The Friendship Bench for adolescents: evaluating strategies for scaling interventions to treat common mental disorders among adolescents in Zimbabwe

Common mental disorders, (CMD) namely anxiety and depression, are highly prevalent among adolescents globally and are the main cause of disability-adjusted life years in this age group. In low resource settings CMD are under diagnosed and there is a large treatment gap. In adults, treatment for CMD delivered by non-specialist health workers is effective. We recently completed a trial of a lay health worker (LHW) delivered intervention (the Friendship Bench Intervention (FBI); www.friendshipbenchzimbabwe.org) in Zimbabwe. It was highly effective at treating CMD in adults. The FBI comprises a 6-session psychological intervention based on problem-solving therapy, delivered by a trained LHW. Participants who do not respond well are referred to a nurse for more specialised treatment. Grand Challenges Canada (GCC) and MSF-Holland are funding scale-up of the FBI for adults to 60 primary care clinics in 3 cities in Zimbabwe in 2016. This scale up provides the ideal framework to introduce and evaluate the FBI for younger patients (16-19 years old).

Data from the original trial indicate that the FBI was equally effective in young people (aged 18-22 years) as in older adults, but a key barrier is that relatively few young people attend clinics. We plan to develop a youth friendly FBI package which is i) delivered by trained and supported youth LHWs; ii) delivered within community settings including schools and clinics; iii) includes targeting of vulnerable young people (including pregnant teenagers and young offenders) iv) supported by community activities to reduce stigma surrounding poor mental health and raise awareness of adolescent mental health specifically and the youth-friendly FBI in particular.

We will determine the uptake, effectiveness and cost-effectiveness of the two strategies to deliver the FBI to 16-19 year olds with CMD in a sustainable way; (a) the usual care clinic-based delivery currently being scaled-up for adults, and (b) the youth-friendly FBI package. Our hypothesis is that implementation of the youth friendly package will i) increase the acceptability and uptake of the intervention to 16-19 year olds compared with usual care FBI; and ii) be an effective and sustainable model to treat CMD among 16-19 year olds.

We will randomly select 30 clinics to receive the usual care FBI and 30 clinics to receive the youth friendly FBI package. Participants will be individuals aged 16-19 years who screen positive for CMD using the locally validated Shona Symptom Questionnaire -14 (SSQ-14). A random sample of 500 eligible participants attending the clinics will be selected over a 6 month period and asked consent to participate in the outcome evaluation 6 months after they receive the FB intervention. The interview after 6 months will be conducted either in person or by telephone and will include socio-demographic data and a comprehensive mental health assessment including the SSQ-14, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and WHO Disability Assessment Schedule (WHO-DAS). Detailed data on how the intervention is delivered, for example, number of young people seen, how many sessions they attended, will be collected, including in-depth interviews with implementing agents, young people and clinic staff to assess acceptability and sustainability of delivering the intervention.

The results of the study will be used to refine the existing Friendship Bench programme to include a sustainable and effective adolescent package to complement the existing programme for adults. This will be done collectively with the City Health Departments and the Ministry of Health who are already involved in the scaling-up of the intervention in adults. We anticipate that these results will be generalizable beyond the immediate research setting, as the Friendship Bench is scaled-up across Zimbabwe and the region more widely.

We recently completed a cluster randomised trial of a lay health worker (LHW) delivered intervention for common mental disorders (CMD) in Zimbabwe called the Friendship Bench Intervention (FBI); (www.friendshipbenchzimbabwe.org). It was very effective among primary healthcare clinic (PHC) attenders aged 18 or older. The FBI comprises 6-sessions of problem-solving therapy, delivered by a trained LHW, stepped-up to treatment by a nurse for those who do not recover. Scale up of the FBI is funded from April 2016 to 60 clinics in 3 cities in Zimbabwe. Trial data indicate that the FBI was equally effective in those aged 18-22 as in older adults but few young people attend PHCs.

We hypothesise that implementation of the FBI as part of a youth friendly package will i) increase the demand for and uptake of the FBI among 16-19 year olds compared to usual care FB delivery; and ii) be an effective, cost-effective, and sustainable model to treat CMD among 16-19 year olds. We will evaluate the uptake, effectiveness and cost-effectiveness of two strategies among 16-19 year olds with CMD. The two strategies are 1) the usual care FBI with delivery extended to include 16-17 year olds; 2) a youth-friendly FBI package. We will randomize 30 clinics to receive the usual care FBI and 30 to the youth friendly FBI package. Individuals aged 16-19 years who screen positive for CMD using the locally validated Shona Symptom Questionnaire (SSQ-14) will be enrolled. A random sample of 500 eligible participants will be recruited to take part in the outcome evaluation after 6 months. This will include a comprehensive mental health assessment using the SSQ-14, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and WHO Disability Assessment Schedule (WHO-DAS). A detailed process evaluation and cost effectiveness study will be conducted.

Our aim is that this study will result in a sustainable, effective adolescent component to complement the existing FBI for adults.

The impact of the FBI in adults is currently being seen by the enthusiastic support for scale-up of the intervention to 60 clinics, funded by GCC/MSF-Holland and supported by the Zimbabwe Ministry of Health and City Health Departments. After scale-up FB will be the largest integrated mental health programme in Africa, with over 50,000 people receiving services each month through the local clinics. If successful, the youth-friendly FBI will provide a sustainable, cost-effective strategy to treat adolescents living with CMD as well as adults. To our knowledge, there are no other proven strategies which are scalable and effective in treating CMDs among adolescents in Africa.

Strategies such as the FBI which improve mental health in adolescence in a cost-effective and sustainable way can have a substantial impact on morbidity globally for several reasons: i) most common mental disorders begin in adolescence, although they are often first detected later in life; ii) building emotional resilience in adolescence can delay the onset of mental illness and mitigate future symptoms; ii) when left untreated, CMD can impair role functioning, self-care and adherence to treatments, and lead to reduced productivity and an increase in healthcare costs; and iv) in addition CMD in adolescence effects educational attainment, sexual and reproductive health and risk of violence, as well as smoking, alcohol and substance misuse. Depressive disorders are the primary cause of disability-adjusted life years (DALYs) in adolescents, responsible for an estimated 12.2 million DALYs globally among 10-19 year olds. Further, in the 2012 WHO global community consultation with adolescents, mental health was the most important problem reported by the adolescents. Effective treatment of CMD has the potential to alter the present and future life course of adolescents.

A strength of our intervention is its sustainable nature through the use of trained lay health workers. This is essential for future impact, not only in adolescents but also in adults, as in many parts of the world, including in sub-Saharan Africa, there are few psychiatrists and other trained mental health specialists. In Zimbabwe, there are only 10 psychiatrists in the country and only four psychologists working in government practice. This intervention has the potential to dramatically increase the accessibility of mental health care for this age group.

In addition to the lack of specialist personnel, there is currently little availability of mental health diagnosis and treatment close to where young people live; our community based approach will directly address this. Further, it is known that primary health care attendance is poor among adolescents regardless of their health need. We anticipate that our integrated youth friendly package of community-based services will encourage young people to access care at places convenient to them.

Lastly in Zimbabwe, as in many parts of the world, mental health stigma is pervasive, myths and misconception relating to mental illness abound and inhumane treatments are common. By working in communities to raise awareness and create demand for the Friendship Bench intervention we anticipate that we will have a positive influence on mental health knowledge and stigma within communities (although we will not measure this directly within this study).