School-based group interpersonal therapy for adolescents with depression in rural Nepal: a mixed methods study exploring feasibility, acceptability, and cost.

Background: Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost. Methods: We recruited 32 boys and 30 girls (aged 13-19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0-2 weeks after IPT), and follow-up (8-10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective. Results: Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70-95); functional impairment decreased by 288% (249-351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity. Conclusions: School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.

Culturally and developmentally adapting group interpersonal therapy for adolescents with depression in rural Nepal.

BACKGROUND: Evidence-based interventions are needed to reduce depression among adolescents in low- and middle-income countries (LMICs). One approach could be cultural adaptation of psychological therapies developed in high-income countries. We aimed to adapt the World Health Organization's Group Interpersonal Therapy (IPT) Manual for adolescents with depression in rural Nepal. METHODS: We used a participatory, multi-stage adaptation process involving: translation and clinical review of the WHO Manual; desk reviews of adaptations of IPT in LMICs, and literature on child and adolescent mental health interventions and interpersonal problems in Nepal; a qualitative study to understand experiences of adolescent depression and preferences for a community-based psychological intervention including 25 interviews with adolescent boys and girls aged 13-18 with depression, four focus group discussions with adolescents, four with parents/caregivers and two with teachers, six interviews with community health workers and one with a representative from a local non-governmental organisation (total of 126 participants); training of IPT trainers and facilitators and practice IPT groups; and consultation with a youth mental health advisory board. We used the Ecological Validity Framework to guide the adaptation process. RESULTS: We made adaptations to optimise treatment delivery and emphasise developmental and cultural aspects of depression. Key adaptations were: integrating therapy into secondary schools for delivery by school nurses and lay community members; adding components to promote parental engagement including a pre-group session with the adolescent and parent to mobilise parental support; using locally acceptable terms for mental illness such as udas-chinta (sadness and worry) and man ko samasya (heart-mind problem); framing the intervention as a training programme to de-stigmatise treatment; and including activities to strengthen relationships between group members. We did not adapt the therapeutic goals of IPT and conserved IPT-specific strategies and techniques, making edits only to the way these were described in the Manual. CONCLUSIONS: Group IPT can be adapted for adolescents in Nepal and delivered through the education system. A randomised controlled trial is needed to assess the impact and costs of the intervention in this setting. Future research in LMICs to adapt IPT for adolescents could use this adapted intervention as a starting point.

National dissemination of interpersonal psychotherapy for depression in veterans: therapist and patient-level outcomes.

OBJECTIVE: To evaluate the effects of training in and delivery of interpersonal psychotherapy (IPT) for depression throughout the U.S. Department of Veterans Affairs health care system on therapists' competency and patients' clinical outcomes. METHOD: Participants included 124 therapists and 241 veteran patients. Therapists participated in a 3-day workshop followed by 6 months of weekly group consultation. Therapy session tapes were rated by expert IPT training consultants using a standardized competency rating form. Patient outcomes were assessed with the Beck Depression Inventory-II and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed with the Working Alliance Inventory-Short Revised. RESULTS: Of the 124 therapists receiving IPT training, 115 (93%) completed all training requirements. Therapist competence in IPT increased from their 1st patient to their 2nd for both initial (d = 0.36) and intermediate (d = 0.24) treatment phases. Of the 241 veteran patients treated with IPT, 167 (69%) completed ≥ 12 sessions. Intent-to-treat analyses indicated large overall reductions in depression (d = 1.26) and significant improvements in quality of life (d = 0.57 to 0.86) and the therapeutic alliance (d = 0.50 to 0.83). CONCLUSIONS: National IPT training in the VA health care system was associated with significant increases in therapist competencies to deliver IPT, as well as large overall reductions in depression and improvements in quality of life among veterans, many of whom presented with high levels of depression. RESULTS support the feasibility and effectiveness of broad dissemination of IPT in routine clinical settings.

Group Interpersonal Psychotherapy for depressed youth in IDP camps in Northern Uganda: adaptation and training.

This article reviews the use of Interpersonal Psychotherapy (IPT) with depressed youth living in Internally Displaced Persons (IDP) camps in North Uganda. This youth has been exposed to severe losses and disruptions in relationships with caregivers, family, and community members; limited access to formal education; exposure to malnutrition and infections; and pressure to prematurely assume adult family roles. The process of adaptation to the content and training of IPT for these youth is presented and illustrated with case examples.

Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India.

Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.

Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial.

CONTEXT: Prior qualitative work with internally displaced persons in war-affected northern Uganda showed significant mental health and psychosocial problems. OBJECTIVE: To assess effect of locally feasible interventions on depression, anxiety, and conduct problem symptoms among adolescent survivors of war and displacement in northern Uganda. DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial from May 2005 through December 2005 of 314 adolescents (aged 14-17 years) in 2 camps for internally displaced persons in northern Uganda. INTERVENTIONS: Locally developed screening tools assessed the effectiveness of interventions in reducing symptoms of depression and anxiety, ameliorating conduct problems, and improving function among those who met study criteria and were randomly allocated (105, psychotherapy-based intervention [group interpersonal psychotherapy]; 105, activity-based intervention [creative play]; 104, wait-control group [individuals wait listed to receive treatment at study end]). Intervention groups met weekly for 16 weeks. Participants and controls were reassessed at end of study. MAIN OUTCOME MEASURES: Primary measure was a decrease in score (denoting improvement) on a depression symptom scale. Secondary measures were improvements in scores on anxiety, conduct problem symptoms, and function scales. Depression, anxiety, and conduct problems were assessed using the Acholi Psychosocial Assessment Instrument with a minimum score of 32 as the lower limit for clinically significant symptoms (maximum scale score, 105). RESULTS: Difference in change in adjusted mean score for depression symptoms between group interpersonal psychotherapy and control groups was 9.79 points (95% confidence interval [CI], 1.66-17.93). Girls receiving group interpersonal psychotherapy showed substantial and significant improvement in depression symptoms compared with controls (12.61 points; 95% CI, 2.09-23.14). Improvement among boys was not statistically significant (5.72 points; 95% CI, -1.86 to 13.30). Creative play showed no effect on depression severity (-2.51 points; 95% CI, -11.42 to 6.39). There were no statistically different improvements in anxiety in either intervention group. Neither intervention improved conduct problem or function scores. CONCLUSIONS: Both interventions were locally feasible. Group interpersonal psychotherapy was effective for depression symptoms among adolescent girls affected by war and displacement. Other interventions should be investigated to assist adolescent boys in this population who have symptoms of depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00280319.

Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes: randomised controlled trial.

BACKGROUND: A randomised controlled trial comparing group interpersonal psychotherapy with treatment as usual among rural Ugandans meeting symptom and functional impairment criteria for DSM-IV major depressive disorder or sub-threshold disorder showed evidence of effectiveness immediately following the intervention. AIMS: To assess the long-term effectiveness of this therapy over a subsequent 6-month period. METHOD: A follow-up study of trial participants was conducted in which the primary outcomes were depression diagnosis, depressive symptoms and functional impairment. RESULTS: At 6 months, participants receiving the group interpersonal psychotherapy had mean depression symptom and functional impairment scores respectively 14.0 points (95% CI 12.2-15.8; P<0.0001) and 5.0 points (95% CI 3.6-6.4; P<0.0001) lower than the control group. Similarly, the rate of major depression among those in the treatment arm (11.7%) was significantly lower than that in the control arm (54.9%) (P<0.0001). CONCLUSIONS: Participation in a 16-week group interpersonal psychotherapy intervention continued to confer a substantial mental health benefit 6 months after conclusion of the formal intervention.

Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial.

CONTEXT: Despite the importance of mental illness in Africa, few controlled intervention trials related to this problem have been published. OBJECTIVES: To test the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction and to evaluate the feasibility of conducting controlled trials in Africa. DESIGN, SETTING, AND PARTICIPANTS: For this cluster randomized, controlled clinical trial (February-June 2002), 30 villages in the Masaka and Rakai districts of rural Uganda were selected using a random procedure; 15 were then randomly assigned for studying men and 15 for women. In each village, adult men or women believed by themselves and other villagers to have depressionlike illness were interviewed using a locally adapted Hopkins Symptom Checklist and an instrument assessing function. Based on these interviews, lists were created for each village totaling 341 men and women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression or subsyndromal depression. Interviewers revisited them in order of decreasing symptom severity until they had 8 to 12 persons per village, totaling 284. Of these, 248 agreed to be in the trial and 9 refused; the remainder died or relocated. A total of 108 men and 116 women completed the study and were reinterviewed. INTERVENTION: Eight of the 15 male villages and 7 of the 15 female villages were randomly assigned to the intervention arm and the remainder to the control arm. The intervention villages received group interpersonal psychotherapy for depression as weekly 90-minute sessions for 16 weeks. MAIN OUTCOME MEASURES: Depression and dysfunction severity scores on scales adapted and validated for local use; proportion of persons meeting DSM-IV major depression diagnostic criteria. RESULTS: Mean reduction in depression severity was 17.47 points for intervention groups and 3.55 points for controls (P<.001). Mean reduction in dysfunction was 8.08 and 3.76 points, respectively (P<.001). After intervention, 6.5% and 54.7% of the intervention and control groups, respectively, met the criteria for major depression (P<.001) compared with 86% and 94%, respectively, prior to intervention (P =.04). The odds of postintervention depression among controls was 17.31 (95% confidence interval, 7.63-39.27) compared with the odds among intervention groups. Results from intention-to-treat analyses remained statistically significant. CONCLUSIONS: Group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction. A clinical trial proved feasible in the local setting. Both findings should encourage similar trials in similar settings in Africa and beyond.

Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda.

The current prevalence of depressive symptoms in Southwest Uganda, an area greatly affected by the HIV epidemic, has been shown to be as high as 21%. Traditional healers have expressed inability to treat these symptoms. The lack of physicians and high cost of medication make the use of antidepressants unfeasible. Therefore, an evidence-based psychotherapy was considered a reasonable treatment option by a team of health researchers familiar with the local culture, who designed a randomized controlled clinical trial. Interpersonal psychotherapy in a group format (IPT-G) was selected because it was time limited, was described in a manual, and had evidence of efficacy from clinical trials. Moreover, its focus on interpersonal triggers of depression was considered compatible with the culture. This paper describes the process of adapting the psychotherapy manual and the training of the group leaders who undertook the first psychotherapy clinical trial in Africa.