Digital delivery of Behavioural Activation to overcome depression and facilitate social and economic transitions of adolescents in South Africa

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Depression affects 350 million in the world and will soon be the single greatest burden on health with the peak onset during adolescence. Adolescence is a key time period as social cognitions and executive function evolve dramatically affecting inter-personal functioning and risky behaviours such as unprotected sex (potentially leading to HIV infection and early pregnancy). It is also a time when adolescents have to negotiate a successful transition to productive adulthood and depression can impact on key life outcomes such as education, employment and physical health. Depression is also the most common cause of suicide; now recognized as major problem in South Africa. Effective treatments for depression in rural South Africa are not available largely due to a dearth of trained professionals. A psychological treatment for depression called Behavioural Activation (BA) has been shown to be as effective as Cognitive Behavioural Therapy (CBT) (the gold standard therapy for depression). BA targets behaviours rather than cognitive processes and attitudes, making it relatively easy to deliver, to adapt cross-culturally, and BA has now successfully been delivered remotely without face-to-face contact. Smartphones and tablet based treatments provide an opportunity to deliver evidence-based therapy to large numbers of individuals. We aim to develop a scalable digital platform using smartphones and tablets to deliver a culturally adapted version of BA. In the first project phase we will conduct interviews and focus group discussions with adolescents, caregivers, community and education stakeholders to develop a culturally relevant and age appropriate app-based intervention. The functionality, acceptability and usability of the app will be refined through an iterative process with adolescents and schools.In years 2-3 we will conduct a pilot randomized controlled trial of adolescents (n=200) to test the effectiveness of this platform in reducing depression in adolescents aged between 15 and 18 years. Adolescents will be screened in schools using the PHQ-9 and those diagnosed with mild to moderate depression will be recruited. Participants will either receive BA treatment via smart phones or active monitoring of mood also via smart phones (control group). All participants will be offered a low-end smartphone with limited airtime and accessibility or be guided to use tablets at school. The app-based BA intervention will comprise of 6 sessions over 10 weeks and will be supplemented by brief support phone calls. The control group will have their mood and psychological functioning monitored on 6 occasions. Appropriate help will be provided to those who present with risk. Assessments will take place at baseline, end of treatment (12 weeks after baseline) and 24 weeks after end of treatment.The primary outcome will be a reduction in adolescent depression and secondary outcomes include anxiety, risk taking behaviours and a range of economic and decision making measures.To test whether social cognition and executive function mediate the effects of BA, culturally adapted tests will be developed. We also aim to conduct exploratory statistical mediational analyses to test these potential mechanisms. The study will be nested within the Agincourt Health and Demographic Surveillance (HDSS) site in MRC/Wits Rural Public Health and Health Transitions Unit (Mpumalanga province) where we have started working closely with the Community Advisory Group to engage local stakeholders and the community who are strongly supportive of this initiative. Formative work will also take place in the Dikgale HDSS (Limpopo province). This pilot study will ultimately lead to the development of a full-scale treatment trial to support a better management of depression among adolescents living in South Africa. Tackling depression in this way is consistent with the aim of the Department of Health to strengthen primary care and community-based health care systems.