National policies and programs for perinatal mental health in India: A systematic review.

BACKGROUND: India is the most populous country in the world with millions of births annually. Perinatal mental disorders (PMDs) are prevalent worldwide including in India. This study was undertaken to evaluate how mental health is addressed in national maternity and mental health policies and programs in India. METHODS: We conducted a systematic review of the national policies and programs in India related to maternity care and mental health. The identified policies and programs were analysed using health policy triangle framework. RESULTS: Our search yielded 11 relevant documents and no peer reviewed publications. No specific national policy or program on maternal mental health could be identified. Universal access to health and mental health including for women and children was clearly articulated in both national mental health and maternity policies, which emphasised that access to mental health care and treatment is a fundamental right. There were few details about how the programs and policies were developed and no accounts of consultations with community members or service providers in their formation. CONCLUSION: National maternity and mental health policies and programs in India appear not to consider perinatal mental health. There are promising state-based initiatives, but, given the disease burden of PMDs in India, the absence of a national policy leads to unrecognized and unmet needs of women in the states without these measures. These inequalities can be effectively minimized by well implemented national policies for perinatal mental health, accompanied by evidence-based locally tailored programs and interventions across the country.

Assessment of Psychological Well-being Among Medical Professionals Working with Patients Who Suffer from Physical Trauma: An Observational Study from India.

Background: Healthcare providers working with victims of physical trauma are exposed to significant human suffering at work. This may place them at risk of burnout, secondary traumatic stress (STS), and other psychological disturbances. This study aimed to evaluate the professional quality of life and psychological well-being among trauma professionals. Methodology: This was a cross-sectional study conducted among 153 staff members (nursing officers, resident doctors, and faculty) of a Level 1 trauma center in North India. The Professional Quality of Life (ProQoL-5) and Depression, Anxiety, and Stress (DASS-21) Scales were used. Results: More than 50% of the participants had a moderate risk of burnout and STS. In addition, 54% of participants reported having anxiety, 40% stress, and 36% depressive symptoms. Depression, anxiety, and stress were all strongly predicted by burnout and STS. Conclusion: Psychological distress symptoms were seen in a significant portion of professionals working in the trauma center. Workplace interventions for the promotion of psychological well-being among trauma professionals are recommended. How to cite this article: Gupta S, Bhatia G, Sagar R, Sagar S. Assessment of Psychological Well-being Among Medical Professionals Working with Patients Who Suffer from Physical Trauma: An Observational Study from India. Indian J Crit Care Med 2023;27(7):493-502.

Comparative assessment of the information available on the treatment of depression over websites in English and Hindi language.

Background: The study aimed to perform a cross-sectional comparative assessment of the content and quality of information available on the treatment of depression over websites in English and Hindi language. Materials and Methods: We screened the first 50 links obtained on searching for depression treatment on Google, and selected 72 (44 in English; 28 in Hindi) websites. They were evaluated for coverage of different aspects of depression, quality of treatments mentioned, esthetics, and interactivity. Results: A significantly lesser number of Hindi websites discussed the minimum duration of treatment needed for a depressive episode (36% vs. 79%), possible side effects of treatment (18% vs. 77%), discussed suicidality in depression explicitly (25% vs. 57%), or recommended consultation with a mental health professional (11% vs. 43%). English websites more commonly mentioned psychotherapy (86% vs. 64%), electroconvulsive therapy (64% vs. 21%), and social support measures (59% vs. 32%) for depression treatment. Whereas, Hindi websites more commonly mentioned Ayurvedic/herbal medicines (46% vs. 16%), and yoga (29% vs. 4%) for treatment. Lastly, the esthetics score for English websites was significantly higher than for Hindi websites. A significantly greater number of Hindi websites were owned by commercial entities. Conclusion: This is the first study to systematically compare online information on depression treatment in English and Hindi language websites, and identify areas for further improvement in the overall quality of online information in Hindi. There is a need for the creation of credible and accessible online resources in regional languages like Hindi for the promotion of depression literacy among the general public by government and non-profit professional organizations.

Cost-Effectiveness of a Collaborative Care Model Among Patients With Type 2 Diabetes and Depression in India.

OBJECTIVE: To assess the cost-effectiveness of collaborative versus usual care in adults with poorly controlled type 2 diabetes and depression in India. RESEARCH DESIGN AND METHODS: We performed a within-trial cost-effectiveness analysis of a 24-month parallel, open-label, pragmatic randomized clinical trial at four urban clinics in India from multipayer and societal perspectives. The trial randomly assigned 404 patients with poorly controlled type 2 diabetes (HbA1c ≥8.0%, systolic blood pressure ≥140 mmHg, or LDL cholesterol ≥130 mg/dL) and depressive symptoms (9-item Patient Health Questionnaire score ≥10) to collaborative care (support from nonphysician care coordinators, electronic registers, and specialist-supported case review) for 12 months, followed by 12 months of usual care or 24 months of usual care. We calculated incremental cost-effectiveness ratios (ICERs) in Indian rupees (INR) and international dollars (Int'l-$) and the probability of cost-effectiveness using quality-adjusted life-years (QALYs) and depression-free days (DFDs). RESULTS: From a multipayer perspective, collaborative care costed an additional INR309,558 (Int'l-$15,344) per QALY and an additional INR290.2 (Int'l-$14.4) per DFD gained compared with usual care. The probability of cost-effectiveness was 56.4% using a willingness to pay of INR336,000 (Int'l-$16,654) per QALY (approximately three times per-capita gross domestic product). The willingness to pay per DFD to achieve a probability of cost-effectiveness >95% was INR401.6 (Int'l-$19.9). From a societal perspective, cost-effectiveness was marginally lower. In sensitivity analyses, integrating collaborative care in clinical workflows reduced incremental costs by ∼47% (ICER 162,689 per QALY, cost-effectiveness probability 89.4%), but cost-effectiveness decreased when adjusting for baseline values. CONCLUSIONS: Collaborative care for patients with type 2 diabetes and depression in urban India can be cost-effective, especially when integrated in clinical workflows. Long-term cost-effectiveness might be more favorable. Scalability across lower- and middle-income country settings depends on heterogeneous contextual factors.

Longitudinal assessment of disability amongst patients of bipolar and unipolar depressive disorders presenting to a tertiary care center in North India.

OBJECTIVES: To assess and compare the changes in disability scores associated with Bipolar Depression (BD) and Unipolar Depression (UD) over 1 year. METHODS: A longitudinal study was taken up in adults diagnosed with unipolar or bipolar depressive disorder with current depressive episode. Diagnosis was made according to Schedule for Clinical Assessment in Neuropsychiatry. Severity scoring was done using Hamilton's Depression (HAM-D) rating scale and Hamilton's Anxiety (HAM-A) rating scale. Disability was assessed using Indian Disability Evaluation and Assessment Scale (IDEAS) and London handicap Scale (LHS) at baseline, 6 and 12 months. RESULTS: Sixty participants were recruited (42 UD and 18 BD). No significant differences were seen in socio-demographic parameters, except higher education levels and males being overrepresented in UD. Significant differences at baseline were seen in HAM-D (p = .001) and HAM-A (p = .003) scores. The extent of disability was seen to correlate with severity of illness only in case of BD at baseline. No significant differences were seen in the IDEAS scores at baseline. IDEAS score improved at each follow-up assessment (p < .001). LHS showed significant improvement over time in UD (p < .001), but not BD (p = .076). Percentage individuals meeting cut-off for benchmark disability (>40%) were comparable at baseline but were significantly more in the BD at 12-months (p = .049). CONCLUSION AND IMPLICATIONS: Disability in psychiatry occurs equally amongst unipolar and bipolar depressive disorders and tends to improve over time, although the level of improvement may differ. It may not always correspond to severity of illness. These factors should be considered while certifying disability.

Adequate Management of Autism Spectrum Disorder in Children in India.

Despite the significant burden of neurodevelopmental disorders such as autism spectrum disorder (ASD) in India, there are areas of unmet needs at every level of the health care system. This includes screening and recognition, reliable and valid tools to evaluate, and to adequately manage ASD. There are also gaps in education and training of medical professionals, paraprofessionals, special education teachers and the related services. Lack of public awareness and cultural factors contribute to delays in early recognition and interventions. A framework is suggested to address these unmet needs at various levels to improve the care of these children with ASD. These include a) a focus on education of medical professionals, paraprofessionals, and teachers; b) setting up infrastructure at community, regional, and statewide levels, with adequate funding; and c) use of audiovisual technology and collaboration with international expertise.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial.

BACKGROUND: There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life. METHOD: This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes. RESULTS: Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective. CONCLUSION: eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

Resilience in Children and Adolescents Survived Psychologically Traumatic Life Events: A Critical Review of Application of Resilience Assessment Tools for Clinical Referral and Intervention.

Psychological traumatic life events (TLEs) and resilience, both are multidimensional, complex, and share salient features. Both are products of individual, familial, and environmental (socio-cultural-political contextual) variables, which is very crucial in children and adolescents. This systematic review used Boolean search strategies in electronic databases, namely, PubMED, PsycNET, JStor, and Google scholar. All researches not studying resilience per se but similar or related constructs such as life strengths, hardiness, protective/risk factors, social support, self-efficacy, social-emotional adjustment, and so on were excluded. A total of 12 resilience tools meant for children between 5 and 18 years were reviewed. The scale characteristics were analyzed in terms of targeted age-group of sample; purpose (i.e. screening and profiling for intervention); number of items; purpose/type of scale; year, country, and domain wise distribution; response format, standardization sample profile; psychometric properties; and availability of manual with norms of cutoff score. Although no scale was originally developed for children and adolescent population with history of TLEs particularly various forms of abuse and trauma, Child and Youth Resilience Measure and Connor-Davidson Resilience Scale had small samples of children from welfare homes. Neither did any scale tested the divergent validity against absence of any psychopathology or global functioning or poor quality of life Nor did Majority of scales provide a cutoff value for institutionalized children and adolescents with history of TLEs; therefore, using an existing scale for this purpose should be carefully examined. Trauma-focused multidimensionality in resilience needs to be explored more rigorously through mixed methods.

Assessment for familial pattern and association of polymorphisms in KIAA0319 gene with specific reading disorder in children from North India visiting a tertiary care centre: A case-control study.

Genetic association studies have identified KIAA0319 gene as a possible susceptibility locus for reading disorder; however, very few studies are available from India. The study was planned to investigate the familial pattern and association of KIAA0319 polymorphisms among children with reading disorder visiting a tertiary centre in North India. This is a case-control, familial, and genetic association study on 30 children diagnosed with reading disorder (ICD-10) and 30 matched healthy controls and their families. The Aggregate Neurobehavioral Student Health and Educational Review System was administered on parents of probands and controls for reading problems in their siblings, and Adult Reading Questionnaire was administered for parents of both groups. The blood sample was taken from probands, and DNA was isolated. Four KIAA0319 coding sequence single nucleotide polymorphisms (SNPs; rs4504469, rs6935076, rs2038137, and rs2179515) were genotyped using SNaPshot single nucleotide extension. The incidence of reading problem was significantly higher in families of probands as compared with families of controls. There were no significant differences in both groups regarding the frequency of alleles of four SNPs. The reading disorder showed a significant familial pattern, but KIAA0319 gene did not appear to be a susceptibility factor. Future replications with larger samples and whole genome studies are warranted.

Assessment of caregiver needs in parents of children suffering from neurodevelopmental disorders in an Indian population.

Parents of children with neurodevelopmental disorders have significant unmet needs in various domains, particularly in a Low-Middle Income Country setting such as India. This study assessed parental needs using a Hindi version of the Caregiver Needs Scale (CNS) and found that 65.7% of the respondents expressed a definite need for help in all the items of the scale. The total score on CNS showed a significant negative correlation with the age of the child. Age of parent showed a significant negative correlation with scores for community and support needs.

Prevalence and determinants of anxiety disorders among adolescents in a rural community from northern India.

INTRODUCTION: There is scarce data available on community based prevalence of Anxiety Disorders (ADs) amongst adolescents in north Indian settings. OBJECTIVE: To determine the prevalence of anxiety disorders, and associated factors amongst adolescents in a rural community of Ballabgarh block, district Faridabad, Haryana. METHODS: Participants (10-19 years) were enrolled through simple random sequence from a sampling frame of adolescents residing in 28 villages of Ballabgarh block using household survey technique. They were screened using Screen for Childhood Anxiety Related Emotional Disorders (SCARED) tool and then subjected to confirmatory diagnosis using Mini-International Neuropsychiatric Interview for Children/Adolescent (MINI KID). All adolescents with ADs were assessed for co-psychiatric morbidities using MINI-KID and functional impairment using Children Global Assessment Scale (CGAS). Prevalence and 95% Confidence intervals are reported. Additionally, socio-demographic factors were elicited using a semi-structured interview schedule and associations were determined using multivariable logistic regression analysis. RESULTS: A total of 678 adolescents participated in this study with mean age (SD) as 14.2 (2.5) years. The age adjusted prevalence of anxiety disorders was found to be 16.6% (95% CI: 16.0-17.2). The most prevalent anxiety disorder among participants was social anxiety disorders followed by specific phobias. Female sex and low socio-economic status were associated with anxiety disorders. Two third of adolescents with ADs had no functional impairment and almost one third were found to have one or more co-existing psychiatric co-morbidity. CONCLUSION: We found a high prevalence of ADs in rural north Indian community settings warranting adequate health system response at primary care level.

Assessment of cognitive functions in bipolar I disorder: A 1-year naturalistic follow-up study.

OBJECTIVE: Available findings from cross-sectional studies have demonstrated cognitive impairments in bipolar I disorder (BD-I) during various phases of illness. However, very little is known about the longitudinal course of these cognitive impairments. The purpose of the study was to explore the longitudinal pattern of changes in cognitive functioning of BD-I patients. METHODS: A total of 129 BD-I subjects (manic, depressed and euthymic groups) and 49 healthy controls were recruited using predefined selection criteria. All four study groups were assessed on various clinical and cognitive parameters (for attention, memory, executive functions and working memory) at study intake and at 3-monthly intervals over the next year. RESULTS: All three patient groups performed poorly compared to controls on all cognitive measures at study intake and on some cognitive measures at the 3-, 6-, 9- and 12-month assessments. No significant time effects were observed for any cognitive test. A significant group by time interaction effect was found for executive functions (ß = -44.74; P = .018) and working memory (ß = 0.77; P ≤ .019) in the depressed group at 12 months; for visual memory (ß = 1.21; P = .039) and working memory (ß = 1.17; P ≤ .029) in the manic group at 12 months; and for working memory (ß = -0.52; P ≤ .036) in the euthymic group at 12 months. CONCLUSION: The patient groups showed significant impairments in all or some test domains relative to controls at all time-points. The cognitive functions largely remained stable in all patient groups, with slight improvement over time in a few tests. Further investigation is warranted in larger samples in longitudinal studies.

ECG Changes in Young Healthy Smokers: A Simple and Cost-Effective Method to Assess Cardiovascular Risk According to Pack-Years of Smoking.

OBJECTIVE: To document the prevalence of ECG abnormalities in young healthy smokers and compare ECG changes in smokers, young healthy non-smokers and amongst smokers with different pack years. METHODS: This was a prospective case-control study consisting of 200 young healthy male and female individuals, 150 smokers and 50 non-smokers between ages 25-40 years, further categorized and compared according to age, sex and pack years of smoking. The ECG recordings were analyzed for different ECG parameters like heart rate, P-wave duration, P-wave amplitude, PR interval, QRS duration, RR-interval, ST-segment duration, QT interval and QTc interval. The results were compared using statistical tools. RESULTS: In present study abnormalities in ECG parameters were significantly more prevalent in smokers as compared to non-smokers (56.66 % Vs 6.00 %) (p <.0001). Heart rate and QTc-interval increased with increase in the number of pack-years. This increase was reflected more in female with a similar number of pack years. P-wave amplitude tended to increase with increase in the number of pack years more so in males. P-wave duration, PR-interval, QRS-duration and RR-interval tended to decrease with increase in the number of pack years more so in females with similar number of pack years. QT-interval and ST-segment duration tended to decrease with increase in the number of pack years more so in males. CONCLUSIONS: ECG abnormalities in this study indicate cardiovascular risk in term of cardiac arrhythmia, pulmonary arterial hypertension, heart blocks etc in such subjects. As this procedure is non-invasive and cost effective it is potentially an effective and yet a simple method for cardiovascular risk evaluation in smokers. Furthermore, such ECG abnormalities may guide the clinician for risk evaluation in smokers and may be used to convince the smokers to quit smoking.

Mental health policies in South-East Asia and the public health role of screening instruments for depression.

The World Health Organization (WHO) South-East Asia Region, which contributes one quarter of the world's population, has a significant burden due to mental illnesses. Mental health has been a low priority in most countries of the region. Although most of these countries have national mental health policies, implementation at ground level remains a huge challenge. Many countries in the region lack mental health legislation that can safeguard the rights of people with mental illnesses, and governments have allocated low budgets for mental health services. It is imperative that concerned authorities work towards scaling up both financial and human resources for effective delivery of mental health services. Policymakers should facilitate training in the field of mental health and aim towards integrating mental health services with primary health care, to reduce the treatment gap. Steps should also be taken to develop a robust mental health information system that can provide baseline information and insight about existing mental health services and help in prioritization of the mental health needs of the individual countries. Although evidence-based management protocols such as the WHO Mental Health Gap Action Programme (mhGAP) guidelines facilitate training and scaling up of care in resource-limited countries, the identification of mental disorders like depression in such settings remains a challenge. Development and validation of brief psychiatric screening instruments should be prioritized to support such models of care. This paper illustrates an approach towards the development of a new culturally adapted instrument to identify depression that has scope for wider use in the WHO South-East Asia Region.

Caregiver burden assessment in primary congenital glaucoma.

PURPOSE: To assess the magnitude of caregiver burden and depression in primary caregivers of patients with primary congenital glaucoma. METHODS: Fifty-five primary caregivers of children diagnosed with primary congenital glaucoma were evaluated. The magnitude of burden on caregivers was assessed using a Caregiver Burden Questionnaire (CBQ). The overall aggregate burden and burden across 3 domains-socioeconomic, emotional, and psychological-was evaluated. Depressive symptomatology was evaluated using a Patient Health Questionnaire-9 (PHQ-9) standard questionnaire and graded from mild to severe. RESULTS: The mean age of the presenting children was 8.11±46.71 months; all of them were male. The mean age of the study participants was 33.6±8.36 years (53 female, 2 male). Thirty-nine (71%) individuals were identified to have moderate aggregate burden and 3 (5%) had severe aggregate burden. Twelve (22%) subjects were noted to have moderate depression, while 6 of them (11%) had either severe or very severe grades of depression. CONCLUSIONS: Caregivers of patients with primary congenital glaucoma have significant emotional and psychological burden. Moderate to severe depression may be present in one-third of individuals giving primary care to children with congenital glaucoma.

An updated global picture of cigarette smoking persistence among adults.

BACKGROUND: Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence. METHODS: Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence--the proportion of adults who started to smoke and persisted in smoking by the date of the survey. RESULTS: There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic = 6845; p < 0.001). Meta-regressions indicated that observed differences are not attributable to differences in country's income level, age distribution of smokers, or how recent the onset of smoking began within each country. CONCLUSION: While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).

A follow-up study of family burden in patients with bipolar affective disorder.

INTRODUCTION: Research in the last two decades has documented a high level of burden in caregivers of bipolar disorder. The present study is aimed at studying family burden among relatives of patients with bipolar affective disorder. METHODS: Thirty four consecutive hospitalized patients with bipolar affective disorder currently in mania and their relatives were assessed twice: at the time of admission and during follow-up four weeks after discharge. A semi-structured performa designed for the study was completed. Patients were assessed on Young's Mania Rating Scale and relatives were assessed on Family Burden Assessment Scale. RESULTS: More than 90% of family members reported severe subjective (rated by relative) and objective burden (rated by interviewer) at admission; none of them was free of burden. At the time of follow-up, about one quarter (23.5%) and two thirds (64.7%) of family members did not experience any objective and subjective burden respectively; subjective and objective family burden was moderate in about one third (35.3%) and a half (52.9%), respectively. None of the family members reported severe burden subjectively, while the objective burden was rated to be severe in a quarter (23.5%) of family members. LIMITATIONS: The study was limited by the lack of a control group from an outpatient setting as hospitalization increases family burden. Also, the rater at the second assessment was not blind to ratings at the first assessment. CONCLUSIONS: Almost all the family members experienced severe burden initially. Even when symptoms subsided, family members continued to experience burden specifically related to finances. OBJECTIVE: burden was significantly higher than subjective burden.

Treatment of suicidal people around the world.

BACKGROUND: Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment. AIMS: To examine the receipt of mental health treatment and barriers to care among suicidal people around the world. METHOD: Twenty-one nationally representative samples worldwide (n=55 302; age 18 years and over) from the World Health Organization's World Mental Health Surveys were interviewed regarding past-year suicidal behaviour and past-year healthcare use. Suicidal respondents who had not used services in the past year were asked why they had not sought care. RESULTS: Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment. CONCLUSIONS: Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking.

Associations of serious mental illness with earnings: results from the WHO World Mental Health surveys.

BACKGROUND: Burden-of-illness data, which are often used in setting healthcare policy-spending priorities, are unavailable for mental disorders in most countries. AIMS: To examine one central aspect of illness burden, the association of serious mental illness with earnings, in the World Health Organization (WHO) World Mental Health (WMH) Surveys. METHOD: The WMH Surveys were carried out in 10 high-income and 9 low- and middle-income countries. The associations of personal earnings with serious mental illness were estimated. RESULTS: Respondents with serious mental illness earned on average a third less than median earnings, with no significant between-country differences (chi(2)(9) = 5.5-8.1, P = 0.52-0.79). These losses are equivalent to 0.3-0.8% of total national earnings. Reduced earnings among those with earnings and the increased probability of not earning are both important components of these associations. CONCLUSIONS: These results add to a growing body of evidence that mental disorders have high societal costs. Decisions about healthcare resource allocation should take these costs into consideration.