Incorporating early pregnancy mental health screening and management into routine maternal care: experience from the Rajarata Pregnancy Cohort (RaPCo), Sri Lanka.

Early identification of mental health problems in pregnancy in low-income and middle-income countries is scarcely reported. We present the experience of a programme assimilating screening and management of antenatal anxiety and depression in conjunction with the Rajarata Pregnancy Cohort, in Sri Lanka. We adopted a two-stage screening approach to identify the symptoms and the reasons for anxiety and depression. Pregnant women (n=3074), less than 13 weeks of period of gestation underwent screening with the Edinburgh Postnatal Depression Scale (EPDS). Scores were positive among 23% and 14% of women in the first and second trimesters, respectively. Clinical (telephone) interviews (n=78, response 56.9%) were held for women having high EPDS scores to screen for clinical depression using the 'mental health GAP' tool. Targeted interventions including counselling, financial and social support and health education were employed. The procedure was repeated in the second trimester with in-person clinical interviews and inquiry into intentional self-harm. Our findings indicated that (1) the majority of mental health problems in early pregnancy were anxiety related to early pregnancy-associated conditions manageable at the primary healthcare level, (2) coupling mental health screening using psychometric tools with clinical interviews facilitates targeted patient-centred care, (3) the majority of intentional self-harm during pregnancy is not in the routine health surveillance system and (4) promoting women to attend the psychiatry clinic in tertiary care hospital has been difficult. Following the experience, we propose a model for mental health service provision in routine pregnancy care programme starting from early pregnancy.

Subclinical memory impairment in unaffected siblings of patients with dementia.

Objective: Family history of dementia is a known risk factor for dementia. The cognitive performance of unaffected siblings of dementia patients has been poorly studied. We aimed to determine whether clinically unaffected siblings of dementia patients have significant cognitive impairment compared to individuals who do not have first-degree relatives with dementia. Methods: We compared the cognitive performance of 67 patients with dementia (24 males; mean age 69.5), 90 healthy siblings of those patients (34 males; mean age 61.56) and 92 healthy adults (35 males; mean age 60.96) who have no first-degree relatives with dementia. We assessed learning and memory (Rey Auditory Verbal Learning Test (RAVLT)), short-term/working memory (Digit Span) executive functions (Stroop Test) and general intelligence (Raven Progressive Matrices). Test scores were compared among three groups, with regression-based adjustments for age, sex, and education. Results: As expected, the patients with dementia were impaired in all cognitive domains. In the Sibling Group, RAVLT total learning was significantly lower compared to controls (B = -3.192, p = .005). In a subgroup analysis, compared to controls, RAVLT delayed recall was poorer in the siblings of patients with early-onset (<65 years) dementia. No significant differences were observed in other cognitive domains. Conclusion: Clinically unaffected siblings of dementia patients seem to have a selective subclinical impairment in memory encoding. This impairment seems to be more prominent in siblings of patients with early-onset dementia who also have deficits in delayed recall. Future studies are needed to determine if the observed cognitive impairment deteriorates to dementia.

Perceived Impact of the COVID-19 Pandemic on Psychiatric Training Among Final-Year Medical Undergraduates in Sri Lanka: an Online Survey of Students from Eight Universities.

OBJECTIVE: This study aimed to assess the perceived impact of the COVID-19 pandemic on undergraduate psychiatry training in Sri Lanka and to explore several potentially associated factors. METHODS: An online survey was distributed among students from eight medical schools who recently faced their final exam. Their perceptions on the impact of the pandemic on the psychiatry training and exam performance were rated on a 10-point scale. Resilience was assessed using a two-item scale. RESULTS: A total of 644 students responded (69.5% female, mean age=27.5 years). Among them, 164 (25.5%) reported being quarantined; 25 (4%) reported becoming infected with COVID-19; and 170 (28.6%) reported ward closure for over a week during the clerkship. Greater impact was reported for patient availability (mean=7.08), mental status assessments (mean=6.3), developing rapport (mean=6.2), and diagnostic skills (mean=5.9), whereas the impact on peer-learning (mean=5.5) and self-study (mean=3.6) was relatively lower. Impact on clinical components of the final exam (mean=6) was rated higher than on theory components (mean=4.5). The majority (70.3%) reported that COVID-19-related stress affected their exam preparations. Higher resilience predicted lower perceived impact on all aspects of training/exam performance. Female gender and ward closure predicted greater impact on diagnostic skills, overall training, and clinical exam performance, whereas being quarantined predicted greater impact on peer-learning and self-study. CONCLUSION: The pandemic has significantly affected the undergraduate psychiatry training in Sri Lanka, particularly its clinical components. Increasing clinical exposure to patients, managing students' stress, and building their resilience should be key concerns for medical educators during the pandemic.

Psychological wellbeing and mental health amongst medical undergraduates: A descriptive study assessing more than 1,000 medical students in Sri Lanka.

BACKGROUND: Studies from around the world have shown higher rates of anxiety, depression, alcohol and other drug use, and burnout in medical students. AIMS: The aim of this study was to identify the socio-demographic factors and severity of difficulties Sri Lankan medical students face regarding psychological wellbeing and burnout. METHOD: This one-off survey used a cross-sectional design, assessing substance use, psychological wellbeing, and burnout using the CAGE, GHQ-12, and OLBI. The survey was open to all medical students in six universities in Sri Lanka. Chi-square analysis was used to assess the statistical significance related to categorical dependent variables and one-way ANOVA for continuous dependent variables. RESULTS: A higher prevalence of diagnosed mental health conditions was found following admission to the medical course in comparison prior to admission. Sixty-two percent of students had a score of more than 2 on the GHQ-12 indicating caseness. The OLBI identified exhaustion in 79% of students. The CAGE questionnaire was positive in 4.8% of students. CONCLUSIONS: Only a small proportion of students are recognizing their mental health difficulties and seeking help. Further understanding is required as to why this is, as well as re-evaluation of the demands of the curriculum. Effective ways of regularly identifying and providing practical and evidence-based support for mental health problems in medical and other undergraduates need to be identified and introduced.

General hospital specialists' attitudes toward psychiatry: a cross-sectional survey in seven countries.

OBJECTIVE: Psychiatric comorbidities are common in physical illness and significantly affect health outcomes. Attitudes of general hospital doctors toward psychiatry are important as they influence referral patterns and quality of care. Little is known about these attitudes and their cultural correlates. The aim of this study was to identify attitudes toward psychiatry among general hospital specialists in relation to culture of the practice setting and other clinician factors (gender, age, seniority and specialty). METHODS: A cross-sectional, descriptive study was carried out in seven countries (New Zealand, China, Sri Lanka, Russia, Israel, Brazil, the Netherlands). Data were collected from senior medical staff of various disciplines using an updated version of Mayou and Smith's (1986) self-administered questionnaire. RESULTS: A total of 889 hospital doctors participated. While favourable attitudes toward both psychiatric consultation and management were endorsed by a majority, significant differences were also observed between countries. Subgroup differences were mostly confined to gender, acuity of practice setting and specialty. For example, female doctors in Russia (χ2=7.7, p=0.0056), China (χ2=9.2, p=0.0025) and the Netherlands (χ2=5.7, p=0.0174) endorsed more positive attitudes compared with their male counterparts, but this gender effect was not replicated in the total sample. Chronic care specialists were overall more inclined to manage patients' emotional problems compared with those working in acute care (χ2=70.8, p (adjusted)<0.0001), a significant finding seen also in individual countries (China, New Zealand, the Netherlands, Russia). Physicians were more favourably disposed toward psychiatry compared with other specialists, especially surgeons, in all countries except Israel. CONCLUSIONS: This study adds to evidence for the association of medical attitudes with individual clinician factors and demonstrates that the influence of these factors varies by country. Understanding these issues may help to overcome barriers and improve quality of care provided to general hospital patients.

The Rajarata Pregnancy Cohort (RaPCo): study protocol.

BACKGROUND: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. METHODS: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. DISCUSSION: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

A significant association between examination results and self-satisfaction with English language proficiency: preliminary findings among pre-clinical undergraduates.

OBJECTIVES: Learning methods and other related factors influence the success of medical undergraduates. This study aims at finding factors associated with the end of pre-clinical stream examination results among medical undergraduates of the Rajarata University of Sri Lanka. The results of this study will inform the tutors to plan and implement teaching methods as well as to guide the social welfare of the undergraduates. In general, we believe this study has the potential to improve the medical undergraduate's academic performance. RESULTS: Eighty-six per cent (112/130) of medical undergraduates have passed the examination and rest was referred. Logistic regression revealed a significant association between examination results and self-satisfaction for English language proficiency (P = 0.048). Passing the examination was more likely with high self-satisfaction for English language proficiency [odds ratio = 6.063 (95% CI 1.014 to 36.249)]. Also, a significant association between obtaining a class at the examination and using peer-revision notes (P = 0.019) was revealed. Obtaining a class at the examination was less likely with the frequent use of peer-revision notes [odds ratio = 0.228 (95% CI 0.066 to 0.790)].

Pro-inflammatory cytokines IL-1ß and TNF-α are not associated with plasma homocysteine concentration in Alzheimer's disease.

Increased concentrations of pro-inflammatory blood cytokines and plasma homocysteine (Hcy) are frequently reported in Alzheimer's disease (AD). Hcy appears to have immunomodulating and pro-inflammatory activities. Further, emerging evidence from animal and non-AD human studies implicates Hcy in potentiating the activities of proinflammatory cytokines; Hcy toxicity may also, in part, be mediated by these cytokines. As little is known about the potential relationship between these inflammatory markers specific to AD, the aim of this study was to assess potential impact of Hcy on the widely reported increases in cytokine concentrations in AD. Blood concentrations of two proinflammatory cytokines, IL-1ß and TNF-α, along with Hcy were assessed in 40 AD patients and 30 cognitively intact controls. Mean blood concentrations of IL-1ß and TNF-α differed significantly between the AD and control groups (p=0.001 and p<0.001 resp). This difference survived adjustment for age and gender on logistic regression. Hcy was significantly correlated with age only in the patient (r(s)=0.38, p=0.02) but not the control group. There was no significant correlation between IL-1ß and Hcy, and between TNF-α, and Hcy in either the AD or the control group. Hence, our AD data did not replicate results obtained from animal and non-AD human studies which have linked pro-inflammatory cytokines concentrations to Hcy. A different inflammatory focus may exist in AD which may be influenced at least in a significant part by non-vascular pathogenesis. However, these results indirectly support the notion that the observed mild hyperhocysteinemia in AD may be due to non-inflammatory factors.