Single Session Intervention and Interpersonal Therapy for Adolescent Depression in Mozambican Primary Care Clinics: A Hybrid Effectiveness/Implementation Cluster Randomized Trial

About This Grant

PROJECT SUMMARY Depression is the leading cause of disability in adolescents worldwide. While multiple adolescent depression interventions have been demonstrated effective in low- and middle-income countries (LMIC), where 90% of the world’s adolescents reside, research on their real-world implementation is lacking. Since 2019, we have collaborated with the Mozambican Ministry of Health to pilot implementation of routine depression screening and Group Interpersonal Therapy for Adolescents (IPT-AG) within primary care clinics of the national health system (K01MH120258). Our results indicate that routine screening leads to a 50-fold increase in identification of depressed adolescents and that IPT-AG is effective at reducing symptoms. However, as similarly seen following universal screening in high-income countries, treatment uptake was low, with around 90% of depressed adolescents not entering IPT-AG due to lack of time and interest. Single session interventions (SSIs), structured programs involving just one visit with a provider, have been proposed as a scalable solution to close the mental health treatment gap. SSIs are not intended to replace traditional therapies, but instead were designed to address the reality that most patients do not return for mental health care after their first contact. The digital SSI Project Personality is among the best supported SSIs for depression, with several trials in U.S.-based adolescents demonstrating its effectiveness at directly reducing depression symptoms and increasing engagement in further mental health support. Therefore, it may fill a critical gap in Mozambique and other LMIC by promoting engagement in traditional, longer-term treatment among depressed adolescents as well as reducing symptoms in those who remain uninterested or unable to engage in further care. Yet, the effectiveness of SSIs has only been tested in two LMIC, and no research has evaluated SSI implementation in a LMIC context. Here, we propose a Hybrid Type I Effectiveness-Implementation cluster randomized control trial to evaluate offering Project Personality immediately after depression screening along with referral to IPT-AG (SSI+IPT-AG) compared to referral to IPT-AG alone for depressed adolescents in Mozambican primary care clinics. We will test our hypothesis that there will be greater reductions in depression symptoms in the SSI+IPT-AG than the IPT-AG alone arm. We will also evaluate the clinical impact of SSI alone and the effectiveness of IPT-AG alone, as well as examine hypothesized intervention mechanisms (Aim 1). Moreover, we will use trial cost and outcomes data to project the cost-effectiveness and budgetary impact of scaling-up the interventions across Mozambican primary care (Aim 2). Finally, we will evaluate implementation outcomes and determinants to explore factors influencing intervention adoption, penetration, fidelity, and sustainability (Aim 3). Together, this study will define clinical outcomes, cost-effectiveness, and implementation determinants of two evidence-based interventions for adolescent depression. These interventions have the potential to provide an innovative approach to sustainably deliver depression care within Mozambique and other LMIC to close the global treatment gap.