Community-based psychological treatment for adolescents with anxiety and depression in India

Anxiety and depression are common mental disorders and two leading causes of illness and disability among adolescents globally.

In India, between 7 and 12% of adolescents have anxiety and depression, but very few have access to treatment because there are too few psychologists and psychiatrists, and poor access to mental health services. We know that psychological treatments can help reduce symptoms of anxiety and depression in adolescents. We also know that 'non-specialist' workers (i.e. those with no specialised mental health training) can provide effective psychological treatments in the community. However, we not know how to identify adolescents with anxiety and depression in the community, which specific treatment could be used by non-specialists in rural and urban slum Indian settings, where many vulnerable adolescents live, or how best to organise referrals for adolescents who do recover or have severe symptoms of anxiety and depression.

In this project, we aim to understand how adolescents, their families, and local health providers think about anxiety and depression in adolescents, identify tools to screen adolescents for anxiety and depression in the community, adapt one of five existing psychological treatments in partnership with adolescents, their families and local non-specialist workers, and develop referral pathways. Finally, we will pilot this adapted psychological treatment - as well as the screening tool and referrals - with adolescents over a period of nine months to find out if providing treatment in this way is acceptable, feasible, and leads to a reduction in symptoms of anxiety and depression in adolescents. We will also collect data on the costs of the screening, psychological treatment and referrals.

We will focus on adolescents with mild or moderate symptoms of anxiety and depression, and refer those with more severe symptoms or suicidal thoughts to mental health services.
Through this project, we hope to greatly expand access for treatment to help adolescents with anxiety and depression in rural and urban India.

India is home to one in five of all adolescents, and an estimated 7-12% of boys and girls aged 10-19 years suffer from mental health problems. The treatment gap for adolescent mental disorders is largely unknown but is likely to be even greater than for adults (>85%). Non-specialist workers employed by India's National Adolescent Health programme do not currently have the tools to screen adolescents for anxiety and depression or training in evidence-based psychological treatments to help them. Our project will aim to answer four research questions:
1 What explanatory models do adolescents, their families and non-specialist workers have for adolescent anxiety and depression in rural and urban settings?
2 What are the most appropriate tools to screen adolescents for anxiety and depression in community settings?
3 How can a stepped care model for anxiety and depression in adolescents be developed, including: (a) a feasible screening approach; (b) an adapted psychological treatment which can be used by community-based non-specialist workers; (c) referral pathways?
4 What are the feasibility, acceptability and cost of this stepped care model for adolescents, their families, and treatment providers?
We will conduct qualitative research with adolescents, their relatives, and non-specialist workers in rural Jharkhand (eastern India) and informal urban settlements (slums) of Mumbai to explore how they understand and address symptoms of anxiety and depression. We will seek to validate two existing tools to screen adolescents for anxiety and depression (the Patient Health Questionnaire - Adolescent and the Revised Children's Anxiety and Depression Scale). We will work with adolescents, their families and non-specialist workers to adapt one of five psychological treatments for anxiety and depression so they can be delivered by non-specialists in the community. Finally, we will pilot the screening, psychological treatment and referral system for a period of nine months.

Our research will have four main beneficiaries beyond the academic community:

1. Adolescents and their families

In the short-term, adolescents and their families living in rural areas of Jharkhand and urban settlements of Mumbai will benefit from access to rigorous screening, psychological treatment and referrals for anxiety and depression. While screening and facility-based treatment are available in Mumbai, community-based psychological treatment is not. Screening, treatment and referrals are unavailable in rural Jharkhand. In the long-term, if the screening, psychological treatment and referrals prove acceptable and feasible, we will proceed to formally test their effects on short and medium-term recovery from anxiety and depression in a trial, following which the interventions may be further recommended for scale up and benefit an even greater number of adolescents.

2. Non-specialist workers (NGO and RKSK peer facilitators and counsellors)

Government (RKSK) peer educators/facilitators, health facility-based counsellors and NGO-trained peer facilitators in Jharkhand and Mumbai do not currently have access to training for screening, psychological treatment or support for adolescent anxiety and depression. Our project will therefore contribute to strengthening their capacities in the context of the National Adolescent Mental Health programme.

3. Indian civil society organisations

In the short-term, our project will build the capacities of two civil society organisations (Ekjut, in Jharkhand, and SNEHA, in Mumbai). Both organisations have a strong track-record of community-based research and action but limited experience of adolescent mental health research to date. By partnering with experienced researchers and clinicians from Sangath, having the support of the Central Institute of Psychiatry in Ranchi, Sion Hospital in Mumbai, as well as King's College London, the London School of Hygiene and Tropical Medicine and University College London, they will gain exposure to training in screening and psychological treatments to improve adolescent mental health.

4. Indian policy-makers

Recent analyses of Indian policies to support adolescent health have highlighted the need for investment in implementation research to improve adolescent mental health. Our project will provide Indian policy-makers at State and National-levels with evidence on the acceptability, feasibility, cost and modalities for offering screening and treatment for anxiety and depression to adolescents in community settings.