Development of a brief psychological intervention for perinatal depression (BIND-P).

BACKGROUND: Lack of recognition in national programs, poor referral system, and non-availability of trained human resources are the important barriers for the delivery of perinatal depression (PND) services in low- and middle-income countries (LAMICs). To address this there is an urgent need to develop an integrative and non-specialist-based stepped care model. As part of its research thrust on target areas of India's National Mental Health Programme (NMHP), the Indian Council of Medical Research funded a research project on the outcome of PND at four sites. In this article, we describe the development of the primary health care worker-based stepped care model and brief psychological intervention for PND. METHODS: A literature review focused on various aspects of PND was conducted to develop a model of care and intervention under NMHP. A panel of national and international experts and stakeholders reviewed the literature, opinions, perspectives, and proposal for different models and interventions, using a consensus method and WHO implementation toolkit. RESULTS: A consensus was reached to develop an ANM (Auxillary nurse midwife)-based stepped-care model consisting of the components of care, training, and referral services for PND. Furthermore, a brief psychological intervention (BIND-P) was developed, which includes the components of the low-intensity intervention (eg, exercise, sleep hygiene). CONCLUSION: The BIND-P model and intervention provide a practical approach that may facilitate effective identification, treatment, and support women with PND. We are currently evaluating this model across four study sites in India, which may help in the early detection and provision of appropriate and integrative care for PND.

Assessing antenatal depression in primary care with the PHQ-2 and PHQ-9: Can It Be carried Out by auxiliary nurse midwife (ANM)?

Antenatal Depression (AD) is prevalent in India but remains unidentified and untreated in primary care settings. The Auxiliary Nursing Midwife (ANM), a non-specialist health care worker at antenatal care (ANC) clinic or at a primary care centre can improve the detection of women with AD. In this study, we aimed to estimate the inter-rater reliability of the Patient Health Questionnaire (PHQ-9) and PHQ-2, administered by ANMs, with mental health professionals, that is, Clinical Psychologists(CP). The prospective, blind, observational study was conducted in an antenatal clinic of tertiary care rural hospital of India. PHQ-2 and PHQ-9(Marathi) valid and translated versions were administered to consecutive antenatal women (n = 108) aged 18-45 years by two raters (CP, ANM) independently. Raters and data analyst were blinded to each other's scores. Kappa Coefficient, weighted kappa, Intra-class correlation coefficients (ICC) were used to assess Inter-rater reliability. The mean age of the study participants was 25.91 ± 4.39 years. Inter-rater reliability for PHQ-2 (Screen -Positive or Negative for depression) and PHQ-9 (Severity of depression) was (k = 0.675) and (kw = 0.732) respectively, which suggested the 'substantial' agreement between ANMs and CP. Among raters, the ICC (95 % confidence interval) was 0.90 (0.85, 0.93) for the PHQ-9 score and for the PHQ-2 was 0.873 (0.819-0.911), which was suggestive of excellent and good reliability respectively. The 'substantial' agreement and 'good to excellent' inter-rater reliability among ANM and CP suggest that these two scales can be used to screen and assess the severity of AD by either qualified or minimally trained, community health workers.

Effectiveness of a Brief Psychological Intervention Delivered by Nurse for Depression in Pregnancy: Study Protocol for a Multicentric Randomized Controlled Trial from India.

BACKGROUND: Perinatal depression (PD) has important implications for maternal and infant well-being but largely goes undetected. There is a need to develop low-intensity psychosocial interventions applicable to obstetric health care facilities. OBJECTIVE: To assess the effectiveness of a brief psychological intervention for mild to moderate PD delivered by a nurse as compared to treatment-as-usual (TAU). METHODS: This study is a randomized, open-label, parallel-group, multicentric trial being conducted in four sites of India. A total of 816 pregnant women with mild to moderately severe depression (Patient Health Questionaire-9 score of 5-19) are being assessed for the effectiveness of the intervention. Participants are randomly allocated to two groups of trial intervention (psychological intervention given by nurse) and TAU. The primary outcome is to compare the proportion of women reporting improvement across both groups. Participants are serially followed-up in each trimester and at 6, 10, 14 weeks, and 6 months postpartum. Secondary outcomes include pregnancy outcomes, feeding practices, physical growth, and immunization status of the infants. CONCLUSION: It is a prospective pregnancy birth cohort with a robust design and long-term follow-up. This is one of the largest studies utilizing non-specialist health workers for the screening and management of PD. This study also holds promise to cast light on the course and outcome of depression during pregnancy in different parts of India. It is envisaged to help in developing a sound screening and referral-based protocol for obstetric settings.

Effectiveness of Psychological Intervention by Videoconference for Family Members with Depression of Farmers Who Have Committed Suicide.

BACKGROUND: In India two thirds of the population is directly or indirectly dependent on agriculture. The suicide rate for farmers throughout the world is higher than the non-farming population with India being no exception. Family members of the household where a member has committed suicide are at an increased risk for depression, anxiety and suicide. There is a paucity of trained counsellors in India, while there is sufficient research showing counselling and therapy through videoconferencing is just as effective as in-person therapy. It is however, not commonly practiced in India, especially in rural settings. We propose to evaluate psychiatric morbidity and assess feasibility and effectiveness of videoconferencing for family members of farmers who had committed suicide. OBJECTIVES: The objective is to evaluate family members of farmers who have committed suicide for psychiatric morbidity and psychosocial risk factors. We aim to identify depression, anxiety and suicidal risk in family members and then administer psychological intervention through video-conferencing for depression to study its effectiveness in the cohort. METHODOLOGY: The data on completed farmer suicide would be collected from district authorities and police departments. Home visit would be made by research staff to assess the risk factors for the farmers who completed suicide. Family members would be screened for anxiety and depression and severity of depression and suicidal ideas would be rated. The family members having mild to moderate depression would be randomised and CBT based psychological intervention (5 sessions) over three months would be given by trained psychologist through videoconferencing. The outcome would be measured at the end of six months. CONCLUSIONS: Psychological interventions through video-conference might be beneficial in the treatment of mild to moderate depression in family members of the farmers who have committed suicide.

Perinatal depression-knowledge gap among service providers and service utilizers in India.

INTRODUCTION: Lack of access to perinatal mental health (PMH) services is a significant public health problem in India. Barriers to accessing PMH services include the stigma, non-availability of services, poor knowledge, negative perception, attitude among perinatal women (PWs) and service providers. The present study attempted to examine the knowledge gap regarding perinatal depression (PD) among service providers [Nursing providers (NPs), Medical Practitioners (MPs)] and service utilizers (PWs). METHODS: This cross-sectional study was conducted in two tertiary care teaching hospitals of India, one in a major metro and the other in a rural area. PWs, MPs and NPs were assessed for knowledge about PD using a semi-structured proforma and Perinatal Depression Monitor. RESULTS: Among the 270 PWs, 8.51% were knowledgeable (PWA) and 91.49% were ignorant (PWB) about depression. PWB group were low educated (n = 140, 56.68%), and unemployed (n = 207, 83.80%) with lower family income [(≤₹10,356 per month), n = 170, 68.28%)]. There was knowledge discrepancy among NPs, MPs and PWA group in terms of a) PD is a normal part of pregnancy (agree- NPs = 71.52%, MPs = 10.00%, PWA-17.39%), b)biological causes of PD (agree- NPs = 45.23%, MPs = 70.00%, PWA = 26.03%) and c)antidepressant medications for PD (useful- NPs = 23.80%, MPs = 70.00%, PWA = 21.73%). Majority of the respondents agreed that all women should be screened for depression during pregnancy (NPs = 34.78%, MPs = 80.95%, PWA = 95.00%) and postpartum periods (NPs = 34.78%, MPs = 76.19%, PWA = 90.00%). CONCLUSIONS: Low PD literacy among the PWs, misconception about aetiology and management among the NPs could be major barrier for delivery and utilisation of PD services. Thus, there is an urgent need to improve PD literacy among PWs and NPs.

Blue Whale Challenge: Perceptions of First Responders in Medical Profession.

CONTEXT: Blue Whale Challenge is a phenomenon which gained its early foothold on the internet chatboards. It is a dare-based harmful game which has a list of fifty tasks which you perform culminating in one's death on the final task. The fatalities caused by individuals playing this game have been reported first in Russia and followed by at least twenty countries reporting it, including India. AIMS: This study was conducted to assess perceptions and knowhow of the first responders in medical profession about online challenges. SETTINGS AND DESIGN: This was a cross-sectional descriptive study. SUBJECTS AND METHODS: Fifty-four medical professionals who practice either psychiatry, clinical psychology, or pediatrics were interviewed using a semi-structured open-ended survey was administered and data were obtained. STATISTICAL ANALYSIS USED: Descriptive statistics was used. RESULTS: Thirty-five (65%) of the total participants have heard about the Blue Whale Challenge but lacked further knowledge about the game. Ten percent of total participants knew about other internet challenges. Only 26% of total participants were largely aware about the details and harmful nature of the game. Only 12 (22%) participants knew the signs to identify the children playing this game. None of the practitioners reported of having encountered any parent or child enquiring or reporting this in their practice at the time of conducting the survey. CONCLUSIONS: The medical fraternity is lagging behind in updating themselves of the online phenomena which are important for the better outcome of children presenting with participation in online challenges. The nature of the game has been discussed, and guidelines for identifying vulnerable population have been put forward.

A Comparative Study of Epicardial Fat Thickness and its Association with Abdominal Visceral Fat Thickness in Obese and Nonobese Type 2 Diabetes Subjects.

CONTEXT: The concept of visceral fat and its role in various metabolic disorders is well-known. Epicardial fat (EF) is also visceral fat, and very few studies are done, especially in the Indian subcontinent. AIMS: To study and establish the relationship of EF thickness (EFT) and abdominal visceral fat thickness (VAT) in obese and nonobese type 2 diabetics and to evaluate the usefulness of EFT as a marker of visceral adiposity. SETTINGS AND DESIGNS: This cross-sectional study was carried out in the Department of Medicine, JSS Hospital, Mysore, India, between October 2012 and October 2014. MATERIALS AND METHODS: A total of 68 patients were studied. Patients underwent transthoracic echocardiography and ultrasound abdomen. EFT and VAT were measured. STATISTICAL ANALYSIS: SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) was used. T-test used for comparing quantitative variables. Correlation analysis was done using Pearson correlation test. P ≤ 0.05 was considered statistically significant. Kruskal-Wallis and Mann-Whitney test were used for analysis. RESULTS: The mean value of EFT was 5.92 mm, 7.43 mm, 12.97 mm, 11.27 mm, and 13.8 mm for nonobese, obesity Grade I, II, III, and morbid, respectively (P < 0.0001). The mean EFT between nonobese and obese diabetics was 5.92 mm and 10.2 mm, respectively (P < 0.0001). The mean VAT between nonobese and obese diabetics was 16.58 mm and 38.53 mm, respectively. EFT was significantly correlating with VAT in obese diabetics. CONCLUSION: EFT and VAT were significantly correlated among obese diabetics while not significantly correlated among nonobese diabetics, suggesting obesity is an independent risk factor for visceral adipose tissue deposition both in abdomen as well as in epicardial surface.

Effect of a course of electroconvulsive therapy on interictal bispectral index values: a prospective study.

OBJECTIVES: Bispectral index (BIS) value measures the level of hypnosis (sedation) during anesthesia. It uses electroencephalographic signals to measure the level of sedation. Electroconvulsive therapy (ECT)-induced changes in electroencephalography last for several hours to days. How this affects BIS values is unknown. METHODS: In 30 patients with schizophrenia or mood disorders who were prescribed ECT (bitemporal, brief-pulse ECT), BIS values were obtained before the start of anesthesia on the first (baseline), fourth (48 hours after the third ECT), and seventh ECT (48 hours after the sixth ECT) sessions. Bispectral index values were recorded in resting state and during a short conversation a few minutes before the induction of anesthesia. The changes in BIS values through the course of ECT were analyzed using repeated-measures analysis of variance and the McNemar test. RESULTS: Mean (SD) resting BIS value dropped from 91.6 (6.6) at baseline to 79.7 (20.2) after the sixth ECT (repeated-measures analysis of variance occasion effect: F = 6.78; df = 2,58; P = 0.02). The drop in corresponding values during conversation was not significant. The proportion of patients whose resting BIS values were in the sedated/anesthetized range increased from 26% at baseline to 60% after the sixth ECT session (McNemar test: P = 0.031). CONCLUSIONS: Bispectral index values of awake individuals in resting state drop significantly through a course of bitemporal brief-pulse ECT. Anesthesiologists should be aware that a considerable proportion of patients who have received a course of ECT may have BIS values in the sedated/anesthetized range even when they are awake. The BIS may not provide accurate estimation of the depth of anesthesia during ECT after the initial ECT sessions.

Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): A new test-battery to assess social cognition.

Social cognition is a cognitive domain that is under substantial cultural influence. There are no culturally appropriate standardized tools in India to comprehensively test social cognition. This study describes validation of tools for three social cognition constructs: theory of mind, social perception and attributional bias. Theory of mind tests included adaptations of, (a) two first order tasks [Sally-Anne and Smarties task], (b) two second order tasks [Ice cream van and Missing cookies story], (c) two metaphor-irony tasks and (d) the faux pas recognition test. Internal, Personal, and Situational Attributions Questionnaire (IPSAQ) and Social Cue Recognition Test were adapted to assess attributional bias and social perception, respectively. These tests were first modified to suit the Indian cultural context without changing the constructs to be tested. A panel of experts then rated the tests on likert scales as to (1) whether the modified tasks tested the same construct as in the original and (2) whether they were culturally appropriate. The modified tests were then administered to groups of actively symptomatic and remitted schizophrenia patients as well as healthy comparison subjects. All tests of the Social Cognition Rating Tools in Indian Setting had good content validity and known groups validity. In addition, the social cure recognition test in Indian setting had good internal consistency and concurrent validity.