Group interpersonal psychotherapy for depression and anxiety among adolescents in rural Nepal: a feasibility and pilot study

Our study seeks to understand how a group interpersonal psychotherapy (IPT) intervention can be made relevant, feasible and acceptable for adolescents with depression and anxiety in rural Nepal.

Addressing depression and anxiety in adolescence is key to improving adolescent health since these disorders are two of the leading causes of disability in this age group. Depression and anxiety are also associated with mortality due to suicide, and have negative long-term health, social and economic effects. In Nepal, adolescents are at high risk of depression and anxiety, due to a complex picture of recent and historical trauma (two major earthquakes in 2015 and a 10-year civil war between 1996-2006) on a background of socio-economic deprivation. Our study will take place in Sindhupalchowk, one of the districts in Nepal that was most severely affected by the earthquakes and where many young people lost family and friends, as well as their homes and schools.

Globally there is a lack of services for child and adolescent mental health. This is especially true in low-and middle-income countries (LMICs) including Nepal, where the burden is highest. The World Health Organization (WHO) Mental Health Gap Action Programme outlines a role for psychological therapies including IPT in the treatment of child and adolescent emotional disorders such as depression and anxiety, however few studies have adapted these for young people in LMICs.

We aim to adapt and pilot the WHO group IPT intervention, which was originally developed for adults. IPT is a psychological therapy to treat depression, and has also been shown to be effective in treating anxiety. It focuses on addressing difficulties linked to four common problems that can trigger depression and anxiety: grief, interpersonal disputes, role transitions and interpersonal isolation. IPT has been shown to be beneficial for adolescent mental health and compared to other psychological therapies it may be more acceptable to adolescents. It has also been delivered by non-specialists in group settings, which is a potentially scalable model for low-resource settings such as Nepal.

Our study will involve a preliminary qualitative study, translation and expert-led revision of the IPT manual, practice training, an intervention adaptation workshop and a community advisory board, and pilot IPT groups. The qualitative study will include interviews and focus group discussions with adolescents, their parents/guardians, teachers, community health workers and government officers to understand how adolescents experience depression and anxiety, how they seek help and potential barriers to intervention. Informed by the qualitative study findings, our team of Nepalese and international investigators, including psychiatrists and psychologists, will then culturally and developmentally adapt the manual for adolescents in Nepal. We will conduct practice training with experienced counsellors and ask for feedback and input from a community advisory board in Sindhupalchowk, comprising adolescents, their parents/guardians, a teacher and community health workers. In the final stage of the project, we will pilot eight IPT groups. We will pilot both community- and school-based groups in order to engage in-school and out-of-school adolescents and to identify a suitable cadre of group facilitators, such as teachers or community health volunteers. Throughout the intervention we will track symptoms of depression and anxiety, and functioning, in order to estimate optimal treatment duration. Post-intervention, we will collect data on intervention acceptability, adherence, quality and cost.

Our study will generate new and important findings that will help us to understand how to deliver psychological interventions for adolescents in LMICs, and will enable us to conduct a randomised controlled trial to evaluate the effectiveness and cost value of an IPT intervention in Nepal.

Depression and anxiety are leading causes of disability adjusted life years among adolescents aged 10-19 and can lead to social and educational impairment, substance misuse and suicide. The treatment gap for adolescent mental disorders is large, especially in LMICs. The WHO Mental Health Gap Action Programme outlines a role for psychological therapies in the treatment of child and adolescent emotional disorders such as depression and anxiety, however there is an urgent need to adapt these for use in LMICs.

We aim to adapt and pilot the WHO group interpersonal psychotherapy (IPT) intervention for adolescents with symptoms of depression and anxiety. We will do this in rural Nepal where adolescents are at high risk of mental disorders and have limited access to mental health services. IPT was selected as the intervention because of evidence that it is more acceptable to adolescents compared to other psychological therapies, also because it can be delivered in groups by non-specialists and is therefore potentially scalable in low-resource settings like Nepal.

Our study has five stages: (i) a preliminary qualitative study to understand adolescents' experiences of depression and anxiety, help-seeking and barriers to intervention; (ii) translation and expert-led revision of the IPT intervention manual; (iii) practice training; (iv) an intervention adaptation workshop and community advisory board to provide feedback on the revised manual, (v) and pilot community and school IPT groups for boys and girls to assess intervention acceptability, adherence, quality and costs, and optimal treatment duration.

Our study will generate essential information on adolescent mental health intervention in LMICs and will enable us to develop a protocol for a randomised controlled trial to evaluate the effectiveness and cost value of an IPT intervention in Nepal. This study will also build research capacity and strong local and international stakeholder partnerships.

Our study is ODA compliant. Depression and anxiety in adolescence are major public health problems given their large contribution to the burden of disease and the treatment gap that exists. We will deliver high quality research to address these disorders in Nepal, a country on the DAC list, drawing on the strength of two UK institutions, UCL and KCL, and partnership with Nepalese and US collaborators.

The ultimate goal of our study is to benefit adolescents with depression and anxiety in rural Nepal who currently have limited access to mental health care. In the short term, within the study timeframe, we will achieve this through implementation of pilot IPT groups and training teachers, health workers and community psychosocial workers to identify adolescents with depression and anxiety and to facilitate IPT sessions. Longer term, as a result of this study, we will impact on adolescents through implementation of a randomised controlled trial of the IPT intervention to evaluate effectiveness and cost value. Pending these results, the intervention will then be suitable for scale up in other districts across Nepal where it could potentially impact on a large population of adolescents.

In addition to adolescents, there are other potential beneficiaries of our research:

1) Communities in Sindhupalchowk will benefit from the opportunity to participate in community advisory board meetings which will help to build awareness and mobilise communities to improve adolescent mental health. We will also develop mental health care capacity in these communities through training community psychosocial workers, teachers and health workers as IPT facilitators. These facilitators will be encouraged to disseminate their learning within their communities in order to benefit individuals who are not directly participating in the research.

2) Researchers working in adolescent mental health and on intervention development: We will develop an IPT manual and training package that academics can refer to and adapt for other similar low-resource settings, and we will be happy to advise and support them in this process. Academics working on intervention development in other areas of health can also potentially benefit from our insights into the process of adapting and piloting a complex intervention according to the MRC development and evaluation guidance. Our focus on engaging adolescents and key stakeholders throughout the intervention development process could help to inspire other research groups to adopt a similarly participatory approach. We will publish our insights into intervention development, alongside findings from the pilot study, in a peer-reviewed journal. Our qualitative research on adolescents' experiences of depression and anxiety will impact on academics working in anthropology, epidemiology and social science disciplines and could help to inform the development of new and locally relevant screening tools and intervention approaches.

3) Policy makers and programmers: We will build intervention development capacity in Nepal through the intervention adaptation workshop and through dissemination of our research findings with government officers and non-governmental organisations. The tools we develop through this study will be shared with the Nepal Ministry of Health and the Ministry of Education. We aim to partner with these ministries to conduct a full-scale evaluation of the IPT intervention. At a global level, policy makers and programmers will be able to synthesise findings from our study with research from other LMICs to refine and update existing packages of mental health care for adolescents, for example the WHO Mental Health Gap Action Programme package of care. We will ensure our research findings are available to these beneficiaries by widely disseminating policy briefs and publications through our existing global mental health networks.