Mental Health, Substance Use and Stigma:

Elucidation of and Intervention on Risk Pathways

Our program of applied research addresses interlocking factors driven by stigma-related mechanisms that exacerbate risk for poor health outcomes. We acknowledge the multi-level determinants of co-morbidity in certain groups, which include systems-, interpersonal- and individual-level barriers to equitable healthcare. Several projects have been designed to further elucidate these relationships and generate guidelines to address these deleterious pathways.

ON-GOING PROJECTS

Project title: Comunică. Despre Mine. Despre Noi. [Communicate. About Me. About Us.]

• Duration: 09/05/2018 – 06/30/2023 Co-Principal Investigators: Corina Lelutiu-Weinberger, PhD (Rutgers University) & John Pachankis, PhD (Yale University)
• Funding Source: National Institute of Mental Health; 1R01MH116829-01A1
• Official project title: “Building Mobile HIV Prevention and Mental Health Support in Low-Resource Settings” This is an individual-level intervention. This project is designed to remedy unaddressed and interlocking HIV-prevention and mental health needs among gay and bisexual men (GBM) in the Central Eastern European country of Romania, and their underpinning stigma-related mechanisms. Rampant stigma contributes to the increasing prevalence of HIV among Romanian GBM (from under 10% in 2009 to close to 20% in 2014, by best available estimates) and keeps GBM out-of-reach of HIV-prevention services. Our mHealth pilot intervention (titled “Despre Mine. Despre Noi.” [DMDN] translated as “About Me. About Us.”), which reduced US and Romanian GBM’s risk for HIV infection while also reducing depression and alcohol abuse in initial pre-post trials, is now ready for testing in a randomized controlled trial with a large national sample in the current study. The DMDN intervention entails eight 60-minute live chat sessions delivered by trained counselors on our mobile study platform using motivational interviewing (MI) and cognitive-behavioral skills training (CBST). First, during pre-trial (mos 1-5), in collaboration with a community advisory board consisting of GBM community members, GBM-affirmative physical and mental health providers, and our technical developer, we will fine-tune the DMDN intervention based on our pilot findings and evaluation interviews, and expand the original DMDN education materials for an education attention condition (EAC) that will serve as our control. Second, during the intervention phase (mos 6-45), we will recruit, screen, assess, and randomize GBM at risk for HIV infection and alcohol abuse to either the DMDN intervention (n=163) or EAC (n=163). The conditions are content matched, and both are hosted on our study platform. While DMDN will consist of eight weekly mHealth live chat sessions, EAC will consist of eight self-administered educational modules. Third, during the follow-up phase (mos 8-55), we will assess at 4, 8, and 12 months post-baseline, in a mobile fashion identical to the baseline, the primary outcome of condomless anal sex with male partners and secondary outcomes of alcohol abuse, depression, biologic HIV/STI infection, HIV/STI testing, and psychosocial mechanisms rooted in the Information-Motivation-Behavioral Skills (IMB) model (e.g., HIV/STI knowledge, condom use self-efficacy) and minority stress theory (e.g., identity concealment, internalized homophobia).

Project title: Increasing Provider Competence for Treating Stress-Related Mental Health Conditions in Low-Resource Settings

• Duration: 08/05/2017 – 07/31/2019
• Investigators: Corina Lelutiu-Weinberger, PhD (Principal Investigator; Rutgers University) & John Pachankis, PhD (Co-Investigator; Yale University)
• Funding Source: National Institute of Mental Health; 5R21MH113673
• This is an systems-level provider intervention. Lesbian, gay, bisexual and transgender individuals (LGBTI) present increased morbidity compared to the general population, which is attributed to healthcare discrimination and lack of LGBT-specific expertise, especially in high-stigma countries. Motivated by fear, Romanian LGBTI conceal their identities and report significantly more barriers to healthcare access than heterosexuals. Poor mental health, specifically anxiety and depression, is elevated for Romanian LGBTI, and associated with poor physical health (e.g., HIV risk, alcohol abuse.) However, LGBT-competent mental health professionals (MHPs) are nearly non-existent in Romania, and thus the negative impact of homophobia on mental health cannot be ameliorated. Neither universities nor continuing education include LGBT identity and health curricula, to the contrary, the dominant discourse promotes homosexuality as a dangerous anomaly in need of eradication. Given that a pilot of our in-person LGBT-affirmative MHP training we tested recently in Romania showed significant receptivity and increased competence among MHPs (3R21TW009925-02S1), this training is now ripe for testing its feasibility and efficacy in creating significant change via mobile delivery, in a randomized controlled trial (RCT). Proving the efficacy of this first mobile training and supervision model has high potential for cost-effective and expeditious boundless dissemination. In Aim 1, we will test the relative feasibility and efficacy of our mHealth MHP training by conducting an RCT comparing a mobile training (MT) of our MHP LGBT-competency program (n=60) to the equivalent in-person training (IPT) (n=60) we recently piloted. Both programs' content and structure will be identical (2-day trainings and two boosters 6 months apart). At baseline, 4, 8, and 12 months, we will assess, in a mobile fashion, all MHPs' LGBT-related attitudes, knowledge of LGBT health needs and clinical practice, and LGBT caseload. In Aim 2, we will test the efficacy of a companion mHealth supervision and consultation program in maintaining LGBT competency and enhancing LGBT-friendly practice. Half of the MHPs in each group will receive our mHealth supervision and expert consultation program, consisting of monthly 2-hour virtual group meetings to discuss case studies, in order to determine the added benefit of mobile supervision. After the training, 10 MHPs will provide interview-based program feedback. We have chosen four types of partners to maximize the project's sustainability and benefit from the power of their multidisciplinarity: academics, direct service agencies supporting LGBTI, practicing MHPs, and a technical developer. This first RCT testing of an mHealth training in LGBT-competent mental healthcare in Romania affords us an unparalleled opportunity to introduce much needed expertize and mHealth methodologies in universities and clinical practice, and create a seed infrastructure for an implementation science R01 of national and global public health significance.

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