Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya

BMC Psychiatry. 2019 Dec 28;19(1):424. doi: 10.1186/s12888-019-2395-x.


Background: Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods/design: We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up.

Discussion: The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability.

Trial registration: NCT03466346, registered March 15, 2018.

Keywords: Depression; Fluoxetine; Implementation science; Interpersonal psychotherapy (IPT); Multiple assignment randomized trial; Post-traumatic stress disorder (PTSD); Primary care; SSRI; Sequential; Sub-Saharan Africa; Trauma.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Ambulatory Care / methods
  • Ambulatory Care / trends
  • Ambulatory Care Facilities / trends
  • Antidepressive Agents, Second-Generation / administration & dosage*
  • Combined Modality Therapy / methods
  • Combined Modality Therapy / trends
  • Delivery of Health Care, Integrated / methods
  • Delivery of Health Care, Integrated / trends
  • Depressive Disorder, Major / epidemiology
  • Depressive Disorder, Major / psychology
  • Depressive Disorder, Major / therapy*
  • Female
  • Fluoxetine / administration & dosage*
  • Hospitals, County / trends
  • Humans
  • Kenya / epidemiology
  • Male
  • Mental Health Services* / trends
  • Psychotherapy / methods*
  • Public Sector / trends
  • Stress Disorders, Post-Traumatic / epidemiology
  • Stress Disorders, Post-Traumatic / psychology
  • Stress Disorders, Post-Traumatic / therapy*
  • Treatment Outcome


  • Antidepressive Agents, Second-Generation
  • Fluoxetine

Associated data