Feasibility and acceptability of a community health worker administered behavioral activation intervention for postpartum depression: a single arm pilot study from India.

Introduction: Women in India experience high rates of postpartum depression (PPD), with minimal availability of screening or treatment. India has an extensive network of community health workers, known as accredited social health activists (ASHAs). While they are knowledgeable about most maternal-child health problems, they have minimal knowledge about PPD. We trained ASHAs to deliver a simple home-based intervention, behavioral activation (BA), which involves individuals in activities that are sources of positive reinforcement to counter depression. The research questions guiding this study were as follows: 1) What are the feasibility and acceptability of ASHAs screening for and delivering a brief behavioral activation intervention addressing PPD among women in Belagavi, South India? 2) What impact did the brief behavioral activation intervention have on PPD? Methods: The mixed methods evaluation used interviews with participants and interventionists, and depression scores were assessed before and after the evaluation. After a 2-day training with 17 ASHAs that focused on understanding PPD, screening using the Edinburgh Postnatal Depression Scale (EPDS), and implementing the BA protocol, ASHAs and researcher supervisors screened the mothers 6-12 weeks postpartum presenting at pediatric immunization clinics. Mothers who screened positive were invited to participate in an ASHA-led 5-week BA intervention, with ASHAs visiting the mothers' homes. We assessed post-intervention EPDS scores and conducted satisfaction assessments and individual interviews. Results: All 26 women who screened positive on the EPDS agreed to be enrolled in the study. All participants had a significant reduction (p < 0.001) in PPD scores. Both ASHAs and mothers had high enthusiasm for the intervention methods and activities. Discussion: This ASHA-delivered BA intervention was found to be feasible, acceptable, and effective in treating PPD in rural Indian mothers. This corroborates literature that demonstrates the efficacy of a BA intervention among individuals with generalized depression in South Asia. In communities with minimal mental health resources, interventions led by trained community workers have the potential to address PPD.

Efficacy of tDCS on craving in patients of alcohol dependence syndrome: A single-blind, sham-controlled trial.

Background: Craving is attributed as one of the main reasons for relapse in alcohol dependence syndrome. Neurostimulation techniques targeting craving in substance use disorders are being researched. Neuroimaging has shown dorsolateral prefrontal cortex (DLPFC) as one of the potential targets responsible for craving, with frontal dysfunction being quintessential in alcohol use disorder. Evidence suggests that stimulation of DLPFC with low-dose current can help in reducing craving. Objectives: To study the effectiveness of transcranial direct current stimulation (tDCS) on craving in patients with alcohol dependence syndrome. Materials and Methods: We performed a single-blind, sham-controlled study involving 76 patients with alcohol dependence syndrome (according to ICD-10 DCR). Participants with Clinical Institute of Withdrawal Assessment in Alcohol Withdrawal (CIWA-Ar) scores less than 10, not on any anti-craving medications were included in the study. Patients were allocated to active and sham tDCS groups in a ratio of 1:1. Such that 38 patients received active, and 38 patients sham tDCS stimulations; with anode as right DLPFC and cathode as left DLPFC receiving 2 mA current (twice daily session, total of 10 sessions). The Alcohol Craving Questionnaire (ACQ-NOW) was administered to measure the severity of alcohol craving at baseline and after the last tDCS session. Results: Our study showed a significant reduction in craving in the Post-tDCS, ACQ-NOW scores as compared to sham tDCS. There was a significant reduction in the compulsivity and emotionality domain of craving after tDCS. The effect size for treatment with time interaction was (0.58). Conclusions: tDCS was superior to sham in reducing caving in patients with alcohol dependence syndrome.

Postpartum Depression in India: Perceptions by Key Stakeholders.

While postpartum depression (PPD) rates in India are among the highest in the world, screening and treatment is minimal. Socio-cultural issues including perceptions of stakeholders play role in this treatment gap. Efficient identification and treatment of women experiencing PPD has great importance for not only maternal, but infant outcomes. Infants born to mothers with PPD have a higher likelihood of lower birth weight, breastfeeding, maternal-infant bonding, and even cognitive delays throughout childhood. With the goal of improving maternal mental health outcomes, researchers conducted group and individual interviews with 26 stakeholders working with peripartum women in India to explore social perceptions of PPD. Analysis followed the social ecological model (SEM). Three themes were found: low awareness, minimal resources, and traditions and customs. Conclusion: Findings of this research can be used to develop interventions based on the three themes and their relation to the facets of the SEM framework.

Capacity to Consent for Treatment in Patients with Psychotic Disorder: A Cross-Sectional Study from North Karnataka.

Background: Recently, the Mental Healthcare Act (MHCA) 2017 was introduced in India. Being a right-based act, it has made the assessment of the capacity to consent an integral part of clinical work. To the best of our knowledge, there are no Indian studies on this topic. Hence, this study aimed to assess the capacity to consent to mental healthcare and treatment in patients with functional psychosis and the factors affecting the same. Methods: This cross-sectional study included participants with the ICD-10 DCR diagnosis of a psychotic disorder admitted in the psychiatry ward of a tertiary health care center in Karnataka, India. MacArthur Competence Assessment Tool for Treatment was used to assess the capacity to consent to treatment. Brief Psychiatric Rating Scale (BPRS) and the Beck Cognitive Insight Scale were applied to assess the severity of psychosis and level of insight, respectively. Results: A hundred participants were recruited. Twenty-four were found to have an intact capacity to consent to treatment. High BPRS scores (P value = 0.0002) and low insight scores (P value = 0.0002) were associated with an impaired capacity. Conclusion: About one-fourth of participants had an intact capacity to consent to treatment. Higher severity of psychosis and a poorer insight into the illness were associated with impaired capacity to consent.

Public-Private Partnership (PPP) Model of Psychiatry Day Care Center in India: Its Challenges and Opportunities-A 2-Year Experience.

Background Most patients admitted in day care center are suffering from schizophrenia who do not recover fully due to nagging negative symptoms and cognitive deficits which linger and persist making the patients unfit and unacceptable for employment. But regular employment can help in recovery. In this way, day care centers would help in recovery of patients and hence the need for these kinds of centers. In India, day care centers are in infancy stage and to a larger extent are inadequately used. There is no data available from psychiatry day care center run as public-private partnership (PPP) project in a tertiary care general hospital psychiatry unit (GHPU). This model is first of its kind in India. Here, we narrate experiences gained in last 2 years. Objectives This article narrates the challenges and opportunities in a psychiatry day care center in PPP model. Materials and Methodology It a cross-sectional study. Description of day care center: Day care center was started as PPP model called Manasadhara model in the state of Karnataka, first of its kind in India. Recruitment Patients currently asymptomatic are recruited into the center after initial interview/assessment of patients and family members from the in-charge psychiatrist after obtaining informed consent. Statistical Analysis Data are analyzed using mean and median mode. A p -value of < 0.05 was considered significant. Appropriate statistical methods were applied. Results Total number of patients recruited in the study were 33 ( n = 33). Mean age of the patients was 34.5 (7.4) years. Majority (51.52%) of patients were in the age group of between 26 and 35 years. Majority (51.52%) of patients' age of onset of illness fell between 21 and 30 years, and 63.64% of patients' duration of illness ranged between 11 and 15 years. Conclusion Running a day care center in PPP model that too in a GHPU set up is difficult. Skills in which patients need to be trained should be decided based on patients' profile and cultural basis of the place. Common problems faced were poor placements, transportation, financial difficulties, and poor funding.

Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital.

BACKGROUND: Prognosis and associated complications of chronic kidney disease (CKD) may result in psychological distress and mood disorders especially depression. Prevalence and clinical correlates of depression in CKD patients in the Indian context are not well studied and established. MATERIALS AND METHODS: This cross-sectional study included 84 CKD patients. The diagnosis was made based on the diagnostic and statistical manual, 4th edition criteria; psychiatric disorders were ruled out through the mini-neuropsychiatric interview. Montgomery-Asberg Depression Rating Scale was used to assess the severity of depression. Suicidal ideations were evaluated by using a modified scale of suicidal ideations. Data were analyzed using Epi Info 7 software. RESULTS: The prevalence of major depression was 44.05%, while the prevalence of depressive symptoms was 82.14%. Age of the patients (P = 0.0065), patients on dialysis (P < 0.0001), and serum creatinine levels >5 (P = 0.0180) showed a statistically significant association with depression. The prevalence of depression was significantly associated with dialysis (P < 0.0001). The severity of depression and the severity of suicidal ideations were well correlated with each other (P < 0.0001). CONCLUSION: The increased prevalence of depression and suicidal ideations was observed in CKD patients. We strongly recommend initiating screening of depression in CKD patients for appropriate rehabilitation and improved the quality of life.

How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India.

BACKGROUND: Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. AIMS: To determine the possible treatment options our clients make as a part of psychiatric advance directives. MATERIALS AND METHODS: Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. RESULTS: About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. CONCLUSION: The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Safe Administration of Electroconvulsive Therapy in Patient with Ventricular Septal Defect Patch: A Rare Case Report.

Electroconvulsive therapy (ECT) is a safe and effective treatment for many psychiatric illnesses. Even in cardiac patients, it is a low-risk procedure as compared to chronic use of the medications with possible side effects. Although rare, cardiovascular events during ECT remain a principal cause of morbidity and mortality. Therefore, administration of ECT in cardiac patients remained questionable. There is no data regarding the safety of ECT administration in patients with repaired ventricular septal defect (VSD), and to the best of our knowledge, this is the first case report of safe administration of ECT in patient with VSD. In this case report, we describe a patient with bipolar affective disorder, with repaired VSD, who was safely and successfully treated with ECT. It is essential that appropriate cardiac management be provided before, during, and after ECT by a multidisciplinary team of psychiatrists, cardiologists, and anesthesiologists. This case report suggests that ECT can be safely given to patients with repaired VSD, wherever there is an absolute indication for ECT.

A study of individuals with intentional self-harm referred to psychiatry in a tertiary care center.

BACKGROUND: Intentional self- harm (ISH) is one of the commonest yet neglected entities of Consultation liaison Psychiatry. More researches in the field of ISH are needed to effectively manage this problem. AIM: To study the socio-demographic and clinical profile of subjects of ISH referred to Psychiatry in a tertiary care hospital. MATERIALS AND METHODS: All subjects of ISH referred to department of Psychiatry, of a tertiary centre, on specified days were recruited in to the study after obtaining an informed consent. Socio-demographic details, details of psychiatric assessment were documented using a semi structured proforma. Appropriate management was done. RESULTS: Forty one subjects were included in the study. About two third of them belonged to the age group of 18 to 35 years. 56% of them were males, and 71% were married. House wives and students formed a significant proportion of sample. Most common method of ISH was self-poisoning. About two third of the patients had no diagnosable psychiatric illness. Interpersonal conflicts with family members (47%), conflicts with spouse (22%), broken emotional relationship (18%) were common causes for impulsive acts of ISH. CONCLUSIONS: ISH is common amongst young, married males. About two third of those who attempt ISH have no diagnosable psychiatric illness, in rest, neurotic stress related disorders, personality disorders and substance use disorders were predominant.

Welcome biological breakthroughs, supply psychosocial insights.

Human behaviour, emotions, and cognition are complex to understand and explain. It is even more difficult to understand the basis for abnormal behaviour, disturbed emotions, and impaired cognitions, something mental health professionals are trying for long. In these pursuits, psychiatry has traversed through eras of humours, witchcraft, spirits, psychoanalysis, and gradually deviated from other medical specialities. Now, with recent biological breakthroughs like advances in psychopharmacology, neuroimaging and genetics, increasingly more emphasis is being given to the biological model of psychiatric disorders. These new biological models have given a more scientific appearance to the speciality. It has also revolutionised the management strategies and outcome of many psychiatric disorders. However, this rapid development in biological understanding of psychiatry also leads to a new wave of reductionism. In an attempt to deduce everything in terms of neurons, neurochemicals, and genes, can we neglect psychosocial aspects of mental health? Patients' personality, expectations, motives, family background, sociocultural backgrounds continue to affect mental health no matter how much 'biological' psychiatry gets. Biological and psychosocial approaches are not mutually exclusive but complementary. Integrating them harmoniously is the skill psychiatry demands for comprehensive understanding of mental and behavioural disorders.

Iatrogenic dependence of anabolic-androgenic steroid in an Indian non-athletic woman.

Anabolic-androgenic steroids (AAS) are increasingly being used by athletes and youngsters to become masculine and to loose body fat. Long-term consumption of AAS causes multiple physical and psychological morbidities. Research has also concluded that AAS have addictive potential and AAS abuse is commonly found with other substance abuse. Abuse of AAS is rare in eastern countries. Abuse among women is even rarer. Here is a case report of an Indian woman, who was prescribed nandrolone decanoate injections by an unqualified medical practitioner to treat multiple non-specific somatic pains and reported weakness, leading to dependence for nandrolonedecanoate. This case report supports the research finding of abuse potential of AAS, raises concern about the need for spreading the awareness about AAS abuse among medical professionals, regulating medical practice by unqualified practitioners, and strict legal check against AAS availability in developing countries.