Assessing the efficacy of a brief universal family skills programme on child behaviour and family functioning in Gilgit-Baltistan, Pakistan: protocol for a feasibility randomised controlled trial of the Strong Families programme.

PURPOSE: The global burden of mental health difficulties among children underscores the importance of early prevention. This study aims to assess the efficacy, feasibility and acceptability of the Strong Families programme in enhancing child behaviour and family functioning in low-resource settings in Gilgit-Baltistan, Pakistan. METHODS AND ANALYSIS: This is a two-arm, multisite feasibility randomised controlled trial with an embedded process evaluation in three districts of Gilgit-Baltistan, namely Gilgit, Hunza and Skardu. 90 families living in these challenged settings, comprising a female primary caregiver aged 18 or above, and at least one child aged 8-15 years, will participate. Participants will be randomly assigned to either receive the Strong Families programme or to the waitlist group. Strong Families is a 7-hour family skills group intervention programme attended by children and their primary caregivers over 3 weeks. The waitlist group will be offered the intervention after their outcome assessment. Three raters will conduct blind assessments at baseline, 2 and 6 weeks postintervention. The primary outcome measures include the feasibility of Strong Families, as determined by families' recruitment and attendance rates, and programme completeness (mean number of sessions attended, attrition rates). The secondary outcomes include assessment of child behaviour, parenting practices, parental adjustment and child resilience. Purposefully selected participants, including up to five caregivers from each site, researchers and facilitators delivering the intervention, will be interviewed. Descriptive statistics will be used to analyse primary and secondary outcomes. The process evaluation will be conducted in terms of programme context, reach, fidelity, dose delivered and received, implementation, and recruitment. ETHICS AND DISSEMINATION: This study has been approved by the UNODC Drug Prevention and Health Branch in the Headquarters office of Vienna and the National Bioethics Committee of Pakistan. Findings will be disseminated through publication in reputable journals, newsletters and presentations at conferences. TRIAL REGISTRATION NUMBER: NCT05933850.

Clinicians', patients' and carers' perspectives on borderline personality disorder in Pakistan: A mixed methods study protocol.

Borderline Personality Disorder (BPD) is a condition characterised by significant social and occupational impairment and high rates of suicide. In high income countries, mental health professionals carry negative attitudes towards patients with BPD, find it difficult to work with patients with BPD, and even avoid seeing these patients. Negative attitudes and stigma can cause patients to fear mistreatment by health care providers and create additional barriers to care. Patients' self-stigma and illness understanding BPD also affects treatment engagement and outcomes; better knowledge about mental illness predicts intentions to seek care. The perspectives of mental health clinicians and patients on BPD have not been researched in the Pakistani setting and likely differ from other settings due to economic, cultural, and health care system differences. Our study aims to understand the attitudes of mental health clinicians towards patients with BPD in Pakistan using a self-report survey. We also aim to explore explanatory models of illness in individuals with BPD and their family members/carers using a Short Explanatory Model Interview (SEMI). The results of this study are important as we know attitudes and illness understanding greatly impact care. Results of this study will help guide BPD-specific training for mental health clinicians who care for patients with BPD and help inform approaches to interventions for patients with BPD in Pakistan.

Culturally adapted motivational interviewing with cognitive behavior therapy and mindfulness-based relapse prevention for substance use disorder in Pakistan (CAMAIB): protocol for a feasibility factorial randomised controlled trial.

BACKGROUND: The use of psychoactive substances significantly impacts the health, social and economic aspects of families, communities and nations. There is a need to develop and test psychological interventions aimed for individuals with substance use disorder (SUD) in lower- and middle-income countries (LMICs), such as in Pakistan. The aim of this exploratory trial is to test the feasibility and acceptability of two culturally adapted psychological interventions in a factorial randomised controlled trial (RCT). METHODS: The proposed project will be conducted in three phases. The first phase of the study will focus on cultural adaptation of the interventions through qualitative interviews with key stakeholders. The second phase will be to refine and produce manually assisted interventions. Third and last stage would be to assess the feasibility of the culturally adapted interventions through a factorial RCT. The study will be carried out in Karachi, Hyderabad, Peshawar, Lahore and Rawalpindi, Pakistan. Recruitment of participants will take place from primary care and volunteer organisations/drug rehabilitation centres. A total of 260 individuals diagnosed with SUD (n = 65) in each of the four arms will be recruited. The intervention will be delivered weekly over a period of 12 weeks in both individual and group settings. Assessments will be carried out at baseline, at 12th week (after completion of intervention) and 24th week post-randomisation. The analysis will determine the feasibility of recruitment, randomisation, retention and intervention delivery. Acceptability of intervention will be determined in terms of adherence to intervention, i.e. the mean number of sessions attended, number of home assignments completed, attrition rates, as well as through process evaluation to understand the implementation process, context, participants' satisfaction, and impact of the study intervention. The health resource use and impact on the quality of life will be established through health economic data. DISCUSSION: This study will provide evidence for feasibility and acceptability of culturally adapted manually assisted psychological interventions for individuals with SUD in the context of Pakistan. The study will have clinical implications if intervention is proven feasible and acceptable. TRIAL REGISTRATION: Name of the registry: ClinicalTrials.gov, Trial registration number: NCT04885569 , Date of registration: 25th April 2021.

Cognitive behavior therapy for diabetes distress, depression, health anxiety, quality of life and treatment adherence among patients with type-II diabetes mellitus: a randomized control trial.

OBJECTIVE: Diabetes distress typically causes depressive symptoms; common comorbidity of diabetes unpleasantly affects patients' medical and psychological functions. Psychotherapeutic interventions are effective treatments to treat depressive symptoms and to improve the quality of life in many chronic diseases including diabetes. The present study investigated the efficacy of cognitive behavior therapy (CBT) to treat depressive symptoms in patients with type 2 diabetes mellitus (T2DM) using experimental and waitlist control conditions. MATERIALS AND METHODS: A total of 130 diagnosed patients with T2DM were taken from outdoor patients services of different hospitals in Faisalabad. Ninety patients met the eligibility criteria and were randomly assigned to experimental (n = 45) and waitlist control (n = 45) conditions. All the patients completed clinical interviews and assessment measures at pre-and post-assessment stages (16 weeks intervals). Medical consultants at the respective hospitals diagnosed the patients on the base of their medical reports and then referred those patients to us. Then we used different scales to assess primary and secondary outcomes: Diabetes Distress Scale (DDS) and Patient Health Questionnaire (PHQ) to assess primary outcomes, and a Short Health Anxiety Inventory (SHAI), a Revised Version of the Diabetes Quality of Life Questionnaire (DQLQ), and a General Medication Adherence Scale (GMAS) were used to investigate secondary outcomes. Repeated measure ANOVA was used to analyze the results. RESULTS: The findings indicated that patients who received CBT got a significant reduction in their diabetes distress F(1,60) = 222.710, P < 0.001, η2 = .788), depressive symptoms F(1,60) = 94.436, P < 0.001, η2 = .611), health anxiety F(1,60) = 201.915, P < .0.001, η2 = 771), and a significant improvement in their quality of life F(1,60) = 83.352, P < 0.001, η2 = .581), treatment adherence F(1,60) = 67.579, P < 0.001, η2 = .566) and physical activity schedule F(1,60) = 164.245, P < .0.001, η2 = .736 as compared to the patients in waitlist control condition. CONCLUSION: It is concluded that cognitive behavior therapy is an effective and promising intervention for depressive symptoms, diabetes distress, and health anxiety which also helps the person to promote quality of life, treatment adherence and physical activity.

Cultural Adaptation and Validation of the Urdu Version of the Cognitive Emotion Regulation Questionnaire (CERQ) in Male Patients With Substance Use Disorders (SUDs) in Pakistan.

Background: Adults with substance use disorders (SUDs) often have co-occurring mental health problems. Emotion regulation may play a vital role in mental health problems. The Cognitive Emotion Regulation Questionnaire (CERQ) is a widely used measure for assessing cognitive emotion regulation. However, it has not been used in Pakistan on patients with co-occurring SUDs and mental health issues. The present study aims to translate and adapt the CERQ into the Urdu language and to determine its reliability and convergent validity in a sample of male patients with SUDs in Pakistan. Method: Participants completed a demographic information form, the CERQ, the Depression, Anxiety, and Stress Scale Short Form [DASS-21)], and the Rosenberg Self-Esteem Scale [RSES)] in Urdu. Results: Male participants (N = 237) 18-50 years of age (M = 29.8, SD = 8.1) were recruited from four substance use disorder treatment centers and hospitals in Karachi. The reliability of the Urdu version of the CERQ was based on an examination of its internal consistency reliability (Cronbach's α) and test-retest reliability for both the total scale and its subscales. Internal consistency for the CERQ total (α = 0.80) was adequate, as it was for subscales of self-blame, (0.76) acceptance (0.78), rumination (0.72), positive refocusing (0.79), focus on planning (0.89), positive reappraisal (0.81), putting into perspective (0.83), catastrophizing (0.73), and other blame (0.70). The 10-14 day test-retest reliability of the CERQ total score was 0.86. Higher CERQ scores were significantly (ps < 0.001) negatively associated with DASS-21depression (r = -0.24), anxiety (r = -0.23), and stress (r = -0.27) subscales, as well as the DASS-21 total score (r = -0.26) and positively associated with the RSES self-esteem score (r = 0.30). Conclusion: The Urdu version of the CERQ is a reliable measure for investigating cognitive emotion regulation strategies related to mental health and SUDs in Pakistan.

The Impact of COVID-19 on Distress Tolerance in Pakistani Men and Women.

The novel coronavirus (COVID-19) is an infectious disease that spread across the world, bringing with it serious mental health problems for men and women. Women in Pakistan are infected with COVID-19 at a much lower rate than men, yet report worse mental health. To explain this paradox, we surveyed 190 participants (46% male) shortly following the country lockdown, focusing on perceptions of the COVID-19 impact and positive adjustment. Measures used in this study included the Warwick-Edinburgh Mental Well-being Scale and Distress Tolerance Scale. Factor analysis revealed five distinct areas related to COVID-19, which did not differ by sex. However, men reported higher levels of both distress tolerance and well-being than women. High endorsement of actions to protect against COVID-19 was related to lower distress tolerance scores, but in different ways for men and women. Men, but not women, who endorsed more protective measures to stop the pandemic reported higher DTS absorption scores, and therefore being more consumed by distress; women who endorsed more protective measures to stop the pandemic reported less acceptance of distress than men, as reflected in DTS appraisal scores. An in-depth analysis of women's beliefs and behaviors related to COVID-19 is warranted to understand why Pakistani women who are infected with COVID-19 at lower rates than men show more mental health symptoms.

Psychometric properties of Urdu version of adolescent peer relation instrument in Pakistan.

OBJECTIVE: To translate the Adolescent Peer Relation Instrument into Urdu language, to make cultural adaptations, and to determine its psychometric properties. METHODS: The two-phase study was done in Karachi; the translation was done from May 2016 to December 2016 and data collection was done from January 2017 to June 2017. The Adolescent Peer Relation Instrument was first translated into Urdu through a clearly outlined process before it was tested in 2017 on a sample of adolescents aged 12-16 years studying in the local private schools. The reliability of the scale was assessed through Cronbach's alpha, split-half reliability and test-retest reliability. The convergent validity was measured using Centre for Epidemiological Studies Depression Scale for Children, and the discriminant validity was measured using the Resilience Scale. Data was analysed using SPSS20. RESULTS: The translated version was tested on 150 subjects with a mean age of 13.31±0.94 years. There were 97(64.66%) boys and 53(35.33%) girls. Internal consistency Cronbach's alpha value for bullying and victimisation subscales was 0.867 (p<0.01) and 0.898 (p<0.01);test-retest reliability values for the two subscales were 0.517 (p<0.01) and 0.581 (p<0.01); and Guttman split-half coefficient was 0.836 (p>0.05) and 0.876 (p>0.05) respectively. Convergent validity of bullying and depression was r=0.298 (p<0.01) and for victimization and depression it was r=0.395 (p<0.01). Discriminant validity for bullying and resilience was r=-0.168 (p<0.01) and for victimisation and resilience it was r= -0.133 (p<0.01). CONCLUSIONS: The Urdu version of the Adolescent Peer Relation Instrument was found to be a reliable and valid measure to use in Pakistan. There was a significant relationship between bullying and depression, and between victimisation and depression, and an inverse relationship between bullying and resilience, and between victimisation and resilience.

Psychometric properties of the Urdu translation of children's perception of Parents scale.

OBJECTIVE: To translate and adapt the children's Perception of Parents Scale in Urdu language, and to determine its psychometric properties. METHODS: The study was conducted in schools from different areas of Karachi (such as Happy Palace Grammar School, Beacon Askari School, The Educators, and Clifton Grammar School) from October, 2017 to March, 2018. The first phase of the study was conducted from January, 2017 to September, 2017. In the first phase, Perception of Parents Scale children version was forward and backward translated in consultation with experts and a final version was prepared and its reliability was assessed through Cronbach's alpha and test-retest reliability. Construct validity was evaluated by using the Urdu versions of standardised scales. In the second phase, the Urdu version of the scale was administered on secondary school students aged 12-16 from October, 2017, to March, 2018, in different areas of the city. Data was analysed using SPSS 20. RESULTS: Of the758 subjects, 383(50.5%) were boys and 375(49.5%) were girls. The overall mean age was 13.57±1.24 years. Cronbach's alpha values for the four subscales were: mother involvement 0.592, mother autonomy support 0.777, father involvement 0.653, and father autonomy support 0.717. Test-retest values were 0.803, 0.791, 0.874, and 0.845 respectively. CONCLUSIONS: The Urdu version of Perception of Parents Scale children version was found to be a reliable and valid instrument.

Urdu translation and adaptation of the HIV stigma scale in Pakistani injectable drug users with HIV.

OBJECTIVE: To translate and adapt the human immunodeficiency virus stigma scale into Urdu language, and to determine its psychometric properties. METHODS: The study was conducted at the Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome Treatment Centre at the Civil Hospital, Karachi, from February to April 2017. The scale was translated and administered on a sample of patients enrolled from the Centre who were aged 25-45 years and had been injecting drugs. The reliability of the measure was assessed by working out Cronbach's alpha, split-half reliability and test retest reliability. The construct validity was measured by correlating the scale with the constructs of depression and self-esteem. Statistical analysis was done using SPSS, 20. RESULTS: There were 150 subjects with a mean age of 31.65±5.88 years. Internal consistency of the Urdu version of scale was 0.94 and that of the subscales ranged 0.81-0.91. Gutman split-half coefficient was 0.93 and test retest reliability was 0.92. The Urdu version of the scale had significant positive correlation with depression (p<0.01) and significant negative correlation with self-esteem (p<0.01). CONCLUSIONS: The Urdu version of the Human Immunodeficiency Virus Stigma Scale was found to have acceptable psychometric properties and it can be used in researches conducted in Pakistan.

Different risk factors are associated with alcohol use versus problematic use in male Pakistani adolescents.

Substance abuse is a significant problem in Pakistan (Hussain, 2017), yet, there are few studies of risk factors in this population, particularly in remote areas. Male adolescents (N = 243; M = 16.9 years, SD = 1.3 years) were recruited from schools in Gilgit-Baltistan, and completed questions on demographics, substance use, and psychosocial functioning. As a Muslim country, there are strict prohibitions against alcohol use, yet 44.9% of the sample reported lifetime alcohol use. The Alcohol Use Disorders Identification Test (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), was used to quantify level of risk associated with use, and 22.6% of the sample had scores indicating significant risk levels. Logistic regression analyses indicated that lifetime alcohol use was associated with internalising problems (e.g., depression, anxiety), while risky alcohol use was associated with externalising problems (e.g., aggressive and delinquent behaviour). Attention problems were related to both outcomes. Implications for prevention are discussed.

Depression and perceived attachment of adolescents with fathers having substance-abuse disorder.

OBJECTIVE: To understand the predictive role of perceived mother, father and peer attachment in depressive symptoms of adolescents living with fathers diagnosed with substance use disorder. METHODS: The quantitative study was conducted at various drug rehabilitation centres in Karachi from January 2016 to September 2017, and comprised adolescents living with fathers diagnosed with substance use disorder. Inventory of Parent and Peer Attachment-Revised, Urdu version, and Centre for Epidemiological Studies- Depression Scale for Children, Urdu Version, were used to gather data which was analysed using SPPS 20. RESULTS: Of the 150 participants, 82(55%) were males and 68(45%) were females. The overall mean age was 13.44}1.50 years. Perceived attachment with mother, father and peers collectively contributed significant variance in the depressive symptoms of the subjects (p=0.0001). Independently, only perceived mother and father attachment played a significant role in such symptoms with highest prediction value observed on father attachment (p<0.05). CONCLUSIONS: Perceived mother and father attachment were found to be significant predictors of depressive symptoms among adolescents living with paternal substance use disorder. Peer attachment was significantly linked to the symptoms, but did not have a definite predictive role.