There is a fundamental gap in the services offered by mental health clinics in Latin America1. These clinics are the primary site of outpatient treatment for individuals with severe mental disorders in urban areas. They offer some basic and important clinical care such as pharmacologic treatment on site. Generally these clinics also have a major limitation; they have minimal or no resources and training for the provision of in vivo community-based services; that is, services delivered outside of the clinic facility, in homes or elsewhere in the community. In most urban areas, they also have weak links to primary health care and are not easily accessible to much of the population2.
Therefore, the primary focus of the mental health hub RedeAmericas (RA) is on community-based care for severe mental disorders in urban areas of Latin America. Participating sites are in Argentina (Buenos Aires, Cordoba, Neuquén), Brazil (Rio de Janeiro), Chile (Santiago), Colombia (Medellín) and the United States (New York). For the following reasons, we chose to adapt the Critical Time Intervention (CTI) model, previously tested in high-income countries (HICs) but not low- and middle-income countries (LMICs)3:
- CTI is a time-limited, nine-month intervention targeted at critical points of transition and explicitly designed so as to have an enduring effect (demonstrated in RCTs in HICs)4. This makes it attractive for Latin America, because to reach the entire population with limited resources, there must be turnover in the persons receiving the intervention.
- CTI is designed to be an adjunctive component that complements but does not substitute existing health and mental health care. This makes it adaptable to the varying service systems encountered across Latin America.
- CTI relies upon in vivo services delivered in the community by mental health workers who meet with patients wherever they spend their time. This crucial feature of community-based care is still absent in most community mental health centres in Latin America; services tend to be provided at the clinic rather than within the social environment of the community.
CTI was adapted to include task shifting for use within Latin America; the adapted CTI-Task Shifting (CTI-TS) has three features, outlined below, that are relevant to this context and which were not included in previous RCTs of CTI (though have been included in some other applications)5.
Period of Transition
The targeted critical period of transition is the nine months after first contact with mental health services for a psychotic disorder. It was reasoned that the long-term pattern of patients’ and families’ relationships with mental health services would be partly shaped by their early encounters.
Peer support workers
The intervention is delivered by worker-pairs, comprising a peer support worker and a community mental health worker. The use of peer support workers, with equivalent pay and status to other workers, is novel in Latin America, but it was thought to be important to introduce and evaluate this component. Among other reasons, the inclusion of peer support workers in mental health services could help to promote and model social integration.
Connection between primary and mental health care services
CTI-TS emphasizes the connection of individuals with severe mental illnesses to both primary care and mental health services. These connections, which tend to be weak in Latin America, are an essential component of community-based care. The process of connecting patients to both primary care and mental health services was thought to contribute to strengthening communication and ongoing ties between the two types of services.