Building resilience in adolescence - improving quality of life for adolescents with mental health problems in Colombia (BRiCs study)

Background
Depression and anxiety are common mental health problems affecting one in four people at some point in their lives. The number of people who experience depression and anxiety greatly increases during adolescence, particularly for those who experience stressful events. This includes adolescents who live in Low and Middle Income Countries (LMICs). In fact, depression and anxiety are the top causes of disability for adolescents in LMICs. Despite the negative impact of depression and anxiety, a treatment gap exists. Less than half of people with depression and anxiety in LMICs access treatment. Even when people do get treatment, only a small proportion (20%) receive a minimum standard of care. This is often due to a lack of resources including enough specially trained staff and services to help people. Therefore, to improve health outcomes for adolescents with depression and anxiety, new approaches are needed. These new approaches need to be low-cost, effective and have the potential to be used by a range of staff. We aim to achieve this goal.

Objectives
The overall aim is to improve health outcomes for adolescents with depression and anxiety in Colombia by adapting an existing effective intervention. To achieve this, we aim to:
1. Adapt an existing intervention to develop a new approach to treat depression and anxiety in adolescence.
2. Assess the acceptability and feasibility of the new intervention by testing it in two places in Colombia.
3. Develop plans to help other services, regions and countries use the intervention (implementation plans).
4. Involve adolescents in the research by setting up an interactive arts-based project.

Methods
The project is organised into four work packages (WPs). In WP1, we will ask people their opinions on an existing intervention (DIALOG+) in focus groups and interviews. We will ask 8 youth workers, mental health or education staff to use DIALOG+ with 24 adolescents with depression and anxiety. This qualitative information will help us "repurpose" the intervention so that it is suitable for adolescents. The new intervention will be called DIALOG-A. We will evaluate DIALOG-A in a randomised controlled trial (RCT) in WP2. The RCT will be conducted in two regions of Colombia - one deprived inner city area and one rural location. We will include 18 staff in mental health, education or youth work, and 90 adolescents. 12 staff and 60 adolescents will use DIALOG-A, and the remaining 6 staff and 30 adolescents will be in the control condition. To test whether DIALOG-A helps adolescents with depression and anxiety, we will ask participants to complete questionnaires at the start of the study and at 6 and 12 months. We will collect data on mental health outcomes, including symptoms of depression and anxiety, quality of life, social situation and self-esteem. To help other LMICs deliver DIALOG-A, we will ask staff and adolescents about their experiences, and what worked and did not work. This will help us develop implementation plans (WP3). Finally, we want to involve adolescents in our research. To do this, we will run an arts-based project, where we will ask young people with depression and anxiety to take photographs and films of their experience. We will hold exhibitions to display the photographs and the short-film made by the adolescents. We hope this will encourage other young people to get involved in research.

Expected results
If successful, the project will develop a new intervention to improve the mental health of adolescents with depression and anxiety. This will improve their quality of life. The project will focus on two areas in Colombia. Yet, if the intervention is successful, it can be used elsewhere in Colombia, Latin America and worldwide, where young people face similar difficulties. Our communication methods will ensure the research is widely disseminated to improve the health of adolescents, especially those living in LMICs across the world.

Although depression and anxiety are leading causes of adolescent disability worldwide, a treatment gap exists, particularly in Low and Middle Income Countries (LMICs), where less than 50% of people access treatment and fewer than 12% receive minimally adequate care. Effective, low-cost and generic interventions are therefore needed. Our aim is to improve adolescent mental health in LMICs by repurposing such an intervention to treat depression and anxiety. To achieve this we will:
1)Repurpose an effective intervention for the treatment of depression and anxiety in adolescence.
2)Assess the feasibility and acceptability of the intervention within two sites in Colombia.
3)Develop an implementation strategy to promote upscale.
4)Engage stakeholders in a participatory arts-based project.
We will follow the initial stages of the MRC framework for designing and evaluating complex interventions. Qualitative interviews and focus groups will be used alongside a pilot study to repurpose the existing intervention (DIALOG+) for use with adolescents. The repurposed intervention (DIALOG-A) will be evaluated in a cluster RCT involving 90 adolescents with depression and anxiety. Mental health, quality of life and social situation will be assessed at baseline, 6 and 12 months, and feasibility tested. Interviews will be analysed using the Theoretical Domains Framework and Quality Improvement projects will develop implementation strategies to promote upscale. An innovative arts-based project will capture the voice of adolescents with depression and anxiety to engage stakeholders throughout. If successful, we will develop a low-cost, generic intervention to treat depression and anxiety in adolescence and hence improve health outcomes. Our focus is on two areas in Colombia where adolescents are exposed to stressors such as violence, conflict and deprivation. If effective here, the intervention has the potential to improve adolescent health in other LMICs facing similar issues.

Depression and anxiety are leading causes of disability worldwide particularly during adolescence where prevalence rapidly increases. This risk may be even greater where individuals are exposed to multiple stressors such as armed conflict, trauma, displacement and violence. Yet, despite the impact of depression and anxiety, treatment gaps still exists regarding access to and the quality of services. This project aims to repurpose an intervention shown to be effective in improving mental health outcomes for adults with mental illness. The project will adapt the intervention to the needs of adolescents, and will evaluate it in two diverse and challenging areas in Colombia. The main impact of the project will be:
1)Repurposing a low-cost, generic and effective intervention (DIALOG+) for use with adolescents with depression and anxiety (DIALOG-A).
2)Providing evidence of acceptability, feasibility and an indication of effectiveness of the intervention.
3)Engaging adolescents in participatory arts-based projects to give voice to their experience of depression and anxiety.
4)Promoting upscale and dissemination through innovative implementation research and Quality Improvement (QI) approaches.
5)Building capacity of researchers, policy-makers and mental health services.
The following groups will immediately benefit:
a)Adolescents with depression and anxiety including those who experience multiple stressors due to the violence and recent conflict in Colombia. The primary aim is to improve mental health outcomes by providing mental health services with an effective, low-cost and generic intervention. The intervention will be developed in partnership with adolescents, youth workers, teachers and mental health professionals to ensure it is appropriate to the needs of adolescents.
b)Healthcare professionals, youth workers and educators will benefit from a new intervention to improve adolescent mental health outcomes and quality of life. Within the exploratory RCT, there will be a focus on upscale and sustainable delivery. This will be realised via the development of implementation plans and small-scale QI projects.
c)Government organisations, charities and NGOs will gain a better understanding of the challenges faced by individuals with depression and anxiety. This will be highlighted in participatory projects resulting in a short film and photography exhibition.
d)Academics: the project relies on close collaboration between two academic institutions in the UK and Colombia. Through knowledge exchange visits and capacity building workshops, research and leadership capacity will be increased. The exploratory RCT will be registered on the ISRCTN Registry with results freely available within 12 months following completion.
e)Members of the public: depression is a leading cause of disability for young people, with many experiencing recurrent episodes throughout adolescence and adulthood. By improving outcomes in a low-cost way, the project has potential to benefit the public more widely by reducing disability and fostering economic and social development - which are key components of the UN sustainable development goals.
ODA compliance
WHO surveys have frequently indicated that the burden of depression and anxiety is greatest for LMICs. The same applies for treatment gaps, where only a small proportion of individuals, including adolescents receive even minimally adequate treatment. This research aims to directly address this gap through repurposing and evaluating an effective, low-cost and generic intervention to treat depression and anxiety in adolescence. The research will be conducted in two challenging regions of Colombia - Soacha and Duitama, with high levels of violence, deprivation and trauma. Colombia is currently on the DAC list, and interventions shown to be effective in these regions have a high chance of success in other contexts across Colombia with potential translation to other LMICs experiencing these issues.