Investing in youth public mental health in India: multi-stakeholder co-production of a whole school program to promote the mental health of Indian adolescents

Siobhan Hugh-Jones^1*Sphoorthi Prabhu²Muthuraju Arelingaiah³Jayalaxmi Podiya²Krupa Lakshman²Ritwika Nag²Lucy Warriner¹Amy Palmer¹Kristian Hudson⁴Mina Fazel⁵Surendran Ventakaraman⁶Paul Cooke¹Pavan Mallikarjun⁷Prachi Khandeparkar⁸Poornima Bhola²Janardhan Navaneetham²

• ¹University of Leeds, Leeds, United Kingdom
• ²National Institute of Mental Health and Neuro Sciences, Bengaluru, India
• ³National Institute of Mental Health and Neurosciences, Bengaluru, India
• ⁴Improvement Academy Institute of Health Research, Bradford, United Kingdom
• ⁵University of Oxford Department of Psychiatry, Oxford, United Kingdom
• ⁶Indira Gandhi Medical College and Research Institute, Puducherry, India
• ⁷Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
• ⁸Sangath, New Delhi, India

In India, although rates of adolescent anxiety and depression are of concern and contribute to a high youth suicide rate, public mental health approaches targeting adolescents are rare. India does not have an integrated whole-school mental health approach to promote youth wellbeing and prevent anxiety and depression. The aim of this study (Project SAMA) was to co- produce a whole school mental health program for delivery in Indian secondary schools. Using the ADAPT framework, we conducted umbrella and systematic reviews to identify school interventions with proven effectiveness which could be culturally adapted to India. Adopting a whole school approach, we sought evidence for interventions targeting risk and protective factors at the level of adolescents, teachers, parents and school climate. Informed by guidance from our Indian Youth Advisory Board and Scientific Advisory Boards, we built on the generally low availability of evidence-based interventions, drawing where possible on broader evidence of what works, to generate prototype interventions to take to co-adaptation and co-production with local communities. Working with 57 Indian stakeholders, spanning adolescents, parents, teachers, headteachers and mental health professionals, we reached consensus on a whole school program ready for feasibility testing, including how the program should be implemented and evaluated, and how safeguarding should be operationalised. We report our final program content and implementation plan ready for feasibility testing. The program consists of four inter-related interventions. These target protective factors for adolescent mental health, including youth, teacher and parent mental health literacy and psychoeducation, a positive and safe school culture, and psychosocial support. They also target the mental health risk factors of stigma, bullying and corporal or harsh discipline. Agreed delivery agents are lay counsellors and local mental health professionals. We report TIDieR checklists and logic models for each intervention and an integrated program Theory of Change. The final program, which reflects six of the World Health Organisation’s and Unesco’s eight global standards for health promoting schools, is freely available. Project SAMA makes a significant contribution to our understanding of what adolescents, school and parents want from a whole school approach to public mental health in India.