Nusrat Husain

Depression and social stress in Pakistan

BACKGROUND The high prevalence of depression in developing countries is not well understood. This study aimed to replicate the previous finding of a high prevalence of depression in Pakistan and assess in detail the associated social difficulties. METHOD A two-phase survey of a general population sample in a Pakistani village was performed. The first-phase screen used the Personal Health Questionnaire (PHQ) and the self-rating questionnaire (SRQ). A one in two sample of high scorers and a one in three sample of the low scorers were interviewed using the Psychiatric Assessment Schedule (PAS) and Life Events and Difficulties Schedule (LEDS). RESULTS A total of 259 people were screened (96% response rate). The second stage yielded 55 cases, of whom 54 had depressive disorder, and 48 non-cases. The adjusted prevalence of depressive disorders was 44-4% (95% CI 35.3 to 53.6): 25.5% in males and 57.5% in females. Nearly all cases had lasted longer than 1 year. Comparison of the cases and non-cases indicated that cases were less well educated, had more children and experienced more marked, independent chronic difficulties. Multivariate analysis indicated that severe financial and housing difficulties, large number of children and low educational level were particularly closely associated with depression. CONCLUSION This study confirms the high prevalence of depressive disorders in Pakistan and suggests that this may be higher than other developing countries because of the high proportion of the population who experience social adversity.

Minocycline benefits negative symptoms in early schizophrenia : a randomised double-blind placebo-controlled clinical trial in patients on standard treatment

The onset and early course of schizophrenia is associated with subtle loss of grey matter which may be responsible for the evolution and persistence of symptoms such as apathy, emotional blunting, and social withdrawal. Such ‘negative’ symptoms are unaffected by current antipsychotic therapies. There is evidence that the antibiotic minocycline has neuroprotective properties. We investigated whether the addition of minocycline to treatment as usual (TAU) for 1 year in early psychosis would reduce negative symptoms compared with placebo. In total, 144 participants within 5 years of first onset in Brazil and Pakistan were randomised to receive TAU plus placebo or minocycline. The primary outcome measures were the negative and positive syndrome ratings using the Positive and Negative Syndrome Scale. Some 94 patients completed the trial. The mean improvement in negative symptoms for the minocycline group was 9.2 and in the placebo group 4.7, an adjusted difference of 3.53 (s.e. 1.01) 95% CI: 1.55, 5.51; p < 0.001 in the intention-to-treat population. The effect was present in both countries. The addition of minocycline to TAU early in the course of schizophrenia predominantly improves negative symptoms. Whether this is mediated by neuroprotective, anti-inflammatory or others actions is under investigation.

Prevalence and social correlates of postnatal depression in a low income country

SummaryBackground: Postnatal depression is an important public health problem worldwide. Recent evidence suggests that rates may be relatively higher in developing countries. We aimed to explore the prevalence of postnatal depression and its association with social support and other risk factors in a sample of Pakistani women. Methods: Population-based survey of 149 women at 12 weeks postnatal using the Edinburgh Postnatal Depression Scale (EPDS), Multidimensional Scale of Perceived Social Support (MSPSS) and Personal Information Questionnaire (PIQ). Results: Thirty six percent women scored ≥12 on EPDS. High depression score was associated with lower social support, increased stressful life events in the preceding year and higher levels of psychological distress in the antenatal period. Conclusions: There is a high prevalence of postnatal depression in Pakistani women. Early interventions should be developed that target the antenatal period and strengthen social support networks in women at risk.

Psychiatrists’ use, knowledge and attitudes to first- and second-generation antipsychotic long-acting injections: comparisons over 5 years

Psychiatrists’ attitudes and knowledge about antipsychotic long-acting injections (LAIs) are important given the increasing emphasis on patient choice in treatment and the availability of second-generation antipsychotic (SGA) LAIs. A cross-sectional study of consultant psychiatrists’ attitudes and knowledge in North West England was carried out. A pre-existing questionnaire on clinicians’ attitudes and knowledge regarding LAIs was updated. Of 102 participants, 50% reported a decrease in their use of LAIs. LAI prescribing was evenly split between first-generation antipsychotic (FGA) and SGA-LAIs. Most regarded LAIs as associated with better adherence (89%) than tablets. A substantial proportion believed that LAIs could not be used in first-episode psychosis (38%) and that patients always preferred tablets (33%). Compared with a previous sample, the current participants scored more favourably on a patient-centred attitude subscale (60.4% vs 63.5%, P = 0.034) and significantly fewer regarded LAIs as being stigmatising and old-fashioned. Reported LAI prescribing rates have decreased in the last 5 years despite an SGA-LAI becoming available and most clinicians regarding LAIs as effective. Most attitudes and knowledge have remained stable although concerns about stigma with LAI use have decreased. Concerns about patient acceptance continue as do negative views about some aspects of LAI use; these may compromise medication choices offered to patients.

Social factors associated with chronic depression among a population-based sample of women in rural Pakistan.

Previous studies have reported a high prevalence of depression in women in Pakistan. This paper investigates whether risk factors for chronic depression established in studies performed in Western countries can explain this high prevalence. A two–phase survey using the self–rating questionnaire (SRQ) for common mental disorders and the Psychiatric Assessment Schedule was performed on a general population sample in rural Pakistan. Demographic data and results of the Life Events and Difficulties Schedule were analysed in relation to SRQ score and psychiatric disorder. A total of 145 women were screened. High SRQ score was associated with low educational status, not having a confidant, having four or more children, being older, not being married and living in a house with more than three people per room. Regression analysis demonstrated that the first three of these independently contributed to SRQ score. In the interviewed sample (74 women), only educational level independently contributed to the presence of depression. In addition, the least educated group experienced the greatest number of marked difficulties: 67% of them had experienced both marked housing and financial difficulties compared to 28% and 25% of the other educational groups (p = 0.005). Experiencing both housing and financial difficulties was a significant risk factor for depression in women with secondary education, but not for those without secondary education. This study suggests that high levels of social adversity and low levels of education are strongly associated with depression in women in Pakistan. The other vulnerability factors found in the West (such as lack of a confidant, the presence of three or more young children at home, or loss of mother during childhood) may be of lesser importance in this population.

A population‐based study of irritable bowel syndrome in a non‐Western population

Abstract  Previous studies have found no female predominance in irritable bowel syndrome (IBS) in non‐Western countries. The aim of the study was to assess the prevalence and correlates of Rome II (IBS) in both sexes in Pakistan. A Population‐based survey in a low‐income inner city area using questionnaires to diagnose Rome II IBS and assess distress, disability and stressful life events. Data were collected from 880/938 (93%) randomly selected residents. 13.4% of women and 13.1% men met criteria for Rome II IBS; 34 (3.9%) had diarrhoea‐predominant, 59 (6.7%) had constipation‐predominant IBS and 24 (2.7%) had ‘mixed IBS’. In logistic regression analysis, IBS was associated in men with high income (OR = 1.56; 95% CI: 1.05–2.3) and few years of education (OR = 2.17; 95% CI: 1.2–3.9) and in women with being married (OR = 3.6; 95% CI: 1.1–11.9) and stressful life events score (OR = 1.14; 95% CI: 1.01–1.3). Disability was associated with constipation‐predominant IBS (OR = 1.99; 95% CI: 1.1–3.6), distress (OR = 1.19; 95% CI: 1.14–1.23) and stressful life events (OR = 1.19; 95% CI: 1.1–1.3). Investigations were more likely in men (54%) than in women (27%) (P = 0.003). These findings suggest that the equal sex ratio of IBS in urban Pakistan could result from a close association between marked distress and IBS in men similar to that found in women in western studies.

Self-harm in British South Asian women: psychosocial correlates and strategies for prevention

ObjectiveTo review the rates of self-harm in British South Asian women, look into the factors that contribute to these high rates of self-harm and discuss possible strategies for prevention and provision of culturally sensitive service for South Asian women who harm themselves.MethodReview.ResultsSouth Asian women are significantly more likely to self harm between ages 16–24 years than white women. Across all age groups the rates of self harm are lower in South Asian men as compared to South Asian women. These women are generally younger, likely to be married and less likely to be unemployed or use alcohol or other drugs. They report more relationship problems within the family. South Asian women are less likely to attend the ER with repeat episode since they hold the view that mainstream services do not meet their needs.ConclusionSouth Asian women are at an increased risk of self harm. Their demographic characteristics, precipitating factors and clinical management are different than whites. There is an urgent need for all those concerned with the mental health services for ethnic minorities to take positive action and eradicate the barriers that prevent British South Asians from seeking help. There is a need to move away from stereotypes and overgeneralisations and start from the users frame of reference, taking into account family dynamics, belief systems and cultural constraints.

Multidimensional scale of perceived social support : Psychometric properties in a South Asian population

Aim:  The Multidimensional Scale of Perceived Social Support (MSPSS) was developed to assess perceived social support, and has been widely used in Western samples. We attempted to translate and adapt this scale into the Urdu language, and herewith report on its psychometric properties in a rural Pakistani setting.

Social stress and depression during pregnancy and in the postnatal period in British Pakistani mothers: A cohort study

Background Depressive disorders are common and disabling among perinatal women. The rates are high in ethnic minority groups. The causes are not known in British Pakistani women. The aim of this study was to estimate the rates, correlates and maintaining factors of perinatal depression in a Pakistani sample in UK. The design used was a cross-sectional two phase population based survey with a prospective cohort study. Methods All women in 3rd trimester attending antenatal clinic were screened with the Edinburgh postnatal depression scale (EPDS). Women scoring 12 or more on EPDS and a random sample of low scorers were interviewed using the Schedules for Assessment in Neuropsychiatry (SCAN) and the Life Events and Difficulties schedule (LEDS). Social support was assessed with the Multidimensional Scale for Perceived Social Support (MSPSS). They were reassessed 6 months after the delivery using the same measures. Results The weighted prevalence of depression was 16.8%. Depressed mothers had more marked non health difficulties (housing, financial and marital). They had less social support and were socially isolated. Marked social isolation and marked non-health related difficulties were independent predictors of depression. Analyses of all the possible risk factors, comparing 26 persistent depressed with 27 depression resolved group showed significant differences in the MSPSS subscales between the two groups. Limitations The study lacked inter-rater reliability testing between the individuals carrying out diagnostic interviews. The study sample did not accurately represent the general population and information about the origins of depression in this group of mothers was limited. Conclusion Depression in British Pakistani mothers is associated with social isolation, poor social support and severe and persistent social difficulties. The findings will have implications in planning suitable services for this group.

Social intervention for British Pakistani women with depression: randomised controlled trial.

BACKGROUND British Pakistani women have a high prevalence of depression. There are no reported psychosocial interventions for depression in ethnic minorities in the UK. AIMS To determine the efficacy of a social group intervention compared with antidepressants, and whether the combination of the two is more efficacious than either alone. METHOD A total of 123 women with depression participated in the primary care-based cluster randomised controlled trial (ISRCTN19172148). Outcome measures were severity of depression (Hamilton Rating Scale for Depression), social functioning and satisfaction at 3 and 9 months. RESULTS Greater improvement in depression in the social intervention group and the combined treatment group compared with those receiving antidepressants alone fell short of significance. There was significantly greater improvement in social functioning in the social intervention and combined treatment groups than in the antidepressant group at both 3 and 9 months. CONCLUSIONS Pakistani women with depression found the social groups acceptable and their social function and satisfaction improved if they received social treatment compared with the receipt of antidepressants alone.