Safeguarding adolescent mental health in India: a co-designed feasibility study of a systems intervention targeting youth anxiety and depression.

Good mental health is essential to one's enjoyment of life, ability to have relationships and capacity for work. Mental health conditions like anxiety and depression are common, and evidence shows that these often start during the teenage years and continue into adulthood. India has the largest number of adolescents in the world (243 million) and many experience poor mental health. It is estimated that 9.8 million Indian 13-17 year olds have a diagnosable mental health condition, often anxiety and depression. There is widespread concern in India about the mental health of young people as suicide is the leading cause of death among adolescents. Young people in India who attend school are at even greater risk of poor mental health as Indian school culture places extreme pressure on young people and there widespread use of corporal punishment. Young people report that these have serious effects on their mental health. There is also little understanding of mental health in families or school communities and there is no school mental health programme in India, even though evidence shows that these can protect and improve mental health. There is an urgent need to find solutions to improve the mental health culture of Indian schools in order to safeguard the mental health of Indian young people.

Our project, called SAMA (meaning equal in Sanskrit) aims to develop and test school-based interventions to provide Indian adolescents with information and strategies to take care of their mental health and to improve school cultures to support well-being. We know that interventions are most effective when they are designed by the people who will be involved or affected by them. Therefore, in Year 1 of SAMA, we will co-design interventions with young people, parents, teachers, school leaders, mental health professional, policy makers and representatives from Indian health and education departments. We will build on international evidence and interventions where available. We plan to have four interventions that (1) help young people understand and manage their own mental health, especially anxiety and depression; (2) help teachers reduce their use of corporal punishment and improve their understanding of adolescent mental health; (3) improve the school climate for mental health and reduce mental health stigma; and (4) improve parents' understanding of adolescent mental health to support their young person. We will develop plans to implement and evaluate these interventions, with close attention to training people who deliver them and how to prepare an intervention's 'soft landing' in school to increase chances of success. In Year 2, we will recruit eight secondary schools in Bangalore. We will test how feasible and acceptable the interventions are when delivered together in these schools and identify the cost implications. In Year 3, we will work with the communities to learn about what we need to do to improve interventions so that we can build towards a trial to determine if the interventions are effective. SAMA will also learn how to increase the use of evidence on school mental health programmes in Indian health policy.

Throughout SAMA, listening to young people will be central. As well as being involved in the design and evaluation of interventions, other young people will be on our Youth Advisory Panel and still others will be involved in community filmmaking. Films will give outsiders an insider view into adolescent mental health and school in India. They will be used, along social media and community events, to raise awareness and campaign for better mental health care within Indian schools. Our UK-India partnership includes the National Institute of Mental Health and Neuroscience (Bangalore), Sangath (NGO in Goa), Mahatma Gandhi Institute (Puducherry) and the Universities of Leeds, Bradford, Birmingham and Oxford. SAMA will strengthen research capacity for school mental health research in low-and-middle income countries.

Anxiety and depression in Indian adolescents are common and youth suicides outnumber AIDS-related and maternal deaths combined. Indian secondary schools, which is often harsh and punitive, can present serious risk factors to adolescent mental health. In principle, schools can be mental health promoting for all young people, and for symptomatic young people, early intervention in the form of low-intensity psychoeducation or self-help can prevent escalation of symptoms to levels of clinical disorder. However, India is without a universal school-based mental health approach. Our 36 month project will co-design and feasibility / acceptability test four interventions to run in parallel in 8 schools (3 to waitlist) with the primary aim of reducing the prevalence of adolescent anxiety and depression. Co-design/co-adaptation will build on evidence and resources where available and LMIC relevant, and span content, implementation and evaluation protocols. Interventions will be target evidence-based individual and contextual risk and protective factors for adolescent mental health. Intervention for young people will be a universal (as recommended by previous reviewers), transdiagnostic, psychologically informed mental health curriculum approach. Interventions for parents and teachers will be MHL, and for teachers also training in positive behaviour practices. School climate will be targeted to reduce stigmatising attitudes and improve community MHL. We will target the wider community and sector with MHL campaigning. Based on rules for progression to trial (centering on trial recruitment, protocol adherence and outcome data), we will determine intervention feasibility and acceptability, and (via process measures) what is needed to optimise the intervention. We will generate cost-estimates, identify pathways to increase policy action on the evidence, promote the visibility of young people, and strengthen mental health research capacity in India and the UK.

Young people in India are the key beneficiaries of this project. Those who participate in our co-design and film-making components will benefit from mental health information, promoting youth voice, new experiences and skills, and community action. Young people in our study schools will benefit from our delivery of multiple interventions there. From intervention 1 (WP1), a curriculum based mental health program, we anticipate improvements in young people's mental health and quality of life. Longer-term impacts could include prevention of new cases of anxiety and depression disorder. However, it is not enough to improve young people's mental health understanding and coping strategies without also addressing the mental health risks in the wider contexts in which young people are living their lives. Therefore, intervention 2 (WP2), a teacher training intervention, is expected to improve teacher mental health literacy and reduce the extent of corporal punishment in Indian schools. This is likely to be a significant improvement to school experience, mental health and safety for young people. Improved school climate and reduced mental health stigma is an aim of intervention 3 (WP3). This will benefit Indian young people via greater agency and involvement in school community change and by anticipated improvements in the care climate of school towards mental health needs, including reduced stigma. Intervention 4 (WP4) aims to improve the mental health literacy of Indian parents in order to improve their awareness and support of their young person's mental health. If intervention feasibility and acceptability is established and progression to an effectiveness trial is supported, these anticipated benefits will be accessible to more young people in India, in other low- and middle-income countries, and in high income countries. There is also potential for Indian young people to benefit from improved policy attention to young people and school mental health which SAMA will seek via WP6.

Indian teachers and schools are likely to benefit from co-design participation enabling them to shape interventions to meet their needs, preference and contexts. This is important given embedded cultural practices around Indian schooling. They can also benefit from participating in interventions 2 and 3. WP2 and 3 will help teachers and schools understand adolescent mental health better, enable them to use positive discipline practices over harsh ones, and to use evidence-based strategies to improve school climate to support adolescent well-being. Indian parents are also likely to benefit from co-design (e.g. meeting other parents, improved understanding of mental health influencing action) and from WP4 intervention to enhance their ability to support adolescent mental health at home.

Policy makers and health and education sector stakeholders (both in our target state of Karnataka and beyond) can benefit from new evidence on ways to tackle the burden of poor mental health in India and from greater insight into community needs and preferences for young people, schools and families for intervention.

Indian and global researchers and mental health professionals can also benefit from the data that SAMA will generate including, for example, new evidence on adolescent mental health, teacher / parent mental health literacy, and public (school) mental health interventions, newly validated mental health measures and developed theory, as well as training for capacity building in implementation research and filmmaking for community participatory projects. Projects in the UK and other LMICs that are designing and testing school based mental health will be able to learn from our study findings.