Background Group Support Psychotherapy (GSP) is an evidence-based, first-line treatment for mild to moderate depression among people living with HIV, though the psychosocial pathways underlying its sustained effects remain poorly understood. Methods We conducted a secondary analysis of a cluster-randomised trial in Uganda, comparing GSP to Group HIV Education among people living with HIV and mild to moderate depression. Using generalised structural equation modelling, we assessed whether changes in coping strategies and psychosocial factors mediated intervention effects on depression at 2 and 6 months. Single-mediator and sequential mediation models were used to evaluate early and sustained pathways, with indirect effects estimated using bias-corrected bootstrap confidence intervals. All analyses accounted for clustering at the therapy-group level. Results In single-mediator models, emotional expression (venting), acceptance, and spiritual coping significantly mediated reductions in depressive symptoms during the active phase of therapy and remained significant indirect pathways to six-month depression outcomes. Additional mediators, including seeking emotional support, distraction, and active coping, emerged as significant predictors of six-month outcomes. Reductions in denial and self-blame, along with increases in social support and active coping during therapy, demonstrated sustained mediation effects at six months. Sequential mediation analyses revealed stronger indirect effects for six-month outcomes compared to two-month outcomes. A significant chained pathway was observed whereby emotional support seeking during therapy led to subsequent help-seeking behaviors, which in turn mediated sustained depression reduction at six months. Conclusion The findings suggest that GSP operates through a phased recovery process in which early emotional processes initiate therapeutic change, while subsequent strengthening of adaptive coping and social connectedness consolidates longer-term recovery. Further research is needed to examine how these interacting mechanisms unfold beyond six months and to identify additional synergistic pathways that sustain durable treatment effects.
Nakimuli-Mpungu et al. (Wed,) studied this question.