School-Based Mental Health Interventions for Children and Adolescents in South Asia: A Review of Randomised Evidence and Implications for Pakistan

Abstract

This review aimed to describe randomised evidence on school-based mental health interventions for children and adolescents in South Asia, examine the approaches used to deliver these interventions, and identify implications and research priorities for Pakistan. A narrative review was undertaken using published trial reports, trial registries, and reference lists of relevant reviews. Randomised and cluster-randomised studies conducted in schools in the eight South Asian countries represented by the SAARC region were considered. Eligible interventions included psychological, psychosocial, whole-school health promotion, and physical activity programmes that reported a mental health or psychosocial outcome. Effectiveness trials and feasibility studies were considered separately. Six effectiveness trials and two feasibility studies were identified from Pakistan, India, Bangladesh, Nepal, and Sri Lanka. Most interventions were delivered by trained non-specialists, lay counsellors, or paraprofessionals rather than specialist psychologists. In Pakistan, a cluster-randomised trial of the WHO-developed EASE intervention among 566 adolescents with elevated psychosocial distress reported a reduction in distress at three months, with an effect size of 0.38 (95% CI 0.18–0.57). In India, the PRIDE intervention produced an effect size of 0.36 (95% CI 0.11–0.61) for self-identified problems at six weeks, while 12-month follow-up showed improvement in some outcomes. The SEHER whole-school intervention in India improved school climate and reduced several adverse outcomes when delivered by lay counsellors, whereas the teacher-delivered arm did not demonstrate effects. A physical activity intervention in Bangladesh was associated with lower depressive symptoms (β = −4.60, 95% CI −5.76 to −3.46) and higher life satisfaction (β = 1.43, 95% CI 0.77–2.10). Evidence from conflict-affected Nepal and Sri Lanka was more mixed. School-based interventions delivered by trained non-specialists appear feasible in South Asia and may provide short-term benefits, particularly among students experiencing psychological distress. However, the evidence base remains geographically limited, long-term follow-up is uncommon, and important implementation and cost-effectiveness questions remain unanswered.