Problem solving therapy: the answer to youth depression?

Hey, Alicia here. Just letting you know that this episode contains mentions of suicide. For me, the question is not where the stresses arise. These are part and parcel of growing up. The question is really how are you able to effectively cope with those stresses in ways that do not lead you into a rabbit hole that ultimately leads you into a mental health problem? Welcome to When Science Finds Away, a podcast about the science changing the world. I'm Alicia Wainwright and this is where you'll hear stories of hope from the people on the front line of our biggest health challenges. Challenges like the global mental health crisis. It's now predicted that half of the world will experience some kind of mental health disorder in their lifetimes. So the need to find low cost, scalable solutions to this is more pressing than ever. And if we can intervene early in people's youth or adolescents, a crucial period for mental health, there can be significant implications for long-term well-being. On this episode, we're going to be talking about problem solving therapy. This isn't something new. It was originally developed in the 1970s and is a well-tested mental health intervention. But there's still a lot we don't know about how, why, and when it can work, especially for young people. My guest, Professor Vikram Patel, is part of a team who have been trying to change that. That's the amazing thing about the work that we do is that we are not passionate about rocket science. We're passionate about the simple things in life that people want. It's a simple things in life that can help fix people's difficult lives that actually are the ones that we focus on. Vikram is professor of global health at Harvard Medical School and co-founder of Sengath, an Indian NGO focused on improving mental health care in the country. You might also remember him from series one of When Science Finds Away, in the episode about cash transfers, a low-cost breakthrough in the treatment of mental health disorders. Vikram and his team recently completed a study applying problem-solving therapy at scale in Indian schools. We're going to be talking about how it was conducted, the results, and the follow-up research, which is already in the works. Vikram is joining us from his home in Goa, so you might hear a barking dog or two outside. Vikram, welcome back to When Science Finds Away. Thank you, Alicia. It's wonderful to be reconnected with you. Vikram, why is India such an important location for looking at adolescent mental health? Well, quite simply because India is the most popular country in the world, and indeed, India's demographic structure means that India is also home to the largest number of young people in the world. In fact, many economists consider this one of India's greatest strengths. They call it the demographic dividend. However, it can only be a dividend if that demographic is healthy, and I think this is an incredibly important point to make to our policymakers. And what percentage of these young people are experiencing mental health difficulties? In India, what we can say is that anywhere between five to 15 percent of young people are currently living with a clinically significant mental health condition. The most common condition is mood and anxiety problems. And in a certain demographic, particularly young adults in the early 20s, you also see the emergence of psychotic conditions. The metric that I think is perhaps the most worrying and the one that catches the policymakers attention the most is that of suicide. And here's the most amazing statistic of all, the most worrying statistic of all, I should say. For the past two decades, suicide has been the leading cause of death in young Indians. In other words, more young Indians will die through suicide than because of any other health condition. The second most important leading cause is accidents or unintentional injuries. A large proportion of which are also related to poor mental health because of impulsivity, substance use, and so on. So if you think of the two leading causes of death in young people in India today, mental health and behavioral factors are central to both of them. Wow, that's really shocking. And I guess five to 15 percent of young people might seem lower rates than somewhere like the US, for example. But in reality, it still equates to up to 56 million young people living with a significant mental health condition. To get a sense of what this looks like, we spoke to Bindiya Churankar, who has worked with teenagers in schools in Goa as a non-specialist counselor. She told us about some of the issues the students are facing. So the kind of problem what a doll is in face are mental health issues such as stress, anxiety, depression, certain emotional issues like anger, irritability, there were pure pressure, academic pressure, even family dynamics, maybe at the home, maybe the family environment where the siblings are the concerns or the parents themselves, or any other family members where they feel that is the cause of concern to them. Even at school or at the college level where they come to learn, so there are the pure pressure or maybe the relationship issues what they get involved in. And plus the societal expectations, like you have to score this marks, the parent pressure is very. Exam pressure was another thing, exam anxiety. And also there are certain pressures from school itself that the school has to perform well because of the, maybe the further repetitions and all those. And also looking at the pure pressure, maybe the child gets involved in certain risky behaviour of maybe smoking or alcohol use, or feelings we sidele the thoughts of feelings we sidele. So these were the things what majorly, you know, adolescent peace. It sounds like what these young people are experiencing, it just can be so varied. And this is typical when it comes to talking about youth mental health. Absolutely, there is so much going on in the lived experience of being an adolescent all the way through into young adulthood. Everything we had been there speak about, the pressures of academic performance, the negotiation and navigation of romantic relationships. And so on, these are universal experiences. Of course, there will be individual differences because every individual's life experiences are slightly different. But the truth be said, the vast majority of adolescents in the world will have to make those transitions. From a developmental perspective, the brain, our physiology and our social worlds undergo the most dramatic transitions from roughly around puberty all the way through into our early 20s. And so it's inevitable when you're making so many different transitions. And we haven't even spoken about the transitions in your own bodies, how dramatically they change during that period. And the need to sort of feel good about the way you look and so on. And you're making them also at that very critical phase we are no longer relying on your parents to guide you through those transitions. You're going to have to make those decisions yourself. I mean, it's not surprising that there will be stresses. Right. Right. And in 2016, you started a project called Pride to address some of these issues. Can you tell me a bit about how that came about and who was involved in the project? So Pride was a project that was building on a decade of work that I had been conducting in India with support from the welcome trust. That was aiming to develop contextually appropriate psychosocial interventions for mental health problems that could be delivered by people who are widely available in the Indian context. This was not psychologist and psychiatrist, but essentially lay people, community health workers and such like. When you say lay people, that means like your common person, just someone who isn't a trained professional, just for someone who maybe has heard the term lay, but may not necessarily know what it means. Yeah, well, you know what, yes, the word literally means somebody who has no professional training in mental health. But actually, this could also include a number of different kinds of health workers, like community health workers, do not have a formal training in mental health. Thank you for clarifying that. So what did Pride focus on? It was essentially a program that sought to apply the lessons, the principles and methods that I had developed in my previous work, but focusing now on emotional problems in school going out of lessons and focusing particularly on low. students who were attending government schools in New Delhi and Goa. The vast majority of young people in India come from low-income backgrounds and for the vast majority of them, the public or government-schooling system is the only option. And so we chose intentionally to focus on those school populations. These are the children who are coming from the least resource, the least privileged backgrounds and the ones who struggle the most when it comes to this highly competitive academic environment that they find themselves in. And so we partnered with Sangat as being the primary implementation partner to essentially conduct the research that involved the design and evaluation of these brief psychosocial interventions for adolescents. So the pride team decided to test a problem-solving intervention. So what is problem-solving therapy and how was it used in pride? So problem-solving therapy is a structured psychological intervention whose goal is to enhance an individual's ability to cope with stressful life experiences. It's a technical term but it also has a very clear everyday meaning to it which is what's beautiful about it. Unlike most psychotherapy terms like cognitive behavior therapy, there is no sort of everyday use-shooter term. When I explain to a young person, I'm going to teach you skills on how to solve your day-to-day problems. It's very engaging. It's intuitive. People immediately understand. And they respond according to say, "Yeah, you know what? I'm facing a whole lot of stuff that's going on and I really need your guidance. It also helps destigmatize because you no longer focus on the adolescents' mental health. And you focus instead on what matters to the adolescent, which is the problems that they're facing, their romantic areas or in the academic performance or problems at home, whatever they might be. And in that way, it's much more comfortable for adolescents to actually take part in this form of psychotherapy. It's supposed to say, for example, that I'm going to now work on your thought patterns and I'm going to try and get you to think about things differently. And you know, that doesn't land as well at least in my experience." Why do you think problem solving might be so impactful for this specific age group? We chose problem solving not only because it's evidence-based. It's been around for a very long time. It's been tested and tried in a variety of different populations. It's fairly simple to learn and to deliver. And therefore, also fairly simple for opposed to receiving the therapy to master. But it also has something very unique, I think, in terms of adolescents. And it is this. One of the reasons why adolescents often develop mood and anxiety problems in the context of stresses is that the executive functioning parts of your brain, which are just behind your forehead, the prefrontal part of your brain, hasn't fully matured until your late 20s. And so you tend to be overwhelmed by your emotional reactions to stresses. And you're unable to think in a calm and measured way as much as you would have when you were in your 30s, for example. And so, what problem solving teaches young people other skills to pause, to reflect on the nature of the stressor you're experiencing, to manage your emotions in a way that doesn't feel like you're losing control. And in a calm and methodical way to plan how you can address those problems. And actually, this very logical intuitive style of reasoning that we take for granted as adults has not yet fully developed when you're 15 or 16 years old. And the problem solving therapy simply is it helps train and teach adolescents who are struggling with those stresses to practice those skills to master them. And in this way, to also address your mental health problem. Bindiya, who we heard from earlier, was one of the non-specialists or lay counselors who were trained to deliver the pride problem solving intervention. Bindiya had worked in adult mental health support services before joining the pride team. But this was her first experience working with adolescents. She ran one-on-one sessions with students teaching them about problem solving using a comic strip booklet and a digital game or app. The program was called POD. And she told us more about how it worked and the impact she saw it have. So basically what POD stands for is problem, options and do it yourself. So they need to identify the list of problems what they are feeling. And then in that particular thing, they have to prioritize which is that particular problem they want to work on. So when they identify this problem, the next step is option like generating multiple options to that particular problem. So the student tried to identify pros and cons for each option. Then the next step is do it. So you know, just you know thinking about okay, these are the things what I'm going to do it for myself. These are my action. And then maybe the next step is review. So that becomes you know what worked well. What were the challenges? There was one this boy who was in 11th grade. When I met him, he was pretty much into what he thought like people used to you know neglect or ignore him. That made him feel sad or you know upset why he's why his peers are doing him because he wouldn't communicate much. So that was the difficulty what he faced. And when I asked him okay, what do you think? Can you work on this problem? Is it in your control? He said yes definitely this is in my control. So he generated multiple you know options like you know a kind of role play. Like you know standing in front of mirror and like talking to the friend like okay, introducing, starting with basic high hello and then maybe you know just increasing the communication. So this definitely helped him to you know build his relationship with his peers. So you know making friends and building his own self-confident as a person we know these are the problems but we do not have that structure right. When we introduce Paul, it becomes easier for us to okay structure okay this is the problem this is these are the option and this is how I'm going to look for. So that becomes like a structured thing for an individual to use and implement throughout the life. Hmm. Just hearing her talk about how simple this was it almost feels too good to be true. It's just so simple and intuitive. You know that's the amazing thing about the work that we do is that we are not passionate about rocket science. You know we're passionate about the simple things in life that people want. It's a simple things in life that can help fix people's difficult lives that actually are the ones that we focus on and actually very many psychosocial interventions are really very intuitive. We can couch them in very complicated jargon which has been unfortunately the practice of my profession for for for decades but our effort has been really to take it out of medical jargon and make it easily accessible by really focusing on the key principles of how these interventions in fact work. What were the headline results of the study? So what we observed is a problem solving how two thirds of the adolescents who took part in our trial remit and ultimately stay well. I think that compares very well with other kinds of psychological treatments that have been tried in school settings. I myself was very surprised by the results of our trial Alicia. You know a brief intervention no more than three to five sessions each session may last anywhere from 20 to 30 minutes and we found not only effects in the short term which most psychotherapy trials do but incredibly 12 months after this very brief intervention the kids who received the intervention showed continuing improvements. In other words it wasn't just that the intervention was the effects were sustained they actually grew and what that really taught me was that these kids were now applying these new found skills in dealing with problems well after the intervention had been delivered and in doing so I believe the acquired more confidence, more self-assuredness and as they did so of course their levels of hope and optimism that are so important in the recovery process increased as well. I do wonder is it is it clear who this treatment does and doesn't work for within this age group? Well let me say first of all the problem solving doesn't work for everyone. Actually no mental health intervention works for everyone and one of the great limitations of all mental health intervention research right now is that we cannot tell what works for home. This is definitely a major research priority going forward. We have so many different options to support the recovery of young people with mood and anxiety problems but unfortunately it's a trial and error to see what works for home and unfortunately that is not good enough for many young people for whom the first intervention will not work. So So in our own trial to be quite honest, a significant proportion of young people remained symptomatic and unwell in spite of receiving the problem, solving intervention, which is why we had a stepcare approach. Those who remained unwell, we would then offer them a more intensive intervention, a more classical cognitive behavioral intervention delivered by a psychologist. Okay. But we don't actually know what words for home. I do think there are other techniques that have also been found to be very helpful for adolescents, such as, for example, behavioral activation. And I think a key priority is to start asking the question, which of these different interventions should we offer to which particular type of adolescent by type, I mean, an adolescent with very characteristics either related to their mental health problem or to other characteristics like the gender, the age, the social circumstances, and so on. Well, on the subject of behavioral activation, there is a new project taking place now, which is exploring this. The Pride Project finished in 2022, but it's now evolved into a new study called Metropolis. This is being led by a key member of your team from Pride, Dr. Daniel Michelson alongside the team at San Gath in India and other leading mental health research institutions in India and the UK. Metropolis is focusing on university age students, so 18 to 24 year olds, testing problem-solving for this age group, but also behavioral activation, another type of treatment. The aim is to work out exactly how these treatments work, who they work for, and why. Patty Gonzales is Project Director at San Gath. She leads the Youth Mental Health Group and is a co-investigator on Metropolis. She told us more about this study. For those who might not be familiar with behavioral activation, it's quite simply the idea that people can activate more positive emotional states by increasing sources of reward in their daily lives. This involves helping people to spend more time doing activities that are enjoyable, or provide a sense of achievement, connection or closeness, and such activities tend to be reduced when people feel depressed, which can lead to a vicious cycle of inactivity and low mood. Problem-solving and behavioral activation both share a focus on behavior change and they often tend to be packaged together. In fact, we did use both ingredients in Pride and in Metropolis, we really wanted to understand these ingredients as individual, as discrete interventions and study whether one holds any advantages over the other. A second major difference in Metropolis is the introduction of peer-delivered interventions. The idea is to empower university students to support each other through brief structured psychotherapies, and this builds on the successful approach of lay counsellors from Pride, but with the focus on peer-to-peer support, which can be more relatable and more accessible for young adults. A third key difference is an emphasis on a mechanistic understanding in Metropolis. So we are using a trial design that allows us to answer questions about how, why and for whom peer-delivered interventions might be effective or not. Our project is also being built using co-design methods to adapt the problem-solving and behavioral activation interventions, and we're working with a group of 20 students with lived experience to actually sort of design these materials for use in the trial. And some of our evaluation activities, which will include, for example, qualitative data collection, will involve trained youth researchers who also university students themselves. What we learned through Metropolis really has the potential to inform the next generation of personalized early interventions for students, which they are confident and feel empowered to deliver. So it feels like Metropolis is really building on the work of Pride and it's still early days, so we may not get results for that just yet. But in this case, they're going to be training peer counsellors, so other students rather than lay counsellors. What potential could this hold? In Homer's, you know, we can't train peers when you're 14, 15, 16 years old in schools, but I think it's a terrific idea to think about young adults as offering incredible human resource in college environments to be peers for others in their community. So I think it's a terrific idea. And I also think, you know, the way Patty described the comparison of problem-solving and behavioral activation is exactly the kind of new science that we need. That is to say, which is comparing different intervention strategies to ask the question not only about whether these are equivalent in effectiveness. I think they'll probably find it is. But more importantly, to certain characteristics of the individual predict that they will respond better to one or the other kind of strategy so that when someone presents with a modern anxiety problem, you are able to say, we think this approach, problem-solving, or that approach, behavioral activation is the right one for you. Patty mentioned the potential influence that Metropolis could have. What impact has Pride had so far, both nationally and internationally? So the impact that it's having is, first of all, by incorporating principles of problem-solving within the training of school counsellors in India. You know, we already have both Sangha but also other organizations. We're now incorporating this technique in the training of their counsellors. But what I'm really excited about is how this whole work has now been exported to the US. So in partnership with the Baltimore Institute out in Oregon and the Children's Hospital of Philadelphia, my lab at Harvard Medical School has been creating a digital curriculum for training school-based providers, counsellors, and so on to deliver problem-solving. What's exciting about this initiative is by using digital curricula, we're able to reach a far greater number of learners than we could as compared to the old-fashioned way of having learners come in to a university setting or a workshop and spend several days. There's also a lot cheaper because you can actually standardize the training in a entirely competency-based video learning framework. Of course, I'm not suggesting for a moment that you can learn to deliver any psychological treatment by watching a bunch of videos, but it is at least taking care of your knowledge needs. Ultimately, it's through practice and supervision that you become a master in the delivery of the treatment. So, we're currently engaged in a pilot right now as I speak in Oregon and in Texas with the first batch of school-based and community-based providers who work with adolescents with emotional problems are now going through the training and I hope to have exciting results about the impact that's had on their knowledge and their skills and hopefully then see that then becoming part of a program of actual delivery in school and college populations. What are these two projects teaching us about the potential for how mental health interventions could be delivered for young people? Well, I think the most important lesson for me from the Pride Study was that actually young people demanded and wanted mental health care completely contrary to what we often think about young people resisting mental health care. However, that demand was entirely related to the intervention being made available in school to meet them where they are and offer them support in the moment and use language and labels that were acceptable and not stigmatizing, which meant, for example, never using a mental illness or a psychiatric diagnostic label, couching all the educational component of the intervention in language that was accessible and did not create shame or fear, but was completely understandable to the adolescent. That was a very important lesson for me and I think a lot of my current work is focusing now on how these approaches can be scaled up, not just in the context of a few schools and a few hundred students in a trial, but actually made available to the literally tens of millions of adolescents in schools all around India and indeed in other countries as well. And finally, how integral are these projects in developing the field of adolescent mental health in India and globally? There's a lot of interest in adolescent and youth mental health today for all the reasons we discussed earlier. It's indefinitely is the most sensitive period of life for the emergence of mental health problems. And therefore early intervention and by early intervention, I mean interventions that are delivered as close to the onset of those problems are the ones that are likely to have the best long term impacts. Alicia, there's a lot of very, very worrying evidence emerging that show that mood and anxiety problems in adolescents when you track these adolescents into adult life, they show systematic disadvantages, for example, in terms of employment opportunities and income. So we're talking about disadvantages that are profound and lifelong. So the earlier we can enter. the better it will be in terms of those outcomes. And those interventions, as we discussed earlier, must address the needs of adolescents, their preferences, their desires. And that means delivering interventions in educational institutions at the time when young people feel they need support. - I just really love how methodical minds have come together to create such a simple and impactful way that may not necessarily solve everyone's problems, but it's a great baseline to understand where these youth are at. You're basically creating a really simple framework to just gently push people towards finding ways to combat their mental health challenges. - Well, absolutely, Alicia, just because a solution is simple, it doesn't mean it is an effective. And medicine and public health are replete with examples of simplicity that has transformed the field. And I hope very much that these brief psychosocial interventions that have been championed by people working in low resource settings around the world will offer a new way of thinking about the prevention and care of mental health problems everywhere. - Well, you know, I am so glad you're back. Maybe we'll see you again for the next series. I love having you on here and I love our conversations. Vikram, thank you so much for joining me today. - Thank you, Alicia. It's been a pleasure talking to you. (upbeat music) - Thanks for listening to When Science Fines Away. Thanks also to my guest, professor Vikram Patel, Bindiya Chadankar and Pati Gansalves. I'm really struck by what an elegant, beautiful solution to what this is. Just a few 20 minute sessions can lead to better outcomes with lasting effects for young people. Will it work for everyone? No, because nothing ever does. But if you can serve a community in a meaningful way and a cost-effective way, let's just say I hope policymakers are listening. And it's cool to see how the project is evolving professionally too. When Science Fines Away is brought to you by Welcome, a charitable foundation that supports the global scientific community working to build a healthier future for everyone. Mental Health is one of Welcome's priorities, along with infectious disease, climate and health, and discovery research. If you visit their website, welcome.org/podcast. That's Welcome with Two Ls. You'll find a whole host of information about mental health, as well as full transcripts of our episodes. It's also where you'll find the episodes about mental health from the first two seasons of the podcast, or just scroll back through the series on your podcast app and you'll find it there too. If you've been enjoying When Science Fines Away, be sure to rate and review us in your podcast app. Next time, we'll be asking how we make healthy diets sustainable. It's not just about saying we want everyone to turn vegan, okay? Just actually, by small changes, by just reducing the amount of meat and dough that are consumed, you can actually have really big effect on the overall environmental footprint of the diet. When Science Fines Away is a chalk and blade production for Welcome.