Developing Evidence-Based Approaches to Collaborative Mental Health Service Provision

This interview explores scalable, evidence-based approaches to adolescent mental health care developed by Sangath and collaborators, led by Vikram Patel. Motivated by limitations of clinic-based models and stigma around psychiatric care in India, the work emphasizes meeting youths in their own settings (notably schools), using task-sharing with trained lay providers, and implementing brief, developmentally appropriate psychological interventions. The conversation addresses the scale of need in India (approximately 250 million adolescents, around 20% of the global 10–19-year-old population), the impact of the COVID-19 pandemic, and the role of digital tools and workforce development in expanding access to mental health services.

The core intervention is a developmentally informed, transdiagnostic problem-solving technique derived from cognitive behavioural therapy. It is structured into three steps—identify Problems, generate Options, and Do it (POD)—to help adolescents address stress-inducing problems and reduce impulsive or harmful behaviors. Delivery details: • Implemented by lay, school-based counselors in low-income neighborhoods in New Delhi (2017–2020). • Brief format: three to four sessions over three weeks in school settings. • Supported by self-help printed booklets with illustrated vignettes and home practice exercises. Evaluation: A randomized clinical trial with 12-month follow-up assessed outcomes. Care model: A stepped-care approach was planned—Step 1 is the brief POD intervention for all; Step 2 offers a tailored, modular, higher-intensity psychological treatment for non-responders (evaluation disrupted by pandemic-related school closures). Digital and workforce strategies: • E-learning platforms used to train frontline providers to deliver the intervention. • A blended, game-based, self-guided problem-solving program for adolescents, potentially facilitated by school counselors/teachers. • A two-step digital training program for providers: (1) didactic modules with lesson objectives and source materials; (2) a case-based internship to master delivery skills. Implementation examples: • Madhya Pradesh, India: partnership with the state health department to train about 500 accredited social health activists (ASHAs) to deliver evidence-based psychosocial interventions. • Texas, USA: partnership with Meadows Mental Health Policy Institute and UT Southwestern Medical Center (supported by Lone Star Prize) to scale behavioral activation for depression in under-resourced communities by recruiting, training, and supporting hundreds of frontline providers over three years.

• The school-based problem-solving intervention reduced self-reported psychosocial problem severity, with effects sustained at least 12 months post-intervention (clinical trial evidence). • Task-sharing models with lay providers can feasibly deliver brief, effective psychological care to adolescents at scale in school settings. • COVID-19 pandemic: multiple studies reported significant increases in anxiety and depression among young people; levels appear to be trending back toward pre-pandemic baselines, but cohorts affected during critical developmental stages may face lasting challenges. • Workforce expansion: around 500 ASHAs are being trained in Madhya Pradesh to deliver psychosocial interventions, demonstrating scalable capacity building in a low-resource state. • Planned scale-up in Texas aims to train hundreds of frontline providers to deliver behavioral activation, addressing access gaps in under-resourced U.S. communities. • India’s adolescent demographic (≈250 million; ~20% of global 10–19 population) underscores the potential public health impact of scalable school-based and community-delivered mental health care.

Findings support the effectiveness and scalability of brief, problem-solving interventions delivered through task-sharing in schools, directly addressing barriers inherent in clinic-centered models (stigma, access, treatment adherence). The stepped-care framework prioritizes efficient resource use by offering low-intensity interventions broadly and reserving specialized care for non-responders, potentially improving cost-effectiveness and coverage. The COVID-19 experience highlights the importance of schools as social and nutritional support spaces and suggests policy considerations for maintaining safe in-person peer contact during future epidemics. Digital tools (e-learning, blended self-help, structured training with supervised practice) can accelerate workforce development and quality assurance, enabling rapid expansion of evidence-based psychosocial care in diverse settings, from low-resource Indian states to under-resourced communities in the United States.

The work demonstrates a practical, evidence-based blueprint for scaling adolescent mental health care via school-based, task-shared, brief psychological interventions supplemented by stepped care and digital training. It contributes to global mental health by showing how to meet youths where they are, reduce stigma-related barriers, and build a competent frontline workforce. Future directions include rigorous evaluation of the higher-intensity second step in the stepped-care model, further real-world implementation studies (e.g., Madhya Pradesh and Texas), continued refinement of digital training and blended adolescent interventions, and policy research on safeguarding access to supportive school environments during public health emergencies.

Evaluation of the higher-intensity second step in the stepped-care model was disrupted by pandemic-related school closures and requires further research. The primary trial evidence cited pertains to schools in low-income neighborhoods in New Delhi, and broader generalizability and long-term outcomes beyond 12 months were not detailed in the interview.