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

抑郁症影响着世界上3.5亿人，并将很快成为健康的最大负担，发病高峰期为青春期。青春期是一个关键时期，因为社会认知和执行功能的演变极大地影响了人与人之间的功能和危险行为，如无保护措施的性行为(可能导致艾滋病毒感染和早孕)。这也是一个青少年必须协商成功过渡到富有成效的成年期的时期，抑郁症可能会影响教育、就业和身体健康等关键的生活结果。抑郁症也是最常见的自杀原因；现在被认为是南非的主要问题。在南非农村，由于缺乏训练有素的专业人员，无法获得有效的抑郁症治疗方法。一种名为行为激活(BA)的抑郁症心理疗法已被证明与认知行为疗法(CBT)(抑郁症的黄金标准疗法)一样有效。BA针对的是行为，而不是认知过程和态度，这使得交付和适应跨文化变得相对容易，而且BA现在已经成功地远程交付，而不需要面对面的接触。智能手机和平板电脑治疗提供了向大量个人提供循证治疗的机会。我们的目标是开发一个可扩展的数字平台，使用智能手机和平板电脑来提供文化适应版本的BA。在第一个项目阶段，我们将与青少年、照顾者、社区和教育利益攸关方进行访谈和焦点小组讨论，以制定与文化相关和适合年龄的APP干预措施。该应用程序的功能、接受度和可用性将通过与青少年和学校的迭代过程进行优化。在第二至第三年，我们将进行一项针对青少年的试点随机对照试验(n=200)，以测试该平台在减少15至18岁青少年抑郁方面的有效性。青少年将在学校使用PHQ-9进行筛查，那些被诊断为轻度至中度抑郁症的人将被招募。参与者将通过智能手机接受BA治疗，或者也通过智能手机主动监测情绪(对照组)。所有参与者都将获得一部通话时间和可访问性有限的低端智能手机，或者被引导在学校使用平板电脑。基于APP的BA干预将包括10周内的6次会议，并将通过简短的支持电话进行补充。对照组进行6次情绪和心理功能监测。将为那些存在风险的人提供适当的帮助。评估将在基线、治疗结束(基线后12周)和治疗结束后24周进行。主要结果将是青少年抑郁的减少，次要结果包括焦虑、冒险行为以及一系列经济和决策措施。为了测试社会认知和执行功能是否调节BA的效果，将开发适应文化的测试。我们还打算进行探索性的统计中介分析，以测试这些潜在的机制。这项研究将嵌套在MRC/Wits农村公共卫生和健康过渡股(姆普马兰加省)的阿金库尔卫生和人口监测(HDSS)网站内，我们已开始在那里与社区咨询小组密切合作，让大力支持这一倡议的当地利益攸关方和社区参与进来。还将在Dikgale HDSS(林波波省)开展筹备工作。这项先导性研究最终将开发一项全面的治疗试验，以支持更好地管理生活在南非的青少年的抑郁症。以这种方式处理抑郁症符合卫生部加强初级保健和以社区为基础的保健系统的目标。

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.