Perinatal mental health in India: protocol for a validation and cohort study

BACKGROUND

Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh).

METHODS

The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women's knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively.

CONCLUSION

Improving understanding, detection and management of CMD among women is key to improving women's health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Gender Issues in the Care of Elderly: A Narrative Review

Aging is an inevitable physiological process. A significant increase has been noted in the elderly population over the years. Aging population face challenges with physical health conditions, but also mental health problems. Care of the elderly is influenced by health conditions, health services, as well socio cultural factors. Gender plays an important role in the aging process with significant differences noted in the aging process, variations in health conditions as well care received. The current review addresses the role of gender in the aging process and its influence in the prevalence, clinical presentation and course of various mental and physical health conditions in the elderly. The review identifies gaps in understanding the gender perspectives related to long-term elderly care, legal and financial issues. The review emphasizes the necessity to address the gender perspective in aging to adequately meet the health demands of the elderly.

Yoga Module for Somatoform Pain Disorders: Development, Content Validation, and Feasibility Testing

BACKGROUND

Yoga practices have been found to be useful in chronic pain conditions but studies focussing specifically on somatoform pain disorders (SPDs) are limited.

AIMS

Current study aims to develop and test the feasibility of a yoga program for patients with SPDs.

MATERIALS AND METHODOLOGY

Athorough search of traditional and contemporary literature was performed with the objective of formulating a yoga program for reducing chronic non-specific pain and associated psychological distress. Content validity of the program was then determined by taking the opinion of 18 yoga experts (who had >5 years of experience in treating mental health disorders) using content validation ratio (CVR) through Lawshe's formula. The feasibility of the module was tested on 10 subjects diagnosed with SPDs as per the International Classification of Diseases (ICD) -10 criteria using standard scales.

RESULTS

In the finalized module, 70.83% (34 out of 48 items) of the practices were retained along with the modifications as suggested by the experts. Two practices were not found to be feasible (Trikonasana and Shalabhasana) and hence were removed from the final module. A significant reduction in pain severity was observed in the subjects after practising the yoga module for 2 weeks. The content validity index for the whole module (average of all CVRs) was 0.55.

CONCLUSIONS

Ayoga module was developed for SPD. The content validity of the module was found to be good. The module was found safe and potentially useful for reducing pain severity in patients with SPD. Future studies should test the efficacy of the developed program through a randomized controlled clinical trial.

Perinatal Mental Health Care for Women With Severe Mental Illness During the COVID-19 Pandemic in India-Challenges and Potential Solutions Based on Two Case Reports

The ongoing COVID-19 pandemic in India has created several challenges in the care of women with perinatal mental illness. Access to healthcare has been disrupted by lockdowns, travel restrictions, and the unavailability of outpatient services. This report aims to discuss the challenges faced by women with severe mental illnesses during the perinatal period with the help of two case reports. Accordingly, we have highlighted the role of COVID-19 infection as a traumatic event during childbirth and its role in triggering a psychotic episode in women with vulnerabilities; difficulties faced by women with postpartum psychosis in accessing perinatal psychiatry services; and the challenges of admission into an inpatient Mother-Baby Unit (MBU). Further, we have discussed potential solutions from the perspectives of Lower and Middle-income (LAMI) countries that need to be extended beyond the pandemic. They include offering video consultations, reviewing hospital policies, and evolving strategies to mitigate traumatic experiences for pregnant and postpartum women with severe mental illnesses in both obstetric and psychiatric care.

Short-term outcome of mothers with severe mental illness admitted to a mother baby unit

BACKGROUND

Mother baby psychiatry units (MBUs) are the expected standard of inpatient care internationally for postpartum mothers with severe mental illness (SMI) and favorable outcomes for mother infant dyads have been reported from these services. However, there are very few such units in low- and middle-income countries. The current study aimed to assess the short-term outcome of mothers in SMI admitted to an MBU in India.

MATERIALS AND METHODS

Mother infant dyads admitted over a year in the MBU were assessed in detail at admission, discharge, and at 3 months. Tools used included the Brief Psychiatric Rating Scale (BPRS), Young's Mania Rating Scale, Edinburgh Postnatal Depression Scale, and Clinical Global Impression. Mother infant interaction was assessed using the NIMHANS maternal behavior scale.

RESULTS

The mean age of the 43 mothers admitted in this period was 27.3 ± 6.2 years. For 27 (62.8%) mothers, this was a first episode of psychosis. Affective disorders and acute psychotic disorders were the most common diagnoses. The average duration of stay in the MBU was 25 days. While all mothers showed significant improvement at discharge, mothers with a first episode in the postpartum had higher BPRS scores (Ws = 309.5, P = 0.02) as compared to the others. At 3 months following discharge, all mothers sustained the improvement achieved.

DISCUSSION

Mothers with SMI admitted to an MBU showed significant clinical and dyadic improvement at discharge which was sustained at 3 months. However, the lack of a control group limits the generalizability of the current findings.

CONCLUSION

The study highlighted a favorable short-term outcome among mothers with SMI admitted to a MBU facility.

Relationship between alexithymia and depression: A narrative review

Alexithymia has been described as difficulty in expressing as well as experiencing feelings. It has been studied in relation with medical as well as psychological conditions and has been seen to impact treatment outcomes. The current review focuses on the relationship of alexithymia with depression and the role of culture in this relationship. The keywords for literature included terms such as depression, alexithymia, depression and alexithymia, Toronto Alexithymia Scale, assessing alexithymia and depression, and alexithymia as a trait. The main findings of the review were that alexithymia and depression are highly correlated, and severity of depression and gender are independently associated with alexithymia and may interfere with treatment outcomes.

"Hear me out": experiences of women with severe mental illness with their healthcare providers in relation to motherhood

BACKGROUND

Most women with severe mental illness (SMI) are mothers, however little is known about their own experiences of how the health care providers offer support in handling motherhood. This study attempted to assess the barriers, expectations and facilitators in seeking help from mental health care providers in matters of pregnancy and motherhood using a qualitative methodology.

METHODS

The study used a qualitative design with social constructivist paradigm to obtain data from 30 mothers with SMI who had children less than five years of age. One-to-one in-depth semi-structured interviews were conducted and inductive thematic analysis was used to explore transcripts using Charmaz's grounded theory.

RESULTS

Main barriers in seeking help from health care providers were perceived stigma, treatment side-effects, misinterpretations of information and health providers not having enough time. On the other hand self-advocacy, early engagement with the health care system, being psychoeducated and involvement of the family with service providers were the facilitating factors. The prime expectations of the mothers were early and direct communication and basic guidance regarding child health and parenting issues.

CONCLUSION

Women who are mothers and also users of mental health services face special challenges in managing their illness and motherhood. Hearing their voices is essential for service provision and ensuring adequate mental health and handling motherhood.

Negative Childbirth Experience and Post-traumatic Stress Disorder - A Study Among Postpartum Women in South India

Purpose: Negative childbirth experience has been associated with post-traumatic stress disorder (PTSD) and depression in the postpartum period with a significant impact on the mother as well as the infant. Methods: The current study aimed at studying the association of negative child birth experience with PTSD and depressive symptoms among primiparous mothers within 6 weeks of child birth. The Childbirth Experience Questionnaire (CEQ), PTSD checklist (PCL), and Edinburgh Postnatal Depression scale (EPDS) were used to assess negative childbirth experience, symptoms of PTSD, and depression respectively. Results: Of the 95 women in the study, fifty women (52.6%) had a score below the median of CEQ score (score of 72) indicating a negative childbirth experience. Lower Scores on CEQ indicating negative childbirth experience correlated with PTSD scores on the PCL (r = -0.560, p = 0.001) and depression scores on the EPDS (r = -0.536, p = 0.001). Of the sample of 95 women, 7.36% (N = 7) met the criteria for probable PTSD and 3.16% (N = 3) met criteria for partial PTSD. Twelve women (12.6%) had EPDS scores above 13 indicating probable clinical depression. Median CEQ scores were lower among the women who had PTSD or partial PTSD (N = 10) and among the women who had probable depression (N = 12) than those who did not. Childbirth experience emerged as the only predictor of PTSD on logistic regression (p = 0.03) (95% CI 1.17-79.61). Conclusions: Negative childbirth experiences are common and appear to be associated with depressive and PTSD symptoms. These findings emphasize the need to provide good intrapartum care including respectful maternity care for a positive childbirth experience.

Factors influencing decision-making around pregnancy among women with severe mental illness (SMI): A qualitative study

BACKGROUND

Decision-making around pregnancy is challenging for women with severe mental illness (SMI), and several clinical and socio-cultural factors might influence this process.

AIM

The main objective of this study was to determine factors that influence decision-making regarding pregnancy for women with SMI.

METHODS

Using a qualitative design, 42 women with SMI who were pregnant or planning pregnancy were assessed using a semi-structured interview by an independent researcher not involved in their clinical care. Areas of inquiry included knowledge about their illness, treatment; family and societal beliefs on mental illness and motherhood; illness management; and attitude towards medical advice.

RESULTS

Among the 42 women, majority of the women (88%) reported reduced autonomy in decision-making related to pregnancy. Stigma was one of the major contributory factors in decision-making. Over 80% reported not using contraception despite medical advice due to lack of control over the decisions related to the use of contraception. Over 50% of the women in the study believed that taking psychotropic medications during pregnancy would definitely harm the baby. A similar number believed that their illness would not recur if medications were to be stopped during pregnancy.

CONCLUSION

Women with SMI who plan to become pregnant, especially from low-income settings in India, are disadvantaged by stigma and societal expectations, affecting their ability to make optimum decisions during this crucial period. Decision-making around pregnancy in women with SMI is complex and appears to be influenced by several socio-cultural factors and needs to be dealt with sensitively.

Psychological Distress, Coping and Perceived Social Support Among Partners of Women with Postpartum Onset Severe Mental Illness (SMI) Admitted to a Mother-Baby Unit

BACKGROUND

The presence of a severe mental illness in the mother during the postpartum period may impact the whole family and specifically have an effect on the health of the spouse. The current study aimed to assess psychological distress, coping, and perceived social support of spouses of women with postpartum onset severe mental illness.

METHODOLOGY

A cross-sectional descriptive research design was used, and 30 spouses of the women admitted to the mother-baby unit (MBU) for psychiatric inpatient care were included in the study. The assessments included sociodemographic details, Kessler psychological distress scale (K10), brief coping orientation to problems experienced scale (brief COPE), and Zimets' multidimensional scale of perceived social support.

RESULTS

Around 50% of the spouses experienced severe psychological distress. Nearly 40% of spouses reported poor coping and 56.7% of spouses had moderate social support from family and friends.

CONCLUSION

The findings indicate the need to address distress and coping in spouses of women with postpartum onset SMI.

Feasibility, Acceptability and Usage Patterns of a 24-Hour Mobile Phone Helpline Service for Women Discharged from a Mother-Baby Psychiatry Unit (MBU) in India

BACKGROUND

For women with perinatal mental illness, phone helplines may be a useful way of accessing help. This study assessed the feasibility, acceptability, limitations, and usage patterns of a helpline service for mothers discharged from a mother-baby psychiatry unit.

METHODS

Mothers discharged from a mother baby unit during an 18-month period were provided with a helpline number. A social worker answered the calls. Details of the calls, including the reasons and the interventions provided, were recorded. Feasibility and acceptability were assessed by calling all users and nonusers. Satisfaction with the helpline was recorded among users, and reasons for not calling were assessed among nonusers.

RESULTS

Among 113 mothers, 51 (45%) made 248 calls. Calls were regarding medication, sleep problems, planning pregnancies, symptom exacerbation, appointments, and suicidal ideation. Some calls were related to domestic violence (n = 13, 5.24%), and infant health and breastfeeding (n = 11, 4.44%). Seventy-six (67%, 44 callers and 32 noncallers) were contacted. The majority (41/44) of the callers found it useful: 91% said they got help, and 95% said they would recommend it to others. However, language difficulties (9%) and technical problems (5%) were reported. Among the noncallers, the majority reported having experienced no problem related to mental health or had contacted a doctor. However, of the noncallers, one woman died of suicide, did not have access to a phone, and the family did not choose to call.

CONCLUSIONS

Helpline phone service appears to be feasible and acceptable and can be adapted in other mother-baby psychiatry units in low and middle-income countries. However, in some women, the nonavailability of a phone may be a limiting factor.

Prevalence and clinical correlates of intimate partner violence (IPV) in women with severe mental illness (SMI)

Women with severe mental illness (SMI) are a vulnerable population in whom varying rates of Intimate Partner Violence (IPV) have been reported with impact on their illness. The current study aimed to assess the prevalence and clinical correlates of IPV among women with SMI admitted to a tertiary care psychiatric hospital. The study was a cross sectional assessment of IPV among women with severe mental illness receiving inpatient care. The assessments included Indian Family Violence and Control Scale (IFVCS) for IPV, Brief Psychiatric Rating Scale (BPRS version 4) for psychopathology, The Suicide Behaviours Questionnaire Revised (SBQ-R) for suicidality, Physical Health Questionnaire (PHQ) for physical health, Scale for Assessment of Somatic Symptoms (SASS) for somatic symptoms and also semi structured schedule for their sociodemographic profile. A total of 100 women diagnosed with SMI with a cohabiting partner were assessed. The lifetime prevalence of IPV in the women with SMI was 22 %. Last 1-year prevalence of IPV in them was 20 %. Control and emotional violence were the most commonly reported form of violence, followed by physical violence, and sexual violence was the least reported. Significant association of IPV with suicidal behaviour, depression scores, physical health and somatic symptoms were found. IPV is prevalent in women with SMI and needs to be addressed. It is important to assess all types of IPV as it can impact the illness and the lives of these women, overall.

Effect of Yoga on Psychological Distress among Women Receiving Treatment for Infertility

Background

Infertility among women has been associated with significant psychological distress, anxiety, and depression. yoga therapy has been found to be useful in the management of anxiety, depression and psychological distress.

Aim

To review studies on the effectiveness of yoga in reducing psychological distress and improving clinical outcomes among women receiving treatment for infertility.

Methodology

PubMed, ScienceDirect, and Google Scholar databases were searched for studies using the following inclusion criteria: studies published in English, those published between 2000 and 2018, published in peer-reviewed journals, and those with Yoga as an intervention. Review articles, studies without any yoga interventions for infertility, and male infertility were excluded. The keywords included for the literature search were: Yoga, Mindfulness, Relaxation technique, Stress, Distress, Anxiety, Infertility, In Vitro Fertilization (IVF), and Assisted Reproductive Technology (ART).

Results

Three studies satisfied the selection criteria. Two studies involved Hatha yoga intervention and one study used structured yoga program. The variables assessed in these studies were: (1) anxiety, (2) depression, (3) emotional distress, and (4) fertility-related quality of life. All the studies reported an improvement in the anxiety scores after yoga intervention.

Conclusion

Yoga therapy may be potentially useful in improving anxiety scores among women suffering from infertility. More studies are needed in this area to establish role of yoga as an adjuvant during the treatment of infertility.

A Comparative Study of Health Anxiety in Neurology and Psychiatry Settings

Objectives  Prevalence of health anxiety is highly varied based on different settings and samples studied. This study aimed to assess the prevalence of health anxiety among outpatients attending neurology and psychiatry outpatient setting in tertiary care hospital and understand the clinical correlates.

Participants and Methods  This was a cross-sectional study conducted in the outpatient settings including participants fulfilling study criteria. The assessments included semi-structured proforma for demographic and clinical details, general hypochondriasis subscale of Illness Behavior Questionnaire, and Short Health Anxiety Inventory. Data were collected in Epi-info and data analysis was done using STATA12.

Results  The health anxiety was reported to be 25% and 19% among psychiatry and neurology outpatients, respectively. Higher education level positively correlated with health anxiety. Skilled workers tend to have higher health anxiety than semiskilled workers. Patients with diagnosis of somatoform disorder and multiple diagnosis scored higher on health anxiety in both the settings.

Conclusion  Health anxiety appears to be common in psychiatry and neurology settings and needs further evaluation to understand its impact on consultation and health resource usages.

Perspectives of consumers in India on factors affecting recovery from schizophrenia

BACKGROUND

Identifying patient perspectives about recovery may help the service providers to enhance active participation of patients in their recovery.

AIM

This study aimed to explore patients' perspectives about factors affecting recovery from schizophrenia.

METHODS

A semi-structured interview schedule was used to explore the perceptions of 18 patients diagnosed with schizophrenia. The interviews were recorded, transcribed and analysed. Codes were identified and similar codes were grouped together and main themes were identified.

RESULTS

Nine main themes on facilitators and barriers of recovery from schizophrenia were derived.

CONCLUSION

Deeper understanding of patients' perspectives of recovery from schizophrenia can help mental health professionals to plan appropriate recovery-oriented services.

COVID-19-related anxiety and concerns expressed by pregnant and postpartum women-a survey among obstetricians

This paper from India describes anxieties that pregnant and postpartum women reported to obstetricians during the COVID-19 pandemic. Of the 118 obstetricians who responded to an online survey, most had been contacted for concerns about hospital visits (72.65%), methods of protection (60.17%), the safety of the infant (52.14%), anxieties related to social media messages (40.68%) and contracting the infection (39.83%). Obstetricians felt the need for resources such as videos, websites and counselling skills to handle COVID-related anxiety among perinatal women.

Association of Childhood Attention Deficit Hyperactivity Disorder Symptoms with Academic and Psychopathological Outcomes in Indian College Students: a Retrospective Survey

OBJECTIVE

To survey the prevalence of retrospectively recalled clinically significant symptoms of attention deficit hyperactivity disorder (ADHD) in childhood and determine the association of ADHD symptoms in childhood with current academic achievement and psychopathological outcomes among college students in the state of Kerala, India.

METHODS

A self-administered questionnaire was distributed to 5784 students from 58 colleges selected by cluster random sampling. The Barkley Adult ADHD Rating Scale-IV was used for recollection of childhood ADHD symptoms; a total score of ≥60 (indicating the 99 percentile) was taken as the cut-off for clinically significant ADHD symptoms in childhood. The Alcohol, Smoking and Substance Involvement Screening Test was used to assess lifetime use of alcohol and tobacco. The Kessler Psychological Distress Scale was used to assess non-specific psychological distress. Lifetime suicidality and exposure to sexual abuse were assessed by asking relevant questions. Students who recalled having clinically significant ADHD symptoms in childhood were compared with those who did not.

RESULTS

Of 5784 students, 639 (11.5%) did not complete the questionnaire. Of the remaining 5145 students, 1750 (34.8%) were men and 3395 (65.2%) were women, with a mean age of 19.4 years. 143 (2.8%) students reported clinically significant ADHD symptoms in childhood. Childhood ADHD symptoms were significantly more common in men and in those living in urban areas. In the bivariate analysis, those with clinically significant ADHD symptoms in childhood had significantly higher odds of poorer academic performance, alcohol use, tobacco use, psychological distress, suicidal thoughts, suicidal attempts, and contact and non-contact sexual abuse, after adjusting for sex and residence.

CONCLUSIONS

Clinical evaluation and appropriate management may be warranted for adults who retrospectively recall clinically significant ADHD symptoms in childhood.

Exploring the knowledge and attitude of public about mental health problems: A pilot intervention for effective mental health promotion

CONTEXT

The knowledge about mental health problems among the general public is comparatively quite low. The pilot study was conducted with an aim to increase the knowledge of the day-to-day mental health problems which people can have among the mass.

AIMS

The aims of this study are (1) to assess the knowledge and attitude about mental health problems of the selected sample and (2) to build the capacity in providing first aid for mental health to the selected sample through training.

SETTINGS AND DESIGN

A cross-sectional study was used in assessing the knowledge and skills of the participants of the first aid for mental health problems. It was conducted in the institute itself.

SUBJECTS AND METHODS

A total of 89 participants were taken to participate in the cross-sectional study. Using a semi-structured self-administered questionnaire, a brief training, and a feedback form, capacity building for first aid for mental health problems was provided.

STATISTICAL ANALYSIS USED

The questionnaires were analyzed using descriptive statistics.

RESULTS

The capacity building program for first aid for mental health problems appears to be effective in improving the knowledge and attitude with regard to the mental health problems. The findings from the program indicated lack of knowledge in understanding of mental health, knowledge of causation, and treatment of mental health problems. Feedback of the training program indicated that it improved the ability of the participants in recognizing persons undergoing mental health problems and brought about a change in their beliefs about mental health, attitudes, and need for prompt referral.

CONCLUSIONS

The program was successful in increasing the confidence of the participants in providing help to someone with a mental health problem and referring to appropriate mental health professional. This shows that there is an immediate need for empowering general public with knowledge and skills to provide support to people with mental health problems.

Idioms of Distress

The presentations of psychosocial distress and cultural conflicts are often bodily symptoms, especially in traditional societies and village backgrounds. These might not meet the criteria of the current psychiatric diagnostic systems. Sociocultural milieu contributes to the unique presentations of the stress in the form of idioms of distress. The latter are alternative modes of expressing distress and indicate manifestations of distress in relation to personal and cultural meaning. Health professionals often consider these as hysterical, functional or having functional overlays, and abnormal illness behaviors. Management of idioms of distress would need cultural competence and sensitivity. This article highlights the common idioms of distress in India with specific focus on bodily symptoms.

An Experiential Account of Sexual Dysfunction Among Women with Schizophrenia: A Qualitative Study from India

Aims: The study aimed to gather the perspectives of women with schizophrenia who had sexual dysfunction (SD) and to assess their perceptions related to discussions about sexual concerns with mental health professionals (MHP).

Settings: Female patients attending the outpatient department of a tertiary care university psychiatric hospital, who were diagnosed to have schizophrenia and in remission, were recruited and assessed for SD. Those who had SD and were willing to participate were interviewed for the qualitative study.

Methods and Materials: A guided interview format was used to gather their narratives. Interviews were transcribed and translated from audio recordings on the same day. The analysis of transcript from 9 patients reached theoretical saturation.

Analysis: The data were retrieved, coded, and systematically organized according to patterns and themes. The manual inductive coding method was used to arrive at the themes.

Results: 4 themes were found for the question assessing their perspective regarding SD and 3 themes on their perspectives regarding the discussion with MHP. Many of them had misconceptions regarding their sexual lives and the relationship between sexuality and their illness. It was evident that hardly any MHP had ever inquired about their sexual functioning.

Conclusion: This qualitative research on women with schizophrenia having SD gives us in-depth knowledge regarding their snags. Results of such studies will help the clinicians pay justifiable attention to these least spoken problems.