Unpacking the 'black box' of suicide: A latent class analysis predicting profiles of suicidal ideation in a longitudinal cohort of adolescent girls from India.

INTRODUCTION: Indian women account for 37% of global suicide-related deaths. As suicide is a growing concern among adolescent girls, identifying the social determinants of suicide with this group targeted prevention. We selected social determinants that include intersectional identities and broader syndemics; we then used longitudinal data from a prospective cohort of adolescent girls from Northern India to classify them into unique profiles across multiple socioecological levels. METHODS: Girls aged 10-19 (N = 11,864) completed self-report questionnaires measuring socio-demographic and trauma exposure variables. At three-year follow-up, they were asked to indicate current suicidal ideation (SI). We conducted latent class analysis (LCA) to classify profiles and then predicted risk of current SI at three-year follow-up. RESULTS: LCA supported a four-class solution: a 'privileged' class (Class 1; n = 1,470), a 'modal' class (Class 2; n = 7,449), an 'intergenerational violence' class (Class 3; n = 2,113), and a 'psychological distress' class (Class 4; n = 732). Classes significantly predicted odds ratios (OR) for SI at follow up; women in Class 4 were associated with the greatest likelihood of SI (OR 1.84, 95% CI 1.38, 2.47), suggesting that psychological distress factors confer greatest risk. CONCLUSION: Results of the distinct classes of risk and protective factors indicate targets for policy-level interventions. Disrupting cycles of psychological distress and substance use, increasing access to behavioral interventions, and intervening to mitigate intergenerational violence may be particularly impactful with this population.

Scaling up the task-sharing of psychological therapies: A formative study of the PEERS smartphone application for supervision and quality assurance in rural India.

Measurement-based peer supervision is one strategy to assure the quality of psychological treatments delivered by non-mental health specialist providers. In this formative study, we aimed to 1) describe the development and 2) examine the acceptability and feasibility of PEERS (Promoting Effective mental healthcare through peER Supervision)-a novel smartphone app that aims to facilitate registering and scheduling patients, collecting patient outcomes, rating therapy quality and assessing supervision quality-among frontline treatment providers delivering behavioral activation treatment for depression. The PEERS prototype was developed and tested in 2021, and version 1 was launched in 2022. To date, 215 treatment providers (98% female; ages 30-35) in Madhya Pradesh and Goa, India, have been trained to use PEERS and 65.58% have completed the supplemental, virtual PEERS course. Focus group discussions with 98 providers were examined according to four themes-training and education, app effectiveness, user experience and adherence and data privacy and safety. This yielded commonly endorsed facilitators (e.g., collaborative learning through group supervision, the convenience of consolidated patient data), barriers (e.g., difficulties with new technologies) and suggested changes (e.g., esthetic improvements, suicide risk assessment prompt). The PEERS app has the potential to scale measurement-based peer supervision to facilitate quality assurance of psychological treatments across contexts.

An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders.

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

Text message-based Cessation Intervention for People who Smoked or Used Smokeless Tobacco in India: a Feasibility Randomised Controlled Trial.

INTRODUCTION: Despite the high burden of tobacco use in India, users do not have access to adequate help. This pilot trial aimed to evaluate the feasibility and acceptability of a text messaging intervention for tobacco cessation, generate preliminary estimates of its impact, and fine-tune procedures for a definitive trial. METHODS: Parallel two-arm single blind individually randomised controlled pilot trial with nested qualitative study. Participants included adult current tobacco users (smoked and smokeless). Eligible and consenting participants were randomised to receive either (a) text messaging intervention (ToQuit) which covered specific content areas such as psychoeducation about consequences of tobacco use and benefits of quitting and tobacco avoidance strategies or (b) information about tobacco cessation helplines such as the helpline number and the languages in which tobacco cessation support was available (control). Feasibility data included screening and consent rates, treatment dropouts and outcome ascertainment. The primary abstinence outcome was self-reported abstinence from tobacco in the past seven days at three months post-randomisation. In-depth interviews were conducted with a sub-sample of participants primarily to collect acceptability data. The primary abstinence analysis used a chi-squared test and logistic regression (complete-case), and qualitative data analysed using thematic analysis. RESULTS: Ninety eight participants were randomised into the two trial arms; 77 (79%) completed outcome evaluation. No between-arm differences in abstinence were found though findings favoured the intervention (7-day abstinence: ToQuit 23%, control 19%; adjusted odds ratio 1.23, 95% confidence interval 0.38, 3.97). Participants appreciated the language, comprehensibility, and relevance of the messages; and reported overall satisfaction with and positive impact from the intervention on their lives. CONCLUSION: The findings indicate the acceptability and feasibility of ToQuit and if found effective, it could be a potentially scalable first-line response to tobacco use in low resource settings. IMPLICATIONS: Our pilot RCT provides sufficient findings supporting the acceptability and feasibility of an intervention for tobacco cessation which is suitable for a context which has a shortage of healthcare workers and for individuals who use smoked or smokeless tobacco. This is critical on a background of limited contextually relevant interventions for a problem with a high burden in low- and middle- income countries such as India.

A systematic review of task-sharing interventions for substance use and substance use disorder in low- and middle-income countries.

INTRODUCTION: Substance use (SU) and substance use disorders (SUDs) are associated with adverse health and socio-economic consequences. Due to the shortage of specialist healthcare providers, people with SUDs in low- and middle-income countries (LMICs) have limited access to adequate treatment. Task-sharing with non-specialist health workers (NSHWs) has the potential to improve treatment accessibility for these individuals. This review synthesizes the evidence on the effectiveness of task-sharing interventions for SU and SUDs outcomes in LMICs. METHODS: PsycINFO, MEDLINE, EMBASE, Global Health and CENTRAL databases were searched to identify eligible studies. Quality assessment was conducted using the Cochrane risk of bias (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was undertaken to analyze the data. RESULTS: Nineteen RCTs and two quasi-experimental studies met the eligibility criteria, and the majority had a low risk of bias rating. NSHW-delivered interventions significantly impact SU and SUDs outcomes, particularly in reducing alcohol and other substance use, cessation of smoking, and use of opioids. Multiple sessions delivered via face-to-face interactions was the most utilized method for intervention delivery. There were variations in terms of components of the intervention across studies; however, the most common intervention strategies used were a) personalized feedback, b) psychoeducation, c) motivational enhancement, d) problem-solving, and e) coping skills. CONCLUSION: Our review highlights the growing interests in leveraging NSHWs to provide interventions to people with SU and SUDs in LMICs where access to treatment is limited. However, additional research is necessary to explore the effectiveness of these interventions and identify the specific active components linked to enhancing treatment outcomes on a broader scale.

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda.

BACKGROUND: The war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent. METHODS: A parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat. DISCUSSION: CHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery. TRIAL REGISTRATION: ISRCTN ISRCTN10360385. Registered on 30 January 2023.

Barriers and facilitators to the implementation of mental health and psychosocial support programmes following natural disasters in developing countries: A systematic review.

Climate change is leading to more frequent and intense natural disasters, with developing countries particularly at risk. However, most research concerning mental health and natural disasters is based in high-income country settings. It is critically important to provide a mental health response to such events, given the negative psychosocial impacts they elicit. The aim of this systematic review is to explore the barriers and facilitators to implementing mental health and psychosocial support (MHPSS) following natural disasters in developing countries. Eight databases were searched for relevant quantitative and qualitative studies from developing countries. Only studies reporting barriers and/or facilitators to delivering MHPSS in response to natural disasters in a low- or middle-income country were included and full texts were critically appraised using the McGill University Mixed Methods Appraisal Tool. Reported barriers and facilitators were extracted and analysed thematically. Thirty-seven studies were included in the review, reflecting a range of natural disaster settings and developing countries. Barriers to implementing MHPSS included cultural relevance, resources for mental health, accessibility, disaster specific factors and mental health stigma. Facilitators identified included social support, cultural relevance and task-sharing approaches. A number of practical approaches can be used to facilitate the implementation of MHPSS in developing country settings. However, more research is needed on MHPSS in the developing country natural disaster context, especially in Africa, and international policies and guidelines need to be re-evaluated using a decolonial lens.

Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda.

In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.

Evaluation of Feasibility and Acceptability of a Text-Messaging Intervention for Tobacco Cessation in India.

INTRODUCTION: The aim of our study was to assess the feasibility and acceptability of a brief behavioral intervention for tobacco cessation delivered via mobile phone text messaging in India. AIMS AND METHODS: We conducted an uncontrolled intervention cohort study in adult current users of tobacco. The participants received intervention messages on their mobile phones for eight weeks. We collected qualitative data about participants' perceptions of intervention delivery and receipt, acceptability, and feasibility of the intervention. The outcomes measured at 3 months post-recruitment were self-reported 7- and 28-day point-prevalence abstinence, and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) risk categories for tobacco-low (0-3), moderate (4-26), and high (≥27). RESULTS: We recruited 26 eligible participants, and 22 completed the outcome assessments. The participants generally perceived the intervention content to be simple to access and useful in facilitating a change in tobacco use. None of the participants indicated that they wanted to discontinue receiving the intervention messages. Some suggestions for enhancing acceptability included supplementing text messaging with more intensive counseling and the use of multimedia content. Eighteen percent of participants reported abstinence in the past 7 and 28 days. A greater proportion of those who used smokeless tobacco were abstinent at follow-up compared to those who smoked (42.9% vs. 6.7%; p = .04). CONCLUSIONS: If effective, simple and low-cost mobile phone text messaging can be used to deliver interventions for tobacco use, and has the potential to be scaled up so it can be delivered to populations of smokers interested in receiving cessation support. IMPLICATIONS: Our study is an important step towards the development of a contextually relevant intervention suited for low- and middle-income countries and which is responsive to the needs of both those who use smoked and smokeless tobacco. If found to be effective, our intervention would be a scalable solution to overcome the human resource related barrier to accessing tobacco cessation services in low resource settings.

Why do men with drinking problems change their behaviour? A qualitative study nested in a randomised controlled trial in India.

The aim of this qualitative study, nested in a randomised controlled trial was to assess the mechanisms of the effects in both arms through examining perceptions of the participants about changes in their drinking behaviour and their attributions for any perceived changes. We conducted semi-structured interviews with a sub-sample of trial participants. We used thematic analysis to analyse the data. Self-perceived change, mostly positive, was reported regardless of the objectively measured remission status. Participating in the trial itself was a major catalyst for change. Participants in both arms used a variety of similar strategies to make these changes; additionally, for those who received the intervention, both the style of the counsellor (for example, the non-judgemental stance) as well as specific elements of the intervention were seen to influence change in drinking behaviour. Absence of self-reported change was relatively uncommon and primarily related to the felt need for alcohol (e.g. drinking was perceived to be necessary to maintain good health), or the belief that one did not need to or want to change. Experiences of participating in a trial, the counsellor style and specific elements of a brief psychological treatment, play a role in influencing change in harmful drinking behaviours.

Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study.

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

Alcohol policies in India: A scoping review.

Globally, alcohol consumption causes significant societal harm and is a leading risk factor for death and disability in adults. In India, 3.7% of all deaths and 3.1% disability adjusted life years (DALYs) can be attributed to alcohol. In the context of rapid economic development and emphasized by the COVID-19 pandemic, India's lack of a consolidated and comprehensive alcohol policy has posed significant challenges to addressing this harm. In this context, the aim of our review was to undertake a comprehensive mapping of the State and national policy environment surrounding alcohol and its use in India, based on an analysis of policy documents. We did this though a scoping review of academic and grey literature, which helped to iteratively identify the websites of 15 international organizations, 21 Indian non-governmental organizations, and eight Indian Federal governmental organizations as well as State/Union Territory government sites, to search for relevant policy documents. We identified 19 Federal policy documents and 36 State level policy documents within which we have identified the specific policy measures which address the 10 categories of the World Health Organization's Global Action Plan to Reduce the Harmful Use of Alcohol. We found that there are major gaps in regulation of marketing and price controls, with much of this controlled by the States. In addition, regulation of availability of alcohol varies widely throughout the country, which is also a policy area controlled locally by States. Through the clear elucidation of the current policy environment surrounding alcohol in India, policy makers, researchers and advocates can create a clearer roadmap for future reform.

Experiences of a mobile phone delivered brief intervention for hazardous drinking: A qualitative study nested in the AMBIT trial from Goa, India.

Background: This study explores the experiences of participants receiving a mobile-based brief intervention (BI) for hazardous drinking in India, to determine characteristics that influenced engagement and examine perceived reasons for change in alcohol consumption. Methods: Semi-structured interviews were conducted with 10 adult hazardous drinkers who received a mobile-based BI in the intervention arm of a pilot randomised control trial. Data were coded through an iterative process and analysed using thematic analysis. Findings: Study participants reported a positive experience, with factors such as customised intervention delivery and personal motivation facilitating their engagement. Participants reported a reduction in quantity and frequency of alcohol use. This was credited to the intervention, particularly, its provision of health-related information, goal-setting content and strategies to manage drinking. Apart from alcohol reduction, participants reported improvements in diet, lifestyle, wellbeing, and familial relations. Implication: By providing a context to explain the impact of the intervention, the learnings from this study can be used to strengthen the implementation of mobile-based interventions. This study outlines the scope for further research in digital health, such as Internet-based health interventions, and incorporating digital interventions within the ambit of existing health care programmes.

Interventions to increase help-seeking for mental health care in low- and middle-income countries: A systematic review.

Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: 'mental health/illness' AND 'help-seeking' AND 'LMICs'; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.

Community-based counselling programme for pregnant women with alcohol problems in Cape Town, South Africa: a qualitative study of the views of pregnant women and healthcare professionals.

Introduction: South Africa lacks services to detect and address alcohol use during pregnancy, particularly outside of health-care facilities. This study aimed to explore pregnant women and healthcare providers' perceptions of the acceptability, feasibility and appeal of a community-based counselling programme for pregnant women with alcohol problems. Methods: Twenty-eight in-depth interviews with pregnant women who drink, Community Health Workers (CHWs) and antenatal service providers were conducted. Transcribed interviews were analyzed thematically using a combined deductive and inductive approach. Results: Women reported feeling uncomfortable seeking help for their alcohol use at antenatal clinics, limiting usefulness of current support services. All stakeholders perceived a community-based intervention to be acceptable and feasible as it could be integrated with other CHW-delivered services. Participants thought an intervention should facilitate early linkage to antenatal services and should include partners or family members. The feasibility of an intervention may depend on the relationship between CHWs and clinic-based antenatal staff, and their relationships with pregnant women. Clinic and community challenges to implementation were raised. Clinic-level challenges included shortage of space, staff capacity, high number of pregnant women, long waiting times, financial burden of having to travel to a clinic, lack of comfort and privacy and staff attitudes. Community-level challenges included crime, lack of privacy, lack of attention given competing interests in the home, fear due to abuse, and stigma and discrimination from other community members. Suggestions for overcoming these challenges were provided. Conclusion: Findings provide essential information to facilitate the adaptation of a community-based alcohol counselling programme for greater acceptability, feasibility and cultural appropriateness for the South African context. Intensive training, supervision and support is required to ensure the programme is delivered as planned.

Determinants of alcohol use among young males in two Indian states: A population-based study.

OBJECTIVES: There is insufficient evidence about the determinants of alcohol use amongst young people in India and other low-and middle-income countries, despite alcohol's high contribution to disease burden and increasing consumption in this population. We aimed to identify and estimate the determinants of alcohol use in a representative sample of 2716 young men from Bihar and Uttar Pradesh who participated in the 'Understanding the Lives of Adolescents and Young Adults' (UDAYA) study. METHODS: First, we developed an exploratory conceptual framework of potential alcohol use determinants in the study settings based on available literature. We then estimated the effects of 35 potential alcohol use determinants identified in the conceptual framework (including 14 latent factors identified through exploratory factor analysis) on any alcohol use in the past 3 years and regular alcohol use amongst past three-year drinkers, using mixed-effects logistic models. The determinants explored were operationalised using longitudinal data from the UDAYA study. RESULTS: Our adjusted models identified 18 determinants for past 3-year alcohol use and 12 determinants for regular use. Distal determinants (e.g., socioeconomic status), intermediate determinants (e.g., parental alcohol use, media use), and proximal determinants (e.g., emotional regulation, early tobacco use) were identified. Geographical variations in both outcomes indicate potential differences in unmeasured community-level determinants (e.g., alcohol availability and acceptability). CONCLUSIONS: Our findings extend the generalizability of several known determinants across settings, yet highlight the importance of addressing alcohol use in young people as a complex and context-dependent issue. Many identified determinants (e.g., education, media use, poor parental support, early tobacco use) are amenable to intervention through multi-sectoral prevention programs/policies. Such determinants should be the focus of ongoing policy/intervention development efforts in the region, and our revised conceptual framework may inform further research in India or similar South Asian settings.

Closing the treatment gap for alcohol use disorders in low- and middle-income countries.

The alcohol-attributable disease burden is greater in low- and middle-income countries (LMICs) as compared to high-income countries. Despite the effectiveness of interventions such as health promotion and education, brief interventions, psychological treatments, family-focused interventions, and biomedical treatments, access to evidence-based care for alcohol use disorders (AUDs) in LMICs is limited. This can be explained by poor access to general health and mental health care, limited availability of relevant clinical skills among health care providers, lack of political will and/or financial resources, historical stigma and discrimination against people with AUDs, and poor planning and implementation of policies. Access to care for AUDs in LMICs could be improved through evidence-based strategies such as designing innovative, local and culturally acceptable solutions, health system strengthening by adopting a collaborative stepped care approach, horizontal integration of care into existing models of care (e.g., HIV care), task sharing to optimise limited human resources, working with families of individuals with AUD, and leveraging technology-enabled interventions. Moving ahead, research, policy and practice in LMICs need to focus on evidence-based decision-making, responsiveness to context and culture, working collaboratively with a range of stakeholders to design and implement interventions, identifying upstream social determinants of AUDs, developing and evaluating policy interventions such as increased taxation on alcohol, and developing services for special populations (e.g., adolescents) with AUDs.

Common strategies in empirically supported psychological interventions for alcohol use disorders: A meta-review.

ISSUES: Despite the large number of effective psychological interventions for alcohol use disorders (AUD), there is still a lack of clarity concerning the strategies that make these interventions effective. APPROACH: The overall goal of this review was to identify, examine and synthesise the information about common strategies from evidence-based psychological interventions for AUDs by conducting a review of systematic reviews, that is, a meta-review. We isolated the relevant primary studies from eligible systematic reviews and extracted information about the interventions from these studies to understand the strategies used. Analysis was restricted to narrative summaries. KEY FINDINGS: Thirteen reviews were eligible for inclusion in our meta-review. Of these, eight demonstrated the effectiveness of a range of psychological interventions-behavioural couples therapy, cognitive behaviour therapy combined with motivational interviewing, brief interventions, contingency management, psychotherapy plus brief interventions, Alcoholics Anonymous and 12-step treatment programs, family-therapy or family-involved treatment, and community reinforcement approach. The most commonly used component strategies in effective interventions for AUDs included assessment, personalised feedback, motivational interviewing, goal setting, setting and review of homework, problem solving skills and relapse prevention/management. IMPLICATIONS: Evidence about commonly used strategies in evidence-based psychological interventions for AUDs offer the possibility of creating menu-driven interventions that can be tailored to respond to individual client needs and preferences in different contexts.

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions.

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.