A Systematic Review and Lived Experience Synthesis of Self-disclosure as an Active Ingredient in Interventions for Adolescents and Young Adults with Anxiety and Depression.

Self-disclosure, referring to the ability to communicate and share intimate personal feelings, has strong face validity for many young people as a way of improving anxiety and depression outcomes. The current review aimed to generate the first comprehensive evidence synthesis of self-disclosure interventions involving young people aged 14-24 years who are either disclosers or recipients of personal information about living with anxiety and/or depression. A systematic review of quantitative and qualitative data was combined with new insights from an adolescents and young adults lived-experience panel (n = 7) with the intention to combine rigorous systematic review methods and experiential knowledge. Six studies of variable quality were included in this review, five were quantitative and one was qualitative. Findings suggest that self-disclosure may be effective at reducing symptoms for adolescents and young adults with established depression; effects were not apparent when delivered as early prevention. No evidence for impacts on anxiety was found. The potential for negative effects like bullying or harassment was identified. Findings were limited by a small number of studies; low representation of peer-reviewed studies from low-or middle-income countries; and varied interventions in terms of format, participants' context, and nature of delivery. Self-disclosure may be of value in the context of interventions intended explicitly to reduce depression for those already showing symptoms. Delivery by non-specialists (such as peers and teachers) in addition to mental health professionals can help build capacity in community health systems. Self-disclosure may also be helpful at reducing stigma and stimulating help-seeking at earlier stages of mental health problems.

Pilot randomised controlled trial of a remotely delivered online intervention for adolescent mental health problems in India: lessons learned about low acceptability and feasibility during the COVID-19 pandemic.

BACKGROUND: 'POD Adventures' is a gamified problem-solving intervention delivered via smartphone app, and supported by non-specialist counsellors for a target population of secondary school students in India during the COVID-19 pandemic. AIMS: To evaluate the feasibility and acceptability of undertaking a randomised controlled trial of POD Adventures when delivered online with telephone support from counsellors. METHOD: We conducted a parallel, two-arm, individually randomised pilot-controlled trial with 11 secondary schools in Goa, India. Participants received either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes were assessed at two timepoints: baseline and 6 weeks post-randomisation. RESULTS: Seventy-nine classroom sensitisation sessions reaching a total of 1575 students were conducted. Ninety-two self-initiated study referrals (5.8%) were received, but only 11 participants enrolled in the study. No intervention arm participants completed the intervention. Outcomes at 6 weeks were not available for intervention arm participants (n = 5), and only four control arm participants completed outcomes. No qualitative interviews or participant satisfaction measures were completed because participants could not be reached by the study team. CONCLUSIONS: Despite modifications to address barriers arising from COVID-19 restrictions, online delivery was not feasible in the study context. Low recruitment and missing feasibility and acceptability data make it difficult to draw conclusions about intervention engagement and indicative clinical outcomes. Prior findings showing high uptake, adherence and engagement with POD Adventures when delivered in a school-based context suggest that an online study and delivery posed the biggest barriers to study participation and engagement.

A Guided Internet-Based Problem-Solving Intervention Delivered Through Smartphones for Secondary School Pupils During the COVID-19 Pandemic in India: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: "POD Adventures" is a gamified mental health intervention delivered via a smartphone app and supported by counsellors for a target population of secondary school students in India. This paper describes the protocol for a pilot randomized controlled trial of a remotely delivered version of the intervention in the context of COVID-19 restrictions. OBJECTIVE: Our objectives are to assess the feasibility of research procedures and intervention delivery and to generate preliminary estimates of the effectiveness of the intervention to inform the sample size calculation of a full-scale trial. METHODS: We will conduct a parallel, 2-arm, individually randomized pilot controlled trial in 11 secondary schools in Goa, India. This pilot trial aims to recruit 70 participants with a felt need for psychological support. Participants will receive either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes will be assessed at two timepoints: baseline and 6 weeks post randomization. RESULTS: The first participant was enrolled on January 28, 2021, and 6-week assessment completed on April 4, 2021. Owing to a second wave of the COVID-19 pandemic in India, schools in Goa were closed on April 22, 2021. Trial participants are currently receiving the intervention or completing follow-up assessments. CONCLUSIONS: This pilot trial will help understand the feasibility of implementing and evaluating a remotely delivered digital mental health intervention in a low-resource setting. Our findings will be used to design future trials that can address difficulties of accessing psychosocial support in-person and support wider efforts to scale up evidence-based mental health interventions for young people. TRIAL REGISTRATION: ClinicalTrials.gov NCT04672486; https://clinicaltrials.gov/ct2/show/NCT04672486. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30339.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health.

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

App-based guided problem-solving intervention for adolescent mental health: a pilot cohort study in Indian schools.

BACKGROUND: This paper describes the pilot evaluation of 'POD Adventures', a lay counsellor-guided problem-solving intervention delivered via a smartphone app in Indian secondary schools. OBJECTIVE: To test the feasibility and acceptability of POD Adventures for adolescents with a felt need for psychological support, and to explore the intervention's effects on self-reported mental health symptoms, prioritised problems, stress and well-being. METHODS: We used a mixed-methods pre-post cohort design. Participants were self-referred from grades 9-12 in two coeducational government-aided secondary schools in Goa, India. The intervention was delivered in two formats, 'mixed' (comprising individual and small group sessions) and 'group' (small group sessions only). FINDINGS: 248 participants enrolled in the study and 230 (92.7%) completed the intervention. Outcomes at 4 weeks showed significant improvements on all measures that were maintained at 12 weeks. Large effects were observed on problem severity scores (4 weeks, d=1.47; 12 weeks, d=1.53) while small to moderate effects were seen on mental health symptoms, stress and well-being. 22 students completed qualitative interviews about their experience of the intervention. Participants found POD Adventures easy to use, engaging and helpful in solving their problems. They were satisfied with the guidance provided by the counsellor irrespective of delivery format. CONCLUSIONS: POD Adventures was feasible to deliver with guidance from lay counsellors in Indian schools, acceptable to participants and associated with large improvements in problem severity and mental health symptom severity. CLINICAL IMPLICATIONS: POD Adventures has promise as an early intervention for adolescents with a felt need for psychological support in low-resource settings.

Suicide prevention: Putting the person at the center.

In September's Editorial, Vikram Patel and Pattie Gonsalves discuss suicide prevention, the focus of World Mental Health Day, 2019.

Design and Development of the "POD Adventures" Smartphone Game: A Blended Problem-Solving Intervention for Adolescent Mental Health in India.

Introduction: Digital technology platforms offer unparalleled opportunities to reach vulnerable adolescents at scale and overcome many barriers that exist around conventional service provision. This paper describes the design and development of POD Adventures, a blended problem-solving game-based intervention for adolescents with or at risk of anxiety, depression and conduct difficulties in India. This intervention was developed as part of the PRemIum for ADolEscents (PRIDE) research programme, which aims to establish a suite of transdiagnostic psychological interventions organized around a stepped care system in Indian secondary schools. Methods and Materials: Intervention development followed a person-centered approach consisting of four iterative activities: (i) review of recent context-specific evidence on mental health needs and preferences for the target population of school-going Indian adolescents, including a multiple stakeholder analysis of school counseling priorities and pilot studies of a brief problem-solving intervention; (ii) new focus group discussions with N = 46 student participants and N = 8 service providers; (iii) co-design workshops with N = 22 student participants and N = 8 service providers; and (iv) user-testing with N = 50 student participants. Participants were aged 12-17 years and recruited from local schools in New Delhi and Goa, including a subgroup with self-identified mental health needs (N = 6). Results: Formative data from existing primary sources, new focus groups and co-design workshops supported a blended format for delivering a brief problem-solving intervention, with counselors supporting use of a game-based app on "offline" smartphones. User-testing with prototypes identified a need for simplification of language, use of concrete examples of concepts and practice elements to enhance engagement. There were also indications that participants most valued relatability and interactivity within real-world stories with judicious support from an in-app guide. The final prototype comprised a set of interactive and gamified vignettes and a structured set of problem-solving questions to consolidate and generalize learning while encouraging real-world application. Discussion: Findings shaped the design of POD Adventures and its delivery as an open-access blended intervention for secondary school students with a felt need for psychological support, consistent with an early intervention paradigm. A randomized controlled trial is planned to evaluate processes and impacts of POD Adventures when delivered for help-seeking students in low-resource school settings.

What are young Indians saying about mental health? A content analysis of blogs on the It's Ok To Talk website.

OBJECTIVES: This study used thematic content analysis to examine submissions to a youth mental health website, www.itsoktotalk.in, in India. SETTING: We considered submissions made to the It's OK to Talk web platform during the first year of its operation (April 2017-March 2018), focusing specifically on website users based in India. PARTICIPANTS: We analysed 37 submissions by 33 authors aged 19-31 years (mean age 22 years) from seven Indian cities (New Delhi, Lucknow, Bengaluru, Mumbai, Pune, Hyderabad and Haryana). Eligible submissions were English-language first-person accounts of self-identified mental health problems, submitted in any media format for online publication by authors aged 18 years or older and who were based in India. Eight study participants were additionally involved in a focus group who contributed to the coding process and preparation of the final manuscript. RESULTS: Four themes were identified: (1) living through difficulties; (2) mental health in context; (3) managing one's mental health and (4) breaking stigma and sharing hope. Overall, the participants expressed significant feelings of distress and hopelessness as a result of their mental health problems; many described the context of their difficulties as resulting from personal histories or wider societal factors; a general lack of understanding about mental health; and widespread stigma and other negative attitudes. Most participants expressed a desire to overcome mental health prejudice and discrimination. CONCLUSIONS: Personal narratives offer a window into young people's self-identified priorities and challenges related to mental health problems and recovery. Such insights can inform antistigma initiatives and other public awareness activities around youth mental health.

Digital Innovations for Global Mental Health: Opportunities for Data Science, Task Sharing, and Early Intervention.

PURPOSE: Globally, individuals living with mental disorders are more likely to have access to a mobile phone than mental health care. In this commentary, we highlight opportunities for expanding access to and use of digital technologies to advance research and intervention in mental health, with emphasis on the potential impact in lower resource settings. RECENT FINDINGS: Drawing from empirical evidence, largely from higher income settings, we considered three emerging areas where digital technology will potentially play a prominent role: supporting methods in data science to further our understanding of mental health and inform interventions, task sharing for building workforce capacity by training and supervising non-specialist health workers, and facilitating new opportunities for early intervention for young people in lower resource settings. Challenges were identified related to inequities in access, threats of bias in big data analyses, risks to users, and need for user involvement to support engagement and sustained use of digital interventions. SUMMARY: For digital technology to achieve its potential to transform the ways we detect, treat, and prevent mental disorders, there is a clear need for continued research involving multiple stakeholders, and rigorous studies showing that these technologies can successfully drive measurable improvements in mental health outcomes.