HALF OF THE
TIME AND ANOTHER HALF WILL USE
IT A QUARTER OF THE TIME OR SOME
PEOPLE WILL NOT USE IT AT ALL
AND SOME PEOPLE WILL USE LOTS OF
IT.
AND THEN YOU WANT TO SEE DOES IT
STILL WORK AND HOW DOES IT WORK
AND HOW MANY PEOPLE ACTUALLY USE
THE BOXES?
NOW WHEN YOU PUT IN A GRANT
PROPOSAL WITH SAY ALL OF THIS,
THE REVIEWERS FIND IT VERY
DIFFICULT.
THIS IS WRONG.
THIS IS JUST NOT WORKING OUT
VERY WELL.
SO I THINK REVIEWERS ALSO NEED
TO REALLY -- I GET CONCERNED
THAT VERY OFTEN THE COMMENTS WE
GET FROM REVIEWERS IF YOU'RE
PUTTING IN IMPLEMENTATION
SCIENCE PROPOSAL, YOU THINK THEY
ARE NOT IMPLEMENTATION SCIENCE
PEOPLE.
THEY DIDN'T SEE WHAT WE WERE
TRYING TO DO.
THEY THINK THIS IS BAD SCIENCE.
IT COMES ACROSS AS BAD SCIENCE
FOR THEM BECAUSE THEY USED TO
CONTROLLING EVERYTHING.
SO WHEREAS YOU DON'T WANT TO
CONTROL -- YOU REALLY DON'T WANT
TO TRY AND -- YOU DON'T WANT TO
DO SOMETHING WITH THE FARMERS
WHO PUSH THEM TO USE IT BECAUSE
YOU WANT TO SEE WHAT HAPPENED IN
REAL LIFE.
>> IT'S AN INTERESTING TENSION
BECAUSE IN -- WE ARE TRAINED TO
THINK WE SHOULD BE ENSURING THE
FIDELITY OF THE INTERVENTION.
THAT IS THE WHOLE FOCUS OF THE
RESEARCH TEAM IS TO MAKE SURE
THE INTERVENTION IS BEING
DELIVERED THE WAY IT'S SUPPOSED
TO BE DELIVERED.
MORE OFTEN IMPLEMENTATION
SCIENCE, WE STOOD THAT ON ITS
HEAD AND WE ARE STUDYING THE
FIDELITY AS THE OUTCOME AND
WHETHER THE FIDELITY -- WHICH
STRATEGY LEADS TO HIGHER
FIDELITY ANTICIPATION WILL LEAD
TO BETTER PATIENT OUTCOMES.
>> MANY PEOPLE IN IMPLEMENTATION
SCIENCE SPACE WILL SAY TO YOU
THAT IF YOU GOT 100 PERSON
FIDELITY, THEY DON'T TRUST YOUR
STUDY AT ALL.
BECAUSE IT CAN'T BE
IMPLEMENTATION SCIENCE STUDY.
IF YOU CALL IT IMPLEMENTATION
SCIENCE STUDY, YOU COULDN'T HAVE
100 --
>> COULDN'T POSSIBLY REFLECT THE
REAL WORLD.
>> CAN I ADD ONE THING TO THAT
REAL QUICKLY?
>> YES, PLEASE.
>> IN VIETNAM OUR STAFF IS
OUTSTANDING.
LIKE THEY ARE REALLY GOOD.
AND ONE OF OUR RESEARCH
ASSISTANCE IS JUST SO ATTENTIVE
TO DETAIL.
AND HAS EXPERIENCE IN EFFICACY
TRIALS.
AND WE'RE AFRAID TO ASSIGN HER
TO THE IMPLEMENTATION TRIAL
BECAUSE SHE'S GOING TO BE TOO
EFFECTIVE AT MAKING SURE THAT
EVERY CLINIC IN BOTH ARMS IS
DOING EVERYTHING THAT THEY ARE
SUPPOSED TO DO.
AND THAT'S NOT GOING TO BE THE
WAY IT IS IN THE REAL WORLD.
>> AND IT'S ALSO, HAS A LITTLE
BIT OF A TENSION -- IF YOU WANT
TO TALK A LITTLE BIT ABOUT THIS
ASPECT OF HOW ARE OUR REGULATORY
MONITORING APPROACHES FOCUS ON
THESE ENROLLMENT TARGETS AND HOW
THAT REALITIES TO IMPLEMENTATION
SCIENCE TRIALS VERSUS STANDARD
EFFECTIVENESS EFFICACY TRIALS.
>> I MEAN, YOU KNOW THIS WHOLE
THING ABOUT RECRUITING PEOPLE
INTO STUDIES NOW.
AS YOU SAID, BILL, VERY OFTEN
THE FOCUS OF THE -- THE UNIT OF
YOUR RECRUITMENT IS NOT ACTUALLY
AN INDIVIDUAL IN IMPLEMENTATION
TRIALS.
HOW DO WE DO THAT?
FOR EXAMPLE WITH OUR SUICIDE
PREVENTION WORK THAT WE WERE
DOING, A RANDOMIZATION AND THE
CLUSTER RANDOMIZATION WAS AT THE
LEVEL OF THE VILLAGES BUT WE
WILL TO GET VILLAGE COUNSELS TO
CONSENT.
AND ONCE THEY CONSENTED, WE PUT
THESE BOXES IN THERE AND THEN WE
GOT PEOPLE USING THE BOXES TO
CONSENT.
NOW, WHEN YOU'RE LOOKING AT
ENROLLMENT, WHAT IS ENROLLMENT?
THE VILLAGES ARE THE ENROLLMENT?
IS IT THE INDIVIDUALS USING THE
BOXES THAT IS THE EP ROLEMENT?
AND WHEN YOU REPORT THE EP
ROLEMENT, IF NOT EVERYONE IS
USING THE BOXES, IS THAT BAD?
IS THAT GOOD?
A LOT OF THE REGULATORY STUFF IS
NOT DESIGNED FOR IMPLEMENTATION
SCIENCE RESEARCH.
IT'S DESIGNED FOR THE STANDARD
VERY CONVENTIONAL EFFICACY RCTN
AND THE PROBLEMS WITH TRIALS.GOV
KIND OF THING, YOU GET THAT WITH
REGULARLY -- YOU GET THAT ALL
THE TIME BECAUSE PEOPLE DON'T
UNDERSTAND HOW -- YOU'RE NOT
DOING WELL OR YOU'RE DOING BADLY
AND HOW DO YOU REPORT TO THE
REGULATORS WHAT YOU'RE DOING?
ONE OF THE OTHER PROBLEMS THAT
HAPPENS WITH IMPLEMENTATION
SCIENCE AND ESPECIALLY WITH
SUICIDE RESEARCH, BECAUSE THAT'S
WHAT WE ENDED UP DOING, IS
SUICIDE IS AN OUTCOME FOR YOUR
STUDY.
PREVENTION OF SUICIDE IS AN
OUTCOME.
BUT FOR MANY -- FOR MOST
RESEARCH, ATTEMPTED SUICIDE OR
SUICIDE IS A SERIOUS ADVERSE
EVENT.
HOW DO YOU DEAL WITH SOMETHING
BEING A SERIOUS ADVERSE EVENT
FOR THE PURPOSES OF A TRIAL BUT
IS AN OUTCOME OF THE PURPOSES OF
YOUR STUDY AND YOU'RE NEVER
GOING TO HAVE AN INTERVENTION
WHICH REDUCES SUICIDE TO ZERO.
SO YOU CAN'T SAY YOU GOT ONE
SUICIDE SO THAT'S BAD.
BECAUSE YOU COULD ALWAYS GET A
FEW EVEN -- SO A LOT OF THE
REGULATORY STUFF DOES NOT
ACTUALLY REALLY UNDERSTAND OR IS
NOT BEING DESIGNED FOR
IMPLEMENTATION RESEARCH.
WE NEED TO REALLY RETHINK HOW
THAT IS DONE AND HOW CAN IT BE
DONE DIFFERENTLY AND EVEN
TRIALS.GOV NEEDS TO PROBABLY
LOOK AT THIS IN A VERY DIFFERENT
WAY.
>> SO AS BILL WAS SAYING, IF
THE -- IF YOU'RE REPORTING TO
YOUR FUNDER AND YOUR MONITORING
BOARD AND YOUR REGULATORY BOARD
THAT YOUR NUMBERS OF
PARTICIPANTS ENROLLED BUT THAT
NUMBER IS A FUNCTION OF THE
FIDELITY, WHICH IS WHAT YOU'RE
STUDYING, DO YOU WANT YOUR STUDY
TEAM TO DO EVERYTHING THEY CAN
TO MAXIMIZE THAT NUMBER OF
PARTICIPANTS ENROLLED?
WHICH THEY'LL DO BY MESSING WITH
THE FIDELITY, WHICH IS WHAT
YOU'RE TRYING TO STUDY?
IT DOES BECOME VERY COMPLICATED.
SO LET'S TRANSITION TO OUR LAST
QUESTION.
AND VICTOR, I'LL TURN THIS FIRST
TO YOU.
HOW CAN IMPLEMENTATION RESEARCH
HAVE MAXIMUM POLICY AND
COMMUNITY IMPACT?
>> YES, I THINK IN ALL THESE
THINGS WE MUST REALIZE THAT WHAT
WE ARE TRYING TO DO IS TO GET
PEOPLE BETTER.
AND EVEN IN THIS CONFERENCE, I
HAVEN'T HEARD ENOUGH ABOUT THE
COMMUNITY.
AND WHAT I HEARD MOSTLY IS THAT
WE CONSULT THE COMMUNITY.
CONSULTING THEM TO PARTICIPATE
IN THE STUDY.
BUT NOT CONSULTING THEM TO CORE
DESIGN THE STUDY.
WHAT DO I MEAN BY CO-DESIGNING
THE STUDY?
YOU FIND THAT IN MY CONTEXT,
MENTAL HEALTH ISSUES COME THE
WAY PEOPLE THINK ABOUT MENTAL
HEALTH ISSUES, IN THE NORMAL
COMMUNITY WHERE I COME FROM, IT
COMES FROM SUPER NATURAL FORCES.
WHICH CRAFT.
A PUNISHMENT FROM GOD.
THAT'S THE PREVAILING UNDERS
UNDERSTANDING.
NOW WHEN WE ARE DESIGNING OUR
INTERVENTIONS, FROM THE WESTERN
PERSPECTIVE, WE SAY WE ARE GOING
TO HAVE A FRIENDSHIP BENCH AND
GIVE ANTIDEPRESSANT BUT, WE
DON'T TAKE INTO ACCOUNT THE CORE
ISSUES IN THE COMMUNITY.
PEOPLE AS WE SPEAK NOW, ARE
BEING TREATED WITH NATURAL
METHODS.
NOW INTERESTINGLY, IN THE
FRIENDSHIP BENCH, WE CHOSE
MOSTLY PSYCHOTHERAPY, SOME
PEOPLE GOT ANTIDEPRESSANT.
THERE IS ONE LINE IN THE STUDY
REPORT THAT 1-10 OF THE STUDY
PARTICIPANTS SOUGHT HEALING FROM
A TRADITIONAL HEALER.
MEANING THAT IN THE REAL
CONTEXT, PEOPLE ARE GOING TO
HAVE CO-INTERVENTIONS AND THEY
THEIR CO-INTERVENTIONS ARE
MOSTLY THE THINGS WE DO NOT
MEASURE.
IN MY CONTEXT, THE MAJORITY OF
PEOPLE ARE RELIGIOUS.
SO THEY WILL NOT HAVE A MENTAL
ILLNESS WITHOUT GOING FOR
RELIGIOUS HEALING.
WE LIVE IN VILLAGES SO THEY DO
NOT HAVE A MENTAL ILLNESS AND
THE DRIVERS OF MENTAL ILLNESS
THAT IS SUPPOSED TO BE THINGS
LIKE WITCHCRAFT.
SO PEOPLE ARE NOT CRAZY THAT
DON'T TRY TO TREAT THAT WITH
JUST MEDICATION FROM THE
HOSPITAL WITHOUT ACTUALLY
CONSULTING THEIR SPIRITUAL
HEALER OR TRADITIONAL HEALER.
SO WHY NOT THE ISSUES THAT I
HAVE -- ONE OF THE ISSUES I HAVE
IS WHEN WE TALK ABOUT
CO-DESIGNING, IT'S NOT WITH THE
COMMUNITY.
IT'S NOT JUST ASKING THEM CAN
YOU BE PART OF THE DELIVERING
THE FRIENDSHIP BENCH?
CO-DESIGNING TO ME MEANS, WHAT
INTERVENTION THAT YOU HAVE
TRADITIONALLY WOULD YOU LIKE TO
BE DELIVERED WITH THIS?
I HAVE SITUATIONS WHERE PEOPLE
THAT ARE TREATING PATIENTS OR
CLIENTS FOR MENTAL ILLNESS, THEY
WILL ADMONISH CLIENTS FOR USING
TRADITIONAL METHODS.
SO, YOU ARE RECEIVING AN
ANTIDEPRESSANT AND YOU'RE DOING
THIS?
YOU WENT TO A HEALER?
YOU SHOULD NOT DO THAT.
YOU WENT TO A SPIRITUAL -- YOU
SHOULD NOT DO THAT.
I THINK THIS IS THE PART THAT WE
ARE MISSING.
IF SOMETHING IS GOING TO BE
EFFECTIVE, REMEMBER THIS MENTAL
HEALTH INTERVENTIONS HAVE TO BE
GIVEN OVER A PERIOD OF TIME.
IT'S THE COMMUNITY THAT ARE
GOING TO GIVE THESE
INTERVENTIONS.
SURELY YOU CAN'T FORGET ABOUT
SPIRITUAL HEALING AND
TRADITIONAL HEALING.
SO FOR ME, ONE THING THAT IS
MISSING IN THE CO-DESIGN OF US,
HOW DID YOU INVOLVE THE
COMMUNITY?
THEY PARTICIPATED WITH
TRANSLATION OF THE LANGUAGE TO
LOCAL.
BUT THAT'S NOT ADAPTATION.
ADAPTATION MEANS, WHAT METHODS
FOR MANAGING MENTAL ILLNESS IN
THE COMMUNITY, HAVE YOU
INCORPORATED INTO YOUR DESIGN?
SO THAT'S THE PART THAT I THINK
WHEN YOU TALK ABOUT COMMUNITY
INVOLVEMENT, WHICH IS VERY
IMPORTANT, WE DON'T USUALLY
CONSIDER IT WHEN WE ARE
DESIGNING OUR STUDIES.
THE SECOND PART, I WANT TO TALK
ABOUT POLICY ENGAGEMENT BECAUSE
AGAIN I HAVE BEEN ASKING THIS
QUESTION TO MOST OF THE
PRESENTERS.
DO YOU CONSULT THE -- YES, YES.
THEY SAY YOU CAN DO THIS STUDY.
WHAT DOES IT MEAN POLICY
ENGAGEMENT?
IN MOST OF OUR COUNTRIES
RESOURCE LIMITED COUNTRIES, ONE
OF THE BIGGEST IMPEDIMENTS IS
THE HEALTH CARE EXPENDITURE.
THEY RECOMMEND THAT WE SPEND 86
DOLLARS PER CAPITA PER YEAR.
86 DOLLARS PER PERSON PER YEAR!
NOW IN MALAWI, THE PER CAPITA
EXPENDITURE PER YEAR IS 65
DOLLARS.
IT USED TO BE 40 DOLLARS.
SO, WHEN WE ARE DESIGNING AN
INTERVENTION, ONE OF THE THINGS
THAT ENGAGE WITH THE
POLICYMAKERS IS, IS THIS GOING
TO BE IMPLEMENTABLE WITH THE
RESOURCES THAT YOU HAVE GOT?
THE COST IS 65 DOLLARS.
I SAW ONE OF THE POSTERS UP
THERE - THEY SAID -- THEY WROTE
A BEAUTIFUL STUDY.
AND ONE LINE WAS THAT THERE IS
ZERO PERCENT CHANCE THIS IS
GOING TO BE SCALED UP IN MALAWI
BECAUSE IT'S TOO EXPENSIVE.
THEN I ENGAGED THE PERSON, SO
WHY ARE YOU DOING THE STUDY IN
THIS SETTING?
IF THERE IS 0% CHANCE?
THE REASON I BELIEVE, IS THE
STAKEHOLDER ENGAGEMENT, THE
POLICYMAKERS, WAS NOT
INTERESTED.
BECAUSE THE POLICYMAKERS SHOULD
HAVE KNOWN THAT WITH OUR TOTAL
HEALTH EXPENDITURE THAT LOW,
THIS INTERVENTION IS NOT GOING
TO WORK.
SO, FOR ME, ENGAGING THE
POLICYMAKERS SHOULD BE DEEPER.
AND THEY MUST BE PART OF THE
DESIGN.
THEY SHOULD TELL YOU OFFHAND
THAT YOU WANT TO THE DO THIS
INTERVENTION, IT WILL REQUIRE --
PROCURE SO MANY DRUGS, REQUIRE
US TO REMODEL THE FACILITY.
SORRY.
WE CAN'T IMPLEMENT THIS.
BUT I SEE A LOT OF INTERVENTIONS
THAT HAVE BEEN TESTED WITHOUT
DUE CONSIDERATION OF THE
RESOURCES THAT ARE AVAILABLE.
SO FOR ME, I THINK THERE NEEDS
TO BE A CHANGE IN MIND.
AND YOU MIGHT ASK WHY IS THAT
THE CASE?
AT THE MOMENT MOST OF OUR
COUNTRIES ARE UNDER IMF
PROGRAMS.
THE IMF SAYS YOU CAN NOT
INCREASE YOUR WORKFORCE SO THERE
IS NO ROOM FOR YOU TO INCREASE.
WE ARE GOING THROUGH A
DEVALUATION NOW, RIGHT?
SO THE CHANCES THAT OUR
RESOURCES WILL INCREASE, THE
CHANCES ARE CLOSE TO ZERO.
IT MEANS THAT IF WE WANT TO
SCALE UP INTERVENTIONS, OUR
ENGAGEMENT WITH THE
POLICYMAKERS, WE SHOULD BE
LOOKING AT WHAT RESOURCES DO YOU
HAVE?
CAN THIS INTERVENTION I'M TRYING
TO DESIGN, CAN YOU AFFORD IT?
AND I THINK WE ARE NOT MOSTLY
DOING THAT.
WE ARE SIMPLY DESIGNING THINGS
TO SAY WE PUBLISHED IN JAMA,
LANCET, BEAUTIFUL BUT THE
CHANCES OF IMPLEMENTATION ARE
CLOSE TO ZERO BECAUSE WE ARE NOT
ENGAGING THE POLICYMAKERS TO
LOOK AT THE RESOURCES THAT THEY
HAVE.
THANK YOU.
>> THANK YOU.
THANK YOU.
[ APPLAUSE ]
PAMELA, CAN I INVITE YOU TO
WEIGH IN ON THIS TOPIC?
>> YES, I WAS GOING TO TALK
ABOUT CO-CREATION AS WELL AND I
THINK YOU SPOKE TO THAT VERY
WELL.
I'M GOING TO TALK ABOUT
SOMETHING ELSE AND THAT'S HOW DO
WE ACTUALLY COMMUNICATE THE
RESULTS THAT WE DO HAVE?
AND WHO ARE WE COMMUNICATING TO?
HOW FREQUENTLY ARE WE
COMMUNICATING?
AND WHAT ARE THE MESSAGES?
SO WHAT IS MOST RELEVANT TO
POLICYMAKER OR COMMUNITY MAY NOT
BE WHAT IS MOST RELEVANT TO JAMA
OR WHATEVER JOURNAL THAT YOU'RE
PUBLISHING IN.
AND SO IT REALLY TRANSLATING THE
OCTOBERUAL FINDINGS REQUIRES AN
ADDITIONAL CONSIDERATION OF THE
DATA AND THE IMPLICATIONS BEYOND
MIGHT BE PUBLISHED IN A
SCIENTIFIC PAPER.
SO, I THINK THE QUESTION IS, HOW
OFTEN DO WE DO THIS?
HOW OFTEN DO WE TAKE THE TIME TO
DO THIS AND HOW OFTEN DO WE SET
OUT THE STRATEGY FOR
COMMUNICATION AND THAT
ENGAGEMENT THAT NEEDS TO HAPPEN
AFTER THE STUDY IS DONE?
HOW DO YOU GO BACK TO THE
COMMUNITY?
HOW DO YOU GO BACK TO YOUR
POLICYMAKERS ENSURING THAT THIS
CAN BE COMMUNICATED IN TERMS OF
CLEAR RECOMMENDATIONS WHETHER
THE RECOMMENDATION MIGHT BE NO,
THIS ISN'T THE BEST THING FOR
THIS COMMUNITY OR THE
RECOMMENDATION MAY BE, YES, AND
HERE IS THE EVIDENCE AND HERE IS
WHAT YOU CAN DO WITH THAT
EVIDENCE.
>> THANK YOU.
BILL?
>> I JUST WANT TO SAY IT'S
ALWAYS REALLY HARD TO FOLLOW
VICTOR.
[ LAUGHS ]
SO I JUST HAD TWO SHORT POINTS.
ONE IS RELATED TO VICTOR'S POINT
REALLY.
IT'S EASY FOR US AS
INVESTIGATORS TO THE HAVE AN
IDEA AND JUST WANT TO GO WITH IT
AND DEVELOP IT AND WRITE A
GRANT.
IT'S A LOT HARDER TO TAKE THE
TIME TO TAKE THAT IDEA AND HAVE
THE MEANINGFUL CONVERSATIONS
WITH THE PEOPLE THAT ARE GOING
TO BE THINKING ABOUT WHETHER
THIS IS IMPLEMENTABLE IN THE END
OR NOT.
AND THE ONLY WAY THAT YOU CAN
REALLY DO THAT IS IF YOU HAVE
EXISTING RELATIONSHIPS WITH
THOSE PEOPLE OVER, TYPICALLY
OVER A LONG PERIOD OF TIME.
ONE OF THE REALLY FORTUNATE
THINGS FOR US IN VIETNAM IS THAT
MY COLLEAGUES HAVE BEEN WORKING
THERE FOR 20 YEARS AND THE
PEOPLE THAT ARE IN THE, WHAT'S
CALLED THE VAAC, THE AUTHORITY
THAT IS RESPONSIBLE FOR
VIETNAM'S HIV CONTROL, ARE LONG
TERM COLLEAGUES AND ARE OPEN TO
HEARING WHAT WE HAVE TO SAY.
AND THEN THEY JUST SAY BACK TO
US, THAT'S CONSISTENT WITH THIS
POLICY AND THE MINISTRY OF
HEALTH OR THEY'LL SAY THAT IT'S
NOT CONSISTENT WITH ANY EXISTING
POLICY.
SO IT DOESN'T REALLY MAKE SENSE
FOR YOU TO DO THAT.
AND THAT GIVES US A MUCH GREATER
HOPE OF MOVING IT FORWARD.
AND WHAT WE HAVE DONE IN A
FOGARTY D43, A TRAINING CENTER,
INCORPORATE THE POLICYMAKERS
INTO THE IMPLEMENTATION SCIENCE
TRAINING AND THEY ARE JUST
SOAKING UP ALL OF THE KNOWLEDGE
ABOUT WHAT IT MEANS TO THINK
ABOUT HOW TO IMPLEMENT AND HOW
TO DO IT STRATEGICALLY AND HOW
TO SORT OF ASSESS IT.
AND I'M HOPEFUL THAT WILL HELP
THE DIALOGUE AND THE DIALOGUE
THE MORE EARLY CAREER PEOPLE
BECAUSE THEY WORKED IN SMALL
GROUPS WHERE THERE IS A
POLICYMAKER WITH THE ACADEMICS
WITHIN VIETNAM SORT OF WORKING
ON THE SAME KIND OF PILOT.
AND THAT, I HOPE THAT THAT
CONTINUES LONG AFTER WE'VE SORT
OF RETIRED FROM OUR ROLE THERE.
>> THANK YOU, BILL.
WHAT IS YOUR RESPONSE ABOUT HOW
IMPLEMENTATION SCIENCE RESEARCH
CAN MAXIMIZE POLICY AND
COMMUNITY IMPACT?
>> I THINK VICTOR AND BILL HAVE
ALREADY COVERED IT ALL.
BUT THE POINT I WANTED TO MAKE
IS THAT IF YOU -- YOU ALWAYS
COMPLAIN THAT WE DON'T GET
EVIDENCE-BASED POLICY.
THAT'S ALWAYS BEEN A PROBLEM
THAT PEOPLE SAY, POLICYMAKERS
MAKE POLICY AND DON'T TAKE
EVIDENCE INTO ACCOUNT.
WHAT THEY MEAN IS THEY DIDN'T
CONSIDER YOUR RESEARCH WHEN THEY
MADE THEIR POLICY.
BUT MAYBE THE QUESTION WE NEED
TO ASK OURSELVES IS WHY DOES
THAT HAPPEN?
I THINK IMPLEMENTATION SCIENCE
IS THAT MISSING LINK WHICH COULD
TAKE YOUR RESEARCH TO BECOME
PART OF THAT POLICY WHICH HAS
BEEN DESIGNED.
AND REALLY THAT IS WHAT WE
SHOULD BE LOOKING AT
IMPLEMENTATION RESEARCH AS
SOMETHING THAT WILL TAKE THE
STUFF YOU HAVE BEEN DOING TO
ENSURE INTO POLICY.
YOU CAN DO THAT IF YOU ACTUALLY
LET THE POLICYMAKERS DESIGN THE
STUDY AND DESIGN THE QUESTIONS
YOU WANT TO ASK.
RATHER THAN GOING THERE.
AND I FULLY AGREE WITH VICTOR.
IF I GO TO POLICYMAKERS AND SAY
I WANT TO DO THIS STUDY, AND
THEN SAY PLEASE GO AHEAD.
ANY SUPPORT YOU NEED WE'LL GIVE
YOU.
AND THEY WRITE THE LETTER AND --
I CAN TELL YOU ONCE I HAVE DONE
IT, IF I GO BACK TO THEM AND SAY
WILL YOU SCALE THIS UP, THIS IS
VERY EFFECTIVE.
AND THEY SAY I'LL SCALE IT UP.
IT WAS JUST A THING I THOUGHT
YOU WANTED SO I'M HELPING YOU.
I'M BEING NICE.
YOU KNOW IF YOU DON'T ENGAGE
THEM - AUTO BETTER WAY TO DO IT
IS SAY, WE WANT TO DO SOMETHING
ABOUT THIS.
HERE IS AN INTERVENTION.
WHAT IS THE QUESTION THAT YOU
WANT ANSWERED?
WHAT IS THE QUESTION THAT STOPS
YOU FROM DOING THIS ON A ROUTINE
REGULAR BASIS?
AND WHAT ARE YOUR CHALLENGES AND
LET'S SEE HOW WE CAN HELP YOU
FIND ANSWERS TO THE QUESTIONS
THAT BOTHER YOU AS TO WHY YOU'RE
NOT SCALING THIS UP OR WHAT IT
WILL TAKE TO SCALE IT UP ACROSS
A POPULATION.
I THINK IF YOU DO IT THAT WAY
AND THEN YOU DESIGN YOUR TRIAL
OR YOUR RESEARCH AROUND THAT,
YOU'RE MORE LIKELY TO GET A
COMMITMENT FROM THEM TO SCALE IT
UP ONCE THAT IS OVER.
SO, YOU KNOW, ONE OF THE THINGS
THAT STRUCK ME AND I'M NOT GOING
TO TAKE NAMES -- ONE OF THE
PRESENTATIONS WAS THAT YOU HAD
THE PERSON WORKING FOR THE
MINISTRY WHO WAS SAYING WE DID
THIS AND YES, WE HAVE GOT THESE
PARTNERS AND POINTING TO THE
ACADEMIC PARTNERS.
AND I THINK THAT IS HOW IT
SHOULD BE.
NOT THE ACADEMIC PARTNERS
DRIVING THE SHOW AND THE
MINISTRY IS THE KIND OF ON THE
SIDELINES.
BUT ACTUALLY HAVING PEOPLE
WITHIN THE POLICYMAKERS TAKING
COMPLETE I'M AND SAYING THESE
ARE THE QUESTIONS WE HAVE AND
THE QUESTIONS WE ANSWERED.
THE ACADEMIC PARTNERS HELPED US
DESIGN IT, RUN IT, EVALUATE IT
AND IT'S ANSWERED OUR QUESTION
NOW WE ARE GOING TO GO UP AND
SCALE THIS UP.
WHICH IS THE IDEAL WAY TO
IMPLEMENT.
>> AND I ALSO WOULD SAY, WE
DON'T UNDERESTIMATE THE POWER OF
COMMUNITY TO ADVOCATE.
SO WHEN SOMETHING WORKS FOR
PEOPLE, THEY ALSO HAVE A ROLE IN
ADVOCATING TO THEIR POLICY
MAKERS TO ENSURE THAT THINGS GO
THE NEXT --
>> WHEN I SAY POLICYMAKERS, I
MEAN STARTING FROM THE VILLAGE.
LIKE YOU HAVE A VILLAGE COUNSEL,
THAT IS A POLICYMAKER.
YOU NEED TO TO THEM AS MUCH AS
YOU TALK TO SOMEBODY SITTING AT
THE MINISTRY OF HEALTH IN THE
CAPITAL CITY.
YOU REALLY NEED TO TALK TO YOUR
COMMUNITY AND POLICYMAKERS, THE
LOCAL POLITICIAN IS AN EQUALLY
IMPORTANT PERSON.
YOU SHOULD BE TALKING TO THEM TO
SAY WHAT ARE THE CHALLENGES?
AND SO, YES, I MEAN I THINK WE
FREQUENTLY THINK POLICYMAKERS IS
JUST SOMEBODY WHO SITS AT THE
CAPITAL CITY IN THE BIG MINISTRY
OF HEALTH BUT THERE IS A LOT OF
PEOPLE ALONG THE WAY, ALONG THE
PATHWAY.
I'M SURE -- I KNOW IN MALAWI, OR
SOME COUNTRIES, FOR EXAMPLE, YOU
HAVE TO SPEAK TO THE RELIGIOUS
LEADERS BECAUSE THEY ARE
IMPORTANT POLICYMAKERS.
OR YOU HAVE TO SPEAK TO THE
TRIBAL CHIEFS BECAUSE THEY ARE
IMPORTANT POLICYMAKERS, AND ASK
EM THIS THE QUESTION THAT IS
COME UP.
AND I THINK THOSE ARE THE KIND
OF PEOPLE WE SHOULD BE LOOKING
AT AND NOT JUST SAY WE'LL GO
MEET THE 60 AND MINISTRY OF
HEALTH AND WE HAVE PERMISSION TO
DO THE TRIAL.
-- SECRETARY AND MINISTRY OF
HEALTH.
>> I THINK THIS HAS BEEN A VERY
RICH CONVERSATION THAT HAS
RAISED A LOT OF ISSUES JUST
ABOUT THE COMPLEXITY OF
IMPLEMENTATION SCIENCE RESEARCH,
HOW IT STANDS.
A LOT OF OUR STANDARD RESEARCH
MODALITIES ON ITS HEAD, BUT YOU
KNOW, IT'S WITH THE INVESTMENT
OF TIME AND APPROACH AND
ENGAGEMENT POSITIONED TO ANSWER
A VERY IMPORTANT QUESTION THAT
WILL HELP THE GLOBAL MENTAL
HEALTH -- THE IMPACT OF THE
GLOBAL MENTAL HEALTH FIELD TO
MOVE FORWARD.
SO WE ARE RIGHT AT TIME.
SO PLEASE JOIN ME IN -- [ OFF
MICROPHONE ]
>> I HAVE BEEN GIVEN STRICT
INSTRUCTIONS.
I APOLOGIZE FOR NOT LEAVING TIME
FOR AUDIENCE PARTICIPATION.
HOW CAN I SAY NO?
HOW CAN HOLLY SAY NO?
>> AUDIENCE MEMBER: [ OFF MIC ]
>> SO WE REALLY NEED TO START
THE PRE-WORK.
IT'S MUCH MORE IMPORTANT THAN
THE ACTUAL WORK OTHERWISE YOU'RE
IN A VACUUM.
SO SUSTAINABILITY AND
SUSTAINABILITY.
>> THANK YOU.
PLEASE JOIN ME IN THANKING OUR
PANELISTS FOR A VERY RICH
CONVERSATION ABOUT
IMPLEMENTATION SCIENCE.
THANK YOU ALL FOR STICKING WITH
US.
WE'VE ALL AGREED THAT WE'RE
GOING TO KEEP OUR CLOSING
COMMENTS VERY SHORT.
BUT WE REALLY WANT TO MAKE SURE
WE SAY THANK YOU TO ALL OF THE
PEOPLE WHO CONTRIBUTED TO THIS
MEETING.
SO FIRST, I SHOULD INTRODUCE
MYSELF, I'M SHELLY, THE DEPUTY
DIRECTOR OF THE NATIONAL
INSTITUTE OF MENTAL HEALTH.
IT'S MY PLEASURE TO BE HERE WITH
YOU TONIGHT AND THE LAST TWO
DAYS.
SO FIRST, AS I SAID, WE WANT TO
MAKE SURE WE DO OUR PROPER THANK
YOU.
THANK YOU VERY MUCH TO LEO WHO
IS OUR DIRECTOR OF THE CENTER
FOR GLOBAL MENTAL HEALTH
RESEARCH AT NIMH, WHO REALLY LED
THIS EFFORT.
THANK YOU TO HIS OFFICE.
[ APPLAUSE ]
TO HOLLY CAMPBELL ROSEN WHO WAS
OUR NICE MODERATOR THROUGHOUT.
TO OTHER DIVISION OF AIDS
RESEARCH STAFF AND TO THE NIMH
GLOBAL MENTAL HEALTH TEAM THAT
REPRESENTS ALL OF OUR NIMH
PEOPLE.
THANK YOU SO MUCH TO ALL OF OUR
PARTNERS WHO ARE IN THE ROOM,
THE W.H.O., WELCOME GRAND
CHALLENGES CANADA AND THE
INTERNATIONAL ALLIANCE OF MENTAL
HEALTH RESEARCH FUNDERS FOR
HELPING TO PLAN AND SPONSOR THIS
EVENT.
THANKS TO OUR CONTRACTORS AND
OTHER STAFF WHO ACTUALLY MADE
THIS POSSIBLE WHO GOT THE VENUE,
WHO HELPED PEOPLE TRAVEL HERE,
WHO HELD THE AWARD CEREMONY,
ET CETERA.
WE THANK YOU VERY MUCH FOR YOUR
TIME AND PATIENTS WITH
CHALLENGES WITH MEETINGS.
THANK YOU VERY MUCH TO THE
PARTICIPANTS.
THANK YOU TO THOSE WHO TRAVELED
HERE FROM LOCAL OR DISTANT
DESTINATION -- LOCATIONS.
THANKS FOR TAKING TIME OUT OF
YOUR BUSY SCHEDULES.
BUT THANK YOU ALSO TO THE PEOPLE
WHO ARE JOINING US ON LINE.
WHILE IT'S FANTASTIC THAT SO
MANY OF US WERE ABLE TO ENGAGE
TOGETHER IN PERSON, IT'S ALSO
FANTASTIC THAT WITH A HYBRID
MEETING, WE ARE ACTUALLY ABLE TO
REACH AN ADDITIONAL 250 PEOPLE
FROM 25 DIFFERENT COUNTRIES
AROUND THE WORLD.
SO WHILE WE HAD FUN HERE
LISTENING TO SEVERAL KEYNOTES,
SEVERAL FIRESIDE CHATS, PLENARY
PANELS, SYMPOSIUM, PAPERS AND
POSTERS, WE HAVE FURTHER
ENGAGEMENT AROUND THE WORLD.
AND I JUST WANT TO LEAVE YOU
WITH A COUPLE OF CLOSING
COMMENTS.
I WANT YOU TO KNOW THAT NIMH
WILL STAY COMMITTED TO THE AREA
OF GLOBAL MENTAL HEALTH THAT WE
WANT TO CONTINUE OUR DIALOGUE.
WE WANT TO CONTINUE OUR
PARTICIPATION AND FUNDING,
CAPACITY BUILDING, INNOVATION
AND RESEARCH AND TRAINING ACROSS
THE GLOBE.
WE WANT TO ACKNOWLEDGE THAT
THERE IS A LOT MORE TO DO AND
IT'S REALLY GOING TO TAKE ALL OF
US IN THE ROOM AND THEN SOME, SO
I REALLY WANT TO ENCOURAGE YOU
TO GO HOME, REFLECT UPON WHAT
YOU HAVE HEARD OVER THE LAST
COUPLE OF DAYS.
THINK ABOUT IT AND DECIDE HOW
YOU CAN REALLY INCORPORATE THOSE
NEW INSIGHTS INTO YOUR FUTURE
WORK.
AND LET'S ALSO VOW TOGETHER TO
STAY CONNECTED TO CONTINUE TO
COLLABORATE, AS THAT WILL BE
ESSENTIAL.
AND THINK ABOUT HOW WE CAN
FURTHER ENHANCE OUR NETWORKS TO
GET THE JOB DONE AND MEET THESE
OBSTACLES AND CHALLENGES THAT WE
FACE.
I HAVE HEARD INCREDIBLE
PROGRESS, INCREDIBLE SUCCESS
STORIES AND THAT'S ALL BECAUSE
WE ARE WORKING TOGETHER.
SO THANKS AGAIN FOR YOUR
PARTICIPATION.
IT'S BEEN MY PLEASURE TO SIT AND
LISTEN AND LEARN FROM ALL OF YOU
AND I'M GOING TO TURN IT OVER TO
MY COLLEAGUES.
>> SO, IN THE SPIRIT OF BEING
BRIEF, I WILL JUST SAY THAT ON
BEHALF OF THE ALLIANCE, AND AS
YOU'RE MAKING YOUR WAY TO YOUR
HOMES OR NEXT MEETING OR STAYING
HERE, WE LISTENED REALLY
CAREFULLY TO YOUR RESEARCH BUT
ALSO THE QUESTIONS YOU'RE
SITTING WITH AND THE CONCERNS
YOU'RE SITTING WITH.
AND OVER THE NEXT COUPLE OF DAYS
WE HAVE OUR OWN CONVENING WITH
MENTAL HEALTH RESEARCH FUNDERS
AND INTERNATIONAL PARTNERS AND
WE'LL BE REFLECTING ON SOME OF
THE SAME TOPICS AND SETTING SOME
AGENDA PRIORITIES FOR THE NEXT
FEW MONTHS.
SO THANK YOU FROM ME AND SAFE
TRAVELS.
>> I WILL ALSO KEEP THIS BRIEF.
SO, FROM CANADA, I WANT TO ALSO
ECHO THANKS TO ALL OF THE
PARTNERS, NIMH FOR HOSTING US,
AND TO ALL OF YOU FOR BEING
HERE.
I LEARNED A LOT.
I'M TAKING SOME THINGS BACK WITH
ME TO REFLECT ON.
I THINK ONE OF THE THINGS THAT
IS SO CLEAR -- IT'S BEEN CLEAR
OUR COMMUNITY FOR A LONG TIME.
WHEN YOU RESEARCH MENTAL HEALTH,
WHEN YOU SEEK TO UNDERSTAND
MENTAL HEALTH AND ADDRESS MENTAL
HEALTH, YOU'RE DOING SO MUCH
MORE THAN IMPACTING A PERSON'S
MENTAL HEALTH.
YOU'RE IMPACTING EVERYTHING
ABOUT THEIR DOMAINS OF
FUNCTIONING, ABOUT A PERSON,
ABOUT SOCIETY, ABOUT A COUNTRY.
AND I THINK THAT THAT'S A STORY
THAT I THINK -- WE AT JCC CAN DO
A BETTER JOB OF TELLING AND ONE
OF THE THINGS I WANT TO TAKE
AWAY FROM HERE AND THINK ABOUT
HOW TO INCORPORATE THAT INTO OUR
WORK FLOW.
BECAUSE LIKE NIMH, THIS IS A BIG
AREA OF COMMITMENT, ONE OF OUR
LARGEST PORTFOLIOS AND REALLY
BELIEVE IN.
I HOPE THAT ALL OF YOU HAVE
INSIGHTS AND REFLECTIONS AND
THINGS THAT YOU'RE TAKING BACK
WITH YOU AND INCORPORATING INTO
YOUR WORK AND THAT WE CAN
CONTINUE TO DRIVE THIS FORWARD
TOGETHER.
I'M REALLY LOOKING FORWARD TO
FUTURE MEETINGS LIKE THIS BOTH
HOPEFULLY IN-PERSON AND FOR OUR
VIRTUAL FRIENDS AS WELL THAT WE
CAN CONTINUE TO ENGAGE.
SO THANK YOU.
>> I'M GOING TO ADD MY THANKS.
THANKS TO THE NATIONAL MENTAL
HEALTH FOR HOSTING US.
ALTHOUGH SOME OF THE QUEUES AND
LINES WERE CHALLENGING AT TIMES,
I HAD SOME OF MY BEST
CONVERSATIONS IN THEM.
I WANT TO SAY THEY WERE AN ADDED
BONUS IN THE END.
SO THANK YOU.
AND I SUPPOSE WHAT I'M TAKING
AWAY FROM THIS IS THAT YOU ARE
AN INSPIRING COMMUNITY.
I'M PARTICULARLY INSPIRED BY NEW
VOICES COMING THROUGH FROM EARLY
CAREER RESEARCHERS, FROM PEOPLE
COMING FROM DIFFERENT PARTS OF
LIFE AND DIFFERENT BACKGROUNDS.
I SUPPOSE WE ARE SPENDING OUR
TIME HOW CAN WE MAKE SURE WE CAN
GET MONEY OUT TO YOU.
HOW CAN WE MAKE SURE THERE ARE
OPPORTUNITIES FOR YOU.
WE ARE SITTING HERE WITH THE
MONEY.
YOU ARE SITTING THERE WITH THE
IDEAS AND THE NEED AND WE HAVE
TO BRING THOSE TWO WORLDS
TOGETHER.
ANY IDEAS YOU HAVE FOR US,
PLEASE E-MAIL US.
WE HAVE A SUGGESTIONS BOX ON OUR
WELCOME WEBSITE.
WE WANT TO HEAR FROM YOU.
PLEASE STAY IN TOUCH AND SAFE
TRAVELS.
THANK YOU.
[ APPLAUSE ]