Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan.

INTRODUCTION: Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan. METHODS: DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500 cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology. RESULTS AND DISCUSSION: Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings. CONCLUSION: DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research.

Efficacy and Safety of Escitalopram Oral Drops to Treat Major Depressive Disorder and Generalized Anxiety Disorder in Adolescent, Adult and Geriatric Patients: A Prospective Multicenter Observational Study in Pakistan.

Background  Escitalopram is widely used for the management of the major depressive disorder and generalized anxiety disorder, but there is no to very limited data available regarding efficacy and safety in Pakistani patients. This study was conducted to evaluate the efficacy and safety of escitalopram oral drops to manage the major depressive disorder and generalized anxiety disorder in a local cluster within Pakistan. Methods This prospective multicenter observational study was conducted in the department of psychiatry from August 2018 - August 2019. Eighty-five patients meeting the selection criteria were included in the study. Adolescent, adult, and geriatric patients of either gender with generalized anxiety disorder having Hamilton Anxiety Rating Scale (HAM-A) rate ≥ 10 and major depressive disorder having Montgomery-Asberg Depression Rating Scale (MADRS) rate ≥ 7 or patients with co-morbid generalized anxiety disorder (GAD), major depressive disorder (MDD) were selected for the study. We are reporting patients' improvement from baseline, response rate, and remission rate. Data analysis is performed by using SPSS version 21 (IBM Inc, Armonk, USA). Results Among enrolled patients, 42 were adolescents, 22 were adults, and 21 were geriatric. The mean age of an adolescent, adult, and geriatric patients was 14.92 ± 2.04, 44.54 ± 12.08, and 64.61 ± 3.16 years, respectively. Among enrolled patients, the mean change in a total score of HAM-A for anxiety and MADRS for depression were -10.04 ± 4.32 and -17.67 ± 14.42, respectively. At the end of the study, the remission rate and response rate for depression were 82 % and 75%, respectively. Similarly, the remission rate and the response for anxiety were 76% and 81%, respectively. Mean HAM-A and MADRS scores were significantly improved for adolescent, adult, and geriatric patients. Adverse events were reported in eight (9.41%) patients with six having gastrointestinal (GI) disturbance and two having to worsen anxiety. All reported adverse events were of mild severity.  Conclusion  Escitalopram oral drops are found effective and tolerable in reducing both anxiety and depression over the duration of study in all age groups, including adolescents, adults, and geriatrics.

Anxiety and Depression among Parents of Children with Intellectual Disability in Pakistan.

BACKGROUND: Studies have shown an association between parental distress and caretaking of children with developmental cognitive delays. There is little data in developing countries, such as Pakistan, concerning the impact of raising children with intellectual disability upon the quality of parent functioning and risk for psychopathology. OBJECTIVE: To assess the level of psychopathology i.e. anxiety, depression and both anxiety and depression together among parents of children with intellectual disability (ID). METHODS: This was a cross-sectional study conducted at a tertiary care hospital in Pakistan. The study was approved by the Institutional Research Committee. Participants were 198 parents (99 fathers/99 mothers) of 100 children with the diagnosis of ID. Informed consents were obtained. The parents were assessed for anxiety and depression using DSM IV criteria. RESULTS: Significantly high proportion of mothers (89%) had anxiety, depression, or both anxiety and depression together as compared to fathers (77%) (p-value <0.05). Among mothers, 35% met criteria for anxiety, 40% for depression and 13% for both anxiety and depression. Among fathers 42% had anxiety, 31% depression and 3% both anxiety and depression. There was a significant association between gender of parent and individual psychiatric diagnosis of anxiety, depression and anxiety and depression together (p-value <0.05). A significant association was also found between mother's anxiety, depression or both and degree of ID of their children (p-value <0.05). CONCLUSIONS: 1) Significantly high proportion of parents of children with ID has psychiatric diagnosis of anxiety, depression or both; 2) the psychiatric diagnosis of anxiety, depression and anxiety and depression together is associated with gender of parent; and, 3) the diagnosis of anxiety, depression or both in mothers was associated with severity of ID in their children.

CONTEXTE: Des études ont montré une association entre la détresse parentale et la garde d'enfants souffrant de retards de développement cognitif. Dans les pays en développement, comme le Pakistan, il existe peu de données au sujet des répercussions d'élever des enfants souffrant de déficience intellectuelle sur la qualité du fonctionnement des parents et le risque de psychopathologie. OBJECTIF: Évaluer le niveau de psychopathologie, c.-à-d., l'anxiété, la dépression et l'anxiété et la dépression à la fois chez les parents d'enfants souffrant de déficience intellectuelle (DI). MÉTHODES: Cette étude intersectorielle a été menée à un hôpital de soins tertiaires du Pakistan. Elle a été approuvée par le comité de recherche institutionnelle. Les participants étaient 198 parents (99 pères/99 mères) de 100 enfants ayant reçu un diagnostic de DI. Des consentements éclairés ont été obtenus. Les critères de l'anxiété et de la dépression du DSM-IV ont servi à évaluer ces troubles chez les parents. RÉSULTATS: Une proportion significativement élevée des mères (89%) souffrait d'anxiété, de dépression ou d'anxiété et de dépression à la fois comparé aux pères (77%) (valeur p < 0,05). Chez les mères, 35 % satisfaisaient aux critères de l'anxiété, 40%, à ceux de la dépression et 13% à ceux de l'anxiété et de la dépression à la fois. Chez les pères, 42% souffraient d'anxiété, 31%, de dépression et 3% d'anxiété et de dépression à la fois. Il y avait une association significative entre le sexe des parents et le diagnostic psychiatrique individuel d'anxiété, de dépression, et d'anxiété et de dépression à la fois (valeur p < 0,05). Une autre association significative a été observée entre l'anxiété, la dépression ou les deux chez la mère et le degré de DI de leurs enfants (valeur p < 0,05). CONCLUSIONS: 1) Une proportion significativement élevée des parents d'enfants souffrant de DI a un diagnostic psychiatrique d'anxiété, de dépression, ou des deux à la fois; 2) le diagnostic psychiatrique d'anxiété, de dépression, ou des deux à la fois est associé au sexe du parent; et 3) le diagnostic d'anxiété, de dépression, ou des deux à la fois chez les mères était associé à la gravité de la DI de leurs enfants.

Comparison of quality of life among cardiac, hepatic, cancer, and dermatological patients.

OBJECTIVE: To assess the level of quality of life (QOL) in patients suffering from various cardiac, cancer, hepatic, and dermatological diseases. METHOD: A total of 339 patients of cardiac, cancer, hepatic, and dermatological diseases from DHQ/Allied hospitals of Faisalabad participated in this study through purposive convenient sampling technique. Quality of life was measured by WHO QOL-BREF (Validated Urdu Version) while demographic variables were recorded on a demographic sheet. The results were obtained by using analysis of variance (ANOVA) on SPSS 13. RESULTS: Out of 339, 156 (46%) patients were males while 183 (54%) patients were females. Of the total, 99 (29.2%) belonged to the lower socio economic status, 113 (33.3%) belonged to the lower middle, 62 (18.3%) belonged to the middle, and 65 (19.2%) belonged to the upper middle socio economic status. In terms of education, 49 (14.5%) were illiterate, 110 (32.3%) had primary level education, 118 (34.8%) had middle level education, 21 (6.2%) had done matriculation, 17 (5%) had intermediate, 14 (4.1%) were graduates, 8 (2.4%) had done masters. Of the whole lot, only 2 (0.6%) patients were professionals. Results showed that the quality of life was most deteriorated in the domain of physical health; while psychological health was the second most deteriorated domain. Social relationship was the least affected domain, while environment was the second least affected area. Quality of life of hepatic patients was significantly lower than dermatological patients with respect to physical health and environment, lower than cancer patients in relation to psychological health, and lower than cardiac patients in the social relationship domain. The quality of life of cardiac patients was noted to be significantly higher than the other three categories in the domains of psychological health and environment. CONCLUSION: In the face of the evidence of high deterioration in the quality of life of the patients in terms of physical and psychological health, medical units should be better equipped with facilities to enhance a sense of betterment in patients. The treating doctors should be better trained to give due consideration to this important aspect of management. Moreover, the role of liaison psychiatry should also be incorporated.

Prevalence and risk factors for depression and anxiety in hospitalized cardiac patients in pakistan.

OBJECTIVE: This study examined the prevalence and risk factors for depression and anxiety in hospitalized cardiac patients in Pakistan. METHODS: All patients admitted to a cardiac unit of a tertiary care hospital in Pakistan over a period of eight weeks were evaluated with clinical interview using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, Hospital Anxiety and Depression Scale (HADS), and Quality of Life (QoL) scale. RESULTS: One hundred patients entered the study. Sixty eight met the criteria for either major depressive disorder, generalized anxiety disorder, or both. A total of 87.5 percent of the entire female sample met the criteria for either a depressive disorder, an anxiety disorder or both. Patients with higher scores on HADS anxiety subscale had longer duration of cardiac illness. Patients with depression and anxiety had poor quality of life on the four domains of QoL scale. CONCLUSIONS: This study shows high prevalence of major depressive disorder and generalized anxiety disorder in cardiac patients in Pakistan. Being female, a housewife, and a widow are high risk factors for developing depression and/or anxiety in this population, requiring close monitoring.