The explanatory models of depression and anxiety in primary care: a qualitative study from India

Understandings of depression among community members and primary healthcare attendees in rural Ethiopia: A qualitative study

Available evidence in Africa suggests that the prevalence of depression in primary care settings is high but it often goes unrecognized. In this study, we explored how depression is conceptualized and communicated among community members and primary care attendees diagnosed with depression in rural Ethiopia with the view to informing the development of interventions to improve detection. We conducted individual interviews with purposively selected primary care attendees with depression (n = 28; 16 females and 12 males) and focus group discussions (FGDs) with males, females, and priests (n = 21) selected based on their knowledge of their community. Data were analyzed using thematic analysis. None of the community members identified depression as a mental illness. They considered depressive symptoms presented in a vignette as part of a normal reaction to the stresses of life. They considered medical intervention only when the woman's condition in the vignette deteriorated and "affected her mind." In contrast, participants with depression talked about their condition as illness. Symptoms spontaneously reported by these participants only partially matched symptoms listed in the current diagnostic criteria for depressive disorders. In all participants' accounts, spiritual explanations and traditional healing were prominent. The severity of symptoms mediates the decision to seek medical help. Improved detection may require an understanding of local conceptualizations in order to negotiate an intervention that is acceptable to affected people.

Mixed-Method Investigations Uncovering Tension, PTSD Symptoms, and Trauma-Related Difficulties Among Indian Women from Slums Reporting Gender-Based Violence

Indian women exposed to gender-based violence (GBV) report experiencing cultural concepts of distress, such as tension, and trauma-related difficulties. However, tension and trauma-related sequalae have not been explicitly explored. The present study examined the symptoms, causes, and coping strategies associated with tension among slum-residing Indian women reporting GBV (N = 100). This study also explored linkages between tension and posttraumatic stress disorder (PTSD) symptom severity. Qualitative results among a subsample of women (n = 38) indicated tension was commonly reported. Tension was characterized by varied affective, behavioral, cognitive, and somatic components and was most commonly caused by interpersonal stressors. Participants described various coping strategies to manage tension, including avoiding, cognitively reframing, considering consequences, distracting themselves, seeking medical, religious and/or spiritual assistance, finding social support, and tolerating tension. Barriers to coping were stigma, hopelessness about present circumstances, and negative reactions from others. One-way analysis of covariance with Bonferroni-adjusted post hoc results (N = 100) indicated that participants with higher tension exhibited significantly higher PTSD symptom severity as compared to participants reporting no tension. Altogether, the polyvalence of tension suggested that it requires idiographic assessment. Tension appears responsive to skills consistent with evidence-based psychological treatments for Indian women from slums reporting GBV.

Explanatory Models and their Relationship with Drug Attitude in Patients with Depression in South India

BACKGROUND

The patient's understanding of the illness may mediate beliefs towards its treatment. There is a paucity of studies examining the relationships between these variables in depression. This study was conducted to know the relationships between explanatory models and attitude to medication in depression.

METHODS

494 patients with depression in remission were assessed with sociodemographic proforma, Drug Attitude Inventory, and Mental Distress Explanatory Model Questionnaire.

RESULTS

A favorable attitude toward medication was observed in 57.49% of participants. Mean scores on MDEMQ subscales Stress, Western Physiology, Non-Western Physiology, and Supernatural were 32.96, 21.87, 10.06, and 47.55, respectively. Statistically significant associations were found between attitude towards medication and the patient's marital status (more negative attitude with single status, χ2 = 11.72, df = 3, P = 0.008) and occupation (more negative attitude among unemployed patients, χ² = 4.17, df = 1, P = 0.041). The scores of explanatory models did not differ based on positive or negative drug attitude.

CONCLUSION

Though explanatory models are not linked to patient attitudes toward medication, patients who are single or unemployed have a negative attitude toward medications. Such negative attitude may impair compliance and worsen patient outcomes.

Healthcare use and costs among individuals receiving mental health services for depression within primary care in Nepal

BACKGROUND

Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources.

METHODS

Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference.

RESULTS

The study included 192 primary care service users (TG = 60, TG + P = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (- 11%, p = 0.51) among TG + P and lower (- 35%, p = 0.01) among UC compared to TG. Visits increased 2.30 times (p < 0.001) at 3 months among TG, with a 50% greater increase (p = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (- 1%, p = 0.97) and cost changes did not significantly differ at three (- 16%, p = 0.67) or 12 months (- 45%, p = 0.13). Costs among UC were 54% lower than TG at baseline (p = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare.

CONCLUSION

Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

"I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence

Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

Explanatory Models of Depression in a Rural Community of Coastal Karnataka, India: A Cross-Sectional Survey

BACKGROUND

Depression is a major public health problem but there is a huge treatment gap in India. Cultural beliefs influence conception of illness, personal meaning, help-seeking behaviors, and adherence to treatment. Research on explanatory models of depression attempt to explore these unique characteristics in an individual and the community. We set out to examine explanatory models of depression in a rural community of coastal Karnataka and explore the association between sociodemographic variables and explanatory models of depression.

METHODS

A cross-sectional household survey in the rural community of Harekala village, Mangaluru taluk, Dakshina Kannada district, Karnataka, was done using Kish tables. A total of 200 individuals were interviewed with an adaptation of the Short Explanatory Model Interview in a local language using a case vignette of depression.

RESULTS

Around 40% of the individuals perceived the problem as tension/stress/excessive worrying and did not perceive it as mental illness. A scant 10% of the participants recognized some mental illness. Around one-fifth of the individuals attributed the problem to evil spirits and black magic; female participants were more likely to endorse consulting a doctor (P = 0.003**) or a psychiatrist (P = 0.012*). In addition, participants belonging to Islam were less likely to consult a doctor (P = 0.028*) and psychiatrist (P = 0.021*). Also, participants belonging to lower social class were less likely to endorse psychiatric consultation (P = 0.018*).

CONCLUSIONS

A vast majority of the study subjects failed to identify depression as an illness or acknowledge biomedical causation. Gender, religion, and socioeconomic class may influence help-seeking behavior.

A pilot study adapting and validating the Harvard Trauma Questionnaire (HTQ) and PTSD checklist-5 (PCL-5) with Indian women from slums reporting gender-based violence

Background

Despite high rates of gender-based violence (GBV) in India, culturally sensitive measures that examine universal and culturally relevant trauma reactions are lacking. Although the Harvard Trauma Questionnaire (HTQ) has been used in India, no study has adapted the measure in full for use with this population. Similarly, the  PTSD checklist-5 (PCL-5) has not yet been validated in India. This study describes the adaptation, validation, and results from the adapted HTQ, and embedded PCL-5, for Indian women from slums reporting GBV.

Method

This study used the adaptation framework proposed by the HTQ measure developers. The adapted HTQ contained a (1) trauma screen relevant for stressors faced by Indian women from slums, (2) description of the index trauma, (3) description of any ongoing stressors, (4) universal trauma reactions (i.e., PTSD measured by the PCL-5), and culturally relevant trauma reactions (i.e., idioms of distress measured by a scale developed for the study). This measure was piloted on 111 women from Indian slums in face-to-face interviews. Trauma characteristics, types of ongoing stressors, and psychometric properties of the PCL-5 and idioms of distress scale were explored. These scales were validated against measures of depression (PHQ-9), anxiety (GAD-7), and somatic complaints (PHQ-15).

Results

The majority of participants (77%) reported physical beatings, 18% reported unwanted sexual touch, and 28.8% reported infidelity as the primary emotional abuse. Further, 96.7% of GBV was perpetrated by partner or family member and over half reported ongoing stressors (e.g., poverty-related strain). The PCL-5 embedded in the HTQ yielded good internal consistency (Cronbach’s alpha = .88) as did the idioms of distress scale with deletion of one item (Cronbach’s alpha = .80). Both scales were externally valid, yielding large correlations with depression, anxiety, and somatic complaints (rs between .54 and .80, ps < .05).

Discussion

This is the first study to develop a comprehensive measure of trauma exposure with universal and culturally relevant trauma reactions in India. This study also enhances HTQ usage in India by delineating all the steps in the adaptation process. Results can inform the development of trauma-focused interventions for Indian women from slums.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01595-3.

Explanatory models of post-traumatic stress disorder (PTSD) and depression among Afghan refugees in Norway

Background

The current situation in Afghanistan makes it likely that we are facing a new wave of Afghan refugees, warranting more knowledge about how to deal with mental health problems among them. This study aims to gain more knowledge on Explanatory Models (EM) of depression and post-traumatic stress disorders (PTSD) among Afghan refugees resettled in Norway.

Methods

We conducted six gender-separated, semi-structured focusgroup interviews based on vignettes with Afghan refugees (total N = 27). The vignettes described a fictional character with symptoms of either depression or PTSD symptoms in line with DSM-5 and ICD-10 criteria.

Results

The findings showed that EM varied with gender, age, generation, and migration stories. Participants suggested different potential causes, risk factors, and ways of managing symptoms of depression and PTSD depending on the context (e.g., in Norway vs. Afghanistan). In describing the causes of the depression/PTSD in the vignettes, females tended to emphasize domestic problems and gender issues while males focused more on acculturation challenges. The younger males discussed mostly traumatic experiences before and during flight as possible causes.

Conclusion

The practice of condensing a single set of EMs within a group may not only be analytically challenging in a time-pressed clinical setting but also misleading. Rather, we advocate asking empathic questions and roughly mapping individual refugee patients’ perceptions on causes and treatment as a better starting point for building trusting relationships and inviting patients to share and put into practice their expertise about their own lives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00709-0.

Explanatory Models for Mental Distress Among University Students in Ethiopia: A Qualitative Study

Background

Socio-culturally determined processes account for how individuals give meanings to health, illness, causal attributions, expectations from treatment, and related outcomes. There is limited evidence of explanatory models for mental distress among higher education institutions in Ethiopia. The objective of this study was to explore the explanatory models for mental distress among Wolaita Sodo University.

Methods

The current study used a phenomenological research approach, and we collected data from 21 students. The participants were purposively recruited based on eligibility criteria. Semi-structured interviews were conducted from December 2017 to January 2018 using the Short Explanatory Models Interview. The interviews were audio-recorded, transcribed into the Amharic language and translated into English. Data were analyzed using framework analysis with the assistance of open code software 4.02.

Results

Most students experienced symptoms of being anxious, fatigue, headaches and feelings of hopelessness. They labeled these symptoms like anxiety or stress. The most commonly reported causal explanations were psychosocial factors. Students perceived that their anxiety or stress was severe that mainly affected their mind, which in turn impacted their interactions with others, academic result, emotions and motivation to study. Almost all the students received care from informal sources, although they wanted to receive care from mental health professionals. They managed their mental distress using positive as well as negative coping strategies.

Conclusion

The policy implication of our findings is that mental health interventions in higher education institutions in Ethiopia should take into account the explanatory models of students’ psychological distress.

Antidepressant prescriptions and adherence in primary care in India: Insights from a cluster randomized control trial

BACKGROUND

The World Health Organization recommends that treatment of depression in low and middle-income countries with a scarcity of psychiatrists could be done in primary care and should include prescription of antidepressant medications for moderate and severe depression. Little is known, however, about the actual practices of antidepressant prescription by primary care physicians in low and middle-income countries, nor about adherence by people receiving such prescriptions. In a large study of primary care clinics in Goa, India, we examined the relationship of actual to recommended prescribing practices for depression, among all patients who screened positive for common mental disorder. We also examined other patient and clinic characteristics associated with antidepressant prescription, and self-reported adherence over a one-month period.

METHODS

Patients attending 24 primary care clinics were screened for common mental disorders. Those who screened positive were eligible to enroll in a trial to assess the effectiveness of a collaborative stepped care (CSC) intervention for mental disorders. Physicians in the 12 intervention and 12 control clinics (usual care) were free to prescribe antidepressants and follow-up interviews were conducted at 2, 6 and 12 months. Screening results were shared with the physician, but they were blinded to the diagnosis generated later using a standardized diagnostic interview administered by a health counsellor. We categorized these later diagnoses as "moderate/severe depression", "mild depression or non-depression diagnosis", and "no diagnosis". We used a two-level hierarchical logistic regression model to examine diagnostic and other factors associated with antidepressant prescription and one-month adherence.

RESULTS

Overall, about 47% of screened positive patients (n = 1320) received an antidepressant prescription: 60% of those with moderate/severe depression, 48% of those with mild depression or non-depression diagnosis, and 31% with no diagnosis. Women (OR 1.29; 95%CI 1.04-1.60) and older adults (OR 1.80; 95%CI 1.32-2.47) were more likely to receive an antidepressant prescription. While the overall rate of antidepressant prescription was similar in clinics with and without CSC, patients without any diagnosis were more likely to receive a prescription (OR 2.20 95% CI 1.03-4.70) in the usual care clinics. About 47% of patients adhered to antidepressant treatment for one month or more and adherence was significantly better among older adults (OR 3.92; 95% CI 1.70-8.93) and those who received antidepressant as part of the CSC treatment model (OR 6.10 95% CI 3.67-10.14) compared with those attending the usual care clinic.

CONCLUSION

Antidepressants were widely prescribed following screening in primary care, but prescription patterns were in poor accord with WHO recommendations. The data suggest under-prescription for people with moderate/severe depression; over-prescription for people with mild depression or non-depression diagnoses; and over-prescription for people with no disorders. For all diagnoses adherence was low, especially in usual care clinics. To address these concerns, there is an urgent need to study and develop strategies in primary care practices to limit unnecessary antidepressant prescriptions, target prescription for those patients who clearly benefit, and to improve adherence to antidepressant treatment. ClinicalTrials.gov Identifier: NCT00446407.

Confirmatory Factor Analysis of Three Versions of the Depression Anxiety Stress Scale (DASS-42, DASS-21, and DASS-12) in Polish Adults

Background: The Depression Anxiety Stress Scales (DASS) are designed to identify quickly and differentiate between the symptoms of depression and anxiety in the non-clinical population. Different versions (original and short) were validated in many cultures. Nevertheless, there are no data of factorial validity of the different versions of this scale in Polish culture. Thus, the aim of this study was to evaluate the factor structure using confirmatory factor analysis (CFA) and internal consistency of DASS-42 (original version) and two short versions (DASS-21 items and DASS-12 items) in the Polish population. Methods: The DASS-42 was administered to a non-clinical sample, broadly representative of the general Polish adult population (n = 1,021) in terms of demographic variables. The DASS-21 and DASS-12 version used in this study comprise seven and four items from each of the following corresponding three subscales of the Polish version of DASS-42. Results: There were two models that fitted best for DASS-42: (a) modified three correlated factors (depression, anxiety, and stress) with cross-loadings and (b) second order (general factor of psychological distress) and three factors with cross-loadings. There were also two models that fitted best for DASS-21 and DASS-12: (a) modified three correlated factors (depression, anxiety, and stress) and (b) second order (general factor of psychological distress) and three factors. Conclusions: All three versions of DASS appear to have an acceptable factorial structure. However, the shorter versions (DASS-21 and DASS-12) may be more feasible to use in general medical practice and also be less burdensome to participants.

Barriers and facilitators to GP-patient communication about emotional concerns in UK primary care: a systematic review

BACKGROUND

In the UK, general practitioners (GPs) are the most commonly used providers of care for emotional concerns.

OBJECTIVE

To update and synthesize literature on barriers and facilitators to GP-patient communication about emotional concerns in UK primary care.

DESIGN

Systematic review and qualitative synthesis.

METHOD

We conducted a systematic search on MEDLINE (OvidSP), PsycInfo and EMBASE, supplemented by citation chasing. Eligible papers focused on how GPs and adult patients in the UK communicated about emotional concerns. Results were synthesized using thematic analysis.

RESULTS

Across 30 studies involving 342 GPs and 720 patients, four themes relating to barriers were: (i) emotional concerns are difficult to disclose; (ii) tension between understanding emotional concerns as a medical condition or arising from social stressors; (iii) unspoken assumptions about agency resulting in too little or too much involvement in decisions and (iv) providing limited care driven by little time. Three facilitative themes were: (v) a human connection improves identification of emotional concerns and is therapeutic; (vi) exploring, explaining and negotiating a shared understanding or guiding patients towards new understandings and (vii) upfront information provision and involvement manages expectations about recovery and improves engagement in treatment.

CONCLUSION

The findings suggest that treatment guidelines should acknowledge: the therapeutic value of a positive GP-patient relationship; that diagnosis is a two-way negotiated process rather than an activity strictly in the doctor's domain of expertise; and the value of exploring and shaping new understandings about patients' emotional concerns and their management.

Adaptation of the WHO group interpersonal therapy for people living with HIV/AIDS in Northwest Ethiopia: A qualitative study

BACKGROUND

Psychological treatments improve depressive symptoms in people living with HIV/AIDS (PLWHA). Adaptation of treatments should be based on explanatory models of depression and other elements within the given context.

AIM

This study aimed to examine explanatory models of depression and acceptable approaches for implementation of group IPT in Northwest Ethiopia.

METHODS

Qualitative data were collected from April to May 2019 from case managers, adherence supporters and service users using focus group discussion and analysed thematically.

RESULTS

PLWHA attributed depression to psychosocial problems, spiritual factors and biological factors. Depression had several impacts at individual and family level. Group-based interpersonal therapy (IPT) was acceptable if provided by trained peer counselors.

CONCLUSION

The current study findings informed how to conduct feasibility and acceptability trials of group IPT in the HIV population in Ethiopia.

Health care use and treatment-seeking for depression symptoms in rural India: an exploratory cross-sectional analysis

BACKGROUND

There is a large "treatment gap" for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression.

METHODS

Data were analysed from a two round cross-sectional community survey conducted in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors using univariable regression.

RESULTS

86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals (p < 0.0001). Private providers were most frequently consulted by screen-positive adults (32%), while only 19% consulted traditional providers. Structural barriers to healthcare use such as cost and distance to services were frequently reported (54 and 52%, respectively) but were not associated with treatment-seeking for depression. The following factors were found to be positively associated with treatment-seeking for depression: higher symptom severity; lack of energy, lack of interest/pleasure, low self-esteem, or slow movements/restlessness on more than 7 days in the past 2 weeks; being married; having discussed depression symptoms; and reporting problems with medication availability and supply as a barrier to healthcare. No evidence was found for an association between treatment-seeking for depression and most socio-economic, demographic or attitudinal factors.

CONCLUSIONS

These findings suggest that the majority of adults who screen positive for depression seek healthcare, although not primarily for depression symptoms, indicating the need to improve detection of depression during consultations about other complaints. Private providers may need to be considered in programmes to improve depression treatment in this setting. Further research should test the hypotheses generated in this descriptive study, such as the potential role of marriage in facilitating treatment-seeking.

Explanatory models of mental illness among family caregivers of persons in psychiatric rehabilitation services: A pilot study

BACKGROUND

Understanding the explanatory models of family caregivers is particularly important in interdependent contexts like India, where they often play a significant role in the help-seeking behaviours, treatment decision-making and long-term care of those diagnosed with mental illness.

AIMS

This study was planned to explore the diversity of explanatory models among family caregivers at a centre for recovery-oriented rehabilitation services in South India.

METHODS

The sample for this study included 60 family caregivers of patients referred to Psychiatric Rehabilitation Services within a tertiary-care hospital for mental health and neurosciences. Bart's Explanatory Model Inventory, including a semi-structured interview and a checklist, assessed the family caregivers' explanatory model of distress on five domains: identity, cause, timeline, consequences and control/cure/treatment.

RESULTS

The results indicated the coexistence of multiple causal explanatory models including psychosocial, supernatural, situational and behavioural contributors. While 36.7% of the caregivers displayed two explanatory models, 33.3% of the caregivers held three explanatory models and 16.6% of the caregivers endorsed four explanatory models. Caregivers shared their concerns about varied consequences of mental illness but less than half of them were aware of the name of the psychiatric disorder. While they accessed various forms of treatments and adjunctive supports such as prayer, medication was the most frequently used treatment method.

CONCLUSIONS

The findings have implications for collaborative goal setting in recovery-oriented services for persons with mental illness and their families.

Cultural Aspects of Social Anxiety Disorder: A Qualitative Analysis of Anxiety Experiences and Interpretation

Objective: Anxiety is a complex phenomenon on which culture has a prominent influence. The present study aimed to investigate the cultural aspects of social anxiety disorder (SAD) in an Iranian population. Method : A qualitative content analysis research was done to answer the study question. A total of 16 individuals with social anxiety disorder (six men and 10 women) were selected using purposeful sampling method (M = 24.43, SD = 4.56). The study was conducted in Tehran, Urmia, and Sanandaj- Iran. Participants were from different ethnic backgrounds (LOR, FARS, TURK, and KURD). Data were analyzed by thematic analysis using an inductive method. Results: Analysis of participants' records yielded five distinct categories with some subcategories, which are as follow: (1) anxiety experiences; (2) core beliefs; (3) reasons of being anxious; (4) effects of SAD on life aspects; and (5) coping strategies. Conclusion: It seems that symptoms of social anxiety and its underlying beliefs, causes and effects and coping strategies are almost experienced and interpreted in a way that could be the same as DSM-5 clinical presentation of social anxiety, with the exception that somatic symptoms are experienced by almost all participants.

Women's Experiences and Perceptions of Depression in India: A Metaethnography

In India, social determinants of health, including poverty, domestic violence, and inadequate social support disproportionately affect women, leaving them more vulnerable to depression than men. We conducted a metaethnography to synthesize qualitative data from 13 studies (1987-2017) that explored women's experiences and perceptions of depression in India. We used a feminist standpoint to critically examine how gender shapes these experiences and perceptions. Indian women's experiences of depression were embedded in their social worlds. Women perceived interpersonal conflict, caregiving burden, domestic violence, financial insecurity, adverse reproductive events and widowhood as causes of depression. Women used cultural expressions to describe physical, emotional, and cognitive distress. The detrimental impact of discriminatory social conditions, gender inequalities, and traditional gender roles on Indian women's mental health highlights the need for gender-sensitive mental health research and practice that can attend to women's sociocultural context and promote values of gender equality and social justice.

Exploration of the understanding and etiology of ADHD in HIV/AIDS as observed by adolescents with HIV/AIDS, caregivers and health workers- using case vignettes

Background

Attention-Deficit / Hyperactivity Disorder (ADHD) is one of the most prevalent behavioural disorder among children and adolescents with HIV infection (CA-HIV).

Objective

To explore the explanations used by adolescents with HIV/AIDS, caregivers and health workers to understand and explain ADHD in HIV/AIDS.

Methods

This was a qualitative sub-study nested within a larger research project whose focus was on mental health among HIV infected children and adolescents in Kampala and Masaka, Uganda (CHAKA study, 2014–2017). Participants were recruited from five study sites: two in Kampala and three in Masaka. We purposively sampled 10 ADHD adolescent-caregiver dyads equally divided between the Masaka and Kampala sites, age groups and gender. Semi-structured interviews were carried out within 12 months of baseline. Ten HIV health workers (two from each study site) participated. The ten health workers were assessed about their knowledge related to psychiatric disorders (especially ADHD in HIV/AIDS), services available for such clients and gaps in service provision for CA-HIV with behavioural / emotional disorders. Participants were recruited over one month. Taped interviews were transcribed and preliminary coding categories generated based on the research questions. Broad categories of related codes were then generated to derive a coding framework. Thematic analyses were conducted to elicit common themes emerging from the transcripts.

Results

Explanations used by respondents to express their understanding related to ADHD among CA-HIV included; psychosocial stressors, biomedical manifestations, personal traits and supernaturalism, which affected health seeking behaviour.

Conclusion

In contexts similar to those in Uganda, treatment approaches for ADHD among HIV positive CA-HIV should consider the explanations provided by CA-HIV, caregivers to CA-HIV and HIV health workers.

[Depressive disorders in primary care: Clinical features and sociodemographic characteristics]

INTRODUCTION

Our aim was to determine the reason for consultation and the clinical features of depressive disorders according to the diagnostic and statistical manual (DSM) 4th edition IV R in primary care and to identify if there is an association between sociodemographic characteristics and depressive pattern.

MATERIALS AND METHODS

In a cross-sectional study conducted to determinate the prevalence of depressive disorders in primary care, at three urban centers in two cities Salé and Oujda by five physicians, we recruited primary care 396 patients of whom 58 were depressed, among these patients we screened for depressive disorders, their clinical features, the melancholic characteristics and suicidal ideation using the Mini International Neuropsychiatric Interview.

RESULTS

Mean age of the 58 depressive patients was 46±15 years. They were predominantly female, inactive and of low socio-economic level. Approximately one-third of the patients were illiterate and single. The symptoms frequently encountered were sadness (63.7%), anhedonia (62%), insomnia (45.7%), anorexia (60.9%), psychomotor retardation (60.9%) and asthenia (73.9%). Somatic symptoms were present 99%, the most common complaint was pain that exhibited 68.6% prevalence. Suicidal ideations were found in 36.2% of these depressive patients.

CONCLUSION

The accuracy of the clinical features of patients with depression in primary care will facilitate the detection of these disorders by general practitioners and improve management of depression.

Knowledge and Attitudes Towards Clinical Depression among Community Medical Providers in Gujarat, India

There is limited data on how community medical providers in India attempt to diagnose and treat depression, as well as on their general knowledge of and attitudes toward depression. A cross-sectional survey was conducted assessing knowledge and views of clinical depression with 80 non-psychiatric physicians and physician trainees recruited from community clinics and hospitals in Gujarat, India. Interviews were also held with 29 of the physicians to assess what they do in their own practices in regards to detection of and treatment of clinical depression. Although subjects showed a generally good basic understanding of the definition of clinical depression and its treatment, their responses reflected the presence of some negative and/or stigmatized attitudes toward clinical depression. Our findings raise the question of possible stigma among physicians themselves and underscore the importance of combatting physicians' stigma against and increasing awareness of how to detect and treat clinical depression.

Temporomandibular Disorders: "Occlusion" Matters!

By analogy with the journal's title Pain Research and Management, this review describes TMD Research and Management. More specific are the (1) research aspects of “occlusion,” still one of the most controversial topics in TMD, and (2) as much as possible evidence-based management aspects of “TMD” for the dental practitioner. Research. The disorders temporomandibular dysfunction and the synonymous craniomandibular dysfunction are still being discussed intensely in the literature. Traditionally, attention is mostly devoted to occlusion and its relationship with these disorders. The conclusions reached are often contradictory. Considering the definitions of temporomandibular and craniomandibular dysfunctions/disorders and “occlusion,” a possible explanation for this controversy can be found in the subsequent methodological problems of the studies. Based on a Medline search of these terms over the past 40 years related to contemporary terms such as “Evidence Based Dentistry” and “Pyramid of Evidence,” these methodological aspects are examined, resulting in recommendations for future research and TMD-occlusal therapy. Management. To assist the dental practitioner in his/her daily routine to meet the modern standards of best practice, 7 guidelines are formulated that are explained and accompanied with clinical examples for an evidence-based treatment of patients with this disorder in general dental practices.

Attitudes of Indian HIV Clinicians Toward Depression in People Living with HIV

BACKGROUND

Depression is highly prevalent in people living with HIV (PLHIV) and is associated with increased morbidity and mortality. In India, where access to mental health specialists is limited, little is known about the attitude of HIV clinicians toward depression in PLHIV.

METHODS

We administered a questionnaire to HIV clinicians attending the 2015 Chennai Antiretroviral Therapy Symposium that assessed respondents' level of agreement with 29 statements regarding the etiology, importance, and management of depression and whether they felt capable and willing to manage depression in PLHIV.

RESULTS

The 69 respondents were from 9 Indian states. Most respondents agreed that depression in PLHIV is a serious problem (91%) and is associated with poorer HIV-related outcomes (62%-81%). Although most respondents (76%) reported feeling comfortable discussing mental health problems with PLHIV, almost half (48%) admitted that lack of knowledge and training about mental health issues hindered the diagnosis and treatment of depression in PLHIV. With few exceptions, there were no significant differences in responses by gender, urban/rural practice location, or government versus private practice.

CONCLUSIONS

Indian HIV clinicians believe that depression in PLHIV is important and are willing to manage depression in the HIV primary care setting. These findings suggest that HIV clinicians require further training to deliver evidence-based interventions to treat PLHIV with depression.

Assessing explanatory models and health beliefs: An essential but overlooked competency for clinicians

Explanatory models of illness – the way people perceive, interpret and respond to it – are mediated not only by the illness itself, but also by cultural and social contexts. This article discusses recent evidence showing how the exploration of explanatory models can help to shape treatment and outcomes for some of the most common categories of mental illness, and presents case studies illustrating dilemmas clinicians face when their explanatory models differ from those of their patients. It concludes with recommendations on how a culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment can be used as an effective way of dealing with the complexity of patients' and families' needs.

Learning Objectives

• Appreciate the use of explanatory models in clinical practice

• Understand the relevance of explanatory models in relation to specific diagnostic categories of mental illness

• Recognise that dilemmas may arise if the explanatory models of the clinician and the patient differ, and be able to manage this tension

Perceptions of Accredited Social Health Activists on Depression: A Qualitative Study from Karnataka, India

BACKGROUND

Depression is a significant public health concern in India, associated with a large treatment gap. Assessing perceptions of Accredited Social Health Activists (ASHAs) on depression can be invaluable as they are selected to work at the interface between their own communities and the health-care delivery system.

AIMS AND OBJECTIVES

This study aimed at utilizing a qualitative approach to examine the ASHAs' understanding of depression, their mental health-care practices specific to depression, and their capacity-building needs with regard to identification and helping persons with depression.

SUBJECTS AND METHODS

A cross-sectional qualitative study using two focus group discussions was conducted. The sample comprised 14 ASHAs in the age range of 25-45 years from Bengaluru urban district. The data were analyzed manually by the method of directed content analysis.

RESULTS

The ASHAs were found to have inadequate knowledge of the signs and symptoms of depression, its biopsychosocial nature, and its impact on functioning. Causation of depression was narrated in terms of psychosocial stressors. The majority expressed the need for primarily psychosocial interventions for depression. All participants reported their motivation to obtain training in identifying persons with depression and providing simple psychosocial intervention for them.

CONCLUSION

This study indicates that ASHAs have poor knowledge of depression, which could be leading to its low recognition and treatment in the communities they work in. They are therefore likely to benefit from capacity building on depression which includes familiar nomenclature, biopsychosocial elucidation of the illness, life-span approach, understanding of its impact on various domains of functioning, and the treatments available.

Insight in psychosis: Standards, science, ethics and value judgment

BACKGROUND

The clinical assessment of insight solely employs biomedical perspectives and criteria to the complete exclusion of context and culture and to the disregard of values and value judgments.

AIM

The aim of this discussion article is to examine recent research from India on insight and explanatory models in psychosis and re-examine the framework of assessment, diagnosis and management of insight and explanatory models.

METHODS

Recent research from India on insight in psychosis and explanatory models is reviewed.

RESULTS

Recent research, which has used longitudinal data and adjusted for pretreatment variables, suggests that insight and explanatory models of illness at baseline do not predict course, outcome and treatment response in schizophrenia, which seem to be dependent on the severity and quality of the psychosis. It supports the view that people with psychosis simultaneously hold multiple and contradictory explanatory models of illness, which change over time and with the trajectory of the illness. It suggests that insight, like all explanatory models, is a narrative of the person's reality and a coping strategy to handle with the varied impact of the illness.

CONCLUSION

This article argues that the assessment of insight necessarily involves value entailments, commitments and consequences. It supports a need for a broad-based approach to assess awareness, attribution and action related to mental illness and to acknowledge the role of values and value judgment in the evaluation of insight in psychosis.

Lay Health Workers' Experience of Delivering a Problem Solving Therapy Intervention for Common Mental Disorders Among People Living with HIV: A Qualitative Study from Zimbabwe

There is growing evidence supporting the use of lay health workers (LHWs) to address the treatment gap for common mental disorders (CMD) through task-shifting. This study looks at the experience of LHWs delivering a problem solving therapy (PST) intervention for CMD for people living with HIV (PLWH) in a primary health care setting. Semi-structured interviews of LHWs (n = 7) and PLWH (10) who received PST were carried out using thematic content analysis. Over a 4 year period LHWs developed indigenous concepts of PST which were: Opening the mind (Kuvhura pfungwa), uplifting (kusimudzira), strengthening and strengthening further (kusimbisa and kusimbisisa) respectively. Using terms locally conceived through knowledge sharing amongst LHWs made it acceptable to deliver PST as part of their daily work. Indigenous terms conceived and developed by LWHs to describe components and processes of PST contribute to the therapy's acceptability and continued use in primary care facilities.

Explanatory Models and Medication Adherence in Patients with Depression in South India

INTRODUCTION

Conceptualization of depression may have bearing on treatment seeking. It may affect adherence behaviour of the patients.

AIM

To find out the explanatory models and their relationship with socio-demographic variables and medication adherence in patients with depression.

MATERIALS AND METHODS

Fifty-eight consecutive patients with depression in remission were recruited as per selection criteria. Socio-demographic details were collected. Patients were assessed using Mental Distress Explanatory Model Questionnaire (MDEMQ) and Morisky Medication Adherence Scale (MMAS).

RESULTS

Significant scores were observed in all dimensions of explanatory models. In the Mann-Whitney U test the patient's marital status (MU=113.500, p=0.05, sig≤0.05, 2-tailed), and family history of mental illness (MU=165.5, p=0.03, sig≤0.05, 2-tailed) had a statistically significant group difference in the score of MDEMQ. In linear regression analysis, four predictors (MDEMQ subscales Stress, Western physiology, Non-Western physiology and Supernatural) had significantly predicted the value of MMAS (R2=0.937, f=153.558, p<0.001).

CONCLUSION

Findings of this study suggested that patients with depression harbor multidimensional explanatory model. The levels of explanatory models are inversely associated with levels of medication adherence.

Association of common mental disorder symptoms with health and healthcare factors among women in rural western India: results of a cross-sectional survey

OBJECTIVES

Information about common mental disorders (CMD) is needed to guide policy and clinical interventions in low-income and middle-income countries. This study's purpose was to characterise the association of CMD symptoms with 3 inter-related health and healthcare factors among women from rural western India based on a representative, cross-sectional survey.

SETTING

Surveys were conducted in the waiting area of various outpatient clinics at a tertiary care hospital and in 16 rural villages in the Anand district of Gujarat, India.

PARTICIPANTS

700 Gujarati-speaking women between the ages of 18-45 years who resided in the Anand district of Gujarat, India, were recruited in a quasi-randomised manner.

PRIMARY AND SECONDARY OUTCOMES MEASURES

CMD symptoms, ascertained using WHO's Self-Reporting Questionnaire-20 (SRQ-20), were associated with self-reported (1) number of healthcare visits in the prior year; (2) health status and (3) portion of yearly income expended on healthcare.

RESULTS

Data from 658 participants were used in this analysis; 19 surveys were excluded due to incompleteness, 18 surveys were excluded because the participants were visiting hospitalised patients and 5 surveys were classified as outliers. Overall, 155 (22·8%) participants screened positive for CMD symptoms (SRQ-20 score ≥8) with most (81.9%) not previously diagnosed despite contact with healthcare provider in the prior year. On adjusted analyses, screening positive for CMD symptoms was associated with worse category in self-reported health status (cumulative OR=9.39; 95% CI 5·97 to 14·76), higher portion of household income expended on healthcare (cumulative OR=2·31; 95% CL 1·52 to 3.52) and increased healthcare visits in the prior year (incidence rate ratio=1·24; 95% CI 1·07 to 1·44).

CONCLUSIONS

The high prevalence of potential CMD among women in rural India that is unrecognised and associated with adverse health and financial indicators highlights the individual and public health burden of CMD.

The 12-item WHO Disability Assessment Schedule II as an outcome measure for treatment of common mental disorders

BACKGROUND

Common mental disorders (CMD) are among the most significant contributors to disability worldwide. Patient-reported disability outcomes should be included as a key metric in the comparative assessment of value across global mental health interventions. This study aims to evaluate the validity of a widely used, cross-cultural tool - the 12-item World Health Organization Disability Assessment Schedule II (WHODAS) - as a functional outcome measure for CMD treatment.

METHODS

The study population includes 1024 participants with CMD enrolled in the MANAS trial in India. CMD was assessed using the Revised Clinical Interview Schedule (CIS-R). Disability was assessed using the 12-item WHODAS II plus a measure of disability days. This analysis presents the correlations between these disability items and CMD symptom severity at 2 months after enrollment (convergent validity) and the items' associations with CMD recovery 4 months later (external responsiveness).

RESULTS

All items showed a positive correlation of disability with CMD symptom severity (p < 0.001). The WHODAS items of 'standing,' 'household responsibilities,' and 'emotional disturbance' explained the most variance in CMD symptom severity. Improvements in 'disability days,' 'emotional disturbance,' 'standing,' 'household responsibilities,' 'day-to-day work,' and 'concentrating' were significantly associated with CMD recovery over follow-up.

CONCLUSIONS

Further research is recommended on a CMD-specific WHODAS subscale comprised of the six WHODAS items found to be most strongly associated with CMD severity and recovery. This shorter, CMD-specific disability subscale would critically serve as a common metric to compare intervention impact on patient-centered outcomes and, in turn, to allocate global mental health resources efficiently.

'I was thinking too much': experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe

OBJECTIVE

To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings.

METHODS

In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team.

RESULTS

The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care.

CONCLUSIONS

Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Knowledge and attitudes toward depression among community members in rural Gujarat, India

Limited data exist regarding community attitudes and knowledge about clinical depression in rural India. We administered 159 questionnaires and 7 focus groups to Gujarati villagers to explore knowledge and beliefs about clinical depression. Quantitative data were analyzed for frequencies, nonparametric correlations, and principal components, whereas qualitative data were coded for prominent themes. Two groups of subjects emerged from our analysis: one "medically oriented" group that viewed depression as a medical condition and expressed optimism regarding its prognosis and one "spiritually oriented" group that expressed pessimism. Correlations emerged between etiological belief, degree of optimism, and associated stigma. The subjects were pessimistic when they attributed depression to a traumatic event, punishment from God, or brain disease but optimistic when depression was attributed to socioeconomic circumstances. Overall, the subjects were knowledgeable and open-minded toward depression and demonstrated curiosity and willingness to learn more. This study will help to inform future clinical and educational outreach in rural Gujarat.

Explanatory models of somatoform disorder patients attending a psychiatry outpatient clinic: a study from North India

BACKGROUND

The symptoms of somatoform disorders are very distressing to the sufferer as well as pose significant burden on the health-care delivery system. Although the nature of symptoms is physical, the underlying mechanisms are not clearly understood.

OBJECTIVE

The purpose of this study was to assess the explanatory models of patients with somatoform disorders presenting to a tertiary care hospital in Northern India.

METHOD

A total of 99 consecutive adult patients (≥ 18 years) with diagnosis of somatoform disorders according to the International Classification of Diseases-10th Revision (ICD-10) were evaluated for their explanatory models using the causal models section of Explanatory Model Interview Catalogue (EMIC).

RESULTS

The mean age of the study sample was 36.52 years, and the mean duration of illness was 59.39 ± 57.68 months. The most common clinical diagnosis was that of persistent somatoform pain disorder. The most common explanations given belonged to the category of psychological factors (68.7%) followed by weakness (67.7%), social causes (51%) and karma-deed-heredity (53.5%) category. The mean number of etiological categories reported were 2.6 (standard deviation (SD) = 1.7). Among the various specific causes, the commonly reported explanations by one half of the sample in decreasing order were general weakness (63.6%), mind-thoughts-worry category (59.6%) and loneliness (53.5%). The mean number of specific etiologies was 4.9 (SD = 3.83).

CONCLUSION

Most of the patients with somatoform disorder attribute their symptoms to psychological factors. It also becomes imperative to understand the physical symptoms in somatoform disorders from the sociocultural aspects of patients.

The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: a qualitative evaluation nested in the MANAS trial in Goa, India

The MANAS trial evaluated the effectiveness of a lay counselor led collaborative stepped care intervention for Common Mental Disorders (CMD) in public and private sector primary care settings in Goa, India. This paper describes the qualitative findings of the experience of the intervention and its impact on health and psychosocial outcomes. Twenty four primary care facilities (12 public and private each) were randomized to provide either collaborative stepped care (CSC) or enhanced usual care (EUC) to adults who screen positive for CMDs. Participants were sampled purposively based on two criteria: gender and, in the CSC arm, adherence with the intervention. The qualitative study component involved two semi-structured interviews with participants of both arms (N = 115); the first interview within 2 months of recruitment and the second 6-8 months after recruitment. Data were collected between September 2007 and November 2009. More participants in the CSC than EUC arm reported relief from symptoms and an improvement in social functioning and positive impact on work and activities of daily life. The CSC participants attributed their improvement both to medication received from the doctors and the strategies suggested by the lay Health Counselors (HC). However, two key differences were observed in the results for the two types of facilities. First, the CSC participants in the public sector clinics were more likely to consider the HCs to be an important component of providing care who served as a link between patient and the doctor, provided them skills on stress management and helped in adherence to medication. Second, in the private sector, doctors performed roles similar to those of the HCs and participants in both arms placed much faith in the doctor who acted as a confidante and was perceived to understand the participant's health and context intimately. Lay counselors working in a CSC model have a positive effect on symptomatic relief, social functioning and satisfaction with care in patients with CMD attending primary care clinics although the impact, compared with usual care, is greater in the public sector.