Scaling-up mental health interventions? Think about these issues before launching your project

?

I was recently asked by Reuters Health to comment on a study published by JAMA Psychiatry that concluded young people can be effectively treated for borderline personality disorder (BPD) with or without individual psychotherapy. I commended the authors for focusing on early interventions for young people with BPD. As highlighted by the U.S. Surgeon General, we need to dedicate our efforts to address the current youth mental health crisis.?Focusing on BPD is particularly important because?BPD is one the most functionally disabling mental disorders.?

Although the results look promising, I didn’t fully agree with the conclusions. First, the authors failed to include the participants and the providers’ race and ethnicity. Both the American Medical Association (AMA) and the American Psychological Association (APA) have specific guidelines on the reporting of race and ethnicity.??The AMA has acknowledged that neglecting to report race and ethnicity in health research can conceal health disparities. The APA has stated that if researchers conduct a study that only includes participants of one racial group, they should explicitly note this and describe limitations of generalizability to other racial and ethnic groups. Moreover, the APA encourages researchers to diversify their samples to improve methodological rigor and external validity.?These limitations were not noted by the authors who went on to conclude that “services could be scaled up immediately, via existing national mental health platforms for young people or similar services globally.” The authors did not appear to be in position to generalize their findings to diverse populations. This oversight highlights the importance of increasing diversity and cultural competency among authors, reviewers and editors.?

Second, it appears that the authors assessed suicidal ideation using the Beck Scale for Suicide Ideation but could have used additional assessment tools to better determine suicide risk. Future studies should consider assessing for Adverse Childhood Experiences (ACEs) during participant selection to identify participants at a heightened risk of suicide and take steps to increase their safety.?Studies have found that the odds of ever attempting suicide are 30 times higher for individuals with four or more ACEs compared to individuals with no history of ACEs. ACES are very prevalent among people with BPD, (between 30 to 90 percent of people with BPD report histories of childhood neglect and abuse).?The authors reported three deaths by suicide; one participant died by suicide while receiving the study intervention and two participants died in the follow-up period. Suicide is the second leading cause of death for people ages 10-34 in the United States.

Third, the authors acknowledged that the interventions did not impact substance abuse rate. This is problematic because approximately half of those with BPD also meet the criteria for at least one substance abuse disorder, usually alcohol abuse disorder.??

In order to address the current mental health crisis, it's fundamental that researchers continue to focus on interventions that can be scaled up. Now more than ever we need strategies that can reduce costs and increase access to care. However, as scientists and enterpreneurs seek to increase their global reach, they should also seek to increase their understanding of the ways in which their interventions can impact marginalized populations across the world.