Pallab K. Maulik

Prevalence of Intellectual Disability: A Meta-Analysis of Population-Based Studies.

Intellectual disability is an extremely stigmatizing condition and involves utilization of large public health resources, but most data about its burden is based on studies conducted in developed countries. The aim of this meta-analysis was to collate data from published literature and estimate the prevalence of intellectual disability across all such studies. The review includes studies published between 1980 and 2009, and includes data from populations that provided an overall estimate of the prevalence of intellectual disability. Meta-analysis was done using random effects to account for heterogeneity. Sub-group analyses were also done. The prevalence of intellectual disability across all 52 studies included in the meta-analysis was 10.37/1000 population. The estimates varied according to income group of the country of origin, the age-group of the study population, and study design. The highest rates were seen in countries from low- and middle income countries. Studies based on identification of cases by using psychological assessments or scales showed higher prevalence compared to those using standard diagnostic systems and disability instruments. Prevalence was higher among studies based on children/adolescents, compared to those on adults. Higher prevalence in low and middle income group countries is of concern given the limitations in available resources in such countries to manage intellectual disability. The importance of using standardized diagnostic systems to correctly estimate the burden is underlined. The public health and research implications of this meta-analysis have been discussed.

Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries - A Systematic Review

Background One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC. Methods A search strategy with the following terms “task-shifting”, “non-physician healthcare workers”, “community healthcare worker”, “hypertension”, “diabetes”, “cardiovascular disease”, “mental health”, “depression”, “chronic obstructive pulmonary disease”, “respiratory disease”, “cancer” was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data. Findings Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective. Conclusions Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

International collaborative project to compare and monitor the nutritional composition of processed foods

Background: Chronic diseases are the leading cause of premature death and disability in the world with overnutrition a primary cause of diet-related ill health. Excess energy intake, saturated fat, sugar, and salt derived from processed foods are a major cause of disease burden. Our objective is to compare the nutritional composition of processed foods between countries, between food companies, and over time. Design: Surveys of processed foods will be done in each participating country using a standardized methodology. Information on the nutrient composition for each product will be sought either through direct chemical analysis, from the product label, or from the manufacturer. Foods will be categorized into 14 groups and 45 categories for the primary analyses which will compare mean levels of nutrients at baseline and over time. Initial commitments to collaboration have been obtained from 21 countries. Conclusions: This collaborative approach to the collation and sharing of data will enable objective and transparent tracking of processed food composition around the world. The information collected will support government and food industry efforts to improve the nutrient composition of processed foods around the world.

Improving access to care for children with mental disorders: a global perspective

Developmental disabilities, emotional disorders and disruptive behaviour disorders are the leading mental health-related causes of the global burden of disease in children aged below 10 years. This article aims to address the treatment gap for child mental disorders through synthesising three bodies of evidence: the global evidence base on the treatment of these priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). Despite the evidence base on the burden of child mental disorders and their long-term consequences, and the recent mental health Gap Action Programme guidelines which testify to the effectiveness of a range of pharmacological and psychosocial interventions for these disorders, the vast majority of children in LMIC do not have access to these interventions. We identify three major barriers for the implementation of efficacious treatments: the lack of evidence on delivery of the treatments, the low levels of detection of child mental disorders and the shortage of skilled child mental health professionals. The evidence based on implementation, although weak, supports the use of screening measures for detection of probable disorders, coupled with a second-stage diagnostic assessment and the use of non-specialist workers in community and school settings for the delivery of psychosocial interventions. The most viable strategy to address the treatment gap is through the empowerment of existing human resources who are most intimately concerned with child care, including parents, through innovative technologies, such as mobile health, with the necessary skills for the detection and treatment of child mental disorders.

The Role of Social Network and Support in Mental Health Service Use: Findings From the Baltimore ECA Study

OBJECTIVE A significant number of people with mental illness do not use mental health services to receive treatment for their symptoms. This study examined the hypothesis that social network and social support affect mental health service use. METHODS Data were from the Baltimore cohort of the Epidemiologic Catchment Area study, a prospective cohort study that gathered data over four time points. This study examined data gathered in 1993-1996 (N=1,920) and 2004-2005 (N=1,071). The study examined indicators of social network and social support in relation to four types of service use (general medical, mental health within general medical, specialty psychiatric, and other human services) with multivariate logistic regression. Examples of other human services include a self-help group or crisis center for help with any psychological problem. Weighted generalized estimating equations were used for the analyses. RESULTS Among persons with major depressive disorder, generalized anxiety disorder, panic disorder, or alcohol use disorder in the past year or psychological distress in the past few weeks, general medical service use was reduced when the frequency of contact with relatives or friends occurred less than daily, but it was increased by about 40% when there was a higher than median level of spousal support. In contrast, receiving general medical services for mental health problems was reduced by about 50% when there was a higher than median level of social support from relatives. Specialty psychiatric service use was reduced when there was regular contact with six or more relatives and there was a higher than median level of social support from friends and relatives. None of the social network or social support measures were significantly (p</=.01) associated with use of other human services. CONCLUSIONS Increased contact with the social network and higher levels of social support were associated with greater use of general medical services. However, more social support was associated with use of fewer services within the specialty psychiatric sector.

The Effect of Social Networks and Social Support on Mental Health Services Use, Following a Life Event, among the Baltimore Epidemiologic Catchment Area Cohort

The study examined the association between life events and mental health services use, accounting for social networks and social support. Main and stress-buffering effects were estimated using longitudinal data from the Baltimore Epidemiologic Catchment Area cohort (1,920 participants in 1993–1996, of whom 1,071 were re-interviewed in 2004–2005). Following a life event, the odds of using general medical services were increased by almost 50% when there was increased social support from spouse/partner (referral function). The odds of using mental health services within general health setup were reduced by 60% when there was increased support from relatives (stress-reduction function). Increased social support from friends and relatives was associated with a 40–60% decreased odds of using specialty psychiatric services after experiencing different life events (stress-reduction function). Overall, social support rather than social networks were more strongly associated with increased mental health service use following a life event. The implications for service delivery and program development are discussed.

Mental Health Services Use: Baltimore Epidemiologic Catchment Area Follow-Up

OBJECTIVE To examine the patterns of previous and current mental health services use among older adults in the Baltimore Epidemiologic Catchment Area Follow-up. Examination of a recent cohort of older adults is important because patterns of utilization may have changed due to treatment advances, changes in mental healthcare services, and greater mental health awareness. DESIGN A population-based longitudinal survey. SETTING Continuing participants in a study of community-dwelling adults who were living in East Baltimore in 1981. PARTICIPANTS In all, 1,067 adults for whom complete data were available. MEASUREMENTS Separately, and before the mental health assessments were made, participants were asked about use of health services. Cognitive status and physical health were assessed using standardized instruments. Mental disorders were assessed using the Diagnostic Interview Schedule. RESULTS Compared with adults aged 40-59 years in 2004, adults aged 60 years and older were less likely to report specialty mental health services versus general medical care without a mental health component (adjusted odds ratio = 0.28, 95% confidence interval [0.14-0.56]). Multivariate models controlled for potentially influential characteristics including major depression or depression associated with recent bereavement, anxiety disorders, and past use of mental health services. CONCLUSION Adults aged 60 years and older are approximately one third as likely to consult a specialist in mental health compared with adults aged 40-59 years even accounting for other factors associated with differential use of services. Our study strengthens evidence that the primary care remains important for the treatment of psychiatric disorders in the elderly.

The effect of social networks and social support on common mental disorders following specific life events

OBJECTIVE This study examined the association between life events and common mental disorders while accounting for social networks and social supports. METHOD Participants included 1920 adults in the Baltimore Epidemiologic Catchment Area Cohort who were interviewed in 1993-1996, of whom 1071 were re-interviewed in 2004-2005. Generalized estimating equations were used to analyze the data. RESULTS Social support from friends, spouse or relatives was associated with significantly reduced odds of panic disorder and psychological distress, after experiencing specific life events. Social networks or social support had no significant stress-buffering effect. Social networks and social support had almost no direct or buffering effect on major depressive disorder, and no effect on generalized anxiety disorder and alcohol abuse or dependence disorder. CONCLUSION The significant association between social support and psychological distress, rather than diagnosable mental disorders, highlights the importance of social support, especially when the severity of a mental health related problem is low.

SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India

Background Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India. Objective The objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting. Methods Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10. Results During validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines. Conclusions A tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful. Trial Registration Clinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq).

Responsible governance for mental health research in low resource countries

Blurb: Taghi Yasamy and colleagues identify challenges facing good research governance in low- and middle-income countries and provide suggestions for a way forward.