Cultural Adaptation of a Depression and Substance use Intervention Module for Integrated Mental Health Care in Pakistan

Abstract

Background: Depression and Substance Use Disorders (SUDs) are highly prevalent and frequently comorbid worldwide, contributing to significant morbidity and treatment challenges. In Pakistan, the dual burden is further worsened by stigma, limited access to care, and lack of culturally tailored psychosocial interventions. The Depression and Substance Use Module (D-SUM) is an evidence-based program, yet requires contextual adaptation to address linguistic, cultural, and health system realities in Pakistan. Objective: Therefore, the aim of this study is to adapt the depression and substance use intervention module for integrated mental health care in Pakistan.  Methods: The descriptive research design was used in the current study. This study used the ADAPT-ITT model and Bernal’s Ecological Validity Model (EVM) to systematically adapt the D-SUM for patients with comorbid depression and SUDs in Pakistan. Four clinical psychologists with expertise in dual-diagnosis treatment were engaged to review the adapted content. Feedback was analysed thematically, focusing on cultural relevance, clinical fidelity, feasibility, and recommendations for refinement. Results: Experts unanimously validated the cultural appropriateness of the adapted D-SUM module, highlighting the inclusion of Urdu translation, local idioms of distress, and integration of Islamic metaphors. Therapeutic fidelity, including core cognitive-behavioural and motivational interviewing principles, was reported as preserved. Family involvement was emphasized as a culturally congruent addition, while simplification of materials for patients with low literacy was recommended. Overall, expert feedback supported the module’s cultural validity and feasibility, with minor refinements required for broader implementation. Conclusion: The culturally adapted D-SUM showed strong acceptability among local experts, balancing cultural sensitivity with clinical integrity. The intervention holds promise for addressing the treatment gap in Pakistan by providing an evidence-based, contextually grounded psychosocial intervention for comorbid depression and SUDs. Future research should focus on pilot testing with patients and evaluating clinical outcomes prior to integration into routine services.