Mitigating depression among orphaned and vulnerable adolescents: a randomized controlled trial of interpersonal psychotherapy for groups in South Africa

Abstract

Background: Children and adolescents affected by HIV are at elevated risk of depression, yet research on related interventions in this population is scarce in sub-Saharan Africa. This study sought to examine the effects of interpersonal psychotherapy for groups (IPTG) on depressive symptomology among orphaned and vulnerable adolescents in South Africa. Method: A cluster randomized controlled trial wherein adolescents ages 14-17 enrolled in community-based programming for HIV-affected and vulnerable families were randomly assigned by geographic cluster to participate in a 16-session IPTG intervention or the standard of care (n = 489). Baseline and postintervention surveys conducted with enrollees included standardized depression screening. Utilizing an intent-to-treat design, mixed effects models were performed to examine treatment effects for all participants and potential moderators including gender and baseline depression level (Clinical Trials registration: ClinicalTrials.gov NCT02386878). Results: While 23% of adolescents in the intervention group did not attend any IPTG sessions, average attendance was 12 out of 16 possible sessions among participants. The intervention was not associated with changes in depression symptomology. Conclusions: Results underscore the importance of mitigating participation barriers prior to intervention roll-out and the need for increased evidence for psychological health interventions to mitigate depression among orphaned and vulnerable adolescents. This intervention and the study selectively targeted at-risk adolescents versus using diagnostic mental health criteria for enrollment; more research is needed to identify the potential benefits and disadvantages of these approaches. Key Practitioner Message• Children and adolescents who have been orphaned due to AIDS or who are living with a chronically ill parent are at increased risk for depression; the need for effective interventions is high in generalized HIV epidemic settings like South Africa.• Interpersonal psychotherapy for groups (IPTG) delivered by lay practitioners has been evaluated in other populations in sub-Saharan Africa and found to be an effective method for treating depression.• Results from this cluster randomized controlled trial did not find IPTG delivered by community workers to be measurably associated with changes in depression symptomology among orphaned and vulnerable adolescents, regardless of gender or preexisting depressive symptomology.• The study took place within the context of rapid program expansion with a cadre of relatively inexperienced facilitators, which may have affected the results; nevertheless, such implementation challenges are common when scaling up interventions in resource-constrained environments. Intervention adjustments, quality control mechanisms, more specific enrollment criteria and efforts to promote participation may deliver better results.

The prevalence of mental health problems in sub-Saharan adolescents: A systematic review

“…Sixteen studies were carried out at sub-Saharan African research institutions [ 21 , 22 , 32 , 33 , 37 – 39 , 41 , 43 , 44 , 47 , 50 – 52 , 54 – 56 ] the majority in South Africa (n = 9). Nineteen of the studies were conducted in collaboration with researchers from HIC or other LMIC [ 13 , 22 – 30 , 35 , 36 , 40 , 43 , 48 , 49 , 53 , 55 , 57 ] and four studies were carried out by researchers based in HIC [ 34 , 42 , 45 , 46 ].…”

“…Most studies used a cross-sectional study design, four studies used baseline data from randomized control trials [ 35 , 36 , 38 , 53 ], and two were cohort studies [ 30 , 57 ]. The most common sampling method was stratified or cluster random sampling.…”

Culturally and developmentally adapting group interpersonal therapy for adolescents with depression in rural Nepal

“…A challenge in the adaptation process was to decide on the number of sessions. Previous evaluations of group IPT for adolescents in LMICs have included 16 sessions [39,60]. A study of individual IPT for adolescents found that a reduction in depressive symptoms of 16% or more at week 4 predicted remission at week 16 [73].…”

“…Our experience from practice groups suggested that adolescents took around four sessions to feel comfortable and contribute to group discussions, and that the eight group sessions outlined in the WHO Manual would be insufficient. Interventions involving 16 group sessions have been tested in other LMICs [39,60], however the remote location of our study was a potential barrier to attendance and we anticipated high drop-out rates with 16 sessions. As a compromise we therefore increased the number of group sessions to 12 (Fig.…”

Can family-centered programing mitigate HIV risk factors among orphaned and vulnerable adolescents? Results from a pilot study in South Africa

“…A randomized trial of a structured family-centered mental health promotion and HIV prevention program in Kenya found reduced sexual risk behavior among adolescents at one month post-intervention (Puffer et al, 2016). However, in spite of the interventions' mental health focus, psychological improvements were not found among participants in either study (Puffer et al, 2016;Thurman, Nice, Taylor, & Luckett, 2017). Let's Talk shows potential to reduce psychological distress among adolescents and their caregivers while also bolstering other protective individual and family-level factors, which could plausibly support HIV preventive behavior (DiClemente et al, 2008).…”