Prevalence of common mental disorders and treatment gap among patients with non-communicable diseases in the rural areas of East India.

BACKGROUND: Mental and physical non-communicable diseases (NCDs) coexist, because they share common environmental and behavioral risk factors. The treatment gap for common mental disorders, such as depression, anxiety, and substance use, is large compared to other NCDs. OBJECTIVE: To determine the prevalence and treatment gap of common mental disorders among patients with non-communicable diseases. METHODOLOGY: The community-based cross-sectional study was conducted in the rural parts of East India, in people aged 30 years and older with NCDs. A simple random sample was chosen to select the villages and participants. Eligible participants administered with screening and diagnostic questionnaire for depression, anxiety, and substance use. Those diagnosed with mental disorders were again assessed for treatment status in the last 12 months. Non-receipt of treatment was considered as treatment gap. RESULTS: A total of 515 participants were included in the analysis. The overall prevalence of common mental disorders among the study population was 46.4% (95% CI 42.0-50.8), and excluding substance use, the prevalence was 11.7% (95% CI 9.0-14.7). The treatment gap for common mental disorders among patients with non-communicable diseases, including and excluding substance use, was 98.3% (95% CI 95.8-99.5) and 93.3% (95% CI 83.8-98.2), respectively. CONCLUSION: The prevalence and treatment gap of common mental disorders among persons with NCDs was high. Public health interventions need to be emphasized for the integration of mental health care into NCD care.

Effectiveness of school-based sexual and reproductive health education among adolescent girls in Urban areas of Odisha, India: a cluster randomized trial.

BACKGROUND: Various studies revealed that adolescent girls have limited knowledge pertaining to sexual and reproductive health (SRH). The current study assessed the effectiveness of SRH education among adolescent girls in urban areas of Odisha, India. METHODS: The study design was a cluster randomized trial, where the clusters composed of eight Odia (regional language) medium government girls' high schools in Bhubaneswar, the capital city of the state of Odisha, India. For the selection of study participants, adolescent girls who were studying in the ninth and tenth standards were recruited from each school. Eight schools were randomized through restrictive randomization at a 1:1 ratio, with four schools each in the intervention and control arm. Baseline and end-line assessments were done using a pre-tested, semi-structured questionnaire. Following baseline assessment, an intervention was given with the help of handbooks developed by the study authors to the schools in the intervention arm. Outcomes included change in knowledge, attitude and practices pertaining to SRH. RESULTS: In our study at baseline, there were a total of 790 students, where 469 (59.4%) students were in the intervention arm, and 321 (40.6%) students were in the control arm. At baseline, only 282 (60.1%) in the intervention arm and 171 (53.3%) in the control arm were aware that physical bodily changes due to puberty were normal. After the intervention, there was a statistically significant increase in knowledge in intervention group 367 (94.8%) (p-value < 0.001). Most students used sanitary pads as absorbent, 97.2% in the intervention group and 98.4% in the control group. However, after the intervention, the use of other absorbents reduced to zero in the intervention group with a statistically significant difference (p < 0.05). The number of students having awareness on different methods of contraception increased from 51 (10.9%) to 337 (87.1%) in the intervention arm (p < 0.001), and of those having awareness on STIs/RTIs increased from 177 (38.2%) to 371 (96.1%) in the intervention group (p < 0.001). CONCLUSION: From our study, there is a significant proportional change in knowledge, attitude, and practices pertaining to SRH. Our study recommends policymakers and program managers for the implementation of comprehensive SRH in the regular school curriculum. Trial registration CTRI/2021/01/030490, registered on January 15, 2021. Prospectively registered at https://ctri.nic.in/Clinicaltrials/login.php.

Adolescent girls lack adequate knowledge pertaining to sexual and reproductive health, for which they face various issues such as teenage pregnancy, unsafe abortions and sexually transmitted infections. Hence the authors conducted this study to assess the effectiveness of school-based sexual and reproductive health education among adolescent girls in Odisha state of India in terms of improving knowledge, attitude and practices pertaining to reproductive health. A total of eight vernacular (Odia language) medium schools were selected for the conduct of the study, and the schools were randomly assigned where four schools received SRH education, and the other four received no intervention. A baseline assessment pertaining to SRH was done among adolescent girls studying in ninth and tenth classes of all eight schools, and then education was given to the four schools in the intervention arm. Students were educated on topics such as puberty, menstrual health, pregnancy, contraception and STIs/RTIs with the help of handbooks prepared by the authors. After 3 months of providing education, an endline assessment was done for the adolescent girls in all eight schools. There was an increase in knowledge, attitude and practices pertaining to SRH among the students who received education when compared to those who didn't. Hence our study recommends policymakers and program managers include SRH education in the regular school curriculum.

Autism spectrum disorder in India: a scoping review.

Autism is a grand challenge in global mental health to be dealt with on a priority basis. Phenotypic knowledge, biological understanding, and evidence-based intervention studies are all from western countries. We know very little about autism in the low- and middle-income countries (LMIC). Lack of infrastructure and difficulties in operationalizing research has widened the knowledge gap. We performed a comprehensive scoping review of research in Autism Spectrum Disorder in India to have an overall impression, identify gaps, and formulate evidence-based recommendations for further study. We searched PubMed, SCOPUS, and Cochrane Library to identify relevant Indian studies. A hundred and fifty-nine publications met the inclusion criteria. Most of the research contribution in autism is from few tertiary care medical centres, technological institutes, and not-for-profit organizations. We identified various themes of research like clinical profile, interventions, biomarkers, psychological, social, epidemiological, and risk factors. Evidence-based intervention studies, translation and adaptation of standard diagnostic instruments, and qualitative research on the experience of autism appeared to be state of the art. However, epidemiological studies, biomarkers identification, risk assessment studies were of low quality. There is a need for nationwide studies with representative sampling on epidemiology, biomarkers, and risk factors for a complete evaluation of the actual burden and biology of autism in India. Also, there is a need to design implementation research to evaluate the effectiveness of evidence-based interventions in routine healthcare settings. We recommend that future research should fill these gaps in understanding autism and improving its outcome in India.

Progressive Muscle Relaxation and Guided Imagery in Breast Cancer: A Systematic Review and Meta-analysis of Randomised Controlled Trials.

Breast cancer affects the mental well-being of patients who may need psychological support. The combined practice of progressive muscle relaxation (PMR) and guided imagery (GI) is known to improve psychological health. Its effect has been studied in patients with breast cancer. We need to systematically review and analyse the available data to outline its role in various stages of disease management. We wanted to evaluate the effect of the combined practice of PMR and GI on stress, anxiety, depression and mood. We also wanted to study the impact on quality of life and chemotherapy-related adverse effects. A systematic search and evaluation of the literature was performed. Five randomised controlled trials were selected for data extraction and construction of forest plots. The intervention was effective for stress and anxiety. It positively improved the quality of life but saw no significant improvement in chemotherapy-related adverse effects.

Post traumatic stress symptoms, anxiety, and depression in patients after intensive care unit discharge - a longitudinal cohort study from a LMIC tertiary care centre.

BACKGROUND: Data on intensive care unit (ICU) related psychiatric morbidity from Low Middle-Income Countries are sparse. We studied the ICU related posttraumatic stress symptoms (PTSS), anxiety, and depression symptoms in a cohort of patients from Eastern India. METHODS: We included adults admitted more than 24 h to a mixed ICU. PTSS, anxiety, and depression symptoms were assessed by telephonic or face to face interviews by using the Impact of Events-r (IES-r) and Hospital anxiety and depression (HADS), respectively, at 0, 7,14, 30, 90 and 180 days from ICU discharge. The loss to follow up was minimal. Demographic, socioeconomic, quality of life (QOL), and critical care related variables were studied. RESULTS: Of 527 patients, 322 (59.4%) completed 6 months' follow up. The majority were male (60%), mechanically ventilated > 48 h (59.4%), mean age of 48 (+/- 16), mean acute physiology and chronic health evaluation II (APACHE II) at admission 9.4 (+/- 4.6), median length of stay 3 (2-28 days). The rates of ICU related clinical PTSS was < 1 and < 3% for anxiety/depression at any point of follow up. Data were analyzed by linear mixed (random effects) models. There was a significant drop in all scores and association with repeated measures over time. Poor QOL at discharge from the ICU showed significant association with PTSS, anxiety, and depression (ß = - 2.94, - 1.34, - 0.7 respectively) when corrected for gender and education levels. Younger age, greater severity of illness, and prior stressful life experiences predicted worse PTSS (ß = - 0.02, 0.08, 3.82, respectively). Benzodiazepines and lower sedation scores (better alertness) predicted lower depression symptoms. (ß = - 0.43, 0.37 respectively). CONCLUSION: ICU related psychiatric morbidity rates in our population are low compared with reported rates in the literature. Poor QOL at ICU discharge may predict worse long-term mental health outcomes. Further research on the impact of ICU and sociocultural factors on mental health outcomes in patients from different backgrounds is needed. The study was registered at CTRI/2017/07/008959.

Effectiveness of Entrustable Professional Activity-Based Clinical Psychiatry Training for Indian Medical Interns: A Preliminary Study.

ObjectiveEntrustable Professional Activities (EPA) are discretely measurable specific professional tasks that integrate multiple competencies to define and provide varying levels of faculty support per trainee needs. Methods: We developed an EPA-based psychiatry curriculum for medical interns. Fifty-four interns completed the OSCE stations, Multiple Choice Questions, and Attitude questionnaires to assess EPAs, knowledge and attitudes towards the relevance and utility of clinical psychiatry in general practice. Results: Two weeks of EPA-based psychiatry training resulted in improvement in median scores on attitude questions (p < 0.05), clinical skills measured using EPA levels. Conclusions: EPA-based curriculum can improve clinical skills, knowledge, and attitudes towards clinical psychiatry in interns.

A Rapid Systematic Review of the Prevalence of Suicide and Self-Harm Behaviors in Adolescents During the COVID-19 Pandemic.

Background: COVID-19 has caused psychological, social, and physical isolation in adolescents resulting in varying rates of suicidal behavior and self-harm. Aims: We investigated the pandemic's impact on adolescent suicidal behavior and self-harm by reviewing the existing literature. Methods: We searched PubMed using keywords: adolescent, suicide, suicidal behavior, self-harm, prevalence, and COVID-19 and included studies reporting primary data only. Results: Of the 551 studies identified, we included 39 studies in the final analysis. Two of the six high-quality population-based suicide registry studies reported increased suicide rates during the pandemic. Seven of fifteen emergency department-based studies out of which four were of high quality and three high-quality population-based health registry studies reported increased self-harm. A few school and community-based surveys and national helpline data also reported an increase in suicidal behavior or self-harm. Limitations: Methodological heterogeneity of the included studies. Conclusions: There is wide variation in study methodology, population, settings, and age groups in the included studies. Suicidal behavior and self-harm were increased in specific study settings and adolescent populations during the pandemic. More methodologically rigorous research is needed to evaluate the impact of COVID-19 on adolescent suicidal behavior and self-harm.

Relationship of Mindfulness with Depression, Self-Management, and Quality of Life in Type 2 Diabetes Mellitus: mindfulness is a Predictor of Quality of Life.

Context: Mindfulness interventions have shown promising results in both psychological and clinical outcomes of type 2 diabetes mellitus. Depression, self-management, and quality of life (QOL) have shown improvement with mindfulness interventions; however, little is known about dispositional mindfulness and its relationship with depression, self-management, and QOL in type 2 diabetes mellitus. Aims: The aim of this study is to assess the relationship of dispositional mindfulness with depression, self-management, and QOL in patients of type 2 diabetes. Settings and Design: Noncommunicable disease outpatient department of a tertiary care medical center of East India. Cross-sectional study. Subjects and Methods: Ninety-nine patients with type 2 diabetes completed the Five Facets Mindfulness Questionnaire, Diabetes Self-Management Questionnaire, and World Health Organization QOL BREF questionnaire and Hamilton Rating Scale for depression. Statistical Analysis Used: Pearson's correlation and hierarchical regression analysis using the SPSS software version 20.0. Results: Describing, acting with awareness, and nonjudging facets of mindfulness showed a negative correlation with depression (P < 0.05). Acting with awareness and nonreactivity to inner experience were positively correlated with the physical activity domains of self-management (P < 0.05). All facets of mindfulness showed a positive correlation with four domains of QOL. In hierarchical regression analysis, after controlling for sociodemographic and clinical variables, mindfulness predicted the psychological domain of QOL, explaining 31% of the variance (P ≤ 0.001). However, mindfulness did not predict depression or self-management. Conclusions: Dispositional mindfulness is a strong predictor of QOL in type 2 diabetes mellitus and hence can be targeted with interventions to improve psychological outcomes.

Association between Gestational Diabetes Mellitus and Postpartum Depression among Women in Eastern India: A Cohort Study.

Background: The study was planned to evaluate the association between Gestational Diabetes Mellitus (GDM) and Postpartum Depression (PPD) in a rural population of Odisha, Eastern India. Material and Methods: Pregnant women in the first trimester were recruited and followed up till six weeks of postpartum. Gestational Diabetes Mellitus was assessed with 75 grams glucose challenge test and PPD was assessed at six weeks after delivery with Edinburgh Postnatal Depression Scale. Statistical difference between variables was assessed using Chi-square test, Fischer's exact test, and unpaired T-test. Covariates were adjusted using bivariate and multivariate logistic regression to estimate the association between GDM and PPD. Results: Out of 436 pregnant women recruited, 347 (89.6%) remained in the study. Prevalence of GDM was 13.9% (95% CI: 10.7-17.3) and PPD was 9.8% (95% CI: 6.6-12.9). Incidence of PPD in the GDM group was 14.58% (95% CI: 4.2-24.9) and in women without GDM was 9.06% (95% CI: 5.76-12.3). However, the association was not significant on multivariate logistic regression (Risk Ratio (RR) = 1.56, 95% C.I: 0.61-6.16; P-value = 0.35). Conclusion: This study demonstrated that women with GDM were at higher risk of developing PPD suggesting that an "at risk" approach should be implemented for screening.

Hypothyroidism in Pregnancy: An Alarming Concern in a Rural Community of Eastern India.

Introduction: Hypothyroidism exerts a multitude of effects on pregnant women and newborns. This study aimed to estimate the prevalence of hypothyroidism and its associated factors among pregnant women. Material and Methods: This cross-sectional study was done at a community health center in Tangi, Eastern India. A total of 436 pregnant women ≤24 weeks gestation attending the ante-natal clinic were recruited by consecutive sampling after obtaining written informed consent. Those who were a known case of any psychiatric disorder and were not able to comprehend interview questions were excluded. Estimation of serum thyroid stimulating hormone levels was done at the central laboratory of the All India Institute of Medical Sciences, Bhubaneswar. Analysis was done using STATA 17.0 and presented as means or proportions. The association of hypothyroidism with various sociodemographic factors was analyzed with bivariate logistic regression. Results: Mean age of the study participants was 23.9 years (SD: 3.65). About 31.4% of participants were found to have hypothyroidism. On bivariate logistic regression, the presence of hypothyroidism was not associated with any variable. Conclusions: Hypothyroidism is widely prevalent in pregnant females in rural India. Screening of high-risk pregnant females followed by appropriate management is essential.

Reduced reward responsiveness in treatment resistant depression of middle-aged adults: Association with carotid artery stiffness and tetrahydrobiopterin.

Nearly one third of the population diagnosed with major depressive disorder (MDD) fail to respond to two or more antidepressant drugs of adequate dose and duration. This necessitates identification of confounding psychological and physiological factors that could contribute to treatment resistant depression (TRD). The present longitudinal study investigated the influence of behavioural inhibition system (BIS) and behavioural approach system (BAS) in treatment resistance. Further, the association of depression severity with physiological factors contributing to arterial stiffness was also investigated. Baseline data was acquired from 101 middle-aged (36-56 years) patients on immediate diagnosis with MDD using DSM-V criteria. Follow ups were conducted at 06 months and 12 months during treatment. Psychological assessment battery at baseline and follow ups comprised of Hamilton depression rating (HAM-D) for depression severity, WHODAS-2 and BIS-BAS score. Atherosclerosis and central arterial stiffness were measured by intima-media thickness of internal carotid artery and brachial-ankle pulse wave velocity. Physiological factors influencing central vascular function viz., body-mass index, estimated glomerular filtration rate, HbA1c, central systolic and diastolic blood pressure, heart rate and tetrahydrobiopterin were also investigated. Our results show lower reward responsiveness (BAS-RR) and higher BIS scores in TRD patients along with differentially higher intima-media thickness of left internal carotid artery. Higher depression severity at all stages of the study was correlated with lower tetrahydrobiopterin and BAS-RR scores. We, therefore, suggest that vascular depression resulting due to increased intima-media thickness of left carotid artery and lower tetrahydrobiopterin could be contributing factors for treatment resistance in middle-aged MDD patients.

Competency-based child and adolescent psychiatry curriculum for Indian medical graduates: Need of the hour.

The National Medical Council of India has introduced a Competency-Based Medical Curriculum for structured training of Indian Medical Graduates. The curriculum envisages training of the medical graduate in Bloom's cognitive, affective and communication skills as per Miller's competence framework. This competency-based curriculum has opened the way towards a structured training program for medical graduates to impart evidence-based teaching and groom them into holistic physicians. The introduction of psychiatry early into the medical graduate curriculum is a welcome step that can generate interest towards the specialty and provide core knowledge and clinical psychiatric skills. In this background, the author proposes introducing a structured Child and Adolescent psychiatry curriculum for undergraduates, which can prepare future doctors to provide child and adolescent psychiatric care in routine clinical settings. This competency-based child and adolescent psychiatry curriculum would help inculcate developmentally and socially appropriate knowledge, attitude and communication skills in managing child and adolescent psychiatric disorders.

Flow cytometry based platelet activation markers and state of inflammation among subjects with type 2 diabetes with and without depression.

Type 2 Diabetes Mellitus (T2DM) and Major Depressive Disorder (MDD) are highly disabling disorders associated with a multitude of vascular complications. Platelets are known to play a role in the pathogenesis of vascular complications in both T2DM and MDD. These complications could increase in patients with comorbid diabetes and depression. To quantify and compare flow cytometry based platelet activation markers and the inflammatory state between individuals of diabetes with depression, individuals of diabetes without depression and healthy controls. Out of 114 participants, each study group contained 38 participants in diabetic group, diabetics with depression group and matched control group. Diabetes was diagnosed with the American Diabetes Association (ADA) criteria. Screening of MDD was done with Patient Health Questionnaire 2 (PHQ2) and severity of depression assessed with Hamilton Depression Rating (HAM-D) scale. Platelet markers CD41, CD42b, CD62P and CD63 were assayed using flow cytometer. Platelet count, surface expression of platelet activation markers CD62P and CD63, hs-CRP, insulin and HOMA-IR score differed significantly between the groups. Post hoc analysis showed significantly high CD63 expression in patients with comorbid diabetes and depression compared to those having diabetes without depression. Patients with comorbid diabetes and depression have enhanced platelet hyperactivation and a pro inflammatory state which increases susceptibility to vascular complications.

Assessment of Copper and Zinc Levels in Hair and Urine of Children With Attention Deficit Hyperactivity Disorder: A Case-Control Study in Eastern India.

Background Attention deficit hyperactivity disorder (ADHD) is a neuro-developmental ailment diagnosed with inattention and hyperactivity-impulsivity. It is one of the most prevalent neurodevelopmental disorders and has complex aetiology, both genetic and environmental. There is a perceived decrease in skill acquirement, leading to insufficient income and job opportunities as adults, which drives them towards poor physical and mental outcomes compared to their contemporaries without ADHD. The impact of heavy metals on ADHD is a topic of interest but is much less studied. Copper has been implicated as a pro-oxidant and in the metal accelerated production of free radicals that may affect oxidative stress. Zinc also serves as an antioxidant, and changes in its concentrations may impact the homeostasis of oxidative stress. Methods Twenty-four children diagnosed with ADHD were taken as cases and matched with 24 healthy controls. Hair and urine samples were collected from all the study participants. The samples were collected in sterile containers according to established protocols. Acid digestion of hair samples was done using 65% nitric acid and 30% hydrogen peroxide. Urine samples were extracted by a solution of 0.1% Triton-X-100 and 1% ultrapure nitric acid. The levels of zinc and copper were determined in both samples by inductively coupled plasma optical emission spectrometry (ICP-OES). The copper/zinc ratio (Cu/Zn) was calculated from these values. Mann Whitney U Test and receiver operating characteristic (ROC) analysis were done to estimate statistical significance. Results The median age of the study population was eight years. Overall, 34 male and 14 female subjects participated. There was no significant difference in height, weight and BMI between the cases and controls. Hair zinc levels in the ADHD group (198.49 µg g-1 of hair) was significantly lower than the control group (527.05 µg g-1 of hair). However, hair copper levels were increased significantly in the ADHD children (14.01 µg g-1 of hair) compared to the controls (7.43 µg g-1 of hair). Urine zinc levels were significantly lower in cases than controls (525.7 µg g-1 of spot urine creatinine vs 1374.09 µg g-1 of spot urine creatinine). However, copper levels in urine were higher in the ADHD children (17.01 µg g-1 of spot urine creatinine compared to 7.26 µg g-1 of spot urine creatinine in controls). Both hair and urine copper to zinc ratio was significantly higher in the ADHD group. On ROC analysis, the hair Cu/Zn ratio had an area under the curve (AUC) of 0.920 (p-value <0.001), and the urine Cu/Zn ratio had an AUC of 0.967 (p-value <0.001). When used as a diagnostic classifier for ADHD based on the cut-off value determined by ROC, both hair and urine Cu/Zn ratio had high sensitivity and specificity. Conclusion Low zinc levels in the urine and hair of children and higher levels of copper may impact the aetiology of ADHD in these children. At an early stage, the Cu/Zn ratio in both hair and urine samples may be used as a precise biomarker to identify and monitor such children.

Effect of Laboratory Mental Stressors on Cardiovascular Reactivity in Young Women During Different Phases of Menstrual Cycle: An Observational Study.

Introduction: Excessive cardiovascular reactivity to mental stress may be a risk factor for cardiovascular disease. However, there is inconsistent report in the literature regarding change in cardiac autonomic tone with the phase of the menstrual cycle and how it is affected by mental stress. Therefore, the present study was aimed at determining the cardiovascular reactivity to different laboratory mental stressors during follicular and luteal phase of menstrual cycle using heart rate variability (HRV). Methods: Thirty-three regularly cycling young females (19-35 years of age) were exposed to four cognitive tasks (Stroop test, Mental Rotation test, n-back test, and Mental Arithmetic Stress Test [MAST]) employed as laboratory mental stressors. HRV of the study participants were recorded before, during, and after each cognitive task and the recording was done in both phases of menstrual cycle for each individual. Results: A significant difference was observed in time domain parameters and nonlinear parameters of HRV in pretest versus during-test condition and during-test versus post-test conditions, but not in frequency domain parameters. No phase difference was found in time domain or frequency domain analysis of HRV in baseline or during performance of task. MAST performance (score out of 50) was significantly higher in luteal than follicular phase, while other tests showed no such difference. Conclusion: All four mental stress tasks used in the present study were able to elicit significant decrease in parasympathetic tone during performance of task as compared with baseline values of HRV. The present study did not elicit any phase difference in cardiovascular reactivity.