Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

If headache has any association with hypertension, it is negative. Evidence from a population-based study in Nepal.

BACKGROUND: Hypertension and headache disorders are major contributors to public ill health, linked by a long-standing but questionable belief that hypertension is a conspicuous cause of headache. In Nepal, where hypertension is common and often untreated, we assessed the substance of this belief, hypothesising that, should hypertension be a significant cause of headache, a clear positive association between these disorders would exist. METHODS: In a cross-sectional, nationwide study, trained health workers conducted face-to-face structured interviews, during unannounced home visits, with a representative sample of the Nepalese adult population (18-65 years). They applied standard diagnostic criteria for headache disorders and measured blood pressure digitally. Hypertension was defined as systolic pressure ≥140 and/or diastolic ≥90 mm Hg. RESULTS: Of 2,100 participants (59.0% female, mean age 36.4 ± 12.8 years), 317 (15.1%) had hypertension (41.0% female) and 1,794 (85.4%) had headache (61.6% female; 728 migraine, 863 tension-type headache, 161 headache on ≥15 days/month [mutually exclusive diagnoses]; 42 unclassified headaches).All headache collectively was less prevalent among hypertension cases (78.9%) than non-cases (86.6%; p = 0.001). A negative association between hypertension and all headache was demonstrated in bivariate analysis (odds ratio: 0.6 [95% Confidence interval: 0.4-0.8]; p < 0.001), but did not maintain significance in multivariate regression analysis (adjusted odds ratio: 0.8 [95% Confidence interval: 0.5-1.1]; p = 0.09). The findings were reflected, without significance, in each headache type. CONCLUSIONS: If any association exists between hypertension and headache disorders, it is negative. From the public-health perspective, headache disorders and hypertension are unrelated entities: they need distinct policies and programs for prevention, control and management.

Mental health education in undergraduate medical curricula across Nepalese universities.

BACKGROUND: Mental and substance use disorders account for 30 % of the non-fatal disease burden and 10 % of the overall disease burden but the treatment gap is daunting. With just one psychiatrist per 200,000 populations in Nepal, the only convincing way to improve access to the services quickly is by mobilizing non-specialized medical practitioner. A robust mental health component within the training curriculum of general medical doctors could produce medical graduates with adequate knowledge and skills to deliver basic mental health service. We reviewed the mental health curricula for medical students of all the medical universities in Nepal. METHODS: Information on existing mental health curricula was collected from the faculty of the respective universities with respect to content coverage, teaching methods and evaluation patterns. The mental health curricula were described in relation to teaching duration, duration of clinical rotation, duration of internship, and the relative weight of mental health in examination marks. Teaching methods were classified broadly as passive and active. Assessment methods were documented. Content coverage of the curricula was evaluated with respect to history taking and general physical examination, the priority mental health conditions, topics on behavioural sciences, and child mental health or other topics. RESULTS: The duration of teaching on mental health in general medical doctor training in Nepalese medical universities ranges from 25 to 92 h. All medical universities have a relative focus on the priority mental neurological and substance use disorders. The clinical rotation on mental health is mostly two weeks, except in one university where it can be extended up to 4 weeks with an elective clinical rotation. The relative weight of summative assessment ranges from 0.21 to 2.5 % total marks of the entire training. CONCLUSIONS: Considerable disparities exist in course content, teaching/learning modalities and assessments for mental health across Nepalese medical universities. The relative proportion of mental health in medical curricula as well as teaching/learning and assessments are far below ideal in these universities. These findings suggest a need for increasing time allocation, adopting newer teaching learning methods, and also having a mandatory clinical rotation during training and during internship.

Impact of Service User Video Presentations on Explicit and Implicit Stigma toward Mental Illness among Medical Students in Nepal: A Randomized Controlled Trial.

This study evaluated the impact of didactic videos and service user testimonial videos on mental illness stigma among medical students. Two randomized controlled trials were conducted in Nepal. Study 1 examined stigma reduction for depression. Study 2 examined depression and psychosis. Participants were Nepali medical students (Study 1: n = 94, Study 2: n = 213) randomized to three conditions: a didactic video based on the mental health Gap Action Programme (mhGAP), a service user video about living with mental illness, or a control condition with no videos. In Study 1, videos only addressed depression. In Study 2, videos addressed depression and psychosis. In Study 1, both didactic and service user videos reduced stigma compared to the control. In Study 2 (depression and psychosis), there were no differences among the three arms. When comparing Study 1 and 2, there was greater stigma reduction in the service user video arm with only depression versus service user videos describing depression and psychosis. In summary, didactic and service user videos were associated with decreased stigma when content addressed only depression. However, no stigma reduction was seen when including depression and psychosis. This calls for considering different strategies to address stigma based on types of mental illnesses. ClinicalTrials.gov identifier: NCT03231761.

Adapting World Health Organization Disability Assessment Schedule 2.0 for Nepal.

BACKGROUND: Disability is a vital public health issue for health care programs. Affluent countries usually prioritize disability-related research, while often it remains neglected in resource-poor countries like Nepal. The aim of this study was to make available a translated and culturally adapted version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for measuring disability in the Nepalese population. METHODS: WHODAS 2.0 (12-items version) was translated into Nepali using a standard forward-backward translation protocol. Purposive and convenience recruitment of participants with psychiatric disabilities was done at the Psychiatry services in a tertiary care hospital. Age and gender-matched participants with physical disabilities were selected from the Internal Medicine department, and participants with no disability were recruited from their accompanying persons. A structured interview in Nepali including the translated WHODAS 2.0 was administered to all participants. Exploratory factor analysis and parallel analysis assessed the construct validity. Content validity was explored, and a quality of life instrument was used for establishing criterion validity. Reliability was measured via Cronbach alpha. Mann-Whitney test explored score differences between the disabled and non-disabled. RESULTS: In total, 149 persons [mean age: 40.6 (12.8); 43.6% males, 56.4% females; 61.7% disabled, 38.3% non-disabled] consented to participate. Parallel analysis indicated that a single factor was adequate for the Nepali WHODAS version that captured 45.4% of the total variance. The translated scale got a good Cronbach alpha (= 0.89). Satisfactory construct, content and criterion validity was found. The WHODAS total scores showed a significant difference between the disabled and non-disabled (U = 2002.5; p = 0.015). However, the difference between psychiatric and physical disabilities was not significant, which underscores that the scale is rating disability in general. CONCLUSION: The one-factor structure of the translated and culturally adapted Nepali-version of WHODAS 2.0 showed acceptable validity and an adequate reliability. For epidemiological research purposes, this version of WHODAS 2.0 is now available for measuring global disability in Nepal.

Use of medicinal plants for headache, and their potential implication in medication-overuse headache: Evidence from a population-based study in Nepal.

BACKGROUND: In Nepal, traditional treatment using medicinal plants is popular. Whereas medication-overuse headache is, by definition, caused by excessive use of acute headache medication, we hypothesized that medicinal plants, being pharmacologically active, were as likely a cause. METHODS: We used data from a cross-sectional, nationwide population-based study, which enquired into headache and use of medicinal plants and allopathic medications. We searched the literature for pharmacodynamic actions of the medicinal plants. RESULTS: Of 2100 participants, 1794 (85.4%) reported headache in the preceding year; 161 (7.7%) reported headache on ≥15 days/month, of whom 28 (17.4%) had used medicinal plants and 117 (72.7%) allopathic medication(s). Of 46 with probable medication-overuse headache, 87.0% (40/46) were using allopathic medication(s) and 13.0% (6/46) medicinal plants, a ratio of 6.7:1, higher than the overall ratio among those with headache of 4.9:1 (912/185). Of 60 plant species identified, 49 were pharmacodynamically active on the central nervous system, with various effects of likely relevance in medication-overuse headache causation. CONCLUSIONS: MPs are potentially a cause of medication-overuse headache, and not to be seen as innocent in this regard. Numbers presumptively affected in Nepal are low but not negligible. This pioneering project provides a starting point for further research to provide needed guidance on use of medicinal plants for headache.

Depression and Quality of Life among the Chronic Kidney Disease Patients.

BACKGROUND: Depression and other mental illness are very common among chronic kidney disease and also Quality of life has been found significantly impaired in chronic kidney disease. The objective of our study is to study Depression, Quality of life and its associations in chronic kidney disease. METHODS: This was a descriptive cross-sectional study. We used convenient method of sampling for data collection. The World Health Organization Quality-of-Life 8-question scale was used for estimating quality of life and Beck Depression Inventory  was used for the assessment of depression.  Independent samples t-test was conducted to analysed bivariate relationship of sociodemographic factors with depression and Quality of life scores and multiple linear regression analysis was performed to determine predictors of Quality of life. RESULTS: The 75.5% participants found to have depression. Depression was found statistically significant across socioeconomic status (p value 0.04) and other medical comorbidities (p value 0.04). Variables found to be significantly associated with total quality of life in multiple linear regression analysis were caste (p value 0.03), socioeconomic status (p value 0.009) and depression (p value 0.001). CONCLUSIONS: Depression and reduced quality of life is very common among chronic kidney patients. Low socioeconomic status and comorbid medical conditions were associated with depression and caste, low socioeconomic status and depression were associated with low quality of life. Screening and management of depression should be included in the routine care and it could help improving the quality of life of patients with chronic kidney disease.

Quality of life and its predictors among aging people in urban and rural Nepal.

PURPOSE: We studied the quality of life (QoL) of the elderly in Nepal and their special needs. Nepal is a low- and middle-income country where the elderly population is growing significantly. METHODS: A random selection of informants from the Kavre district was carried out in this cross-sectional, population-based, door-to-door survey. The district has a mixture of urban and rural communities. In Nepal, families generally take care of their elderly. Hardly any placement is made in institutions. A validated Nepali version of World Health Organization Quality of Life 8-question scale (WHOQoL-8) estimated QoL among the elderly (≥ 60 years; N = 439). Other variables of interest were socio-demographics, substance use, physical and psychological health, and family support. Depression was measured by Geriatric Depression Scale short form [GDS-15]. Due to a high illiteracy rate, a structured and culturally adapted questionnaire was presented in an interview format. The relationships between the variables and QoL were analyzed using independent sample t tests, linear regression and Pearson's correlations. RESULTS: The mean QoL score was 25.7 (± 4.2); 49.2% rated their QoL as good. Positive predictors of QoL were: urban residence (p = 0.03); employment (p = 0.02); absence of chronic physical health problems (p = 0.02); absence of depression (p < 0.001); adequate time given by family (p = 0.001), and reports of non-abusive family relationships (p < 0.001). A negative correlation was found between geriatric depression and the QoL score (r = - 0.697; p < 0.001). CONCLUSION: QoL of the elderly in Nepal may potentially improve by care directed towards their physical and psychological health, by strengthening family relations, and by financial independence.

Nepali Version of Geriatric Depression Scale-15 - A Reliability and Validation Study.

BACKGROUND: Geriatric depression is a significant problem in both the developed and the developing world. To identify this condition, Geriatric Depression Scale has been used in different languages and cultural settings; it has proved to be a reliable and valid instrument. However, the Geriatric Depression Scale-15 version in Nepali has so far not been validated. METHODS: The original 15-item version of the Geriatric Depression Scale-15 was translated into Nepali and administered by trained nurses to a target sample aged ?60 years at Dhulikhel Hospital (n=106). Subsequently, the participants were blindly interviewed by a consultant psychiatrist for possible geriatric depression according to the ICD-10 criteria. Cronbach's alpha checked the reliability. Validity was assessed for three different cut-off points (4/5, 5/6, and 6/7); the related sensitivity, specificity, positive predictive value, and the negative predictive value of the scale were estimated. RESULTS: The mean participant age was 68.1 (±7.2); males and females, 50.9% and 49.1%, respectively. Cronbach's alpha was 0.79.The optimal cut-off point was found to be 5/6 with sensitivity and specificity 86.3% and 74.5%, respectively. CONCLUSIONS: Using a standard statistical protocol, a reliable and valid Geriatric Depression Scale-15-Nepali was developed with an adequate internal consistency and an optimal balance between sensitivity and specificity at cut-off point 5/6.The Geriatric Depression Scale-15-Nepali can serve as an appropriate instrument for assessing geriatric depression in epidemiological research as well as in primary health care settings in Nepal.

Prevalence of geriatric depression in the Kavre district, Nepal: Findings from a cross sectional community survey.

BACKGROUND: The increasing elderly population worldwide is likely to increase mental health problems such as geriatric depression, which has mostly been studied in high-income countries. Similar studies are scarce in low-and-middle-income-countries like Nepal. METHODS: A cross-sectional, population-based, door-to-door survey was conducted in randomly selected rural and urban population clusters of the Kavre district, Nepal. Trained nurses (field interviewers) administered structured questionnaires that included a validated Nepali version of the Geriatric Depression Scale short form (GDS-15) for identifying geriatric depression among the elderly (≥60 years) participants (N = 460). Those scoring ≥6 on GDS-15 were considered depressed. Logistic regression analysis explored the associations of geriatric depression with regard to socio-demographic information, life style, family support and physical well-being. RESULTS: Of the total 460 selected elderly participants, 439 (95.4%) took part in the study. More than half of them were females (54.2%). The mean age was 70.9 (± 8.6) years. Approximately half (50.6%) were rural inhabitants, the majority (86.1%) were illiterate, and about three-fifths (60.1%) were living with their spouses. The gender-and-age adjusted prevalence of geriatric depression was 53.1%. Geriatric depression was significantly associated with rural habitation (AOR 1.6), illiteracy (AOR 2.1), limited time provided by families (AOR 1.8), and exposure to verbal and/or physical abuse (AOR 2.6). CONCLUSION: Geriatric depression is highly prevalent in Kavre, Nepal. The findings call for urgent prioritization of delivery of elderly mental health care services in the country.

Health-care utilization for headache disorders in Nepal: a population-based door-to-door survey.

BACKGROUND: Headache disorders are an important global public-health problem, but under-diagnosed, undertreated and under-prioritized. Deficiencies in health care for headache, present everywhere, are likely to be greater in poorly-resourced countries. This study reports on health-care utilization for headache in Nepal, a low-income country with high headache burden. METHODS: We took data from a cross-sectional, nationwide population-based door-to-door survey, with multistage cluster random sampling. Face-to-face structured interviews included enquiry into consultations with professional health-care providers (HCPs), and investigations and treatments for headache. Analysis included associations with sociodemographic variables and indices of symptom severity. RESULTS: Of 2100 participants, 1794 reported headache during the preceding year (mean age 36.1 ± 12.6 years; male/female ratio 1:1.6). Of these, 58.4% (95% CI: 56.1-60.7%) had consulted at least once in the year with HCPs at any level, most commonly (25.0%) paramedical; 15.0% had consulted pharmacists, 10.8% general physicians and 7.6% specialists (of any type). Participants with probable medication-overuse headache consulted most (87.0%), followed by those with migraine (67.2%) and those with tension-type headache (48.6%; p < 0.001). A minority (11.9%) were investigated, mostly (8.9%) by eye tests. Half (50.8%) had used conventional medications for headache in the preceding month, paracetamol being by far the most common (38.0%), and 10.3% had used herbal therapies. Consultation was positively associated with rural habitation (AOR = 1.5; p < 0.001). Proportions consulting increased in line with all indices of symptom severity. CONCLUSIONS: Although over half of participants with headache had consulted professional HCPs, this reflects demand, not quality of care. Although 7.6% had seen specialists, very few would have been headache specialists in any sense of this term. High persistent burden, with only half of participants with headache using conventional medications, and these not best chosen, suggests these consultations fell far short of meeting need. Health policy in Nepal should recognise this, since the consequences otherwise are costly: lost health, diminished productivity and damaged national economy. On a positive note, the proportions consulting suggest that capacity exists at multiple levels within the Nepalese health system. With this to build upon, structured headache services in line with international recommendations appear achievable in Nepal. Educational programmes are the essential requirement.

Anxiety and depression in Nepal: prevalence, comorbidity and associations.

BACKGROUND: Anxiety and depression are two important contributors to the global burden of disease. In many developing countries, including Nepal, their prevalences are yet to be assessed. METHODS: A nationwide cross-sectional study was conducted among a representative sample of Nepalese adults aged 18-65 years (N = 2100), selected by multistage random cluster sampling and interviewed at home during unannounced visits. The validated questionnaires included the Hospital Anxiety and Depression Scale (HADS), to detect cases of anxiety (HADS-A), depression (HADS-D) and comorbid anxiety and depression (HADS-cAD), the Eysenck Personality Questionnaire Revised Short Form-Neuroticism (EPQRS-N), and the World Health Organization Quality of Life 8-question scale (WHOQOL-8). Logistic regression analyses were used to explore associations of caseness with four groups of variables: demographic, domicile, substance use, and behavioural and health. RESULTS: Age- and gender-adjusted point prevalences of HADS-A, HADS-D and HADS-cAD were 16.1, 4.2 and 5.9% respectively. In a multivariate model, HADS-A was positively associated with urban residence (AOR = 1.82; p < 0.001) and neuroticism (AOR = 1.32; p < 0.001), and negatively with alcohol consumption (AOR = 0.71; p = 0.041). HADS-D was positively associated with marijuana use (AOR = 3.61; p = 0.017) and negatively with quality of life (QoL) (AOR = 0.86; p < 0.001). HADS-cAD was positively associated with widowhood (AOR = 2.71; p = 0.002), urban residence (AOR = 2.37; p = 0.001), living at altitude ≥2000 m (AOR = 2.32; p = 0.002) and neuroticism (AOR = 1.26; p < 0.001), and negatively with alcohol use (AOR = 0.56; p = 0.026) and QoL (AOR = 0.79; p < 0.001). CONCLUSION: Depression and anxiety are important mental health conditions in Nepal, and major contributors to public ill health, being very highly prevalent, comorbid and associated with psychosocial burden. They are also linked to the unique topography, habitation and social structure of the country. High prevalence coupled with the disabling nature of these disorders establishes their health-care priority and their importance in national health policy.

Comorbidities of psychiatric and headache disorders in Nepal: implications from a nationwide population-based study.

BACKGROUND: Headache disorders, anxiety and depression - the major disorders of the brain - are highly comorbid in the western world. Whether this is so in South Asia has not been investigated, but the question is of public-health importance to countries in the region. We aimed to investigate associations, and their direction(s), between headache disorders (migraine, tension-type headache [TTH] and headache on ≥15 days/month) and psychiatric manifestations (anxiety, depression and neuroticism), and how these might affect quality of life (QoL). METHODS: In a nationwide, cross-sectional survey of the adult Nepalese population (N = 2100), trained interviewers applied: 1) a culturally-adapted version of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire to diagnose headache disorders; 2) a validated Nepali version of the Hospital Anxiety and Depression Scale (HADS) to detect anxiety (HADS-A), depression (HADS-D) and comorbid anxiety and depression (HADS-cAD); 3) a validated Nepali version of the Eysenck Personality Questionnaire Revised Short Form-Neuroticism (EPQRS-N); and 4) the World Health Organization Quality of Life 8-question scale (WHOQOL-8). Associations with headache types were analysed using logistic regression for psychiatric caseness and linear regression for neuroticism. Adjustments were made for age, gender, household consumption, habitat, altitude and use of alcohol and marijuana. RESULTS: HADS-A was associated with any headache (p = 0.024), most strongly headache on ≥15 days/month (AOR = 3.2) followed by migraine (AOR = 1.7). HADS-cAD was also associated with any headache (p = 0.050, more strongly among females than males [p = 0.047]) and again most strongly with headache on ≥15 days/month (AOR = 2.7), then migraine (AOR = 2.3). Likewise, neuroticism was associated with any headache (p < 0.001), most strongly with headache on ≥15 days/month (B = 1.6), followed by migraine (B = 1.3). No associations were found between HADS-D and any headache type, or between TTH and any psychiatric manifestation. Psychiatric caseness of any sort, when comorbid with migraine or TTH, aggravated the negative impact on QoL (p < 0.001). CONCLUSION: Headache disorders are highly comorbid with anxiety and show associations with neuroticism in Nepal, with negative consequences for QoL. These findings call for reciprocal awareness, and a holistic coordinated approach to management and in the health service. Care for common headache and common psychiatric disorders should be integrated in primary care.

The prevalence of primary headache disorders in Nepal: a nationwide population-based study.

BACKGROUND: Headache disorders are among the most prevalent and burdensome global public-health problems. Within countries, health policy depends upon knowledge of health within the local populations, but the South-East Asia Region (SEAR), among WHO's six world regions, is the only one for which no national headache prevalence data are available. METHODS: In a cross-sectional population-based study, adults representative of the Nepali-speaking population aged 18-65 years and living in Nepal were randomly recruited using stratified multistage cluster sampling. They were visited unannounced at home by trained interviewers who used a culturally-adapted Nepali translation of the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire. RESULTS: There were 2,100 participants (1,239 females [59.0 %], 861 males [41.0 %]; mean age 36.4 ± 12.8 years) with 9 refusals (participation rate 99.6 %). Over half (1,100; 52.4 %) were resident above 1,000 m and almost one quarter (470; 22.4 %) lived at or above 2,000 m. The 1-year prevalence of any headache was 85.4 ± 1.5 % (gender- and age-adjusted 84.9 %), of migraine 34.7 ± 2.0 % (34.1 %), of tension-type headache (TTH) 41.1 ± 2.1 % (41.5 %), of headache on ≥15 days/month 7.7 ± 1.1 % (7.4 %) and of probable medication-overuse headache (pMOH) 2.2 ± 0.63 % (2.1 %). There was a strong association between migraine and living at altitude ≥1,000 m (AOR = 1.6 [95 % CI: 1.3-2.0]; p < 0.001). There was a less strong association between TTH and urban dwelling (AOR = 1.3 [95 % CI: 1.1-1.6]; p = 0.003), and a possibly artefactual negative association between TTH and living above 1,000 m (AOR = 0.7 [95 % CI: 0.6-0.8]; p < 0.001). CONCLUSION: Headache disorders are very common in Nepal. Migraine is unusually so, and strongly associated with living at altitude, which in very large part accounts for the high national prevalence: the age- and gender- standardised prevalence in the low-lying Terai is 27.9 %. Headache occurring on ≥15 days/month is also common. This new evidence will inform national health policy and provide a basis for health-care needs assessment. However, research is needed to explain the association between migraine and altitude, since it may be relevant to health-care interventions.

The burden of headache disorders in Nepal: estimates from a population-based survey.

BACKGROUND: Headache disorders, particularly migraine and tension-type headache (TTH), are among the most prevalent global public-health problems. Medication-overuse headache (MOH) is a common sequela of mismanagement of these. Migraine and MOH are highly disabling. Formulation of responsive health policy requires reliable, locally-derived, population-based data describing both individual and societal impact of headache disorders. South-East Asia is the only one of WHO's six world regions in which no such national data have yet been gathered. METHODS: In a nationwide population-based cross-sectional study, a representative sample of Nepalese-speaking adults (18-65 years) were randomly selected by stratified multistage cluster sampling. Trained interviewers made unannounced door-to-door visits and enquired into headache and its attributable burden using a culturally-adapted and validated Nepalese translation of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire. RESULTS: Among 2100 participants, 1794 (85.4 %) reported headache during the preceding year (male: 689 [38.4 %], female 1105 [61.6 %]; mean age 36.1 ± 12.6 years). Mean headache frequency was 3.8 ± 6.2 days/month, mean headache intensity 2.1 ± 0.7 on a 0-3 scale, and mean attack duration 41.9 ± 108.5 h. All aspects of symptom burden (frequency, intensity and duration) were greater among females (p < 0.001). Participants with headache had poorer quality of life (QoL) than those without (p < 0.001); QoL was worst among those with probable MOH (pMOH). Mean proportions of total available time spent in the ictal state were 5.4 % among participants with migraine, 3.9 % among those with TTH and 44.7 % among those with pMOH, with headache-related disabilities of 2.4, 0.15 and 9.7 % respectively. At population level, these disorders were responsible for reduced functional capacities of 0.81, 0.06 and 0.20 %. Total lost productive time due to headache was 6.8 % for the 85 % of the population with headache. Males lost more paid worktime than females (p < 0.001); the reverse was so for household worktime (p < 0.001). CONCLUSIONS: Headache disorders, very common in Nepal, are also highly burdensome at both individual and population levels. There is a substantial penalty in lost production. The remedy lies in better health care for headache; structured headache-care services are urgently needed in the country, and likely to be cost-saving.

Estimating prevalence and burden of major disorders of the brain in Nepal: cultural, geographic, logistic and philosophical issues of methodology.

BACKGROUND: Headache, anxiety and depression are major disorders of the brain in terms of their prevalence and the burdens and costs they impose on society. Nationwide population-based studies of these disorders are necessary to inform health policy but, in research-naïve and resource-poor countries such as Nepal, a host of methodological problems are encountered: cultural, geographic, logistic and philosophical. METHODS: Expert consensus was sought among researchers from different professional and cultural backgrounds in planning and conceptualizing an epidemiological study and adapting established methods to the special situation and circumstances of Nepal. RESULTS: The methodological problems were sorted into different themes: study design; climate; geography, access and transport; sociocultural issues; safety of interviewers. Each of these was dealt with separately, and their inter-relationships explored, in finding solutions that were sometimes pragmatic. A cross-sectional questionnaire-based study, with teams of interviewers visiting households across the three physiographic divisions (with extremes in altitude) in each of the five development regions of the country, would enable national sampling with sociocultural representativeness. However, the study instruments and interviews would be in Nepali only. Transport and access challenges were considerable, and their solutions combined travel by air, bus, river and foot, with allowances for rain-damaged roads, collapsed bridges and cancelled scheduled flights. The monsoon would render many routes impassable, and therefore set an absolute time limitation. Engaging participants willingly in the enquiry would be the key to success, and several tactics would be employed to enhance the success of this, most importantly enlisting the support of local community volunteers in each study site. CONCLUSION: Anticipating problems in advance of investing substantial resources in a large nationwide epidemiological study in Nepal was a sensible precaution. The difficulties could be resolved or circumvented without expected compromise in scientific quality. Expert consensus was an effective means of achieving this outcome.

Estimating the prevalence and burden of major disorders of the brain in Nepal: methodology of a nationwide population-based study.

BACKGROUND: The major disorders of the brain (MDBs), in terms of their prevalence and the burdens of ill health, disability and financial cost that they impose on individuals and society, are headache, depression and anxiety. No population-based studies have been conducted in Nepal. AIM: Our purpose was to assess the prevalence and burden attributable to MDBs in Nepal in order to inform health policy. Here we report the methodology. METHODS: The unusual sociocultural diversity and extreme geographical variation of the country required adaptation of standard methodology. We ran pre-pilot and pilot studies before embarking on the main study. The study design was cross-sectional. The population of interest were adults aged 18-65 years who were Nepali speaking and living in Nepal. We selected, employed and trained groups of interviewers to visit randomly selected households by cold-calling. Households were selected from 15 representative districts out of 75 in the country through multistage cluster sampling. One participant was selected randomly from each household. We used structured questionnaires (the HARDSHIP questionnaire, Hospital Anxiety and Depression Scale, and Eysenck Personality Questionnaire -Neuroticism), culturally adapted and translated into Nepali. We recorded blood pressure, weight, height and waist circumference, and altitude of each household. We implemented various quality-assurances measures. RESULTS: We completed the survey in one month, prior to onset of the monsoon. Among 2,210 selected households, all were contacted, 2,109 were eligible for the study and, from these, 2,100 adults participated. The participation rate was 99.6%. CONCLUSION: Standard methodology was successfully applied in Nepal, with some adaptations. The sociocultural and extraordinary geographic diversity were challenging, but did not require us to compromise the scientific quality of the study.

Diagnosis, prevalence estimation and burden measurement in population surveys of headache: presenting the HARDSHIP questionnaire.

The global burden of headache is very large, but knowledge of it is far from complete and needs still to be gathered. Published population-based studies have used variable methodology, which has influenced findings and made comparisons difficult. The Global Campaign against Headache is undertaking initiatives to improve and standardize methods in use for cross-sectional studies. One requirement is for a survey instrument with proven cross-cultural validity. This report describes the development of such an instrument. Two of the authors developed the initial version, which was used with adaptations in population-based studies in China, Ethiopia, India, Nepal, Pakistan, Russia, Saudi Arabia, Zambia and 10 countries in the European Union. The resultant evolution of this instrument was reviewed by an expert consensus group drawn from all world regions. The final output was the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, designed for application by trained lay interviewers. HARDSHIP is a modular instrument incorporating demographic enquiry, diagnostic questions based on ICHD-3 beta criteria, and enquiries into each of the following as components of headache-attributed burden: symptom burden; health-care utilization; disability and productive time losses; impact on education, career and earnings; perception of control; interictal burden; overall individual burden; effects on relationships and family dynamics; effects on others, including household partner and children; quality of life; wellbeing; obesity as a comorbidity. HARDSHIP already has demonstrated validity and acceptability in multiple languages and cultures. Modules may be included or not, and others (e.g., on additional comorbidities) added, according to the purpose of the study and resources (especially time) available.

Attitude toward mental illness and psychiatry among the medical students and interns in a medical college.

INTRODUCTION: Medical students tend to have a neutral or negative attitude to Psychiatry as a discipline. This study was initiated to explore the attitude towards mental illness and Psychiatry among the medical students and interns in Kathmandu University School of Medical Sciences. METHODS: A cross-sectional questionnaire based study was conducted among the medical students and interns at Dhulikhel Hospital.Two self-rating scales; Attitudes towards Psychiatry-30 and Attitudes to Mental Illnesswere used to assess attitudes towards mental illness and Psychiatryamong the total 159 subjects. Descriptive statistics and independent sample t-test were applied using SPSS- 16 for analysis. RESULTS: Among the total 159 subjects, 44 (27.7%) were interns. Comparison of means of each item in Attitudes towards Psychiatry-30 and Attitudes to Mental Illnesswas done between males and females, medical students and interns, fi rst semester and ninth semester students. Most of the subjects showed neutral attitude towards all the scoring items; though there were a few signifi cant differences in mean scores of some items in group wise comparison. CONCLUSIONS: Overall attitudes towards mental illness and psychiatry among the medical students and interns in our medical school were positive or neutral. A further study with medical students from different institutions is needed to get a detail nationwide picture. KEYWORDS: attitude; interns; medical students; mental illness; psychiatry.

Psychiatric morbidity patterns in referred inpatients of other specialties.

INTRODUCTION: Consultation-liaison psychiatry is an upcoming field dealing with interdepartmental collaboration heading into multidisciplinary and holistic care. In general hospital setting, psychiatrists need to be involved in evaluation of patients referred from other specialties. This study analyzed the psychiatric morbidity among the inpatients referred to Psychiatry Department from different wards in a Tertiary care University Teaching Hospital. METHODS: Total 385 subjects were referred to the Department of Psychiatry from different wards during a period of one year. Each of them underwent a detailed psychiatric evaluation by a consultant psychiatrist once they were medically stable. Psychiatric diagnosis was considered as per International Classification of Disease-10 criteria. RESULTS: The mean age of the subjects evaluated was 37.26 (±1.86); most of them were females 216 (56.4%), married 287 (74.5%), and homemaker 159 (41.3%). Maximum 271 (70.4%) referral was from Medical ward, and most of them 292 (75.8%) were admitted in general bed. The most common medical diagnosis was self-poisoning 115 (30.6%) followed by alcoholic liver disease 49 (12.7%); while the commonest 123 (31.9%) psychiatric diagnosis was depression (including Dysthymia and Adjustment disorder). Depression remained the commonest diagnosis among those referred from medical ward 131 (34.7%); while anxiety was mostly found in the emergency referral 94 (24.5%). Significant Correlation (P <0.05) was seen between the source of referral and Psychiatric diagnosis. CONCLUSIONS: Psychiatric consultation was sought mostly by medical ward that had maximum number of patients presenting with self-poisoning. The commonest diagnosis seen in the referred in-patients was depression and anxiety disorder.