Chowdhary et al conducted the research reported in their paper ^{Reference Chowdhary, Anand, Dimidjian, Shinde, Weobong and Balaji1} under the aegis of PREMIUM (a Program for Mental Health Interventions for Under-Resourced Health systems) in India. They state the overall aim of this programme in their introduction: ‘to investigate a systematic, reproducible method for developing psychological treatments that incorporate global evidence, are contextually appropriate and can be delivered by non-specialist health workers’. In this paper, the authors set out to develop an intervention to be delivered by lay health workers, with the intention of addressing the treatment gap for mental health. The elaborate methodology they adopted to develop this intervention requires a highly skilled research team such as their own. There are simpler and more economical methods for cultural adaptation of evidence-based therapies ^{Reference Naeem, Phiri, Munshi, Rathod, Ayub and Gobbi2,Reference Rathod, Phiri, Harris, Underwood, Thagadur and Padmanabi3} that have been tested in similar cultures and well described. We are not clear about the rationale for their use of a complex and expensive methodology, given the aim of a ‘reproducible method for developing psychological treatments’. The authors started with a pool of techniques that were considered to be useful. These techniques were mostly based on cognitive–behavioural therapy (CBT). However, based on expert advice, they adapted the manual Behavioral Activation for Depression: A Clinician's Guide. A massive evaluation found this intervention to be unfeasible. Therefore, they further adapted the intervention and tested it in a pilot study. The title of their paper does not reflect the fact that this was an adaptation of an existing intervention and not the development of a new intervention. They used a complex, time-consuming and resource-intensive process that is highly unlikely to be repeatable in low- and middle-income countries (LMICs).

We have adapted CBT for the local population in Pakistan and for the ethnic minority population in England. ^{Reference Naeem, Phiri, Munshi, Rathod, Ayub and Gobbi2,Reference Rathod, Phiri, Harris, Underwood, Thagadur and Padmanabi3} These methods of adaptation have been described in detail and have been tested for depression ^{Reference Naeem, Gul, Irfan, Munshi, Asif and Rashid4} and schizophrenia, ^{Reference Rathod, Phiri, Harris, Underwood, Thagadur and Padmanabi3,Reference Naeem, Saeed, Irfan, Kiran, Mehmood and Gul5} and in a guided self-help format for depression. ^{Reference Naeem, Sarhandi, Gul, Khalid, Aslam and Anbrin6} The methodology evolved over the years, resulting in the development of semi-structured interviews that can be conducted by students and easily analysed using a framework analysis method. ^{Reference Naeem, Saeed, Irfan, Kiran, Mehmood and Gul5} This low-cost methodology is being used in China and the Middle East to adapt CBT. We hope the authors find this work useful in their future attempts to adapt therapy.

The issue of cost becomes even more important in the delivery of therapy. In our two-pronged approach, therapy in secondary care was delivered by psychology graduates (with a typical monthly salary of $200) and by carers using a culturally adapted CBT-based self-help manual developed locally. No financial help was provided to the carers. We believe it is not just the development or adaptation of an intervention that is important; it should also be deliverable by existing mechanisms. This leads to our second concern: how practical it is to create a new workforce of lay therapists in a low-income country? This lack of understanding of the ground realities has possibly resulted in minimal change in health settings in LMICs. For example, to the best of our knowledge, the Thinking Healthy programme ^{Reference Rahman, Malik, Sikander, Roberts and Creed7} – contrary to initial hopes – is not currently being practised in mainstream healthcare in any part of Pakistan. There is a need for researchers in this area to consider the local resources. Otherwise, there is a risk that highly funded programmes will not produce realistic evidence that they can address the treatment gap. We, therefore, believe the paper by Chowdhary et al describes a strategy that is not consistent with the current methods of culturally adapting therapy, and one that is too costly to be replicated in LMICs.