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July 26, 2020 by Lucie Cluver | The Lancet Child & Adolescent Health

Solving the global challenge of adolescent mental ill-health

In The Lancet Child & Adolescent Health, Daniel Michelson and colleagues1 report the results of the first randomised controlled trial of a transformative research programme: PRemIum for aDoLEscents (PRIDE). The authors set out a vision of evidence-based, rigorously tested mental health services for adolescents in low-income and middle-income settings.1

These services are designed as a stepped series of interventions to be implemented at low cost, by lay workers, and at scale.2 In low-income settings globally, only a tiny fraction of adolescents with mental health distress will ever have access to psychiatric or psychological support.3 There is no question that this work is both essential and urgent.

The trial compares two delivery mechanisms of a problem-solving intervention for common mental health problems.1 In very low-income urban Indian schools, adolescents (aged 12–20 years) self-referred with clinical-level mental health problems. They received either lay counsellor directed sessions with accompanying comic-based booklets about problem solving and how to cope with common difficulties, or the booklets alone. Although the booklet-only delivery was intended as a control group, both groups of adolescents showed reductions in overall mental health symptoms, functional impairment, internalising symptoms, externalising symptoms, and improved wellbeing. The group receiving additional lay counsellor support showed greater reductions in adolescent-prioritised problems, and in perceived stress. It is remarkable that the rates of clinical remission for both groups were within the benchmarked range of 40–60% for evidence-based psychological treatments.

The findings of this study have important and wide-ranging implications. As the authors discuss,1 the booklets are likely to have been an active intervention, especially in low-resourced settings where adolescents were receiving no other mental health support. This observation supports initial evidence for the effectiveness of a low-intensity, low-resource mental health intervention that could feasibly be delivered at the population level in low-income settings. The results of the planned 12 month post-hoc study and economic evaluation will help to inform and refine these findings. The study also shows the effectiveness of transdiagnostic approaches and common design principles in adolescent mental health, supporting the validity of moving beyond narrower diagnostic criteria to achieve wider reach without sacrificing clinical value.1

A core aspect of this work is the conscious effort of mental health research and service provision in joining forces with the education sector.4 The researchers recognise that reaching adolescents at the population level will not be achieved through health services alone. In India, where secondary school enrolment is high, this approach has exceptional potential to be scaled up. However, this approach could miss some of the most vulnerable adolescents, particularly in rural areas and among the poorest groups. In settings with lower adolescent school enrolment or gender differences in access to education, additional sectoral partnerships and innovative approaches will be necessary.

This study might also indicate opportunities for the new realities we face in service provision. The study presents a scalable intervention that could be used when face-to-face counselling is challenged by physical distancing, school closures, and reduced timetables that restrict flexibility. The COVID-19 epidemic has brought increased mental health distress among young people and new needs for mental health support,5 as well as an anticipated economic downturn that will hit hardest in low-income and middle-income countries.6 As options for remote learning are developed, the inclusion of mental health support within educational responses could be achievable and effective.

At the UNICEF and WHO’s Leading Minds Conference in November, 2019, Vikram Patel, the corresponding author of this study, threw down a gauntlet to the field of mental health: the overwhelming majority of children who already have mental health problems receive no recognition, nor any form of intervention that we know can transform their lives.7

The PRIDE programme of research aims to develop low-cost scalable interventions for adolescents, and test them rigorously in high-poverty educational contexts. Sangath—the non-governmental organisation leading this work—makes their interventions publicly and freely available online, setting a standard for other researchers and developers. Their work provides a strong argument that mental health programmes developed by researchers should never be commercialised, but instead be considered a public good.

The next challenge is achieving sustainability and scale, which will mean building coalitions with policy makers, funders, and advocacy groups, and further bridges beyond the health sector. Sustainability and scaling up might require new research and testing of the effects of low-cost mental health interventions across Sustainable Development Goal outcomes beyond health, such as school achievement, employment, and gender equality.8

Expanding beyond India will also require careful assessment of acceptability and effectiveness in other low-resource regions.

This study, and the wider programme of research that it is part of, are important steps to reaching adolescent mental health-care provision at scale.

I declare no competing interests.


  1. Michelson D, Malik K, Parikh R, et al. Effectiveness of a brief lay counsellor-delivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in India: a randomised controlled trial. Lancet Child Adolesc Health. 2020; (published online June 22. 
  2. Michelson D, Malik K, Krishna M, et al. Development of a transdiagnostic, low-intensity, psychological intervention for common adolescent mental health problems in Indian secondary schools. Behav Res Ther.2019; (published online July 30.)
  3. Morris J, Belfer M, Daniels A, et al. Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries. J Child Psychol Psychiatry.2011; 521239-1246
  4. Parikh R, Michelson D, Sapru M, et al. Priorities and preferences for school-based mental health services in India: a multi-stakeholder study with adolescents, parents, school staff, and mental health providers. Glob Ment Health (Camb).2019; 6e18
  5. Dalton L, Rapa E, Stein A. Protecting the psychological health of children through effective communication about COVID-19.
    Lancet Child Adolesc Health.2020; 4346-347 
  6. World Bank. Global Economic Prospects, June 2020. International Bank for Reconstruction and Development/The World BankWashington, DC2020
  7. Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development.
    Lancet.2018; 3921553-1598
  8. Sherr L, Cluver L, Desmond C et al. A new vehicle to accelerate the UN Sustainable Development Goals. Lancet Glob Health.2020; 8e637-e638



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