Community perspectives on the implementation of a group psychological intervention for adolescents with depression: A qualitative study in rural Nepal.

Group-based psychological interventions could help to close the treatment gap for depression in low-resource settings, but implementation barriers exist. In Nepal we sought community members' perspectives on how to implement group interpersonal therapy for adolescents. We conducted qualitative interviews with 25 adolescents with depression (aged 13-18) and seven health and non-governmental organization workers, and four focus groups with non-depressed adolescents, four with parents/guardians, and two with teachers (126 participants total). Data were analyzed using the Framework Method. Participants recommended same-sex groups. School was the preferred location because it is accessible for adolescents and acceptable to parents. Adolescents wanted facilitators from their own community with good communication skills. They did not want parents or teachers to participate in groups but emphasized the need to inform parents and obtain their permission. Community members supported group psychological intervention. School-based psychological interventions facilitated by local people could be an acceptable option in rural Nepal.

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.

A cross-cultural interpersonal model of adolescent depression: A qualitative study in rural Nepal.

Most cross-cultural qualitative research on depression has been descriptive, documenting symptoms and explanatory models. There is a lack of qualitative research testing theoretical models of depression. The interpersonal model conceptualises grief, interpersonal disputes, role transitions and social isolation as the context in which depression develops and is the basis of interpersonal therapy (IPT), which is increasingly used in cross-cultural settings to treat depression. We aimed to qualitatively evaluate to what extent the interpersonal model can explain adolescent depression in Nepal. Data were collected between December 2018 and April 2019 and comprised transcripts from 126 participants: 25 semi-structured interviews with depressed adolescents aged 13-18; four focus group discussions with adolescents (N = 38), four with parents/caregivers (N = 39), and two with teachers (N = 17); and seven semi-structured interviews with health and non-governmental organisation workers. We coded data using an analytical framework comprising deductive codes representing key concepts from the interpersonal model of depression and IPT, including principles, techniques and strategies. Participants mainly related depression to interpersonal problem areas of grief, dispute, role transition and social isolation. Interpersonal disputes were common, and for many adolescents this involved parental physical and emotional abuse. Although role transitions were common few adolescents grieved loss of the prior role. Distress related to social isolation was evident despite close physical proximity and extensive social interaction with family and community members. Adolescents described coping strategies that were similar to strategies central to IPT, e.g. identifying helpful and unhelpful relationships and generating options and ways of managing problems. In conclusion, interpersonal problems are relevant to this population and conceptualisations align with core principles of the interpersonal model of depression. The findings highlight the importance of addressing abuse and maltreatment in depression aetiology. They also inform future cultural adaptations of IPT in Nepal and beyond, including the opportunity to integrate local coping strategies.