Meta-analysis: The Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries

Objective Because most youth psychotherapies are developed and tested in high-income countries, relatively little is known about their effectiveness or moderators in low- and middle-income countries (LMICs). To address this gap, we conducted a meta-analysis of randomized controlled trials (RCTs) testing psychotherapies for youth with multiple psychiatric conditions in LMICs, and we tested candidate moderators. Method We searched 9 international databases for RCTs of youth psychotherapies in LMICs published through January 2021. The RCTs targeted elevated symptoms of youth anxiety (including posttraumatic stress disorder [PTSD] and obsessive-compulsive disorder), depression, conduct problems, and attention problems. Using robust variance estimation, we estimated the pooled effect sizes (Hedges g) at posttreatment and follow-up for intervention vs control conditions. Results Of 5,145 articles identified, 34 articles (with 43 treatment−control comparisons and 4,176 participants) met methodological standards and were included. The overall pooled g with winsorized outliers was 1.01 (95% CI = 0.72-1.29, p < .001) at posttreatment and 0.68 (95% CI = 0.29-1.07, p = .003) at follow-up. Interventions delivered by professional clinicians significantly outperformed those delivered by lay providers (g = 1.59 vs 0.53), but all interventions for conduct problems were delivered by professionals, and the difference for interventions targeting internalizing problems (g = 1.33 vs .53) was not significant. Interventions developed non-locally were more effective if they were not adapted to local contexts than if they were adapted locally (g = 2.31 vs 0.66), highlighting a need for further research on effective adaptations. Significant risk of bias was identified. Conclusion Overall, pooled effects of youth psychotherapies in LMICs were markedly larger than those in recent comparable non-LMIC meta-analyses, which have shown small-to-medium effects for youth psychotherapies. Findings highlight the potential benefits of youth psychotherapies in LMICs, as well as a need for more RCTs and improved study quality. Study preregistration information Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries (LMICs): A Systematic Review and Meta-Analysis of Randomized Clinical Trials; https://www.crd.york.ac.uk/PROSPERO/; CRD42021240031. Because most youth psychotherapies are developed and tested in high-income countries, relatively little is known about their effectiveness or moderators in low- and middle-income countries (LMICs). To address this gap, we conducted a meta-analysis of randomized controlled trials (RCTs) testing psychotherapies for youth with multiple psychiatric conditions in LMICs, and we tested candidate moderators. We searched 9 international databases for RCTs of youth psychotherapies in LMICs published through January 2021. The RCTs targeted elevated symptoms of youth anxiety (including posttraumatic stress disorder [PTSD] and obsessive-compulsive disorder), depression, conduct problems, and attention problems. Using robust variance estimation, we estimated the pooled effect sizes (Hedges g) at posttreatment and follow-up for intervention vs control conditions. Of 5,145 articles identified, 34 articles (with 43 treatment−control comparisons and 4,176 participants) met methodological standards and were included. The overall pooled g with winsorized outliers was 1.01 (95% CI = 0.72-1.29, p < .001) at posttreatment and 0.68 (95% CI = 0.29-1.07, p = .003) at follow-up. Interventions delivered by professional clinicians significantly outperformed those delivered by lay providers (g = 1.59 vs 0.53), but all interventions for conduct problems were delivered by professionals, and the difference for interventions targeting internalizing problems (g = 1.33 vs .53) was not significant. Interventions developed non-locally were more effective if they were not adapted to local contexts than if they were adapted locally (g = 2.31 vs 0.66), highlighting a need for further research on effective adaptations. Significant risk of bias was identified. Overall, pooled effects of youth psychotherapies in LMICs were markedly larger than those in recent comparable non-LMIC meta-analyses, which have shown small-to-medium effects for youth psychotherapies. Findings highlight the potential benefits of youth psychotherapies in LMICs, as well as a need for more RCTs and improved study quality.