Introduction
Common mental health problems—such as symptoms of depression and anxiety—are the leading cause of disability in adolescents, contributing 45% to the overall burden of disease among young people.1 However, only a small fraction of those in need receive any treatment. Even in high-income countries such as the USA, about 65% of the youth with psychiatric disorders do not receive treatment; among those who do, 30%–60% drop out prematurely.2 3 Access to treatment is especially poor in low-income and middle-income countries.4 Common barriers to services include high costs of treatment, lack of trained mental health professionals, transportation and scheduling difficulties and stigma associated with professional help-seeking.4 5
This challenge is commonly referred to as the treatment gap—a gap between those with mental health problems and those who receive treatment.6 Currently, most empirically supported interventions for the youth are face-to-face interventions that last multiple months.7 8 Although these interventions generally yield medium effects, their implementation often requires substantial time and resources.8 To address the treatment gap, experts have called for scalable treatment delivery formats such as digital interventions, self-help interventions and low-intensity prevention interventions.6 9
One promising strategy to reduce the treatment gap involves the development and testing of brief, efficient and digital mental health interventions. A growing body of evidence suggests that digital interventions, such as those delivered as web-based programmes, are effective for a variety of mental health conditions.10 11 Furthermore, meta-analytic evidence suggests that online interventions can be effective in just a single session.12 As an example, some self-administered, online single-session interventions centred around growth mindsets have been shown to reduce depressive symptoms even at the follow-ups at 4–9 months.13 14 Such interventions could be disseminated widely at low costs, making them particularly promising candidates as scalable global mental health interventions.15 16 However, most of the researches on single-session interventions have been conducted in Western countries, and little is known about the potential effectiveness and acceptability of these interventions in non-Western settings. Our team previously conducted one of the first pilot trials of an online single-session intervention in Sub-Saharan Africa with Kenyan adolescents. In that trial, participants randomised to Shamiri-Digital—an intervention that included lessons on growth mindsets, gratitude and value affirmations—experienced greater reductions in depression and anxiety than those randomised to a study-skills control condition.17 While this work suggests that single-session interventions have potential, follow-up work with larger sample sizes and longer follow-up time points is needed.
Additionally, little is known about which content is best suited for brief digital interventions. While previous research has shown that active interventions outperform control groups12, it remains unclear if certain active interventions are more effective than others. Understanding which single-session interventions are most effective is especially important in low-resource settings, where investment in mental health interventions is poor. Such research can benefit policymakers and practitioners who could prioritise limited resources to disseminate the most impactful interventions.
Guided by this logic, we are performing a randomised controlled trial (RCT) comparing two active single-session interventions against each other and against an active control group. The first intervention, Shamiri-Digital, will be derived from our team’s previous work with Kenyan adolescents.17 The second intervention, Digital-CBT, will be adapted from traditional cognitive–behavioural therapy (CBT) exercises as well as our team’s previous work in India and the USA.18 19 The active control group will consist of online study-skills exercises that have been used previously in RCTs with Kenyan youths.17
Our trial has four aims. The first is to test whether Shamiri-Digital can effectively reduce depressive and anxiety symptoms among Kenyan adolescents. We hypothesise that adolescents assigned to Shamiri-Digital condition will experience larger symptom reductions than those assigned to an active study-skills control group.
The second aim is to evaluate the efficacy of a single-session intervention based on CBT exercises. Previous meta-analytic research has shown that digital CBT interventions are effective for depression and anxiety.11 20 Notably, trials from these meta-analyses have generally tested digital CBT interventions that last multiple months. In contrast, limited number of researches have examined the effects of single-session interventions grounded in CBT. In this study, we hypothesise that adolescents assigned to the Digital-CBT condition will experience larger symptom reductions than those assigned to the study-skills control group.
Our third aim is to compare the effects of Shamiri-Digital and Digital-CBT. Although there are many trials of digital CBT interventions, we are unaware of any digital CBT interventions that have been tested specifically for Kenyan youths. In contrast, there has been only one trial of Shamiri-Digital, but this trial was conducted with Kenyan youths and produced medium-to-large effects on youth depressive symptoms.17 Thus, Digital-CBT has a broader evidence base, but Shamiri-Digital has been tested specifically with Kenyan youths. As a result, we do not have a hypothesis regarding which intervention will be more effective. For each intervention, we expect that the effect will be stronger at 2-week follow-up than at 4-week or 12-week follow-up.
Our fourth aim is to examine the acceptability and appropriateness of each intervention. We hypothesise that each intervention will receive adequate acceptability and appropriateness ratings. Through this aim, we hope to identify which interventions Kenyan adolescents perceive to be appealing and helpful.
