The effect of mental health training on the knowledge of common mental disorders among medical officers in primary health centres in rural Karnataka.

Background: Deficits in knowledge regarding identification and treatment of common mental disorders (CMD) and stigmatizing attitudes towards CMDs exist among primary care physicians in India. Objectives: We aimed to assess the gain in knowledge of CMDs among primary health centre (PHC) doctors, after they underwent training in the identification and treatment of CMDs, and to assess the relationship between the gain in knowledge and demographic variables. We also assessed attitudes towards depression among PHC doctors who underwent training. Methods: We assessed knowledge of CMDs among 38 PHC doctors before and after training using a multiple-choice questionnaire (MCQ). The training session included didactic teaching and case-based discussions. Results: The post-test mean score was significantly higher compared to the pre-test mean score (P < 0.0001), indicative of a significant mean gain in knowledge of CMDs among PHC doctors following training. Significant improvements were noted on the questions assessing identification of CMDs, knowledge of depressive symptoms and identification of panic attacks, post-training (all P < 0.05). Participants with lower pre-test scores had greater improvements in knowledge post-training. Around half of the PHC doctors endorsed negative attitudes towards depression. Conclusions: We demonstrated the efficacy of a training programme for PHC doctors in improving their knowledge of CMDs. Stigmatizing attitudes towards depression were present among around half the PHC doctors even after the training. This has implications for the strategy of integrating mental healthcare into primary care, with the overall goal of reducing the treatment gap for CMDs.

Downregulation of apolipoprotein A-IV in plasma & impaired reverse cholesterol transport in individuals with recent acts of deliberate self-harm.

Background & objectives: The major limiting factor in the prevention of suicide is the limited knowledge on molecular insights in individuals at risk. Identification of peripheral protein markers which can classify individuals at high-risk of suicide might aid in early diagnosis and effective medical intervention. The aim of the present study was, therefore, to analyze the differential regulation of plasma proteins in individuals with deliberate self-harm compared to controls. Methods: Using two-dimensional gel electrophoresis coupled with matrix-assisted laser desorption-ionization mass spectrometry, differentially expressed plasma proteins were identified in study participants with deliberate self-harm compared to age- and gender-matched controls. The finding was validated using mass spectrometry-based isotope-labelled relative quantification and Western blot analysis in a new set of individuals with deliberate self-harm and controls. Results: The plasma proteomic analysis showed that apolipoprotein A-IV (Apo A-IV ) was downregulated by 2.63-fold (confidence interval: 1.52-4.54) in individuals with deliberate self-harm (n=10) compared to matched controls, which was consistent in mass spectrometry-based relative quantification and Western blot analysis performed in an independent set of individuals with deliberate self-harm (n=18). In addition, plasma levels of total cholesterol, esterified cholesterol and high-density lipoprotein (HDL) were observed to be significantly lower individuals with deliberate self-harm compared to controls. Interpretation & conclusions: Apo A-IV, which plays a crucial role in the esterification of free cholesterol, was found to be downregulated with concomitantly decreased levels of HDL, esterified cholesterol and total cholesterol in individuals with deliberate self-harm compared to matched controls. The present findings might provide a link between the differential regulation of plasma proteins and the previously reported results on altered cholesterol levels in individuals with deliberate self-harm.

Intimate Partner Violence among Ever-married Women Treated for Depression at a Rural Health Center in Bengaluru Urban District.

BACKGROUND: Intimate partner violence (IPV) is a risk factor for depression among women. Spousal alcoholism and marital quality are associated with both depression and spousal abuse Knowledge about the factors contributing to IPV in depression will enable us to have interventions to address IPV in tandem with treating depression. OBJECTIVES: (1) To estimate the prevalence of IPV in women treated for depression in a rural community health-care facility in Bengaluru Urban District. (2) To assess the association between IPV and various other factors in women treated for depression in a rural community health care facility. METHODOLOGY: A cross-sectional study was conducted among ever-married women above 18 years, registered under mental health program in the mental health clinic in Mugalur, Karnataka, and currently on treatment for depression. The women who consented were interviewed using structured questionnaires - WHOQOL-BREF, standard of living index, Hamilton Depression Rating Scale, Index of Spouse Abuse, family interview for genetic studies for reported alcohol use, and marital quality scale. RESULTS: The mean age of the study participants was 49.7 ± 13.2 years. The prevalence of physical IPV and non-physical IPV was found to be 18% and 7%, respectively. Marital quality was significantly lower among women who experienced IPV. Women with husbands who ever used alcohol were found to have six times more risk of experiencing physical IPV, odd ratio 6.193 (1.595, 24.047). CONCLUSION: Health education, involvement of self-help groups, and awareness programs are required to alleviate IPV.

Elevated Unconjugated Bilirubin in Schizophrenia Compared to Bipolar Affective Disorder.

OBJECTIVE: The evidence linking schizophrenia and total and unconjugated bilirubin is primarily from retrospective studies. To overcome this limitation, we conducted a prospective study of total and unconjugated bilirubin levels of patients diagnosed with schizophrenia or bipolar affective disorder. METHODS: Serum total and unconjugated bilirubin levels were compared between patients diagnosed with schizophrenia (n = 50) and bipolar affective disorder (n = 43) (ICD-10 criteria) admitted to an inpatient psychiatric unit of a tertiary hospital in India. The study was conducted between October 2013 and July 2015. RESULTS: The median serum levels (mg/dL) of total and unconjugated bilirubin were significantly higher (P = .027 and P = .004, respectively) among patients with schizophrenia compared to those with bipolar affective disorder. Analysis of covariance revealed that unconjugated bilirubin was significantly higher (P = .029) in patients with schizophrenia compared to those with bipolar affective disorder, even after controlling for the effects of age, sex, and medications. CONCLUSIONS: In this prospective study, serum levels of unconjugated bilirubin were significantly higher in patients with schizophrenia compared to patients with bipolar affective disorder. The findings suggest that serum unconjugated bilirubin could be a potential marker for schizophrenia. However, the results need to be replicated in a larger sample including patients living in the community.

Challenges in Taking Sexual History: A Qualitative Study of Indian Postgraduate Psychiatry Trainees.

CONTEXT: In India, psychiatrist is an important point of helpseeking for sexual complaints. A detailed sexual history can go a long way in understanding sexual difficulties. In this background, there is inadequate information on the difficulties that psychiatry postgraduate trainees experience while taking a sexual history as part of a routine mental health evaluation. AIMS: The aim was to study the difficulties experienced by postgraduate psychiatry trainees while taking sexual history as a part of routine mental health evaluation. SETTING: This study was conducted in an Indian medical college general hospital psychiatry setting. MATERIALS AND METHODS: This is a qualitative study using focus group discussions and in-depth interviews with postgraduate psychiatry trainees. STATISTICAL ANALYSIS: Content analysis was used to identify direct and latent themes. RESULTS: Thematic saturation was achieved with 17 participants. Major themes of difficulties that emerged included trainee-related factors such as gender and sociocultural background of the trainee; patient-related factors such as age, gender, and sexual orientation; setting-related factors; and language-related difficulties. CONCLUSIONS: Specific and regular training in taking a sexual history is essential in addressing the difficulties faced by postgraduate psychiatry trainees in India.

Suicidal behaviour is associated with decreased esterified cholesterol in plasma and membrane fluidity of platelets.

BACKGROUND: Altered cholesterol levels in body fluids and brain tissues have been shown to be associated with suicidal behaviour, violence and aggression. But the biological underpinnings of this association in the pathophysiology of suicide are not clear. Cholesterol plays a crucial role in maintaining the cellular membrane fluidity and alterations in cellular membrane fluidity may impair serotonergic neurotransmission in the central nervous system. METHODS: We measured plasma esterified cholesterol and platelet membrane fluidity using fluorescence anisotropy and estimated flow activation energy which is a measure of order of membrane lipid bilayer in patients with recent suicidal attempt and compared with age and gender matched controls. RESULTS: The plasma esterified cholesterol, platelet membrane fluidity and flow activation energy was found to be significantly lower in patients with recent suicidal attempts compared to controls. CONCLUSION: Altered levels of plasma esterified cholesterol which is in equilibrium with membrane cholesterol might have resulted in decreased membrane fluidity and an increase in the order of membrane lipid bilayer. This might impair the serotonergic neurotransmission, which has been implicated in the pathophysiology of suicide.

A Rare Case of Complicated Opioid Withdrawal in Delirium Without Convulsions.

Opioids are one of the commonly abused substances in India. Opioid withdrawal symptoms classically include severe muscle cramps, bone aches, autonomic symptoms, anxiety, restlessness, insomnia, and temperature dysregulation. However, reports of cases with delirium during withdrawal are few. A 25-year-old male with severe opioid withdrawal symptoms developed delirium. Investigations were normal. There were no comorbidities, no significant past history and family history. Patient treated for opioid dependence with tapering doses of lorazepam and clonidine. He was discharged with naltrexone. Patient lapsed 3 months later with similar presentation. Complications such as convulsions and delirium are recognized in alcohol withdrawal. However, these are rare as a feature of opioid withdrawal. This case illustrates the need for psychiatrists and physicians to be aware of the possibilities of delirium with opioid withdrawal and monitoring for the same is important because of its complications.

Integrated Cognitive Behavioral Intervention Reduces Intimate Partner Violence Among Alcohol Dependent Men, and Improves Mental Health Outcomes in their Spouses: A Clinic Based Randomized Controlled Trial from South India.

BACKGROUND AND AIM: Alcohol abuse has been associated with intimate partner violence (IPV). The current study examined the effectiveness of an integrated cognitive-behavioral intervention (ICBI) in reducing intimate partner violence (IPV) perpetration among alcohol dependent men, and improving mental health outcomes among their wives and children. METHODS: One hundred seventy-seven alcohol dependent male inpatients who screened positive for IPV perpetration in the last 6 months were randomly assigned to receive ICBI which addressed both the alcohol use and IPV (n=88), or TAU (TAU: treatment as usual) (n=89). The ICBI sessions were attended by the patients alone. All patients and their spouses were followed up over 3 months following discharge from the treatment centre. RESULTS: Compared to TAU participants in the ICBI group reported significantly lower IPV perpetration, and their wives scored significantly lower on depression, anxiety, and stress levels at 3-month follow up. Alcohol consumption in the men and emotional and behavioral problems in their children were not significantly different between the groups, from baseline to follow up. CONCLUSIONS: Findings demonstrate the feasibility and effectiveness of an ICBI which addressed both the IPV and alcohol use in a coordinated manner in a vulnerable sample.

Enhanced care by community health workers in improving treatment adherence to antidepressant medication in rural women with major depression.

BACKGROUND & OBJECTIVES: Depression remains largely undiagnosed in women residing in rural India and consequently many do not seek help. Moreover, among those who are diagnosed, many do not complete treatment due to high rates of attrition. This study was aimed to compare the effectiveness of enhanced care with usual care in improving treatment seeking and adherence to antidepressant medication in women with depression living in rural India. METHODS: Six villages from rural Bangalore were randomized to either community health worker supported enhanced care or usual care. A total of 260 adult depressed women formed the final participants for the analysis. The outcome measures were number of women who sought and completed treatment, number of clinic visits, duration of treatment with antidepressant, changes in severity of depression (HDRS) and changes in quality of life [WHO-QOL (Brev) scale]. RESULTS: A significantly greater number of women from the treatment intervention (TI) group completed the treatment and were on treatment for a longer duration compared to the treatment as usual (TAU) group. However, there were no significant differences in the severity of depression or quality of life between the TI and the TAU groups or between treatment completers and treatment dropouts at six months. INTERPRETATION & CONCLUSIONS: Enhanced care provided by the trained community health workers to rural women with major depression living in the community resulted in greater number of women seeking help and adhering to treatment with antidepressants. However, despite enhanced care a significant number of rural women diagnosed with depression either did not seek help or discontinued treatment prematurely. These findings have significant public health implications, as untreated depression is associated with considerable disability.

Alcohol-dependence syndrome: Postural challenge on heart rate variability.

BACKGROUND: Cardiac autonomic involvement in Alcohol-Dependence Syndrome (ADS) patients has been demonstrated using conventional autonomic tests. Resting heart rate variability (HRV) without normalization has also been reported. AIMS: To evaluate cardiac autonomic changes with postural challenge using HRV in ADS and controls while controlling for confounding factors. SETTINGS AND DESIGN: Cross-sectional study involving 27 male subjects with ADS and age-matched healthy controls. MATERIALS AND METHODS: Clinical assessments included Schedules for Clinical Assessment in Neuropsychiatry and Severity of Alcohol Dependence Questionnaire. Spectral measures of HRV while lying and with active standing were assessed. RESULTS: There was an attenuated response in delta high-frequency (P=0.06) and delta low-frequency (P=0.04) power to standing in ADS subjects compared with controls. CONCLUSION: Patients with ADS appear to have attenuated cardiac vagal and sympathetic responses to standing. HRV with postural challenge may help earlier recognition of autonomic dysfunction in ADS.

Heart rate variability responses to standing are attenuated in drug naive depressed patients.

Depression has been linked to altered cardiac autonomic regulation. Previous studies have been inconsistent in terms of measurement of heart rate variability (HRV), selection of depressed patients with cardiac disorders and not controlling for co-morbid conditions such as substance use and anxiety disorders. The objective of this study is to compare the effect of posture on spectral measures of HRV in drug naive healthy patients with major depression with age and gender matched healthy controls. Spectral measures of HRV in supine position and with active standing were obtained (using Task force recommendations). Repeated measure ANOVA revealed an attenuated response in HRV parameters (HF normalized units & LH/HF ratio) to active standing in depressed subjects compared to healthy controls. We conclude that there is an impaired parasympathetic modulation in response to physiological maneuver (orthostatic challenge) in drug naive subjects with major depression (co-morbid medical or psychiatric conditions) compared to healthy controls.