Implementing changes in mental health among at-risk groups: a decade-long Brazilian roadmap.

As we make incremental advances in fighting stigma, increasing awareness of mental illness and developing novel, effective therapies, another important challenge emerges – one that is shared across almost all disciplines: how can new knowledge be successfully and timely disseminated without wasting time but receiving the best return on the investment?

Stigma still is a significant barrier to service uptake for those who are recognized as suffering from mental illnesses; prevention is likely to be one of the most important steps in addressing the burden associated with mental health issues, and yet little attention has been paid so far to preventative measures among at-risk sub-populations. As a response to these emerging needs, risk-reduction or harm-reduction research and implementation science are gaining space in mainstream mental health research. The gap between research and practice should ideally be addressed by implementation studies, which could then inform new policies and provide a roadmap to further develop and expand services.1

Managing psychiatric conditions among individuals with chronic, concurrent medical problems such as diabetes, hypertension, or HIV poses numerous challenges – from awareness and prevention to continuous engagement and effective treatments.2 Brazil’s overall response to the HIV pandemic over the past few decades, focused on prevention and treatment, has been a success story and has paved the way for initiatives targeting mental health needs and preventative strategies in this population.3

Wainberg et al.4 describe a decade-long initiative in Brazil that aimed to increase information about different behaviors among individuals with HIV, motivate engagement in safer behaviors, and transform knowledge into real-world practice. Their study was based on the accumulated experience of U.S.-based studies on the effective use of the Information-Motivation-Behavioral Skills (IMB) model to address the needs of individuals with severe mental illnesses regarding HIV, e.g., to reduce misinformation about risky sexual behaviors. Through NIMH funding, the authors conducted the PRISSMA studies (PRojeto Interdisciplinar em Sexualidade, Saúde Mental e AIDS, i.e., the Interdisciplinary Project on Sexuality, Mental Health and AIDS), which included the most current knowledge of outpatient settings in the Brazilian public health system. The pilot study found a reduction in high-risk behaviors (i.e., unprotected sex among sexually active participants in the HIV prevention group) three months post-intervention.5

In a current (PRISSMA-2) study, the authors determined whether HIV prevention would significantly reduce sexual risk 12 months post-intervention. The IMB model used in PRISSMA-2 was compared to an attention-control model more commonly used in managing other chronic medical conditions. For PRISSMA-2, the authors did not limit the recruitment to individuals with severe mental illness, but included individuals with common mental disorders (e.g., depression, anxiety, post-traumatic stress disorder, etc.).4

Assigning more than 400 participants to either an IMB-based HIV prevention group (n=233) or a health promotion group (n=231), Wainberg et al. found that after 12 months both groups reported reductions in high-risk behaviors, i.e., the number of occasions of unprotected vaginal or anal intercourse. The IMB model, however, was more successful in improving knowledge about HIV, increasing motivation for safer sex, and increasing HIV prevention behavioral skills. The study demonstrated that clinicians could sucessfully implement interventions to reduce the likelihood of risky sexual behavior among patients with mental illness, even with the limited resources of a public-funded health system in Brazil.4

One noteworthy methodological advancement was comparing an intervention group with another attention-control intervention group, rather than with treatment as usual, which better served evidence-based best practices. The authors also assessed the consistency and fidelity with which the intervention was administered, including adaptations and long-term effects on individual and setting levels.

As implementation science aims to close to gap between research and practice, Wainberg et al. have provided us with a local roadmap, built over the course of a decade, about how to strike a balance between state-of-the-art methodology, scientific rigor, and the needs of the community, conducting a study that promises meaningful change in a sustainable way.

Disclosure

The author reports no conflicts of interest.