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

Psychosocial Intervention Among Orphans: A Meta-Analysis

BACKGROUND

There has been an increase in the number of orphans around the world as a result of natural or man-made causes. Orphans are likely to face a number of challenges throughout their lives that go unrecognized. Considering these challenges, much focus needs to be given to manage their mental health issues.

PURPOSE

The aim of the study is to examine the effectiveness of various psychosocial interventions in managing post-traumatic stress symptoms, emotional and behavioural problems, and depression among orphans.

METHOD

Electronic searches on seven databases was done to identify studies investigating the effectiveness of interventions among orphans. The effectiveness of psychosocial interventions to reduce post-traumatic stress symptoms, emotional and behavioural problems, and depression was analyzed in seventeen studies. The risk of bias was assessed using the Cochrane risk of bias tool.

RESULT

The overall intervention effect size of post-traumatic stress symptoms was found to be high with high heterogeneity, while low effect size for emotional and behavioural problems, and depression with substantial heterogeneity. Publication bias and exploratory moderating effects of study design and intervention type were also analyzed.

CONCLUSION

Psychosocial interventions were more effective in reducing post-traumatic stress symptoms when compared to emotional and behavioural problems and depression.

Psychosocial interventions for depression among young people in Sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Depression among young people is a global health problem due to its rising prevalence and negative physical and social outcomes. The prevalence of depression and the treatment gap among young people in Sub-Saharan Africa (SSA) is higher than global estimates. Most psychosocial interventions for adolescent and youth depression were developed in high-income countries and less is known about their effectiveness in SSA. Due to contextual differences, findings from High-Income Countries (HICs) are less applicable to SSA. Yet, no systematic review of psychosocial interventions for depression among young people in SSA has been conducted.

METHODS

A systematic literature search of four databases (Medline, Web of Science, PsycInfo, and Cochrane library) was conducted. Experimental studies published before May 2024 that evaluated the effect of psychosocial interventions on depressive symptoms among young people (aged 10-24 years) in SSA were included in the systematic review. Effect sizes (Hedge's g (g)) indicating differences between intervention and control groups were calculated using a random effects model.

RESULTS

Twenty-two eligible studies were identified for the systematic review, of which eighteen randomized control trials (RCTs) involving 2338 participants were included in the meta-analysis. The findings revealed that psychosocial interventions significantly reduced depressive symptoms (g = -1.55, 95% CI -2.48, -0.63), although heterogeneity was high (I2 = 98.8%). Subgroup analysis revealed that efficacy differed significantly by intervention type, with Cognitive Behavioural Therapy (9 studies) showing the strongest effect (g = -2.84, 95% CI -4.29; -1.38). While Wise Interventions (a form of positive psychology interventions; 2 studies) had a moderate effect (g = -0.46, 95% C.I -0.53, -0.39), Interpersonal Psychotherapy (2 studies; g = -0.08, 95% CI -1.05, 0.88) and Creative Psychological Interventions (3 studies; g = -0.29, 95% CI -1.38, 0.79) showed smaller, non-significant effects. Sensitivity analysis excluding studies at high risk of bias strengthened the effect size. Few studies assessed factors affecting intervention efficacy and showed mixed effects of age, gender, and adherence levels.

CONCLUSION

Psychosocial interventions, particularly CBT, significantly reduced depressive symptoms among young people in SSA. However, it is crucial to acknowledge the high heterogeneity which likely stems from variations in study populations and intervention delivery modalities. This highlights the need for further research to identify the specific intervention components and delivery methods that work best for distinct subpopulations. Future research should also explore how long intervention effects are maintained and factors affecting efficacy.

Long-term effects of psychosocial interventions for adolescents on depression and anxiety: a systematic review and meta-analysis

Background

Adolescence represents a distinctive phase of development, and variables linked to this developmental period could affect the efficiency of prevention and treatment for depression and anxiety, as well as the long-term prognosis. The objectives of this study were to investigate the long-term effectiveness of psychosocial interventions for adolescents on depression and anxiety symptoms and to assess the influence of different intervention parameters on the long-term effects.

Methods

In this systematic review and meta-analysis, we searched five databases (Cochrane Library, Embase, Medline, PsychInfo, Web of Science) and trial registers for relevant papers published between database inception and Aug 11, 2022, with no restrictions on the language or region in which the study was conducted. An updated search was performed on Oct 3, 2023. Randomised controlled trials of psychosocial interventions targeting specifically adolescents were included if they assessed outcomes at 1-year post-intervention or more. The risk of bias in the results was assessed using the Cochrane RoB 2.0. Between-study heterogeneity was estimated using the I2 statistic. The primary outcome was depression and studies were pooled using a standardised mean difference, with associated 95% confidence interval, p-value and I2. The study protocol was pre-registered on PROSPERO (CRD42022348668).

Findings

57 reports (n = 46,678 participants) were included in the review. Psychosocial interventions led to small reductions in depressive symptoms, with standardised mean difference (SMD) at 1-year of -0.08 (95% CI: -0.20 to -0.03, p = 0.002, I2 = 72%), 18-months SMD = -0.12, 95% CI: -0.22 to -0.01, p = 0.03, I2 = 63%) and 2-years SMD = -0.12 (95% CI: -0.20 to -0.03, p = 0.01, I2 = 68%). Sub-group analyses indicated that targeted interventions produced stronger effects, particularly when delivered by trained mental health professionals (K = 18, SMD = -0.24, 95% CI: -0.38 to -0.10, p = 0.001, I2 = 60%). No effects were detected for anxiety at any assessment.

Interpretation

Psychosocial interventions specifically targeting adolescents were shown to have small but positive effects on depression symptoms but not anxiety symptoms, which were sustained up to 2 years. These findings highlight the potential population-level preventive effects if such psychosocial interventions become widely implemented in accessible settings, such as schools. Future trials should include a longer term-follow-up at least at 12 months, in order to determine whether the intervention effects improve, stay the same or wear off over time.

Funding

UKRIMedical Research Council.

Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review

OBJECTIVE

In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA.

DESIGN

Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach.

DATA SOURCES

A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021.

ELIGIBILITY CRITERIA

Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10-24 years.

DATA EXTRACTION AND SYNTHESIS

We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants.

RESULTS

Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes.

CONCLUSIONS

The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts.

PROSPERO REGISTRATION NUMBER

CRD42021258826.

Community perspectives on the implementation of a group psychological intervention for adolescents with depression: A qualitative study in rural Nepal

Group-based psychological interventions could help to close the treatment gap for depression in low-resource settings, but implementation barriers exist. In Nepal we sought community members' perspectives on how to implement group interpersonal therapy for adolescents. We conducted qualitative interviews with 25 adolescents with depression (aged 13-18) and seven health and non-governmental organization workers, and four focus groups with non-depressed adolescents, four with parents/guardians, and two with teachers (126 participants total). Data were analyzed using the Framework Method. Participants recommended same-sex groups. School was the preferred location because it is accessible for adolescents and acceptable to parents. Adolescents wanted facilitators from their own community with good communication skills. They did not want parents or teachers to participate in groups but emphasized the need to inform parents and obtain their permission. Community members supported group psychological intervention. School-based psychological interventions facilitated by local people could be an acceptable option in rural Nepal.

Exploring mental health interventions for youth in Southern Africa: A rapid review

A significant mental health treatment gap prevails in Southern Africa. Whilst some treatments exist for adults and school children, treatment options for young adults, at a particularly vulnerable time of life, are scarce. Understanding success mechanisms of existing youth mental health interventions is vital for informed development and scaling of interventions to address this critical gap. This rapid review identifies 27 recent health interventions addressing common youth mental disorders in Southern Africa. Eight studies that quantitatively measured success found significant mental health improvements as an intervention result. Studies that identified success via non-statistical means also found, albeit self-reported, generally favourable outcomes. No single best-practice intervention was identified to replicate throughout the region. Our review instead highlights three important mechanisms for intervention success: including youth in intervention design and delivery; indirectly addressing mental health; and developing multi-modal interventions. We recommend collaborative, ecological approaches to youth mental health interventions in Southern Africa.

Mental health interventions for adolescents in sub-Saharan Africa: A scoping review

Background

Globally, adolescents are vulnerable to mental health problems, particularly those from sub-Saharan Africa (SSA) due to impoverished living conditions and a higher prevalence of chronic conditions such as HIV/AIDS in the region. The COVID-19 pandemic has further exacerbated this risk. This calls for an urgent need for evidence-based adolescent mental health interventions to reduce the risk and burden of mental health problems in SSA. The review aims to identify and characterize existing adolescent mental health interventions in SSA, as well as to evaluate their implementation strategies and effectiveness.

Methods

We systematically searched PubMed, African Index Medicus, PsycINFO, Web of Science, and CINAHL databases for relevant articles. Furthermore, we searched gray literature databases, including Think Tank search, open gray, NGO search engine, and IGO search engine for additional relevant articles. The scoping review was conducted to identify original research articles on mental health interventions among adolescents in sub-Saharan Africa published from database inception to 31 December 2021. We carried out a narrative synthesis to report our findings.

Results

Our literature search generated 4,750 studies, of which 1,141 were duplicates, 3,545 were excluded after screening, and 64 articles met the inclusion criteria. The 64 studies describe a total of 57 unique mental health interventions comprising 40,072 adolescents. The nature of these interventions was diverse, encompassing various implementation strategies such as economic-based, family strengthening, psychoeducation, interpersonal psychotherapy, Cognitive Behavioral Therapy, and resilience training, among others. Most of the interventions were selective interventions that targeted adolescents at high risk of developing mental health problems including adolescents living with HIV, war-affected adolescents, orphans, adolescents from poorer backgrounds, and survivors of sexual violence. Half of the interventions were delivered by lay persons. Sixty-two of the eligible studies examined the effectiveness of the mental health interventions, of which 55 of them reported a positive significant impact on various mental health outcomes.

Conclusions

The review findings show that there exist several diverse interventions that promote mental health among adolescents in sub-Saharan Africa. These interventions can be implemented in diverse settings including schools, communities, health facilities, and camps, and can be delivered by lay persons.

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

Background and purpose

Most research regarding child and adolescent mental health prevention and promotion in low-and middle-income countries is undertaken in high-income countries. This systematic review set out to synthesise findings from epidemiological studies, published between 2008 and 2020, documenting the prevalence of mental health problems in adolescents from across sub-Saharan Africa.

Methods

A systematic search of multiple databases (MEDLINE, PsycINFO, Scopus) and Google Scholar was conducted guided by the Joanna Briggs Institute (JBI) Reviewer’s manual for systematic reviews of observational epidemiological studies. Studies included reported prevalence outcomes for adolescents aged 10–19 using either clinical interviews or standardized questionnaires to assess psychopathology. Clinical samples were excluded.

Results

The search yielded 1 549 records of which 316 studies were assessed for eligibility and 51 met the inclusion criteria. We present a qualitative synthesis of 37 of these 51 included articles. The other 14 studies reporting prevalence rates for adolescents living with HIV are published elsewhere. The prevalence of depression, anxiety disorders, emotional and behavioural difficulties, posttraumatic stress and suicidal behaviour in the general adolescent population and selected at-risk groups in 16 sub-Saharan countries (with a total population of 97 616 adolescents) are reported.

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

BACKGROUND

Evidence-based interventions are needed to reduce depression among adolescents in low- and middle-income countries (LMICs). One approach could be cultural adaptation of psychological therapies developed in high-income countries. We aimed to adapt the World Health Organization's Group Interpersonal Therapy (IPT) Manual for adolescents with depression in rural Nepal.

METHODS

We used a participatory, multi-stage adaptation process involving: translation and clinical review of the WHO Manual; desk reviews of adaptations of IPT in LMICs, and literature on child and adolescent mental health interventions and interpersonal problems in Nepal; a qualitative study to understand experiences of adolescent depression and preferences for a community-based psychological intervention including 25 interviews with adolescent boys and girls aged 13-18 with depression, four focus group discussions with adolescents, four with parents/caregivers and two with teachers, six interviews with community health workers and one with a representative from a local non-governmental organisation (total of 126 participants); training of IPT trainers and facilitators and practice IPT groups; and consultation with a youth mental health advisory board. We used the Ecological Validity Framework to guide the adaptation process.

RESULTS

We made adaptations to optimise treatment delivery and emphasise developmental and cultural aspects of depression. Key adaptations were: integrating therapy into secondary schools for delivery by school nurses and lay community members; adding components to promote parental engagement including a pre-group session with the adolescent and parent to mobilise parental support; using locally acceptable terms for mental illness such as udas-chinta (sadness and worry) and man ko samasya (heart-mind problem); framing the intervention as a training programme to de-stigmatise treatment; and including activities to strengthen relationships between group members. We did not adapt the therapeutic goals of IPT and conserved IPT-specific strategies and techniques, making edits only to the way these were described in the Manual.

CONCLUSIONS

Group IPT can be adapted for adolescents in Nepal and delivered through the education system. A randomised controlled trial is needed to assess the impact and costs of the intervention in this setting. Future research in LMICs to adapt IPT for adolescents could use this adapted intervention as a starting point.

Effects of interventions to reduce adolescent depression in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

International comparisons found that depression prevalence ranged from 18.3% (China) to 51.5% (Zambia) among school students in some low- and middle-income countries (LMICs). The evidence base for treatment of adolescent depression in LMICs is limited and inadequate. Moreover, most treatment interventions are developed in high income countries and the effectiveness of these treatments in LMICs is largely unknown.

METHOD

Randomized controlled trials, including cluster-randomized trials that have been implemented in LMICs to reduce adolescent depression, were examined in this systematic review and meta-analysis. Only one-time point (3 months or close to 3 months) of the outcome measures was chosen to evaluate effectiveness of interventions.

RESULTS

Studies that used cognitive-behavioral therapy reduced depressive symptoms more effectively than other treatments with standardized mean difference (SMD) = -1.27, (95% CI -2.19 to -0.35). Microfinance/economic interventions also reduced depression in adolescents with SMD = - 0.35, (95% CI -0.71 to 0.01) and Interpersonal therapy was used in three studies and depressive symptoms reduced by SMD = -0.23, (95% IC -0.60 to 0.13). Moreover, complex psychotherapeutic interventions that used integrated techniques showed a reduction in depression with SMD = -0.23, (95% IC -0.33 to -0.14) as well.

CONCLUSIONS

Across twenty-eight studies, the evidence showed that cognitive behavioral therapy that delivered by nurses, social workers and counselors at community-based settings were more effective treatments in decreasing adolescent depression in LMICs. Future studies should implement these universal treatment approaches to identify accessible, feasible, affordable and sustainable depression treatments in the countries with less available resources.

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

Let's Talk is a structured, family-centered adolescent HIV prevention program developed for use in South Africa using key components adapted from programs successfully implemented in the US and South Africa. It is designed to address individual HIV transmission risk factors common among orphaned and vulnerable adolescents, including elevated risk for poor psychological health and sexual risk behavior. These efforts are accentuated through parallel programing to support caregivers' mental health and parenting skills. Twelve Let's Talk groups, each serving approximately 10 families, were piloted by two local community-based organizations in Gauteng and Kwa-Zulu Natal provinces, South Africa. Face-to-face interviews were conducted among participating caregivers and adolescents at baseline and three months post-intervention to explore the potential effects of the program on intermediate outcomes that may support HIV preventive behavior. Specifically, generalized estimation equations were used to estimate average change on HIV prevention knowledge and self-efficacy, caregiver and adolescent mental health, and family dynamics. Among the 105 adolescents and their 95 caregivers who participated in Let's Talk and completed both surveys, statistically significant improvements were found for adolescents' HIV and condom use knowledge as well as condom negotiation self-efficacy, but not sexual refusal self-efficacy. Both caregivers and adolescents demonstrated significantly better mental health at post-test. Adolescent/caregiver connection and communication about healthy sexuality also improved. These preliminary results highlight the potential of HIV prevention interventions that engage caregivers alongside the vulnerable adolescents in their care to mitigate adolescent HIV risk factors. A more rigorous evaluation is warranted to substantiate these effects and identify their impact on adolescents' risk behavior and HIV incidence.