School-based group interpersonal therapy for adolescents with depression in rural Nepal: a mixed methods study exploring feasibility, acceptability, and cost

Abstract

Background Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost. Methods We recruited 32 boys and 30 girls (aged 13–19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0–2 weeks after IPT), and follow-up (8–10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective. Results Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70–95); functional impairment decreased by 288% (249–351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity. Conclusions School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.

Feasibility and Acceptability of a School-Based Emotion Regulation Prevention Intervention (READY-Nepal) for Secondary School Students in Post-Earthquake Nepal

“…Additionally, we preliminary compared changes on a broad range of outcome measures relative to a wait-list control condition. Based on prior initial findings of gender-based differences in group interventions in Nepal and other LMIC [ 18 , 30 , 31 ] our second research question concerned differential intervention effects based on gender. We examined if females, relative to males, would be more engaged in the intervention and experience greater improvements on outcome measures.…”

“…there were no improvements in PTSD or depressive symptoms. And, in one non-controlled study of school-based Interpersonal Therapy delivered by non-specialist providers, students with depressive symptoms and functional impairment experienced improvements across both categories [ 18 ]. Given this scarce and heterogeneous evidence base for classroom-based interventions in Nepal and other resource-strained settings, it is therefore crucial to implement novel treatment outcome studies.…”

Editorial Perspective: Adapting western psychological interventions for children and adolescents in LMICs: lessons from Nepal

“…With the support of the local community, Rose‐Clarke et al. (2022) adapted an interpersonal psychotherapy (IPT) protocol for group delivery in a school setting. The comprehensive adaptation process included qualitative interviews to understand adolescent's experience of depression in Nepal, and a session with the adolescents and their parents to mobilise parental support and build rapport.…”

“…First, the content of the intervention appears less important than prefacing it with robust community engagement work. Some studies labelled this specifically as an engagement process (Adhikari et al., 2018; Rose‐Clarke et al., 2022), and others were arguably already engaged with western approaches through their training (Antle, Chesick, Sridharan, & Cramer, 2018) or it occurred as part of the way the intervention was situated within wider community‐based activities (Jordans et al., 2010). Second, there needs to be a closer consideration of the impact of caste and gender on the acceptability of interventions and outcomes.…”

“…In addition, insecurity caused by threats to their social status adversely impacts high‐caste boys. This is important as there is some evidence in the existing literature for differential effects of the interventions on boys compared with girls (Jordans et al., 2010; Rose‐Clarke et al., 2022).…”