Adolescents' Resilience and Treatment nEeds for Mental health in Indian Slums (ARTEMIS)

The project will implement a mobile-technology enabled mental health services delivery model for adolescents living in slums in two Indian cities - Delhi and Hyderabad. It will be for 36 months. As part of the intervention we will train primary care health workers and doctors to screen, diagnose, and treat adolescents suffering from depression and increased suicide risk. Primary health care workers will use a questionnaire on depression, based on a tablet-device to screen the adolescents and those who score above a cut-off score will be referred to the primary care doctor, who will in turn use a standard diagnosis and treatment algorithm to treat patients who reach the primary health centre. Anyone with more serious condition will be referred to a mental health professional. Stress and depression as a result of intimate partner violence or domestic violence (which is high in urban slums)will also be specifically inquired and managed by primary care workers. There will also be a mental health awareness campaign in the community to increase knowledge about metal health and the reduce stigma.

Forty wards/blocks (including only urban slums) from both cities will receive the proposed intervention or receive care as usual. We hope that the intervention will lead to significant improvements in community behaviours among adolescent towards mental disorders, and lead to significantly lower depression and suicide risk among adolescents. We will also study the impact of different components of the project which were delivered, and understand if the costs of doing such an intervention was beneficial to the society. If the project is found to be beneficial and not too expensive to deliver, it could be conducted in other regions of India and integrated into government led programmes. It also could have learning lessons for other countries having similar economies and health care infrastructure as India.

The proposed trial will be a hybrid effectiveness-implementation cluster randomised trial with wards/blocks (only urban slums will be included) being the unit of allocation.

The trial will implement a mobile-technology enabled mental health services delivery model for adolescents living in slums in two Indian cities - New Delhi and Hyderabad. Duration of the trial will be for 36 months. It will train primary healthcare workers and doctors to screen, diagnose, and manage adolescents suffering from depression and increased suicide risk, and also inquire and manage those identified at high risk of intimate partner violence leading to stress/depression. Besides task sharing, the complex intervention will also include an anti-stigma campaign. We hypothesise that: (1) a community-based anti-stigma campaign will lead to significant improvements in community's behaviours toward adolescents with mental disorders; (2) a mobile device-based decision support system for primary health care staff will significantly lower depression and suicide risk in adolescents.

Forty wards (only slums will be included) will be randomized to intervention or control group and we aim to recruit 2560 adolescents into the study, in total. Standardized tools will be used to screen for depression and suicide risk and management will be done using evidence-based WHO guidelines. The primary outcomes will be assessed at the end of 12 months of intervention. Process evaluation will be done throughout the intervention, but the detailed evaluation will follow the intervention. Economic evaluation will use statistical modelling to ascertain cost-effectiveness.

If successful, the trial could be scaled up across other areas of India or even other low and middle income countries with the help of the government and other key stakeholders.

The project will impact in the following ways.

Academic and research impact
1. Early and mid-career researchers involved in the project - They will be trained in research methods, paper writing skills, networking skills, and grant writing skills. They will learn both through their interaction with senior researchers and any additional training courses. ARTEMIS data can be used to do masters and doctoral training, both in India and United Kingdom.
2. Non-academic research staff - Field staff will be trained in data collection and research techniques that will not only help in building their ability to do this project, but will add to their skills which can be used in future opportunities.
3. Health workers and doctors - They will be trained in evidence-based care practices to manage some of the commonest mental health conditions affecting adolescents in a community - stress, depression and suicide risk. This training should help them to also perform any future duties as part of the National Mental Health Programme which is being rolled out across the country, by the government.
4. Developing collaborations with researchers - ARTEMIS will actively seek collaborations with other researchers - globally and nationally - to develop future projects.
5. Engaging with policy makers - ARTEMIS has inbuilt mechanisms within the study design to actively engage with policy makers and involve them in decision making. Additionally, the researchers will liaise with policy makers such as the National Health Systems Resource Centre, Government of India. PI Maulik in on the National Taskforce for Integrating Mental Health in Primary Care and will use the learnings from ARTEMIS to inform that policy document in future. Other opportunities will also be explored to engage with policy makers both at national and regional levels through meetings, policy briefs, and any workshops organized by the policy makers. The interventions, if successful, will have implications for the Rashtriya Kishore Swasthya Karyakram (RKSK) program of the Government of India which has a specific focus on adolescent health and health services delivery including mental health. Even the process documents and tools will be of value and could be adapted as per need by RKSK or other agencies. Additionally, WHO could use the lessons learned from this intervention and inform other partners in their network.

Economic and societal impact
1. Direct impact of collaborative research between India and UK - ARTEMIS builds on existing partnerships between the applicants from India and UK, and will identify opportunities for engaging with other researchers in future. These research partnerships could benefit both India and UK - socially by improving the lives of people in India with lessons for UK citizens (especially South Asians), and economically by generating revenue for both countries.
2. Direct impact on the lives of individuals - The project will directly affect the lives of adolescents with mental disorders and should lead to improvement in their mental health status and affect their productivity- both academic and work related. This should lead to better economic development of the community. We also believe that the knowledge gained by the health workers will help them to identify symptoms suggestive of stress and depression affecting them and seek appropriate care.
3. The mental health awareness campaign - ARTEMIS should lead adolescents to discuss mental health issues in a more non-stigmatizing way and seek care, when needed. They could use their network to inform other adolescents and develop campaigns using social media. We would identify 'champions' amongst adolescents both as individuals who form part of the expert advisory group, and also in the community. These 'champions' will talk about adolescent mental health in their immediate community, speak about the same in conferences and meetings, and act as spokesperson for adolescents.