Cultural adaptation and randomised evaluation of a multi-component school- based intervention for common mental disorders in Pakistani adolescents

We are currently working with the WHO to implement school mental health in a number of countries in the Eastern Mediterranean region, including Pakistan. This large-scale programme in collaboration with Ministries of Health and Education seeks to implement evidence-based interventions for children and adolescents in school-settings. The key stakeholders, including teachers and health-care providers, have identified a large unmet need for a targeted intervention to address high levels of anxiety and depression in older adolescents. In response, the WHO after consultation with international experts, and conducting a review of available evidence, have developed a brief transdiagnostic intervention called Early Adolescence Skills for Emotions (EASE). This brief group psychological intervention is based on cognitive behavioural therapy (CBT) recognised to treat anxiety and depression in young people. The intervention is designed to be delivered by non-specialists in low resource settings.

The aim of this project is to adapt and add EASE to the ongoing school mental health programme in Pakistan to address the needs of adolescents with symptoms of depression and anxiety. Following this, we will conduct a study to see if the intervention is effective in improving symptoms of anxiety and depression in school-going adolescents aged 14-16 who receive the intervention, compared to those who don't. We will also evaluate the costs, and barriers and facilitators of integrating such an intervention into the Pakistani school system.

Depression and anxiety are the leading contributors to health burden among adolescents worldwide. These disorders are associated with increased mortality due to suicide and intentional and unintentional injuries. If untreated, these conditions severely influence children's development, their educational attainments, and their potential to live fulfilling and productive lives. However, globally the treatment gap for mental disorders in adolescence is large. To address this treatment gap, the WHO has developed a brief transdiagnostic, group psychological intervention programme based on empirically supported cognitive behavioural therapy (CBT) techniques. The programme is called Early Adolescence Skills for Emotions (EASE).

Our project has two objectives:

1) Using the MRC Framework for development and evaluation of complex interventions, we seek to understand how the WHO's EASE intervention can be made relevant, feasible and acceptable for school-going adolescents living in low socioeconomic rural settings in Pakistan.

2) Evaluate the effectiveness and cost-effectiveness of EASE using a cluster randomised controlled design. The intervention will be delivered to over 250 adolescents with symptoms of depression and anxiety in 10 schools randomised to the intervention arm, while a similar number of adolescents in 10 control schools will receive routine care and equivalent support groups. A number of questionnaires will measure outcomes at 1-week and 3-month post-intervention. Our primary outcome is psychological distress, and secondary outcomes include depression, anxiety, functioning, self-esteem and coping skills.

The research will inform the WHO's efforts to lower the global mental health treatment gap for common mental disorder in low and middle income countries and help the Pakistani school system implement and establish its school mental health programme.

The findings are likely to inform early interventions that can help prevent mental health problems in later life. The findings are also likely to advance the understanding of how complex interventions should be culturally adapted and feasibly integrated into school and health systems. Our close collaboration with several academic groups (see academic beneficiaries) working in these fields have the potential to inform integrated interventions to reduce the burden from depression and anxiety in young people globally.

Scalable integrated interventions that address adolescent mental health have great promise to improve the developmental potential, physical and mental health of the children of the Eastern Mediterranean Region. Such interventions are necessary to limit the psychosocial consequences of armed conflict and displacement faced by many children in the Eastern Mediterranean region. This is a priority of the WHO's Eastern Mediterranean Regional Office, our partner in this project.

The research findings are likely to assist the Education Department in Pakistan to improve the health of students living in poorer rural settings. The Pakistani Education Department are partners in our project, committed to scaling up school mental health interventions in the District of Rawalpindi. Our co-Investigator in Pakistan, Minhas, leads the WHO Collaborating Centre for Mental Health Research and Training in Rawalpindi, is already engaged with the Education Department to achieve this.