ADOLESCENT TALKING THERAPIES FOR LOW-RESOURCE SETTINGS: ASKING WHAT WORKS FOR WHOM, HOW, AND IN WHAT CIRCUMSTANCES

在世界范围内，抑郁症在青少年中很常见，可能会对他们的健康和发育产生有害影响。在高收入国家，患有抑郁症的青少年可以接受循证干预，包括谈话疗法，如认知行为疗法和人际关系疗法。世界上90%的青少年生活在低收入和中等收入国家(LMIC)，这些疗法通常是不可用的。研究人员已经尝试了在高收入国家开发的疗法，并将其用于LMICs，但取得了不同的成功。在不同的环境下实施疗法的一个主要障碍是，我们不太了解它们是如何起作用的，为谁工作，在哪里效果最好，在什么时间框架内起作用。回答这些问题是推动全球心理健康领域发展的关键，因此也是我的研究重点。我将测试IPT，这是一种有可能改善LMICs青少年抑郁症的谈话疗法。为此，我将进行一项现实主义随机对照试验(RCT)。这是一种创新的方法，将测试干预机制和修正背景因素的影响与评估总体干预影响结合起来。我还将通过对试验参与者的长期跟踪来解决缺乏对LMIC患者抑郁的纵向研究。通过个性化的培训计划和国际安置，我的目标是发展成为一名干预科学家、影响冠军和心理健康倡导者，同时通过培训和指导，努力建设参与该项目的早期职业研究人员的能力。我将在尼泊尔测试IPT，这是一个低收入国家，我在那里有很强的合作，并在2018-20年度领导了一项由英国皇家国际研究院资助的研究，该研究调整并展示了针对13-18岁抑郁青少年的校本小组IPT的可行性。我将以我在尼泊尔的工作为跳板，稍后将我的重点扩大到其他LMIC。我的FLF(根据兼职工作调整的5[+3年]FLF模型的第1-5年)的第一阶段涉及：i)开发一个IPT逻辑模型，以绘制IPT的所有潜在投入和结果、变化机制以及修改干预机制和效果的背景因素。为此，我将与利益攸关方(青少年、尼泊尔和国际精神卫生专家)进行磋商，通过案头审查巩固关于IPT的心理学和社会理论，并整合我早先进行的IPT适应和可行性研究的结果。这将涉及从13-18岁的青少年参与者和主要利益攸关方收集定性和定量数据。我将利用这些数据来评估IPT的影响和成本效益，并完善和测试IPT逻辑模型提供的关于干预机制和结果的假设，以及它们如何因背景(农村/城市、学校环境)和参与者特征(种姓/种族、年龄、性别)而变化。在随机对照试验的准备过程中，我将通过一项小规模的试点试验，制定和测试数据收集、控制和干预条件的程序。在第二阶段(6-8年)，我将通过随机对照试验参与者的混合方法跟踪研究，探索网络疗法和青少年抑郁的长期影响。我将在干预18个月和30个月后对参与者进行评估，以检查结果是否保持不变，以及对健康、教育、就业和关系的连锁反应。数据还将有助于回答更广泛、更难以捉摸的问题，包括：青春期抑郁症复发和缓解的机制是什么？青春期早期的抑郁症如何影响青春期后期和青春期的健康和社会经济轨迹？我将与识别青春期早期抑郁(IDEA)研究联盟合作，综合尼泊尔和其他LMIC的队列数据。

Worldwide, depression is common among adolescents and can have detrimental effects on their health and development. In high-income countries adolescents with depression can be treated with evidence-based interventions including talking therapies such as cognitive behaviour therapy and interpersonal therapy (IPT). These therapies are generally unavailable in low- and middle-income countries (LMICs) where 90% of the world's adolescents live. Researchers have tried with varying success to take therapies developed in high-income countries and adapt them for LMICs. A major barrier to implementing therapies in different settings is that we do not know much about how they work, who they work for, where they work best and over what time frame. Answering these questions is key to advancing the field of global mental health and is therefore the focus of my FLF.I will test IPT, a talking therapy with the potential to improve adolescent depression in LMICs. To do this I will conduct a realist randomised controlled trial (RCT). This is an innovative approach that combines testing intervention mechanisms and modifying effects of contextual factors with an evaluation of the overall intervention impact. I will also address the lack of longitudinal research on depression in LMICs through a longer term follow-up of trial participants. Through a personalised training programme and international placements, I aim to develop as an intervention scientist, impact champion and mental health advocate, whilst also working to build the capacity of early career researchers involved in the project through training and mentorship.I will test IPT in Nepal, a low-income country where I have strong collaborations and in 2018-20 led a UKRI-funded study that adapted and showed the feasibility of school-based group IPT for depressed adolescents aged 13-18. I will use my work in Nepal as a springboard for the fellowship and later broaden my focus to other LMICs.The first phase of my FLF (Years 1-5 of a 5[+3 year] FLF model adjusted for part-time working) involves:i) Development of an IPT logic model to map all the potential inputs and outcomes of IPT, mechanisms of change, and contextual factors that modify the mechanisms and effects of the intervention. I will do this through stakeholder consultation (adolescents, Nepali and international mental health specialists), consolidating psychological and social theory on IPT through a desk review, and integrating findings from my earlier IPT adaptation and feasibility study.ii) Testing short and medium-term effects of IPT by conducting a realist RCT in Nepal. This will involve collecting qualitative and quantitative data from adolescent participants aged 13-18 and key stakeholders. I will use the data to assess IPT's impact and cost-effectiveness, and to refine and test hypotheses informed by the IPT logic model about intervention mechanisms and outcomes and how they vary by context (rural/urban, school environment) and participant characteristics (caste/ethnicity, age, gender). In preparation for the RCT I will develop and test procedures for data collection and control and intervention conditions through a small pilot trial.In the second phase (Years 6-8) I will explore longer term effects of IPT and adolescent depression through a mixed methods follow-up study of RCT participants. I will assess participants 18 and 30 months after the intervention to examine whether outcomes are maintained and knock-on consequences for health, education, employment, and relationships. Data will also help to answer broader, elusive questions including: what are the mechanisms of relapse and remission in adolescent depression?; how does depression in early adolescence influence health and socio-economic trajectories in later adolescence and young adulthood? I will collaborate with the Identifying Depression Early in Adolescence (IDEA) Research Consortium to synthesise data from Nepal and cohorts in other LMICs.