This chapter is adapted from Abotsie et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Background
There is extensive and growing demand for services to meet the needs of young people with poor mental health.2 Depression is a common health problem during adolescence. Adolescent lifetime prevalence of major depressive disorder (MDD) is 11–20%.3,4 However, mild/subthreshold depression is much more common in adolescents than full MDD.5 Such mild depression is associated with significant personal and public health consequences6 and is a strong predictor for future onset of full MDD.7 Depression in adolescence predicts a range of adverse outcomes in adulthood, including ongoing mental health problems,8 poorer physical health9 and social, legal and financial problems,10 and it is the most prevalent psychiatric disorder in young people who die by suicide.11 The total annual cost of depression in England has been estimated to be at least £20.2B.12 However, there is evidence that prompt psychological intervention can prevent relapse and recurrence,13 and therefore intervening early, before depression symptoms become severe, could generate substantial savings.
The majority of adolescents seeking treatment for depression have mild disorders.14 In the UK, such cases of mild depression are not likely to meet treatment thresholds for specialist (tier 3) Child and Adolescent Mental Health Services (CAMHS). Instead, young people with mild depression are seen by staff working in local authority child and family services or tier 2 NHS-funded mental health services often delivered by third-sector/voluntary agencies. Most of those working with depressed young people within these non-specialist services are not qualified mental health professionals and have no formal training in delivering evidence-based treatments for people with depression.
At present, there is not a standard treatment as usual (TAU) in these non-specialist sectors. There is great variation between and within services about what is offered to young people with low mood, for example, psychoeducation, non-directive counselling and/or behavioural activation. There is usually little specific training and supervision for these interventions. There is no evidence as to whether these interventions are effective, nor whether a systematic intervention with manualised training, delivery and supervision would be more effective and cost-effective than the current approach of non-systematic and varied interventions.
Current guidelines for the treatment of mild depression in children and young people (CYP)15 recommend simple, non-specific psychosocial strategies, such as non-directive supportive therapy. A recent, large network meta-analysis has shown that while non-directive supportive therapy is better than a waiting list (i.e. no treatment) for adolescent depression, it is not significantly better than placebo.16 It is important to note that the primary studies included in this meta-analysis took place in a range of services for a range of severities of depression. No randomised controlled trials (RCTs) have taken place in the services described above, where most cases of mild depression are treated in the UK. Thus, there is a clear lack of evidence as to how to treat young people accessing these services.17–19
Study rationale
Interpersonal psychotherapy (IPT) is a National Institute for Health and Care Excellence (NICE)-recommended first-line treatment for adolescents with moderate to severe depression. IPT helps patients to understand the two-way links between their depressive symptoms and current interpersonal relationships. It also helps patients to improve their interpersonal relationships. In doing so, it aims to reduce depressive symptoms. Whereas non-directive supportive therapy aims ‘to help patients accommodate to existing reality rather than try to help them change it’,20 IPT focuses on helping patients to take active steps to improve their relationships in order to decrease their depressive symptoms. Theoretical influences on IPT included Adolf Meyer’s ‘psychobiological’ approach, which emphasised patients’ current interpersonal and psychosocial experiences, and21 Harry Stack Sullivan’s ‘interpersonal’ approach, which conceptualised psychiatry as the scientific study of people and interpersonal processes.22 Both approaches contrasted with the dominant psychoanalytic approach at that time, which emphasised intrapsychic processes over interpersonal relationships.
Meta-analyses have demonstrated IPT to be superior to control treatments for depression in both adults23 and adolescents16 and to lead to similar outcomes as cognitive–behaviour therapy in both age groups. Crucially, IPT has been shown to be significantly more effective than supportive counselling for depressed adolescents.24 Given the importance of interpersonal relationships in the causation of adolescent depression,17 and the developmental priority given to interpersonal relationships during adolescence, this approach has high face validity for this age group.
However, in common with other evidence-based treatments for adolescent depression, IPT must be delivered by a qualified mental health professional. As such, it is unlikely to be a feasible treatment option outside of specialist CAMHS. Interpersonal counselling (IPC) is an adaptation of IPT with three main differences: the treatment duration is shorter (three to six sessions); it is designed for clients with mild depression; and it can be delivered by non-mental health professionals after participation in a brief (2-day) training course.
Interpersonal counselling has been found to be an effective treatment for adults with mild to moderate depression.25,26 A recent trial in Brazil found that staff without prior psychotherapy training were able to successfully deliver IPC to adults with depression.27 These staff were similarly effective at providing TAU as qualified psychologists. There has yet to be a published trial of the effectiveness or cost effectiveness of this approach in adolescents. An adapted form of IPC designed to meet the needs of young people (IPC-A) has been developed and piloted in a single-arm study by members of the research team. IPC-A was delivered by staff without prior psychotherapy training and was found to be well accepted by staff and young people,28 but its effectiveness as a treatment for adolescent depression has yet to be tested. Although there are many similarities between adult and adolescent depression, there are also important differences, particularly in treatment response.17 Adult and young people’s services also differ in their organisation, ethos and staff training.29 Therefore, it cannot be assumed that an effective treatment for adult depression can be transferred to adolescents without evaluation.
There is currently not any evidence to support decision-making regarding which interventions staff members from services providing young people with non-specialist mental health support should be trained to deliver.
Developing skills of staff members by training them to deliver evidence-based interventions will be important to meeting workforce requirements. This study aimed to contribute to this evidence base and is in line with the Department of Health’s Framework for Mental Health Research, which recommends that research should focus on early intervention and involve organisations beyond traditional health services, including local authorities and the voluntary sector. We believed that IPC-A may be effective for young people with mild depression presenting to non-specialist services and may be more effective than current ‘treatment as usual’ (which is not a specific treatment – it is an approach of trying to help young people with one or several strategies that a therapist has learnt about).
It is important to state that while there is a good evidence base for IPT for adolescent depression and evidence that IPC is effective for mild depression in adults, there is minimal evidence that IPT or IPC is more effective than control treatments for anxiety disorders in either age group.30 This is because depressive and anxiety disorders are different disorders. Although there is increased risk of the second disorder if one is present, they are best conceptualised as different disorders with different core symptoms (low mood vs. anxiety). (For a full discussion of commonalities and differences between depressive and anxiety disorders, please see Wilkinson31) IPT was specifically designed to focus on the link between low mood (and other depressive symptoms) and interpersonal relationships; hence, it should not be assumed that it works for other disorders. Given it is more likely that IPC is effective for depression than anxiety, this initial pilot study focused on young people with mild depression. Given there is no evidence that IPC is effective for depression or anxiety in this clinical setting, we believed it to be ethically acceptable for young people with depression to be randomised to IPC-A or TAU, and for young people with anxiety but not depression to continue to receive TAU, as they would have done before the trial.
This study was intended to provide the information needed to progress to a national full-scale clinical trial of IPC-A delivered by staff without core professional training (referred to in this report as ‘youth mental health workers’). The training (including subsequent supervised casework) required to deliver IPC-A can be completed by staff without prior mental health qualifications in < 12 weeks. Therefore, if found to be an effective treatment, training existing workers as IPC-A therapists could facilitate a rapid and relatively low-cost expansion of the therapy workforce in line with NHS England and government commitments.
Aim and objectives
The research was designed to inform a future trial of the effectiveness and cost effectiveness of the intervention (IPC for adolescents with mild depression). The aim of the research was to answer the following feasibility questions which arose partly from the variability in service models across providers of non-specialist mental health support for young people:
Feasibility question 1
Are trial procedures, including recruitment (of participants and therapists), randomisation, research assessments and follow-up, feasible and acceptable?
Feasibility question 2
How are IPC-A and TAU delivered, and how and why does intervention delivery vary across differing service contexts?
Feasibility question 3
To what extent does contamination of the control arm occur, and should it be mitigated against in a future trial?
Feasibility question 4
Does the interval estimate of benefit of IPC over TAU in depression scores post treatment include a clinically significant effect?