Testing pathways to scale: study protocol for a three-arm randomized controlled trial of a centralized and a decentralized ("Train the Trainers") dissemination of a mental health program for Kenyan adolescents.

BACKGROUND: Providing care in Kenya to all youth in need is difficult because of a shortage of professional providers and societal stigma. Previous trials of the Anansi model, which involves delivering low-touch mental health interventions through a tiered caregiving model (including lay-providers, supervisors, and clinical experts), have shown its effectiveness for reducing depression and anxiety symptoms in school-going Kenyan adolescents. In this trial, we aim to assess two different scale-up strategies by comparing centralized implementation (i.e., by the organization that designed the Anansi model) against implementation through an implementing partner. METHODS: In this three-arm trial, 1600 adolescents aged 13 to 20 years will be randomized to receive the Shamiri intervention from either the Shamiri Institute or an implementation partner or to be placed in the treatment as usual (TAU) control group. The implementation partner will be trained and supplied with protocols to ensure that the same procedures are followed by both implementors. Implementation activities will run concurrently for both implementors. The Shamiri intervention will be delivered by trained lay providers to groups of 10-15 adolescents over four weekly sessions which will take place in secondary schools in Machakos and Makueni counties in Kenya. The TAU group will receive the usual care offered by their respective schools. Outcomes will be assessed at baseline, midpoint (2 weeks), endpoint (4 weeks), and 1 month follow-up. The analysis will be based on an intent-to-treat approach. Mixed effects models will be used to assess trajectories over time of the primary outcomes (anxiety and depressive symptoms, mental well-being, perceived social support, and academic performance) and secondary outcomes for the intervention groups and the control group. Effect sizes will be computed for the mean differences of the intervention and control arms at midpoint, endpoint, and follow-up. DISCUSSION: This trial will provide insight into the comparative effectiveness of different strategies for scaling a school-based mental health care model. Findings will also indicate areas for improved efficiency of the model to enhance its replicability by other implementors. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR) (ID: PACTR202305589854478, Approved: 02/05/2023).

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice.

BACKGROUND: Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression. METHODS: Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression. RESULTS: Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal. CONCLUSIONS: Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

What Four Decades of Meta-Analysis Have Taught Us About Youth Psychotherapy and the Science of Research Synthesis.

Intervention scientists have published more than 600 randomized controlled trials (RCTs) of youth psychotherapies. Four decades of meta-analyses have been used to synthesize the RCT findings and identify scientifically and clinically significant patterns. These meta-analyses have limitations, noted herein, but they have advanced our understanding of youth psychotherapy, revealing (a) mental health problems for which our interventions are more and less successful (e.g., anxiety and depression, respectively); (b) the beneficial effects of single-session interventions, interventions delivered remotely, and interventions tested in low- and middle-income countries; (c) the association of societal sexism and racism with reduced treatment benefit in majority-girl and majority-Black groups; and, importantly, (d) the finding that average youth treatment benefit has not increased across five decades of research, suggesting that new strategies may be needed. Opportunities for the future include boosting relevance to policy and practice and using meta-analysis to identify mechanisms of change and guide personalizing of treatment.

Meta-analysis: The Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries.

OBJECTIVE: Because most youth psychotherapies are developed and tested in high-income countries, relatively little is known about their effectiveness or moderators in low- and middle-income countries (LMICs). To address this gap, we conducted a meta-analysis of randomized controlled trials (RCTs) testing psychotherapies for youth with multiple psychiatric conditions in LMICs, and we tested candidate moderators. METHOD: We searched 9 international databases for RCTs of youth psychotherapies in LMICs published through January 2021. The RCTs targeted elevated symptoms of youth anxiety (including posttraumatic stress disorder [PTSD] and obsessive-compulsive disorder), depression, conduct problems, and attention problems. Using robust variance estimation, we estimated the pooled effect sizes (Hedges g) at posttreatment and follow-up for intervention vs control conditions. RESULTS: Of 5,145 articles identified, 34 articles (with 43 treatment-control comparisons and 4,176 participants) met methodological standards and were included. The overall pooled g with winsorized outliers was 1.01 (95% CI = 0.72-1.29, p < .001) at posttreatment and 0.68 (95% CI = 0.29-1.07, p = .003) at follow-up. Interventions delivered by professional clinicians significantly outperformed those delivered by lay providers (g = 1.59 vs 0.53), but all interventions for conduct problems were delivered by professionals, and the difference for interventions targeting internalizing problems (g = 1.33 vs .53) was not significant. Interventions developed non-locally were more effective if they were not adapted to local contexts than if they were adapted locally (g = 2.31 vs 0.66), highlighting a need for further research on effective adaptations. Significant risk of bias was identified. CONCLUSION: Overall, pooled effects of youth psychotherapies in LMICs were markedly larger than those in recent comparable non-LMIC meta-analyses, which have shown small-to-medium effects for youth psychotherapies. Findings highlight the potential benefits of youth psychotherapies in LMICs, as well as a need for more RCTs and improved study quality. STUDY PREREGISTRATION INFORMATION: Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries (LMICs): A Systematic Review and Meta-Analysis of Randomized Clinical Trials; https://www.crd.york.ac.uk/PROSPERO/; CRD42021240031.

Using wearable activity trackers for research in the global south: Lessons learned from adolescent psychotherapy research in Kenya.

Wearable activity trackers have emerged as valuable tools for health research, providing high-resolution data on measures such as physical activity. While most research on these devices has been conducted in high-income countries, there is growing interest in their use in the global south. This perspective discusses the challenges faced and strategies employed when using wearable activity trackers to test the effects of a school-based intervention for depression and anxiety among Kenyan youth. Lessons learned include the importance of validating data output, establishing an internal procedure for international procurement, providing on-site support for participants, designating a full-time team member for wearable activity tracker operation, and issuing a paper-based information sheet to participants. The insights shared in this perspective serve as guidance for researchers undertaking studies with wearables in similar settings, contributing to the evidence base for mental health interventions targeting youth in the global south. Despite the challenges to set up, deploy and extract data from wearable activity trackers, we believe that wearables are a relatively economical approach to provide insight into the daily lives of research participants, and recommend their use to other researchers.

Depression and anxiety symptoms amongst kenyan adolescents: Psychometric Properties, Prevalence Rates and Associations with Psychosocial Wellbeing and Sociodemographic factors.

This study assessed the psychometric properties of standard Western-derived instruments, the prevalence of depression and anxiety symptoms, and their associations with sociodemographic and wellbeing variables in a large sample of Kenyan adolescents. Self-report measures of depression (PHQ-8) and anxiety (GAD-7) symptoms, social support, gratitude, happiness, optimism, and perceived control were administered to 2,192 Kenyan youths (57.57% female) aged 12-19. Both the PHQ-8 (α = 0.78) and GAD-7 (α = 0.82) showed adequate internal consistency. EFA with a sub-sample (N = 1096) yielded a 1-factor structure for both PHQ-8 and GAD-7, a subsequent CFA conducted on the basis of a 1-factor model on another sub-sample (N = 1096) yielded good and moderate goodness of fit, respectively, for the PHQ-8 (χ2 = 76.73; p < 0.001; RMSEA = 0.05; CFI = 0.96; TLI = 0.95) and the GAD-7 (χ2 = 88.19; p < 0.001; RMSEA = 0.07; CFI = 0.97; TLI = 0.95). Some 28.06% and 30.38% of participants met the clinical cut-off for depressive and anxiety symptoms, respectively. Social support, gratitude, happiness, and perceived control were negatively associated with both depression and anxiety symptoms. Older adolescents reported higher symptoms while adolescents with more siblings reported lower symptoms. The western-derived PHQ and GAD met conventional psychometric standards with adolescents in Kenya; depression and anxiety symptoms showed relatively high prevalence and significant associations with important psychosocial and sociodemographic factors.

Long-term health outcomes of adolescent character strength interventions: 3- to 4-year outcomes of three randomized controlled trials of the Shamiri program.

BACKGROUND: Adolescents in low- and middle-income countries in need of mental health care often do not receive it due to stigma, cost, and lack of mental health professionals. Culturally appropriate, brief, and low-cost interventions delivered by lay-providers can help overcome these barriers and appear effective at reducing symptoms of depression and anxiety until several months post-intervention. However, little is known about whether these interventions may have long-term effects on health, mental health, social, or academic outcomes. METHODS: Three previous randomized controlled trials of the Shamiri intervention, a 4-week, group-delivered, lay-provider-led intervention, have been conducted in Kenyan high schools. Shamiri teaches positively focused intervention elements (i.e., growth mindset and strategies for growth, gratitude, and value affirmation) to target symptoms of depression and anxiety and to improve academic performance and social relationships, by fostering character strengths. In this long-term follow-up study, we will test whether these mental health, academic, social, and character-strength outcomes, along with related health outcomes (e.g., sleep quality, heart-rate variability and activity level measured via wearables, HIV risk behaviors, alcohol and substance use), differ between the intervention and control group at 3-4-year follow-up. For primary analyses (Nanticipated = 432), youths who participated in the three previous trials will be contacted again to assess whether outcomes at 3-4-year-follow-up differ for those in the Shamiri Intervention group compared to those in the study-skills active control group. Multi-level models will be used to model trajectories over time of primary outcomes and secondary outcomes that were collected in previous trials. For outcomes only collected at 3-4-year follow-up, tests of location difference (e.g., t-tests) will be used to assess group differences in metric outcomes and difference tests (e.g., odds ratios) will be used to assess differences in categorical outcomes. Finally, standardized effect sizes will be used to compare groups on all measures. DISCUSSION: This follow-up study of participants from three randomized controlled trials of the Shamiri intervention will provide evidence bearing on the long-term and health and mental health effects of brief, lay-provider-delivered character strength interventions for youth in low- and middle-income countries. TRIAL REGISTRATION: PACTR Trial ID: PACTR202201600200783 . Approved on January 21, 2022.

Designing Culturally and Contextually Sensitive Protocols for Suicide Risk in Global Mental Health: Lessons From Research With Adolescents in Kenya.

In cross-cultural psychological treatment research, investigators must ensure that protocols for addressing risk are culturally tailored and feasible, while also protecting against harm. Guidelines including the Belmont Report1 and the Declaration of Helsinki2 emphasize respecting participants' autonomy and right to equitable treatment, minimizing harm and maximizing benefit, while considering unique circumstances, local laws and regulations, and cultures. They highlight the importance of supervision from qualified health professionals,2 and special protections for children.1 Suicide risk poses distinctive challenges for cross-cultural research; actions that protect participants in one cultural context may harm participants in another. For example, because suicide attempts are illegal in many countries (eg, Kenya, Gambia, Nigeria), involving law enforcement, or others who may report to them, can generate penalties and incriminate those at risk. Upholding the Belmont and Helsinki principles can therefore require adapting strategies for different cultural contexts. This Commentary outlines strategies for applying principles of ethical risk management3,4 that prioritize sensitivity to context. We focus on addressing participant suicide risk during clinical research in low-resource and high-stigma settings, presenting the example of risk among adolescents in Kenya.5,6.

Single-session interventions for adolescent anxiety and depression symptoms in Kenya: A cluster-randomized controlled trial.

OBJECTIVE: Expanding mental healthcare for adolescents in low-income regions is a global health priority. Group interventions delivered by lay-providers may expand treatment options. Brief, positively-focused interventions conveying core concepts of adaptive functioning may help reduce adolescent symptoms of mental illness. In this trial, we tested three such interventions (growth mindset, gratitude, and value affirmation) as separate single-session interventions. METHOD: Consenting adolescents (N = 895; Mage = 16.00) from two secondary schools in Kenya were randomized by classroom (24 classrooms; Mclass = 37.29 students) into single-session interventions: growth (N = 240), gratitude (N = 221), values (N = 244), or an active study-skills control (N = 190). Mixed-effects models controlling for age and gender were used to estimate individual-level intervention effects on anxiety and depression symptoms. RESULTS: Within the universal sample, the values intervention produced greater reductions in anxiety symptoms than the study-skills control (p < .05; d = 0.31 [0.13-0.50]). Within the clinical sub-sample (N = 299), the values (p < .01; d = 0.49 [0.09-0.89]) and growth interventions (p < .05; d = 0.39 [0.01-0.76]) produced greater reductions in anxiety symptoms. There were no significant effects on depression. CONCLUSIONS: The values intervention reduced anxiety for the full sample, as did the growth mindset and values interventions for symptomatic youths. Future efforts should examine durability of these effects over time.

In Their Own Words: Using Open-Ended Assessment to Identify Culturally Relevant Concerns among Kenyan Adolescents.

Standardized assessment tools developed in western contexts may systematically miss certain problems that are considered important in non-western cultures. In this mixed-methods study, we used an open-ended assessment tool (the Top Problem Assessment; TPA) to identify culturally relevant concerns among low-income Kenyan youth. We then (a) applied thematic analysis to identify the most frequently reported problems and (b) examined the extent to which these problems were reflected in standardized mental health measures. Using the TPA, we identified common social, academic, and economic problems facing Kenyan youths. Specifically, 61% of the sample reported a social problem, 38% an academic problem, and 35% an economic problem. By contrast, the standardized assessments revealed that worrying and difficulty concentrating were the most commonly reported symptoms. However, the emotional and behavioral problems assessed via the standardized measures were only reported as top problems by 17% of the sample. Overall, our findings are consistent with the idea that standardized measures can miss certain culturally-salient concerns that can be acquired through open-ended assessments. We discuss how brief open-ended assessment tools could complement standardized measures, inform the development of culturally relevant standardized measures, and offer rich data about the experiences of people in understudied cultural contexts.

Effectiveness of youth psychotherapy delivered remotely: A meta-analysis.

Reports on remote psychotherapies for youth (e.g., technology-based treatment) suggest it is acceptable, feasible, and useful in overcoming logistical barriers to treatment. But how effective is remote care? To find out, PsycINFO and PubMed were searched from 1960 through 2020, supplemented by journal searches and reference trails, to identify randomized controlled trials of youth psychotherapy for anxiety (including obsessive-compulsive disorder and trauma), depression, attention-deficit/hyperactivity disorder (ADHD), or conduct problems, in which all therapeutic contact occurred remotely. Articles (N = 37) published from 1988 through 2020, reporting 43 treatment-control group comparisons, were identified. Robust variance estimation was used to account for effect size dependencies and to synthesize overall effects and test candidate moderators. Pooled effect size was .47 (95% confidence interval [CI: .26, .67], p < .001) at posttreatment, .44 (95% CI [.12, .76], p < .05) at follow-up-comparable to effects reported in meta-analyses of in-person youth psychotherapy. Effects were significantly (a) larger for remote psychotherapies supported by therapeutic provider contact (.64) than for those accessed by youths, with only logistical support (.22), (b) larger for treatments with phone contact (.65) than for those without (.25), (c) larger for treatment of anxiety (.62) and conduct problems (.78) than ADHD (-.03), and (d) smaller for therapies involving attention/working memory training (-.18) than for those without (.60). Among studies with therapeutic contact, effects were significantly larger when therapists facilitated skill-building (e.g., practicing exposures or problem solving [.68]) than when therapists did not (.18). These findings support the effectiveness of remote psychotherapies for youths, and they highlight moderators of treatment benefit that warrant attention in future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Testing the effects of the Shamiri Intervention and its components on anxiety, depression, wellbeing, and academic functioning in Kenyan adolescents: study protocol for a five-arm randomized controlled trial.

BACKGROUND: Treatments for youth mental disorders are a public health priority, especially in sub-Saharan Africa (SSA), where treatment options remain limited due to high cost, elevated stigma, and lack of trained mental health professionals. Brief, accessible, and non-stigmatizing community-based interventions delivered by lay providers may help address treatment needs in SSA. One such intervention, the Shamiri Intervention, consisting of three elements (growth mindset, gratitude, and value affirmation) has been tested in randomized controlled trials with school-going Kenyan adolescents. This three-element Shamiri Intervention has been shown to significantly reduce depression and anxiety symptoms and improve social support and academic performance relative to a control group. In this trial, we aim to investigate the effects of each element of the Shamiri Intervention. METHODS: In this five-arm randomized controlled trial, we will test each of the intervention components (growth mindset, gratitude, and value affirmation) against the full Shamiri Intervention and against a study skills control intervention. Students (Nplanned = 1288) at participating secondary schools who are interested in participating in this universal intervention will be randomized in equal numbers into the five groups. The students will meet in groups of 8-15 students led by local high school graduate lay providers. These lay providers will receive a brief training, plus expert supervision once a week throughout the intervention delivery. Multi-level models will be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes in each intervention group to the control group. Multi-level models will also be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes of participants in the single-element interventions compared to the full Shamiri Intervention. Finally, effect sizes (calculated as mean gain scores) will be used to compare all groups on all measures. DISCUSSION: This trial will shed light on the mechanisms and outcomes targeted by each individual intervention, helping prioritize which mental health interventions are most important to disseminate. TRIAL REGISTRATION: PACTR Trial ID: PACTR202104716135752 . Approved on 4/19/2021.

Which symptoms of depression and anxiety are most strongly associated with happiness? A network analysis of Indian and Kenyan adolescents.

BACKGROUND: Network analyses have been applied to understand the relationships between individual symptoms of depression and anxiety. However, little is known about which symptoms are most strongly associated with "positive" indicators of mental health, such as happiness. Furthermore, few studies have examined symptom networks in participants from low- and middle-income countries. METHODS: To address these gaps, we applied network analyses in a sample of Indian adolescents (Study 1; n=1080) and replicated these analyses in a pre-registered study with Kenyan adolescents (Study 2; n=2176). Participants from both samples completed the same measures of depressive symptoms, anxiety symptoms, and happiness. RESULTS: Feeling sad and feeling like a failure had the strongest (negative) associations with happiness items. These two symptoms, as well as worrying and feeling nervous, had the strongest associations with other symptoms of depression and anxiety. Symptoms of depression and anxiety formed a single cluster, which was distinct from a cluster of happiness items. Main findings were consistent across the two samples, suggesting a cross-culturally robust pattern. LIMITATIONS: We used cross-sectional data, and we administered scales assessing a limited subset of symptoms and happiness items. CONCLUSIONS: Our findings support the idea that some symptoms of depression and anxiety are more strongly associated with happiness. These findings contribute to a body of literature emphasizing the advantages of symptom-level analyses. We discuss how efforts to understand associations between individual symptoms and "positive" mental health indicators, like happiness, could have theoretical and practical implications for clinical psychological science.

Effect of Shamiri Layperson-Provided Intervention vs Study Skills Control Intervention for Depression and Anxiety Symptoms in Adolescents in Kenya: A Randomized Clinical Trial.

Importance: Low-cost interventions for adolescent depression and anxiety are needed in low-resource countries such as those in Sub-Saharan Africa. Objective: To assess whether Shamiri, a 4-week layperson-delivered group intervention that teaches growth mindset, gratitude, and value affirmation, can alleviate depression and anxiety symptoms in symptomatic Kenyan adolescents. Design, Setting, and Participants: This school-based randomized clinical trial included outcomes assessed at baseline, posttreatment, and 2-week and 7-month follow-up from 4 secondary schools in Nairobi and Kiambu County, Kenya. Adolescents aged 13 to 18 years with elevated symptoms on standardized depression or anxiety measures were eligible. Intent-to-treat analyses were used to analyze effects. Recruitment took place in June 2019; follow-up data were collected in August 2019 and February 2020. Intervention: Adolescents were randomized to the Shamiri intervention or to a study skills control. All adolescents in both conditions met in groups (mean group size, 9) for 60 minutes per week for 4 weeks. Main Outcomes and Measures: Primary outcomes were depression (Patient Health Questionnaire-8 item) and anxiety (Generalized Anxiety Disorder-7 item) symptoms. Analyses of imputed data were hypothesized to reveal significant reductions in depression and anxiety symptoms for adolescents assigned to Shamiri compared with those in the study skills group. Results: Of 413 adolescents, 205 (49.6%) were randomized to Shamiri and 208 (50.4%) to study skills. The mean (SD) age was 15.5 (1.2) years, and 268 (65.21%) were female. A total of 307 youths completed the 4-week intervention. Both Shamiri and study skills were rated highly useful (4.8/5.0) and reduced symptoms of depression and anxiety, but analyses with imputed data revealed that youths receiving Shamiri showed greater reductions in depressive symptoms at posttreatment (Cohen d = 0.35 [95% CI, 0.09-0.60]), 2-week follow-up (Cohen d = 0.28 [95% CI, 0.04-0.54]), and 7-month follow-up (Cohen d = 0.45 [95% CI, 0.19-0.71]) and greater reductions in anxiety symptoms at posttreatment (Cohen d = 0.37 [95% CI, 0.11-0.63]), 2-week follow-up (Cohen d = 0.26 [95% CI, -0.01 to 0.53]), and 7-month follow-up (Cohen d = 0.44 [95% CI, 0.18-0.71]). Conclusions and Relevance: Both the Shamiri intervention and a study skills control group reduced depression and anxiety symptoms; the low-cost Shamiri intervention had a greater effect, with effects lasting at least 7 months. If attrition is reduced and the clinical significance of outcome differences is established, this kind of intervention may prove useful in other global settings where there are limited resources, mental illness stigma, or a shortage of professionals and limited access to mental health care. Trial Registration: Pan-African Clinical Trials Registry Identifier: PACTR201906525818462.

Conducting global mental health research: lessons learned from Kenya.

Mental health disorders are prevalent among youth and adolescents in low- and middle-income countries, and access to evidence-based treatments is poor. Although there is a great need for high-quality research to serve young people in low- and middle-income countries, there is limited guidance available for researchers who wish to conduct such work. Here, we describe our process of conducting school-based youth mental health work in Kenya over the last several years. We focus on five key lessons we learned that could guide future global mental health work with youth: (a) reducing stigma with strengths-focused interventions, (b) expanding access by working in schools, (c) generating buy-in from local stakeholders, (d) adapting the intervention via multicultural collaboration, and (e) applying insights from low- and middle-income countries to serve young people in high-income countries. We conclude by discussing how these lessons, and those shared by other teams, can be applied to help reduce the treatment gap for young people around the world.

A qualitative exploration of mechanisms of intimate partner violence reduction for Zambian couples receiving the Common Elements Treatment Approach (CETA) intervention.

RATIONALE: Despite well-established associations between alcohol use, poor mental health, and intimate partner violence (IPV), limited attention has been given to how psychological and behavioral interventions might prevent or treat IPV in low- and middle-income countries. OBJECTIVE: In a recent randomized controlled trial in Lusaka, Zambia, transdiagnostic cognitive-behavioral psychotherapy (the Common Elements Treatment Approach; CETA) demonstrated significant treatment effects on men's alcohol use and women's IPV victimization in couples in which hazardous alcohol use by the male and intimate partner violence against the female was reported. In this study, we sought to gain a more in-depth understanding of mechanisms of behavior change among CETA participants. METHODS: We conducted 50 semi-structured in-depth interviews and 4 focus groups with a purposeful sample of adult men and women who received CETA between April and October 2018. Transcripts were analyzed using an inductive constant comparison approach by a team of US- and Zambia-based coders. RESULTS: Participants described interrelated mechanisms of change, including the use of safety strategies to not only avoid or prevent conflict but also to control anger; reductions in alcohol use that directly and indirectly reduced conflict; and, positive changes in trust and understanding of one's self and their partner. Several overarching themes also emerged from the data: how gender norms shaped participants' understanding of violence reduction strategies; the role of household economics in cycles of alcohol and violence; and, deleterious and virtuous intercouple dynamics that could perpetuate or diminish violence. CONCLUSIONS: Results suggest important avenues for future research including the potential for combining CETA with poverty reduction or gender norms focused interventions and for incorporating cognitivebehavioral skills into community level interventions.

The Shamiri group intervention for adolescent anxiety and depression: study protocol for a randomized controlled trial of a lay-provider-delivered, school-based intervention in Kenya.

BACKGROUND: Developing low-cost, socio-culturally appropriate, and scalable interventions for youth depression and anxiety symptoms in low-income regions such as countries in sub-Saharan Africa is a global mental health priority. We developed and intend to evaluate one such intervention for adolescent depression and anxiety in Kenya. The intervention, named Shamiri (a Swahili word for "thrive"), draws upon evidence-based components of brief interventions that involve nonclinical principles rather than treatment of psychopathology (e.g., growth mindset, gratitude, and virtues). METHODS: Four hundred twenty Kenyan adolescents (ages 13-18) with clinically elevated depression and/or anxiety symptoms will be randomized to either the 4-week Shamiri group intervention or a group study-skills control intervention of equal duration and dosage. Participating adolescents will meet in groups of 8-15, led by a high-school graduate trained to deliver Shamiri as a lay-provider. Adolescents will self-report primary outcome measures (depression-measured by the PHQ-8, and anxiety symptoms-measured by the GAD-7) and secondary outcome measures (perceived social support, perceived academic control, self-reported optimism and happiness, loneliness, and academic grades) at the 2-week intervention midpoint, 4-week post-intervention endpoint, and 2-week post-intervention follow-up. We predict that adolescents in the Shamiri group, when compared to the study-skills control group, will show greater improvements in primary outcomes and secondary outcomes. DISCUSSION: Results may suggest that a brief, lay-provider delivered, school-based intervention may reduce depression and anxiety symptoms, improving academic outcomes and other psychosocial outcomes in adolescents with clinically-elevated symptoms in sub-Saharan Africa. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201906525818462 . Registered on 12 June 2019.

Reassessing evidence-based content in popular smartphone apps for depression and anxiety: Developing and applying user-adjusted analyses.

OBJECTIVE: To assess the dissemination of evidence-based content within smartphone apps for depression and anxiety by developing and applying user-adjusted analysis-a method for weighting app content based on each app's number of active users. METHOD: We searched the Apple App Store and Google Play Store and identified 27 apps within the top search hits, which real-world users are most likely to encounter. We developed a codebook of evidence-based treatment elements by reviewing past research on empirically supported treatments. We coded the apps to develop an initial tally of the frequency of treatment elements within the mental health (MH) apps. We then developed and applied user-adjusted analysis to refine the tallies based on each app's number of monthly active users. RESULTS: The 2 most popular apps were responsible for 90% of monthly active users, and user-adjusted analysis markedly altered conclusions of prior reports based on tallies alone. For example, mindfulness was present in 37% of apps but reached 96% of monthly active users, cognitive restructuring was present in 22% but reached only 2%, and exposure was present in 7% but reached only 0.0004%. CONCLUSIONS: The potential impact of MH apps on mental health may be best evaluated via assessment that combines tallies of evidence-based content with data on the content users are actually accessing. Given wide variation in the popularity of MH apps, findings weighted by usage data may differ markedly from findings based on raw tallies alone. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Why I recovered: A qualitative investigation of factors promoting motivation for eating disorder recovery.

OBJECTIVE: It is difficult for individuals with eating disorders (EDs) to build and maintain motivation to recover. This challenge contributes to high rates of treatment dropout and relapse. To date, motivational interventions have been largely ineffective, and there is little research on factors that affect recovery motivation. To better understand recovery motivation and identify potential intervention targets, this study examines factors that affect recovery motivation in individuals with EDs. METHOD: N = 13 participants completed qualitative interviews. All had been recovered from their diagnosed and treated ED for at least 1 year. We applied thematic analysis to interview transcripts in order to identify factors that had influenced recovery motivation and to classify their effects as helpful, harmful, or mixed. RESULTS: Six main themes were identified, with subthemes detailed under each: (a) important people and groups (e.g., social circle, mentor), (b) actions and attitudes of others (e.g., judgmental responses, failure to intervene), (c) treatment-related factors (e.g., therapeutic skills, therapeutic alliance), (d) influential circumstances (e.g., removing triggers, pregnancy/children), (e) personal feelings and beliefs (e.g., obligation to others, hope for the future), and (f) the role of epiphanies (i.e., sudden insights or moments of change). DISCUSSION: In this study, we identified potentially malleable factors that may affect ED recovery motivation (e.g., removing triggers, focusing on obligation to others, getting involved in meaningful causes, securing non-judgmental support, building hope for the future). These factors may be investigated as potential targets or strategies in motivational interventions for EDs.

Group Intervention for Adolescent Anxiety and Depression: Outcomes of a Randomized Trial with Adolescents in Kenya.

Youth mental health interventions in low-resource communities may benefit from including empirically supported elements, using stigma-free content, and using trained lay-providers. We developed and evaluated such an intervention, targeting adolescent depression and anxiety in Kenya, where mental health care is limited by social stigma and a paucity of providers. Kenyan adolescents (N = 51, ages 14-17, 60.78% female) from a school in an urban slum in Nairobi with self-reported moderate-to-severe symptoms of depression or anxiety were randomized to the 4-week "Shamiri" ("thrive") group intervention or a study skills control intervention of equal duration. The Shamiri intervention included growth mindset, gratitude, and value affirmation exercises. The content was delivered by recent high school graduates (ages 17-21, 60% male) trained as lay-providers. Participants met in school once-a-week in groups of 9-12 youths (average group size 10). Compared to the study-skills control, Shamiri produced greater reductions in adolescent depression symptoms (p = .038; d = .32) and anxiety symptoms (p = .039; d = .54) from baseline to 4-week follow-up, and greater improvements in academic performance (p = .034; d = .32) from the school-term before versus after the intervention. There were no effects on overall social support or perceived control, but the Shamiri group showed larger increases in perceived social support from friends (p = .028, d = .71). This appears to be the first report that a brief, lay-provider delivered, community-based intervention may reduce internalizing symptoms and improve academic outcomes in high-symptom adolescents in Sub-Saharan Africa. Larger replications with extended follow-ups will help gauge the strength and durability of these effects.