Globally, burns are responsible for around 11 million injuries and 180 000 burn-related deaths yearly. Unfortunately, 9 of 10 burn injuries and deaths happen in low-and-middle-income countries (LMICs) such as Pakistan. One in three people admitted to hospitals with burn injuries die within three weeks, and survivors face serious lifelong physical, emotional and psychosocial problems. This may result in anxiety, depression, post-traumatic stress disorder, increased mortality and social disintegration. This study aims to evaluate if implementation of a culturally adapted multidisciplinary rehabilitation programme for burn survivors is clinically and cost-effective, sustainable and scalable across Pakistan.

• - To understand lived experiences of burn survivors, families, and other stakeholders including the experience of care and impact of burns To work together with key stakeholders (such as burn survivors, family members) to adapt a culturally appropriate affordable burn rehabilitation programme

• - To undertake social media campaigns to promote burn prevention and risk assessment at communities, workplaces/industries/households; improve first aid; and address burn related stigma

• - To work with policy makers/parliamentarians to develop national guidelines for burns care and prevention in Pakistan

There are 6 work-packages (WPs). WP1 is to co-adapt a culturally appropriate burn care and rehabilitation programme. WP2 will develop and implement national burn registry on WHO’s initiative. WP3 is a cluster randomised controlled trial to determine clinical and cost-effectiveness in Pakistan. WP4 will evaluate social media campaigns for burn prevention and reduce stigma. WP5 involves working with key-stakeholders for burns-related care and policy and WP6 offers sustainable capacity and capability for burns treatment and rehabilitation.

A clinical and cost-effective burn care quality and rehabilitation programme may have a huge potential to save lives and contribute health and socio-economic benefits for patients, families, and the healthcare system in Pakistan. The nation-wide implementation and involvement of burn centres across all provinces offer an excellent opportunity to overcome the problem of burn care access experienced in LMICs.

To date, burns prevention, care and rehabilitation have not received sufficient attention in policy initiatives in Pakistan and other LMICs. This study is an excellent opportunity to evaluate culturally adapted burn care and rehabilitation programmes that can be implemented across LMICs. We will disseminate our findings widely, using a variety of approaches, supported by our stakeholder and patient advisory groups.

None Declared

Low and middle-income countries (LMICs) hold the majority of disease burden attributed to major depressive disorder (MDD). Despite this, there remains a substantial gap for access to evidence-based treatments for MDD in LMICs like Pakistan. Measurement-based care (MBC) incorporates systematic administration of validated outcome measures to guide treatment decision making and is considered a low-cost approach to optimise better clinical outcomes for individuals with MDD but there is a paucity of evidence on the efficacy of MBC in LMICs.

This protocol highlights a randomized trial which will include Pakistani outpatients with moderate to severe major depression.

Participants will be randomised to either MBC (guided by schedule), or standard treatment (guided by clinicians’ judgement), and will be prescribed with paroxetine (10–60mg/day) or mirtazapine (7.5–45mg/day) for 24 weeks. Outcomes will be evaluated by raters blind to study protocol and treatment.

National Bioethics Committee (NBC) of Pakistan has given full ethics approval. The trial is being conducted and reported as per recommendation of the CONSORT statement for RCTs.

With increasing evidence from high-income settings supporting the effectiveness of MBC for MDD, it is now necessary to explore its feasibility, utility. and efficacy in low-resource settings. The results of the proposed trial could inform the development of a low-cost and scalable approach to efficiently optimise outcomes for individuals with MDD in Pakistan.

None Declared

Suicide is a leading cause of death among young people and most deaths by suicide occur in low and middle-income countries. School is the best place where we can identify and respond to youth suicide risk. School-based interventions for suicide prevention in young people have been successful across US, Europe and Australia, but require adaptations to be acceptable and feasible in Pakistan.

To develop and test culturally adapted preventative interventions for suicidal behaviours among pupils in secondary schools in Pakistan. The qualitative component aimed at exploring the views of students, parents, teachers and general practitioners on cultural adaptation, experience of participation, areas of improvement and suggestions for scale-up of the school-based suicide prevention program (SEPAK).

A clustered randomised controlled trial. The four culturally modified interventions 1) Linking Education and Awareness of Depression and Suicide Awareness (LEADS) Training for pupils (students=260) 2) the Question, Persuade, and Refer (QPR) for teachers (students=203) 3) QPR for parents (students=445); 4) Screening by Professionals (Profscreen) (students=260) were compared against control intervention (educational posters) (students=227). Structured questionnaires were administered at baseline and 1-month post-intervention to assess suicidal behaviours, psychological well-being and quality of life. A total of 8 focus groups (FGs) were conducted at pre and post intervention stage with each stakeholders.

Patient and public involvement and Engagement (PPIE) was strongly embedded in the project to ensure meaningful benefits for participants. A total of 40 schools were recruited from 8 cities across Pakistan. A total of 243 students attended LEADS intervention, 92 teachers and 304 parents completed QPR training, and 9 general practitioners were trained in ProfScreen. The retention rate at follow-up was 99% that shows feasibility of delivering intervention package in Pakistan. All participants marked SEPAK as effective in identifying risk of and preventing self-harm and suicide in young people and in improving pathways to treatment. Interventions were perceived as helpful in improving knowledge about mental health, impact of mental health difficulties on functioning, reducing stigma, equipping stakeholders to identify and signpost at-risk people. Improvement in clinical and teaching practice as well as understanding others behaviors were also reported.

This study suggest feasibility of integrating a suicide prevention program in existing educational system and highlights positive role of creating awareness about suicide in youth, introduction of school-based mental health programs, parental counseling and strengthening of the health system by training general practitioners in early identification of suicide risk and promoting suicide prevention strategies

None Declared

Bipolar disorder (BD) is a source of marked disability, morbidity, and premature death. There is a paucity of research on personalized psychosocial interventions for BD, especially in lowresource settings. A previously published pilot randomized controlled trial (RCT) of a Culturally adapted PsychoEducation (CaPE) intervention for BD in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes towards BD, and improvement in mood symptom scores and health-related quality of life measures compared to treatment-as-usual (TAU).

This protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan.

A multicentre individual, parallel arm, RCT of CaPE in 300Pakistani adults with BD. Participants over the age of 18, with adiagnosis of bipolar I and II and who are currently euthymic, will berecruited from seven sites including Karachi, Lahore, Multan, Rawalpindi,Peshawar, Hyderabad and Quetta. Time to recurrence will be the primaryoutcome assessed using Longitudinal Interval Follow-up Evaluation(LIFE). Secondary measures will include mood symptomatology, qualityof life and functioning, adherence to psychotropic medications, andknowledge and attitudes towards BD.

Full ethics approval has been received from National Bioethics Committee (NBC) of Pakistan and Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The study has completed sixty-five screening across the seven centres, of which forty-eight participants have been randomised.

A successful trial will 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 patients with BD.

None Declared

Depression is the leading cause of disability worldwide and low and middle-income countries (LMICs) carry over 80% of this disease burden. Attempts have been made to address depression in LMICs, with improvements in the home environment and maternal knowledge. However paternal depression is a neglected and under-researched area. Since maternal depression is associated with depression in fathers there is a need for partner inclusive parenting programs to address parental mental health and improve child outcomes.

To evaluate the clinical and cost effectiveness of partner inclusive Learning through play plus (LTP+) intervention in reducing depression in fathers and mothers.

To evaluate the effectiveness of LTP + intervention in improving child outcomes.

To conduct process evaluation and identify challenges in transition to scale up of the intervention across Karachi, Pakistan from the perspective of fathers, mothers, and other stakeholders.

This is a cluster randomised controlled (cRCT) trial of partner inclusive group parenting program called (Learning Through Play (LTP+) across 18 towns in the city of Karachi. Over 5000 parents (fathers and partners) will participate in the study with a capacity building component of training 4000 Community Health Workers across Pakistan.

This large cRCT will confirm the clinical and cost-effectiveness of LTP+ in reducing depression in parents and improving child outcomes along with the barriers and facilitators to implement the LTP+ group parenting program and the possibilities to roll out the innovation at national level through engagement with policy makers.

Addressing depression in parents is hugely important because of its adverse effects both for child and parents. This low-cost group parenting program will help in scaling up the innovation across health services in Pakistan and other LMICs.

None Declared

Repeated self-harm represents the single strongest risk factor for suicide. Worldwide, suicide is the second leading cause of death in young people aged 15-29 year, and the leading cause of death in many Asian countries.

This qualitative study was nested in a multi-center effectiveness trial of a Youth Culturally-adapted Manual Assisted Problem-solving intervention (Y-CMAP) for prevention of self-harm in Pakistan and aimed to explore young people’s perspective on the intervention.

One-to-one in-depth qualitative interviews were conducted with 20 participants from 5 cities across Pakistan, using a semi-structured topic guide to explore their views about self-harm, Y-CMAP intervention content, perceived effectiveness and challenges. Interviews were conducted in Urdu language, digitally recorded, transcribed verbatim and translated into English. Thematic analysis was conducted by the trained qualitative researchers.

Interpersonal conflicts including relationship difficulties, financial problems, and lack of social support were highlighted as precipitating factors of self-harm. Participants reported that Y-CMAP intervention is structured and easy to understand. They acknowledged the role of distraction techniques, cost-benefit analysis, discussion on thinking pattern, problem-solving and anger management in improving their mental health and wellbeing and reduce self-harm. Participants also shared their initial fears regarding the intervention, such as fear of disclosure of information to media. School and job timings were described as potential challenges for participation in the intervention.

Exploring the perspectives of young people about culturally-appropriate intervention is imperative in their journey towards preventing suicide, which is a preventable cause of premature death. Findings are particularly relevant for Pakistan, one of the youngest nations in the world with limited resources for suicide prevention.

None Declared

Immune mechanisms have been implicated in the pathogenesis of schizophrenia. This has lead to clinical trials of re-purposing drugs with off-target anti-inflammatory actions. They include the antibiotic minocycline and simvastatin (HMP-Co reductase inhibitor), which decrease microglial activation, and ondansetron a 5-HT3-receptor antagonist that has limited effects on cytokine production. This presentation will address their efficacy and mechanism of action.

1) Update on trials with minocycline including our own positive finding on negative symptoms (PMID: 16959472)

2) Present new results with ondansetron and simvastatin summarised below.

Ondansetron (8mg) and simvastatin (40mg) vs placebos in 2x2 design (PMID: 23782463). Patients aged 18-65, stable treatment, DSM IV schizophrenia-related diagnosis. PANSS and cognition at 0,3,6 months.

The four cells of the 2x2 design contained 302 patients. The interaction between ondansetron and simvastatin was significant at p=.006 reflecting the lower scores in the 3 active treatment groups than in the P+P group. Ondansetron improved verbal (p=.007) and visual list learning (p=.02) with no other treatment effects on cognition.

Minocycline appears to benefit negative symptoms in early psychosis with a minor effect on cognition. Simvastatin had limited effects in our patients with established schizophrenia but its anti-inflammatory effects could be worth investigating in early psychosis. Ondansetron has a significant effect on new learning, which might be expected from its 5-HT3 antagonist properties. This may underlie a benefit on negative symptoms reported by others and us.

Cognitive impairments are well established findings in schizophrenia and are associated with significant impairment of social functioning. Episodic memory, working memory and executive function test scores are typically 1 standard deviation below healthy controls. There are reports suggesting the presence of neurocognitive deficits prior to illness onset, opening the possibility of using cognitive profiles as disease markers. Interest in exploring cognitive functioning in early stages schizophrenia has continued to grow, as earlier treatments could possibly lead to improved outcomes.

This is a cross-sectional assessment of cognitive profiles in patients with early psychosis. A total of 51 patients suffering from psychosis in the age group of 18–65 years were recruited and matched with 51 healthy controls. A wide range of neurocognitive domains were assessed using standardised neuropsychological tests.

There was evidence of statistically significant impairments in cognitive functioning across a broad range of cognitive domains in early-psychosis patients, as compared to healthy controls. More pronounced deficits were seen in executive function tests.

To our knowledge, this is the first study to report cognitive deficits across a range of domains in patients with first episode psychosis from a low-income country. This study found deficits across multiple domains, including language, memory, attention, executive function, and visuospatial function in patients with early psychosis. Evidence of neuropsychological deficits in the early course of the disease may highlight crucial therapeutic windows for both pharmacological treatments and cognitive rehabilitation. This may improve functional outcomes in this patient group in the longer term.

The authors have not supplied their declaration of competing interest.

Postnatal depression is known to cause disability and suffering in women and negative consequences both for their infants and their families, with huge costs globally. Several studies from low and middle income countries (LAMIC) have demonstrated that effectively delivered psychological interventions are cost effective for improving maternal and child health, but access to these interventions is limited in both the low and high income countries.

The objective of the study is to develop and test a mobile phone-based intervention (TechMotherCare), which will include components of cognitive behavioural therapy (CBT) and child development related psychoeducation.

The aim of the study is to examine the feasibility and acceptability of the TechMotherCare intervention.

A total of 36 participants will be recruited from health centers in Karachi, Pakistan for this 2-arm randomized pilot study. The TechMotherCare App intervention will be based on principles of CBT and learning-through-play (LTP) a parenting intervention and will assess the real-time depressive symptoms of participants and respond, using intelligent real time therapy (iRTT) dependent on symptoms reported by participants.

Outcome assessments will be completed after 3 months (end of intervention). In-depth qualitative interviews will also be conducted with participants pre- and post-intervention. The trial is ongoing and we will present both the qualitative and quantitative results.

The results of this pilot trial will inform the design of a larger randomised controlled trial using a mobile based technology platform to address the huge treatment gap in LAMICs.

The authors have not supplied their declaration of competing interest.

It is becoming well established that CBT is both effective and cost efficient in the treatment of positive and negative symptoms of schizophrenia. However, there is a need to adapt CBT to the cultural, linguistic, and socioeconomic context of diverse cultural groups. We aimed to establish the feasibility of culturally adaptive cognitive behavior therapy for treatment of psychosis in a low-income country.

This is a rater-blind, randomized, controlled trial of the use of CBT in patients with psychosis from a low-income country. Patients with a DSM-IV diagnosis of schizophreniform disorder were assessed using Positive and Negative Syndrome Scale for Schizophrenia (PANSS), PSYRATS (Psychotic Symptom Rating Scales), and the Insight Scale. Participants were randomized into the intervention group (n = 18) and TAU group (n = 18). The intervention group received 12 weekly sessions of culturally adapted CBT for psychosis (CaCBTp).

There were no significant differences between the two groups at baseline. At three months follow-up, there was a statistically significant improvement in the CaCBTp group on PANSS general Psychopathology subscale, PANSS overall score and Insight scale, as compared to the TAU group. The CaCBTp group had lower scores on PANSS positive, PANSS negative sub-scales, and the two subscales of Psychotic Symptom Rating Scale, but differences were not statistically significant.

Culturally adapted CBT added to pharmacological treatment as usual was acceptable to patients and was helpful in reduction of severity of psychotic symptoms. Adjunctive culturally adapted CBT should be further investigated in this population.

The authors have not supplied their declaration of competing interest.