School based stepped care TrEatment for adolescent depression in Pakistan- a Sequential Multiple Assignment Randomized Trial (SMART-STEP)

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Project summary Depression and anxiety (common mental disorders, CMD’s) are the leading contributors to health burden in adolescents worldwide and are associated with adverse outcomes1,2. In Pakistan, the reported prevalence estimates of emotional problems in school going adolescents range between 25%- 35%3,4. Schools have been identified as a scalable platform to bridge the treatment gap for adolescent mental health5,6. However, in Pakistan, no formal system for school-based programs to promote youth mental health exists. To address this unmet need, a President’s Program to Promote Mental Health of Pakistanis, an ambitious plan to scale-up the school based mental health programs to the entire country, was initiated7,8. Under the umbrella of the President’s program and through our NIMH U19 Global Mental Health Research Hub, SHINE (School Health Implementation Network: Eastern Mediterranean Region), we 1) adapted and feasibility tested the WHO School Mental Health Program (SMHP)9 into an online teachers’ training program (Enhanced School Mental Health Program [eSMHP], www.learnwithshine.org) and 2) supported the development and feasibility testing of the Cognitive Behavioral Therapy (CBT) based, WHO STARS (Sustainable Technology for Adolescent to Reduce Stress) self-help chat- bot to address the symptoms of CMDs in adolescents studying in low resource public schools of Pakistan10. Pilot implementation of eSMHP and STARS has identified a need to integrate these interventions into a stepped care package and to determine their optimal delivery sequence to address heterogeneity in the presentation and progression of CMDs’ symptoms over time, and to ensure cost-effective implementation at-scale. Therefore, the aim of the ‘SMART-STEP study’ is to investigate the effectiveness of eSMHP (low intensity and least resource intensive treatment) (vs. Treatment as Usual-TAU) as a front-line treatment to improve the symptoms of depression in adolescents, and STARS self-help chat-bot as an augmentation tactic (second-line treatment) to address early signs of non-response to the eSMHP and TAU. By using Sequential Multiple Assignment Randomized Trial (SMART) design to compare the timing and dosage of these intervention strategies, we will answer ‘what works, for whom, under what conditions and why for adolescent depression’ in public schools of Pakistan. We hypothesize that adolescents who receive the eSMHP will show improved symptoms of depression compared to TAU, and among non-responding adolescents, augmenting eSMHP with the STARS self-help chat- bot (vs. continue with the initial intervention) will improve symptoms of depression from baseline to 9-months. We will begin our work by establishing an External Advisory Committee, consulting stakeholders and engaging young people to guide project implementation. Next, the SMART-STEP trial will investigate the (cost) effectiveness of stepped care package. These research aims are aligned with my research career development plans to become a global mental health expert in optimizing interventions for adolescents with CMDs in low- income communities and are supported by a highly experienced team of co-investigators and consultants.