Critical Time Intervention – Task Shifting (CTI-TS) in Chile and Brazil

Innovation summary

Both Brazil and Chile are known regionally for their mental health service networks, which are part of their wide-reaching public health systems. Nevertheless, due to limited human capacity and financial resources, along with high demand for traditional biomedical psychiatric services, less than 1 in every 4 service users with psychosis receives psychosocial interventions in their local community settings. The gap is even greater for new users.

In light of this, a group of researchers have created a regional collaborative network for community mental health, known as RedeAmericas (RA). It is one of five such initiatives that were funded by the National Institute of Mental Health (NIMH) in Latin America, Africa, and South Asia. RA brings together an interdisciplinary group of investigators from urban centers in Argentina (Buenos Aires, Córdoba, and Neuquén), Brazil (Rio de Janeiro), Chile (Santiago), Colombia (Medellín) and also from New York City in the United States. Representatives from all sites have decades of experience in developing and adapting interventions in a Latin American context. The overarching aim of RA is to improve the living conditions of people with mental disorders.

RA is piloting a regional randomized controlled trial (RCT) of a psychosocial intervention for people with severe mental disorders, Critical Time Intervention-Task Shifting (CTI-TS), in two cities (Santiago and Rio de Janeiro). CTI-TS is a time-limited, community-based psychosocial intervention, which is complementary to existing health services. It is designed to work with individuals (and their families) who are being treated for serious mental illness in order to support recovery and facilitate their full participation in society. CTI-TS is based on a community model of mental health and aims to promote users’ continuity of care by working in their local settings, with the participation of their family members and larger community, to promote active social integration and improve service users’ quality of life.

The intervention is personalized, based on an evaluation of the participant’s goals, familial and societal roles, interests, and strengths. A team of CTI-TS workers (community mental health workers and peer support workers), who are trained and supervised by mental health professionals, collaborate with the participants to identify specific factors that are impeding recovery and continuity of care. Together, they make a feasible plan to address the obstacles and expand support networks. Additionally, the CTI-TS team works to increase participants’ autonomy and empower them to make progress on the recovery path and take on roles in their community.

Impact summary

Pilot RCT of CTI-TS, had a total of 110 participants, from 5 outpatient community mental health public services in Santiago and 3 Community Health Centers for Psycho-Social Assistance in Rio

Data collection still in progress.

“My work as a peer support worker is to speak with the user, who is a person just like me, about my experience – how I overcame my obstacles, how to flip the switch from negative to positive, how to see life in a different way. It’s telling them, ‘Look, if I could do it, you can do it too'.”

Peer Support Worker

National Institute of Mental Health (NIMH) Hub

Innovation details

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.

Key drivers

Political will and congruence

Understanding of the importance of the CTI-TS intervention
Increased buy-in and inclusion of CTI-TS intervention by the government / mental health system
Consistency of the task sharing model with other policy priorities that are currently in place

Mental health services support

Monitoring the uptake of services and emphasising the need for mental health care

Buy in from mental health providers

Strong support for the intervention and facilitation by mental health providers
Strong motivation and previous experience working on community interventions of peer workers and community workers

Challenges

Political will and congruence

Lack of integration of the CTI-TS intervention in mental health services
Task sharing model inconsistent with other policy priorities

Access to care

The CTI-TS intervention is dependent on participants’ use of the mental health system, and barriers to accessing mental health care in general will also apply for the CTI-TS intervention

Complex skills requirements/support

A potential barrier is the competencies of community and peer workers. E.g. these workers need to have not only the skills to conduct the CTI-TS intervention, but also have various personal attributes; being caring, patient, non-judgemental, flexible, and persistent. In the RedeAmericas trial these workers were carefully selected to have these characteristics, but workers without these attributes could be a barrier to the viability of the task sharing model.

Partners

School of Public Health, Faculty of Medicine, University of Chile
Institute of Psychiatry of the Federal University of Rio de Janeiro
Mailman School of Public Health, Columbia University

Funders

National Institute of Mental Health
Ministry of Health, Chile
Ministerio da Saude, Brazil

Evaluation methods

Recruitment

Sixty people have been recruited in Santiago and 50 in Rio. We have successfully conducted the first two evaluations (baseline and 9-month) and are currently conducting the 18-month follow up assessment.

Peer support and community health workers

During the course of this study, both peer support workers and community mental health workers have shown their willingness and ability to create trusting relationships with participants, providing appropriate support and inspiring hope by sharing their own experiences. Fortunately, their work has been welcomed and appreciated by relatives and has contributed to a change in the beliefs and stereotypes that families have in regard to their own relatives with mental disorders. Thus they have been able to provide better support and promote the participants’ recovery. In addition, mental health providers have recognized the important contribution of peer workers in terms of understanding consumer needs. They have stated that the worker-pair might be an effective tool for improving continuity of care, and also have noted that levels of self-esteem and autonomy of peer support workers (who are also users of mental health services) have improved significantly. Similarly, peer workers reported feeling more confident and hopeful about their future and the possibility of attaining their personal goals, not only in terms of their job but also their contribution to society.

Fidelity Assessments

Feedback about the quality of the CTI-TS implementation from two 6-month fidelity assessments using the CTI-TS Fidelity Scale has been obtained. The fidelity score uses a 5-point Likert scale (1=not at all implemented, 5= ideally implemented) and is based on a pre-specified process for combining ratings of the individual fidelity items for both Rio and Santiago. The score for the first assessment period (from 6/1/14 to 11/30/14) was 5, and the score for the second (from 12/1/14 to 5/31/15) was also 5. We infer that the excellent scores reflect the intensive training and ongoing supervision that the intervention teams received.

Qualitative feedback by stakeholders

“Peer workers, who share their life experiences with new services users, are important models, showing that the possibility of Independence and complete well-being.”

- David Guerra, Clinical Psychologists COSAM Peñalolén

“The importance I see, of our work in general, is that we have realized that it really helps the recovery process. For me specifically, it has been very effective to work in conjunction with the user, the family, and the community. We have truly been able to serve as a bridge, a nexus, so that users incorporate themselves into the community, and in cases in which we have met families who have denied [involvement], who are tired, who, for a million different reasons, don’t want to continue supporting their family member, who is a user, we have achieved that they too incorporate. We have gotten them to commit.”

-Guillermina Astorga, Community Mental Health Worker, CTI-TS

See http://www.criticaltime.org/2015/10/06/proyecto-cti-ts-chile-photo-essay/ for more.

Pilot RCT evaluation

This is a pilot randomized control trial. The follow-up is ongoing, therefore the investigators are still blind and the analysis of the outcomes has not begun.

Cost of implementation

Data not available.

Impact details

Outcomes from the RCT are not available yet.

References

Rodríguez, J. (2007). La atención de Salud Mental en América Latina y el Caribe. Revista de Psiquiatría, 71(2),117-124.
Minoletti, A., Galea, S., & Susser, E. (2012). Community mental health services in Latin America for people with severe mental disorders. Public health reviews, 34(2).
Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W. Y., & Wyatt, R. J. (1997). Preventing recurrent homelessness among mentally ill men: a" critical time" intervention after discharge from a shelter. American Journal of Public Health, 87(2), 256-262.
Herman, D. B., & Mandiberg, J. M. (2010). Critical time intervention: Model description and implications for the significance of timing in social work interventions. Research on Social Work Practice, 20(5), 502-508.
Alvarado, R., Shilling, S., & Jorquera, M. J. (2016). Uso de la Intervención Critical Time Intervention en personas con primer episodio de psicosis. Revista de la Facultad de Ciencias Médicas, 72(4), 331-338.

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Country

Chile, Brazil