Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India

Chorpita, Bruce F.; Daleiden, Eric L.; Malik, Kanika; Gellatly, Resham; Boustani, Maya M.; Michelson, Daniel; Knudsen, Kendra; Mathur, Sonal; Patel, Vikram

doi:10.1016/j.brat.2020.103698

Cited by 24 publications

(40 citation statements)

References 36 publications

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“…The PRemIum for aDolEscents (PRIDE) research program was conceived to meet the need for contextually sensitive, evidence-based interventions that target common adolescent mental health problems in India and LMICs more generally. The PRIDE intervention model is situated in secondary schools and built around a transdiagnostic stepped care architecture, which comprises a brief problem-solving intervention (“Step 1”) and a higher-intensity personalized psychological treatment (“Step 2”) for adolescents who do not respond to the first-line intervention [ 5 , 6 ]. The first step was evaluated in a randomized controlled trial in New Delhi, India, where lay counselors functioned as the delivery agent in the intervention arm [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Effectiveness and costs associated with a lay counselor–delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial

et al. 2021

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Background Psychosocial interventions for adolescent mental health problems are effective, but evidence on their longer-term outcomes is scarce, especially in low-resource settings. We report on the 12-month sustained effectiveness and costs of scaling up a lay counselor–delivered, transdiagnostic problem-solving intervention for common adolescent mental health problems in low-income schools in New Delhi, India. Methods and findings Participants in the original trial were 250 school-going adolescents (mean [M] age = 15.61 years, standard deviation [SD] = 1.68), including 174 (69.6%) who identified as male. Participants were recruited from 6 government schools over a period of 4 months (August 20 to December 14, 2018) and were selected on the basis of elevated mental health symptoms and distress/functional impairment. A 2-arm, randomized controlled trial design was used to examine the effectiveness of a lay counselor–delivered, problem-solving intervention (4 to 5 sessions over 3 weeks) with supporting printed booklets (intervention arm) in comparison with problem solving delivered via printed booklets alone (control arm), at the original endpoints of 6 and 12 weeks. The protocol was modified, as per the recommendation of the Trial Steering Committee, to include a post hoc extension of the follow-up period to 12 months. Primary outcomes were adolescent-reported psychosocial problems (Youth Top Problems [YTP]) and mental health symptoms (Strengths and Difficulties Questionnaire [SDQ] Total Difficulties scale). Other self-reported outcomes included SDQ subscales, perceived stress, well-being, and remission. The sustained effects of the intervention were estimated at the 12-month endpoint and over 12 months (the latter assumed a constant effect across 3 follow-up points) using a linear mixed model for repeated measures and involving complete case analysis. Sensitivity analyses examined the effect of missing data using multiple imputations. Costs were estimated for delivering the intervention during the trial and from modeling a scale-up scenario, using a retrospective ingredients approach. Out of the 250 original trial participants, 176 (70.4%) adolescents participated in the 12-month follow-up assessment. One adverse event was identified during follow-up and deemed unrelated to the intervention. Evidence was found for intervention effects on both SDQ Total Difficulties and YTP at 12 months (YTP: adjusted mean difference [AMD] = −0.75, 95% confidence interval [CI] = −1.47, −0.03, p = 0.04; SDQ Total Difficulties: AMD = −1.73, 95% CI = −3.47, 0.02, p = 0.05), with stronger effects over 12 months (YTP: AMD = −0.98, 95% CI = −1.51, −0.45, p < 0.001; SDQ Total Difficulties: AMD = −1.23, 95% CI = −2.37, −0.09; p = 0.03). There was also evidence for intervention effects on internalizing symptoms, impairment, perceived stress, and well-being over 12 months. The intervention effect was stable for most outcomes on sensitivity analyses adjusting for missing data; however, for SDQ Total Difficulties and impairment, the effect was slightly attenuated. The per-student cost of delivering the intervention during the trial was $3 United States dollars (USD; or $158 USD per case) and for scaling up the intervention in the modeled scenario was $4 USD (or $23 USD per case). The scaling up cost accounted for 0.4% of the per-student school budget in New Delhi. The main limitations of the study’s methodology were the lack of sample size calculations powered for 12-month follow-up and the absence of cost-effectiveness analyses using the primary outcomes. Conclusions In this study, we observed that a lay counselor–delivered, brief transdiagnostic problem-solving intervention had sustained effects on psychosocial problems and mental health symptoms over the 12-month follow-up period. Scaling up this resource-efficient intervention is an affordable policy goal for improving adolescents’ access to mental health care in low-resource settings. The findings need to be interpreted with caution, as this study was a post hoc extension, and thus, the sample size calculations did not take into account the relatively high attrition rate observed during the long-term follow-up. Trial registration ClinicalTrials.gov NCT03630471.

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Section: Introductionmentioning

confidence: 99%

Effectiveness and costs associated with a lay counselor–delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial

et al. 2021

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“…In resource limiting setting like India, these findings are useful for developing and implementing primary care physician-based collaborative and integrative model (stepped care or matched care) for mental illness. [ 27 28 ] Under these models, the primary care physician can direct the patient care while the specialist provides collaborative care. Actigraphy has been found as a useful objective tool in these models and minimizes human errors and subjective bias in other countries.…”

Section: Discussionmentioning

confidence: 99%

Comparison of actigraphy indices among patients with depression and schizophrenia

Ransing

Patil

et al. 2021

Journal of Family Medicine and Primary Care

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Background: Schizophrenia (SCZ) and depression (MDD) are associated with changes in sleep and activity patterns. However, because of a lack of objective evaluation, the diagnostic or clinical value of these sleep-activity patterns is unknown. In this study, we attempted to assess and compare the sleep and activity patterns using actigraphy. Materials and Methods: We have recruited 35 patients with SCZ (mean age: 29.29 ± 7.54 years) and 42 patients with MDD (mean age: 27.5 ± 5.59 years) in this cross-sectional study. The actigraphy indices [Time in bed (minutes), Onset latency (minutes), Total sleep time (Minutes), Sleep efficiency (%), WASO (minutes), number of awakening, and activity duration (minutes) were compared among the two groups using unpaired t -test and Fisher exact test. Results: In the MDD group, the time in bed (minutes) was significantly higher than in the SCZ group (402.7 ± 41.97 vs. 379.1 ± 40.45, P = 0.01), while the sleep efficiency was lower in the SCZ group than in the MDD group (60.04 ± 9.25 vs. 65.05 ± 7.16, P = 0.0092). An increase in onset latency (minutes) was observed in the SCZ group compared to the MDD group (49.06 ± 16.09 vs. 43.6 ± 10.14, P = 0.074). The difference in WASO (minutes), the number of awakenings, and activity duration (minutes) among the two groups were insignificant. Conclusion: Actigraphy parameters such as sleep efficiency and time in bed may be a useful sleep process, etiological, and prognostic markers in patients with SCZ and MDD. The longitudinal studies are needed to estimate the predictive role of these parameters for therapeutic outcome in these patients.

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“…More specifically, the researchers reported a 36-45% reduction in depressive symptoms including suicide plans or attempts (Patel et al, 2011). Given these successes, a stepped-care model was recently adapted for adolescents in India (Chorpita et al, 2020). Additionally, LHWs have been trained to be the primary providers of EBPs in LMICs, including parent management training (Puffer et al, 2015), trauma-focused cognitive-behavioral therapy (TF-CBT) for traumatic stress in children (Dorsey et al, 2020), and modular transdiagnostic treatments for anxiety, depression and trauma in adults (Bolton et al, 2014;Murray et al, 2014).…”

Section: Task-sharingmentioning

confidence: 99%

Future Directions in Lay Health Worker Involvement in Children’s Mental Health Services in the U.S.

Barnett

Sanchez

Rosas

et al. 2021

Journal of Clinical Child & Adolescent Psychology

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Nearly half of children meeting criteria for a mental health disorder in the United States (U.S.) do not receive the treatment they need. Unfortunately, lack of access to and engagement in mental health services can be seen at even higher rates for historically marginalized groups, including low-income, racial, and ethnic minority youth. Lay Health Workers (LHWs) represent a valuable workforce that has been identified as a promising solution to address mental health disparities. LHWs are individuals without formal mental health training who oftentimes share lived experiences with the communities that they serve. A growing body of research has supported the mobilization of LHWs to address service disparities around the globe; however, challenges persist in how to scale-up and sustain LHW models of care, with specific barriers in the U.S. In this paper, we describe LHWs' different roles and involvement in the mental health field as well as the current state of the literature around LHW implementation. We integrate the RE-AIM Framework with a conceptual model of how LHWs address disparities to outline future directions in research and practice to enhance equity in the reach, effectiveness, adoption, implementation, and maintenance of LHW models of care and evidencebased practices for historically marginalized communities within the U.S.

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Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India

Cited by 24 publications

References 36 publications

Effectiveness and costs associated with a lay counselor–delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial

Effectiveness and costs associated with a lay counselor–delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial

Comparison of actigraphy indices among patients with depression and schizophrenia

Future Directions in Lay Health Worker Involvement in Children’s Mental Health Services in the U.S.

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