Nasim Chaudhry

A systematic review of explanatory models of illness for psychosis in developing countries

Abstract Background: Explanatory models of illness, held by patients and treating clinicians, offer justifications and propose explanations for sickness, treatment evaluations and choice. These have been studied in relation to common mental disorders but research on explanatory models of psychosis (EMOP) has received scant attention. Adequately understanding patients’ explanatory models for psychosis has important clinical implications. Method: We systematically examined studies on EMOP in the developing world to report on the nature of explanatory models, their relationship with help-seeking, duration of untreated psychosis (DUP), perceived stigma and any differences in the explanatory models between first and subsequent episodes. Results: 14 studies examining EMOP in developing countries were identified. The majority of studies reported predominantly supernatural and psychosocial EMOP. Holding supernatural and psychosocial explanatory models affected help-seeking behaviour, treatment modalities used and DUP. Discussion: EMOP in developing countries are rich and varied. The literature reports on a variety of populations using different methods and suffers from methodological limitations. Some recent studies have also attempted to modify explanatory models by using educational interventions; however, this was not examined in patient populations. Further research is needed to examine the impact of different explanatory models on DUP and help-seeking behaviours.

Brief psychological intervention after self-harm: randomised controlled trial from Pakistan

BACKGROUND Self-harm is a major risk factor for completed suicide. AIMS To determine the efficacy of a brief psychological intervention - culturally adapted manual-assisted problem-solving training (C-MAP) - delivered following an episode of self-harm compared with treatment as usual (TAU). METHOD The study was a randomised controlled assessor-masked clinical trial (trial registration: ClinicalTrials.gov NCT01308151). All patients admitted after an episode of self-harm during the previous 7 days to the participating medical units of three university hospitals in Karachi, Pakistan, were included in the study. A total of 250 patients were screened and 221 were randomly allocated to C-MAP plus treatment as usual (TAU) or to TAU alone. All patients were assessed at baseline, at 3 months (end of intervention) and at 6 months after baseline. The primary outcome measure was reduction in suicidal ideation at 3 months. The secondary outcome measures included hopelessness, depression, coping resources and healthcare utilisation. RESULTS A total of 108 patients were randomised to the C-MAP group and 113 to the TAU group. Patients in the C-MAP group showed statistically significant improvement on the Beck Scale for Suicide Ideation and Beck Hopelessness Inventory, which was sustained at 3 months after the completion of C-MAP. There was also a significant reduction in symptoms of depression compared with patients receiving TAU. CONCLUSIONS The positive outcomes of this brief psychological intervention in patients attempting self-harm are promising and suggest that C-MAP may have a role in suicide prevention.

Development and pilot testing of a social intervention for depressed women of Pakistani family origin in the UK

Background: Depressive disorders are common in women of Pakistani origin living in the UK. In a pilot study we developed and tested a culturally sensitive social group intervention for persistently depressed Pakistani women. Methods: A total of 55 persistently depressed women were identified in a population-based study. The first consecutive 18 who agreed to participate were enrolled into the study. Out of these, eight women dropped out before the start of the intervention, one woman attended the first session only and nine women attended 10 weekly sessions of the group. Outcome measures at baseline and at the end of the intervention were the 20 item Self Reporting Questionnaire (SRQ) and the Schedule for Clinical Assessment in Neuropsychiatry (SCAN). Results: All 9 women attended at least six of the 10 sessions. Mean SRQ score at baseline was 15.0 (SD = 3.08) and 11.7 (SD = 5.95) at the end of the intervention (p = 0.039). Three women reported reduction in suicidal ideas. Conclusions: A culturally appropriate social intervention successfully brought together a group of isolated chronically depressed Pakistani women, enabling them to form informal networks and forming the basis of an RCT to treat the depression.

Prevention of: self harm in British South Asian women: study protocol of an exploratory RCT of culturally adapted manual assisted Problem Solving Training (C- MAP)

BackgroundSuicide is a major public health problem worldwide. In the UK suicide is the second most common cause of death in people aged 15-24 years. Self harm is one of the commonest reasons for medical admission in the UK. In the year following a suicide attempt the risk of a repeat attempt or death by suicide may be up to 100 times greater than in people who have never attempted suicide.Research evidence shows increased risk of suicide and attempted suicide among British South Asian women. There are concerns about the current service provision and its appropriateness for this community due to the low numbers that get involved with the services. Both problem solving and interpersonal forms of psychotherapy are beneficial in the treatment of patients who self harm and could potentially be helpful in this ethnic group.The paper describes the trial protocol of adapting and evaluating a culturally appropriate psychological treatment for the adult British South Asian women who self harm.MethodsWe plan to test a culturally adapted Problem Solving Therapy (C- MAP) in British South Asian women who self harm. Eight sessions of problem solving each lasting approximately 50 minutes will be delivered over 3 months. The intervention will be assessed using a prospective rater blind randomized controlled design comparing with treatment as usual (TAU). Outcome assessments will be carried out at 3 and 6 months. A sub group of the participants will be invited for qualitative interviews.DiscussionThis study will test the feasibility and acceptability of the C- MAP in British South Asian women. We will be informed on whether a culturally adapted brief psychological intervention compared with treatment as usual for self-harm results in decreased hopelessness and suicidal ideation. This will also enable us to collect necessary information on recruitment, effect size, the optimal delivery method and acceptability of the intervention in preparation for a definitive RCT using repetition of self harm and cost effectiveness as primary outcome measures.Trial RegistrationCurrent Controlled Trials 08/H1013/6

Antidepressant and Group Psychosocial Treatment for Depression: A Rater Blind Exploratory RCT from a Low Income Country

BACKGROUND Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. AIM To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. METHOD This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. RESULTS More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. CONCLUSION Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

Difficult decisions: are intellectually disabled patients given enough information to consent to medical treatment?

Patients with learning disabilities are not always involved in decision-making about their medications. This may mean that some patients are unfairly denied of their autonomy. We carried out an audit of current practice concerning consent to treatment in patients with learning disabilities against best practice guidelines. Data were collected via a questionnaire given to a sample of 70 patients with learning disabilities within the Salford catchment area. This questionnaire assessed whether patients were involved in decision-making regarding their medications and whether they were being given enough information to give informed consent. A total of 45 patients completed questionnaires. Overall, the patients’ knowledge of their medications was poor, particularly of the proposed duration, possible disadvantages and name of the treatment. It appears that doctors are engaging these patients during consultations and discussing their medications. However, the delivery of this information needs to be improved, and patients’ understanding and recall need to be checked more thoroughly.

A prospective study of social difficulties, acculturation and persistent depression in Pakistani women living in the UK.

BACKGROUND The reasons for the high prevalence of depressive disorders in women of Pakistani origin living in the UK are not clear. The aim of this study was to determine the relative importance of life events, chronic social difficulties and acculturation in a population-based sample of British Pakistani women. METHOD A cross-sectional and prospective cohort study of 18- to 65-year-old Pakistani women in UK was carried out. The Schedule for Clinical Assessment in Neuropsychiatry for diagnosis, the Life Events and Difficulties Schedule for social stress and an acculturation questionnaire were used. RESULTS Depressive disorder at baseline was associated with older age, social isolation and marked difficulties involving health and close relationships. Depressive disorder at follow-up was associated with severity of depression at baseline, difficulties in close relationships and two aspects of acculturation, especially less acculturation in relation to use of the English language. CONCLUSIONS Lack of acculturation, especially less familiarity with the English language, is an independent predictor of persistence of depression in Pakistani women in UK. This needs to be taken into consideration when planning treatment, which also needs to address the personal difficulties associated with persistent depression. The implication of this work is that women of Pakistani origin with depression should be encouraged to receive help in the use of English as one part of treatment that may prevent relapse.

Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women

BackgroundPostnatal depression affects 10–15 % of all mothers in Western societies and remains a major public health concern for women from diverse cultures. British Pakistani and Indian women have a higher prevalence of depression in comparison to their white counterparts. Research has shown that culturally adapted interventions using Cognitive Behavioural Therapy (CBT) may be acceptable and may help to address the needs of this population. The aim of this study was to assess the acceptability and overall experience of the Positive Health Programme by British South Asian mothers.MethodsThis was a nested qualitative study, part of an exploratory randomized controlled trial (RCT) conducted to test the feasibility and acceptability of a culturally-adapted intervention (Positive Health Programme or PHP) for postnatal depression in British South Asian women. In-depth interviews (N = 17) were conducted to determine the views of the participants on the feasibility and acceptability of the intervention.ResultsThe participants found the intervention acceptable and experienced an overall positive change in their attitudes, behaviour, and increased self-confidence.ConclusionsThe findings suggest that the culturally adapted Positive Health Programme is acceptable to British South Asian women. These results support that culturally sensitive interventions may lead to better health outcomes and overall satisfaction.Trial registrationProtocol registered on Clinicaltrials.gov NCT01838889

Prevalence and risk factors for psychological distress and functional disability in urban Pakistan

Background and Objectives: Water and sanitation are major public health issues exacerbated by rapid population growth, limited resources, disasters and environmental depletion. This study was undertaken to study the influencing factors for household water quality improvement for reducing diarrhoea in resource-limited areas. Materials and Methods: Data were collected from articles and reviews from relevant randomized controlled trials, new articles, systematic reviews and meta-analyses from PubMed, World Health Organization (WHO), United Nations Children′s Fund (UNICEF) and WELL Resource Centre For Water, Sanitation And Environmental Health. Discussion: Water quality on diarrhoea prevention could be affected by contamination during storage, collection and even at point-of-use. Point-of-use water treatment (household-based) is the most cost-effective method for prevention of diarrhoea. Chemical disinfection, filtration, thermal disinfection, solar disinfection and flocculation and disinfection are five most promising household water treatment methodologies for resource-limited areas. Conclusion: Promoting household water treatment is most essential for preventing diarrhoeal disease. In addition, the water should be of acceptable taste, appropriate for emergency and non-emergency use.

Which antidepressant would psychiatrists and nurses from a developing country choose for themselves

Abstract Objective. To determine the prescribing preference of mental health professionals in a developing country for antidepressants if they themselves developed a depressive illness. Methods. A specifically designed self reporting questionnaire was used to investigate which antidepressant was the preferred choice of psychiatrists and nurses and the factors which influenced their decision making. Results. Fluoxetine was the antidepressant most likely to be chosen by psychiatrists for themselves, followed by escitalopram and tricyclic antidepressant. A total of 21 (27.6%) nurses said that they did not know which antidepressant they would prefer for themselves and 22 (29%) said that they would choose a benzodiazepine. Majority of the psychiatrists (71.9%) had more experience with SSRIs, 26.6% with tricyclic antidepressants and only about 1.5% had used venlafaxine and mirtazapine. Efficacy and safety of antidepressants were the two most important factors in selecting an antidepressant. Conclusions. SSRIs are the preferred antidepressants of Pakistani psychiatrists and nurses for their patients and for themselves. Efficacy and safety of a drug are likely to play a greater role in drug choice than cost of the drug.