Youth Culturally adapted Manual Assisted Problem Solving Training (YCMAP) in Pakistani adolescent with a history of self-harm: protocol for multicentre clinical and cost-effectiveness randomised controlled trial.

INTRODUCTION: Suicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence's and are condemned on both religious and social grounds. The proposed intervention 'Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)' is based on principles of problem-solving and cognitive-behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective. METHOD AND ANALYSIS: A multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12-18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8-10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants' experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04131179.

Prevalence of depression and anxiety in patients with chronic obstructive pulmonary disease and their association with psychosocial outcomes: A cross-sectional study from Pakistan.

OBJECTIVES: Chronic obstructive pulmonary disease contributes to substantial health and economic burden worldwide. Co-morbid depression and anxiety are highly prevalent in patients with chronic obstructive pulmonary disease. Depressive symptoms in chronic obstructive pulmonary disease are associated with poorer survival, longer hospitalisation and impaired quality of life. Literature on chronic obstructive pulmonary disease is largely derived from high-income countries; yet 90% of deaths related to chronic obstructive pulmonary disease occur in low- and middle-income countries. We aimed to establish the prevalence of anxiety and depression in patients with chronic obstructive pulmonary disease, as well as the association with psychosocial outcomes. METHODS: This was a cross-sectional study of chronic obstructive pulmonary disease patients attending outpatient primary care clinics in Karachi, Pakistan. The Patient Health Questionnaire-9 was used to assess depression and the Generalised Anxiety Disorder-7 scale was used for the assessment of anxiety. Health-related quality of life was assessed with EuroQol-Five Dimensions, social support with Oslo-3 and social stress with Life Events Checklist. We recruited 293 subjects. RESULTS: The prevalence of depression and anxiety in the sample was 51% (n = 149) and 20% (n = 59), respectively. Depressed chronic obstructive pulmonary disease patients reported significantly lower health-related quality of life scores as compared to non-depressed patients. Participants with depression had significantly higher levels of anxiety, less social support, higher social stress and more subjective impairment in quality of life. CONCLUSION: Given the association with reduced social support and increased perceived stress, the role of psychosocial interventions must be explored in improving outcomes of chronic obstructive pulmonary disease patients in Pakistan.

An integrated parenting intervention for maternal depression and child development in a low-resource setting: Cluster randomized controlled trial.

BACKGROUND: Rates of depression among Pakistani mothers are high, leading to poor developmental outcomes in their children. This study tested the effectiveness of a manualized integrated parenting program; Learning through Play Plus (LTP+) for maternal depression in Karachi, Pakistan. METHODS: A cluster randomized control trial conducted from January 2014 to December 2015 across 120 villages in Karachi. A total of 774 depressed mothers aged 18-44 years with children aged 0-30 months old, were included. Villages were randomized to receive LTP+ added to treatment as usual (TAU) or TAU alone. Primary outcomes were severity of maternal depression at 3 and 6 months measured by the Edinburgh Postnatal Depression Scale and child socio-emotional development at 6 months measured by the Ages and Stages Questionnaire (ASQ). Secondary outcomes included maternal anxiety, quality of life, social support, parenting competence, and knowledge about child development. RESULTS: Mothers in the LTP+ group reported significantly lower depression scores compared to those in the TAU group (6.6 vs. 13.8, effect size [ES]: -7.2; 95% confidence interval [CI]: -8.2, -6.1) at 3 and 6 months (7.2 vs. 12.00; ES: -4.6; 95% CI: -5.9, -3.4). Child socio-emotional development at 6 months was significantly better in the LTP+ group on all domains of the ASQ. There were also statistically significant improvements on all secondary outcomes at 3- and 6-month follow-up. CONCLUSION: In low-resource settings like Pakistan, low-cost integrated parenting interventions delivered by lay health workers can provide effective treatment for depressed mothers, leading to improvements in child development.

Treatment of maternal depression in urban slums of Karachi, Pakistan: A randomized controlled trial (RCT) of an integrated maternal psychological and early child development intervention.

BACKGROUND: Maternal depression is a major public health problem. This may affect a mother's ability to provide adequate care for the child. The objective of this study was to evaluate the effectiveness of the Learning through Play Plus program (LTP Plus) - a parenting program integrated with Cognitive Behaviour Therapy (CBT). METHODS: A total of 247 women with symptoms of depression in Karachi, Pakistan were assigned randomly to either LTP Plus or routine care (Clinical Trials Identifier: NCT00835016). Symptoms of maternal depression were measured using the Edinburgh Postnatal Depression Scale (EPDS) at 3 and 6 months after baseline. RESULTS: At 3 months, there was a significant reduction in the EPDS scores in the intervention group compared to the routine group (adjusted mean difference [AMD] -3.65, 95% CI -6.14 to -1.15, p <0.004). This effect was sustained at 6 months (AMD -2.62, 95% CI -4.43 to -0.81, p<0.005). These women also reported less parental distress and disability. There was also a significant improvement in maternal knowledge about child development at 6 months. CONCLUSION: There was a significant reduction in depression among women who received the group parenting program LTP Plus. This intervention has the potential to be scaled up and integrated with mother and child health programs.

Antenatal Depression is Not Associated with Low-Birth Weight: A Study from Urban Pakistan.

BACKGROUND: Low-birth weight (LBW) (<2500 g) is considered to be a leading cause of cognitive impairment and physical disabilities in children. Incidence of LBW in South Asia has been reported to be as high as 33%. We investigated the association between antenatal depression and LBW in an urban community, in Karachi, Pakistan. METHODS: A total of 1357 pregnant women in their third trimester were recruited into the study. They were screened for antenatal depression with Edinburgh postnatal depression scale. Self-reporting questionnaire was also used to measure psychological distress. Birth weights of 763 newborns were obtained from the hospital records. RESULTS: We did not find a significant association between antenatal depression and LBW (odds ratio 0.881, 95%CI 0.732-1.060) in mothers attending a charity run hospital in an urban setting in Pakistan. CONCLUSION: Antenatal depression is not associated with LBW in this urban population in Pakistan. However, the prevalence of depression is high during pregnancy. There is a need to develop culturally adapted psychosocial interventions to address the high rates of depression for this population group.

Antidepressant and group psychosocial treatment for depression: a rater blind exploratory RCT from a low income country.

BACKGROUND: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. AIM: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. METHOD: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. RESULTS: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. CONCLUSION: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

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.

Detecting maternal depression in a low-income country: comparison of the self-reporting questionnaire and the edinburgh postnatal depression scale.

OBJECTIVE: To validate the Self-Reporting Questionnaire (SRQ-20) and the Edinburgh Postnatal Depression Scale (EPDS) against the Clinical Interview Schedule-Revised (CIS-R). DESIGN: Two-phase design. SUBJECTS AND METHODS: 664 mothers were approached, 601 of them completed the EPDS and SRQ questionnaires. The CIS-R was administered to confirm the diagnosis for depression. The diagnostic accuracy was compared using the receiver operating characteristic analysis. RESULTS: At the threshold of 11, the SRQ had better sensitivity, negative predictive values and positive predictive values compared with the EPDS optimal threshold of 14. CONCLUSION: Both measures (EPDS and SRQ) have adequate validity to screen for depression in mothers in Pakistan. However, the SRQ performed better, with participants finding it easy to understand. The scales can be of great value to detect maternal depression in primary care and pediatric settings in low-income countries.

Characteristics and outcome of dengue infection; clinical perspective from a secondary care hospital of Karachi.

OBJECTIVE: To determine the frequency and characteristics of dengue fever (DF) in patients of acute febrile illness presenting at a secondary care hospital. METHODOLOGY: The observational cross sectional study was carried out from May to October 2010 in Remedial Centre Karachi and included patients above the age of 12 years who presented with acute febrile illness. The WHO classification and case definitions were used to classify the disease as Dengue Fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Clinical, hematological and biochemical findings were recorded serially until discharge. RESULTS: During the study period, 90 (34.75%) presented with typical features of DF, 28 (31.11%) were dengue proven, seven (7.7%) proved to be of malaria in which malarial parasites were found positive in the peripheral blood, while the remaining 55 (61.11%) patients were dengue probable. Age of the patients ranged from 13 to 76 years. Fever was the most common clinical presentation (100%) followed by vomiting 50 (55.56%), body ache 31 (34.44%) abdominal pain 17 (18.89%) and headache 9 (10%). Maculopapular rash was seen in 4(4.44%) patients. Laboratory findings included thrombocytopenia, leucopenia and raised alanine aminotransferase levels. Eighty one patients (90%) improved clinically and hematologically and were discharged in stable condition. CONCLUSION: Fever and thrombocytopenia were the most common presentation of dengue fever (DF). The overall mortality of DF is low, if treated appropriately. Awareness of health care professionals and public regarding preventive strategies is essential to fight against this disease.

Prevalence and psychosocial correlates of perinatal depression: a cohort study from urban Pakistan.

Depression around childbirth is common in low income countries. The aim of this study was to examine the factors associated with persistence of depression from the antenatal to the postnatal period in urban Pakistan. A total of 1,357 pregnant women in their third trimester attending the antenatal clinic were included in the study. From these, 763 mothers who delivered at the study maternity home were reassessed after 3 months of childbirth. Edinburgh Postnatal Depression Scale (EPDS) was administered to measure depression in both the antenatal and the postnatal periods. Psychological distress, disability and life events experienced by mothers were also measured by using the Self-Reporting Questionnaire (SRQ-20), Brief Disability Questionnaire (BDQ), and Life Events Checklist, respectively. We found 25.8% prevalence rate of antenatal depression and 38.3% persistent depression in a private clinic. Persistently depressed mothers had significantly high psychological distress, more disability, and experienced more stressful life events than the resolved group. Our findings confirm the high rates of depression during pregnancy but we found low rates of persistent depression in this urban population as compared to the previous report. There is a need for further investigation of factors associated with persistent depression in order to develop appropriate interventions.