PRIDE comic book - Ajay and Priyanka’s ‘POD’ adventures

· A randomized trial in large, low-income secondary schools in New Delhi tested a novel intervention based on practical problem-solving, which was delivered by school counsellors with no prior mental health training

· The study showed very high demand for the brief (3-week) counselling programme, despite stigma around mental health

· The low-cost programme showed improvements in students’ psychological and social problems and reduced stress over a three-month period and could have global implications for youth mental health intervention

Academics from the University of Sussex and Harvard Medical School have been working on one of the world’s largest school mental health research programmes, in collaboration with India’s leading mental health research organization, Sangath and the London School of Hygiene and Tropical Medicine. Results from the PRIDE (PRemIum for aDolEscents*) project, published in the Lancet Child & Adolescent Health, showed that a low-cost, three-week programme delivered within a school setting could be an effective first-line mental health intervention for young people in India. The study was financially supported by the Wellcome Trust in the UK.

The participants were aged between 12-20 years and were selected on the basis of having persistently high mental health symptoms linked to a variety of psychosocial problems, including difficulties experienced at school, with peers and in family contexts. Students learned how to apply a structured problem-solving approach with the aid of specially designed comic books and one-to-one guidance from counsellors. The school counsellors were supervised by psychologists from Sangath but had no formal mental health training prior to the study. This model of “task-sharing” was important given the severe shortage of mental health specialists in India. According to WHO estimates from 2018, approximately 2 mental health workers are found in India per 100,000 population, compared with more than 70 per 100,000 in high-income countries.

Mental health problems are a leading health concern for young people in India – which is home to 20% of all adolescents globally – and suicide is the leading cause of death for 15–24-year-olds. Despite this, almost all adolescent-focused mental health intervention studies to date have focused on high-income and high-resourced settings, leaving a gap in effective programmes for low-resource settings.

The PRIDE school-based intervention model has been developed on the basis of stepped care, where increasingly specialised, resource-intensive interventions are reserved for individuals who do not respond to simpler first-line treatments. This research tested the first step in the care pathway and is one of the largest-ever studies to test a youth mental health intervention applicable across multiple problem types. Rather than focusing on a single mental health condition, it offers the promise of a broadly applicable, simple and scalable solution to improve mental health outcomes within a low-income setting. Sangath has been delivering its PRIDE counselling services completely free-of-cost in low-resource, government-run and government-aided schools since 2015. This research was conducted over an academic year at six large Delhi government schools in 2018-19. As part of the programme, students and school faculty were introduced to basic mental health concepts via interactive audio-visual presentations. Afterwards students were invited to volunteer to join the programme.

The counselling was delivered in four or five thirty-minute sessions supported by explanatory comic-style booklets, spread over three weeks. The content of the programme was designed to help students learn problem-solving skills. These fall under the larger umbrella of cognitive-behavioural therapies which help people to develop personal coping strategies for life difficulties and associated stress. Compared to the control group, who received only the booklets, the students who took part in counselling reported significant reductions in their main problems and stress levels.

On the release of the findings, Dr. Daniel Michelson, a Senior Lecturer in Clinical Psychology from the University of Sussex who co-led the study said: “This study found that a short counselling program – involving no more than five brief meetings with a school counsellor over three weeks – helped to reduce stressful problems faced by vulnerable teens in Delhi.

"Moreover, demand for the counselling programme was such that we filled our counselling slots ahead of schedule. The high level of interest that we observed among students runs counter to ideas that young people are reluctant to seek help for emotional, behavioural and interpersonal difficulties. This has important lessons for how we can deliver cost-effective, non-stigmatising mental health support for some of the most disadvantaged young people in society, both in India and potentially on a global scale.”

Prof. Vikram Patel, The Pershing Square Professor of Global Health at Harvard Medical School and Principal Investigator of the study added: “This study is a wonderful demonstration of the scientific impact of collaboration between international researchers with NGOs, universities and government departments in India. I am especially excited that these results show how a very low-cost psychological intervention can be delivered by counsellors with no prior mental health training to students in the poorest neighbourhoods of New Delhi. We must now work towards improving the effectiveness of the interventions and scaling these up across the school sector.”

Given the low input in terms of time and resources but high impact in terms of outcomes for students, the PRIDE problem-solving intervention holds great promise as a first-choice treatment that could be scaled up in various languages and offered widely to schools across India. Where resources allow, this could be augmented by a second-stage intervention for those adolescents with persistent problems.

The full paper, titled “Effectiveness of a Brief Lay Counselor-Delivered, Problem Solving Intervention for Adolescent Mental Health Problems in Urban, Low-Income Schools in India” is available here: https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30173-5/fulltext 

* PREMIUM is an acronym developed in a previous Wellcome Trust research programme: Programme for Effective Mental Health Interventions in Under-Resourced Health Systems 

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