Digital delivery of Behavioural Activation to overcome depression and facilitate social and economic transitions of adolescents in South Africa

Depression affects 350 million in the world and will soon be the single greatest burden on health with the peak onset during adolescence. Adolescence is a key time period as social cognitions and executive function evolve dramatically affecting inter-personal functioning and risky behaviours such as unprotected sex (potentially leading to HIV infection and early pregnancy). It is also a time when adolescents have to negotiate a successful transition to productive adulthood and depression can impact on key life outcomes such as education, employment and physical health. Depression is also the most common cause of suicide; now recognized as major problem in South Africa.
Effective treatments for depression in rural South Africa are not available largely due to a dearth of trained professionals. A psychological treatment for depression called Behavioural Activation (BA) has been shown to be as effective as Cognitive Behavioural Therapy (CBT) (the gold standard therapy for depression). BA targets behaviours rather than cognitive processes and attitudes, making it relatively easy to deliver, to adapt cross-culturally, and BA has now successfully been delivered remotely without face-to-face contact. Smartphones and tablet based treatments provide an opportunity to deliver evidence-based therapy to large numbers of individuals.
We aim to develop a scalable digital platform using smartphones and tablets to deliver a culturally adapted version of BA. In the first project phase we will conduct interviews and focus group discussions with adolescents, caregivers, community and education stakeholders to develop a culturally relevant and age appropriate app-based intervention. The functionality, acceptability and usability of the app will be refined through an iterative process with adolescents and schools.
In years 2-3 we will conduct a pilot randomized controlled trial of adolescents (n=200) to test the effectiveness of this platform in reducing depression in adolescents aged between 15 and 18 years. Adolescents will be screened in schools using the PHQ-9 and those diagnosed with mild to moderate depression will be recruited. Participants will either receive BA treatment via smart phones or active monitoring of mood also via smart phones (control group). All participants will be offered a low-end smartphone with limited airtime and accessibility or be guided to use tablets at school.
The app-based BA intervention will comprise of 6 sessions over 10 weeks and will be supplemented by brief support phone calls. The control group will have their mood and psychological functioning monitored on 6 occasions. Appropriate help will be provided to those who present with risk. Assessments will take place at baseline, end of treatment (12 weeks after baseline) and 24 weeks after end of treatment.
The primary outcome will be a reduction in adolescent depression and secondary outcomes include anxiety, risk taking behaviours and a range of economic and decision making measures.
To test whether social cognition and executive function mediate the effects of BA, culturally adapted tests will be developed. We also aim to conduct exploratory statistical mediational analyses to test these potential mechanisms.
The study will be nested within the Agincourt Health and Demographic Surveillance (HDSS) site in MRC/Wits Rural Public Health and Health Transitions Unit (Mpumalanga province) where we have started working closely with the Community Advisory Group to engage local stakeholders and the community who are strongly supportive of this initiative. Formative work will also take place in the Dikgale HDSS (Limpopo province).
This pilot study will ultimately lead to the development of a full-scale treatment trial to support a better management of depression among adolescents living in South Africa. Tackling depression in this way is consistent with the aim of the Department of Health to strengthen primary care and community-based health care systems.

Depression accounts for more disability-adjusted life-years (DALYs) throughout the world than any other condition or illness. The onset of depression peaks during adolescence, a time characterised by substantial development of the brain, cognition, and social and affective processing. Thus depression can negatively affect social, cognitive and executive functioning leading to greater risk for substance use disorders, suicide, academic underachievement, poor sexual health and significant reduction in future income.

We aim to i) develop a scalable digital platform using smart phones and tablets to deliver a culturally adapted version an effective treatment for depression called Behavioural Activation (BA) ii) conduct a pilot trial to test the effectiveness of this app-based BA intervention in treating depression in 15 to 18 year olds in rural Agincourt sub-district. We will recruit 200 adolescents from schools who will be randomized to receive either 6 sessions of the app-based BA via smart phones/tablets, or active monitoring of mood via smart phones/tablets on 6 occasions. Assessments will take place at baseline, end of treatment (12 weeks after baseline) and 24 weeks after end of treatment.

The main outcome is a reduction in adolescent depression measured using the PHQ-9 and secondary outcomes are: educational outcomes including school attendance and progression; decision-making and impatience across time (present biased decisions and discount rates using choice-based methods); risky behaviours and self-control skills such as unprotected sex and substance misuse. We will also test whether changes in executive functioning and social cognitions mediate the effects of BA in reducing depression and improving educational, economic and risk outcomes.

Depressed adolescents: Under-resourced healthcare services are unable to provide treatment for even a small proportion of depressed adolescents. A scalable, digital treatment targeting adolescent depression has the potential to improve the lives of many adolescents: (a) depression can have a major impact on social and emotional functioning as well as comprising the ability to become productive members of society. Effectively treating adolescent depression also reduces the likelihood of later episodes of depression. Treatment should enable an individual to successfully engage in educational opportunities, improving life trajectories, and enable the accumulation of human capital. (b) BA has the potential to alter adolescent's propensity to engage in risky behaviours such as unprotected sex which can lead to teenage pregnancy and HIV infection. (c) Depression carries a significant risk of suicide. In South Africa, 9% of all adolescent deaths are due to suicide, 90% of which are associated with mental health disorders (SADAG, 2014). BA has proved to be particularly useful in reducing the frequency of suicide-related behaviours (Hopko, 2003) and has the potential to reduce suicidal behaviour in South African adolescents.

Family members: (a) Symptoms of depression such as withdrawal, hopelessness, low mood, and irritability can have marked effects on interpersonal relationships especially within the family. (b) Many adolescents have their first child by the age of 20 (40% in the Agincourt sub-district) and it is well established that depression in young parents negatively impacts on their offspring. Thus effective treatment of depression could have enormous benefits on the family including the next generation.

Primary health care systems: (a) In line with South Africa's 'Mental Health Policy Framework and Strategic Plan 2013-2020,' this study will inform the delivery of mental health services by identifying best practices, and providing local policymakers with the type of evidence to advocate for government action. (b) If successful, digitally delivered BA has the potential to be easily incorporated into primary care or community services with only limited need for specialized workers. According to recent findings, delivering a scaled-up package of mental health interventions for key mental illnesses in sub-Saharan Africa and south Asia would cost on the order of US$3-$4 per person (Patel et al, 2015). (c) Digital technologies will reduce the burden on primary care systems and enable them to identify depressed adolescents and increase overall access to treatment.

The wider communities: The cumulative global impact of mental disorders in terms of lost economic output has been estimated be approximately US$16 trillion over twenty years (Bloom et al., 2006). In addition, some studies have linked depression to sleep deprivation, drug use, violent crime, and HIV infection which can impact on poverty, inequality and the wider economy. Treating depression is likely to have positive economic and health benefits, not only in those who are treated, but on the wider community. This study may help in raising public awareness of mental health and reduce the widespread stigma and discrimination associated with mental health illnesses. Our research would generate evidence regarding the feasibility and acceptability of a digitally delivered BA intervention, that has the potential to be used by policy makers and Ministries of Health to scale-up care for adolescent mental health, with a key focus being increasing coverage, in line with Universal Health Coverage and the SDGs.