Expanding mental health counselling from primary care to reach at-risk youth (Expanding MINDS-Y).

Ensuring youth (aged 15-24) who are at high risk for common mental disorders like depression and hazardous alcohol use have access to mental health counselling could improve their emotional well-being and prevent injuries, the acquisition of communicable diseases such as HIV, and the onset of non-communicable diseases (NCDs). Like many low- and middle-income countries (LMICs), South Africa (SA) faces the challenge of how to reduce the high prevalence and impact of communicable diseases and NCDs, including mental disorders where limited services are available. Common mental disorders among youth are important to address to prevent these future physical health problems. Yet, the mental health treatment gap in SA is large, particularly for youth. Failure to reach 15-24 year olds is a major service gap as this is often the age of onset for common mental disorders. Service planners recognise that they need to expand the coverage of mental health counselling to include at-risk youth. However, a lack of information about where to situate mental health counselling services, who should be delivering these services, and how to format services to ensure acceptability to and utilisation by at-risk youth has hampered the expansion of available services to this key population. The expansion of mental health counselling to at-risk youth also has been delayed by a lack of youth-oriented counselling programmes that are acceptable to and effective for improving the mental health of at-risk youth.

The goal of this study is to address this knowledge gap by providing information on youth preferences for mental health counselling services, adapting an adult-oriented programme to meet the needs of youth; and testing the feasibility of recruiting youth and initial outcomes of this adapted counselling programme on mental health outcomes. Through this study, we hope to obtain information that can be directly useful to health planners for the design and development of youth-friendly mental health counselling services and have a feasible, youth-friendly counselling programme that shows promise for reducing both depression and hazardous alcohol use among at-risk youth. Findings from this study are likely to be highly relevant for use in other LMICs given similarities between the burden of disease, treatment populations, and profile of risk behaviours among youth in SA and other LMICs.

The study will comprise three phases. In the first phase, we will conduct in-depth interviews with service providers, at-risk youth, and their caregivers to assess barriers to youth participation in mental health counselling and to identify youth preferences for where and how services should be delivered (Aim 1). Findings from this phase will be used to initially adapt our proposed programme to address these barriers and ensure acceptability. In Aim 2, we will demonstrate this adapted intervention in focus groups with at-risk youth in order to obtain information on how the intervention content, structure and layout should be adapted to meet the needs of youth. In Phase 3, we will test the feasibility of recruiting at risk youth to participate in the adapted intervention and the initial effect of the adapted intervention on depression and hazardous alcohol use. We will recruit 100 at-risk youth from impoverished community settings and we will randomize them to receive the intervention or be in a control group. We will assess the effect of the intervention on depression and alcohol use three months after study enrolment. Once the three month assessment has been completed, participants in the control group will be offered the counselling intervention. Findings from this phase will be used to initially evaluate the feasibility and effect of the intervention (Aims 3-4). If the outcomes are promising, findings will also be used to inform the design of a large trial to assess the effectiveness and cost-effectiveness of this intervention.

Background:
The mental health treatment gap is large. Untreated, these disorders enhance risk for communicable and non-communicable diseases and injury. Reducing this treatment gap is thus a global priority. At-risk youth (15-24 years old) remain largely underserved by efforts to reduce this gap. Unanswered questions about youth preferences for services, the feasibility of recruiting and retaining youth in services, and the adaptations needed to ensure adult-oriented services are relevant and acceptable for youth have hampered efforts to reach at-risk youth for mental health care. We propose addressing this knowledge gap through adapting and initially testing a counselling intervention for at-risk youth.

Objectives:
(1) To identify barriers to at-risk youth initiating, engaging and being retained in counselling for common mental disorders and their service preferences.
(2) To establish how to adapt an adult-focused motivational interviewing-problem-solving therapy (MI-PST) intervention to meet the needs of at-risk youth.
(3) To test the feasibility of recruiting and retaining at-risk youth in an adapted MI-PST intervention and (4) the initial effects of this intervention on hazardous alcohol use and symptoms of depression.

Methods:
Interviews will be conducted with service providers, at-risk youth, and caregivers to assess barriers and service preferences (Aim 1). Focus groups will be conducted with at-risk youth to co-adapt the intervention to enhance relevance and appropriateness (Aim 2). Next, a randomised controlled trial will be conducted in which 100 community recruited at-risk youth will be allocated to the adapted MI-PST intervention or a wait-list control. Findings will be used to assess feasibility of recruitment and retention (Aim 3) and initial effect on mental health outcomes at three month follow-up (Aim 4). In-depth interviews with 20 randomly selected intervention recipients will explore their experiences of the intervention.

This study will provide new, internationally relevant knowledge of how to expand mental health counselling to reach at-risk youth who are underserved in low-and middle-income countries (LMICs). The existing knowledge base is insufficient for guiding evidence-based service design for at-risk youth as there are questions about where services for this population should be located, who should deliver them, and how existing programmes must be adapted to meet the needs of and enhance relevance and acceptability for at-risk youth. The existing knowledge base is also insufficient for guiding the choice of counselling programme that is able to address multiple mental health concerns of at-risk youth. We propose addressing these gaps by identifying youth preferences for mental health counselling services and ways in which a trans-diagnostic intervention that has shown effectiveness for reducing depression, hazardous alcohol use and psychological distress in adults for a younger population. To the best of our knowledge, a trans-diagnostic mental health counselling intervention has not been previously adapted and tested among at-risk youth in a LMIC setting. If positive outcomes are achieved we would have identified an approach to mental health service delivery with potential applicability across a range of common mental disorders. Further, should our proposed intervention have promising outcomes, it is likely to be more cost-effective to implement and therefore more appealing to service planners and policy makers in resource-poor LMIC settings to adopt than other interventions that focus narrowly on a single risk behaviour or mental health concern. In addition, the lessons learned from this youth engagement and adaptation process could benefit other LMICs as they embark on similar initiatives to expand mental health care to include at-risk youth. As SA faces a quadruple burden of communicable diseases, NCDs, injury and mental disorders, with many of the behavioral and mental health risks for these health problems starting in adolescence, it provides the ideal laboratory for adapting and testing interventions that are potentially useful for other LMICs concerned with preventing future health problems among at-risk youth.

Second, this study will have an economic and societal impact. Study participants in both the intervention and wait-list control arms are likely to benefit from receiving the counselling programme, which may improve the quality of their own and their family's lives and reduce risk of future health problems. The knowledge generated by this study will be of direct relevance to current efforts to reform the public health system in SA and many other LMICs where there is a focus on expanding access to mental health care, particularly for younger people. The WCDOH also is likely to benefit from this study. The WCDOH is acutely aware that at-risk youth are under-served and has prioritised the expansion of mental health counselling services to reach at-risk youth in its service delivery plans. The findings from this study will be used to guide decision making about where these youth services should be located, who should deliver them and how they should be delivered (delivery mechanisms and platforms) in ways that ensure youth utilize these new services. Should the study find promising outcomes for the adapted counselling intervention, the WCDOH is likely to support a wider, pragmatic evaluation of its effects on the mental and physical health outcomes of at-risk youth. In addition, the WCDOH will use these findings to influence regional and national health policies and legislation, with a view to strengthening the provision of mental health services to youth. We will also try and influence international health guidelines through disseminating findings to the World Health Organisation and other international mental health networks. As such, results could be influential for the development of services in similar LMICs.