Effectiveness of a brief lay counsellor-delivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in India: a randomised controlled trial

Abstract

Background Mental health problems are a leading cause of disability in adolescents worldwide. Problem solving is a well-tested mental health intervention in many populations. We aimed to investigate the effectiveness of a brief, transdiagnostic problem-solving intervention for common adolescent mental health problems when delivered by non-specialist school counsellors in New Delhi, India. Methods This randomised trial was done in six government-run schools (three all-boys schools, two all-girls schools, and one coeducational school) that serve low-income communities. We recruited participants from grades 9 to 12 (ages 12-20 years) by selecting students with persistently elevated mental health symptoms accompanied by distress or functional impairment. Clinical eligibility criteria were assessed by research assistants using the Hindi-language version of the Strengths and Difficulties Questionnaire (SDQ), with reference to locally validated borderline cutoff scores of 19 or greater for boys and 20 or greater for girls on the SDQ Total Difficulties scale, an abnormal score of 2 or more on the SDQ Impact scale, and persistence of more than 1 month on the SDQ Chronicity index. Participants were randomly allocated (1:1) to problem solving delivered through a brief (2-3 week) counsellor-led intervention with supporting printed materials (intervention group), or problem solving delivered via printed booklets alone (control group). Primary outcomes were adolescent-reported mental health symptoms (SDQ Total Difficulties scale) and idiographic psychosocial problems (Youth Top Problems [YTP]) at 6 weeks. Primary analyses were done on an intention-to-treat basis at the 6-week endpoint. The trial is registered with ClinicalTrials.gov, NCT03630471. Findings Participants were enrolled between Aug 20, and Dec 4, 2018. 283 eligible adolescents were referred to the trial, and 251 (89%) of these were enrolled (mean age 15•61 years; 174 [69%] boys). 125 participants were allocated to each group (after accounting for one participant in the intervention group who withdrew consent after randomisation). Primary outcome data were available for 245 (98%) participants. At 6 weeks, the mean YTP scores were 3•52 (SD 2•66) in the intervention group and 4•60 (2•75) in the control group (adjusted mean difference-1•01, 95% CI-1•63 to-0•38; adjusted effect size 0•36, 95% CI 0•11 to 0•61; p=0•0015). The mean SDQ Total Difficulties scores were 17•48 (5•45) in the intervention group and 18•33 (5•45) in the control group (-0•86,-2•14 to 0•41; 0•16,-0•09 to 0•41; p=0•18). We observed no adverse events. Interpretation A brief lay counsellor-delivered problem-solving intervention combined with printed booklets seemed to have a modest effect on psychosocial outcomes among adolescents with diverse mental health problems compared with problem-solving booklets alone. This counsellor-delivered intervention might be a suitable first-line intervention in a stepped care approach, which is being evaluated in ongoing studies. Funding Wellcome Trust.

Culturally and developmentally adapting group interpersonal therapy for adolescents with depression in rural Nepal

“…Existing research on school-based mental health interventions has mainly been in conflict-affected settings and examined prevention or promotion interventions [63]. A recent study in India reported benefits of a school-based transdiagnostic problem-solving intervention with booklets delivered by lay counsellors (college graduates) for reducing adolescents' psychosocial problems compared to using booklets alone, though no significant reductions in internalising or externalising symptoms [66]. This problem-solving intervention is intended to be an initial brief intervention as part of a stepped care system which also includes higher intensity treatment for individuals with more severe symptoms.…”

App-based guided problem-solving intervention for adolescent mental health: a pilot cohort study in Indian schools

“…We also note that similar effects on problem severity and mental health symptoms were observed irrespective of participants' baseline symptom severity. This is particularly relevant in India where previous PRIDE studies have demonstrated high demand for counselling from students who do not meet clinical thresholds [18][19][20] and where early interventions for emerging mental health problems are scarcely available. 4 In deciding on potential intervention modifications, we considered findings from this study as well as overall programme aim and resources required to make the changes.…”

Problem-Solving Training as an Active Ingredient of Treatment for Youth Depression: A Scoping Review and Meta-Analysis

“…Characteristics of the included PST trials are summarized in PST with a wait-list control, one compared PST with booklets to the use of booklets alone, and one compared PST with supportive counselling. Risk of bias was rated as low for one (30), medium for two (28,29), and high for one study (27),…”

“…Meta-analyses considering over 30 randomized control trials (RCTs) of PST for adult depression suggest it is as effective as CBT and IPT and more effective than waitlist or attention controls (22)(23)(24). PST has been applied with children, adolescents, and young adults (25)(26)(27)(28)(29)(30), although dedicated manuals for different developmental stages are not readily available. PST aims to foster a positive problem orientation, by teaching clients that challenges are an inherent feature of life and often can be overcome (9,19).…”

“…In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, surpassed only by behavioural activation and increased social support (41). PS training is versatile: It can be brief (i.e., involve fewer than 10 sessions) (22), and has been delivered to youth by trained clinicians (29), lay counsellors (30), and via online platforms (28). It can also be adapted for primary care (24).…”