Dr. Mark Jordans on Mental Health and Psychosocial Support during COVID-19

Biography:

Dr. Mark Jordans, MSc, PhD, is a child psychologist and holds academic affiliations as Professor of Child and Adolescent Global Mental Health at the University of Amsterdam, and Reader, Child and Adolescent Mental Health in Humanitarian Settings, at the Center for Global Mental Health, King’s College London. Additionally, Dr. Jordans serves as the Director of Research & Development of War Child Holland, which is an NGO dedicated to improving the lives of children and communities affected by conflict. Dr. Jordans’ research interests are in psychosocial and mental health care systems in low and middle income countries. From 1999-2011, Dr. Jordans founded and worked at TPO Nepal, a mental health NGO. Dr. Jordans has led several global mental health initiatives and collaborates with humanitarian agencies such as the WHO. 

What are the most important factors that comprise effective psychosocial interventions for youth in developing countries, and how can they be applied to the current COVID-19 crisis? 

First of all is to work in what I call a  “care system approach.” In the last decade, there have been a lot of fantastic initiatives to support mental health and psychosocial support or care of children affected by conflict or low-income settings in general. But they’re very often singular interventions, and they’re often stand-alone interventions. While they might be effective in indeed addressing a particular problem, for those children or youth, they often only address a small aspect of it. I’ve been arguing for a more “care system approach” in which you combine different interventions to actually target multiple needs that children have rather than singular ones. That’s the first [factor]. Within that, to also look at it interdisciplinarily. So not just to have a specific mental health or psychosocial focus, but also to look at what are the social determinants of mental health problems for children.  Thereby addressing, for example, the families that the children live in and the well-functioning of families to address issues of maltreatment or neglect or child protection issues or the community, to address issues around school or education. So to really look at it from an interdisciplinary point of view. The third angle I would say and I am increasingly focusing on is quality. How do we maintain quality of care for mental health services? There’s been a lot of emphasis on developing interventions, especially psychological treatments, a lot of emphasis on doing studies to demonstrate the effectiveness of psychological interventions, but I think now we need to have clearer ideas and tools on how to maintain the quality of those psychological interventions when they’re implemented. Even more so in the situation of COVID-19 where everything happens remotely and a lot of that direct contact and the effects of that direct contact fall away.

What are certain characteristics of “quality” psychosocial interventions? 

I work for an organization called War Child and I do that together with my academic affiliations at the University of Amsterdam and King’s College. Our work in War Child is indeed to develop such a care system, but not to just have the interventions but to also bring them to scale. The idea is we transition an evidence-based intervention to scale to then have a quality framework to guide that process. We have identified 5 key criteria or indicators to monitor the quality: 1) Competence - do providers or facilitators that implement psychological treatments have sufficient clinical competence to do that; 2) Fidelity - does the implementation of the evidence-based intervention at scale happen as it was intended or studied in a hyper-controlled setting such as a trial; 3) Attendance - do children actually continue to come and get sufficient dosage of the intervention. Those are 3 parameters that we are evaluating and validating. You need to reach this level of competence, fidelity, or attendance to know that it translates to quality enough care at scale. That’s on the quality side. On the feasibility side, there’s two other criteria that we feel are important to operationalize, to make that transition from research to practice. On the feasibility axis, we need to make sure that 4) cost is as minimal and under a particular threshold so that Ministries of Education or Ministries of Health can actually take those interventions up as they’re not so expensive. And the last criteria on that feasibility axis is 5) coverage - to actually say even if you have quality of care and even if it is cheap, we can only really make an impact if it reaches sufficient children that are in need of that particular intervention. Through that set of 5 criteria, we try to monitor that process of quality and feasibility.

How can public policy responses better support psychosocial interventions, or education in emergencies, for youth in developing countries? 

That’s the one million dollar question because I think that there are very few examples where great initiatives have actually translated to policy changes and to implementation of those policies if you’re looking at mental health in low- and middle-income countries. There’s very few and those that are there are for adults. For children, it is a hugely important aspect. I’m going to give one example. Over the last 8-10 years, colleagues and I in Nepal have been evaluating integration of mental health into primary healthcare. We’re actually working together with the Ministry of Health to demonstrate that we can set up a district-wide and a population-level mental health system through integrating mental health services at the primary healthcare and community level. We developed a district mental healthcare plan, evaluated what worked, what did not work, barriers, facilitators, fine-tuned it, and ultimately had a plan that got adopted by the Ministry of Health as a policy for mental health in community and primary healthcare settings. That in itself was great. But the trick comes the translation after that. How does that policy translate into operationalization of that policy? In Nepal, for example, it translated to the government putting psychotropic drugs on the free drug list and actually making it freely available for people. It translated to the standard curriculum of health worker training to have a module on mental health and the detection and treatment of mental health in primary care. I think it’s those multiple steps that are needed, and there’s just very few examples where that happens. Again, I can only stress for children and adolescent mental health that there’s even less of it. There’s a very urgent call for action needed to get children and adolescent mental health on the policy agenda and it’s entirely lacking.