Demographic factors, social problems and material amenities as predictors of psychological distress: a cross-sectional study in Karachi, Pakistan

The Severity of Depression, Anxiety, and Stress: Recommendations From Joint Work of Research Center and Psychology Clinics in COVID-19 Pandemic

The COVID-19 pandemic has significantly affected the psychological stability of general population of Pakistan. However, research on the severity of COVID-19 induced depression, anxiety, and stress (DAS) in Pakistan is scarce. This paper thereby investigates the severity of COVID-19 induced DAS based on demographic, socioeconomic, and personal feeling variables by modeling DAS. Snowball sampling strategy was adopted to conduct online survey from July 03, 2021 to July 09, 2021. Out of 2,442, 2,069 responses from Karachi were included. Descriptive and inferential statistics (binary and multinomial logistic regression analysis) were performed using SPSS V21 (IBM, 2013) to identify significant determinants and their association with DAS severity. The result of this study indicates 27.8, 21.7, and 18.3% respondents suffer from severe and extremely severe states of depression, anxiety, and stress, respectively. Binary logistic regression revealed that age is a significant determinant with odds of having 4.72 (95% CI = 1.86-11.97) and 5.86 (95% CI = 2.26-15.2) times greater depression, and stress for respondents aged 19-26 years. Moreover, gender-based difference is also observed with females 1.34 (95% CI = 1.08-1.68) and 1.75 (95% CI = 1.40-2.20) times more likely to exhibit anxiety and stress than males. Furthermore, marital status is a significant determinant of depression with odds of having depression is 0.67 (95% CI = 0.48-0.93) times greater for married population. Multinomial logistic regression revealed that those who believe COVID-19 pandemic has affected them mentally, fear new COVID-19 cases and deaths, depressed due to imposition of lockdown, believe they will not survive COVID-19 infection, and spend more time on social media gathering COVID-19 updates suffer from extremely severe state of depression (OR mental-effect-of-pandemic = 3.70, OR new-COVID-19-cases-and-deaths = 2.20, OR imposition-of-lockdown = 17.77, OR survival-probability = 8.17, OR time-on-social-media = 9.01), anxiety (OR mental-effect-of-pandemic = 4.78, OR new-COVID-19-cases-and-deaths = 3.52, OR imposition-of-lockdown = 5.06, OR survival-probability = 8.86, OR time-on-social-media = 5.12) and stress (OR mental-effect-of-pandemic = 6.07, OR imposition-of-lockdown = 11.38, OR survival-probability = 15.66, OR time-on-social-media = 4.39). Information regarding DAS severity will serve as a platform for research centers and psychological clinics, to work collectively and provide technology-based treatment to reduce the burden on the limited number of psychologist and psychotherapist.

Psychological Distress Reported by Primary Care Physicians in China During the COVID-19 Pandemic

OBJECTIVE

Primary care physicians (PCPs) play a key role in responding to the COVID-19 epidemic. The objective of this study was to explore the influencing factors associated with self-reported psychological distress among a sample of PCPs in China in relation to COVID-19.

METHODS

An online survey was distributed to a sample of PCPs in Chengdu city between February 10 and February 13, 2020. The survey consisted of three sections: demographic characteristics, COVID-19-related questions, and the General Health Questionnaire-12 (GHQ-12). After 5 months, a follow-up survey investigating the change of the GHQ-12 was conducted.

RESULTS

A total of 712 PCPs completed the baseline survey (11.8% of those invited), 55.6% were female and 74.4% were aged between 30 and 49 years. High levels of psychological distress (GHQ-12 ≥3) were observed in 29.2% and were associated with low preparedness, high work impact, working with infected residents, personal life impact, and concerns, as well as older age and being married (p values < .05). Logistic regression analysis showed that psychological distress was associated with low preparedness (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.87-0.96), high work impact (OR = 1.11, 95% CI = 1.03-1.20), personal life impact (OR = 1.12, 95% CI = 1.07-1.17), and safety-related concerns (OR = 1.09, 95% CI = 1.02-1.16). At the 5-month assessment point, high psychological distress was less frequent (21.8%).

CONCLUSIONS

COVID-19 has resulted in high levels of distress in approximately 30% of PCPs in China. Factors associated with high psychological distress levels include low preparedness and high levels of work impact, personal life impact, and concerns. These findings highlight the importance of enhancing psychological health throughout the course of infectious pandemics.

Associations among sexuality-related factors, recent two-week morbidity and annual hospitalization in female migrant workers: a cross-sectional study in southern China

To explore the influence of sexuality-related factors on recent two-week morbidity and annual hospitalization in female migrant workers, 880 Chinese rural-to-urban female migrant workers aged 16-57 years were studied. Clustered logistic regression analyses revealed that women who never or seldom experienced lubrication difficulties had a lower risk of recent two-week morbidity (adjusted odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.17-0.60, P< 0.001; adjusted OR = 0.35, 95% CI = 0.18-0.69, P= 0.003) than those who always experienced lubrication difficulties; women who never felt a lack of sexual interest had a significantly lower risk of annual hospitalization (adjusted OR = 0.40, 95% CI = 0.20-0.79, P= 0.009) than those who always or seldom lacked sexual interest, and women who never felt sexual satisfaction had a higher risk of annual hospitalization (adjusted OR = 3.08, 95% CI = 1.75-5.42, P< 0.001) than those who always or seldom experienced sexual satisfaction. The independent contributions of sexuality-related factors to the risk of recent two-week morbidity and annual hospitalization were 5.8% and 29.5%, respectively. This study suggests that sexuality may have a modest influence on recent two-week morbidity and a dominant impact on annual hospitalization.

Epidemiological Correlates of Psychological Distress in a Rural Community of South India: A Cross-sectional Study

Context:

Integration of mental health into primary care is essential to establish access to mental health services. Screening the community for psychological distress is the first step.

Aims:

The aim of the study was to estimate the burden and the determinants of psychological distress in a rural community.

Settings and Design:

This was a community-based cross-sectional study among adult members of a rural community of Nitte Village in Udupi district in Karnataka, South India.

Methodology:

Three hundred and ten households were surveyed using the World Health Organization Self-Reported Questionnaire (SRQ). A cutoff value of 8 in SRQ was taken as screening positive.

Statistical Analysis Used:

Descriptive data were analyzed in proportions, whereas Chi-square test and regression analysis were used to explore associations.

Results:

Hypertension and diabetes were the two common comorbidities. The prevalence of psychological distress was 42.4 per thousand. “Being easily tired” and “feeling tired all the time” were the two most common responses out of the SRQ checklist. Distress was significantly associated with gender, educational status, and marital status.

Conclusions:

The prevalence of psychological distress was 42.4 per thousand, and somatic complaints were common presentations of distress in the study population.

Validation of the Recent Life Changes Questionnaire (RLCQ) for stress measurement among adults residing in urban communities in Pakistan

BACKGROUND

Recent Life Changes Questionnaire (RLCQ) developed by Richard Rahe has enabled quantification of stress by analyzing life events. The overall aim of the study was to create a reliable version of the Rahe's RLCQ for measuring stress in individuals living in developing countries and assess its validity. This paper discusses criterion validation of the adapted RLCQ in urban communities in Pakistan.

METHODS

This is a criterion validation study. Four urban communities of Karachi, Pakistan were selected for the study in which households were randomly chosen. Two data collectors were assigned to administer the adapted RLCQ to eligible participants after obtaining written informed consent. Following this interaction, two psychologists interviewed the same participants with a diagnostic gold standard of Mini International Neuropsychiatric Interview (MINI) which is utilized in usual practice within Pakistan to confirm the presence of stress related mental disorders such as Depression, Anxiety, Dysthymia, Suicide, Phobia, OCD, Panic Disorder, PTSD, Drug abuse and dependence, Alcohol abuse and dependence, Eating Disorders and Antisocial Personality Disorder to validate the accuracy of the adapted RLCQ. We generated the ROC curves for the adapted RLCQ with suggested cut-offs, and analyzed the sensitivity and specificity of the adapted RLCQ.

RESULTS

The area under the receiver operating characteristic curve (ROC) of common mental disorders such as depression and anxiety was 0.64, where sensitivity was 66%, specificity was 56% and the corresponding cut off from the adapted RLCQ was 750. Individuals scoring ≥750 were classified as high stress and vice versa. In contrast, the area under the ROC curve for serious mental disorder and adverse outcomes such as suicide, bipolar and dysthymia was 0.75, where sensitivity was 72% and specificity was 60% at the cut off of 800 on the adapted RLCQ. Individuals scoring ≥800 were classified as high stress and vice versa. The rate of agreement between the two psychologists was 94.32% (Kappa = 0.84).

CONCLUSION

The adapted and validated RLCQ characterizes common mental disorders such as depression and anxiety with moderate accuracy and severe mental disorders such as suicide, bipolar and dysthymia with high accuracy.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02356263 . Registered January 28, 2015. (Observational Study Only).

Associations between psychological stress and smoking, drinking, obesity, and high blood pressure in an upper middle-income country in the African region

The direction and magnitude of the associations between cardiovascular risk factors (CVRFs) and psychological stress continue to be debated, and no data are available from surveys in the African region. In this study, we examine the associations between CVRFs and psychological stress in the Seychelles, a rapidly developing small island state in the African region. A survey was conducted in 1,240 adults aged 25-64 years representative of the Seychelles. Participants were asked to rank psychological stress that they had experienced during the past 12 months in four domains: work, social life, financial situation, and environment around home. CVRFs (high blood pressure, tobacco use, alcohol drinking, and obesity) were assessed using standard procedures. Psychological stress was associated with age, sex, and socioeconomic status. Overall, there were only few consistent associations between psychological stress and CVRFs, adjusting for age, sex, and socioeconomic status. Social stress was associated with smoking, drinking, and obesity, and there were marginal associations between stress at work and drinking, and between financial stress, and smoking and drinking. Psychological stress was not associated with high blood pressure. These findings suggest that psychological stress should be considered in cardiovascular disease prevention and control strategies.

Mental Health of the Prison Medical Workers (PMWs) and Influencing Factors in Jiangxi, China

Prison medical workers (PMWs) are critically important, but they are also vulnerable to psychological problems. Currently, there is no study on examining PMWs’ mental health conditions and possible influencing factors in China. Hence, we conducted this cross-sectional survey, aiming to understand the mental health status of the PMWs and related impact factors in Jiangxi province of China. We employed the Chinese version of the Symptom Checklist-90-R (SCL-90-R) to assess the mental disorders and psychological health conditions of PMWs in Jiangxi. The t tests were used to compare the differences for the average score of SCL-90-R between the Chinese general population and targeted PMWs of this study. Multivariable logistic regression analyses were conducted to identify the main factors associated with overall detection rate of PMWs’ psychological health conditions. The scores of four dimensions (somatization, obsessive-compulsive symptoms, anxiety, and paranoid ideation) were significantly higher than the Chinese national norm, and the total positive rate was 49.09% among the PMWs. Gender, marital status, age, and length of employment are identified to be the most significant predictors to affect PMWs’ mental health. Positive correlations between each of the nine dimensions of the SCL-90-R have been verified. This study demonstrated for the first time that PMWs are facing mental health risk and suffering serious psychological problems with psychopathology symptoms, which has become a growing concern in China. Our current findings suggest a need for more in-depth studies on this subject going forward to validate our conclusions and also to identify more impact factors, since such studies and knowledge of PMWs’ mental health and influencing factors are very limited in China.

Problem Management Plus (PM+) in the management of common mental disorders in a specialized mental healthcare facility in Pakistan; study protocol for a randomized controlled trial

Background

The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, psychological intervention program delivered by trained non-specialist that addresses common mental disorders. The objectives of this study are to evaluate effectiveness and cost-effectiveness of PM+ in a specialized mental health care facility in Pakistan.

Methods

A single blind individual randomized controlled trial (RCT) will be carried out in the outpatient department of a specialized mental healthcare facility in Rawalpindi, Pakistan. After informed consent, patients with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ plus treatment as usual (n = 96) or TAU only (n = 96). The primary outcome is the psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale and improvement in functioning as measured by WHODAS at 20 weeks after baseline. Secondary outcomes include improvement in symptoms of depression, post-traumatic stress disorder, levels of social support and cost effectiveness evaluation. Qualitative interviews will be conducted to evaluate the process of implementing PM+ including barriers and facilitators in implementation and possibility of integration of PM+ program in specialized mental health care facilities in Pakistan.

Discussion

The results of this study will be helpful in evaluating the effectiveness of the approach of training non specialists, based in the specialized mental health care facilities in delivering evidence based psychological interventions in the low resource settings.

Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered Retrospectively on March 23, 2016

Electronic supplementary material

The online version of this article (doi:10.1186/s13033-017-0147-1) contains supplementary material, which is available to authorized users.

Adaptation of the Recent Life Changes Questionnaire (RLCQ) to measure stressful life events in adults residing in an urban megapolis in Pakistan

BACKGROUND

Contextually relevant stressful life events are integral to the quantification of stress. None such measures have been adapted for the Pakistani population.

METHODS

The RLCQ developed by Richard Rahe measures stress of an individual through recording the experience of life changing events. We used qualitative methodology in order to identify contextually relevant stressors in an open ended format, using serial in-depth interviews until thematic saturation of reported stressful life events was achieved. In our next phase of adaptation, our objective was to scale each item on the questionnaire, so as to weigh each of these identified events, in terms of severity of stress. This scaling exercise was performed on 200 random participants residing in the four communities of Karachi namely Kharadar, Dhorajee, Gulshan and Garden. For analysis of the scaled tool, exploratory factor analysis was used to inform structuring. Finally, to complete the process of adaption, content and face validity exercises were performed. Content validity by subject expert review and face validity was performed by translation and back translation of the adapted RLCQ. This yielded our final adapted tool.

RESULTS

Stressful life events emerging from the qualitative phase of the study reflect daily life stressors arising from the unstable socio-political environment. Some such events were public harassment, robbery/theft, missed life opportunities due to nepotism, extortion and threats, being a victim of state sponsored brutality, lack of electricity, water, sanitation, fuel, destruction due to natural disasters and direct or media based exposure to suicide bombing in the city. Personal or societal based relevant stressors included male child preference, having an unmarried middle aged daughter, lack of empowerment and respect reported by females. The finally adapted RLCQ incorporated "Environmental Stress" as a new category.

CONCLUSION

The processes of qualitative methodology, in depth interview, community based scaling and face and content validity yielded an adapted RLCQ that represents contextually relevant life stress for adults residing in urban Pakistan.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02356263 . Registered January 28, 2015. (Observational Study Only).

Evaluating effectiveness and cost-effectiveness of a group psychological intervention using cognitive behavioural strategies for women with common mental disorders in conflict-affected rural Pakistan: study protocol for a randomised controlled trial

Background

The impact of humanitarian disasters upon mental health is well recognised. The evidence for psychological interventions for mental health is mounting, but few interventions have been rigorously tested in humanitarian settings. To be sustainable in humanitarian settings interventions need to be short, simple, deliverable by nonspecialists under supervision, and adopt a transdiagnostic approach where an array of mental health outcomes are addressed simultaneously. These elements have been incorporated into the newly developed WHO Problem Management Plus (PM+) Group intervention. The aim of this trial is to evaluate the locally adapted PM+ Group intervention for women in Swat, Pakistan.

Methods

This PM+ Group trial is a two-arm, single-blind, cluster randomised controlled trial conducted in a community-based setting with women in rural Pakistan. PM+ is delivered in partnership with the Lady Health Worker (LHW) Programme which provides community-based health care to women in Pakistan. Thirty-four LHW clusters will be randomised in a 1:1 allocation ratio using a permuted-block randomisation method. Participants screened and found to meet the inclusion criteria will be allocated to either the PM+ intervention group (n = 306), or the control arm (n = 306). The manualised PM+ intervention involves five sessions, each lasting 3 h, and introduces four strategies applied by participants to problems that they are facing. It is delivered by local female facilitators with a minimum of 16 years of education who are provided with targeted training and supervision. The primary outcome is individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 20 weeks after baseline. Secondary outcomes include major depression, post-traumatic stress disorder, levels of social support, levels of functioning, and economic effectiveness. Intervention acceptability will be explored through an embedded qualitative study.

Discussion

The PM+ Group trial will provide important evidence on the effectiveness of an empirically supported psychological treatment delivered by nonspecialists in a humanitarian setting. If proven effective, the qualitative component will inform strategies for PM+ Group scale-up in health systems in other humanitarian settings.

Trial registration

Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000037404. Registered on 19 January 2016; WHO Protocol ID RPC705, v.4, 2 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1905-8) contains supplementary material, which is available to authorized users.

Exploring Psychological Distress in Burundi During and After the Armed Conflict

We assessed symptoms of psychological distress among a population-based sample of 9000-plus adults in Burundi during (1998) and after (2007) armed conflict. After exploratory and confirmatory factor analysis to an 8-item, self-report measure, we identified two domains of psychological distress "Depression/Anxiety" and "Functioning" with good fit to data. The questionnaire was invariant in males and females. Depression and Anxiety symptoms during conflict were more frequently reported than Functioning symptoms; all symptoms were more frequently reported by women. Psychological distress was found in 44 % of individuals during conflict and in 29 % 2 years after the conflict. Results call for further research in Burundi that can inform the development of mental health interventions.

Problem Management Plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT)

BACKGROUND

In humanitarian settings common mental disorders (depression, anxiety disorders, posttraumatic stress disorder) are highly prevalent. The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, individual psychological intervention program, delivered by paraprofessionals that addresses common mental disorders in people in communities affected by adversity. The objectives of this study are to test effectiveness and cost-effectiveness of the locally adapted PM+ compared to Treatment as usual (TAU) in Peshawar District, Pakistan.

METHODS

A randomised controlled trial will be conducted in 346 primary care attendees in 3 health care centres in Peshawar District, Pakistan. After informed consent, primary care attendees with high levels of psychological distress according to the General Health Questionnaire-12 (GHQ-12) and functional impairment (WHO Disability Assessment Schedule 2.0 (WHODAS)) will be assigned to PM+ (n = 173) or TAU (n = 173). At baseline, 1 week and 3 months following PM+, independent assessors will assess psychological distress with the Hospital Anxiety and Depression Scale (HADS), and functional disability with the WHODAS. Secondary outcomes are posttraumatic stress disorder (PTSD) symptoms, and client-perceived priority problems. Further, cost-effectiveness will be assessed using the Service Receipt Inventory (SRI).

DISCUSSION

If proven effective, PM+ will be rolled out to other areas for further adaptation and testing in diverse humanitarian settings.

TRIAL REGISTRATION

ACTRN12614001235695. Registered 26 November 2014. Australian New Zealand Clinical Trials Registry.