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.

Breast cancer is major cause of mortality in females, affecting 2.1m women annually. Annual mortality rates are double within south Asian women compared with high-income countries. Pakistan has very high rates of breast cancer. Co-morbid depression and anxiety is reported in more than one third of breast cancer survivors and predict higher recurrence and poorer survival.

Objective:

To evaluate the clinical effectiveness of Moving on After Breast Cancer Plus Cognitive Behaviour Therapy (Moving on ABC Plus) to reduce depression and anxiety in breast cancer survivors in Pakistan.

A mixed method randomized controlled trial with 354 survivors of breast cancer recruited from the in- and out-patient services of oncology departments both from public and private hospitals of 5 major cities in Pakistan.

Individuals scoring 10 or higher on either the Patient Health Questionnaire-9 (PHQ-9) or the Generalized Anxiety Disorder scale (GAD-7) were enrolled. All participants underwent assessments using the PHQ-9, GAD-7, Functional Assessment of Cancer Therapy—Breast; EuroQol-5D; Multidimensional Scale for Perceived Social Support; Intrusive Thoughts Scale; and Rosenberg Self-Esteem Scale at the baseline and were randomly assigned to one of two trial groups: Moving on ABC plus or routine care. Those in the intervention group received 12 individual sessions of Moving on ABC plus, facilitated by trained master-level psychologists over 4 months. Follow-up assessments were conducted at 3- and 6-months after randomization. Individuals in routine care group continued their standard care. Qualitative interviews were conducted with 15 participants from the intervention group upon completion of the intervention.

The trial established the effectiveness of the integrated intervention, at 6-month follow up preserving 96% of retention. Intervention group reported a significantly higher reduction in depression, anxiety and intrusive thoughts, and improvement in health-related quality of life and self-esteem compared with routine care arm at end of the intervention. They endorsed the usefulness of intervention during qualitative interviews with improvement in psychological well-being, social support network, and interpersonal relationships. Fatigue was reported as a potential barrier to participating in the intervention.

Results of this trial are in favour of psychological intervention; therefore, such programs should be implemented as part of routine care to reduce psychological distress and improve quality of life of this vulnerable population.

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.

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.

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.

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.

We aimed to examine the burden of mental disorders in Pakistan over the past three decades. We used the crude data of disability-adjusted life-years (DALYs) obtained from the Global Burden of Disease Study database (1990–2019) to represent burden. Data were retrieved on 26 January 2021. Data for adults of reproductive age (aged 15–49 years) were analysed to discuss and interpret the disease burden. An analysis was conducted on total DALYs separately for the genders for ten mental disorders reported in Pakistan.

DALYs increased drastically with the onset of reproductive age. Depressive disorder was the most reported mental disorder, contributing 3.13% (95% CI 2.25–4.24) of total DALYs, and varied significantly between genders: females 3.89% (95% CI 2.73–5.29) versus males 2.37% (95% CI 1.62–3.25).

A nationwide high-quality epidemiological surveillance system should be implemented to monitor mental disorders and offer culturally appropriate preventive services.

Bipolar disorder is a source of marked disability, morbidity and premature death. There is a paucity of research on personalised psychosocial interventions for bipolar disorder, especially in low-resource settings. A pilot randomised controlled trial (RCT) of a culturally adapted psychoeducation intervention for bipolar disorder (CaPE) in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes regarding bipolar disorder, and improvement in mood symptom scores and health-related quality of life measures compared with treatment as usual (TAU).

The current protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan. Trial registration: NCT05223959.

A multicentre individual, parallel-arm RCT of CaPE in 300 Pakistani adults with bipolar disorder. Participants over the age of 18, with a diagnosis of bipolar I or II disorder who are currently euthymic, will be recruited from seven sites: Karachi, Lahore, Multan, Rawalpindi, Peshawar, Hyderabad and Quetta. Time to recurrence will be the primary outcome assessed using the Longitudinal Interval Follow-up Evaluation (LIFE). Secondary measures will include mood symptoms, quality of life and functioning, adherence to psychotropic medications, and knowledge and attitudes regarding bipolar disorder.

This trial will assess the effectiveness of the CaPE intervention compared with TAU in reducing the time to recurrence for people with bipolar disorder currently in remission in Pakistan and determine the effect on clinical outcomes, quality of life and functioning.

A successful trial might lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings, including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority group patients with bipolar disorder.

Prevalence of post-traumatic stress disorder (PTSD) is high in Pakistan both due to natural disasters and ongoing conflicts. Offspring of trauma survivors are at increased risk for mental and physical illnesses. Parental PTSD has been linked to troubled parent–child relationships, behaviour problems, trauma symptoms, and depression in children. This study aims to explore the acceptability, feasibility and indications of the effectiveness of group learning through play plus trauma-focused cognitive behaviour therapy (LTP Plus TF-CBT) for parents experiencing PTSD.

This is a two-arm pilot cluster randomised controlled trial (RCT). We aim to recruit 300 parents with a diagnosis of PTSD. The screening will be done using the Impact of Event Scale-Revised. Diagnosis of PTSD will be confirmed using the Clinician-Administered PTSD Scale-5 (CAPS-5). Union Councils from Peshawar and Karachi will be randomised into either group LTP Plus TF CBT arm or treatment as usual (TAU). The intervention includes 12 sessions of LTP Plus TF-CBT delivered weekly in the first 2 months and then fortnightly in a group setting by trained psychologists. The groups will be co-facilitated by the community health workers (CHWs). Parents will be assessed at baseline and 4th month (end of the intervention), using the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7) Scale, Client Service Receipt Inventory (CSRI), and Ages and Stages Questionnaire (ASQ-3)

This trial would help build an understanding of the acceptability, feasibility and indications of the effectiveness of a low-cost parenting intervention.

Globally, nearly two-thirds of people with dementia reside in low- and middle-income countries (LMICs), yet research on how to support people with dementia in LMIC settings is sparse, particularly regarding the management of behavioural and psychological symptoms of dementia. Understanding how best to manage these symptoms of dementia with non-specialist approaches in LMICs is critical. One such approach is a non-pharmacological intervention based on the Montessori method.

To evaluate the feasibility and acceptability of a culturally adapted, group-based Montessori intervention for care home residents with dementia and their study partners, who were paid care workers in Pakistan.

This was a two-stage study: a cultural adaptation of the Montessori intervention and a single-arm, open-label, feasibility and acceptability study of 12 participant dyads. Feasibility and tolerability of the intervention and study procedures were determined through the recruitment rate, adherence to the protocol and acceptance of the intervention. Qualitative interviews were undertaken with the study partners. A pre–post exploratory analysis of ratings of behavioural and psychological symptoms of dementia, functional ability and quality of life were also conducted.

The recruitment and retention rates of people with dementia were acceptable, and the intervention was well tolerated by participant dyads. Findings show a reduction in agitation levels and improvement in mood and interest for the activities.

Feasibility studies of low-cost, easy-to-deliver and culturally adapted interventions are essential in laying the groundwork for subsequent definitive effectiveness and/or implementation trials for dementia in LMICs, where awareness and resources for dementia are limited.