Abstract
<p>Background: Adolescents in rural communities face significant geographic, cultural, and economic barriers to accessing mental health care, and depression treatments are often expensive, time-consuming, and inaccessible, leading many youth to drop out of treatment prematurely. Moreover, most evidence-based depression interventions fail to target relational difficulties, a fundamental, well-established depression risk factor in rural communities that increases susceptibility to depression and suicidal ideation. Method: This study had two aims: first, to iteratively co-design and tailor a single-session relationship competence intervention that was feasible, acceptable, and engaging for at-risk rural youth with elevated depressive symptoms using a human-centered design approach (n = 7; 85.7% Black; 57.1% Female); second, to test whether the resulting SSI improved relationship and communication knowledge, perceived change, and relationship learning, and reduced depressive symptoms at 3-month follow-up, using a randomized controlled trial (n = 440; 50.2% White; 31.4% Women). Results: Youth randomized to the SSI exhibited significantly lower depressive symptoms at follow-up than youth in the control condition, though both groups improved significantly overall. All participants reported similar gains in secondary outcomes (e.g., interpersonal skills) and rated the program as highly acceptable. Discussion: A relationship-focused SSI may offer a brief, scalable approach to improving depressive symptoms in rural adolescents over time by targeting relational difficulties as a modifiable risk factor. Recruitment challenges, including extensive exclusions for suspected fraudulent or bot-generated responses, limited the eligible rural sample size and constrain generalizability; future work should explore recruitment strategies embedded within trusted community settings.</p>