Western values influence cognitive behavioural therapy (CBT) as it was primarily developed and practised in the West. As understanding the cultural context has been linked to better therapy outcomes, it has been suggested that CBT might need modification to non-Western clients’ cultural backgrounds. Previously we developed a cost-effective approach to adapt CBT for clients in China and Pakistan. In this study, we applied the same methodology for local clients suffering from depression and anxiety in the Kingdom of Saudi Arabia and Bahrain. This study aimed to understand the views of patients with depression and anxiety, caregivers and mental health professionals about CBT to develop guidelines for culturally adapting CBT for depression and anxiety. We conducted semi-structured interviews with the patients (n= 42), caregivers (n= 11), and psychiatrists and psychologists (n= 16). The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The themes emerging from the analyses of interviews by each interviewer were compared and contrasted with those of other interviewers. The results highlighted barriers of access to and strengths of CBT while working with these patient groups. Patients and their caregivers in both countries use a bio-psycho-spiritual-social model of illness and seek help from multiple sources. Therapists emphasized the need for using local idioms, culturally appropriate translation and minor adjustments in therapy. There were no thematic differences between the two sites. These findings will be used to culturally adapt a CBT manual, which will be tested in a randomized controlled trial.Key learning aims: After reading this article, readers will be able to: (1)Understand the need for cultural adaptation of CBT. (2)Identify the necessary steps to adapt CBT for the Muslim Arab population. (3)Understand the modifications required to deliver culturally adapted CBT for the Muslim Arab population.

Background: Social anxiety is common among adolescents in Pakistan and is associated with low self-esteem. Among the recommended treatments, cognitive behavioural therapy (CBT) is effective, and self-help approaches are encouraged.Aim: To determine the effectiveness of culturally adapted CBT-based guided self-help (CACBT-GSH) intervention, using a manual ‘Khushi aur Khatoon’, for treating social anxiety when added to treatment as usual (TAU) compared with TAU only.Method: A total of 76 adolescents with social anxiety aged 13–16 years from six schools in Multan, Pakistan were recruited into this randomized controlled trial. Participants were divided into intervention and control groups in a 1:1 ratio. Social anxiety, self-esteem and fear of negative evaluation were assessed through the Liebowtiz Social Anxiety Scale for children and adolescents, the Rosenberg Self-Esteem Scale and the Brief Fear of Negative Evaluation, respectively, at baseline and at the end of the study. Guided self-help using culturally adapted CBT (CACBT)-based self-help manual (eight sessions, one session per week) was provided to the intervention group. The effect of the CACBT-GSH intervention was analysed with ANCOVA.Results: There was a statistically significant difference between the intervention and the control groups in favour of intervention. Participants in the intervention group showed reduced symptoms of social anxiety (p < .001), fear of negative evaluation (p < .001) and enhanced self-esteem (p < .001).Conclusion: The study demonstrated the effectiveness of CACBT-based guided self-help intervention in treating social anxiety and addressing the symptoms associated with it.

Objective: To assess the effect of COVID-19 vaccination on menstrual patterns and mental health of medical students and to explore the students’ perspective regarding this effect. Materials and methods: This mixed-method study was conducted on the medical and dental students of the private and public sector institutions of Peshawar from September 2021 to March 2022. A Menstrual symptom questionnaire (MSQ) and hospital anxiety and depression scale (HADS) were used. This was followed by qualitative interviews with the students who faced problems in their menstruation after the COVID-19 vaccination. Results: A total of 953 students were included, with a mean age of 20.67±1. 56 years. More than half (n = 512, 53.7%) experienced menstrual cycle abnormalities post-vaccination. The majority having disturbances in their menstrual cycle had significantly higher levels of anxiety (p = 0.000). Results on the menstrual symptom questionnaire, anxiety, and depression subtype of HADS showed a negative and statistically significant relationship with changes after COVID-19 vaccination (p<0.05). In the qualitative interviews, 10 (58.8%) students each had problems with frequency and flow, followed by 7 (41.2%) students, who had dysmenorrhea. Seven (41.2%) consulted a gynecologist for management. The majority (n = 14, 82.4%) stated that these issues had an adverse impact on their mental health and almost half (n = 8, 47.1%) suggested consulting a gynecologist while facing such situations. Conclusion: This study showed the impact of the COVID-19 vaccine on women`s menstrual patterns and subsequent mental health status. Although the majority of the students experienced menstrual cycle abnormalities and subsequent mental health adversities post COVID-19 vaccination but these were temporary and self-limiting and were attributed to the psychological impact of the vaccination. Therefore, it is imperative to alert health care professionals about possible side effects and prior counseling is expected to play an important role in this context.

Online cognitive behaviour therapy (CBT), self-help and guided self-help (GSH) interventions have been found to be efficacious and cost-effective for treatment of anxiety and depression, but there are limited data from low- and middle-income countries on culturally adapted digital interventions for these common mental disorders. The aim of this study was to investigate the feasibility and acceptability of an online culturally adapted CBT-based guided self-help (CaCBT-GSH) for patients with anxiety and depression in Pakistan. This randomized controlled trial recruited 39 participants from primary care in Karachi, Pakistan and randomized them to two groups. The intervention group received seven modules of CaCBT-GSH plus treatment as usual (TAU) over 12 weeks. The control group was a waitlist control plus TAU. The primary outcomes were feasibility and acceptability. Clinical outcomes included results from the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHODAS 2). Assessments were carried out at baseline and at 12 weeks. All 39 individuals who met eligibility criteria for the study agreed to participate. Adherence to the intervention was excellent, with 85% (17/20) completing more than five modules. Statistically significant improvements were found in all clinical outcomes in the intervention group. This was the first trial of an online CaCBT-GSH intervention, which was found to be feasible and acceptable to Pakistani patients with anxiety and depression. CaCBT-GSH may help improve symptoms, depression, anxiety and overall functioning in this population. The results provide rationale for a larger, confirmatory randomized controlled trial of digital CaCBT-GSH. Key learning aims: (1) Leveraging digital and virtual platforms to deliver psychosocial interventions may contribute to addressing the significant treatment gap in low-resource settings. (2) CBT-informed guided self-help is feasible and acceptable in the treatment of common mental disorders in Pakistan. (3) The results of this study merit a larger, appropriately powered confirmatory randomized controlled trial to determine clinical and cost effectiveness.

In people with TB, co-existence of long-term conditions (e.g., depression, diabetes and HIV) and risk factors (e.g.,alcohol misuse, malnutrition, and smoking) are associated with increased mortality and poor treatment outcomes including delayed recovery, TB treatment failure and relapse. However, it is unclear as to what extent these comorbidities are addressed in TB policy and practice. Between August and October 2021, we conducted an online cross-sectional survey in high-TB burden countries. We recruited a purposive sample of TB health workers, managers, policy makers, advisors and advocates from these countries. The survey enquired about the extent to which various comorbid conditions are: (a) mentioned in TB policies, plans, and guidelines; (b) screened, diagnosed, treated or referred to specialist services by TB healthcare workers. We summarised using descriptive analysis. Of the 1100 potential respondents contacted in 33 countries, 543 responded but only 446 (41%) from 27 countries provided sufficient data for inclusion in the study. We found no notable differences between these providing insufficient data and those completing the survey. HIV, diabetes mellitus, depression and tobacco and alcohol use disorders were identified as the most common and concerning comorbid conditions in TB. HIV was screened for and managed by TB services in most countries. Screening for diabetes and/or tobacco and alcohol use disorders was offered by almost half of all TB services but only a few offered relevant treatments. Depression was rarely screened for, almost never treated, and only infrequently referred to specialist services. Most respondents felt confident in screening/diagnosing these comorbid conditions but not in treating these conditions. With the exception of HIV, chronic comorbid conditions are only partially screened for and rarely managed within TB services. Mental health conditions are for the most part neglected. Given their adverse impact on TB outcomes, integrating screening and management of these comorbidities within TB programmes offers a significant opportunity to meet TB targets, address non-communicable diseases and improve patient well-being.

In a humanitarian crisis, healthcare workers are on the frontline in providing their services. Despite being crisis management personnel, healthcare workers may get exposed to occupational stress due to unprecedented circumstances, challenges in delivery of high-quality care, lack of resources, and most importantly for being at high risk to suffer from the impact of the situation itself. Therefore, it is imperative to maintain the mental health of healthcare workers on a regular basis and more so during a pandemic like COVID-19. For addressing the occupational stress in healthcare workers, a Cognitive Behaviour Therapy (CBT) based intervention is suggested, also supported by a Cochrane review, which can build/ improve/ enhance resilience, needed to shield individuals against the development of psychopathology, at the public health level in humanitarian crises. In addition to developing resilience, which will be helpful in combating anxiety, depression, somatization, and incapacitation, CBT will also help in dealing with the social isolation which has been part and parcel of COVID-19 and similar pandemic situations.