Efficacy of school-based interventions for mental health problems in children and adolescents in low and middle-income countries: A systematic review and meta-analysis

Effectiveness of combining psychological prevention interventions with interventions that address the social determinants of mental health in low- and middle-income countries: a systematic review and meta-analysis

QUESTION

Task-shared preventive psychological interventions combined with interventions addressing social determinants of mental health may prevent common mental health conditions (CMHCs), particularly in low- and middle-income countries (LMICs). However, an evidence synthesis of their combination has not yet been investigated. We aimed to systematically assess the effectiveness of these combined interventions in LMICs.

STUDY SELECTION AND ANALYSIS

We searched Epistemonikos, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, GIM, ClinicalTrials.gov and WHO ICTRP until 2 September 2024. Two reviewers independently abstracted the data and evaluated the risk of bias of included studies using the Cochrane Risk of Bias 2 tool. We performed random-effects meta-analyses to assess the primary outcome, which was the incidence of CMHCs, and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. The protocol was registered in PROSPERO (CRD42023451072).

FINDINGS

Of the 21 780 records identified from electronic sources, we included 31 randomised controlled trials from 21 LMICs involving 35 885 participants. Combined interventions were effective in reducing the incidence of depression and post-traumatic stress disorders at postintervention compared with control conditions for adults (risk ratio (RR) 0.82, 95% CI 0.73 to 0.93) and children (RR 0.70, 95% CI 0.49 to 0.99). At 7-24 months, we only found beneficial effects of combined interventions for depressive symptoms in children (standardised mean difference -0.41, 95% CI -0.63 to -0.18). No data were available on the incidence of anxiety.

CONCLUSIONS

Combined task-shared interventions are effective in mostly short-term prevention of CMHCs in LMICs. Combining strategies targeting social determinants with psychological prevention approaches offers a potential opportunity to reduce the global mental health burden. Future research should focus on key intervention components and head-to-head comparisons between different interventions and between their components.

PROSPERO REGISTRATION NUMBER

CRD42023451072.

The Perniciousness and Promise of School-Based Mental Health Service Delivery for Youth

Rates of child and adolescent mental disorder have risen sharply while access to community-based mental health care options continues to be elusive for many families. Substantial and persistent barriers to community-based mental health care have prompted multiple stakeholders to pursue an approach that emphasizes health promotion and intervention practices within the context of ecologically valid and more accessible environments. The most prominent of these environments has been schools that can serve as local and centralized access points to various services, including mental health care. The rapid expansion of school-based mental health service delivery systems, however, carries both risk of perniciousness as well as significant promise with respect to effective and equitable care. This article summarizes key concerns surrounding school-based mental health service delivery systems, including non-beneficence and harm, support disparities, unsustainable implementation, oppressive school climate, and linkage to punitive and discriminatory practices. Broad-based recommendations to help realize the promise of effective and equitable care for students with mental health and behavioral challenges are also presented vis-à-vis each of these concerns. At the same time, natural tensions between various mandates assigned to schools as well as between schools and their surrounding communities will need to be addressed to reach the full potential of school-based mental health service delivery systems.

Impact of a music therapy program on mental health and school attendance among female adolescents in Kasai-Central province, Democratic Republic of Congo

This study assessed whether a music therapy program improved mental health and school attendance among girls in the Democratic Republic of Congo (DRC) following economic and conflict-related insecurity. It included 483 girls aged 10-14 who participated in the Healing in Harmony (HiH) program, implemented by World Vision and Make Music Matter in Kasai-Central province. Participants completed surveys before and after the program, and up to two follow-up interviews assessing depression, anxiety, self-esteem, and school attendance. Before the program, 36.0% (95% CI 31.7%-40.3%) and 60.5% (95% CI 56.1%-64.8%) screened positive for depression and anxiety, respectively. After participation, the risk of screening positive declined by 75% for depression (RR = 0.27, 95% CI 0.22-0.32) and by about half for anxiety (RR = 0.46, 95% CI 0.41-0.53), with improvements sustained up to 17 months. Self-esteem scores increased by 3.93 points (95% CI 3.22-4.64, p<0.001). School absenteeism decreased from 10% (95% CI 7.2%-12.6%) to 5.4% (RR = 0.54, 95% CI 0.40-0.73). Participation in HiH was associated with sustained improvements in mental health and school attendance. These findings support integrating psychosocial care into humanitarian responses to improve both mental health and educational outcomes for crisis-affected children.

Exploring the synergy between emotional intelligence and self-esteem among university students in Ghana

BACKGROUND

The need for educational institutions to create a conducive learning environment for participation of all students in school activities is one of the pillars advocated under Goal 4 of the United Nations Sustainable Development Goals. While there are structures institutionalized to promote students' well-being, universities are faced with a myriad of challenges which can negatively impact mental health and disrupt the overall learning experiences of students. This study explored the relationship between Emotional Intelligence and Self-Esteem which have been found to influence the mental health of students.

METHOD

Informed by the cross-sectional design, one thousand and twenty (N = 1020) university students were recruited to self-report their Emotional Intelligence and Self-Esteem. The participants completed the Schutte Emotional Intelligence scale and the Rosenberg's Self-Esteem scale. The data were validated using confirmatory factor analysis, means were computed, followed by multivariate analysis of variance and hierarchical multiple regression.

RESULTS

The study showed that participants were ambivalent on both EI and self-esteem. The hypothesized relationship between Emotional Intelligence and Self-Esteem was supported by the study findings. More so, demographic variables such as gender, religion and programme of study provided further insight into Emotional Intelligence and Self-Esteem of participants.

CONCLUSION

In conclusion, the researchers of this study called on educators and university administrators to prioritize the Emotional Intelligence and Self-Esteem of students in mental health interventions. The need for partnership between administrators and religious leaders and other study implications, are discussed.

School mental health prevention and intervention strategies in China: a scoping review

Student mental health issues remain a significant global concern, imposing considerable health, social, and economic burdens. China has also published numerous national policies prioritizing this area. To further investigate the current prevention and intervention programs, we conducted a scoping review, searching six databases (three in English and three in Chinese) up to May 2024. A total of 77 eligible studies were included. Our findings highlight several gaps in current practices, such as regional disparities in school-based mental health programs, insufficient focus on younger children and developmental issues, limited comprehensive pathways from screening to classification, prevention, and intervention, and a lack of an integrated approach to promoting mental health among children and adolescents. These findings indicate an urgent need for improvements in this field, calling for future studies to help reduce the burden of mental health problems and support the holistic development of children in China.

Suicidal behaviour, depression and generalized anxiety and associated factors among female and male adolescents in Mozambique in 2022-23

BACKGROUND

The purpose of the study was to assess the prevalence and associated factors of major depressive disorder (MDD), generalized anxiety disorder (GAD), and past 12-month suicidal behaviour (PSB) among adolescents in Mozambique.

METHODS

Data from 3,109 females (aged 15-19 years) and 1,439 males (aged 15-19 years) that participated in the 2022-23 Mozambique Demographic and health Survey were analysed. MDD was assessed with the PHQ-9 and GAD with the GAD-7.

RESULTS

Results indicate that among girls the prevalence of PSB was 4.3% (attempt 1.0%, plan 1.9% and/or ideation 3.6%) and among boys 2.5% (attempt 0.3%, plan 0.7% and/or ideation 2.4%). Among girls and boys, the prevalence of MDD (≥ 8 scores) was 15.5% and 3.7%, respectively, and the prevalence of GAD (≥ 5 scores) was 25.0% and 10.3%, respectively. In adjusted logistic regression analysis, among girls, GAD was positively and solid fuel use was negatively associated with PSB, while among boys MDD and urban residence were positively associated with PSB. Among female adolescents, currently being pregnant and "big problem to get money for medical treatment" increased the odds of MDD. While among male adolescents, urban residence, having a genital sore or ulcer, has living children, and early sexual debut were positively associated with MDD. Urban residence, current alcohol use, and early sexual debut were positively associated with GAD in male adolescents, while poorer wealth status, being pregnant, and having a "big problem to get money for medical treatment" were positively associated with GAD in female adolescents.

CONCLUSION

About 3% of participants had PSB, among girls one in five had MDD or GAD and among boys more than 5% had MDD or GAD. Public health interventions can be guided by several associated factors that have been identified.

Tipping the scales for global mental health: A summary of the Presidential Panel at the 39th Annual Meeting of the International Society for Traumatic Stress Studies

In the past decade, there has been an increasing focus within scientific research on how to assist people affected by the negative consequences of trauma and crises around the globe. As many countries struggle with a lack of resources to deliver mental health interventions, scalable strategies have been developed to help more people in need. These scalable strategies were the theme of the 39th annual meeting of the International Society for Traumatic Stress Studies (ISTSS). The presidential panel, chaired by Marit Sijbrandij during her ISTSS presidency, brought together a group of experts in the field of scalable interventions: Kenneth Carswell, Syed Usman Hamdani, Judy Bass, and Eirini Karyotaki. The panel highlighted the current state of the evidence on scalable interventions for adults and children and outlined important next steps for research and implementation. These recommendations include further improving the availability of, and evidence for, scalable interventions through increased training and sustained funding; conducting more studies in underrepresented samples, such as children and adolescents; and promoting open access availability of research findings worldwide. In this paper, we provide an overview of the topics discussed in the panel as well as the key takeaways.

How Distressed Are Adolescent Students? A Mix-Method Study on High School Students in Northern Italy, Two Years after the Beginning of the COVID-19 Pandemic

Adolescence is a central phase for the development of a person's identity, involving complex multidimensional changes and increasing vulnerability to distress. This study aimed to investigate the psychological well-being of adolescent students in Brescia (Northern Italy), two years after the beginning of the COVID-19 pandemic. An online survey investigated the extent and the reasons reported by high school students (13-21 years) for their emotional distress (ED), also considering other factors such as physical activity, nutrition, sleep and smartphone overuse. The main reasons for ED were classified through a qualitative analysis of the free-text answers. A total of 1686 students agreed to participate, and 50% showed a presence of ED. According to a multiple logistic analysis, adolescents were more at risk of ED if they were female (AdjOR 2.3), older (AdjOR 1.6), slept less than 8 h (AdjOR 1.5), perceived increased anxiety (AdjOR 3.4), and adopted certain eating behaviors, e.g., comfort food consumption (AdjOR 2.0). According to free-text answers, the main reasons for ED were "school pressure", "relationships with family and peers", "negative emotional states" and "the pandemic". The results show a high level of ED among adolescents, and the reported reasons may help to better address their psychological needs after the pandemic.

Effectiveness of a group psychological intervention to reduce psychosocial distress in adolescents in Pakistan: a single-blind, cluster randomised controlled trial

BACKGROUND

Emotional problems in adolescents living in low-income and middle-income countries (LMICs) remain largely unaddressed; key reasons include a scarcity of trained mental health professionals and unavailability of evidence-based, scalable psychological interventions. We aimed to evaluate the effectiveness of a non-specialist-delivered, group psychological intervention to reduce psychosocial distress in school-going adolescents in Pakistan.

METHODS

In a two-arm, single-blind, cluster randomised controlled trial, eligible public school clusters from a rural subdistrict of Gujar Khan, Rawalpindi, Pakistan, were randomised (1:1, stratified by sex) using permuted block randomisation into intervention (n=20) and wait-list control (n=20) groups. Adolescents aged 13-15 years who provided informed assent and caregivers' consent were screened for psychosocial distress using the youth-reported Pediatric Symptoms Checklist (PSC; total psychosocial distress scores from 0 to 70), and those scoring 28 or more and their caregivers were enrolled into the trial. Adolescents in the intervention group received seven weekly group sessions and their caregivers received three biweekly group sessions in school settings from trained non-specialists. The primary outcome was change from baseline in the total PSC scores at 3 months post-intervention. The trial was registered prospectively with the International Standard Randomised Controlled Trial Number registry, ISRCTN17755448.

FINDINGS

From the 40 school clusters that were included, 282 adolescents in the intervention group and 284 adolescents in the wait-list control group were enrolled between Nov 2 and Nov 30, 2021. At 3 months, adolescents in the intervention group had significantly lower mean total score on the PSC compared with adolescents in the control group (mean difference in change from baseline 3·48 [95% CI 1·66-5·29], p=0·0002, effect size 0·38 [95% CI 0·18-0·57]; adjusted mean difference 3·26 (95% CI 1·46-5·06], p=0·0004, effect size 0·35 (0·16-0·55). No adverse events were reported in either group.

INTERPRETATION

The group psychological intervention most likely represents a feasible and effective option for adolescents with psychosocial distress in school settings.

FUNDING

UK Medical Research Council, Foreign Commonwealth and Development Office, Department of Health and Social Care.

TRANSLATION

For the Urdu translation of the abstract see Supplementary Materials section.

Development of a school-based programme for mental health promotion and prevention among adolescents in Nepal and South Africa

Introduction

Adolescence is a critical time for mental health promotion and prevention and establishing healthy behaviours. Implementing universal, school-based psychosocial interventions can improve short- and long-term health trajectories for adolescents. While these interventions may offer important opportunities for fostering skills and relationships, few school-based interventions have been developed for and tested in low- and middle-income countries (LMICs) where adolescent mental health needs may be significant and under-served. This manuscript details the development of a multi-component, universal school-based intervention, Health Action in ScHools for a Thriving Adolescent Generation (HASHTAG), for adolescents aged 12-15 years in Nepal and South Africa.

Methods and results

We describe HASHTAG's development over four phases, combining methods and results as each phase was iteratively conducted between 2018 and 2021. Phase 1 included a systematic review and components analysis, building from WHO guidelines for adolescent mental health. Seven components were strongly supported by the evidence: emotional regulation, stress management, mindfulness, problem-solving, interpersonal skills, assertiveness training, and alcohol and drug education. Phase 2 encompassed site selection, theory of change development, and formative research engagements; research teams in each site engaged adolescents and key adult stakeholders to identify priorities for intervention. Stakeholders voiced preferences for external facilitators and key content and delivery for intervention sessions. These findings informed Phase 3, a draft manual of HASHTAG, including a whole-school component, called Thriving Environment in Schools, and a classroom-based, six-session component, Thrive Together. In Phase 4, participants engaged in consultative workshops to review and contextualise content by country, preparing HASHTAG for implementation in a feasibility trial. Minor adaptations were made in Nepal, including using school nurses and adjusting take-home materials; both country's workshops identified practical considerations for implementing activities.

Conclusions

HASHTAG was designed around core evidence-based components to increase translatability across LMICs, while enabling country-specific tailoring to enhance feasibility. Future research will test whether this multi-component, whole-school approach can improve adolescent mental health.

Possible Mental Health Interventions for Family Members of a Close Relative Who Has Suicidal Thoughts or Committed Suicide: A Pilot Project at a Mental Health Center

Background: Suicides are an actual issue, especially in Lithuania, where, despite significant efforts, the number of suicides remains very high. In cases of suicide, society painfully loses its members, and the relatives of the person who committed suicide, engaged in self-harm, or attempted suicide face many negative experiences. Methods: The purpose of this article is to describe the pilot project applied for 2 years in the Mental Health Center (MHC) in the city of Vilnius, Lithuania, in organizing and providing services to people whose relatives committed suicide or attempted suicide or self-harm. This prevention and early intervention program, organized by an interdisciplinary team at an MHC, appeared appropriate, effective, and well-attended. Program clients could participate anonymously and have the opportunity to choose the time and the right services for themselves from the offered program services package. Results: Providing the possibility for family members to receive flexible mental health services at the primary center increased the attractiveness of the program and reduced stigma. Conclusions: The program results demonstrated the applicability of the implementation of such an initiative as a relevant possibility when providing complex help for the relatives of self-harming and/or suicidal people.