Sudipto Chatterjee

Treatment and prevention of mental disorders in low-income and middle-income countries

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial.

: Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders. : In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407. : 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide. : A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities. : The Wellcome Trust.BACKGROUND Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders. METHODS In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407. FINDINGS 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide. INTERPRETATION A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities. FUNDING The Wellcome Trust.

Scale up of services for mental health in low-income and middle-income countries

Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally.

Arecibo pulsar survey using alfa. I. Survey strategy and first discoveries

We report results from the initial stage of a long-term pulsar survey of the Galactic plane using the Arecibo L-band Feed Array (ALFA), a seven-beam receiver operating at 1.4 GHz with 0.3 GHz bandwidth, and fast-dump digital spectrometers. The search targets low Galactic latitudes, |b| 5°, in the accessible longitude ranges 32° l 77° and 168° l 214°. The instrumentation, data processing, initial survey observations, sensitivity, and database management are described. Data discussed here were collected over a 100 MHz passband centered on 1.42 GHz using a spectrometer that recorded 256 channels every 64 μs. Analysis of the data with their full time and frequency resolutions is ongoing. Here we report the results of a preliminary, low-resolution analysis for which the data were decimated to speed up the processing. We have detected 29 previously known pulsars and discovered 11 new ones. One of these, PSR J1928+1746, with a period of 69 ms and a relatively low characteristic age of 82 kyr, is a plausible candidate for association with the unidentified EGRET source 3EG J1928+1733. Another, PSR J1906+07, is a nonrecycled pulsar in a relativistic binary with an orbital period of 3.98 hr. In parallel with the periodicity analysis, we also search the data for isolated dispersed pulses. This technique has resulted in the discovery of PSR J0628+09, an extremely sporadic radio emitter with a spin period of 1.2 s. Simulations we have carried out indicate that ~1000 new pulsars will be found in our ALFA survey. In addition to providing a large sample for use in population analyses and for probing the magnetoionic interstellar medium, the survey maximizes the chances of finding rapidly spinning millisecond pulsars and pulsars in compact binary systems. Our search algorithms exploit the multiple data streams from ALFA to discriminate between radio frequency interference and celestial signals, including pulsars and possibly new classes of transient radio sources.

Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months

This paper has been corrected post-publication in deviation from print and in accordance with a correction printed in the February 2012 issue of the Journal. Background Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare. Aims To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders. Method Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinicaltrials.gov (NCT00446407). Results A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities. Conclusions Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities.

Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial

Summary Background Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middle-income countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care. Methods We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16–60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013. Findings 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference −3·75, 95% CI −7·92 to 0·42; p=0·08; IDEAS −0·95, −1·68 to −0·23; p=0·01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0·89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (−9·29, −15·41 to −3·17; p=0·003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease. Interpretation The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas. Funding Wellcome Trust.

Getting Its Kicks: A VLBA Parallax for the Hyperfast Pulsar B1508+55

The highest velocity neutron stars establish stringent constraints on natal kicks, asymmetries in supernova core collapse, and the evolution of close binary systems. Here we present the first results of a long-term pulsar astrometry program using the VLBA. We measure a proper motion and parallax for the pulsar B1508+55, leading to model-independent estimates of its distance (2.37 kpc) and transverse velocity (1083 km s-1), the highest velocity directly measured for a neutron star. We trace the pulsar back from its present Galactic latitude of 523 to a birth site in the Galactic plane near the Cyg OB associations, and find that it will inevitably escape the Galaxy. Binary disruption alone is insufficient to impart the required birth velocity, and a natal kick is indicated. A composite scenario including a large kick along with binary disruption can plausibly account for the high velocity.

Arecibo Pulsar Survey Using ALFA. II. The Young, Highly Relativistic Binary Pulsar J1906+0746

We report the discovery of PSR J1906+0746, a young 144 ms pulsar in a highly relativistic 3.98 hr orbit with an eccentricity of 0.085 and expected gravitational wave coalescence time of � 300 Myr. The new pulsar was found during precursor survey observations with the Arecibo 1.4 GHz feed array system and retrospectively detected in the Parkes Multibeam plane pulsar survey data. From radio follow-up observations with Arecibo, Jodrell Bank, GreenBank,andParkes,wehavemeasuredthespin-downandbinaryparametersofthepulsaranditsbasicspectral and polarization properties. We also present evidence for pulse profile evolution, which is likely due to geodetic precession, a relativistic effect caused by the misalignment of the pulsar spin and total angular momentum vectors. Our measurements show that PSR J1906+0746 is a young object with a characteristic age of 112 kyr. From the measured rate of orbital periastron advance (7N57 � 0N03 yr � 1 ), we infer a total system mass of 2:61 � 0:02 M� . While these parameters suggest that the PSR J1906+0746 binary system might be a younger version of the double pulsar system, intensive searches for radio pulses from the companion have so far been unsuccessful. It is therefore not known whether the companion is another neutron star or a massive white dwarf. Regardless of the nature of the companion, a simple calculation suggests that the Galactic birthrate of binaries similar to PSR J1906+0746is � 60Myr � 1 .ThisimpliesthatPSRJ1906+0746willmakeasignificantcontributiontothecomputed cosmic inspiral rate of compact binary systems. Subject headingg pulsars: general — pulsars: individual (PSR J1906+0746)

Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India

Background There is little evidence of the feasibility, acceptability and impact of services for the care of people with psychotic disorders in low- and middle-income countries. Aims To describe the scaling up and impact of a community-based rehabilitation programme for people with psychotic disorders in a very-low-resource setting. Methods Longitudinal study of people with psychotic disorders who had been ill for an average of 8 years in a rural Indian community. All individuals received a community-based intervention package comprising psychotropic medications, psychoeducation, adherence management, psychosocial rehabilitation and support for livelihoods. The primary outcome was change in disability scores. Results The cohort consisted of 256 people with psychotic disorders (schizophrenia, bipolar affective disorder and other psychosis) of whom 236 people completed the end-point assessments (92%), with a median follow-up of 46 months. There were significant reductions (P<0.05) in the levels of disability for the cohort, the vast majority (83.5%) of whom engaged with the programme. On multivariate analyses, lower baseline disability scores, family engagement with the programme, medication adherence and being a member of a self-help group were independent determinants of good outcomes. Lack of formal education, a diagnosis of schizophrenia and dropping out of the programme were independent determinants of poor outcomes. Conclusions Community-based rehabilitation is a feasible and acceptable intervention with a beneficial impact on disability for the majority of people with psychotic disorders in low-resource settings. The impact on disability is influenced by a combination of clinical, programme and social determinants.

Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India

Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.