Automatic Speech Recognition (ASR) is increasingly used to document clinical encounters, yet its reliability in multilingual and demographically diverse Indian healthcare context remains largely unknown. In this study, we first conduct the systematic audit of ASR performance on real-world psychiatric interview data spanning Kannada, Hindi and Indian English, comparing eight state-of-the-art models including IndicWhisper, WhisperLargeV3, Sarvam, GoogleS2T, Gemma3n, OmniLingual, Vaani, and Gemini. Our results reveal substantial variability across models and languages, with some systems performing competitively in Indian English but failing in regional speech. We further fine-tune two of the best performing opensource models, i.e., Gemma3n and OmniLingual, using various methods. With this, we uncover systematic performance gaps tied to speaker role and gender, raising concerns about equitable deployment in clinical settings, which are further mitigated by fairness-aware fine-tuning. To this end, we propose SamaVaani, a unified debiasing technique that simultaneously improves ASR performance and improves fairness across demographic groups.

The National Mental Health Survey of India - 2 (NMHS-2), currently underway (2024-26), is one of the largest psychiatric epidemiological studies globally, interviewing more than 250,000 individuals across all 36 states and union territories. Given India's scale and diversity, a rigorous quality control (QC) protocol has been developed to ensure methodological fidelity, data reliability, and operational consistency. Designed through iterative consultations with national and international experts, and approved by the National Technical Advisory Group, the protocol leverages lessons from NMHS-1 and integrates global best practices to meet India's unique challenges. This protocol aims to describe the QC framework of NMHS-2, highlighting its design, core components, and implementation strategies. Key components include a multi-tiered administrative structure, systematic instrument selection, its validation and translation; structured training programs for field data collectors; and pre-survey pilot testing of the sampling design. The critical Core QC strategy involves a custom-made digital data collection platform with built-in logic checks, real-time dashboards, multi-source data verification, and re-interviews, apart from standardized data cleaning protocols. Comprehensive documentation and regular review meetings at both state and central levels further strengthen accountability and transparency. By integrating international standards with locally tailored approaches, NMHS-2 establishes a replicable model for quality assurance in large-scale mental health surveys. This paper addresses a critical gap in the literature on structured QC protocols for psychiatric epidemiological studies.

India's Tele-MANAS (Tele Mental Health Assistance and Networking Across States) programme, launched in October 2022, is the world's largest government-led tele-mental-health initiative. Operating via a multilingual 24/7 helpline, it provides stepped-care support, offering immediate counselling and escalating complex cases to psychiatrists or local services. In its first few years, Tele-MANAS has responded to more than 3.43 million calls across all Indian states and union territories. The majority of callers present with anxiety, depression or psychosocial stressors, while a critical minority report suicidal distress. Features such as linguistic inclusivity, anonymity and integration with India's digital health ecosystem have driven rapid uptake, particularly among young adults. A World Health Organization (WHO) assessment has recognised Tele-MANAS as a scalable and equity-focused solution. The initiative illustrates how low- and middle-income countries can leverage technology and task sharing to reduce the treatment gap, offering a potential global blueprint for digital mental health care. This article aims to provide a programmatic overview of Tele-MANAS, including its design, early outcomes and key implementation challenges.

People with severe mental illness (SMI) die 10-20 years earlier than the general population, largely due to non-communicable diseases (NCDs) such as hypertension and diabetes and risk factors such as hypercholesterolaemia. This cross-sectional study gathered data from people with SMI from three national mental health institutions in South Asia. Data was collected based on the WHO Stepwise approach to NCD risk factor surveillance and the prevalence of screening, diagnosis and treatment for diabetes, hypertension, and hypercholesterolaemia was assessed. Logistic regression models assessed the associations of sociodemographic characteristics with NCD screening. Three thousand nine hundred and eighty nine participants were recruited. Screening prevalence varied by country and disease, with hypertension being the most commonly screened NCD (Bangladesh = 52.5% [50.0-55.1], India = 43.1% [40.3-45.9], Pakistan = 60.9% [58.2-63.5]), and cholesterol was the least common (Bangladesh = 4.1% [3.2-5.2], India = 14.8% [12.9-17.0], Pakistan = 9.6% [8.1-11.3]). Characteristics such as BMI, age and education level were positively associated with screening, and females were more likely to be screened than males. There are low levels of screening for NCDs among individuals with SMI accessing tertiary institutions in South Asia, with significant sociodemographic disparities. Standardised screening protocols tailored to South Asian populations could mitigate the increased risk of NCDs in this population.

Moving beyond a traditional deficit-based model of recovery in substance use disorders (SUDs), the current study is grounded in contemporary strength-based personality framework, which frames Personality Functioning Strengths (PFS) as dynamic, context‑specific motives, goals, strategies, values and socio‑cognitive capacities that promote psychological well‑being in SUDs. The study addresses the precise question: What personality functioning strengths do individuals with SUDs identify as aiding their recovery? Ten adult participants (seven men, three women; mean age 31.5 years, range 18–43) with DSM‑5‑diagnosed SUDs, abstinent for ≥ 1 month, engaged in psychotherapy and in early‑mid recovery (1–5 years) were purposively recruited from a tertiary treatment centre in Bangalore. Based on the philosophical assumption and aim of the study, the concept of “informational power” was used to determine the sample size. Data was analysed using reflexive thematic analysis (RTA) following Braun and Clarke’s six‑phase framework, with iterative coding, theme development and peer debriefing supported by ATLAS.ti software. Five overarching themes of PFS were identified: (1) Being Emotionally Resilient, characterised by gratitude, hope, and humour; (2) Being Goal-Directed and Thinking Flexibly, which includes creativity, determination, and self-reflection; (3) Being Self-Aware and Value-Driven, involving self-care, autonomy, and help-seeking; (4) Building Connections with Empathy, encompassing conflict resolution and fostering social bonds; and (5) Being Rooted in Culture, which draws on family values, spirituality, and a sense of social responsibility. The findings highlight that PFS are multifaceted, spanning emotional, cognitive, interpersonal, and cultural domains. Integrating culturally anchored PFS, such as family values and a sense of oneness into SUD treatment better aligns with a strengths‑based, recovery approach in the Indian sociocultural context. The results have implications for refining strengths-based frameworks and developing culturally sensitive assessments and interventions for individuals with SUDs.

Tobacco use is the leading cause of preventable death globally, claiming more than 7 million lives each year. The burden of disease is highest in low- and middle-income countries, where more than 80% of the world's 1.3 billion tobacco users reside. The World Health Organization (WHO) defines six proven strategies to reduce tobacco use, referred to by the acronym MPOWER, with one of the strategies being to offer tobacco users help with quitting. Many low- and middle-income countries provide tobacco-cessation services; however, only 31 meet the WHO best practice, defined as providing both cost-covered behavioral interventions and pharmacotherapy. In this article, case studies from India and Vietnam illustrate how cross-country differences in tobacco-related sociocultural norms, tobacco-use patterns (e.g., smokeless tobacco or water pipes), the tobacco-control regulatory environment, industry influence, and health care system financing shape treatment access and uptake. These cases further show that cost-effective population-level strategies, including quitlines, digital interventions, and systemwide screening for tobacco use paired with clinician advice to quit, are essential for expanding treatment reach. Combining these interventions with pharmacotherapy products that are included on the WHO Model List of Essential Medicines (e.g., cytisine and nicotine-replacement therapy) further improves cessation outcomes. System-level models, such as the Ask-Advise-Connect model (ask about tobacco use, advise to quit, connect to cessation help), offer a feasible, low-burden pathway for integrating cessation care into routine practice. Ultimately, curbing the rising global burden of tobacco-related disease requires establishing comprehensive cessation support as a universal standard of care, which would ensure equitable access for those most affected.

Background: Tobacco is consumed by two-thirds of individuals with severe mental illness (SMI). Despite a high tobacco-related disease burden, there is a lack of evidence-based cessation interventions for individuals with SMI living in low- and middle-income countries. This study aims to evaluate the feasibility and acceptability of a culturally adapted behavioural intervention for tobacco cessation (SCIMITAR-SA) delivered in mental health services in Bangladesh, India, and Pakistan. Methods: A two-arm, parallel-group, individually randomised, multi-country feasibility trial will be conducted across six mental health facilities in urban centres. All trial participants will receive Very Brief Advice (VBA) and an educational leaflet from their clinical team. Additionally, those in the intervention arm will receive up to seven structured behavioural support sessions. Salivary cotinine and anabasine will be used to biochemically verify abstinence at seven months post-randomisation. Quantitative outcomes will assess feasibility of conducting a definitive trial, including recruitment and retention rates, session attendance, completeness of baseline assessments and outcome measures at four and seven months and use of health resources. An embedded process evaluation will explore the feasibility and acceptability of trial processes, and of the delivery and receipt of the VBA and SCIMITAR-SA interventions. Economic outcomes will assess the feasibility of collecting cost and resource-use data to inform a future definitive trial. Discussion: The SCIMITAR-SA trial will provide essential evidence on the feasibility of delivering culturally adapted cessation support for people with SMI in South Asia and inform scalable integration into routine psychiatric care across low- and middle-income settings. Registration: ISRCTN registry (ISRCTN91038721)

BackgroundAlcohol dependence and cirrhosis are key outcomes of increased alcohol use, with genetic factors increasingly implicated. A functional promoter variant (rs361525) in the TNF-α gene may contribute to ALD pathogenesis, while a loss-of-function variant (rs58542926) in TM6SF2 modifies liver disease progression. We aimed to study these SNPs and assess DNA methylation at TM6SF2 loci in individuals with and without alcohol-related cirrhosis.MethodsThe study included men (N = 243) with alcohol dependence with cirrhosis (AUD-C+ve) and without cirrhosis (AUD-C-ve), based on ICD-10 criteria, recruited from SJMCH. Fibroscan and/or sonography (LSM < 14 kPa) ruled out severe fibrosis. Genotyping was performed for TNFα (rs361525) and TM6SF2 (rs58542926). Genomic DNA (N = 100) underwent bisulfite conversion followed by pyrosequencing at TM6SF2 loci. Methylation levels were calculated separately for individual CpG sites and as the mean of four CpG sites. Group differences were assessed using unpaired t-tests, and genetic models were applied based on risk allele status.ResultsGenotype and allele frequencies at both loci were comparable between AUD-C+ve and AUD-C–ve groups. TM6SF2 methylation was significantly reduced in the AUD-C+ve group (uncorrected p = 0.03). A trend was also noted for TNF-genotype with A-carriers having lower TM6SF2 global methylation levels (p = 0.06). We did not observe any differences in genotype and allele frequencies for both TM6SF2 and TNFα variants. Duration of alcohol consumption was significantly associated with TM6SF2 methylation (p = 0.02).ConclusionTM6SF2 hypomethylation in AUD-C+ve individuals may influence lipid metabolism and contribute to liver injury and HCC progression. Reduced methylation among TNF-α risk allele carriers suggests a potential gene–epigenetic interaction. Overall, higher alcohol exposure and genetic susceptibility may together predispose to worsening alcohol-related cirrhosis.

The Flexible Interview for ICD-11 (FLII-11) is a new structured diagnostic interview developed by the World Health Organization (WHO) for diagnosing mental disorders based on the ICD-11's clinical descriptions and diagnostic requirements. The instrument is to be used for India's National Mental Health Survey-2 as the primary assessment instrument for mental health morbidity. This paper outlines the systematic process of culturally adapting the FLII-11 for India. Given India's immense cultural and linguistic diversity, this was deemed a crucial step to ensure a valid and reliable data collection process. Key steps included: preliminary evaluation by experts for language and cultural congruence; ascertaining the adaptation's effectiveness in clinical settings; interim analysis, followed by modifications and retesting; and incorporating feedback from both Indian and international collaborators. It also describes the protocol for translating the instrument into 22 recognized Indian languages, ensuring that it can be administered in each state's language. This project was an international collaboration involving teams from India, South Africa, the UK and the USA. Almost all of the changes made from this study were also incorporated into the current version of the FLII-11, which is being tested in other countries, representing the study's global contribution of the study.

OBJECTIVE:Cannabis use is a known risk factor for psychosis, but it remains unclear whether cannabis-associated psychosis (CAP) differs meaningfully from non-cannabis-associated psychosis (NCAP) in clinical presentation, biology, or illness course. The objective of this study was to characterize the presentation and course of first-episode psychosis with and without cannabis exposure. METHODS:In this prospective study, males hospitalized for new-onset psychosis with confirmed cannabis exposure (CAP; N=66) were compared with those without cannabis exposure (NCAP; N=53). Participants were assessed at admission and after 4 weeks of standardized inpatient treatment, using cognitive tests (CogState Schizophrenia Battery, Hopkins Verbal Learning Test), electroencephalography (EEG), and symptom scales (Positive and Negative Syndrome Scale [PANSS], Calgary Depression Rating Scale [CDRS], Young Mania Rating Scale [YMRS]). RESULTS:Cognitive test performance significantly improved in the CAP group but not in the NCAP group, despite the absence of group differences at the time of admission. At admission, relative to the NCAP group, the CAP group had significantly higher power spectral density exponent in the EEG, a proxy index of cortical excitatory/inhibitory (E/I) balance. CAP participants presented with lower PANSS negative and total scores but greater depressive (CDRS) and manic (YMRS) symptoms at admission. Psychosis symptoms improved with treatment in both groups, but the CAP group experienced greater improvement in mood symptoms. Follow-up data were available for 16 CAP participants; 10 were rehospitalized for psychosis exacerbation after resuming cannabis use, whereas relapse was rare among those who remained abstinent. CONCLUSIONS:Relative to the NCAP group, the CAP group exhibited better cognitive function, lower cortical E/I balance, lesser negative symptoms, and greater mood symptoms. Cannabis resumption was associated with relapse, highlighting its role in illness recurrence. Together, these results raise the possibility that cannabis-associated psychosis is a distinct subtype of first-episode psychosis. Given the increasing rates of psychosis related to cannabis, further studies are needed to examine its long-term trajectory and refine treatment approaches.

Background Depression is three times more common in Tuberculosis (TB) patients than in the general population and worsens TB outcomes, often goes undetected or untreated. Integrating depression care into existing TB services is essential. Objectives To develop and assess the feasibility of a tailored care pathway that integrates depression screening and management into existing TB services in India. Methods The study was conducted in three TB care facilities in Bengaluru, Karnataka, India, in two phases: (i)Co-design of tailored depression in the TB care pathway through a series of workshops. (ii)Testing the feasibility of the pathway A training manual was developed and used to train TB health workers. The feasibility of the care pathway was assessed by evaluating the proportion of persons with TB attending each facility during the study period who were screened for depression, as well as through a series of feedback workshops to assess acceptability. Results A total of 114/164 (69.51%) TB patients underwent screening over a six month period, with seven reporting scores of over 2 on the PHQ-2. The feedback workshops identified the acceptability and appropriateness of the tools, as well as areas for improvement in knowledge and understanding. Addressing complex health issues such as suicidality, alcohol and tobacco use and the burden on existing staff due to a higher volume of cases reported as challenges. Conclusions This care pathway warrants further testing to establish its feasibility in a larger context and to understand how to optimise its wider implementation, scale-up and sustainability.

Background: Tapentadol, a dual-action opioid, is increasingly misused in India by intravenous injection of crushed tablets. Objective urine testing is scarce, and pharmacokinetic data for injected supratherapeutic use are limited. Aim: To validate a practical liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine assay, estimate optimal detection time-points in clinical settings, and define concentration cut-offs at those time-points. Methods: We interviewed people with injecting Tapentadol use for last-use details (time since use, dose). Multiple urine specimens were collected (May 2023–Feb 2024). LC-MS/MS quantification was validated using UNODC guidelines. Optimal thresholds and maximal accuracy were estimated at prespecified clinically relevant time-points (24, 72, 120, and 168 hours). Results: We analyzed 778 samples from 342 male patients; median age 24 years (IQR 22–26). Median daily Tapentadol dose 1,000 mg (IQR 500–1500); median injection frequency 10/day (IQR 8–15); median last-use-dose 300 mg (IQR 200–500). Urine concentrations declined exponentially over time. Analytical performance: linearity r² > 0.998 (50–1000 ng/mL), negligible carryover, matrix effect ≤10%, and limit of quantification 1 ng/mL. Accuracy was highest at 72 hours with an optimal concentration cut point of 205 ng/mL (sensitivity 1.00, specificity 0.98, and accuracy 0.99). Conclusion: We report a feasible, validated LC-MS/MS urine assay for Tapentadol with good performance at clinically relevant time-points, best performance being at 72 hours after last use. Tapentadol concentration decreased exponentially over time (first-order elimination kinetics), but remained detectable beyond 48 hours, possibly due to saturation kinetics with supratherapeutic-dose IV use or the impact of excipients. These concentration thresholds can support objective monitoring of abstinence/relapse in clinical care.

Abstract Externalizing disorders are common neurodevelopmental conditions, yet their underlying biology is not fully understood. Integrating peripheral biomarkers with brain imaging offers a powerful approach to elucidate the pathophysiology of these disorders. This study aimed to investigate the association between indicators of glial activation (glial fibrillary acidic protein; GFAP) and axonal injury (neurofilament light chain; NfL) in plasma with functional brain connectivity, and externalizing psychopathology (EXT) in a neurodevelopmental cohort. Towards this, a cross-sectional study was conducted with 144 participants selected from the Indian cVEDA cohort and balanced into EXT and healthy control (HC) groups using Mahalanobis distance matching. Plasma GFAP and NfL were quantified using Simoa technology. Resting-state fMRI data were used to generate between-network connectivity deviation scores via normative modelling. We used Gamma General Linear Models (Gamma GLMs) to test for an age-by-EXT interaction on GFAP/ NfL levels and sparse partial least squares (sPLS) regression to identify connectivity features that correlated with them. We found a significant age-by-EXT interaction for GFAP (p = 0.002), where EXT was associated with higher GFAP levels only in younger participants (<14 years). No significant effects were found for NfL. The sPLS analysis identified a significant five-feature brain connectivity signature that correlated with GFAP levels. This pattern was characterized by atypically strong connectivity between sensorimotor-limbic and attention-default mode networks, and weaker-than-expected connectivity within the default mode network. In conclusion, our findings identify a strong association between plasma GFAP and EXT in youth in an age dependent manner, suggesting a key role for glial activation in the early pathophysiology of these disorders. This process is linked to a specific, multivariate pattern of brain dysconnectivity, providing a potential neurobiological signature that warrants further investigation.

Tobacco use poses a major public health challenge in the World Health Organization’s South-East Asia Region, where it contributes to approximately 2.3 million deaths each year. In 2020 alone, tobacco smoking was responsible for around 1.6 million of these deaths. The region faces a dual burden of high prevalence of both smoking and smokeless tobacco use, underscoring the urgent need for strengthened tobacco control measures. The toxic substances found in the emissions of smoked tobacco products are inadequately researched. This study presents primary scientific information on levels of nicotine, water, and benzo[a]pyrene (BaP) in mainstream smoke deliveries from popular cigarettes from India and Myanmar, and bidis from India; additionally, flavours and humectants were tested in fillers. Globally accepted methods from the World Health Organization’s Tobacco Laboratory Network (TobLabNet), the Centers for Disease Control and Prevention (CDC), and the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) were used. When comparing Indian and Myanmar cigarettes, we discovered that nicotine and carbon monoxide (CO) levels in Myanmar cigarettes were slightly higher than those in Indian ones, though the difference was not statistically significant. Water, tar, and total particulate matter (TPM) also exhibited no statistically significant variations. Significantly higher (p = 0.008) concentrations of BaP, ranging from 8.02 to 14.90 ng/cigarette (median, 9.95 ng/cigarette), were observed in Myanmar-origin cigarettes, indicating increased exposure risks for users. Among humectants, only propylene glycol showed significant variation (p = 0.023). Compared with Indian cigarettes, bidis showed significantly higher nicotine and CO (p = 0.023), as well as water and TPM (p = 0.008). When bidis were compared with cigarettes from both countries, nicotine (p = 0.041), water, and TPM differed significantly (both p < 0.001). The intended flavours were not detected in the mainstream smoke of the cigarettes and bidis examined. The findings of this study can be leveraged to enhance public health by identifying harmful chemicals that exceed established limits and potentially motivating manufacturers to produce less harmful products by conforming to toxicant emission standards.

Background: Measuring disability is one of the primary objectives of India’s National Mental Health Survey-2 (NMHS-2). The survey required a scale that was short, free to use, culturally flexible, administrable by lay-interviewers, and measuring disability aligned with the current understanding of mental disorders. Aim: Lacking a scale meeting these requisites, the NIMHANS-NMHS-2 Disability Scale (NNDS) was developed as a new adult disability scale. This manuscript reports on its development and validation. Methods: Nineteen items across six domains were generated by desk review. Content validation conducted by 16 Consultants at the National Institute of Mental Health and Neuro Sciences led to removal of six items (Content Validity Index <0.75). Analysis included Cronbach’s alpha for internal consistency and Exploratory Factor Analysis. K-means cluster analysis identified disability severity groups, while receiver operating characteristic analysis determined optimal disability cut-offs based on WHO-Disability Assessment Schedule (WHODAS) and NNDS scores. Results: The NNDS was validated across inpatient (n = 141) and Outpatient (n = 142) sample from NIMHANS, and a community sample (n = 133). It demonstrated excellent internal consistency (α-0.94), a stable five-factor structure, and strong correlations with the WHODAS 2.0 (rho = 0.93), and Brief Psychiatric Rating Scale (rho = 0.80). Cut-off scores established were: No disability: 13–17; Mild: 18–31; Moderate: 32–40, and Severe: >40. Conclusion: The NNDS has demonstrated robust psychometric properties for measuring disability. Being open-source, the scale has broad applicability for clinical practice, community assessments and research. (For the NMHS-2, an eight-item short version is being used, its development and validation are separately submitted for consideration of publication).

Schizophrenia is increasingly recognized as a neurodevelopmental disorder arising from excitation-inhibition (E/I) imbalance within cortical and subcortical networks. The E/I imbalance model posits that converging genetic, epigenetic and environmental influences act through glutamatergic (Glu) and gamma-aminobutyric acid (GABA)-ergic dysfunction, redox and immune dysregulation to destabilize neural E/I homeostasis across sequential stages of the neurodevelopmental trajectory. This framework provides a mechanistically integrated explanation for the diverse symptom dimensions and progressive course of schizophrenia, while identifying modifiable targets for intervention. Grounded in the E/I imbalance model, we outline a novel mechanistically informed framework for treatment of schizophrenia with an emphasis on prevention and recovery. Across the lifespan, this approach advocates stage-specific preventive strategies that begin well before illness onset, extend through early and chronic phases of the illness and incorporate therapeutic strategies to modify underlying neurobiology rather than simply alleviating symptoms. By connecting molecular neuroscience with clinical medicine and precision health approaches, the model outlines a realistic path towards mechanism-based prevention and recovery that is applicable not only to schizophrenia and neuropsychiatric disorders, but also to other non-communicable systemic disorders.

Importance:Opioid withdrawal involves sympathetic hyperactivity and reduced parasympathetic tone, which standard pharmacological treatments may not adequately address, contributing to relapse vulnerability. Objective:To evaluate yoga as adjuvant therapy to accelerate opioid withdrawal recovery and assess its impact on heart rate variability, anxiety, sleep, and pain. Design, Setting, and Participants:This 2-arm, early-stage randomized clinical trial was conducted at an addiction medicine inpatient ward in India from April 30, 2023 to March 31, 2024. The outcome assessors and data analyst were blinded to group allocation. Participants included adults aged 18 to 50 years with opioid use disorder experiencing mild to moderate withdrawal symptoms (Clinical Opiate Withdrawal Scale [COWS] scores 4-24). Exclusion criteria included severe withdrawal, neurological conditions affecting autonomic function, severe psychiatric conditions, and recent yoga training. Of 68 individuals screened, 59 were randomized (30 yoga and 29 control participants). Intervention:Participants in the yoga group received 10 supervised 45-minute sessions during 14 days alongside standard buprenorphine treatment, including relaxation practices, postures, breathing techniques, and guided relaxation. Participants in the control group received standard buprenorphine treatment only. Main Outcomes and Measures:Co-primary outcomes included time to withdrawal stabilization (COWS score <4) and heart rate variability parameters. Secondary outcomes included anxiety (Hamilton Anxiety Rating Scale), sleep latency, and pain scores. Assessments were conducted at baseline (day 1) and day 15. Results:Fifty-nine participants (59 male [100%]; mean [SD] age, 25.6 [3.9] years) completed intent-to-treat analysis. Participants in the yoga group recovered faster than those in the control group (hazard ratio [HR], 4.40; 95% CI, 2.40-8.07; P < .001), with a median stabilization time of 5 days (95% CI, 4-6 days) for those in the yoga group vs 9 days (95% CI, 7-13 days) for the control group. Participants in the yoga group showed superior heart rate variability improvements with large effects on low frequency (LF) power (ω2 = 0.16), high frequency (HF) power (ω2 = 0.14), and LF/HF ratio (ω2 = 0.12); all effects were statistically significant (P < .001). Mediation analysis showed that increases in parasympathetic activity accounted for 23% of the treatment effect (indirect HR, 1.38; 95% CI, 1.10-2.03). Anxiety reduction was significantly greater among those in the yoga group (ω2 = 0.28; P < .001), with moderate improvements in sleep latency (a 61-minute reduction; P = .008) and pain (P = .004). Conclusions and Relevance:In this randomized clinical trial, yoga significantly accelerated opioid withdrawal recovery and improved autonomic regulation, anxiety, sleep, and pain. These findings support integrating yoga into withdrawal protocols as a neurobiologically informed intervention addressing core regulatory processes beyond symptom management. Trial Registration:Clinical Trials Registry of India Identifier: CTRI/2023/04/051302.

INTRODUCTION:An estimated 78% of the total deaths attributable to smoking tobacco use occurred in low- and middle-income countries (LMICs) in 2019. In addition, smokeless tobacco increases the risk of all-cause mortality, all cancers, including upper aero-digestive tract cancer, stomach cancer, ischemic heart disease and stroke, with 88% of the mortality burden being borne by the South-East Asian region. Evidence-based interventions from high-income countries (HICs) are not easily transferable to LMICs, as patterns of tobacco use, health beliefs associated with tobacco use, and awareness of specific health risks vary substantially. METHODS:We synthesized the effectiveness of behavioral interventions for tobacco cessation in LMICs through a systematic review and meta-analysis. Interventional studies which delivered individual behavioral intervention and assessed abstinence from tobacco use were included. We examined the pooled intervention effect at 6 months postintervention follow-up. RESULTS:For continuous abstinence at 6 months, the intervention was superior to the active comparator (RR 2.32; 95% CI 1.78 to 3.02) and usual care (RR 4.39; 95% CI 2.38 to 8.11). For point prevalence abstinence at six months, the intervention was superior to the active comparator (RR 1.76; 95% CI 1.28 to 2.44), and usual care (RR 2.37; 95% CI 1.47 to 3.81). The statistical heterogeneity was substantial to considerable for all comparisons. Only six studies had an overall low risk of bias. Publication bias was observed for all comparisons except for 6-month continuous outcomes. CONCLUSIONS:Implementation research is needed to understand factors for programme sustainability and equity of the impact of behavioral interventions in reducing tobacco use in LMICs. IMPLICATIONS:Our review is an important step towards understanding the effectiveness of behavior interventions for tobacco cessation suited for LMICs and which are responsive to the contextual needs of such countries.