Digital delivery of Behavioural Activation to overcome depression and facilitate social and economic transitions of adolescents in LMICs

Depression is the leading cause of disability worldwide, with the incidence of depression peaking during adolescence. Depression affects cognitive functioning, interpersonal relationships, interferes with schooling, and disrupts work and productivity. Untreated depression can have serious consequences, as it is associated with more than 90% of all cases of suicide, which has recently been recognized as the second largest and fastest growing cause of unnatural deaths among young people in South Africa (SADAG, 2014). These impairments have a greater impact on adolescents in low- and middle-income countries due to the additional adversities they face and the lack of available, effective treatments.


This three year project will focus on developing an intervention in an understudied group, adolescents with depression in low-resource settings. Relying on digital technology and aligning this with the evolving community-oriented primary care system, we will use low-end smartphones to adapt and deliver a tailored psychological therapy, Behavioural Activation (BA), among adolescents (15 to 19 years old) living in rural South Africa.


In the first project phase (Jul 2019 – Dec 2020), we will conduct interviews and focus group discussions with adolescents, caregivers, community and education stakeholders to develop a culturally relevant and age appropriate app-based intervention. The functionality, acceptability and usability of the app will be refined through an iterative process with adolescents.

In the following phase (Jan-Dec 2021), we will conduct a pilot randomized controlled trial of adolescents (n=200) to test the effectiveness of this platform in reducing depression (primary outcome), and possible mechanisms, principally executive function and social cognition. As secondary outcomes, we will assess anxiety, risk-taking behaviours and a range of economic and decision-making measures. Further, the proposed work will produce relevant measures of executive functions and social cognition through language translation and cultural adaptation and evaluate their reliability and validity in a rural context.


The team comprises a multidisciplinary group of psychologists, psychiatrists, neuroscientists and economists from South Africa, as well as from the UK and the USA. The study will be nested within the Agincourt Health and Demographic Surveillance (HDSS) site in MRC/Wits Rural Public Health and Health Transitions Unit (Mpumalanga province). Formative work will also take place in the Dikgale HDSS (Limpopo province).


If the pilot study produces promising results it will inform the development of a fully powered definitive trial which we believe could support better management of depression among adolescents living in low-resource settings, and would align effectively with efforts by the South Africa’s Department of Health to strengthen primary care and community-based health care systems.


Kathleen Kahn (South Africa PI); Professor and Senior Scientist, MRC/Wits Rural Public Health and Heath Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand.

Alan Stein (United Kingdom PI); Professor and Head of Section, Child and Adolescent Psychiatry, University of Oxford.

Sarah-Jayne Blakemore; Chair in Psychology, University of Cambridge.

Michelle Craske; Professor of Psychology, University of California, Los Angeles.

Alastair van Heerden; Associate Professor, University of the Witwatersrand.

Emma Kilford; Postdoctoral Researcher, University College London.

Crick Lund; Professor in the Alan 

J. Flisher Centre for Public Mental Health, University of Cape Town.

Heather O’Mahen; Associate Professor in Perinatal Clinical Psychology, University of Exeter.

Mahreen Mahmud; Postdoctoral Research Fellow, Centre for Studies 

of African Economies, University of Oxford.

Sumaya Mall; Senior Lecturer, University of the Witwatersrand.

Kate Orkin; Senior Research Fellow

 in Behavioural Economics, Centre for Studies of African Economies, University of Oxford

Julia Ruiz Pozuelo; DPhil student in Psychiatry, Research Assistant in t

he Centre for Studies of African Economies, University of Oxford.

Tholene Sodi; Professor and Head of Department of Psychology, University of Limpopo

Stephen Tollman; Research Professor and Director, MRC/Wits Rural Public Health and Heath Transitions Research Unit

 (Agincourt), School of Public Health, University of the Witwatersrand.

Imraan Valodia; Professor and Dean, Faculty of Commerce, Law & Management, University of the Witwatersrand.

Bianca Moffett; Project Manager DoBAT Study, MRC/Wits Rural Public Health and Heath Transitions Research Unit (Agincourt)