Mechanisms of emerging resistance associated with non-antibiotic antimicrobial agents: a state-of-the-art review.

Although the development of resistance by microorganisms to antimicrobial drugs has been recognized as a global public health concern, the contribution of various non-antibiotic antimicrobial agents to the development of antimicrobial resistance (AMR) remains largely neglected. The present review discusses various chemical substances and factors other than typical antibiotics, such as preservatives, disinfectants, biocides, heavy metals and improper chemical sterilization that contribute to the development of AMR. Furthermore, it encompasses the mechanisms like co-resistance and co-selection, horizontal gene transfer, changes in the composition and permeability of cell membrane, efflux pumps, transposons, biofilm formation and enzymatic degradation of antimicrobial chemicals which underlie the development of resistance to various non-antibiotic antimicrobial agents. In addition, the review addresses the resistance-associated changes that develops in microorganisms due to these agents, which ultimately contribute to the development of resistance to antibiotics. In order to prevent the indiscriminate use of chemical substances and create novel therapeutic agents to halt resistance development, a more holistic scientific approach might provide diversified views on crucial factors contributing to the persistence and spread of AMR. The review illustrates the common and less explored mechanisms contributing directly or indirectly to the development of AMR by non-antimicrobial agents that are commonly used.

Primary mental health care in rural Punjab, Pakistan: providers, and user perspectives of the effectiveness of treatments.

Neuro-psychiatric disorders are associated with a considerable burden of disease, not only globally, but also in low- and middle-income countries. Epidemiological information about treatment of these disorders is required to help formulate treatment and prevention strategies. The aim of this study was to describe different types of mental health care providers, and examine patients' knowledge of the treatments and their views about its effectiveness in rural Punjab, Pakistan. We conducted a cross-sectional survey of attenders at a 1-day psychiatric consultation clinic in rural Punjab, Pakistan. Patients sought help from five different types of providers and were treated with physical, psychotherapeutic and spiritual treatments. Most recognised psychiatric problems as treatable. There was a discrepancy between belief and knowledge of the treatment of mental disorders; most had a very basic understanding of treatment. They reported general practitioner (GP) treatments as more effective (56%) compared to other practitioners (20%). We argue that treatments given by primary mental health care providers need to be standardised. A systematic appraisal of the theoretical rationale of the mental health treatments prescribed in primary care settings is required in low-income countries like Pakistan. This will help ensure standardisation of care especially regarding spiritual/psychological therapies so that in future valid inferences can be made about their effectiveness in populations. Further work should include improving mental health literacy with special reference to treatments available for mental health problems.

Knowledge and practice of help-seeking for treatment of mental disorders in Pemba Island, Zanzibar.

The objective of this study was to describe how people explain mental disorders and its treatment in Pemba Island, Zanzibar. Eight hundred and twenty-one participants (users, carers, health professionals, traditional healers, community members and leaders) were interviewed as part of a cross-sectional survey. Most people viewed mental disorder as arising within their internal or supernatural world. Although they thought that they could be helped both by primary health care and alternative healing, the majority described going to the traditional healers when things went wrong. This provides evidence that there is considerable reliance on traditional care for the treatment of mental disorders. It is therefore important for the health services to be in dialogue with the traditional healers.

Eliciting explanatory models of common mental disorders using the Short Explanatory Model Interview (SEMI) Urdu adaptation--a pilot study.

The purpose of this pilot study was to describe the presenting symptoms and its explanation from the patients' perspective of GHQ (General Health Questionnaire) positive cases attending primary care facility/a general practice in semiurban Lahore. Fifteen consecutive attenders were screened with GHQ and 11 GHQ positive cases went on to complete an adapted questionnaire derived from SEMI (Short Explanatory Model Interview). Though there was no consistency in the presenting symptoms of GHQ positive cases on presentation to a general practitioner, all described their problems as intense, less than 2 years on onset and on reflection located its origins in their social worlds. These findings have implications in terms of providing preliminary data for a larger study, perhaps looking at development of psychosocial interventions for treatment of mental distress in our local context as it seems to have its origins in their social worlds.

Managing physical illness in people with severe mental illness.

People with severe mental illness have poor physical health, and increased morbidity and mortality compared to the general population. Community-based mental health care has led to hospital doctors being more involved in the physical care of psychiatric patients. This paper focuses on key issues in the medical management of psychiatric patients in a general hospital setting.

Reducing non-attendance rates in a community mental health team.

The project aimed to improve productivity of psychiatric out patient clinic using quality improvement techniques through "Listening Into Action", a national programme designed to engage and support front-line clinicians to make improvements to patient care. We identified reasons as to why our patients missed appointments and then introduced a system to reduce "did not attend" (DNA) rates. Non-attendance at appointments results in a waste of resources and increases waiting times. It has been reported that DNA rates in mental health are higher compared to other settings. Therefore, reducing DNA rates are a priority for mental health care providers. We collected DNA rates over a period of months over May 2013 to September 2013. We conducted a patient survey to inquire why the patients missed their appointments. The aim of the project and results from the survey were presented and discussed at the multi-disciplinary team meeting to generate ideas for improvement and engage the team with the project. As the most frequent response from the survey was 'forgetting the appointment', we decided to introduce text messaging as an intervention to remind patients of their appointments. We also ensured that staff updated the mobile phone records for the patients at each appointment. We monitored the DNA rates after introducing this change on a monthly basis. Following our intervention, there was an overall reduction in DNA rates for all disciplines from 11.4% to 10.62% with the greatest change for medical DNA's from 17.7% to 11.8 %. Results from a patient survey showed that the reasons for non-attendance are multi-factorial and require a complex approach. Our intervention was a simple one but still it demonstrated some effectiveness. Reducing DNA rates requires interventions to be regularly monitored so that their effect is sustained over a period of time.

Prevalence and risk factors for psychological distress and functional disability in urban Pakistan.

BACKGROUND: There is a close association between poor mental health status and both poor physical health and decreased productivity. An evidence base on the risk factors for psychological distress in low-income countries is lacking and is much needed to help develop appropriate interventions. We aimed to estimate the prevalence of psychological distress in urban Pakistan and identify associated risk factors and functional disability. METHODS: This was a population-based study of 18-75-year-olds in urban Pakistan. The Self-Reporting Questionnaire (SRQ) was offered to 1000 adults to measure psychological distress. The Life Events Checklist, Oslo-3 for Social Support and Brief Disability Questionnaires were used to establish social stressors, support and functional disability. RESULTS: Questionnaires were completed by 880 (94%) eligible participants, of whom 41% of women and 19% of men scored 9 or more on the SRQ (possible range 0-20). Low educational status was associated with high rates of psychological distress. Women had significantly higher levels of distress than men and were less likely to receive practical support. CONCLUSIONS: The prevalence of psychological distress was lower in urban Karachi than that reported previously for rural Punjab province, Pakistan. However, in urban Karachi, as in rural Punjab, socioeconomic status seemed to have more of an impact on the mental health of women than that of men.

Community mental health provision in Pemba Island, Zanzibar: a cross-sectional survey of different stakeholder groups.

There is limited information about stakeholder perceptions of health service provision in low- and middle-income countries. We conducted a cross-sectional survey of 821 stakeholders of the community mental health services in Pemba Island, Zanzibar, Tanzania. The aim was to obtain systematic information about coverage, barriers, accountability and room for improvement as a baseline before implementation of a new mental health policy to strengthen mental health services.

Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review.

OBJECTIVES: To assess the available evidence on the prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan. DESIGN: Systematic review of published literature. STUDIES REVIEWED: 20 studies, of which 17 gave prevalence estimates and 11 discussed risk factors. MAIN OUTCOME MEASURES: Prevalence of anxiety and depressive disorders, risk factors, effects of treatment. RESULTS: Factors positively associated with anxiety and depressive disorders were female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems. Arguments with husbands and relational problems with in-laws were positively associated in 3/11 studies. Those who had close confiding relationships were less likely to have anxiety and depressive disorders. Mean overall prevalence of anxiety and depressive disorders in the community population was 34% (range 29-66% for women and 10-33% for men). There were no rigorously controlled trials of treatments for these disorders. CONCLUSIONS: Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan. This evidence is limited because of methodological problems, so caution must be exercised in generalising this to the whole of the population of Pakistan.

The needs of patients receiving depot antipsychotic medication within primary care.

BACKGROUND: Depot antipsychotic medication is a vital treatment for many people with schizophrenia. Many patients receive this medication from primary care, and have little or no contact with specialist mental health services. OBJECTIVE: The aim of the present study was to compare the characteristics and needs of patients receiving depot medication within primary care with those receiving their medication from specialist mental health services. METHODS: A total of 58 patients were identified from four primary care teams. Data were collected from medical records, and staff interviews were conducted using standardized interview schedules. RESULTS: Patients receiving medication from primary care had more than twice as many health and social needs compared with those receiving medication from specialist services. CONCLUSIONS: There are advantages for patients to receive depot medication from primary care, but the needs of the patients must be reviewed regularly, and primary care staff must have easy access to specialist mental health services.