From the Editor
“There are more psychiatrists of African origin in the US than in the whole of Africa. And I could actually say similar examples from the Philippines, or India, or many other countries. There is an enormous shortage of mental health resources…”
So comments Dr. Vikram Patel (of Harvard University). Across low-income nations, mental health care services are profoundly difficult to access. Could Shamir (Kiswahili for thrive) – an intervention built on simple psychological concepts and delivered by laypersons – be part of the solution?
This week, we look at a new paper from JAMA Psychiatry. Tom L. Osborn (of Kenya’s Shamiri Institute) and his co-authors describe the results of a study involving adolescents with depression and anxiety symptoms. “To our knowledge, this is one of the first adequately powered tests in this population of a scalable intervention grounded in simple positive psychological elements.” We look at the big paper.
But is the work ethical? In our second selection, we consider the editorial that accompanies the Osborn et al. paper. JAMA Psychiatry Editor Dr. Dost Öngür (of Harvard University) defends the study and his decision to publish it: “Because this trial was already conducted, we considered the obligations of the journal to be different than those of investigators and prospective reviewers. The question for us was whether there is a benefit to society by publishing the study as it was conducted.”
Finally, in our third selection, a reader writes us. Giorgio A. Tasca (of the University of Ottawa) responds to The New York Times article by Karen Brown considering chatbots. “Is scaling up an intervention with dubious research support – that results in low adherence and high dropout (and perhaps more demoralization as a result) – worth it?”
Please note that there will be no Reading next week.
Selection 1: “Effect of Shamiri Layperson-Provided Intervention vs Study Skills Control Intervention for Depression and Anxiety Symptoms in Adolescents in Kenya: A Randomized Clinical Trial”
Tom L. Osborn, Katherine E. Venture-Conerly, Susana Arango G., et al.
JAMA Psychiatry, 9 June 2021
Adolescent depression and anxiety account for 45% of the global burden of disease in youths aged 10 to 24 years, based on worldwide estimates per disability-adjusted life-years, and are linked to important medical and life outcomes. Both are prevalent in Sub-Saharan Africa, but youths with these problems in Sub-Saharan Africa may not find help. Few mental health professionals exist, and social stigma surrounding mental illness prevents help seeking. Attempts to improve the psychological well-being of youths in Sub-Saharan Africa have had mixed success. As the population of Sub-Saharan Africa becomes increasingly youthful, developing interventions to overcome these barriers is a global health priority.
One approach to expanding access to care may involve using brief theory-driven treatments that are sometimes called wise interventions. Wise interventions differ from most evidence-based treatments in that they (1) are often delivered by laypersons rather than trained clinicians, an approach the World Health Organization recommends for low-resource settings, (2) focus on simple psychological concepts rather than behavioral and cognitive skills, (3) are often delivered in nonclinical settings, and (4) invoke positive human attributes and principles rather than psychopathology. One example is growth-mindset intervention, which conveys the concept that one’s traits and characteristics are malleable and can be improved via effort and has been shown in US samples to reduce symptoms of depression and anxiety and to improve functioning. Similar effects have been found in the US for gratitude interventions, which teach individuals to notice and appreciate good things in their lives and express their gratitude. A third form of wise intervention is value affirmation: encouraging individuals to identify and reflect on their self-defining values and plan actions consistent with those values.
Given the apparent clinical, conceptual, and practical advantages of these 3 simple interventions, our multicultural Kenya-US team brought elements of the 3 together to form a combined intervention for anxiety and depression symptoms in Kenyan youths. This intervention, Shamiri (Kiswahili for thrive), is designed for implementation with adolescents meeting in groups led by trained laypersons.
So begins a paper by Osborn et al.
Here’s what they did:
- The authors conducted “a school-based randomized clinical trial included outcomes assessed at baseline, posttreatment, and 2-week and 7-month follow-up.”
- Participants were chosen from four schools in Kenya; they were adolescents (13 to 18 years of age) with elevated symptoms on standardized depression or anxiety measures.
- Recruitment took place in June 2019.
- Adolescents were randomized to the Shamiri intervention or to a study skills control. About the former: “The Shamiri intervention included 3 modules: growth mindset (2 sessions), gratitude (1 session), and value affirmation (1 session).”
- “Primary outcomes were depression (Patient Health Questionnaire-8 item) and anxiety (Generalized Anxiety Disorder-7 item) symptoms…”
- Statistical analyses were done.
Here’s what they found:
- “Of 413 adolescents, 205 (49.6%) were randomized to Shamiri and 208 (50.4%) to study skills.”
- Demographics: the mean age was 15.5 years; most participants were female (65.2%)
- 307 youths completed the 4-week intervention.
- “Both Shamiri and study skills were rated highly useful (4.8/5.0)…” by the participants.
- “Youths receiving Shamiri showed greater reductions in depressive symptoms at posttreatment (Cohen d = 0.35…), 2-week follow-up (Cohen d = 0.28…), and 7-month follow-up (Cohen d = 0.45…) and greater reductions in anxiety symptoms at posttreatment (Cohen d = 0.37…), 2-week follow-up (Cohen d = 0.26…), and 7-month follow-up (Cohen d = 0.44…).”
A few thoughts:
- This is interesting study.
- For low-income nations, there is something very attractive about this work – a minimal cost intervention with layperson counseling. The authors are, needless to say, enthusiastic: “The positive findings suggest the testable possibility that interventions that are simple in design, low in cost, focused on positive human attributes and character strengths, and delivered by laypersons may contribute usefully to global mental health.”
- To be clear: the intervention worked – but, then, so did the study skills. The authors point out, though, that the intervention group had fewer anxiety and depression symptoms at 7 months.
- While all studies have limitations, this RCT was particularly effected by a government decision to ban research past two week post-intervention; that decision was eventually reversed. (!) Needless to say, the government action was disruptive: “the ban described previously led to significant attrition at 7-month follow-up…” Ouch. The authors laboured to overcome the problem using different types of analysis.
- Still, take note: the 7-month follow up included just 54% of the participants.
- This Reading opens with a quotation from Dr. Patel. For a lively interview with this global psychiatry expert, see a past Reading:
- The Osborn et al. study is big… but is it ethical? See the next selection.
The full JAMA Psychiatry can be found here:
Selection 2: “Considerations in Publishing a Psychiatric Randomized Clinical Trial with Kenyan Children”
JAMA Psychiatry, 9 June 2021
The article by Osborn and coauthors in this issue of JAMA Psychiatry underscores several challenges conducting clinical research in an underresourced environment, such as Kenya. In this study, the investigators screened schoolchildren for moderately severe anxiety and depression and offered a subset of them entry into a randomized clinical trial. Those eligible but not offered entrance into the trial were instead informed of the services that were available to them within their school, and in addition, they were encouraged to contact the study team if they had questions about mental health issues or needed help or support. Those who did enter were randomized to the Shamiri intervention or a Study Skills control arm, both of which are described in the article in detail. The control is not a treatment directed at moderately severe anxiety and depression. As noted by the reviewers of the manuscript, this design raises ethical questions about whether the investigators met their duties toward the participants in the conduct of this research. These questions are even more intense because this study was conducted with a vulnerable pediatric population. We considered these questions in detail, as described here, and ultimately decided to publish this article.
So begins the editorial by Dr. Öngür.
He makes two arguments:
First, with regard to only offering the randomized clinical trial to a subset of those screened, the authors noted that they were required by some of the schools where the study took place to screen all students and did offer certain supports and resources to all individuals who underwent screening. They shared information about help and support available from the students’ schools and the study team and encouraged all who would like to receive help and support to contact the study team, whether or not they were involved in the study.
He adds: “an estimated 40 students of more than 150 who were deemed eligible but not offered entry into the study took advantage of these services…”
Second, with regard to the choice using Study Skills as a control (and not an evidence-based treatment, such as cognitive-behavioral therapy), the authors’ reasoning was that a major source of anxiety and depressive symptoms among children who attend school in Kenya is concern about academic performance. In this context, the authors saw the Study Skills training condition as addressing a source of anxiety and depression symptoms.
Dr. Öngür argues that the project wouldn’t have met National Institutes of Health standards for funding. And he acknowledges further problems with the study: “There were other aspects of the study that also raised concerns for multiple reviewers, including the sampling across schools and the very different school settings, the supervision and training of the therapists, the role of allegiance bias, the use of self-reports as outcome measures, and whether the role of culture and sociodemographic factors were fully accounted for.”
Nevertheless, he feels that paper was important to publish: “The question for us was whether there is a benefit to society by publishing the study as it was conducted. We concluded that the investigators made good-faith decisions based on local context and available resources to conduct their study. The work was conducted in a unique underserved setting by a diverse team. ”
A couple of thoughts:
- This is a well argued editorial.
- Did JAMA Psychiatry make the right decision?
The full editorial can be found here:
Selection 3: Letter to the Editor: “The New York Times’ Optimism and Apps”
Re: “Something Bothering You? Tell It to Woebot.”
The New York Times, 1 June 2021
Thanks for your regular blog and email. I really enjoy reading it. (You might be aware of my blog that is specific to psychotherapy research at www.pprnet.ca.)
I would like to comment on the smart phone apps article in The New York Times.
I find The New York Times to be overly optimistic (sometimes giddy) about unproven treatments – especially industry sponsored interventions like apps and psychedelics. The recent article on psychedelics for example did not mention that the blinding of participants and clinicians failed, thus severely biasing the findings (in effect, it was not a double blind trial as advertised).
Regarding apps, I find it curious that one would expect people who feel depressed, alienated, socially isolated, unmotivated, etc. to find solace in an app (we’re very social animals and apps are antithetical). In any case, the research on apps is quite poor (5% high quality, >50% very low quality); uptake is very low (only 17% of patient complete them); drop outs are very high – but they do make a lot of money for the companies that produce and advertise them. See this review: https://www.nature.com/articles/s41746-019-0188-8 and my blog post: https://socialsciences.uottawa.ca/pprnet/blog?p=2&cat_2=36.
Is scaling up an intervention with dubious research support – that results in low adherence and high dropout (and perhaps more demoralization as a result) – worth it?
Giorgio A. Tasca, PhD, CPsych
University of Ottawa
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.