Experience and Reporting of Postnatal Depression Across Cultures: A Comparison Using Anchoring Vignettes of Mothers in the United Kingdom and India.

Postnatal mental health is often assessed using self-assessment questionnaires in epidemiologic research. Differences in response style, influenced by language, culture, and experience, may mean that the same response may not have the same meaning in different settings. These differences need to be identified and accounted for in cross-cultural comparisons. Here we describe the development and application of anchoring vignettes to investigate the cross-cultural functioning of the Edinburgh Postnatal Depression Scale (EPDS) in urban community samples in India (n = 549) and the United Kingdom (n = 828), alongside a UK calibration sample (n = 226). Participants completed the EPDS and anchoring vignettes when their children were 12-24 months old. In an unadjusted item-response theory model, UK mothers reported higher depressive symptoms than Indian mothers (d = 0.48, 95% confidence interval: 0.358, 0.599). Following adjustment for differences in response style, these positions were reversed (d = -0.25, 95% confidence interval: -0.391, -0.103). Response styles vary between India and the United Kingdom, indicating a need to take these differences into account when making cross-cultural comparisons. Anchoring vignettes offer a valid and feasible method for global data harmonization.

Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment.

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

Child developmental outcomes associated with postpartum depression and anxiety in low and middle-income countries: a systematic review.

AIMS: This systematic review aims to summarize the findings of empirical studies conducted in low- and middle-income countries (LMICs) examining the relationship between postpartum depression and anxiety, and child developmental outcomes measured at 24 months of child's age. METHODS: The study was performed as per PRISMA guidelines for a systematic review. EBESCO, ProQuest, PubMed, Science Direct, Google Scholar, and BMJ databases were examined, along with a forward and backward examination of the citations published. The New Ottawa scales (NOS) was used to assess the quality of the studies. The findings of the studies were integrated using a narrative synthesis approach. RESULTS: The systematic review revealed that there are 14 studies examining the impact of postpartum depression (n=14) and postpartum anxiety (n=2) across different domains of child development in LMICs. Studies varied regarding the severity and duration of maternal depression, the context and nature of evaluation, and motherinfant characteristics which are important to understand the association between postpartum depression and anxiety and infant development. Maternal depression is negatively associated with language development, socio-emotional and behavioural development while its association with motor and cognitive development is inconsistent. The impact of maternal anxiety on infant development was examined in two studies, and both have identified a negative association. However, the results of the current review need to be interpreted within the scope and limitations of the methodologies adopted by each study details of which are elaborated in the manuscript. CONCLUSION: Postpartum depression and anxiety can have a wide range of effects on child development. Therefore, periodic infant developmental assessments should become part of routine psychiatric evaluation. There is a need for uniform guidelines for conducting studies and reporting data related to postpartum mental health and child development.

Exploring the feasibility, acceptability and preliminary effects of a nurse delivered mhealth intervention for women living with HIV in South India: a pilot randomized controlled trial.

PURPOSE: We evaluated the feasibility, acceptability and preliminary efficacy of a standardized nurse delivered mobile phone intervention to improve adherence to antiretroviral treatment and clinical outcomes. METHODS: Feasibility and acceptability of the phone intervention was assessed with rates of eligibility, completed visits, and attritions. Intervention fidelity was assessed by checking recorded calls and feedback. Efficacy was assessed using a randomized controlled trial in which 120 women living with HIV and psychosocial vulnerabilities, were randomized to Treatment as Usual (TAU = 60) or TAU plus the mobile phone intervention (N = 60). Trained basic nurses delivered the theory-guided, standardized mobile phone intervention for mental health issues and psychosocial risk factors to improve antiretroviral treatment (ART) adherence and retention in care and improve clinical outcomes. Blind raters performed the assessments at 6, 12 and 24 weeks post-randomization. RESULTS: Adherence diminished over time in the TAU only group, while it was sustained in the TAU Plus group, only dropping at 24 weeks after the intervention had been discontinued. Among participants with depressive symptoms (CESD ≥ 16), the intervention had significant improvement in adherence rates (p < 0.01), psychological quality of life (p < 0.05) and illness perception (p < 0.05) compared to those in the TAU only group. Greater improvements of quality of life subscales were observed in the TAU Plus group among participants with less psychological vulnerability (PSV < 2). HIV RNA was not significantly different between the groups at week 24. CONCLUSIONS: The mobile-delivered counseling intervention was feasible and acceptable and shows promise among women living with HIV and psychosocial vulnerabilities in rural South India. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02319330 [Registered on: December 18, 2014].

Development of a tool for infant facial emotion recognition (InFER) for postpartum mothers with mental illnesses.

Understanding deficits in recognition of infant emotions in mothers with mental illnesses is limited by the lack of validated instruments. We present the development and content validation of the infant facial emotion recognition tool (InFER) in India to examine the ability of mothers to detect the infants' emotions. A total of 164 images of infant faces in various emotional states were gathered from the parents of four infants (two male and two female: up to 12 months old). Infant emotion in each image was identified by the respective mother. Content validation was carried out by 21 experts. Images with ≥70% concordance among experts were selected. The newly developed tool, InFER, consists of a total 39 infant images representing the six basic emotions. This tool was then administered among mothers during their postpartum period-10 healthy mothers and 10 mothers who had remitted from any schizophrenia spectrum disorder, bipolar affective disorder or major depressive disorder. The mean age and mean years of education for both groups were comparable (age∼25 years, education ∼15 years). A significant difference was found between the two groups in their ability to recognize infant emotions (Mann-Whitney U = 12.5; p = 0.004). InFER is a promising tool in Indian settings for understanding maternal recognition of infant emotions.

La comprensión de los déficits en el reconocimiento de las emociones del infante en madres con enfermedades mentales está limitada por la falta de instrumentos validados. Presentamos el desarrollo y la validación de contenido de una herramienta para reconocer la emoción facial del infante (InFER) en la India. para examinar la habilidad de las madres para detectar las emociones del infante. Se recogió un total de 164 imágenes de caras de infantes en varios estados emocionales, aportadas por los progenitores de 4 infantes (dos varones y dos niñas: de hasta 12 meses de edad). La mamá respectiva identificó la emoción del infante en cada imagen. La validación del contenido la llevaron a cabo 21 expertos. Para la construcción de esta herramienta se seleccionaron las imágenes que presentaban el ≥70% de concordancia entre los expertos. La recientemente desarrollada herramienta, InFER está compuesta de un total de 39 imágenes de infantes las cuales representan las seis emociones básicas. Esta herramienta entonces se puso en práctica entre madres durante su período de postparto ­10 madres saludables y 10 madres que habían sido remitidas en relación con cualquiera de los trastornos de la gama de la esquizofrenia, el trastorno afectivo bipolar o un trastorno depresivo mayor. El promedio de edad y el promedio de años de educación en ambos grupos eran comparables (edad ∼25 años, educación ∼15years). Una diferencia significativa se encontró entre los dos grupos en cuanto a su habilidad de reconocer las emociones del infante (Mann­Whitney U = 12.5; p = 0.004). InFER es una herramienta prometedora en entornos de la India para comprender el reconocimiento materno de las emociones del infante.

La compréhension des déficits dans la reconnaissance des émotions du bébé chez les mères ayant des maladies mentales est limitée par le manque d'instruments validés. Nous présentons le développement et la validation du contenu d'un outil de reconnaissance de l'émotion faciale du nourrisson (InFER) en Inde afin d'examiner la capacité des mères à détecter les émotions du bébé. Un total de 164 images de visages de bébés dans des états émotionnels variés ont été assemblées de parents de 4 bébés (deux garçons et deux filles: jusqu'à l'âge de 12 mois) L'émotion du bébé dans chaque image a été identifiée par la mère respective. La validation du contenu a été faite par 21 experts. Des images avec ≥70% de concordance entre les experts ont été sélectionnées pour la construction de l'outil. Ce nouvel outil, InFER, consiste en un total de 39 images de bébés représentant les six émotions de base. Cet outil a ensuite été utilisé chez des mères durant leur période postpartum ­ 10 mères en bonne santé et 10 mères s'étant remises soit d'un trouble du spectre schizophrénique, soit d'un trouble affectif bipolaire ou d'un trouble dépressif majeur. La moyenne d'âge et la moyenne d'années d'éducation pour les deux groupes étaient comparables (âge∼25ans, éducation ∼15ans). Une différence importante a été trouvée entre les deux groupes dans leur capacité à reconnaître les émotions du bébé (Mann­Whitney U = 12,5; p = 0,004). InFER est un outil prometteur dans les contextes de l'Inde pour comprendre la reconnaissance maternelle des émotions du bébé.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study.

BACKGROUND: Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India. METHODS: Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis. RESULTS: Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported. CONCLUSIONS: Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Postpartum psychosis: a public involvement perspective across three continents.

Postpartum psychosis is a psychiatric emergency that is currently not represented in diagnostic systems, to the detriment of people with lived experience. Engaging with stakeholders offers an important avenue to improve clinical practice and make research more impactful, by providing perspectives based on first-hand, expert experience. There is a paucity of reports on stakeholders' engagement in psychiatry. Activities have thus far been limited to Western countries and there are few reports on postpartum psychosis. We report the results of public involvement activities (in the form of discussion groups) with key stakeholders in India, Malawi and the UK. These discussions centred around the clinical picture of postpartum psychosis and the terminologies used to describe these episodes. Seven major areas were highlighted: how postpartum psychosis is handled within services, common symptoms and characteristics, impact of episode, barriers to care, non-medical approaches, terminology and research areas of interest. According to the discussions, postpartum psychosis presents similarly across countries, although there are differences in access to services, approaches to mental health and terminologies used within and across countries. With this understanding comes the foundation for cross-cultural assessment, service improvement and a stakeholder-informed research agenda.

Burden of severe maternal peripartum mental disorders in low- and middle-income countries: a systematic review.

Peripartum severe mental disorders (PSMDs) encompass schizophrenia, affective psychosis, and psychotic and non-psychotic forms of bipolar disorders. PSMDs are well documented in high-income countries. However, much less is known about the prevalence of PSMDs in low- and middle-income countries (LMICs). The aim was to review the available literature systematically and estimate the prevalence of PSMDs among women in LMICs. We searched the Ovid MEDLINE, Embase, PsycINFO, CINAHL and Maternity and Infant Care databases systematically from the date of inception to Dec 31, 2020, for English-language publications with data on the prevalence of PSMDs among women in World Bank-defined LMICs. Selection of studies, extraction of data and assessment of study quality were each undertaken independently by at least two of the investigators. A total of five studies (completed in three countries spanning two continents) met the inclusion criteria. Five studies reported cumulative incidence of postpartum psychosis (ranging from 1.1 to 16.7 per 1000 births). We found no studies on the prevalence of severe mental disorder during pregnancy in these settings. Marked heterogeneity in methodology precluded meta-analysis. These findings indicate that PSMDs occur at a similar prevalence in low- and middle-income to high-income countries. However overall, there is a paucity of high-quality evidence from these settings. There is a need for rigorous studies with standardized methods to increase knowledge of the nature, prevalence, and determinants of PSMDs among women in resource-constrained LMICs to inform policies, service development, program planning and health professional training.

Prevalence and determinants of antenatal common mental disorders among women in India: a systematic review and meta-analysis.

To review the available evidence about the prevalence and determinants of antenatal common mental disorders (antenatal CMDs) among women in India. We searched Ovid Medline, Embase and Psyinfo systematically from date of inception to Oct. 31, 2019 for publications in English language on the prevalence of antenatal CMDs and their determinants among women in India. All study designs were included. Quality was assessed with Standard Quality Assessment Criteria for Evaluating Primary Research Papers. We performed a meta-analysis using a random effects model. Twenty-seven studies involving 7780 women were analysed. There was a high degree of heterogeneity ((I2 = 97.53%). Publication bias [Egger bias = 0.65 (95% CI: 0.36; .94)] was evident. The overall pooled estimate of the prevalence of antenatal CMDs was 21.87% (95% CI: 17.46; 26.29). Significant risk factors reported in the 18 studies which examined them were negative reaction of husband or in-laws to the dowry, difficult relationship with husband/in-laws, lack of support or experiencing violence perpetrated by an intimate partner and preference for or feeling pressured to have a male child. Protective factors were having more education and being employed, having a supportive husband and opportunities for recreation during pregnancy. Antenatal CMDs are highly prevalent among women in India. There is an urgent need for locally developed policies and programmes for mental health promotion during pregnancy, preventive and early intervention for antenatal CMDs among women to be integrated into maternity care in India.

Lifetime traumatic experiences and postpartum depressive symptoms in a cohort of women in South India.

Studies in western cultures have proposed mechanisms by which adverse childhood experiences can affect mental health, including mediating variables such as social support and resilience. However, research replicating these findings in perinatal populations are sparse in Asia. This study assessed the association between lifetime trauma and postpartum depressive symptoms. Additionally, the study examined the mediating role that resilience and social support can play in this association. This study was conducted on 458 women participating in the PRAMMS cohort in urban Bangalore. Information on lifetime trauma was collected through a culturally appropriate trauma interview and postpartum depressive symptoms (8 weeks) were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Resilience was assessed using the Connor-Davidson Resilience Scale-10 and social support was assessed through the Zimet's Multidimensional Scale of Perceived Social Support. A linear model was used to measure the association between lifetime trauma and postpartum depression and mediation analysis was used to assess the role of resilience and social support in the primary association. All analyses were conducted using SPSS. In this cohort, 254 women reported at least one trauma and 204 reported no trauma. A higher number of lifetime traumatic events was associated with higher EPDS scores (ß = 0.487, 95%CI: 0.267-0.707). Social support was found to have a negative association between the predictor and the outcome; however, resilience was not a statistically significant mediator. Lifetime trauma was associated with postpartum depressive symptoms in our study and social support negatively mediated the association between lifetime trauma and postpartum depressive symptoms.

Anxiety and depressive symptoms in pregnancy predict low birth weight differentially in male and female infants-findings from an urban pregnancy cohort in India.

PURPOSE: This study examined the contributions of antenatal anxiety, depression, and partner violence to low birth weight (LBW) in infants and to sex-specific birth weight outcomes among mothers from a cohort in urban India. METHODS: Data from 700 mothers from the PRAMMS cohort (Prospective Assessment of Maternal Mental Health Study) were used. Pregnant women were assessed in each trimester-T1, T2 and T3, for symptoms of anxiety, and depression as well as partner violence. Multivariate analyses were performed for the whole sample and then for male and female infants separately. The final multivariable logistic regression models were each built using a backward selection procedure and controlling for confounders. To accommodate longitudinally measured data, change in scores (T2-T1 and T3-T2) of anxiety and depression were included in the model. RESULTS: Of the 583 women with a singleton live birth, birth weight was available for 514 infants  and LBW was recorded in 80 infants (15.6%). Of these, 23 infants were preterm. Overall, higher T1 Depression scores (OR: 1.11; 95% CI 1.040, 1.187) and an increase in both Depression scores (OR: 1.12; 95% CI 1.047, 1.195) from T1 to T2 and Anxiety scores (OR: 1.32; 95% CI 1.079, 1.603) between T2 and T3 were predictors of LBW. Female infants had a higher chance of LBW with increase in maternal anxiety between T1-T2 (OR: 1.69; 95% CI 1.053, 2.708) and T2-T3 (OR: 1.49; 95% CI 1.058, 2.086); partner violence during pregnancy just failed to reach conventional statistical significance (OR: 2.48; 95% CI 0.810, 7.581) in girls. Male infants had a higher chance of LBW with higher baseline depression scores at T1 (OR: 1.23; 95% CI 1.042, 1.452) and an increase in depression scores (OR: 1.25; 95% CI 1.060, 1.472) from T1 to T2. CONCLUSION: Increasing prenatal anxiety and depressive symptoms in different trimesters of pregnancy were associated with LBW with sex-specific patterns of association in this sample from a Low and Middle Income Country.

COVID-19-related anxiety and concerns expressed by pregnant and postpartum women-a survey among obstetricians.

This paper from India describes anxieties that pregnant and postpartum women reported to obstetricians during the COVID-19 pandemic. Of the 118 obstetricians who responded to an online survey, most had been contacted for concerns about hospital visits (72.65%), methods of protection (60.17%), the safety of the infant (52.14%), anxieties related to social media messages (40.68%) and contracting the infection (39.83%). Obstetricians felt the need for resources such as videos, websites and counselling skills to handle COVID-related anxiety among perinatal women.

Reflections on the first conference of the International Marcé Society for Perinatal Mental Health convened in India, a middle-income country.

Since its establishment in 1980, all biennial conferences of The International Marcé Society for Perinatal Mental Health had been convened in high-income nations. Relatively little consideration had been given to the experiences and needs of most women who live in the world's low- and middle-income countries (LMICs). The aim is to provide an account of the first conference convened in India, a middle-income country. The Global Experiences, Global Dialogues, Global Responses Biennial Conference of the International Marcé Society for Perinatal Health was convened at the National Institute for Mental Health and Neurosciences (NIMHANS) held in Bengaluru 26th-28th September 2018. The conference achieved all its aims of maximizing access for people living and working in LMICs through scaled registration fees, building capacity through a young professionals' program, promoting collaboration through symposia co-convened by South Asian and other international experts, and visits to NIMHANS' clinical services. It made an impact on the agendas of sister expert professional societies, and public policies in India and generated significant public interest. It was appraised as pivotal, transformative and presenting exceptionally high-quality science. It was financially successful in making the largest contribution to date from a biennial conference to the Society's resources. We commend this initiative to other international expert professional societies seeking to benefit from the opportunities for mutual learning that conferences convened in low- and middle-income countries can provide, and to reduce disparities in access to evidence to address health inequalities.

The current status of gender-sensitive mental health services for women-findings from a global survey of experts.

Integrating gender in all aspects of health services is important and mental health is no exception. Despite several recommendations regarding the need for gender-sensitive mental health services, the actual availability of these is not clear, both in high and low-income countries. We sought to understand what aspects of gender-sensitive mental health care were considered a priority by global experts in women's mental health and how satisfied they were with the current availability of these services in their own place of work. A survey with 43 items under 7 domains of gender-sensitive mental health care for women was sent to 150 experts in women's mental health across the world, of whom 73 responded. Rating on each item was from 0 to 5. While majority of the experts rated most of the items as being very important (median score of 4 and above), some areas that were considered most important included training of mental health professionals in gender sensitivity, having private spaces for examination, using a life course approach to service planning and delivery, and assisting women who find it difficult to navigate the system and mother-baby units. However, satisfaction rates with available services were quite low overall and much lower among experts in low-income countries compared with those from high-income countries. Even in high-income countries, only 6 of the top 20 items were scored as satisfactory by at least 50% of experts. This expert survey method to arrive at consensus on top priorities for improving delivery of gender-sensitive mental health care indicates that at least 72% of the items provided in the survey were considered extremely important. Poor satisfaction of experts in both high- and low-income countries with availability of gender-sensitive services indicates the need for local and global strategic action and multilevel stakeholder engagement.

The prevalence and determinants of depression among HIV-positive perinatal women receiving antiretroviral therapy in India.

To assess the prevalence and correlates of perinatal depression, 200 HIV-positive pregnant/post-partum women receiving antiretroviral therapy (ART) were interviewed at eight government ART centers in four states across India. 52.5% (105) participants had depressive symptomology (Edinburgh Postnatal Depression Scale score > 13) while 23% of the participants reported thoughts of self-harm; there was no difference between pregnant and postpartum participants. Poor illness perception was associated with depression (AOR, 1.09; 95%CI, 1.05, 1.14); there was no association between adherence and depression in this population.

Denial of Pregnancy: Psychopathology and Clinical Management.

Denial of pregnancy (DOP) is a challenging condition with poorly understood psychopathology. DOP is reported to be associated with problems such as severe psychological conflicts, obstetric complications, risks to the newborn, and difficulties in bonding with the infant. In this paper, we present and discuss the clinical manifestations of a severe form of DOP that lasted until the time of delivery with resultant multifaceted complications. Our paper highlights the severity of psychopathology and the need for coordinated management. Descriptions from different cultural backgrounds would improve the conceptual understanding of DOP.

"End-of-Life Care is more than Wound Care": Health-Care Providers' Perceptions of Psychological and Interpersonal needs of Patients with Terminal Cancer.

AIM: People diagnosed with cancer and in end-of-life care may have a range of needs. These needs may be inadequately expressed, recognized, or responded to by family members and health-care providers. The present study aimed at exploring health-care providers' perceptions of the interpersonal needs, psychological needs, and unfinished business among terminally ill cancer patients during the end-of-life care. METHODS: The sample consisted of 11 health-care providers, including physicians, counselors, social workers, and nurses from the end-of-life care settings in Bengaluru, India. A cross-sectional qualitative design was used and involved semi-structured interviews and focus group discussions. RESULTS: Thematic analysis identified themes related to health-care providers' perceptions of patients' prominent interpersonal needs, psychological needs, and expressions of "unfinished business" and their perspectives and experiences. There were three themes related to psychological needs and concerns: (i) experience and expression of negative emotions, (ii) mental health concerns, and (iii) confronting mortality. Three themes emerged in the domain of interpersonal connections: (i) support and closer connections with family, (ii) disconnection from family relationships, and (iii) building new connections at the hospice. Two themes were identified related to unfinished business: (i) types of unfinished business and (ii) addressing unfinished business. The findings also highlighted health-care providers' perspectives and experiences: (i) need for expanded end-of-life care training and (ii) experiences of emotional labor. CONCLUSIONS: The findings have implications for comprehensive training of health-care providers and for assessment, support, and care services in palliative care settings in India.

A Qualitative Study to Assess Collusion and Psychological Distress in Cancer Patients.

INTRODUCTION: Collusion is frequently encountered but least studied entity in palliative care services in India. Impact of collusion is manifold and identifying it requires good communication skills. Once identified, it gives an indication for existing healthy versus developing unhealthy collusion to be dealt within families. OBJECTIVE: The objective of this study was to identify the prevalence of collusion and its clinical and psychological correlates among patients and caregivers in a palliative cancer care. MATERIALS AND METHODS: We describe systematic identification and unraveling of collusion across multiple levels in a palliative cancer care eventually drafting an algorithm to unravel the collusion. Patients and families were recruited from in-patient palliative care services after obtaining written informed consent. Qualitative interviews were conducted using collusion questionnaire, EQ5D, Visual Analog Scale, and NIMHANS psychiatric morbidity screen. RESULTS: Among 62 cancer families interviewed, we identified that 71% collusion exists between doctor and patient, 61.3% between doctor and caregiver, and 75.83% between patient and caregiver. Around 50% collusions were unraveled systematically. Collusion was more prevalent in patients with rapid progression of illness (<6 months), patients with poor coping skills, and preference of being interviewed alone. CONCLUSION: This statistics suggests that collusion goes unnoticed in terminal illnesses and communication skills play a major role in identifying and dealing with collusion. This also unearths need to formulate interview techniques and structured assessment tools or questionnaire in palliative cancer care which are sparse.