Extensive evidence indicates that rates of psychotic disorder are elevated in more urban compared with less urban areas, but this evidence largely originates from Northern Europe. It is unclear whether the same association holds globally. This study examined the association between urban residence and rates of psychotic disorder in catchment areas in India (Kancheepuram, Tamil Nadu), Nigeria (Ibadan, Oyo), and Northern Trinidad.

Comprehensive case detection systems were developed based on extensive pilot work to identify individuals aged 18–64 with previously untreated psychotic disorders residing in each catchment area (May 2018–April/May/July 2020). Area of residence and basic demographic details were collected for eligible cases. We compared rates of psychotic disorder in the more v. less urban administrative areas within each catchment area, based on all cases detected, and repeated these analyses while restricting to recent onset cases (<2 years/<5 years).

We found evidence of higher overall rates of psychosis in more urban areas within the Trinidadian catchment area (IRR: 3.24, 95% CI 2.68–3.91), an inverse association in the Nigerian catchment area (IRR: 0.68, 95% CI 0.51–0.91) and no association in the Indian catchment area (IRR: 1.18, 95% CI 0.93–1.52). When restricting to recent onset cases, we found a modest positive association in the Indian catchment area.

This study suggests that urbanicity is associated with higher rates of psychotic disorder in some but not all contexts outside of Northern Europe. Future studies should test candidate mechanisms that may underlie the associations observed, such as exposure to violence.

‘POD Adventures’ is a gamified problem-solving intervention delivered via smartphone app, and supported by non-specialist counsellors for a target population of secondary school students in India during the COVID-19 pandemic.

To evaluate the feasibility and acceptability of undertaking a randomised controlled trial of POD Adventures when delivered online with telephone support from counsellors.

We conducted a parallel, two-arm, individually randomised pilot-controlled trial with 11 secondary schools in Goa, India. Participants received either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes were assessed at two timepoints: baseline and 6 weeks post-randomisation.

Seventy-nine classroom sensitisation sessions reaching a total of 1575 students were conducted. Ninety-two self-initiated study referrals (5.8%) were received, but only 11 participants enrolled in the study. No intervention arm participants completed the intervention. Outcomes at 6 weeks were not available for intervention arm participants (n = 5), and only four control arm participants completed outcomes. No qualitative interviews or participant satisfaction measures were completed because participants could not be reached by the study team.

Despite modifications to address barriers arising from COVID-19 restrictions, online delivery was not feasible in the study context. Low recruitment and missing feasibility and acceptability data make it difficult to draw conclusions about intervention engagement and indicative clinical outcomes. Prior findings showing high uptake, adherence and engagement with POD Adventures when delivered in a school-based context suggest that an online study and delivery posed the biggest barriers to study participation and engagement.

There is evidence of an association between life events and psychosis in Europe, North America and Australasia, but few studies have examined this association in the rest of the world.

To test the association between exposure to life events and psychosis in catchment areas in India, Nigeria, and Trinidad and Tobago.

We conducted a population-based, matched case–control study of 194 participants in India, Nigeria, and Trinidad and Tobago. Cases were recruited through comprehensive population-based, case-finding strategies. The Harvard Trauma Questionnaire was used to measure life events. The Screening Schedule for Psychosis was used to screen for psychotic symptoms. The association between psychosis and having experienced life events (experienced or witnessed) was estimated by conditional logistic regression.

There was no overall evidence of an association between psychosis and having experienced or witnessed life events (adjusted odds ratio 1.19, 95% CI 0.62–2.28). We found evidence of effect modification by site (P = 0.002), with stronger evidence of an association in India (adjusted odds ratio 1.56, 95% CI 1.03–2.34), inconclusive evidence in Nigeria (adjusted odds ratio 1.17, 95% CI 0.95–1.45) and evidence of an inverse association in Trinidad and Tobago (adjusted odds ratio 0.66, 95% CI 0.44–0.97).

This study found no overall evidence of an association between witnessing or experiencing life events and psychotic disorder across three culturally and economically diverse countries. There was preliminary evidence that the association varies between settings.

Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs.

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June–December 2019), midline (n = 366) (Jan–March 2020) and endline (n = 877) (June 2020–Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours.

There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37–2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55–3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31–2.95), recent hunger (aOR 1.69; 95% CI 1.15–2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00–2.23).

Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence.

Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance are associated with poor mental health outcomes in the general population. These risks are likely to be exacerbated among Female Sex Workers (FSWs), however there are few studies examining risks factors for mental health problems among FSWs. We examine the prevalence and correlates of common mental health problems including suicidal behaviour among FSWs in Kenya.

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline data were collected from June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, and the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD). Recent suicidal behaviour was defined as reported suicide attempt or suicidal ideation in the past 30 days. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the WHO ASSIST tool (to measure harmful alcohol/substance use in the past 3 months). Descriptive statistics and multivariable logistic regression were conducted in Stata 16.1.

Of 1039 eligible FSWs, 1003 FSWs took part in the study (response rate: 96%) with a mean age of 33.7 years. The prevalence of moderate/severe depression was 23.2% (95%CI: 20.7–25.9%), moderate/severe anxiety 11.0% (95%CI: 9.3–13.1%), PTSD 14.0% (95% CI: 12.2–16.5%) and recent suicidal behaviour 10.2% (95%CI: 8.5–12.2%) (2.6% suicide attempt; 10.0% suicidal ideation). Among women with any mental health problem 63.0% also had a harmful alcohol/substance use problem. One in four women (25%; 95%CI: 22.5–27.8%) had depression and/or anxiety and this was independently associated with higher ACE scores, hunger (skipped a meal in last week due to financial difficulties), death of a child, perceived sex work stigma and recent sexual/physical violence. PTSD was associated with higher ACE scores, hunger, increased STI prevalence (chlamydia trachomatis) and recent violence. Recent suicidal behaviour was associated with higher ACE scores, low literacy, hunger, and recent violence. Mental health problems and suicidal behaviour were less prevalent among women reporting social support.

The high burden of mental problems among FSWs indicates a need for accessible services tailored for FSWs alongside broader structural interventions addressing poverty, harmful alcohol/substance use and violence. High rates of ACEs among this population indicates the need to consider early childhood and family interventions to prevent poor mental health outcomes.

Funding: Medical Research Council and the UK Department of International Development

Adolescents living with HIV (ALHIV) experience a high burden of mental health disorder which is a barrier to antiretroviral therapy adherence. In Zimbabwe, trained, mentored peer supporters living with HIV (Community Adolescent Treatment Supporters – CATS) have been found to improve adherence, viral suppression and psychosocial well-being among ALHIV. The Friendship Bench is the largest integrated mental health programme in Africa. We hypothesise that combining the CATS programme and Friendship Bench will improve mental health and virological suppression among ALHIV compared with the CATS programme alone.

We will conduct a cluster-randomised controlled trial in 60 clinics randomised 1:1 in five provinces. ALHIV attending the control arm clinics will receive standard CATS support and clinic support following the Ministry of Health guidelines. Those attending the intervention arm clinics will receive Friendship Bench problem-solving therapy, delivered by trained CATS. Participants with the signs of psychological distress will be referred to the clinic for further assessment and management. The primary outcome is HIV virological failure (≥1000 copies/ml) or death at 48 weeks. Secondary outcomes include the proportion of adolescents with common mental disorder symptoms (defined as Shona Symptom Questionnaire (SSQ-14) score ≥8), proportion with depression symptoms (defined as Patient Health Questionnaire (PHQ-9) score ≥11), symptom severity (mean SSQ-14 and PHQ-9 scores) and EQ-5D score for health-related quality of life.

This trial evaluates the effectiveness of peer-delivery of mental health care on mental health and HIV viral load among ALHIV. If effective this intervention has the potential to be scaled-up to improve these outcomes.

Trial registration: PACTR201810756862405. 08 October 2018.

Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare.

To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders.

Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinicaltrials.gov (NCT00446407).

A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities.

Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities.

Adolescents comprise a fifth of the population of India, but there is little research on their mental health. We conducted an epidemiological study in the state of Goa to describe the current prevalence of mental disorders and its correlates among adolescents aged between 12 and 16 years.

To estimate the prevalence and correlates of mental disorders in adolescents.

Population-based survey of all eligible adolescents from six urban wards and four rural communities which were randomly selected. We used a Konkani translation of the Development and Well-Being Assessment to diagnose current DSM-IV emotional and behavioural disorders. All adolescents were also interviewed on socio-economic factors, education, neighbourhood, parental relations, peer and sexual relationships, violence and substance use.

Out of 2684 eligible adolescents, 2048 completed the study. The current prevalence of any DSM-IV diagnosis was 1.81%; 95% CI 1.27–2.48. The most common diagnoses were anxiety disorders (1.0%), depressive disorder (0.5%), behavioural disorder (0.4%) and attention-deficit hyperactivity disorder (0.2%). Adolescents from urban areas and girls who faced gender discrimination had higher prevalence. The final multivariate model found an independent association of mental disorders with an outgoing ‘non-traditional’ lifestyle (frequent partying, going to the cinema, shopping for fun and having a boyfriend or girlfriend), difficulties with studies, lack of safety in the neighbourhood, a history of physical or verbal abuse and tobacco use. Having one's family as the primary source of social support was associated with lower prevalence of mental disorders.

The current prevalence of mental disorders in adolescents in our study was very low compared with studies in other countries. Strong family support was a critical factor associated with low prevalence of mental disorders, while factors indicative of adoption of a non-traditional lifestyle were associated with an increased prevalence.