British South Asians have a greater incidence of psychotic illness, which is associated with cognitive deficits. Computerised cognitive remediation aims to improve cognition.

We aimed to culturally adapt computerised cognitive remediation for British South Asians with first-episode psychosis, and assess its feasibility.

Qualitative interviews were analysed using thematic analysis to guide cultural adaptation of cognitive remediation, followed by a case series to determine feasibility. Our sample comprised 20 participants: ten in the qualitative interviews and ten in the feasibility evaluation. The sample was generated via purposive sampling from early intervention services in England, and was an entirely Muslim cohort, who were mainly Pakistani and born in the UK. Our intervention was computerised interactive remediation of cognition training for schizophrenia (CIRCuiTS), which was culturally adapted based on formative qualitative interviews and using an established framework. Participants engaged with 40 h of tasks over 12 weeks, with the aim of improving attention, memory and executive functioning. Feasibility was explored by assessing acceptability, engagement and retention in the study, and a range of measures were used to assess impact on cognition and mental state.

The cultural adaptation of CIRCuiTS was found to be acceptable, with high levels of engagement and satisfaction. Despite the small sample, the intervention led to improved cognition and mental state.

This is the first study to culturally adapt computerised cognitive remediation for British South Asians who are Muslim, and it had high acceptability with good retention, engagement and satisfaction. Future effectiveness testing is recommended.

Data on associations between inflammation and depressive symptoms largely originate from high income population settings, despite the greatest disease burden in major depressive disorder being attributed to populations in lower-middle income countries (LMICs).

We assessed the prevalence of low-grade inflammation in adults with treatment-resistant depression (TRD) in Pakistan, an LMIC, and investigated associations between peripheral C-reactive protein (CRP) levels and depressive symptoms.

This is a secondary analysis of two randomised controlled trials investigating adjunctive immunomodulatory agents (minocycline and simvastatin) for Pakistani adults with TRD (n = 191). Logistic regression models were built to assess the relationship between pre-treatment CRP (≥ or <3 mg/L) and individual depressive symptoms measured using the Hamilton Depression Rating Scale. Descriptive statistics and regression were used to assess treatment response for inflammation-associated symptoms.

High plasma CRP (≥3 mg/L) was detected in 87% (n = 146) of participants. Early night insomnia (odds ratio 2.33, 95% CI 1.16–5.25), early morning waking (odds ratio 2.65, 95% CI 1.29–6.38) and psychic anxiety (odds ratio 3.79, 95% CI 1.39–21.7) were positively associated, while gastrointestinal (odds ratio 0.38, 95% CI 0.14–0.86) and general somatic symptoms (odds ratio 0.34, 95% CI 0.14–0.74) were negatively associated with inflammation. Minocycline, but not simvastatin, improved symptoms positively associated with inflammation.

The prevalence of inflammation in this LMIC sample with TRD was higher than that reported in high income countries. Insomnia and anxiety symptoms may represent possible targets for personalised treatment with immunomodulatory agents in people with elevated CRP. These findings require replication in independent clinical samples.

Psychosis is one of the leading causes of disability. First Episode Psychosis (FEP) significantly impacts the long-term course of the disorder. While a majority of FEP service users show signs of ‘recovery' within 12 months of treatment, the early course involves frequent relapses, with up to 80% relapsing within five years. This elevates the risk of persistent psychotic symptoms, affecting cognitive, social, and occupational functioning. Medication, the core treatment, reduces relapse by 75%, necessitating additional psychosocial treatments. Mobile-based interventions are recognized for meeting families' needs in terms of information, guidance, and support. This paper explores stakeholder views on developing mobile interventions for those experiencing their first psychosis episode.

This qualitative paper was part of the TechCare app development process in which face-to-face interviews with patients (17), and 4 focus groups with health professionals were carried out. The qualitative interviews and focus groups explored the views of stakeholders on the need for mobile-based treatment, the structure of the application, the content of the application and barriers and challenges were also explored in detail. All the audio-recorded interviews were transcribed and analyzed through a framework approach.

Qualitative analysis revealed three themes. The first theme centers on stakeholders' views about mobile-based treatment. Health professionals reported that app-based treatment enhances help-seeking behavior, reduces societal stigma, and aids in managing treatment and activities. The second theme focuses on suggestions for the Techcare application, emphasizing logical and easy-to-understand content, with a major focus on crisis management, hallucinations, and psycho-education about symptoms. Participants also highlighted the need for a section providing psycho-education for families. Carers emphasized the necessity of an activity plan in the app, including an activity log for medication management and activities. The third theme delves into barriers and challenges in app-based treatment, including difficulty levels and privacy concerns. Stakeholders stressed the importance of content in simple Urdu language for broader understanding.

In conclusion, mobile-based treatment contributes to reducing stigma, increasing awareness about the illness in its early stages, and facilitating the management of functional activities for patients. The insights gathered from stakeholders provide valuable guidance for the development of an effective and culturally sensitive mobile-based intervention for individuals experiencing FEP.

Severe Mental Illnesses (SMI) are a group of disorders which can have a debilitating impact on an individual's daily life functioning. The National Institute for Health and Care Excellence (NICE) has set out clinical guidelines for the treatment of SMI including the use of Second Generation Antipsychotic (SGA) medication as well as psychological therapies. However, Treatment Resistant Schizophrenia (TRS) affects approximately 34% of patients with schizophrenia. Clozapine, a SGA, has shown superiority in treatment resistant schizophrenia as well as its potential benefits in reducing suicidality and improving functioning.

The following study aimed to examine the longitudinal trends in prescribing clozapine based on the NHS Digital prescription cost analysis (PCA) between 2015–2023.

The results show that a number of prescriptions decrease simultaneously from the financial year 2015 (n = 5536) to 2023 (n = 3059). The cost was also found to be reducing until the financial year 2018–19 where there was an increase in costs which reached the maximum (14%) despite the number of prescriptions being lower as compared with 2015–16. In addition, it was found that clozapine prescribing trends have been reducing over time, despite a large proportion of service users with schizophrenia experiencing TRS (34%). Overall, since 2015–2023 a total of n = 34,440 items of clozapine were prescribed costing £1,252,052.27.

Considering clozapine's superior efficacy in the treatment of TRS, further research is required to better understand prescribing practices, monitoring compliance of clozapine and treatment adherence. Further qualitative research is needed to better understand the views and perspectives of both service users and prescribers in the clinical use of clozapine. Future research may also look at referrals of clozapine-prescribed patients to psychological services, the impact of clozapine in TRS patients who are offered psychological therapy, and the potential clinical and cost implications of not prescribing clozapine.

Depression is a leading cause of disability, contributing to the global burden of disease. Low- and middle-income countries (LMICs) carry over 80% of this disease burden. There are high rates of depression in men in Pakistan. Paternal depression is often overlooked and is an under-researched area. Fathers are at risk of depression particularly if their partner is depressed. There is a need for integrated partner inclusive interventions to improve both parent and child outcomes including overall child development. Therefore, this nested qualitative study aims to identify barriers in transition to scale up an innovative low-cost partner inclusive culturally adapted psychosocial intervention for depressed fathers through a process evaluation from the perspective of fathers.

This qualitative study was nested within a cluster randomized controlled trial, with depressed fathers of young children (0–3 years) recruited from 18 towns in Karachi, Pakistan. Face to face or digitally audio-recorded interviews were conducted with depressed fathers (N = 24) from the intervention arm of the trial at end of intervention period (i.e., 4-month post-baseline). The intervention involved twelve sessions of a parenting intervention called Learning Through Play integrated with group Cognitive Behaviour Therapy and manual content from “Focus on Fathers”. Interviews were guided by a semi-structured topic guide to explore perceived usefulness of the intervention with particular focus on exploring any additional benefits or challenges of engaging partners into the intervention. Interviews lasted approximately an hour. Data were analysed using the principles of Framework Analysis. A concurrent analysis of initial interviews directed towards further interviews until data saturation.

Analysis highlighted perceived usefulness of the intervention such as improvement in mood, engagement in routine tasks, healthy thinking patterns, increased attachment with child, improved relationship with the family, improvement in parenting knowledge and more positive attitudes towards child development, supporting partners in household chores, and recommendation to promote this partner inclusive parenting program throughout the country.

Addressing depression in parents is hugely important due to its adverse impact on both parents and children. This low-cost parenting program supported fathers in their parenting role along with improvement in psychological well-being. This has also informed barriers and facilitators to implement the LTP plus parenting program and the possibilities to roll out the intervention at national level.

Suicide is a serious global public health concern. Most suicide related deaths occur in low- and middle-income countries (LMICs) such as Pakistan. Self-harm is a major predictor of death by suicide and has cost implications both in terms of treatment and subsequent suicide. Therefore, culturally relevant interventions that have the potential to reduce self-harm in Pakistan may have major implications for the costs incurred by service provision and productivity losses due to illness or premature death. This trial investigated the clinical and cost effectiveness of the CMAP intervention verses enhanced treatment as usual (E-TAU) to reduce self-harm over 12 months in Pakistan.

Participants were recruited from emergency departments, primary care settings, medical units of participating hospitals and self-referral from community settings in Karachi, Lahore, Rawalpindi, Quetta and Peshawar. Eligible consented participants were assessed at baseline, 3- (end of intervention), 6-, 9- and 12-month post-randomization. Participants in the intervention arm received 6 one-to-one sessions of culturally adapted manual assisted psychological intervention (CMAP) over 3 months. The Client Service Receipt Inventory was used to record health service utilization, both formal and informal. Health related quality of life was measured using the EQ-5D-3L. The Thailand tariff value set (developed by the EuroQol Organization) was used to calculate quality-adjusted life year (QALY) because Thailand was deemed similar to Pakistan. The Incremental Cost Effectiveness Ratio (ICER) was calculated based on between arm differences in estimated cost and Quality Adjusted Life Years (QALYs) gains in the sampled population. Costs were converted to US dollars using the currency exchange rate on February 2024 (US$1 = PKR276)

A total of 901 participants were randomized into either the CMAP arm (n = 440) or E-TAU arm (n = 461). Total QALY gained in the CMAP arm was 0.40 (95% CI: 0.36–0.45) and in the E-TAU arm was 0.33 (95% CI: 0.30–0.38) at 12-month post-randomization. The additional QALY gained due to CMAP intervention is 0.07. The difference in costs per participant between CMAP and TAU arms was US$59. The ICER for the CMAP versus E-TAU was US$843 per QALY gain.

Results revealed that the CMAP intervention is likely to be cost-effective compared with the E-TAU, given the cost-effectiveness threshold. These findings suggest that implementing culturally relevant self-harm and suicide prevention measures such as CMAP can lead to significant societal cost savings by preventing self-harm and suicides.

Background: Mental health policy is crucial for enhancing mental health and well-being. Despite the significant contribution of mental disorders to the global burden of disease, 68% of the countries possess a comprehensive mental health policy. This review aimed to identify similarities and differences between low-income countries' (LICs) and lower middle-income countries' (LMICs) mental health policies, along with key gaps, limitations, and strengths, to inform Pakistan's mental health policy.

We conducted searches on Google, the WHO Mental Health Atlas, and the country's Ministry of Health website for mental health and general health policies. Recent mental health policies were included from LMICs that were available in English, whether published or unpublished. Scholarly articles, commentaries, books, and health policies that did not address mental health were excluded. Data extraction covered document title, policy status, country, policy formulation process, human resources, suicide prevention, finances, health service delivery, governance, leadership, involvement of ministries, and implementation plans. We synthesized the data through a comparative narrative review in both text and tables.

Fifty percent (8/16) of LICs and sixty-five percent (17/26) of LMICs have health and mental health policies in English. These policies cover topics like psychiatric disorders, psychotropic drugs, forensic mental health, substance abuse disorders, and communicable and non-communicable diseases. Approximately 65% of LMICs' policies outline the structure of their federal or national government, and 59% provide information on provincial and local government structures. Most LICs include their vision, mission, and objectives in their policies.

Mental health is often neglected in the healthcare policies of LICs and LMICs. To reduce the burden of mental illness and prevent self-harm, suicide, and substance misuse disorders, the implementation of evidence-based mental health policies in line with the Sustainable Development Goals (SDGs) is crucial.

The COVID-19 pandemic has significantly impacted healthcare systems, economies, and global health, raising concerns about its potential effects on mental health. A recent systematic review found a 40% prevalence of poor sleep quality, with 34%, 26%, and 27% prevalence for psychological distress, depression, and anxiety. The systematic review investigated COVID-19-related stress, suicidal ideation, and self-harm thoughts among low- and lower-middle-income countries (LLMICs).

We search four electronic databases (PsycINFO, Medline, Embase, and PubMed). Quantitative studies, including both published and grey literature, from LLMICs focused on the prevalence of suicidal ideation or psychological distress during COVID-19 were included. Qualitative studies, non-English studies without full-text English translation, meta-analysis, commentary, books, and discussion articles were excluded.

1157 titles and abstracts were screened for inclusion and exclusion, resulting in 79 full-text articles. After full text screening, 11 articles were included. In Bangladesh, 12.8% of university students reported suicidal ideation (SI), while 19% of young adults had SI, and 18.5% reported suicidal planning. In addition to this, in Iran, 12.8% of pregnant women and in the Philippines, 24.9% of the general population reported SI. Mental health conditions like depression and anxiety, female gender, younger age groups, economic loss or financial stress, fear of COVID-19 infection, lack of social support, family problems, lower education levels, smoking, and substance use are identified as risk factors. Moreover, anosmia and dysgeusia symptoms were associated with a 30–80% increased risk of transitioning to suicidal ideation or depression in India. A study from Nepal reported a 44% increase in suicide attempts during lockdown compared with pre-pandemic periods in Nepal.

The findings of this review suggest that the impact of the COVID-19 pandemic on mental health in LLMICs is substantial. In addition to the increased risk of SI and suicide attempts, there was a significant rise in depression and SI associated with anosmia and dysgeusia symptoms. These results underscore the urgent need for increased psychosocial support in LLMICs to address the growing mental health burden caused by the pandemic. Moreover, understanding the long-term effects of the pandemic is crucial for developing effective interventions and support systems. Further research is needed to examine the lasting impact of the pandemic on mental well-being and identify future strategies.

Suicide is a global public health issue that requires sensitive research to inform effective prevention and treatment strategies. Despite the benefits of such research, it is accompanied by significant ethical challenges such as the potential for harm to participants' wellbeing. Various studies have explored the views of researchers in suicide research. This qualitative study aimed to explore the research ethics committee (REC) members’ experiences with suicide-related study applications to ascertain whether there are differences in approaches to dealing with suicide-related study applications.

We conducted semi-structured interviews with members of RECs (n = 9) from research-intensive universities and ethics committees in Pakistan. We also conducted a discussion group (n = 13) with members of REC from Pakistan, Nigeria and Sri Lanka. The topic guide delved into the opinions of REC members regarding ethical issues that they have come across while reviewing self-harm/suicide-related research proposals, the relevance of these issues with specific study designs, recommendations to resolve these issues, their approach to balancing risk and benefit, and guidance for researchers.

The preliminary findings from thematic analysis revealed five major themes; 1) Ethical challenges, 2) Reasons for application rejection, 3) Areas of improvement, 4) Suggestions for addressing ethical issues, and 5) Researchers' attitudes towards amendments. Challenges in self-harm and suicide research included the sensitivity and stigma surrounding the topic, lack of interest and support, and difficulties in participant recruitment. The application faced rejection from the ethics committees primarily due to methodological errors, lack of procedural clarity, and insufficient understanding of the research procedure. Identified areas for improvement were the need for enhanced methodology and research patterns, as well as a better understanding of the methodological procedure. Recommendations for developing a robust research proposal included training and supervision for intervention studies, the inclusion of comprehensive ethical elements and practical plans in the proposal, and a focus on data protection, confidentiality, risk management, and harm identification. While a significant number positively acknowledged reviewer comments, some researchers opted for in-depth discussions rather than directly addressing the issues.

The study highlights the importance of ethical considerations and emphasises the need to address the lack of robust methodological procedures in self-harm and suicide research. Addressing these challenges and adopting suggested improvements is paramount for advancing ethical and impactful research in this context.

Suicide is a global public health concern, affecting not only the individuals but also families. It is the leading cause of maternal death during pregnancy and up to one year after birth and commonly occurs after a period of suicidal ideation (SI). It is imperative to have interventions to help with SI and behaviors. We therefore aimed to adapt and test the feasibility and acceptability of a culturally adapted intervention for SI in women during postnatal period in Pakistan.

This is a two phase, mixed method Randomized Controlled Trial (RCT). First phase included adaptation of an existing Culturally Adapted Manual-Assisted Problem-Solving intervention (CMAP) for women experiencing SI. Adaptation process included two focus group discussion (FGDs), one with lived experience experts (women who experienced suicidal ideation during postnatal period), the other with health professionals (n = 8 in each group). Second phase involves a feasibility RCT with aim to recruit and randomize a total of 90 postnatal women experiencing suicidal ideation (screened using the Beck Scale for Suicidal Ideation), randomize into either of two study arms: CMAP (n = 45) or Treatment as usual (n = 45). Potential participants are being recruited from hospitals, communities, and self-referrals from 5 major cities in Pakistan. Culturally adapted CMAP is a brief problem-solving therapy of 6 individually delivered sessions, lasting about 50 minutes. The primary outcome is to assess the feasibility of CMAP through semi-structured qualitative interviews. Secondary outcomes include measuring SI, self-harm, depression, social support, and quality of life. Assessments will be conducted at baseline and 3rd month post randomization.

Analysis of qualitative data from FGD with lived experience experts highlighted importance of incorporating additional techniques of trust building, modifying thinking behavior, mindfulness, distraction exercises including religious practices as a preventive measure of self-harm, child safety measures, and involvement of partner in intervention. Analysis of FGD with healthcare professionals emphasized addition of visualized content, re-assessing depression and suicidal ideation in-between the sessions to monitor relapse, involving family, and capacity building of health professionals to improve their understanding about perinatal mental health problems.

Women in postnatal period are at high risk of SI, specifically those women from low- and middle-income countries, due to limited resources and mental healthcare provision. The earlier detection of SI, early intervention for suicide risk by delivery of culturally sensitive interventions can help reduce maternal mortality rates.

A worldwide public health concern is major depressive disorder (MDD) with limited availability and access to evidence-based treatment in low- and middle-income countries (LMICs) such as Pakistan. Measurement-based care (MBC) is a low-cost strategy to improve clinical outcomes for people with MDD that involves the systematic administration of validated outcome measures to inform treatment decisions. However, research on MBC's effectiveness in LMICs is scarce. This paper aims to evaluate the feasibility and clinical effectiveness of MBC against standard care for patients with moderate to severe MDD in Pakistan.

This is a multicenter randomized control trial. Participants (n = 154) of 18 to 65 years of age recruited from psychiatric units of teaching and non-teaching hospitals and primary care settings such as General Physician (GP) clinics and Basic Health Units (BHUs) from 6 cities were randomised to receive MBC (guided by a schedule), or standard treatment (guided by clinicians’ judgement). Patients were prescribed by treating clinicians either with mirtazapine (7.5–45 mg/day) or paroxetine (10–60 mg/day) for a period of 12 weeks. All participants, regardless of their treatment arm, were followed-up till 24 weeks post-randomization and assessed for severity of depression. Side effects were regularly monitored using standard checklist. Outcome assessors were blind to treatment allocation.

The Pakistani National Bioethics Committee (NBC) has granted complete ethical approval. A total of 15 psychiatrists and 4 General Practitioners (GPs) were approached and invited to participate in the study and consent was given by 9 psychiatrists and 2 GPs. A total of 351 patients were screened against eligibility criteria and 177 were eligible to participate. A total of 154 eligible participants consented (87%) to participate and were recruited and randomized into the trial. A total of 131 randomized participants (85%) completed 24-month follow-up. Only two adverse events were reported during the trial period. Recruitment, retention and safety analysis indicates feasibility of the trial in Pakistani healthcare context. The data are being analyzed for effectiveness outcomes.

It is essential to investigate the viability, usefulness, and efficacy of MBC for MDD in low-resource settings due to mounting data from high-income settings confirming its effectiveness. The planned trial's outcomes may help build a scalable, low-cost method for effectively improving outcomes for MDD patients in Pakistan.

First Episode Psychosis (FEP) emerges at a young age, significantly shaping the trajectory of the disorder. Literature indicates a 60% increased risk of suicide within the initial year of diagnosis in FEP, early intervention in psychosis reduces the risk of suicide. Therefore, this study aims to co-adapt an existing culturally appropriate suicide prevention intervention (CMAP) and integrate this with a culturally adapted Cognitive Behavioral Therapy for Psychosis (CaCBTp) for individuals with FEP experiencing suicidal ideation and to test its feasibility and acceptability in Pakistan.

This is a mixed-method study that involves two stages. Stage 1 was co-adaptation of the CMAP intervention for people with FEP patients. This involved one-to-one, in-depth interviews with individuals with FEP (n = 5), carers (n = 5) and a focus group discussion with 10 healthcare professionals. The second stage involves feasibility testing of the intervention. Participants are being recruited (n = 90) from outpatient psychiatric units across the cities of Karachi, Lahore, Rawalpindi, Multan, and Hyderabad in Pakistan. Eligible, consented participants are being randomized into either of two trial arms; intervention arm or treatment as usual arm (TAU). All participants are being assessed at baseline and at 3-month post-randomization on assessing participants on severity of suicidal ideation, severity of symptoms, functionality and quality of life using different scales. The intervention is comprised of 12 one-to-one sessions delivered over 3 months by trained therapists. Participants (n = 15) from the intervention arm will be interviewed at the end of intervention to explore the acceptance.

Qualitative analysis of stage 1, utilizing thematic framework analysis, highlights barriers to help-seeking such as lack of awareness, inadequate social support, and mental health stigma. To adapt CMAP intervention, participants suggested changes in the use of Urdu words to make content simple for patients to understand, increase number of family sessions, include information about possible risk and protective factors of self-harm in this population and emphasize the addition of resilience-building messages in the manual. Stage 2 is currently ongoing, and we have successfully recruited healthcare facilities across all sites and randomized 12 participants into the trial.

This study will add valuable insights for refinement of existing interventions to address the unique needs of individuals with FEP in Pakistan. Intervention with suicide preventive strategies may help in reducing the risk of suicide. The culturally grounded approach ensures relevance, contributing to the global discourse on evidence-based mental health interventions.

Suicide is one of the leading causes of death among young people. For adolescents, schools are considered as the best place to identify and respond to youth suicide risk but evidence on culturally sensitive, school-based suicide prevention programs is limited in low-resource settings such as Pakistan. This study aims to explore the perspectives of students, parents, teachers, and general practitioners regarding cultural adaptation, participation experiences, identified areas for improvement, and recommendations for scaling up the school-based suicide prevention program in Pakistan.

This qualitative study was nested in a pilot randomized controlled trial that aimed at exploring the feasibility, acceptability and preliminary effectiveness of three suicide prevention interventions: (1) Linking Education and Awareness of Depression and Suicide-LEADS training for students (12–17 years), (2) Question-Persuade-Refer (QPR) training for teachers and parents and (3) Professional screening of at-risk students (ProfScreen) for health practitioners. A total of 8 focus group discussion (FGDs) were conducted at pre- and post-intervention stage with each type of stakeholder (students, teachers, parents and health professionals) by trained qualitative researchers using the semi-structured topic guides. Each FGDs involved a detailed presentation on intervention, sharing videos and educational posters.

As a result of pre-intervention FGDs, adaptations were made in the content of the interventions and were further refined through consultations with Patient and Public Involvement and Engagement group. All stakeholders who participated in post-intervention FGDs marked this suicide prevention program as feasible, acceptable and helpful in both identifying the risk of and preventing self-harm and suicide among young individuals, while also enhancing treatment pathways. Stakeholders perceived the interventions as valuable in augmenting knowledge about mental health, understanding the impact of mental health challenges on functioning, reducing stigma, and providing stakeholders with the necessary skills to identify and guide at-risk individuals. Teachers and parents endorsed the importance of discussing issues with children. Improvement in clinical practice of clinicians and teaching practice of teachers as well as understanding others’ behaviors were also reported.

This study highlights potential role of culturally adapted school-based youth suicide prevention program for settings where rates of suicide are high and there are limited mental healthcare resources in addition to limited access to healthcare. School-based suicide prevention program is perceived as helpful in improving knowledge, attitudes, and help-seeking behaviours in adolescents.

Suicide and substance use all contribute significantly to the global burden of mortality and morbidity. While existing evidence establishes the association between substance use and suicidal behaviour in Lower- and Middle-Income Countries (LMICs), only a few studies illustrate how substance use affected deceased people's lifestyles and suicide attempts. The study addresses this gap by exploring the role of substance use (particularly, alcohol and drug use) in overall lifestyles and suicides of deceased with substance use in Pakistan – an underexplored and under-researched country regarding suicide and substance use.

We conducted in-depth qualitative interviews (N = 11) with close relatives and friends of those who died by suicide and have a history of substance use. The topic guide was comprised of a narrative part exploring the circumstances that surrounded the suicidal death of the deceased and a problem-focused part collecting comprehensive details about the deceased's personal, family, psychological, and social context and the role of substance use in the lifestyles and the suicide of the deceased.

The content analysis of interviews revealed five key themes: 1) Reasons for suicide, 2) Personality traits, 3) Psychological distress, 4) Initiation of substance use, and 5) Suicidal tendencies. Most of the participants reported the reason for their loved one's suicide was either an overdose of drugs or alcohol, family dynamics, or societal attitudes such as difficulty in building trust and finding acceptance within the family or society. Deceased individuals were perceived as impulsive with low control over their emotional states. Participants highlighted the underlying psychological distress in the deceased, emphasising the complexity of mental health and substance use problems. Participants reported that the deceased initiated drugs at an early age; had suicidal ideations; and overdosed themselves as a means of suicide.

This study provides valuable insights into the role of substance use in suicide. The findings highlight the need for a holistic approach to understanding the multifaceted factors that may influence suicidal behaviours in individuals with substance use. Understanding these factors can help develop targeted suicide prevention and intervention strategies, particularly in low-resource settings such as Pakistan.

Self-harm is the preventable cause of premature death by suicide. In adolescents suicide is the fourth leading cause of death and Pakistan is one of the youngest nations in the world. Culturally relevant solutions for the prevention of self-harm among adolescent are almost non-existent in LMICs. The aim of this trial is to assess the clinical and cost-effectiveness of a culturally adapted manual assisted problem-solving intervention for youth (YCMAP) with history of self-harm (within 3 months) to reduce self-harm repetition over the period of 12 months.

This was a rater-blind, multicenter randomised controlled trial, with a nested qualitative component to explore perceived usefulness of the intervention from the perspective of different stakeholders. Primary care centers, emergency departments, medical units from participating healthcare facilities in Karachi, Hyderabad, Lahore, Rawalpindi and Multan, Pakistan served as recruitment sites in addition to self-referrals. Patients with a recent history of self-harm (n = 684) were assessed and randomised (1:1) into either of the two trial arms; YCMAP with enhanced treatment as usual (E-TAU) or E-TAU. The YCMAP is a manualized, psychological intervention based on problem-solving therapy, principles of cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), psychoeducation, and a comprehensive assessment of the self-harm attempt using stories of four young people, comprising 8–10 one-to-one sessions delivered over three months by trained therapists. Primary outcome was the reduction in the self-harm repetition at 12-month post-randomisation and secondary outcomes were distress, suicidal ideation, hopelessness, health-related quality of life (QoL), and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation.

We screened 1099 young people for eligibility and 684 eligible, consented patients were randomly assigned to the YCMAP plus E-TAU arm (n = 342) and E-TAU arm (N = 342). Improvement in repetition rates of self-harm, hopelessness, suicidal ideation and psychological distress were clinically significant in YCMAP arm as compared with E-TAU. Thematic analysis of interviews with adolescents who participated in the intervention arm (N = 20) highlighted the intervention as useful in improving their mental health and well-being, and easy to understand.

Adolescents are an important target population for the prevention of suicide and other mental health problems. Implementation strategies are needed such as digitalization of culturally adapted manual assisted psychological interventions or task shifting approach for scalable suicide prevention interventions in low resource settings like Pakistan to meet mental health needs.

The burden of mental health difficulties is a global problem and preventing them from childhood is paramount. Children living in challenged and underserved settings can suffer various harmful lifelong consequences including alcohol and substance abuse, low self-esteem, health issues, poor school performance, self-harm and suicide. This study aims to assess the feasibility, acceptability and efficacy of the culturally adapted Strong Families program in improving child behaviour and family functioning in families living in a challenged setting i.e. Gilgit-Baltistan (GB), Pakistan.

This is a two-arm, multisite feasibility randomised controlled trial with 90 families (n = 45 in intervention, and n = 45 in waitlist group) including a female primary caregiver (mostly mother) and at least one of their children between the age of 8–15 years in three districts of GB. There will be three raters’ blind assessments: at baseline, week 2, and 6 weeks after Strong Families Program sessions.

Strong Families Program is a brief evidence-based prevention programme designed to improve parenting skills, child well-being and family mental health. The primary outcome measures include the feasibility of Strong Families, as determined by families' recruitment, attendance rates, and program completeness (mean number of sessions attended, attrition rates). Additionally, purposefully selected participants, including up to 5 caregivers from each study 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 program context, reach, fidelity, dose delivered and received, implementation, and recruitment.

The findings from this feasibility trial hold the potential to carry out the large multicentre trial of clinical and cost-effectiveness and scale-up across Pakistan and other similar settings to meaningfully impact child behaviour and family dynamics in culturally diverse contexts.

The at-risk mental state (ARMS) describes individuals at high risk of developing schizophrenia or psychosis. This study aimed at exploring the demographic characteristics of individuals who transitioned to psychosis from a large multicenter factorial design trial.

This was a secondary analysis of large multicenter randomised controlled trial of minocycline and/or omega-3 fatty acids added to treatment as usual for at-risk mental states. Participants (n = 326) were randomised to minocycline, omega-3, combined minocycline and omega-3 or to double placebo for 6 months. The primary outcome was transition to psychosis at 12 months.

Forty-five (13.8%) participants transitioned to psychosis. The mean age of participants was 23.31 (5.31 SD) and 15.6% no formal education, 8.9% primary, 48.9% matriculation, 8.9% intermediate and 15.6% graduation and above. Majority 66% of participants were male and 71.1% single, 66.7% living in a joint family, 44.4% were employed, 24% students, 17.8% household/housewife and 3% unemployed. Interestingly 36.8% participants had a family history of psychosis, followed by 21.0% any unknown mental illnesses, 15.8% bipolar disorder, 15.8% depression, 5.3% anxiety and 5.3% intellectual disability. The mean total score for the Prodromal Questionnaire was 8.93, with a standard deviation of 1.67. The mean score on the Comprehensive Assessment for At Risk Mental State (CAARMS) unusual thoughts was 3.98 (SD = 0.84), Non-Bizarre Ideas 3.64 (SD = 0.77), Perceptual Abnormalities 3.76 (SD = 0.71) and disorganized speech 2.49 (SD = 1.12). Participants had mean Social and Occupational Functioning (SOFAS) score of 66.67 which suggests moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

Transition to psychosis appears to have different demographic and clinical correlates which may have the causal relationship to transition. The cross-comparative studies are warranted to understand differences and similarities between the groups.

Suicide poses a significant public health issue, and the presence of suicidal thoughts stands out as a prominent risk factor, highlighting the importance of addressing this aspect for early intervention and prevention efforts. While older adults face an elevated risk of attempted suicide, research in this domain is currently constrained. This study aims to enhance and evaluate the efficacy of an E-CMAP (Culturally Manual Assisted psychological intervention for Elderly) in mitigating suicidal ideation among individuals aged 55 years and older in Pakistan.

The study will be carried out in 2 phases. Phase 1 is cultural adaptation and refinement of the intervention and phase 2 is exploratory randomised control trial. In Phase 1, focus groups were conducted (N = 2) with Health professionals and service users and carers for adaptation of CMAP manual for suicidal ideation. In Phase 2 randomized exploratory trial will be conducted with 192 older adults with suicidal ideation randomized either to 1) E-CMAP added to Treatment As Usual (TAU) or TAU arm. ECMAP is a problem solving intervention comprising 6 sessions delivered one to one over 3 months by trained therapists. All participants will be assessed at baseline and after intervention (i.e. 3 months) for suicidal ideation, hopelessness, depression, health-related quality of life, coping resources, satisfaction with intervention, and episodes of self-harm.

Thematic Analysis of focus group discussions indicates that participants expressed a preference for incorporating a religious element into distraction techniques, delivering information about the significance of medical treatment, showcasing recorded sessions illustrating problem-solving techniques, and involving family throughout the intervention period.

A culturally tailored psychosocial intervention that incorporates problem-solving and cognitive components has the potential to decrease the risk of suicide among older adults.

Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups.

To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire.

Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas.

A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased.

Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

Suicide is one of the leading causes of mortality worldwide, and the majority of suicide deaths occur in low- and middle-income countries.

To evaluate the demographic and clinical characteristics of individuals who have presented to health services following self-harm in Pakistan.

This study is a cross-sectional baseline analysis of participants from a large multicentre randomised controlled trial of self-harm prevention in Pakistan. A total of 901 participants with a history of self-harm were recruited from primary care clinics, emergency departments and general hospitals in five major cities in Pakistan. The Beck Scale for Suicide Ideation (BSI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS) and Suicide Attempt Self Injury Interview assessment scales were completed.

Most participants recruited were females (n = 544, 60.4%) in their 20s. Compared with males, females had lower educational attainment and higher unemployment rates and reported higher severity scores on BSI, BDI and BHS. Interpersonal conflict was the most frequently cited antecedent to self-harm, followed by financial difficulties in both community and hospital settings. Suicide was the most frequently reported motive of self-harm (N = 776, 86.1%). Suicidal intent was proportionally higher in community-presenting patients (community: N = 318, 96.9% v. hospital: N = 458, 79.9%; P < 0.001). The most frequently reported methods of self-harm were ingestion of pesticides and toxic chemicals.

Young females are the dominant demographic group in this population and are more likely to attend community settings to seek help. Suicidal intent as the motivator of self-harm and use of potentially lethal methods may suggest that this population is at high risk of suicide.