Project SUMS (scaling up of mental health in schools): design and methods for a pragmatic, cluster randomised waitlist-controlled trial on integrated school mental health intervention for adolescents

In recent years, there is an increasing concern about adolescents’ mental health, especially in developing countries. An estimated 10–20% of children and adolescents are affected by mental health problems worldwide [1]. Adolescence is a period that is characterised by rapid physical and psychological changes with altered social perceptions and expectations [2]. The expectations and the choices made during this period have a significant impact not only on current health-practices and well-being but also on their health as adults. We must engage with them and enable them to make right choices about their expectations and address their mental health needs effectively through mental health promotion (MHP). With rapid socio-demographic and lifestyle transition, such mental health promotion will help adolescents build resilience to cope well in difficult situations or adversities. This will be critical not only for their well-being during adolescence but also for their physical and mental health in adulthood.

Today, suicide is one of the leading cause of preventable deaths, and depression is one of the leading cause of morbidity among adolescents [3]. Based on the life-course perspective, it has been emphasised to target adolescents in school to accommodate the contextual factors that influence suicide during adolescence [4]. Even though these mental health problems have detrimental effects on well-being, and development in adolescence, a reluctance to seek professional help due to stigma and lack of mental health knowledge has been documented in various studies across the globe [5‐7]. Thus, there is a need to improve help-seeking to reduce the growing burden of mental health problems among adolescents and promote mental health literacy as an important strategy to promote help-seeking among adolescents [8‐10].

Mental health literacy (MHL) is defined as “knowledge and attitudes regarding mental health that aid in recognition, management and prevention of mental health issues” [11]. Low levels of MHL were associated with depression and MHL among adolescents was positively associated with their mental health [12, 13]. Even though mental health literacy has significant implications on adolescent mental health, poor mental health literacy has been demonstrated for adolescents across various settings [14, 15]. Thus, MHL must become a focus of mental health interventions for adolescents. With the adolescents preferring to disclose mental illness symptoms to their peers and reluctant to seek professional help, the importance of improving behaviours for First Aid in Mental Health (MH-FA) to facilitate social support and help-seeking for mental illness cannot be overlooked. Mental health first aid is the help provided to a person who is developing a mental health problem, experiencing a worsening of an existing mental health problem or in a mental health crisis [16]. As adolescents begin to make decisions about their health and often have a preference for seeking help from peers, mental health literacy to adolescents should be provided ideally as a part of the school curriculum and not as ad-hoc events that occur infrequently (such as mental health parades, campaigns etc.,) [8]. It is further emphasised that schools should promote not only positive mental health but also MHL to enable students to understand mental health problems, reduce mental health stigma, promote mental health self-care and help-seeking behaviours of students [13]. Thus, integration of First Aid in Mental Health (MH-FA) with MHP and MHL, becomes a potential strategy for mental health promotion and prevention in adolescents.

Given the critical role of education in health literacy, schools become an ideal setting for reaching vulnerable adolescents for improving mental health literacy. This is because adolescents spend most of their time in schools, and health is intrinsically linked with education. Furthermore, many risks and protective factors for adverse mental health outcomes are operated in the school context. Presently, the evidence base for educational interventions targeting adolescents for mental health literacy and mental health promotion is limited [17]. Even though there is a concept of Health Promoting Schools (HPS) by World Health Organization that provides a broad framework for action, there is little evidence on schools’ ability to implement this approach. Existing evaluations of schools that had implemented HPS initiative have shown that mental health (despite being an important outcome of HPS initiative) was not addressed, apart from substance use [18, 19]. A clear need for well-controlled research in the area of mental health literacy and mental health promotion has been documented due to previous studies with small sample sizes, lack of follow-up, low response rates and potential contamination [20].

In India, adolescent mental health assumes a great relevance where adolescents aged 10–19 years constitute about 22% of the population [21]. With increasing enrolment in secondary schools in India, schools become the ideal platform for promoting positive mental health among adolescents. Even though there are Adolescence Education Programme and Rashtriya Kishor Swasthya Karyakram programme in India, it was evident that such programmes have either failed to account for the mental health needs of school communities or failed to measure the changes or values that are intended for the sustenance of mental health promotion [22, 23].

Developing personal skills for both students and teachers has been emphasised for successful mental health interventions [13] Among various approaches to address mental health literacy in schools, a natural approach builds on schools’ existing social ecologies such as curriculum presented by usual classroom teachers. Also, teacher-led approaches were found to facilitate the creation of a school-wide environment of acceptance and normalisation of mental illnesses as well as facilitate recognition and help-seeking in adolescents [8]. MHL delivered by external providers had limited value on the sustained and enhanced MHL capacity embedded into educational systems [13]. Further, MHL delivered by teachers was found to have positive mental health literacy outcomes across various settings and teacher delivered MHL curriculum found to have an advantage in normalising mental health knowledge as a part of education [13].

With this in the background, we developed a classroom-based teacher-led integrated school mental health intervention called SUMS (MHP + MHL + MH-FA) based on “School Friendly” mental health literacy approach and “School-Based Integrated Pathway to Care Model” developed by Kutcher et al. [24]. Like MHL approach, SUMS intervention is based on existing classroom friendly pedagogical approach that can be easily delivered in the current educational systems without extracurricular or outside-of-school inputs [13]. Basically, SUMS intervention focuses on curriculum resource approaches delivered by teachers (https://​mhlcurriculum.​org/​) where a curriculum resource guide was developed through desk review and expert inputs. The curriculum resource guide contained content and delivery methods for each SUMS intervention (MHL, MHP and MH-FA). This curriculum resource guide was adapted to the local context through key informant interviews and intervention designing workshops conducted among school teachers, students, block education officers and subject experts.

In this context, we have undertaken a cluster randomised controlled trial to evaluate the effectiveness of SUMS (Scaling Up of Mental Health in Schools) intervention (an integrated school mental health intervention) for adolescents, integrated into the classroom and delivered by teachers. We hypothesise that SUMS intervention delivered by teachers will lead to significant improvement in mental health knowledge, positive attitudes toward mental illness, and behaviours for First Aid in Mental Health as compared to ongoing regular school approach among school-going adolescent children. The ongoing regular school approach was used as comparator to reflect real-life scenario.

This pragmatic, cluster randomised waitlist-controlled design will examine the effectiveness of classroom-based teacher-led integrated school mental health intervention in improving school-going adolescent children’s mental health and well-being. To the best of our knowledge, this is the first study to integrate MHL with MHP and MH-FA for promoting mental health well-being among adolescent school children in India.

The trial is an extension of a series of focused research activities undertaken in Child and Adolescent Mental Health (CAMH) in Kolar district, Karnataka. The activities included situational analysis, numerous consultation workshops with teachers and various training programmes organised in-collaboration with the education department in Kolar. Following interactive discussions with NIMHANS experts and a national-level symposium, a road-map and draft action plan for integrated CAMH services in a district was finalised. The present trial is a part and extension of the action plan developed for promoting CAMH. Though the mental health intervention domains (MHP+ MHL + MH-FA) are closely interlinked with considerable cross-cutting areas of action, we intentionally compartmentalised it for better focus and delivery. With a need to build a more substantial evidence base on effective School Mental Health Promotion approaches in low-income countries, the study builds on the facilitating role of school climate in promoting mental health and related outcomes among adolescents and evaluates its effectiveness through a robust and systematic methodology.