Waquas Waheed

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVE To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- and middle-income (LAMI) countries. METHODS Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother-infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions. FINDINGS Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was -0.38 (95% confidence interval: -0.56 to -0.21; I (2) = 79.9%). Where assessed, benefits to the child included improved mother-infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates. CONCLUSION In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.

The relationship between the duration of untreated psychosis and outcome in low-and-middle income countries: A systematic review and meta analysis

BACKGROUND The duration of untreated psychosis (DUP) is defined as the period between the onset of symptoms of psychosis and the start of antipsychotic treatment. Delay in the initiation of treatment, resulting in a long DUP, is associated with a poor prognosis in high-income (HI) countries. It is not known if longer DUP is associated with poor outcomes in Low and Middle Income (LAMI) countries, where schizophrenia might have a more benign course. METHODS A systematic review and meta-analysis of studies from LAMI countries that reported an association between DUP and response to treatment, measures of disability and mortality. The association between DUP, symptoms and cognitive function at presentation were also examined. FINDINGS Meta analysis of five studies that reported the association between DUP and the reduction in total symptoms scores after treatment found a significant negative correlation between DUP and improvement in symptoms after treatment (r=-0.290, 95% CI=-0.483 to -0.069, z=-2.559, p<0.011). Prolonged DUP was also associated with increased levels of disability. One study reported that longer DUP was associated with a higher mortality in the following decade. CONCLUSIONS Delay in the initial initiation of treatment for psychosis is associated with a poorer response to treatment and increased levels of disability in LAMI countries.

Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease

Objective To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions. Design Cluster randomised controlled trial. Setting 36 general practices in the north west of England. Participants 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial. Interventions Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses. Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF). Results 19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval −0.41 to −0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support. Conclusions Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity. Trial registration ISRCTN80309252.

Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials

Background Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication). Methods and Findings Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient −0.11, 95% CI −0.20 to −0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. Conclusion Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.

The relationship between anxiety, depression and illness perception in tberculosis patients in Pakistan

ObjectiveAs the rates of TB world over have increased during the past 10 years, there has been a growing awareness of depression and its role in the outcome of chronic disorders. Though depression is common in patients with TB no study as yet has examined the prevalence of depression in this group in Pakistan. We aimed to determine the presence of depression, anxiety and illness perceptions in patients suffering from Tuberculosis (TB) in Pakistan.Methods108 consecutive outpatients with tuberculosis completed the Hospital Anxiety and Depression scale (HADS) and the Illness Perception Questionnaire (IPQ).ResultsOut of 108 patients, 50 (46.3%) were depressed and 51 (47.2%) had anxiety. Raised depression and anxiety scores were associated with an increase in the number of symptoms reported (HADS Depression: r = 0.346, p = < 0.001), more serious perceived consequences (HADS Depression: r = 0.279, p = 0.004, HADS Anxiety: r = 0.234, p = 0.017) and less control over their illness (HADS Depression: r = 0.239, p = 0.014, HADS Anxiety: r = 0.271, p = 0.005).ConclusionWe found that about a half of patients in our sample met the criteria for probable depression and anxiety based on HADS score. Negative illness perceptions were clearly related to reports of mood symptoms. As depression and lack of perceived control over illness in those suffering from tuberculosis are reported to be independent predictors of poor adherence further studies to investigate their relationship with medication adherence are required.

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.

Prevalence and psychosocial risk factors of PTSD: 18 months after Kashmir earthquake in Pakistan

BACKGROUND On average in a year 939 earthquakes of a magnitude between 5 and 8 on the Richter scale occur around the world. In earthquakes developing countries are prone to large-scale destruction because of poor structural quality of buildings, and preparedness for earthquakes. On 8th October 2005, a major earthquake hit the remote and mountainous region of northern Pakistan and Kashmir. We wanted to find out the rate of PTSD in a randomly selected sample of participants living in earthquake area and the correlates of the PTSD. METHOD The study was conducted 18 months after the earthquake. We selected a sample of men and women living in the houses and tents for interviews. Using well established instruments for PTSD and general psychiatric morbidity we gathered information from over 1200 people in face to face interviews. We gathered information about trauma exposure and loss as well. RESULTS 55.2% women and 33.4% men suffered from PTSD. Living in a joint family was protective against the symptoms of PTSD. Dose of exposure to trauma was associated with the symptoms of PTSD. Living in a tent was associated with general psychiatric morbidity but not with PTSD. LIMITATIONS We used questionnaire instead of interviews to detect the symptoms of psychiatric disorders. CONCLUSIONS The symptoms of PTSD are common 18 months after the earthquake and they are specifically associated with the dose of trauma exposure. This may have implications for rehabilitation of this population.

Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: findings from Developing Culturally-sensitive CBT Project (DCCP).

BACKGROUND There is sufficient research evidence in favour of cognitive therapy in western world. However, only limited research has been carried out on its effectiveness in other countries. It is suggested that adaptations in content, format and delivery are needed before CBT can be employed in non-western cultures. We describe a preliminary evaluation of culturally adapted CBT for depression in Pakistan. AIMS We aimed to evaluate the efficacy of this culturally adapted CBT using a therapist manual. METHOD In a randomized controlled trial we compared combination of CBT and antidepressants with antidepressants alone (treatment as usual) in primary care. Referred patients with ICD-10 diagnosis of depression were invited to participate and randomized to the intervention and control groups. Hospital Anxiety and Depression Scale (HADS) and Bradford Somatic Inventory (BSI) were used to measure changes in depression, anxiety and somatic symptoms. RESULTS Seventeen patients each were randomized to each arms of the trial. Except for financial status there were no differences between the two groups on various demographic variables. Patients receiving CBT showed statistically significant improvement on measures of depression (p < .001), anxiety (p < .001) and somatic symptoms (p < .000) as compared to antidepressant alone group. 82% patients attended six or more sessions of therapy. CONCLUSIONS A culturally sensitive manualized CBT was effective in reducing symptoms of depression and anxiety in Pakistan.

Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence.

BackgroundCommon mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care.MethodsWe began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users.ConclusionsOur methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

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.