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IntroductionEmotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents.Method and analysisA two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver–adolescent relationship and caregivers’ well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings.EthicsEthics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan.DisseminationThe findings of the study will be disseminated by WHO and through peer-reviewed publications.Trial registration numberISRCTN17755448.

Background Ninety percent of children with mental health problems live in low or middle-income countries (LMICs). School-based programs offer opportunities for early identification and intervention, however implementation requires cross-sector collaboration to assure sustainable delivery of quality training, ongoing supervision, and outcomes monitoring at scale. In Pakistan, 35% of school-aged children are reported to have emotional and behavioral problems. As in many other LMICs, the government agencies who must work together to mount school-based programs have limited resources and a limited history of collaboration. The “Theory of Change” (ToC) process offers a way for new partners to efficiently develop mutual goals and long-term prospects for sustainable collaboration. Objective Develop a model for scale-up of school based mental health services in public schools of Pakistan. Methods We used ToC workshops to develop an empirically supported, ‘hypothesized pathway’ for the implementation of WHO’s School Mental Health Program in the public schools of rural Pakistan. Three workshops included 90 stakeholders such as policy makers from education and health departments, mental health specialists, researchers, head teachers, teachers and other community stakeholders including non-governmental organizations. Results The ToC process linked implementers, organizations, providers and consumers of school mental health services to develop common goals and relate them (improved child socioemotional wellbeing, grades and participation in activities) to interventions (training, monitoring and supervision of teachers; collaboration with parents, teachers and primary health care facilities and schools). Key testable assumptions developed in the process included buy-in from health care providers, education officials and professionals, community-based organizations and families. For example, teachers needed skills for managing children’s problems, but their motivation might come from seeking improved school performance and working conditions. Poverty, stigma and lack of child mental health literacy among teachers, administration, and parents were identified as key hypothesized barriers. Children and their families were identified as key stakeholders to make such a program successful. Discussion ToC workshops assisted in team building and served as a stakeholders’ engagement tool. They helped to develop and support testable hypotheses about the structures, collaborations, and knowledge most important to scaling-up school based mental health services in Pakistan.

Background Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization’s Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan. Methods A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors. Results The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions. Conclusions The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

Objective: To determine role of primary care physicians, in management of MH disorders at primary health care level, by assessing the proportion of cases they manage or refer and to identify the barriers effecting the management of common mental health disorders through primary care physicians working in Rawalpindi area. Study Design: Cross sectional study. Place and Duration of Study: Private and Public sector health facilities in Rawalpindi district for a duration of 6 months, from July to Dec 2016. Material and Methods: Data was collected from respondents, selected through convenient sampling, using a pretested structured questionnaire. Results: Of 114 (75.7%) of primary care physicians were found to have a negative attitude towards mental disorders and their management at primary care setups while 117 (78%) showed a positive attitude. Primary care physicians in aggregate had good knowledge of common mental disorders however participants’ knowledge about medicines used in management of mental disorders was below median value. Conclusion: The study provides evidence about knowledge and attitude of primary care physicians, working in Rawalpindi regarding mental disorders and their management primary care level. Moreover, it identifies major barriers in the system, through primary care physicians, which need to be addressed for successful integration of mental health into primary care.

Background Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan. Methods In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters. Results At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes. Conclusions In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention. Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894

AimsEarly interventions are recommended in adolescents to prevent long-term psychiatric morbidity. However, in Low and Middle Income Countries (LMICs), where there are no child and adolescent mental health services, early identification of adolescents at-risk of mental health problems remains a challenge. Pediatric Symptoms Checklist (PSC) is used in preventive child healthcare services in a number of high income countries for early identification of children and adolescents in need of mental health services. The aim of this study was to assess the reliability and validity of self-rated, Urdu version of PSC to identify at-risk adolescents studying in the public schools of rural Rawalpindi in Pakistan.MethodWe did a cross-sectional epidemiological survey with all adolescents aged 13–15 years, studying in 41 public schools of Kallar Syedan sub-district in Rawalpindi, Pakistan. An adapted Urdu version of self-reported PSC was used to assess the psychosocial distress in adolescents in-terms of externalizing, internalizing and attention problems. Strengths and Difficulties Questionnaire (SDQ) was used as a gold standard measure. Youth version of PSC and SDQ were administered in classroom settings by trained research teams.ResultThe data were collected from 5856 adolescents (response rate 97%) between April-May, 2019. The mean age of the participants was 14.37 years (±1.06); 51% participants were female. The internal consistency reliability of Urdu version of PSC was good (Cronbach alpha 0.85). At the standard cut-off score of PSC ≥28, the prevalence rate of psychosocial distress in adolescents was 25.5% (27.4% in boys & 23.6% in girls). Using the SDQ total difficulties score ≥16 as a standard criterion; the area under the ROC curve was 0.85 (95% CI 0.82–0.88), with a sensitivity of 57.64% and specificity of 89.10% of PSC. If the sensitivity and specificity of PSC is optimized to 76% at the cut-off score of PSC ≥ 24, the prevalence rates of psychosocial distress in adolescents is increased to 41%.ConclusionIn our study, 1 in 4 adolescents in public schools of rural Rawalpindi in Pakistan have been identified at-risk of poor socio-emotional development. Urdu version of PSC is a reliable and valid tool to identify adolescents in need of psychosocial interventions in public schools of rural Pakistan. While the standard cut-off score yields a better specificity; PSC with relatively lower cutoff score can be used a screening tool to identify at-risk adolescents in public schools of rural Pakistan.

Background In many low resource settings, the provision of government mental health care services is limited to specialized psychiatry units in urban hospital care facilities, where the most common treatment for common mental disorders (CMDs) is pharmacotherapy, occasionally with adjunct nonspecific psychological support. We aimed to evaluate the effectiveness of adding a low intensity, psychological intervention, Problem Management Plus (PM+) for CMDs into routine care in a specialized mental health care facility in Pakistan. Methods A two arm, single-blind individual randomized controlled trial (RCT) was carried out with adults (N = 192), referred for psychological support by psychiatrists. The study participants were randomized (1:1) to PM + plus Treatment as Usual (TAU) (n = 96) or TAU only (n = 96). The primary outcomes were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) and functional impairment as measured by WHO Disability Assessment Schedule (WHODAS 2.0) at 20 weeks after baseline. Results The analysis was done on intention-to-treat principle. The linear mixed model analysis showed that at 20 weeks after baseline, there was a significant reduction in symptoms of anxiety and depression (mean [SD], 16.23 [8.81] vs 19.79 [7.77]; AMD, − 3.10; 95% CI, − 0.26 to − 5.76); p  = 0.03 and improvement in functioning (mean [SD], 22.94 [9.37] vs 27.37 [8.36]; AMD, − 4.35; 95% CI, − 1.45 to − 7.24); p  = 0.004 in PM + plus TAU versus TAU arm. The follow-up rate was 67% at primary end-point. Conclusions Specialized care facilities in LMICs may consider adding brief, evidence-based psychological treatments for CMDs to their routine care. Trial Registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered March 23, 2016. Retrospectively registered, https://www.anzctr.org.au/Default.aspx/ ACTRN12616000381482

Terrorism is often construed as a well-thought-out, extreme form of violence to perceived injustices. The after effects of terrorism are usually reported without understanding the underlying psychological and social determinants of the terrorist act. Since ‘9/11’ Pakistan has been at the epicentre of both terrorism and the war against it. This special paper helps to explain the psychosocial perspective of terrorism in Pakistan that leads to violent radicalisation. It identifies the terrorist acts in the background of Pakistan's history, current geopolitical and social scenario. The findings may also act as a guide on addressing this core issue.

Background The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, psychological intervention program delivered by trained non-specialist that addresses common mental disorders. The objectives of this study are to evaluate effectiveness and cost-effectiveness of PM+ in a specialized mental health care facility in Pakistan. Methods A single blind individual randomized controlled trial (RCT) will be carried out in the outpatient department of a specialized mental healthcare facility in Rawalpindi, Pakistan. After informed consent, patients with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ plus treatment as usual (n = 96) or TAU only (n = 96). The primary outcome is the psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale and improvement in functioning as measured by WHODAS at 20 weeks after baseline. Secondary outcomes include improvement in symptoms of depression, post-traumatic stress disorder, levels of social support and cost effectiveness evaluation. Qualitative interviews will be conducted to evaluate the process of implementing PM+ including barriers and facilitators in implementation and possibility of integration of PM+ program in specialized mental health care facilities in Pakistan. Discussion The results of this study will be helpful in evaluating the effectiveness of the approach of training non specialists, based in the specialized mental health care facilities in delivering evidence based psychological interventions in the low resource settings. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered Retrospectively on March 23, 2016

[This corrects the article DOI: 10.1186/s13033-017-0147-1.].