Mental Health of Mothers with Malnourished Children in Nepal: A Prospective Observational Study.

BACKGROUND: Maternal mental health may influence the nutritional status of their children. It was intended to assess the mental health status of the mothers of children admitted to a nutrition rehabilitation center. We specifically explored the relationship between maternal mental health and malnutrition of the child; to observe any change of maternal depressive/anxiety symptoms and weight gain in the child following admission. METHODS: In a prospective observational study, malnutrition of children was assessed based on weight for height z scores using the WHO Anthro-Survey-Analyser. We evaluated anxiety using the Generalized Anxiety Disorder Scale (GAD-7) and depression by Patient Health Questionnaire (PHQ-9). Demographic and clinical variables were collected. RESULTS: The degree of malnutrition of the children at admission and discharge was: mild (3.6% v 31.7%), moderate (37.7% v 26.3%), severe (58.7% v 8.4%), and no malnutrition (0.0% v 33.5%) (p<0.001). At admission, 12% of mothers had anxiety, depression, or both, which decreased to 3.0% at the time of discharge. There was no difference in malnutrition scores among children of mothers with or without anxiety/depression at admission or discharge, except that children of depressed mothers continued to have significantly greater levels of malnutrition at discharge compared with the mothers without depression. Maternal anxiety or depression was not associated with the severity of malnutrition. CONCLUSIONS: A proportion of mothers of children with malnutrition had clinical anxiety and depression; and maternal mental health concerns, especially depression may influence the nutrition of children. It is imperative to explore maternal mental health routinely for malnourished children.

Antipsychotic Use: Cross-Sectional Opinion Survey of Psychiatrists in India and United Kingdom.

The aim of this survey of psychiatrists from the UK and India was to compare their opinions on antipsychotic medication choice and their experiences of such medications' effectiveness and tolerability in patients who were newly diagnosed with acute schizophrenia. Following ethical approval, a cross-sectional online survey of psychiatrists from the UK and India was conducted. Ninety-five responses were received from each country. The most selected first-line APDs in both countries were olanzapine (47.5%), risperidone (42.8%) and aripiprazole (25.3%). A total of 60% of psychiatrists from India (60%) and 48% from the UK (48%) selected 'medication efficacy' as the main factor in their choice. Reassessment and consideration to switch most often took place within 4-6 weeks (53.7%) and 3-6 months (11.6%). The major reasons for switching antipsychotic medications were poor clinical efficacy (69%) and lack of tolerability (45%). Nonadherence was the most common reason for relapse (90% of UK psychiatrists and 70% of Indian psychiatrists), followed by illicit drug use (27.6%). The most commonly reported side effects that led to nonadherence were weight gain (10.8%), drowsiness (10.4%), erectile dysfunction and movement disorders (equally 8.7%). It was concluded that olanzapine, risperidone and aripiprazole are the most commonly selected as the initial treatment choice by psychiatrists from India and the UK. They are perceived as widely effective and well tolerated.

Impact of hyperthyroidism and its treatment on the outcome of mental health, occupational functioning, and quality of life: A naturalistic, prospective study.

Context Background: Hyperthyroidism has a major impact on mental health. Aims: We intended to determine the magnitude of the unmet need for mental health support in patients with hyperthyroidism attending an endocrinology clinic. Settings and Design: General Hospital Endocrine Department, Prospective Study. Methods and Material: In a naturalistic, prospective study, consecutive (n = 176) hyperthyroid patients were assessed for anxiety (generalized anxiety disorder, GAD-7), depression (Patient Health Questionnaire PHQ-9), functional impairment (work and social adjustment scale, WSAS), and quality of life (EuroQol ED5D) using standardized instruments. Statistical Analysis Used: Percentages, mean and standard deviation (SD), Chi-square, Student's t-test, ANOVA, Spearman's correlation. Results: A considerable proportion (40.5%) of patients had moderate and severe anxiety, around half (50.6%) had moderate or severe depression, and 20.8% had severe functional impairment at presentation. Mean EQ5D score was 59.6 ± 23.5. The scores of anxiety, depression, and functional impairment were significantly correlated with each other and negatively correlated with QOL. Following treatment of hyperthyroidism, improvement in psychiatric symptoms was noted which could be correlated with the lowering of T4. However, a significant proportion of patients continued to have psychiatric symptoms and functional impairment despite achieving euthyroidism. There was no correlation between the severity of hyperthyroidism to persistence of mental health parameters. Conclusions: Our findings of high prevalence and persistence of impairment of mental health and functional status of patients with hyperthyroidism have highlighted the unmet needs for these patients.

Post-traumatic stress and depression following a landslide linked to the 2018 floods in Kerala, India: Relevance of screening.

There is scant information on early manifestation of trauma due to catastrophic natural events and its relation with stress-related disorders. The specific objective of this study was to estimate and compare the prevalence of post-traumatic stress and depression on day 3 (D3) and week 6 (W6) following the 2018 flood in Kerala, India. In a cross-sectional study, symptoms of post-traumatic stress and depression were studied at D3 using primary care Post-Traumatic Stress Disorder screen for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PC-PTSD-5), and then at W6 using PC-PTSD-5, Screening Questionnaire for Disaster Mental Health, PTSD Checklist for DSM-5 (PCL-5), and Becks Depression Inventory. Majority (70 percent) were screen positive at D3 (n = 20) compared with 30 percent at W6 (n = 50), with a decreased frequency of all symptoms. Being PC-PTSD-5 screen positive at W6 was significantly associated with the presence of threat to life, physical injury, and death of relatives or neighbors. According to PCL-5, at W6, 46 percent had possible PTSD. Except damage to property, other disaster related or sociodemographic variables were not associated with the risk of having PTSD. Positive predictive value of PC-PTSD-5 (D3) for PTSD (PCL-5) at W6 was 64.3 percent. Depression and possibility of PTSD were significantly associated. A considerable proportion of victims continued to have post-traumatic stress and depression although the -frequency decreased over time. A simple screening measure may help to identify victims with possible PTSD.

Timing of Exposure to ICU Diaries and Its Impact on Mental Health, Memories, and Quality of Life: A Double-Blind Randomized Control Trial.

Optimal time for ICU diary delivery and impact on mental health (MH), anxiety-depression, post-traumatic stress symptoms (PTSS), quality of life (QOL), and memories is unclear. We evaluated the effect of ICU diaries, dispatched at different time points, on outcomes in an Indian cohort. DESIGN: Double-blind randomized controlled trial. SETTING: A 1,000-bedded teaching hospital in East India. PATIENTS: Mechanically ventilated (>24 hr) adults were recruited, excluding those dead or incapable of meaningful-communication at discharge or follow-up. Eighty-three patients, aged 46.2 ± 17.2 years, Acute Physiology and Chronic Health Evaluation II scores 13.7 ± 4.9 were assessed. Length of ICU stay was 8.2 ± 7.1 days with 3.7 ± 3.2 ventilator days. INTERVENTION: Of 820 screened, 164 had diaries created. Including photographs, diaries were comaintained by healthcare workers and family members. Ninety patients were randomized at 1-month follow-up: diary sent to 45 at 1 month (group ID1) and to 45 at 3 months (ID3). MEASUREMENTS AND MAIN RESULTS: Anxiety-depression, memory, and QOL were assessed telephonically or home visits by a psychologist using the Hospital Anxiety-Depression Scale (HADS) and other tools at ICU discharge, 1-month (prerandomization), and 3 months of discharge. ID3 was reassessed after receiving diaries at 3.5 months. Primary outcome was anxiety-depression; secondary outcomes included PTSS, QOL, and memories. There was 100% follow-up. At 3 months, ID1 patients had a significant (p < 0.001) reduction in HADS from baseline when compared with ID3 that had not received diaries (4.16 ± 2.9 vs 2.15 ± 1.8; 95% CI, 2.8-1.2). PTSS scores were likewise better (p < 0.001). ID3 patients demonstrated significant improvement (p < 0.01) in QOL and memories along with HADS and PTSS when assessed at 3.5 months. CONCLUSIONS: ICU diaries improve MH but not QOL when delivered at 1 month and assessed 2 months thereafter. Assessed after 15 days, delayed exposure at 3 months significantly improved QOL and memories in addition to MH.

A follow-up study on treatment effects of cognitive-behavioral therapy on social anxiety disorder: Impact of COVID-19 fear during post-lockdown period.

There is a paucity of research on the role of COVID-19 related fear and lockdown on social anxiety disorder (SAD). In a follow-up study during post-lockdown period, we compared social anxiety of individuals with SAD who received cognitive-behavioral therapy (CBT) versus psychoeducational-supportive therapy (PST) before the COVID-19 pandemic, and the impact of COVID-19 related fear. Social anxiety severity was rated by the Social Phobia Inventory (SPIN) at pre-intervention, post-intervention, and post-lockdown periods. Fear of COVID-19 was assessed during the post-lockdown period. The treatment effects in the CBT group (n = 33) were significantly better than the PST group (n = 32) at post-intervention; this was maintained at 14-months following intervention despite COVID-related lockdown. In the PST group, there was no change following the intervention; and the social phobia increased after lockdown. The CBT group had significantly less COVID-19 related fear than the PST group. Social anxiety was positively correlated with fear of COVID-19; and individuals with comorbidities had significantly more fear. Using the hierarchical multiple regression, SPIN post-intervention, COVID-19 fear, and duration of SAD predicted social anxiety severity during the post-lockdown period. In conclusion, the effect of CBT for SAD was maintained through lockdown and was associated with significantly less COVID-19 related fear.

Anxiety, Depression, and Post-traumatic Stress a month after 2019 Cyclone Fani in Odisha, India.

BACKGROUND: Early Identification of disaster victims with mental health problems may be useful, but information within a short period after a disaster is scarce in developing countries. This study examined anxiety, depression, and post-traumatic stress symptoms at 1 month following 2019 Cyclone Fani in Odisha, India. METHOD: Post-traumatic stress symptoms (PTSS) were assessed by the Primary care PTSD screen for DSM 5 (PC-PTSD-5), anxiety symptoms by the Generalised Anxiety Disorder (GAD-7), and depression by the Patient Health Questionnaire (PHQ-9). The survey included participants' disaster experience e.g., evacuation, fear of death, injury, death in family, damage to house, difficulty for food, displacement, and effect on livelihood. RESULTS: Proportion of sample (n = 80) with probable PTSD was 42.9%, with severe anxiety was 36.7%, moderately severe depression was 16.5%, and severe depression was 3.8%. Suicidal cognitions were reported to increase by 14%. Comorbidity was common; with significant (P < 0.01) correlation between PTSS and anxiety (r = 0.69), depression (r = 0.596), and between anxiety and depression (r = 0.63). Damage of house and displacement were associated significantly with PTSD; evacuation and displacement with moderate and severe depression; and displacement with severe anxiety. No specific demographic factors were significantly linked to the psychiatric morbidities. CONCLUSION: A considerable proportion of victims had psychiatric morbidities at 1 month. Associated risk factors included housing damages, evacuation, and displacement, suggesting the need to improve the disaster-management process.

Matching the Symptom Profile of Adolescent Disaster Survivors with Changing Diagnostic Criteria of Posttraumatic Stress Disorder: Focus on ICD-11.

BACKGROUND: Considering recent changes in the diagnostic guidelines for posttraumatic stress disorder (PTSD), it has become imperative to review their influence, especially on the symptoms related to children and adolescent victims of disasters. We intended to assess the profile of posttraumatic stress symptoms (PTSS) of adolescents following an earthquake, especially the gender differences, in relation to the changing diagnostic guidelines, particularly ICD-11. METHODS: In a cross-sectional study, PTSS and functional impairments were evaluated in school-going adolescents in Nepal, one year after the 2015 earthquake, using the Child Posttraumatic Stress Scale (CPSS). RESULTS: A considerable proportion of adolescent survivors of the earthquake had PTSS. Most common ones were intrusive thoughts (46.7%), avoiding thoughts, conversations and feelings about the disaster (44.2%), decreased interest in activities (40.0%), distress with reminders (35.6%), and concentration problems (35.6%). Females had a higher prevalence for all the PTSS compared with males, except for avoiding thought, conversations, feelings, and being overly careful/vigilant. Proportion of adolescents who met symptomatic criteria for PTSD diagnosis in different systems ranged from 14.7% in DSM-5 to 15.6% in ICD-11 three-factor model, and 22.2% in DSM-IV and 31.7% in ICD-10. Inclusion of the criterion of significant functional impairment changed the proportions to 10.0%, 10.3%, 12.8%, and 16.4%, respectively. In all of the diagnostic systems, higher proportions of females had possible PTSD. CONCLUSION: Adolescent females had a higher prevalence for most of the PTSS and at the diagnostic level. It appears that for adolescents, diagnosis of PTSD in ICD-11 has become more robust with a focus on core symptoms and having a functional impairment criterion.

ICU Memories and Patient Outcomes in a Low Middle-Income Country: A Longitudinal Cohort Study.

OBJECTIVES: To study memories of ICU following discharge, their associations, and impact on mental health and quality of life in a low- and middle-income country. DESIGN: Prospective observational cohort; data on memories (pain, fear, nightmare, factual), clinical and demographic variables, anxiety-depression, posttraumatic stress symptoms, and quality of life were collected 0, 7, 14, 30, 90, and 180 days post discharge. Home visits for assessment minimized loss to follow-up. Linear mixed-models and regression analyses were used to estimate adjusted effects of memories controlling for age, sex, time, and severity of illness. SETTING: Twenty-five bedded ICU of a tertiary care center in East India. PATIENTS: Adult ICU survivors between January 2017 and July 2018 able to communicate their memories. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Final sample consisted of 322 patients who completed 180 days follow-up. Pain, fear, factual, and nightmare memories dropped from 85%, 56%, 55%, and 45% at discharge to less than or equal to 5% at 180 days. Patients with gaps in ICU memory had worse anxiety-depression, posttraumatic stress symptoms, and quality of life at all follow-up points. Sedation (odds ratio, 0.54; CI, 0.4-0.7), steroids (odds ratio, 0.47; CI, 0.3-0.8), benzodiazepines (odds ratio, 1.74; CI, 1-3.04), and mechanical ventilation (odds ratio, 0.43; CI, 0.2-0.8) were independently associated with gaps in memory. Non-ICU factor such as substance addiction (odds ratio, 5.38; CI, 2-14) was associated with memories affecting mental health and quality of life. CONCLUSIONS: Gaps in memory and various memory types were common after ICU admission, whose prevalence waned over time. Compared with nightmares and fearful memories, gaps in memories were most strongly associated with poor mental health and quality of life. Identifying patients with gaps in memories might be an objective way of planning interventions to improve their long-term outcomes.

Stress and coping during COVID-19 pandemic: Result of an online survey.

We intended to assess stress, anxiety, depression and coping strategies during COVID-19 pandemic. Through an online survey, we used primary care posttraumatic stress disorder (PTSD) screen for DSM 5 (PC-PTSD-5), Generalised Anxiety Disorder (GAD)-7 and Patient Health Questionnaire (PHQ)-9, along with coping methods. Of the respondents (n=733), a considerable proportion had moderate to severe anxiety (21.2%) and depression (15%). Stress symptoms, above the cut-off point of 3 in PC-PTSD-5 suggestive of probable PTSD, were present in 34.1%. Mental health problems were significantly associated with students, 20 to 30 year olds, those who are single, and university educated. Considerable proportions of healthcare workers presented with stress symptoms (21.4%), anxiety (5.6%) and depression (5.6%), however, the proportions were significantly less in comparison with others. Various coping strategies were reported; respondents who avoided thinking about the pandemic or seemed unsure of coping strategies and those struggling to cope had significantly greater anxiety and depression. As large proportions of people have anxiety, depression, and stress symptoms in relation to COVID-19, there is a need to establish a mental health support system that can address the need of the general population. Public education on coping strategies and stress management may be helpful.

Personality and mental health factors associated with performance at university level: A study of business administration students.

BACKGROUND: Performance of students at university level may be influenced by various factors. AIM: In a sample of business administration students, we explored personality, mental health, and life style factors associated with high and low achievers based on their examination grades (Grade A and higher vs. Grade B and lower). METHODS: We studied personality factors using big five inventory (BFI)-10, anxiety through generalized anxiety disorder-7 screening scale, and depression by patient health questionnaire-9 scale. In open-ended questionnaires, stress, relationship, and drug uses were enquired about. RESULTS: Considerable proportions of students had anxiety (33%) and depression (41%) at moderate-to-severe level; however, they were not different in the two groups. Higher examination grades were associated significantly with higher scores on conscientiousness factor of BFI-10 and female gender. There was no difference in self-reported stress or substance use between the two groups. CONCLUSIONS: While conscientiousness was associated with better performance, mental health factors were comparable between higher and lower grades in examination. The results highlight the need for further research on personality and modifiable factors such as stress, anxiety, and depression and to evaluate effectiveness of interventional approaches on academic performance.

Geriatric Telepsychiatry: Promoting Access to Geriatric Mental Health Care Beyond the Physical Barriers.

Psychiatric illnesses are an important contributor of morbidity and mortality in older adults. There is increase in older adults with psychiatric disorders paralleling their growth in absolute numbers. This leads to challenges in mental health care and service delivery. Several barriers that exists in our community hinder older adults from receiving mental health care. Additionally, lack of adequate human resources in geriatric mental health care compounds the problem. Telemedicine, though not new in other fields of medicine, is relatively new in the practice of psychiatry in India. This is probably due to lack of clear guidelines and regulations regarding the same in India. There is a recent increase in teleconsultations in India similar to other developed countries due to ongoing COVID-19 pandemic. The recent telepsychiatry operational guidelines have made telepsychiatry a legitimate and official practice in India. Challenges specific to older adults in the form of low digital literacy, sensory issues, and cognitive impairment can be overcome by adopting telepsychiatry services in coming years. Concerns related to security and safety of telepsychiatry require further evaluation.

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 cognitive behavioral therapy on social anxiety disorder: A comparative study.

BACKGROUND: Both cognitive behavior therapy (CBT) and paroxetine (PX) are the preferred treatments for social anxiety disorder (SAD). However, in literature, there have been divided opinions for the efficacy of the combination of these treatments. This study intended to evaluate whether the combination of CBT and PX would be superior to monotherapy of PX in the treatment of SAD. METHODS: This was a single centre, rater-blind, non randomised study which included 40 consenting adult participants who received CBT+PX or PX only. The Liebowitz Social Anxiety Scale, Social Interaction Anxiety Scale, and Brief Fear of Negative Evaluation scale (BFNE) were assessed at baseline (0 weeks), immediate posttreatment (16-18 weeks for CBT + PX and 16-20 weeks for PX only), and at follow-ups 2 months after posttreatment. RESULTS: Both the treatment groups have a statistically significant difference in mean scores in all outcome measures in posttreatment and follow-up stages compared with pretreatment scores. However, CBT + PX has a better treatment and maintenance gain as compared to PX alone in the posttreatment and follow-up stages. CONCLUSIONS: In SAD management, combinations of CBT + PX are superior to PX alone, and the treatment gains are also better maintained in former than latter.

Psychiatric Morbidity in the Post-ICU Patient-Ethnocultural Differences.

How to cite this article: Tripathy S, Kar N. Psychiatric Morbidity in the Post-ICU Patient-Ethnocultural Differences. Indian J Crit Care Med 2019;23(9):440-441.

Depression in Youth Exposed to Disasters, Terrorism and Political Violence.

PURPOSE OF REVIEW: This paper reviews recent research on the depression in young people following exposure to catastrophic stresses such as disasters, terrorism and political violence. RECENT FINDINGS: Depression is one of the commonest outcomes following mass trauma, for all ages including children and adolescents. Recent articles continue to report high prevalence of depression which often continues for years. It is often comorbid with other psychiatric disorders, especially PTSD. Post-traumatic depression in children and adolescence affects purpose of life, impairs scholastic achievements, increases suicidality and has extensive comorbidity. Besides the trauma, individual constructs, personality factors, social support, exposure to other traumatic events are some of the predicting factors. Biological and genetic basis of post-traumatic depression has been reported. Studies suggest some benefit to psychotherapeutic interventions such as trauma-focussed cognitive behavioural therapy and web-based therapy. A considerable proportion of youths develop depression following mass traumatic events. More research is required regarding the effectiveness of interventions in this population.

Prevalence of child abuse in Kerala, India: An ICAST-CH based survey.

BACKGROUND: Child abuse is a major concern in India with frequent reports of extreme maltreatment and fatalities. A dearth of robust and methodologically sound studies has resulted in ambiguity regarding the extent of child abuse in the general population. OBJECTIVES: To estimate the one-year and lifelong prevalence of exposure to violence, physical abuse, emotional abuse, sexual abuse, and neglect using a validated instrument-the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool - Child, Home Version (ICAST-CH). PARTICIPANTS AND SETTING: Adolescents (n = 6957) attending randomly selected schools in one city in Kerala, India. METHODS: Cross-sectional survey using self-report instrument. RESULTS: The one-year prevalence of any abuse was 89.9% (95% CI: 89.1-90.7) suggesting that child maltreatment was widespread. Physical and emotional abuses were also very common. Although sexual abuse was least common, a considerable proportion of adolescents reported it; one-year prevalence of sexual abuse was 16.7% and lifetime prevalence was 19.9%. Boys reported more abuse than girls across all the categories of abuse (including sexual abuse). Abuse was more frequent in the higher age groups and classes at school. Abuse was also more frequent in nuclear families and families that reported alcohol use. Children who reported an abusive experience usually faced more than one category of abuse; abuse in one category was significantly associated with abuse in other categories. CONCLUSIONS: Abuse of children is alarmingly common. There is an urgent need for improving the awareness surrounding this issue as it is a major public health challenge faced by the country. The priority should be on setting up easily accessible support services for children.