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Paul Bolton, MBBS
Center for Refugee and Disaster Response, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Room E8646, Baltimore, MD, 21205, USA;
How effective are interventions for depression symptoms in displaced adolescent survivors of war in northern Uganda?
314 adolescents (14–17 years old) of the Acholi ethnic group living in camps for internally displaced persons, who had depression-like syndromes, defined using the Acholi Psychosocial Assessment Instrument (APAI; a locally defined and validated instrument assessing severity of 35 symptoms). For inclusion, adolescents had to score at least 32 on the APAI (score range 0–105, higher score indicates greater severity of symptoms), although 14 adolescents with scores between 28 and 31 were included to achieve target sample size, and report some difficulties in function on a gender-specific local function measure. Main exclusion criteria: severe suicidal ideation or disability preventing interview.
Two camps for internally displaced persons in northern Uganda; May 2005 to December 2005.
Group interpersonal psychotherapy, creative play, or waiting list control. The active intervention groups met for weekly sessions lasting 1.5–2 hours for 16 weeks. Group interpersonal psychotherapy was delivered in single sex groups of 6–8 adolescents by a trained facilitator of the same sex, based on a locally adapted manual. Creative play consisted of activities with specific psychosocial goals, followed by discussion relating the activity with real life. Creative play was delivered in mixed sex groups of 25–30 adolescents by trained facilitators.
Primary outcome: change in depression symptoms (APAI).
83% completed post-intervention assessment; 100% included in last observation carried forward analyses.
Randomised controlled trial.
Single blind (assessors blinded).
16 weeks (intervention period only).
Group interpersonal therapy significantly reduced depression symptoms compared to control (difference in adjusted mean depression score change from baseline: 9.97, 95% CI 1.66 to 17.93; p = 0.02). However, there was no significant difference between creative play and control in depression symptoms (adjusted mean difference: −2.51, 95% CI −11.42 to +6.39, p = 0.58). If analysed by gender, group interpersonal therapy significantly reduced depression symptoms in girls, but not in boys (adjusted mean difference: girls 12.61, 95% CI 2.09 to 23.14; boys 5.72, 95% CI −1.86 to +13.30).
Group interpersonal therapy, but not creative play, reduces depression symptoms in adolescent survivors of war and displacement in northern Uganda. Group interpersonal therapy may be more effective for girls than boys.
Bolton P, Bass J, Betancourt T, et al. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. JAMA 2007;298:519–27.
Notes: The study was not powered to show gender-specific differences; therefore these subgroup analyses should be interpreted with caution.
This article is highly significant in that it is the only randomised controlled trial (RCT) of a psychosocial intervention for adolescents that has been conducted with African adolescents who reside in an impoverished, developing country devastated by war. Until recently, the majority of RCTs have been conducted with middle class Caucasian adolescents, with a smaller percentage including ethnic minorities who reside in impoverished populations in the Western world.
Studies in adults examining treatments such as cognitive-behavioural therapy,1 psychoeducation2 and interpersonal psychotherapy3 demonstrated the effectiveness of these interventions in clinical trials conducted in developing countries, but there is no comparable body of literature with children and adolescents. The lack of studies of effective treatments in non-Western countries needs to be addressed as research informs us that children and adolescents living in war-torn countries are at great risk for mental health problems.4 ,5 This study is to be commended for its demonstration of methods for translating a westernised definition of a mental illness into a culturally relevant syndrome that could be identified and treated effectively.
The implications of this study are many: (1) it shows that empirically supported treatments developed in the Western world can be adapted, applied and tested in developing countries; (2) it shows that the adaptations of interventions, when done systematically and thoughtfully in collaboration with members of the targeted population, can be translated into culturally meaningful treatments; and (3) it provides preliminary evidence that a group model of interpersonal psychotherapy can be effective in treating a depression-like syndrome in adolescents who have been affected by war and poverty. Further research is needed to better understand the response to treatment among girls in comparison to boys and to replicate the findings in other similar communities. This study is an important first step in transporting culturally-adapted and empirically-supported psychosocial interventions for adolescents into developing countries.
Source of funding: World Vision and War Child Holland.
Competing interests: None declared.
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