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，并可能对他们的健康和发展产生有害影响。在高收入国家，患有抑郁症的青少年可以通过基于证据的干预措施进行治疗，包括谈话疗法，如认知行为疗法和人际关系疗法。在低收入和中等收入国家（世界上90%的青少年生活在这些国家），通常无法获得这些治疗。研究人员尝试将高收入国家开发的治疗方法用于中低收入国家，并取得了不同程度的成功。在不同环境中实施治疗的一个主要障碍是，我们不太了解它们是如何起作用的，它们对谁起作用，它们在哪里起作用最好，以及在什么时间框架内起作用。回答这些问题是推进全球精神卫生领域的关键，因此也是我的FLF的重点。我将测试IPT，一种有可能改善低收入国家青少年抑郁症的谈话疗法。为此，我将进行一项现实随机对照试验（RCT）。这是一种创新的方法，将测试干预机制和环境因素的修改效果与评估整体干预效果相结合。我还将通过对试验参与者的长期随访来解决中低收入国家抑郁症纵向研究的缺乏问题。通过个性化的培训计划和国际实习，我的目标是成为一名干预科学家、影响力冠军和心理健康倡导者，同时也致力于通过培训和指导来培养参与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关系。2018- 2020年，我领导了一项由英国研究院资助的研究，该研究适应并展示了针对13-18岁抑郁青少年的基于学校的团体IPT的可行性。我将以我在尼泊尔的工作作为奖学金的跳板，然后将我的重点扩大到其他中低收入国家。我的FLF的第一阶段（针对兼职工作调整的5年[+3年]FLF模型的第1-5年）包括：i)开发一个IPT逻辑模型，以映射IPT的所有潜在输入和结果、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、尼泊尔和国际心理健康专家）进行磋商，通过案头审查巩固有关IPT的心理和社会理论，并整合我以前的IPT适应和可行性研究的结果。ii)通过在尼泊尔进行现实随机对照试验，测试IPT的短期和中期效果。这将涉及从13-18岁青少年参与者和主要利益攸关方那里收集定性和定量数据。我将使用这些数据来评估IPT的影响和成本效益，并完善和检验IPT逻辑模型所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。在准备随机对照试验的过程中，我将通过小型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年级），我将通过对RCT参与者的混合方法随访研究来探索IPT和青少年抑郁症的长期影响。我将在干预后的18个月和30个月对参与者进行评估，以检查结果是否得到维持，以及对健康、教育、就业和人际关系的连锁影响。数据还将有助于回答更广泛的、难以捉摸的问题，包括：青少年抑郁症的复发和缓解机制是什么？青春期早期的抑郁如何影响青春期后期和青年期的健康和社会经济轨迹？我将与青少年早期抑郁症识别（IDEA）研究联盟合作，综合尼泊尔和其他中低收入国家的数据。

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.