Mark van Ommeren’s research while affiliated with Department of Mental Health and Substance Abuse Services, Tennessee and other places

Aims The majority of studies of mental health interventions for young adolescents have only evaluated short-term benefits. This study evaluated the longer-term effectiveness of a non-specialist delivered group-based intervention (Early Adolescent Skills for Emotions; EASE) to improve young adolescents’ mental health. Methods In this single-blind, parallel, controlled trial, Syrian refugees aged 10-14 years in Jordan who screened positive for psychological distress were randomised to receive either EASE or enhanced usual care (EUC). Primary outcomes were scores on the Paediatric Symptom Checklist (PSC) assessed at Week 0, 8-weeks, 3-months, and 12 months after treatment. Secondary outcomes were disability, posttraumatic stress, school belongingness, wellbeing, and caregivers’ reports of distress, parenting behaviour, and their perceived children’s mental health. Results Between June, 2019 and January, 2020, 185 adolescents were assigned to EASE and 286 to EUC, and 149 (80.5%) and 225 (78.7%) were retained at 12 months, respectively. At 12 months there were no significant differences between treatment conditions, except that EASE was associated with less reduction in depression (estimated mean difference -1.6, 95% CI –3.2 to -0.1; p=.03; effect size, -0.3), and a greater sense of school belonging (estimated mean difference -0.3, 95% CI –5.7 to -0.2; p=.03; effect size, 5.0). Conclusions Although EASE led to significant reductions in internalising problems, caregiver distress, and harsh disciplinary parenting at 3-months, these improvements were not maintained at 12 months relative to EUC. Scalable psychological interventions for young adolescents need to consider their ongoing mental health needs. Prospectively registered: ACTRN12619000341123.

The World Health Organization (WHO) Flexible Interview for ICD-11 (FLII-11) is being developed as an open-access tool to support national epidemiological investigations and other population-based and clinical studies of mental disorders. It is a fully structured diagnostic interview that can be administered by trained lay interviewers and assesses mental disorders associated with the greatest global disease burden. It builds on the operationalization work completed for the SCII-11. Like the SCII-11, the FLII-11 is modular and customizable to assess a subset of disorders, and can evaluate current and lifetime diagnostic status. Available modules include psychotic, mood, anxiety, obsessive- compulsive and related, post-traumatic, eating, addictive behaviour, and substance use disorders, and attention deficit hyperactivity disorder. An adaptation for adolescents aged 13-17 has also been developed.

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.

Plain language summary Do psychological and social interventions promote improved mental health in people living in low‐ and middle‐income countries affected by humanitarian crises? Key message – We did not find enough evidence in favour of interventions for promoting positive aspects of mental health in humanitarian settings. Larger, well‐conducted randomised studies are needed. Mental health during a humanitarian crisis A humanitarian crisis is an event, or series of events, that threatens the health, safety, security, and well‐being of a community or large group of people, usually over a wide area. Examples include wars and armed conflicts; famine; and disasters triggered by hazards such as earthquakes, hurricanes, and floods. People living through a humanitarian crisis may experience physical and mental distress and experience highly challenging circumstances that make them vulnerable to developing mental disorders, such as post‐traumatic stress disorder, depression, and anxiety. The estimated occurrence of mental disorders during humanitarian crises is 17% for depression and anxiety, and 15% for post‐traumatic stress disorder. What are psychological and social interventions? Psychological and social interventions (also called psychosocial) recognise the importance of the social environment for shaping mental well‐being. They usually have both psychological components (related to the mental and emotional state of the person; e.g. relaxation) and social components (e.g. efforts to improve social support). They can be aimed at promoting positive aspects of mental health (e.g. strengthening hope and social support, parenting skills), or prevent and reduce psychological distress and mental disorders. What did we want to find out? We wanted to know if psychosocial interventions could promote positive mental health outcomes in people living through humanitarian crises in low‐ and middle‐income countries, compared with inactive comparators such as no intervention, intervention as usual (participants are allowed to seek treatments that are available in the community), or waiting list (participants receive the psychosocial intervention after a waiting phase). What did we do? We searched for studies that looked at the effects of psychosocial interventions on positive aspects of people's mental health in low‐ and middle‐income countries affected by humanitarian crises. In these studies, we selected those outcome measures representative of positive emotions, positive social engagement, good relationships, meaning, and accomplishment. This is in line with the definition of mental health given by the World Health Organization, according to which mental health is "a state of mental wellbeing that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community." We looked for randomised controlled studies in which the interventions people received were decided at random. This type of study usually gives the most reliable evidence about the effects of an intervention. What did we find? We found 13 studies on mental health promotion with a total of 7917 participants. Nine studies were with children and adolescents (aged seven to 18 years), and four were with adults (aged over 18 years). Four studies were carried out in Lebanon; two in India; and one study each in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The average study duration was 18 weeks (minimum 10 weeks, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non‐governmental organisations. The studies measured mental well‐being, functioning, and prosocial behaviour (a behaviour that benefits other people or society as a whole), at the beginning of the study, at the end of the intervention, and three or four months later. They compared the results in people who did and did not receive the intervention. What are the results of our review? There is not enough evidence to make firm conclusions. In children and adolescents, psychosocial interventions may have little to no effect in improving mental well‐being, functioning, and prosocial behaviour, but the evidence is very uncertain. For the adult population, we found encouraging evidence that psychosocial interventions may improve mental well‐being slightly, but there were no data on any other positive dimensions of mental health. Overall, for both children and adults, we are not confident that these results are reliable: the results are likely to change when further evidence is available. What are the limitations of the evidence? The main limitation of this review is that we cannot guarantee that the evidence we have generated is trustworthy. This is a direct consequence of the small amount of data that addressed our research question. By conducting analyses from such a small pool of data, we cannot be sure that the changes in outcomes are related to the interventions provided, rather than due to the play of chance. Furthermore, people in the studies were aware of which treatment they were getting, and not all the studies provided data about everything that we were interested in. How up to date is this evidence? We included evidence published up to January 2023.

In low- and middle-income countries (LMICs), children and families face a multitude of risk factors for mental health and well-being. These risks are even further exacerbated in humanitarian emergencies. However, access to effective mental health services in such settings is severely limited, leading to a large mental health treatment gap. Middle childhood (5–12 years) is a crucial period for human development during which symptoms of emotional distress often emerge, with one in three mental disorders developing prior to age 14. However, there is little evidence of effective psychological interventions for children in this developmental stage, and suitable for implementation within LMICs and humanitarian emergencies. We conducted this evidence review to inform the development of a new intervention package based on existing best practice for this age group, drawing insights from both global and LMIC resources. Our review synthesizes the findings of 52 intervention studies from LMICs and humanitarian settings; 53 existing systematic reviews and meta-analyses covering both LMICs and high-income countries, and 15 technical guidelines. Overall, there is limited high-quality evidence from which to draw recommendations for this age group; however, some promising intervention approaches were identified for children experiencing externalizing and internalizing symptoms, traumatic stress and a combination of difficulties. Several effective interventions utilize cognitive-behavioral techniques for children, in either group or individual format, and incorporate caregiver skills training into treatment, although the findings are mixed. Most evaluated interventions use specialists as delivery agents and are lengthy, which poses challenges for scale-up in settings where financial and human resources are scarce. These findings will inform the development of new psychological interventions for children in this age group with emotional and behavioral difficulties.