Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India

Prevalence of common mental disorders and treatment gap among patients with non-communicable diseases in the rural areas of East India

BACKGROUND

Mental and physical non-communicable diseases (NCDs) coexist, because they share common environmental and behavioral risk factors. The treatment gap for common mental disorders, such as depression, anxiety, and substance use, is large compared to other NCDs.

OBJECTIVE

To determine the prevalence and treatment gap of common mental disorders among patients with non-communicable diseases.

METHODOLOGY

The community-based cross-sectional study was conducted in the rural parts of East India, in people aged 30 years and older with NCDs. A simple random sample was chosen to select the villages and participants. Eligible participants administered with screening and diagnostic questionnaire for depression, anxiety, and substance use. Those diagnosed with mental disorders were again assessed for treatment status in the last 12 months. Non-receipt of treatment was considered as treatment gap.

RESULTS

A total of 515 participants were included in the analysis. The overall prevalence of common mental disorders among the study population was 46.4% (95% CI 42.0-50.8), and excluding substance use, the prevalence was 11.7% (95% CI 9.0-14.7). The treatment gap for common mental disorders among patients with non-communicable diseases, including and excluding substance use, was 98.3% (95% CI 95.8-99.5) and 93.3% (95% CI 83.8-98.2), respectively.

CONCLUSION

The prevalence and treatment gap of common mental disorders among persons with NCDs was high. Public health interventions need to be emphasized for the integration of mental health care into NCD care.

Examining the mental health services among people with mental disorders: a literature review

BACKGROUND

Mental disorders are a significant contributor to disease burden. However, there is a large treatment gap for common mental disorders worldwide. This systematic review summarizes the factors associated with mental health service use.

METHODS

PubMed, Scopus, and the Web of Science were searched for articles describing the predictors of and barriers to mental health service use among people with mental disorders from January 2012 to August 2023. The initial search yielded 3230 articles, 2366 remained after removing duplicates, and 237 studies remained after the title and abstract screening. In total, 40 studies met the inclusion and exclusion criteria.

RESULTS

Middle-aged participants, females, Caucasian ethnicity, and higher household income were more likely to access mental health services. The use of services was also associated with the severity of mental symptoms. The association between employment, marital status, and mental health services was inconclusive due to limited studies. High financial costs, lack of transportation, and scarcity of mental health services were structural factors found to be associated with lower rates of mental health service use. Attitudinal barriers, mental health stigma, and cultural beliefs also contributed to the lower rates of mental health service use.

CONCLUSION

This systematic review found that several socio-demographic characteristics were strongly associated with using mental health services. Policymakers and those providing mental health services can use this information to better understand and respond to inequalities in mental health service use and improve access to mental health treatment.

Prevalence of major depressive disorder and its determinants among young married women and unmarried girls: Findings from the second round of UDAYA survey

INTRODUCTION

Depression is a prevalent and debilitating mental illness affecting young women worldwide. This study aimed to identify psychosocial determinants of major depressive disorder (MDD) among young women in Bihar and Uttar Pradesh, India.

METHODS

Data from "Understanding the Lives of Adolescents and Young Adults" (UDAYA) study (2018-19) for young women aged 12-23 years, both married and unmarried was used for this paper. MDD was evaluated using the Patient Health Questionnaire PHQ-9 with a cut-off score of ≤10. The determinants of MDD were identified through multilevel binary logistic regression analysis.

RESULTS

The prevalence of MDD was 13.6% (95% CL 12.2-15.2) and 5.1% (95% CL 4.2-6.1) for young married women and unmarried girls, respectively. Among the young married women, community-level variables like dowry-related humiliation (1.74, 95% CI 1.15-2.64), and sexual assaults (2.15, 95% CI 1.24-3.73) were significantly associated with MDD. For unmarried girls, reporting of family violence <10% of participants (0.45, 95% CI 0.24-0.85), family violence (≥10% of participants) % (0.35 95% CI 0.19-0.68) and interpartner violence (>25% of participants) (0.42; 95% CI 0.23-0.74) remain significant predictors of MDD. At individual level, for both the groups, age, participation in decision making (on education), social capital (currently attending school/educational course and number of friends), self-efficacy, telephonic harassment, and physical activity were associated with MDD. Wealth index, job seeking, participation in decision making (on health-seeking), parental interactions and physical abuse (for unmarried girls only) and education, reported last sexual intercourse, pressure from the in-laws' to conceive (for young married women only) were associated with MDD.

CONCLUSIONS

For young married women, community level targeted interventions should focus on the social ecology to foster a sense of safe community environment. For unmarried girls, additionally, interventions should aim to optimize their family environment for effective mental health outcomes.

Exploring barriers to seek mental health services among patients with severe mental illness and their caregivers in a modified assertive community treatment program: A qualitative thematic analysis

Background

Affordability, lack of public mental healthcare facilities, inadequate insurance coverage, and stigma and discrimination are barriers to mental healthcare utilization in India. There is limited research on these barriers and the factors influencing the use of mental health services.

Aim

To explore the barriers to seeking mental healthcare for individuals with severe mental illness and their caregivers in a modified assertive community treatment program.

Methods

In a qualitative study using a descriptive thematic analysis, we conducted in-depth interviews with 19 adults, including seven individuals with severe mental illness and twelve caregivers. All the participants had been in the modified assertive community treatment program for at least two years. Using thematic analysis, we identified and grouped codes into subthemes and then clustered into themes.

Results

Three major themes on barriers to seeking mental health services emerged: service-related factors, societal-related factors, and illness-related factors. Service-related factors included affordability, accessibility and geographical disparity, and noncoverage under insurance schemes. Societal-related factors included social stigma and discrimination, lack of mental health service knowledge and seeking other forms of treatment, and poor social support. Illness-related factors included poor insight into the illness and no relief from the symptoms despite medication.

Conclusions

Barriers to seeking mental healthcare can be categorized as service-related, societal-related, and illness-related. Identifying these factors will improve mental health service delivery.

Gender differences in the prevalence of anxiety and depression and care seeking for mental health problems in Nepal: Analysis of nationally representative survey data

Background

Assessing gender disparity in mental health is crucial for targeted interventions. This study aims to quantify gender disparities in mental health burdens, specifically anxiety and depression, and related care-seeking behaviors across various sociodemographic factors in Nepal, highlighting the importance of gender-specific mental health interventions.

Methods

Data from the 2022 Nepal Demographic and Health Survey was utilized, employing the Generalized Anxiety Disorder 7 scale (GAD-7) and Patient Health Questionnaire (PHQ-9) scales for anxiety and depression symptoms, respectively. Multiple logistic regression models assessed gender associations with these conditions and care-seeking behaviors.

Results

Women had a higher point prevalence of anxiety (21.9% vs. 11.3%) and depression (5.4% vs. 1.7%) than men. Large variations were noted in gender disparities in the prevalence of anxiety and depression, influenced by age, geographical areas, level of education and household wealth. After adjustment for sociodemographic factors, women were more likely to experience anxiety (adjusted odds ratio (aOR) = 2.18, 95% confidence interval [CI]: 1.96-2.43) and depression (aOR = 3.21, 95% CI: 2.53-4.07). However, no difference was observed in the rates of seeking care for anxiety or depression (aOR = 1.13, 95% CI: 0.91-1.40).

Conclusions

Our findings show a higher point prevalence of mental health issues among women than men, influenced by sociodemographic factors, underscoring the need for gender-focused mental health interventions in Nepal and globally.

ESSENCE: An Implementation Research Program to Scale Up Depression Care in Rural Communities

BACKGROUND

Task sharing may involve training nonspecialist health workers (NSHWs) to deliver brief mental health interventions. This approach is promising for reducing the global mental health treatment gap. However, capacity is limited for training large cadres of frontline workers in low- and middle-income countries, hindering uptake of these interventions at scale.

METHODS

The ESSENCE (enabling translation of science to service to enhance depression care) project in Madhya Pradesh, India, aims to address these challenges through two sequential randomized controlled trials. First, a training trial will evaluate the effectiveness and cost-effectiveness of digital training, compared with conventional face-to-face training, in achieving clinical competency of NSHWs in delivering an intervention for depression. This initial trial will be followed by an implementation trial aimed at evaluating the effectiveness of a remote enhanced implementation support, compared with routine implementation support, in addressing barriers to delivery of depression care in primary care facilities.

RESULTS

This project involved developing and pilot testing a scalable smartphone-based program for training NSHWs to deliver a brief psychological intervention for depression screening. This initial research guided a randomized trial of a digital training approach with NSHWs to evaluate the effectiveness of this approach. This trial will be followed by a cluster-randomized trial to evaluate the effectiveness of remote implementation support in ensuring efficient delivery of depression care in primary care facilities.

NEXT STEPS

Findings from these trials may inform sustainable training and implementation support models to integrate depression care into primary care for scale-up in resource-constrained settings.

"ReachOut": Pilot Evaluation of a Help-Seeking Intervention for Common Mental Health Concerns Among Distressed Non-Treatment-Seeking Young Adults

Purpose There is a pressing need for interventions with the potential for scalability to enhance help-seeking inclination and behavior among individuals experiencing common mental health concerns. These interventions are important for addressing the widespread treatment gap. This study aimed to test the effectiveness, feasibility, and acceptability of a newly developed simple technology-based multi-component help-seeking intervention ("ReachOut") for common mental health concerns among distressed, non-treatment-seeking young adults. Methods "ReachOut" was delivered to 172 young adults aged 20-35 years, scoring above the cut-off on the Kessler Psychological Distress scale. Effectiveness was studied using a single-group short-term prospective study design to examine changes in help-seeking barriers, inclination, and behavior. We assessed intervention feasibility in terms of demand, implementation, practicality, and limited efficacy and acceptability was determined based on the rate of participation consent, the extent of pro-active initiation of contact with the facilitator during the intervention, feedback obtained on various "ReachOut" components and ratings on the likelihood of recommending the intervention to a person in distress. Results Significant reductions in the mean barriers and improvement in mean help-seeking inclination from mental health professionals (MHPs) were observed on the Friedman test from baseline to the two-month follow-up period after the intervention. Thirty-eight percent of participants (N=41) reported seeking help from MHPs by two-month follow-up. Feedback from participants, assessments, and observations indicated that "ReachOut" was feasible and acceptable among the target sample. Conclusions The study provides preliminary evidence of the effectiveness, feasibility, and acceptability of the help-seeking intervention "ReachOut" in reducing barriers and improving help-seeking inclination and behavior for common mental health concerns among distressed non-treatment-seeking young adults.

Current prevalence and determinants of generalized anxiety disorder from a nationally representative, population-based survey of India

Introduction

Generalized anxiety disorder (GAD) is one of the common anxiety disorders leading to impairment and burden. However, GAD remains the least studied anxiety disorder. There is a need for nationally representative epidemiological data of GAD to understand the current burden and plan the mental health policies and programs to attain their unmet needs. Hence, this study focuses on epidemiology, socio-demographic correlates, disability, and treatment gap of GAD from India's National Mental Health Survey (NMHS) 2016.

Materials and Methods

NMHS 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. NMHS is a multi-stage, stratified, random cluster sampling with random selection based on probability proportional to size at each stage. The Mini-International Neuropsychiatric Interview 6.0.0 used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of GAD was estimated. Association between GAD and socio-demographic factors was done using Firth's penalized logistic regression. The treatment gap and disability in GAD also calculated.

Results

The current weighted prevalence of GAD is 0.57%. The male gender and higher education groups have significantly lesser odds with current GAD. Urban metro and the married group have significantly higher odds with current GAD. The most common comorbid psychiatric disorders are depression (15.8%) followed by agoraphobia (9.4%). Among respondents with current GAD in the past 6 months across three domains, around 2/5th has mild and moderate disability, 1/10th has a severe disability, and 1/20th has an extreme disability. The overall treatment gap of current GAD is 75.7%.

Conclusion

NMHS 2016 has provided valuable insights into the epidemiology and burden of GAD among the general population. The available findings provide a glimpse of the current scenario in GAD to aid policymakers in targeting interventions.

Treatment gap for mental and behavioral disorders in Punjab

Background and Aims

There is no data on the treatment gap and health care utilization for mental disorders from Punjab. The present study reports on the same by using the data collected during the National Mental Health Survey.

Settings and Design

Multisite, multistage, stratified, random cluster sampling study conducted in four districts, namely Faridkot, Moga, Patiala, and Ludhiana (for urban metro areas). Data were collected from October 2015 to March 2016.

Materials and Methods

Mini International Neuropsychiatric Interview 6.0.0 and Adapted Fagerstrom Nicotine Dependence Scale were used to diagnose mental and behavioral disorders and tobacco use disorder, respectively. Pathways Interview Schedule of the World Health Organization was applied to persons having any disorder to assess treatment gap and health care utilization. Exploratory focused group discussions (FGDs) were conducted to understand the community perceptions regarding mental and behavioral disorders.

Results

The treatment gap for mental and behavioral disorders was 79.59%, and it was higher for common mental disorders than severe mental disorders and higher for alcohol and tobacco use disorders as compared to opioid use disorders. The median treatment lag was 6 months. Only seven patients out of 79 were taking treatment from a psychiatrist, and the average distance traveled by the patient for treatment was 37.61 ± 45.5 km. Many attitudinal, structural, and other barriers leading to high treatment gaps were identified during FGDs in the community, such as stigma, poor knowledge about mental health, deficiency of psychiatrists, and distance from the hospital.

Conclusions

Vertical as well as horizontal multisectoral integration is required to reduce the treatment gap and improve healthcare utilization. Increasing mental health literacy, providing high-quality mental health services at the primary-healthcare level and human resources development are the need of the hour.

Panic disorder: Epidemiology, disability, and treatment gap from nationally representative general population of India

Introduction

Panic disorder (PD) is one of the most common and debilitating anxiety disorder. Individuals with PD seek frequent healthcare and emergency services leading to frequent work absenteeism and economic burden. However, its prevalence patterns in the Indian context are poorly understood. Hence, this article discusses the epidemiology, disability, and treatment gap from India's National Mental Health Survey 2016.

Materials and Methods

National Mental Health Survey 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. Mini International Neuropsychiatric Interview 6.0.0 is used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of PD was estimated. Association between PD and its sociodemographic correlates was done using Firth penalized logistic regression. The treatment gap and disability in PD were also calculated.

Results

The lifetime and current weighted prevalence of PD was 0.5% (95% confidence interval 0.49-0.52) and 0.3% (95% confidence interval 0.28-0.41), respectively. The male gender and unemployed have significantly lesser odds with current PD. The elderly, Urban metro, and the married/separated group have significantly higher odds with current PD. The most common comorbid psychiatric disorder is agoraphobia (42.3%) and depression (30.9%) followed by Generalized Anxiety Disorder (10%). Among respondents with current PD in the past 1 month across three domains, around 80% had a disability of any severity and 20%-25% had marked disability. The overall treatment gap of current PD is 71.7%.

Conclusion

It is the first study reporting prevalence from a nationally representative sample from the general population of India. The survey has shed light on the epidemiology and the challenges faced by those with PD which emphasizes the urgency of bridging the treatment gap. These findings are paramount to the development of more inclusive and effective mental health policies and interventions to tackle the current burden due to PD.

Prevalence of mental disorders in South Asia: A systematic review of reviews

Mental disorders are increasing in South Asia (SA), but their epidemiological burden is under-researched. We carried out a systematic umbrella review to estimate the prevalence of mental disorders and intentional self-harm in the region. Multiple databases were searched and systematic reviews reporting the prevalence of at least one mental disorder from countries in SA were included. Review data were narratively synthesised; primary studies of common mental disorders (CMDs) among adults were identified from a selected subset of reviews and pooled. We included 124 reviews. The majority (n = 65) reported on mood disorders, followed by anxiety disorders (n = 45). High prevalence of mental disorders and intentional self-harm was found in general adult and vulnerable populations. Two reviews met our pre-defined criteria for identifying primary studies of CMDs. Meta-analysis of 25 primary studies showed a pooled prevalence of 16.0% (95% CI = 11.0-22.0%, I 2 = 99.9%) for depression, 12.0% (5.0-21.0%, I 2 = 99.9%) for anxiety, and 14.0% (10.0-19.0, I 2 = 99.9%) for both among the general adult population; pooled estimates varied by country and assessment tool used. Overall, reviews suggest high prevalence for mental disorders in SA, but evidence is limited on conditions other than CMDs.

Mapping of mental health care facilities and psychiatrists in a North Indian district of India

Introduction

Since 1990, the proportional contribution of mental disorders to India's total disease burden has nearly doubled, but the number of psychiatrists has not increased proportionately. Even after two decades of District Mental Health Programme (DMHP) launch, a considerable treatment gap still exists for mental illness. The present study aimed to map all health facilities providing mental health services and all psychiatrists in district Faridabad, Haryana.

Methods

The starting point was the information available with the DMHP and district health office. This was supplemented by web search and snowball sampling. All identified facilities were visited to map the mental health services provided. All the mental health care providers and health care facilities were mapped using "Google my Maps". 2011 census data on population were used.

Results

In Faridabad, 0.88 psychiatrists per lakh population were present. Most psychiatrists were concentrated in the urban area. The number of psychiatrists per lakh population was 1.1 in urban, compared to 0.54 in rural Faridabad. Clustering of mental health facilities was also observed more in urban areas (8.7 per 100 Sq Km) compared to rural areas (0.95 per 100 Sq Km) of district Faridabad.

Conclusion

There was a scarcity of psychiatric manpower and facilities in the district with a distinct urban skew.

Mental health related stigma, service provision and utilization in Northern India: situational analysis

Stigma, discrimination, poor help seeking, dearth of mental health professionals, inadequate services and facilities all adversely impact the mental health treatment gap. Service utilization by the community is influenced by cultural beliefs and literacy levels. We conducted a situational analysis in light of the little information available on mental health related stigma, service provision and utilization in Haryana, a state in Northern India. This involved: (a) qualitative key informant interviews; (b) health facility records review; and (c) policy document review to understand the local context of Faridabad district in Northern India. Ethical approvals for the study were taken before the study commenced. Phone call in-depth interviews were carried out with a purposive sample of 13 participants (Mean = 38.07 years) during the COVID-19 pandemic, which included 4 community health workers, 4 people with mental illness, 5 service providers (primary health care doctors and mental health specialists). Data for health facility review was collected from local primary health and specialist facilities while key policy documents were critically analysed for service provision and stigma alleviation activities. Thematic analysis was used to analyse patterns within the interview data. We found poor awareness and knowledge about mental illnesses, belief in faith and traditional healers, scarcity of resources (medicines, trained professionals and mental health inpatient and outpatient clinics), poor access to appropriate mental health facilities, and high costs for seeking mental health care. There is a critical gap between mental health related provisions in policy documents and its implementation at primary and district level.

Prevalence of depression and anxiety in older people in low- and middle- income countries in Africa, Asia and South America: A systematic review and meta-analysis

BACKGROUND

There is rapid growth of older people in Low- and Middle- Income Countries (LMICs). The aim of this review was to assess the literature on prevalence of anxiety and depression in this demographic, which to our knowledge, has not yet been conducted.

METHODS

Databases including Medline, PsychInfo, Embase, Scielo and African Journals Online were searched for terms including "mental disorders", "neurotic disorders", "mood disorders" and "anxiety disorders". Studies published between 1990 and 2020 providing data on older people (≥50 years) in LMICs (defined by World Bank Criteria) were included and quality-assessed. Meta-analysis was conducted on a subset of higher-quality studies to derive pooled prevalence estimates of depression.

RESULTS

One hundred and forty relevant studies were identified, of which thirty-two were included in meta-analysis. One hundred and fifteen studies reported depression prevalence only, 19 reported both depression and anxiety, and six reported anxiety only. In all studies identified, depression prevalence ranged from 0.5 % to 62.7 %, and Generalised Anxiety Disorder prevalence ranged from 0.2 % to 32.2 %. The pooled prevalence of depression on meta-analysis was 10.5 % (95 % CI, 8.9 % - 11.2 %). Reported prevalence rates of depression were significantly different in studies using ICD-10 compared with DSM criteria, and between community and clinical settings.

LIMITATIONS

The search strategy contained bias towards English language papers and high income country (HIC) publications. There is significant heterogeneity within the meta-analysis.

DISCUSSION

A wide range of methodologies and clinical criteria are used in prevalence studies of depression and anxiety in older people. Studies using screening tools found higher prevalence rates; clinicians and researchers should ensure diagnosis is made with gold-standard clinical criteria. Meta-analysis data suggest that rates of depression are similar in older people in LMICs compared to HICs but mental healthcare resources are limited, suggesting a large potential treatment gap.

Perceived Wellbeing, Happiness, and Related Challenges among Indian College Students

The present study aimed to examine the conceptualisation and determinants of happiness among Indian college students and identify areas in which they require help. The sample consisted of 362 students in the age group of 18 to 30 years (M_age = 20.9, SD_age = 2.25) from two locations in North and South India. Online forms, including the Satisfaction with Life Scale (Diener et al., 1985), Positive and Negative Affect Schedule (Watson et al. in J Pers Soc Psychol 54:1063-1070, 1998) and a qualitative survey, were used to collect the data. Results indicated that participants from institutions that offered mental health initiatives reported higher well-being than those who did not. Findings from the qualitative survey suggest that most participants conceptualised happiness in terms of need for satisfaction and well-being. The responses also indicated that leisure activities and time spent with the family determined the participants' happiness. Concerns related to interpersonal relationships made the participants unhappy, and most of them were willing to seek help in this regard. Factors beyond immediate self and interpersonal networks had a limited role in participants' perceived happiness and unhappiness. Study findings could guide the development of customised mental health and well-being promotion initiatives to meet the needs of Indian college students.

Operational challenges in the pre-intervention phase of a mental health trial in rural India: reflections from SMART Mental Health

BACKGROUND

Availability of mental health services in low- and middle-income countries is largely concentrated in tertiary care with limited resources and scarcity of trained professionals at the primary care level. SMART Mental Health is a strategy that combines a community anti-stigma campaign with a primary health care workforce strengthening initiative, using electronic decision support with the goal of better identifying and supporting people with common mental disorders in India.

METHODS

We describe the challenges faced and lessons learnt during the pre-intervention phase of SMART Mental Health cluster Randomised Controlled Trial. Pre-intervention phase includes preliminary activities for setting-up the trial and research activities prior to delivery of the intervention. Field notes from project site visit, project team meetings and detailed follow-up discussions with members of the project team were used to document operational challenges and strategies adopted to overcome them. The socio-ecological model was used as the analytical framework to organise the findings.

RESULTS

Key challenges included delays in government approvals, addressing community health worker needs, and building trust in the community. These were addressed through continuous communication, leveraging support of relevant stakeholders, and addressing concerns of community health workers and community. Issues related to use of digital platform for data collection were addressed by a dedicated technical support team. The COVID-19 pandemic and political unrest led to significant and unexpected challenges requiring important adaptations to successfully implement the project.

CONCLUSION

Setting up of this trial has posed challenges at a combination of community, health system and broader socio-political levels. Successful mitigating strategies to overcome these challenges must be innovative, timely and flexibly delivered according to local context. Systematic ongoing documentation of field-level challenges and subsequent adaptations can help optimise implementation processes and support high quality trials.

TRIAL REGISTRATION

The trial is registered with Clinical Trials Registry India (CTRI/2018/08/015355). Registered on 16th August 2018. http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=23254&EncHid=&userName=CTRI/2018/08/015355.

Sub-national patterns and correlates of depression among adults aged 45 years and older: findings from wave 1 of the Longitudinal Ageing Study in India

BACKGROUND

Depression is a major public health challenge linked with several poor health outcomes and disabilities among adults aged 45 years and older in India. We aimed to describe the prevalence of depression and its association with a variety of sociodemographic correlates and co-existing health conditions for this age group in India and its states.

METHODS

In this prospective cohort study, data from wave 1 (baseline) of the Longitudinal Ageing Study in India were used to estimate the national and subnational state level age-standardised prevalence of depression-major depressive episodes-using the internationally validated Composite International Diagnostic Interview-Short Form (CIDI-SF) scale. Hierarchical mixed effect multivariate logistic regression models were used to study the sociodemographic correlates and co-existing health conditions of major depressive episodes among the nationally representative sample of 72 250 adults aged 45 years and older from 35 states or union territories (except the state of Sikkim). Associations between depression and self-rated health, co-morbid conditions, functional health, and life satisfaction measures were also examined.

FINDINGS

A total of 40 335 (58·3%) females and 29 407 (41·7%) males aged 45 to 116 years (median age 58 years) participated. The overall age-standardised prevalence of depression based on CIDI-SF scale was 5·7% (95% CI 5·5-5·8) compared with 0·5% (0·5-0·6) self-reported prevalence of depression among adults aged 45 years and older in India. Wide sub-national variations were seen in depression prevalence, ranging from 0·8% (95% CI 0·3-1·3) in Mizoram state to 12·9% (11·6-14·2) in Madhya Pradesh. Prevalence was higher in females (6·3% [95% CI 6·1-6·6] vs 4·3% [4·1-4·6]) for India, and this higher prevalence was more pronounced in some of the northern states. The risk of depression was higher in those residing in rural areas, widowed, with no or low education, and in the poorest quintile. Depression showed a strong positive association with poor self-rated health (OR 2·39 [95% CI 2·21-2·59]; p<0·0001), with one or more limitations in the activities of daily living (ADL; OR 1·60 [1·46-1·75]; p<0·0001), instrumental ADL limitations (OR 1·51 [1·40-1·64]; p<0·0001), and low cognitive judgment of life satisfaction (OR 1·94 [95% CI 1·78-2·10]; p<0·0001).

INTERPRETATION

Despite the substantial burden, depression remains undiagnosed and strongly linked with poor health and wellbeing outcomes in adults aged 45 years and older in India. The ageing population of India and the subnational variations amplify the implications of this new evidence to address the substantial gaps in prevention and treatment of depression.

FUNDING

LASI was funded by the Ministry of Health and Family Welfare, Government of India, the National Institute of Ageing, USA and the United Nations Population Fund, India.

An intervention to reduce stigma and improve management of depression, risk of suicide/self-harm and other significant emotional or medically unexplained complaints among adolescents living in urban slums: protocol for the ARTEMIS project

BACKGROUND

There are around 250 million adolescents in India. Adolescents are vulnerable to common mental disorders with depression and self-harm accounting for a major share of the burden of death and disability in this age group. Around 20% of children and adolescents are diagnosed with/ or live with a disabling mental illness. A national survey has found that suicide is the third leading cause of death among adolescents in India. The authors hypothesise that an intervention involving an anti-stigma campaign co-created by adolescents themselves, and a mobile technology-based electronic decision support system will help reduce stigma, depression, and suicide risk and improve mental health for high-risk adolescents living in urban slums in India.

METHODS

The intervention will be implemented as a cluster randomised control trial in 30 slum clusters in each of the cities of Vijayawada and New Delhi in India. Adolescents aged 10 to 19 years will be screened for depression and suicide ideation using the Patient Health Questionnaire (PHQ-9). Two evaluation cohorts will be derived-a high-risk cohort with an elevated PHQ-9 score ≥ 10 and/or a positive response (score ≥ 2) to the suicide risk question on the PHQ-9, and a non-high-risk cohort comprising an equal number of adolescents not at elevated risk based on these scores.

DISCUSSION

The key elements that ARTEMIS will focus on are increasing awareness among adolescents and the slum community on these mental health conditions as well as strengthening the skills of existing primary healthcare workers and promoting task sharing. The findings from this study will provide evidence to governments about strategies with potential for addressing the gaps in providing care for adolescents living in urban slums and experiencing depression, other significant emotional or medically unexplained complaints or increased suicide risk/self-harm and should have relevance not only for India but also for other low- and middle-income countries.

TRIAL STATUS

Protocol version - V7, 20 Dec 2021 Recruitment start date: tentatively after 15th July 2022 Recruitment end date: tentatively 14th July 2023 (1 year after the trial start date) TRIAL REGISTRATION: The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries ( https://www.who.int/clinical-trials-registry-platform/network/primary-registries ) Reference No. CTRI/2022/02/040307 . Registered on 18 February 2022. The tentative start date of participant recruitment for the trial will begin after 15th July 2022.

Protocol for process evaluation of SMART Mental Health cluster randomised control trial: an intervention for management of common mental disorders in India

INTRODUCTION

In India about 95% of individuals who need treatment for common mental disorders like depression, stress and anxiety and substance use are unable to access care. Stigma associated with help seeking and lack of trained mental health professionals are important barriers in accessing mental healthcare. Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health integrates a community-level stigma reduction campaign and task sharing with the help of a mobile-enabled electronic decision support system (EDSS)-to reduce psychiatric morbidity due to stress, depression and self-harm in high-risk individuals. This paper presents and discusses the protocol for process evaluation of SMART Mental Health.

METHODS AND ANALYSIS

The process evaluation will use mixed quantitative and qualitative methods to evaluate implementation fidelity and identify facilitators of and barriers to implementation of the intervention. Case studies of six intervention and two control clusters will be used. Quantitative data sources will include usage analytics extracted from the mHealth platform for the trial. Qualitative data sources will include focus group discussions and interviews with recruited participants, primary health centre doctors, community health workers (Accredited Social Health Activits) who participated in the project and local community leaders. The design and analysis will be guided by Medical Research Council framework for process evaluations, the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, and the normalisation process theory.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of the George Institute for Global Health, India and the Institutional Ethics Committee, All India Institute of Medical Sciences (AIIMS), New Delhi. Findings of the study will be disseminated through peer-reviewed publications, stakeholder meetings, digital and social media platforms.

TRIAL REGISTRATION NUMBER

CTRI/2018/08/015355.

Maximizing the non-specific factors in brief cognitive behavioral therapy for panic disorder and agoraphobia: A multiple baseline case series documenting feasibility and initial efficacy

There is evidence for non-specific factors impacting treatment outcomes, with pragmatic concerns regarding the need to popularize briefer formats of cognitive behavioral therapy (CBT). The need to have more culturally suitable and acceptable forms of CBT is also indicated. We evaluated the feasibility and efficacy of a brief 5 session CBT (bCBT) in participants (N = 4) with panic disorder (PD) and agoraphobia, using a non-concurrent multiple baseline design. In this case series, efforts were made to maximize non-specific factors of psychotherapy in bringing about treatment outcomes. Reliable and significant treatment effects were observed at post-intervention and follow-up assessments. The present study offers preliminary evidence of a bCBT protocol that comprises the efforts to maximize the non-specific factors in psychotherapy such as credibility, expectancy, and the therapeutic alliance in bringing treatment outcomes; however, further controlled evaluation is warranted. We also discuss the mechanisms contributing to these treatment outcomes in the present protocol.

Treatment non-adherence pattern among persons with neuropsychiatric disorders: A study from a rural community mental health centre in India

BACKGROUND

Treatment gap causes significant loss to individuals, families, societies and the nation. Treatment adherence enhancement is a major challenge in psychiatric disorders. Globally, the community mental health services are obligated to minimize the treatment and adherence gap. In recent years' retrospective studies are gaining importance to measure the trend of mental health service utilization, cost effectiveness, resources allocation and similar aspects.

AIM

To explore the treatment adherence pattern of persons with neuropsychiatric illness from a rural community mental health centre.

METHOD

Five hundred and ninety-six medical records of persons with neuropsychiatric disorders who registered for outpatient treatment between 2015 and 2017 at Sakalawara Rural mental health centre of National Institute of Mental Health and Neuro Sciences, Bangalore, India, were reviewed to understand their adherence pattern.

RESULTS

Out of 596 patients, 68 (11.4%) were referred to tertiary care mental health and District Mental Health Programme (DMHP) services. Out of the remaining 528 patients, 29.7% were regular to mental health services over a period of 12 months and above; majority of the patients (36.2%) dropped out of their treatment after their first contact and 34.1% discontinued their follow up visits over a period of first week to 12 months.

CONCLUSION

Community based mental health centres too face challenges of and problems related to treatment non-adherence. Persons with neuropsychiatric disorders require continuity of care through regular home visits, out-reach services and innovative methods which will enhance treatment adherence.

Prevalence and its correlates of anxiety disorders from India's National Mental Health Survey 2016

INTRODUCTION

Anxiety disorders (ADs) impact the quality of life and productivity at an individual level and result in substantial loss of national income. Representative epidemiological studies estimating the burden of ADs are limited in India. National Mental Health Survey (NMHS) 2016 of India aimed to strengthen mental health services across India assessed the prevalence and pattern of public health priority mental disorders for mental health-care policy and implementation. This article focuses on the current prevalence, sociodemographic correlates, disability, and treatment gap in ADs in the adult population of NMHS 2016.

MATERIALS AND METHODS

NMHS 2016 was a nationally representative, multicentered study across 12 Indian states during 2014-2016. Diagnosis of ADs (generalized AD, panic disorder, agoraphobia, and social AD) was based on Mini-International Neuropsychiatric Interview 6.0.0. Disability was by Sheehan's Disability Scale.

RESULTS

The current weighted prevalence of ADs was 2.57% (95% confidence interval: 2.54-2.60). Risk factors identified were female gender, 40-59 age group, and urban metro dwellers. Around 60% suffered from the disability of varying severity. The overall treatment gap for ADs was 82.9%.

CONCLUSIONS

The burden of AD is similar to Depressive disorders, and this article calls for the immediate attention of policymakers to institute effective management plans in existing public health programs.

Panic disorder in general medical practice- A narrative review

The under-or misdiagnosis, and symptomatic treatment of the panic disorder (PD), despite high prevalent medical illness, is common among non-psychiatric physicians. The non-psychiatrist physician’s role is vital in the care of PD as most patients initially approach general medical settings for medical help, including primary care. However, a significant proportion is undiagnosed and undergoes either unnecessary investigation, misdiagnosed, or mismanaged even among post-Coronary Artery Bypass Grafting patients, which profoundly affects the patients functioning and quality of life. This article aims to provide overviews of relevant epidemiological aspects, presenting features across medical specialties with respective diagnostic dilemmas, assessment, and management of the PD in their general medical settings, including emergency visits. Apart from psychiatrists, this will also assist non-psychiatrist physicians across all medical specialties, including general practitioners, to understand, identify, and provide the first line evidence-based pharmacotherapy and address the unmet need of patients with PD in their day-to-day busy clinical practice. This paper also provides a referral guide for non-psychiatrist physicians to refer to psychiatrists for further management after their first-line management.

Epidemiology of common mental disorders: Results from "National Mental Health Survey" of India, 2016

BACKGROUND

Despite their higher prevalence, the Common Mental Disorders (CMDs) are under-recognized and under-treated resulting in huge disability. India, home to one-fifth of the global population, could offer insights for organizing better services for CMDs. However, the prevalence and resultant disability in the general population is unknown, and consequently, gaps in management or plan for services are enormous, by default overlooked.

AIM

Estimating the current prevalence, disability, socioeconomic impact, and treatment gap of CMDs in a nationally representative sample from India. We attempt to identify the missed opportunities and list priorities for planning.

METHODOLOGY

The National Mental Health Survey of India (2016) is a multisite nationwide household survey conducted across India using a uniform methodology. Overall, 39,532 adults were surveyed with a response rate of 88%. Diagnoses are based on the Mini International Neuropsychiatric Interview 6.0.0. CMDs for this analysis include depressive and anxiety disorders (generalized anxiety disorder, social phobia, agoraphobia, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder).

RESULTS

The weighted prevalence of current CMDs was 5·1% (95% CI: 5.06-5.13). Prevalence was highest in females, among the 40-59 years of age group, and in metros. Nearly 60% of them reported disabilities of varying severity. The treatment gap was 80·4%. On average, patients and their families spent ₹1500/month towards the treatment of CMDs.

CONCLUSIONS

This survey gives valuable insights regarding the disability and treatment gap due to CMDs and is imperative for reframing mental health policies and planning interventions. This study also suggests an international investigation to understand the difference in the prevalence of CMDs in developing versus developed countries.

Estimating the global treatment rates for depression: A systematic review and meta-analysis

BACKGROUND

Depression is considered a global crisis due to its high prevalence and associated disabilities. The burden posed by depression could be reduced by increasing access to timely treatment. Limited information is available on treatment rates of depression, particularly in low- and middle-income countries. This study aimed to estimate the treatment rates for depression in the general adult population by World Bank income classification.

METHODS

We searched PubMed, EMBASE, PsycINFO, and CINAHL, supplemented with hand-search of reference lists to identify community-based studies. The overall treatment rate for depression was estimated from studies that reported any treatment (behavioral or pharmacological treatments) in healthcare or informal non-healthcare settings. Data were pooled using a random-effects meta-analysis model. Subgroup analyses by income classification were completed. Meta-regression was conducted by study characteristics. The protocol was pre-registered at PROSPERO (CRD42020161683).

RESULTS

We included 65 studies comprising 1.1 million participants from 79 countries and territories. The global 12-month/lifetime pooled treatment rate was 34.8% (95% confidence interval: 29.9, 39.9%). The treatment rates were 48.3% (43.0, 53.6%) in high-income countries, 21.4% (15.1, 27.7%) in middle-income countries, and 16.8% (11.3, 23.0%) in low-income countries. Among the treated samples, 12-month minimally adequate treatment was estimated to be 40%.

LIMITATION

We reported a substantial level of between-study heterogeneity, which was partially explained by study characteristics in the meta-regression.

CONCLUSION

Globally, approximately one-third of people with depression receive treatment. Three in five treated people with depression did not receive minimally adequate treatment. Depression treatment rates are considerably lower in low-and middle-income countries.

Challenges, Barriers, and Good Practices in the Implementation of Rashtriya Bal Swasthya Karyakram in Jodhpur, India

Introduction The Rashtriya Bal Swasthya Karyakram of the Government of India subsumes the existing school health program to provide care and treatment to children below 18 years through screening and early interventions. Benefitting an estimated 270 million children for 30 preidentified conditions is a step toward “health for all.” Although the program is running since 2013, due to paucity of studies particularly in Thar desert region and its associated challenges, this study was planned to assess challenges and good practices in the implementation of RBSK in Jodhpur.

Objectives To assess the challenges, barriers, and good practices in the implementation of RBSK among the mobile health team (MHT) in Jodhpur, Rajasthan.

Methods A community based descriptive cross-sectional study in all 11 medical blocks of Jodhpur district, with purposive sampling to invite all members of MHT to participate in the study as grassroot workers was planned. A pretested, semistructured questionnaire was processed using SPSS for quantitative component and in-depth interviews were reported using qualifiers for qualitative observations.

Results As much as 74.1% (n = 40) of the staff perceived the trainings to be sufficient for daily work needs but needed more sessions for birth defects (33.3%) and development delays (29.6%). As much as 96.3% (n = 52) of the staff considered salaries to be low and 55.5% were dissatisfied with the jobs. However, 70.4% found targets to be achievable and 76% found the work environment helpful. Taboos and superstitions in community, harsh climate, dual workload on pharmacists as data operators, and noninclusion of AYUSH medicines for AYUSH medical officers (MOs) were few of the challenges, while good practices such as fully equipped MHTs, readily available vehicles, information education communication (IEC) materials, and treatment coverage under Bhamashah Bima Yojana (BSBY) were also observed.

Conclusion Many good practices were observed during the study which can be adopted by other states for better implementations elsewhere. Certain challenges such as belief in quackery, superstitions and taboos could be minimized by conducting rapport-building meetings with community stakeholders. Feedback and regular trainings of MHT staff can further increase the success manifold.

Protecting Mental Health Data Privacy in India: The Case of Data Linkage With Aadhaar

In an underprepared and under-resourced digital mental health system, the linkage of health and personal data with Aadhaar, a biometric system that provides a unique identification number to all Indian residents, poses significant privacy risks to individuals seeking mental health care. We discuss the challenges in protecting mental health data privacy due to these emerging digital health technologies.

Development and implementation of COVID-19 safety protocols for conducting a randomized trial in global mental health: Field report from Central India

The COVID-19 pandemic impacted ongoing clinical trials globally resulting in the suspension, cancellation or transition to entirely remote implementation of studies. In India, the first countrywide lockdown was imposed in phases starting from March 2020 to June 2020, followed by a continued restriction on in-person activities including study procedures, which halted the ESSENCE (Enabling translation of Science to Service to ENhance Depression CarE) trial activities such as recruitment, consenting, baseline assessment, digital training orientation, face to face training and end-line assessment evaluation. This situation made it imperative to amend procedures in order to mitigate the risk and address safety requirements for participants and the research team. This paper summarizes the need, development and implementation of the protocols focused on risk reduction and safety enhancement with an objective to resume and continue the research activities while ensuring the safety of study participants and research staff. These protocols are comprised of guidelines and recommendations based on existing literature tailored according to different components in each arm of the trial such as guidelines for supervisors, travellers, training/recruitment venue safety procedures, individual safety procedures; and procedures to implement the study activities. These protocols can be adapted by researchers in other settings to conduct research trials during pandemics such as COVID-19.

Estimation of Years Lived with Disability Using a Prevalence-Based Approach: Application to Major Psychiatric Disease in Korea

To help develop policies concerning the prevention of psychiatric disease in Korea, we reviewed the literature on this topic in different countries and used a prevalence-based approach to estimate the years lived with disability (YLDs) in Korean patients with major psychiatric diseases. We calculated YLDs by extracting data on the number of patients with mild, moderate, and severe cases of schizophrenia, bipolar disorder, and major depressive disorder, as classified by International Statistical Classification of Disease (ICD) codes. YLDs were highest for patients with major depressive disorder (1190.6; 73.9%), schizophrenia (303.3; 18.8%) and bipolar disorder (117.9; 7.3%). Men had higher YLDs for schizophrenia, 2502 (20-24 years); bipolar disorder, 477 (40-44 years); and major depressive disorder, 2034 (75-79 years). Women had higher YLDs for schizophrenia, 484 (45-49 years); bipolar disorder, 214 (≥80 years); and major depressive disorder, 3541 (75-79 years). The prevalence-based approach and severity distribution is useful for estimating long-term psychiatric disease burden and YLDs. However, YLD-estimation studies must compensate for the shortcomings of the ICD-10 by referencing the Diagnostic and Statistical Manual of Mental Disorders 5th edition, as well as updating the disability weight score according to disease severity.

COVID-19-Related Financial Hardship, Job Loss, and Mental Health Symptoms: Findings from a Cross-Sectional Study in a Rural Agrarian Community in India

Several countries, including India, imposed mandatory social distancing, quarantine, and lockdowns to stop the spread of the SARS-CoV-2 virus. Although these measures were effective in curbing the spread of the virus, prolonged social distancing, quarantine, and the resultant economic disruption led to an increase in financial stress and mental health concerns. Prior studies established a link between the first lockdown and an increase in mental health issues. However, few studies investigated the association between post-lockdown financial hardship, job loss, and mental health. In this study, we examined the association between COVID-19-related financial hardship, job loss, and mental health symptoms approximately nine months after the end of the first nationwide lockdown in India. Job loss was associated with higher reporting of mental health symptoms among men (aIRR = 1.16) while financial hardship was associated with poor mental health symptoms among women (aIRR = 1.29). Conversely, social support and government aid were associated with better mental health symptoms among women. Our findings highlight the need for financial assistance and job creation programs to aid families in the recovery process. There is also an urgent need for improving the availability and affordability of mental health services in rural areas.

Proactive case finding for severe mental illness in a rural area in the Indian Punjab: findings and lessons

People with severe mental illnesses may experience barriers in accessing community mental health services. We used the key informant method to detect people with untreated severe mental illness in seven villages in the Indian state of Punjab. The key informant was a local community leader. We were able to contact 11 patients who were identified as suffering from severe mental illness by the key informants. On assessment, eight of them had intellectual disability and three had psychotic and affective illness. We discuss the barriers and opportunities for providing mental health services in the community.

An integrated community and primary healthcare worker intervention to reduce stigma and improve management of common mental disorders in rural India: protocol for the SMART Mental Health programme

BACKGROUND

Around 1 in 7 people in India are impacted by mental illness. The treatment gap for people with mental disorders is as high as 75-95%. Health care systems, especially in rural regions in India, face substantial challenges to address these gaps in care, and innovative strategies are needed.

METHODS

We hypothesise that an intervention involving an anti-stigma campaign and a mobile-technology-based electronic decision support system will result in reduced stigma and improved mental health for adults at high risk of common mental disorders. It will be implemented as a parallel-group cluster randomised, controlled trial in 44 primary health centre clusters servicing 133 villages in rural Andhra Pradesh and Haryana. Adults aged ≥ 18 years will be screened for depression, anxiety and suicide based on Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorders (GAD-7) scores. Two evaluation cohorts will be derived-a high-risk cohort with elevated PHQ-9, GAD-7 or suicide risk and a non-high-risk cohort comprising an equal number of people not at elevated risk based on these scores. Outcome analyses will be conducted blinded to intervention allocation.

EXPECTED OUTCOMES

The primary study outcome is the difference in mean behaviour scores at 12 months in the combined 'high-risk' and 'non-high-risk' cohort and the mean difference in PHQ-9 scores at 12 months in the 'high-risk' cohort. Secondary outcomes include depression and anxiety remission rates in the high-risk cohort at 6 and 12 months, the proportion of high-risk individuals who have visited a doctor at least once in the previous 12 months, and change from baseline in mean stigma, mental health knowledge and attitude scores in the combined non-high-risk and high-risk cohort. Trial outcomes will be accompanied by detailed economic and process evaluations.

SIGNIFICANCE

The findings are likely to inform policy on a low-cost scalable solution to destigmatise common mental disorders and reduce the treatment gap for under-served populations in low-and middle-income country settings.

TRIAL REGISTRATION

Clinical Trial Registry India CTRI/2018/08/015355 . Registered on 16 August 2018.

Economic evaluations of psychological treatments for common mental disorders in low- and middle-income countries: protocol for a systematic review

BACKGROUND

Common mental disorders (CMDs) are highly prevalent conditions that constitute a major public health and economic burden on society in low- and middle-income countries (LMICs). Despite the increased demand for economic evidence to support resource allocation for scaled-up implementation of mental health services in these contexts, economic evaluations of psychological treatments for CMDs remain scarce.

OBJECTIVE

The proposed systematic review aims to synthesize findings on methods and outcomes of economic evaluations of psychological treatments for CMDs in LMICs and appraise quality.

METHODS

We will identify, select, and extract data from published economic evaluations of psychological interventions for CMDs conducted in LMICs. We will search bibliographic databases (PubMed, EMBASE, CINAHL, Web of Science, EconLit, PsycINFO, Africa-Wide Information, Cochrane library, Centre for Reviews and Dissemination (CRD), Cost Effectiveness Analysis (CEA) Registry), and the African Journals Online (AJOL) and Google Scholar platforms. Only full economic evaluations (Cost-Effectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Consequence Analysis (CCA), or Cost-Benefit Analysis (CBA)) of psychological treatments for CMDs (defined as depressive, anxiety, and substance use disorders) conducted in LMICs will be included. There will be no restrictions based on date of publication, perspective, follow-up duration or sample size. Data extraction will be guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The results presented will be examined using a narrative synthesis approach. The quality of included studies will be assessed using the Drummond & Jefferson checklist.

CONCLUSION

The fledgling evidence base in this area provides an opportunity to promote improved economic evaluation methods in line with repeated calls for economic evidence alongside effectiveness evidence in these settings. A rigorously developed economic evaluation evidence base will support resource allocation decisions for scaled up implementation of psychological interventions in LMIC settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020185277.

Systematic review of interventions to reduce mental health stigma in India

BACKGROUND

Stigma is a barrier for help-seeking, mental health service access, and contributes to the mental health treatment gap. Because the mental health treatment gap is greatest in low- and middle-income countries, it is vital to identify effective strategies to reduce stigma in these settings. To date, there has been a lack of synthesis of findings from interventions to reduce stigma related to mental disorders within India.

METHOD

A systematic review was conducted to provide an overview of the characteristics and effectiveness of stigma reduction interventions studies in India. PubMed, Embase and PsycINFO databases were searched for literature published up to 30th June 2020.

RESULTS

From a total of 1,984 articles identified, only 9 were eligible for final inclusion, published between 1990-2020. No study was found from North, North-East, Central or East India. Most stigma-reduction interventions were multi-level, that is, using a combination of intra-personal, inter-personal and community level strategies to target changes in outcomes of individuals, environments and community groups. Three studies focused on health and stigma-related changes at the organisational/institutional level. No interventions focused on the governmental/structural level. There were only two randomised controlled trials, and two studies focused on all three stigma components of knowledge, attitudes and behaviour. Most interventions were delivered to community members. None focused on mental health professionals as intervention delivery target.

CONCLUSION

There is a need for the development of comprehensive, culturally acceptable evidence-based interventions that act at multiple levels, and involve a mixture of various stigma reducing strategies with multiple target groups.

Prevalence of Common mental disorders in older adults: Results from the National Mental Health Survey of India

OBJECTIVE

We estimate the prevalence of common mental disorders (CMD) among older adults and compare them with that of younger adults at the national level.

METHOD

We analysed data on older adults from the National Mental Health Survey of India undertaken across 6 regions and 12 states of India during 2015-16. Multi-stage cluster sampling technique was adopted which permitted state level and subsequently pooled national estimates. Mini International NeuroPsychiatric Interview (MINI) adult version 6.0 was used for measuring psychiatric morbidity.

RESULTS

Older adults had a higher lifetime (6.93%) and current (3.53%) prevalence of depressive disorders as compared to the younger adults (4.96% and 2.54%). There was no difference in the prevalence of anxiety disorders in different agegroups. The most prevalent anxiety disorder in older adults was specific phobias (1.72%) followed by agoraphobia (1.6%). All CMD in the older population were more common in females, those living in urban metros, the unemployed, who were not currently married and those with lower household income.

DISCUSSION

These findings support planning better mental health policies and programs for older adults in India.

Age-Period-Cohort Analysis of Trends in Mental Health Mortality in India from 2001 to 2015

The current study was done to examine the trend of mental health mortality in India using age-period-cohort (APC) analysis. We have conducted a secondary data analysis by using the data on mental health mortality from WHO Global Health Estimates. We performed APC analysis by weighted least squares regression with assumption that data follows Poisson distribution.Annual increase in the age adjusted mortality rate due to mental health problems was 1.52%. Rate ratio (RR) increased consistently across all the age groups from 15-19 to 80-84 years. RR of period effects also showed increase from 2001-2005 to 2011-2015 periods. RR of cohort effects showed consistent increase from 1921-1925 to 1986-1990 cohorts and then decreasing from 1991-1995 to 1996-2000. To summarize, we found that mental health mortality shows increasing trend in India over the past decade with maximum increase among older population.

Barriers to Professional Help-seeking for Distress and Potential Utility of a Mental Health App Components: Stakeholder Perspectives

Introduction

A high prevalence of common mental disorders and the associated treatment gap, particularly in low and middle-income countries such as India, calls for novel mental health approaches with widespread reach. There is a need to enhance our understanding of the barriers experienced by distressed persons as well as to utilize these insights for breaking such barriers. Despite the rise in the use of technology-based solutions in the field of mental health, there is a dearth of app-based interventions that help in breaking barriers to seeking professional help for mental health concerns in distressed persons. The present study aimed at exploring the perspectives of distressed persons concerning barriers to seeking professional help for mental health concerns. It also sought to understand their perspectives on the perceived utility of proposed app components for breaking these barriers.

Methods

The study utilized a cross-sectional exploratory design. The sample included two groups of distressed participants who could be considered potential users (and thereby the stakeholders) of a mental health app under development for common mental health concerns: distressed treatment seekers (D-TS) and distressed non-treatment seekers (D-NTS). The D-TS group included 10 individuals (average age: 33 years; six men) with self-reported or clinician-reported depressive and anxiety symptoms at intake who were seeking help from mental health professionals. The D-NTS group included 10 distressed individuals (average age: 23 years; five men) who were recruited from the local community through an announcement. The announcement called for participants who were experiencing anxiety and low mood but had not yet sought help for their distress. A semistructured interview schedule was used to explore the nature of barriers encountered and the perceived utility of the content of the proposed app. The questions that aimed at understanding the perceived barriers were open-ended. The perceived utility of various components of the proposed app was explored via 11 items, with a 5-point Likert scale.

Results

Personal barriers frequently reported by both groups were doubts about treatment and fear of social consequences. The role of inadequate self-awareness about one’s mental health concerns as a barrier to reaching out for professional help was articulated more frequently by the D-TS group than the D-NTS group. Proposed app components such as self-assessment with individualized feedback, informative videos by mental health professionals, testimonials from mental health service users, and a platform for an online connection with a professional were rated as potentially useful in reducing barriers to professional help-seeking. Insights based on stakeholder perspectives have implications for further research and are being utilized for the development of a mental health app for common mental health concerns.

The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990-2017

BACKGROUND

Mental disorders are among the leading causes of non-fatal disease burden in India, but a systematic understanding of their prevalence, disease burden, and risk factors is not readily available for each state of India. In this report, we describe the prevalence and disease burden of each mental disorder for the states of India, from 1990 to 2017.

METHODS

We used all accessible data from multiple sources to estimate the prevalence of mental disorders, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by these disorders for all the states of India from 1990 to 2017, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We assessed the heterogeneity and time trends of mental disorders across the states of India. We grouped states on the basis of their Socio-demographic Index (SDI), which is a composite measure of per-capita income, mean education, and fertility rate in women younger than 25 years. We also assessed the association of major mental disorders with suicide deaths. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

In 2017, 197·3 million (95% UI 178·4-216·4) people had mental disorders in India, including 45·7 million (42·4-49·8) with depressive disorders and 44·9 million (41·2-48·9) with anxiety disorders. We found a significant, but modest, correlation between the prevalence of depressive disorders and suicide death rate at the state level for females (r²=0·33, p=0·0009) and males (r²=0·19, p=0·015). The contribution of mental disorders to the total DALYs in India increased from 2·5% (2·0-3·1) in 1990 to 4·7% (3·7-5·6) in 2017. In 2017, depressive disorders contributed the most to the total mental disorders DALYs (33·8%, 29·5-38·5), followed by anxiety disorders (19·0%, 15·9-22·4), idiopathic developmental intellectual disability (IDID; 10·8%, 6·3-15·9), schizophrenia (9·8%, 7·7-12·4), bipolar disorder (6·9%, 4·9-9·6), conduct disorder (5·9%, 4·0-8·1), autism spectrum disorders (3·2%, 2·7-3·8), eating disorders (2·2%, 1·7-2·8), and attention-deficit hyperactivity disorder (ADHD; 0·3%, 0·2-0·5); other mental disorders comprised 8·0% (6·1-10·1) of DALYs. Almost all (>99·9%) of these DALYs were made up of YLDs. The DALY rate point estimates of mental disorders with onset predominantly in childhood and adolescence (IDID, conduct disorder, autism spectrum disorders, and ADHD) were higher in low SDI states than in middle SDI and high SDI states in 2017, whereas the trend was reversed for mental disorders that manifest predominantly during adulthood. Although the prevalence of mental disorders with onset in childhood and adolescence decreased in India from 1990 to 2017, with a stronger decrease in high SDI and middle SDI states than in low SDI states, the prevalence of mental disorders that manifest predominantly during adulthood increased during this period.

INTERPRETATION

One in seven Indians were affected by mental disorders of varying severity in 2017. The proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. Substantial variations exist between states in the burden from different mental disorders and in their trends over time. These state-specific trends of each mental disorder reported here could guide appropriate policies and health system response to more effectively address the burden of mental disorders in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Psychological disturbances in patients with pigmentary disorders: a cross-sectional study

BACKGROUND

Data on prevalence and factors influencing psychological burden in pigmentary disorders are scarce.

OBJECTIVE

To determine the point prevalence of anxiety disorder, depression and somatoform disorder in patients with melasma, vitiligo and acquired dermal macular hyperpigmentation (ADMH).

METHODS

A prospective cross-sectional study involving 100 patients each with melasma, ADMH and vitiligo with lesions on exposed body parts was conducted in the pigmentary clinic of a tertiary care referral hospital from June 2015 to December 2017. Dermatology life quality index, PRIME-MD Patient Health Questionnaire, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Patient Health Questionnaire-15 were used for assessment of quality of life, psychiatric comorbidities, depression, general anxiety disorder and somatoform disorders, respectively, and correlated with age, gender, occupation, marital status, severity and progression of the disease.

RESULTS

The prevalence of anxiety disorder in patients with melasma, vitiligo and ADMH was 11.6%, 21% and 18.7%, respectively. Depression was seen in 12.8%, 27% and 24.1% patients with melasma, vitiligo and ADMH, respectively. Somatoform disorder was more common in vitiligo (17.9%) as compared to ADMH (14.3%) and melasma (8.1%). There were positive correlations between the severity of disease and the point prevalence of anxiety and depression in all disorders.

CONCLUSION

A high point prevalence of anxiety, depression and somatoform disorders was observed with pigmentary diseases, especially vitiligo and ADMH. The prevalence of anxiety and depression correlated with the disease severity and activity. Future research involving comparison with the general healthy population is required for a more affirmative conclusion.

Predictors of Number of Healthcare Professionals Consulted by Individuals with Mental Disorders or High Psychological Distress

This study assesses the contribution of predisposing, enabling, and needs factors and related variables that predicted the number of healthcare professionals consulted for mental health reasons among 746 individuals with mental disorders and high psychological distress. The data were drawn from the third (T3) and fourth data collection periods (T4) of a longitudinal study conducted in a Quebec/Canada epidemiological catchment area. Hierarchical linear regression was performed on the number of types of healthcare professionals consulted in the 12 months prior to T4. Predictors were identified at T3, classified as predisposing, enabling, and needs factors (i.e., clinical and related variables) according to the Andersen Behavioral Model. Three needs factors were associated with the number of types of healthcare professionals consulted: Post-traumatic stress disorder, stressful events, and marginally suicide ideation. Three enabling factors: Having a family physician, previous use of mental health services, and employment status were also related to the dependent variable. Poor self-perception of mental health status was the only predisposing factor retained. While needs factors were the main predictors of the number of types of healthcare professionals consulted, enabling factors may reduce the influence of needs factors, by the deployment of various strategies that facilitate continuous and appropriate care.

Prevalence of Childhood Mental Disorders Among School Children of Kashmir Valley

Prevalence of mental disorders among children is affected by armed conflict and same is true in protracted conflict of Kashmir, where the ongoing conflict has affected mental health of children badly. In order to understand mental health condition of school going children, the present study was designed to study the nature and prevalence of mental disorders among school children in Kashmir valley. The present study employed multi-stage sampling and multi-informant reporting of mental health problems in children. A sample of 1000 school children was taken from 12 schools of Shopian district through systematic random sampling method. Data was collected at different levels of screening by using Strength and Difficulties Questionnaire (SDQ) (Teacher form) and Mini International Neuropsychiatric Inventory (MINI-Kid). Socio-demographic data sheet was included to gather relevant information. The prevalence rates of mental disorders among school children were presented at different levels of screening. It was found to be 27.1% based on SDQ and 22.2% when assessed by MINI-Kid at second level of screening. The most commonly found mental disorders were of anxiety (8.5%), followed by mood disorders (6.3%) and then behavioural disorders (4.3%). Percentage of schoolgoing children with mental disorders in Kashmir is much more than in other states of India. The political conflict in the state and lack of mental health facilities give rise to high prevalence rates of mental disorders and warrant our urgent attention.

Prevalence and socioeconomic impact of depressive disorders in India: multisite population-based cross-sectional study

OBJECTIVES

The National Mental Health Survey (NMHS) of India was undertaken with the objectives of (1) estimating the prevalence and patterns of various mental disorders in representative Indian population and (2) identifying the treatment gap, healthcare utilisation, disabilities and impact of mental disorders. This paper highlights findings pertaining to depressive disorders (DD) from the NMHS.

DESIGN

Multisite population-based cross-sectional study. Subjects were selected by multistage stratified random cluster sampling technique with random selection based on probability proportionate to size at each stage.

SETTING

Conducted across 12 states in India (representing varied cultural and geographical diversity), employing uniform, standardised and robust methodology.

PARTICIPANTS

A total of 34 802 adults (>18 years) were interviewed.

MAIN OUTCOME MEASURE

Prevalence of depressive disorders (ICD-10 DCR) diagnosed using Mini International Neuropsychiatric Interview V.6.0.

RESULTS

The weighted prevalence of lifetime and current DD was 5.25% (95% CI: 5.21% to 5.29%, n=34 802) and 2.68% (95% CI: 2.65% to 2.71%, n=34 802), respectively. Prevalence was highest in the 40-59 age groups (3.6%, n=10 302), among females (3.0%, n=18 217) and those residing in cities with population >1 million (5.2%, n=4244). Age, gender, place of residence, education and household income were found to be significantly associated with current DD. Nearly two-thirds of individuals with DD reported disability of varying severity, and the treatment gap for depression in the study population was 79.1%. On an average, households spent INR1500/month (~US$ 23.0/month) towards care of persons affected with DD.

CONCLUSION

Around 23 million adults would need care for DD in India at any given time. Since productive population is affected most, DD entails considerable socioeconomic impact at individual and family levels. This is a clarion call for all the concerned stakeholders to scale up services under National Mental Health Programme in India along with integrating care for DD with other ongoing national health programmes.

The prevalence of non-communicable disease risk factors in community-living patients with psychiatric disorders: A study from North India

OBJECTIVE

Screening for non-communicable disease (NCD) risk factors can help in prevention or reduction in the ill-effects of NCDs. Data on NCD risk factors in community-dwelling patients with common mental disorders (CMD) is lacking. This study was designed to screen for selected NCD risk factors in patients attending a community psychiatry service (CPS) in the states of Punjab and Haryana in North India.

METHODS

Following ethical clearance, the study was conducted in 4 satellite clinics of the CPS of a tertiary hospital from North India. Consecutive adult patients were approached and 719 patients were assessed. A one-time cross-sectional assessment was carried out which included socio-demographic data, clinical details, history of tobacco and alcohol use, personal history of hypertension and diabetes, family history of diabetes, prevalence of hypertension, obesity (central and generalised) and levels of physical activity.

RESULTS

302 males and 417 females were assessed. Most patients were diagnosed with CMD. The prevalence of hypertension was 42.7% in males and 34.1% in females. The prevalence of central and generalised obesity in males and females was 41.4%, 71.2% and 34.8%, 45.6% respectively. 32.5% of males and 40.2% females were assessed to be inadequately physically active.

CONCLUSIONS

The results of the study suggest that there is high prevalence of NCD risk factors in patients with CMD. Hypertension is more common in males while obesity and inadequate physical activity is more common in females. NCD risk factor screening and management, health education should be integrated in CPS.

A Performance Audit of First 30 Months of Manochaitanya Programme at Secondary Care Level of Karnataka, India

Introduction:

Lifetime prevalence of psychiatric disorders in India is about 14%, and the treatment gap is huge necessitating large-scale public health efforts. Manochaitanya programme (MCP), one such innovative program, was launched by the Government of Karnataka in October 2014. MCP entails provision of outpatient psychiatric care in subdistrict (Taluk) hospitals and primary health centers under a public–private (Indian Psychiatric Society-Karnataka chapter) partnership model, at least one Tuesday of every month.

Aim:

The aim was to do a secondary care level performance audit of MCP of initial 2½ years at all Taluka general hospitals of Karnataka.

Methodology:

Data on MCP were collected and tabulated from all 31 districts using a specially designed semistructured pro forma. This includes the number of self-reported psychiatric consultations in each Tuesday's clinic, number of psychiatrists, and their visit details. Prospective data were obtained from monthly reports.

Results:

The district coverage was 100% during initial 2½ years over this period, i.e., MCPs were successfully covered in at least one Taluka hospital in all 31 districts. A total number of estimated consultations under this initiative were 73,663 with an average of 24.1 patients per psychiatrist consultation. One hundred and eleven psychiatrists participated in a total of 3,056 visits across the state. Patient footfall increased consistently over this time period.

Conclusions:

Psychiatrist-based Manochaitanya programme at secondary care level at Taluk hospitals has noticed substantial benefits to patient care. There is a need for psychiatrist-based secondary care at Talukas (subdistrict) level across the country.

Province-Level Prevalence of Psychiatric Disorders: Application of Small-Area Methodology to the Iranian Mental Health Survey (IranMHS)

Objective: National surveys revealed a high prevalence of psychiatric disorders in Iran. Province-level estimates are needed to manage the resources and focus on preventive efforts more efficiently. The objective of this study was to provide province-level estimates of psychiatric disorders. Method : In this study, Iranian Mental Health Survey (IranMHS) data (n = 7886) was used to produce province-level prevalence estimates of any psychiatric disorders among 15-64 year old males and females. Psychiatric disorders were diagnosed based on structured diagnostic interview of the Persian version of Composite International Diagnostic Interview (CIDI, version, 2.1). The Hierarchical Bayesian (HB) random effect model was used to calculate the estimates. The mental health status of half of the participants was also measured using a 28-item general health questionnaire (GHQ). Results: A wide variation in the prevalence of psychiatric disorders was found among 31 provinces of Iran. The direct estimates ranged from 3.6% to 62.6%, while the HB estimates ranged from 12.6% to 36.5%. The provincial prevalence among men ranged from 11.9% to 34.5%, while it ranged from 18.4% to 38.8% among women. The Pearson correlation coefficient between HB estimates and GHQ scores was 0.73. Conclusion: The Bayesian small area estimation provides estimation with improved precision at local levels. Detecting high-priority communities with small-area approach could lead to a better distribution of limited facilities and more effective mental health interventions.

Prevalence and pattern of mental illnesses in Uttar Pradesh, India: Findings from the National Mental Health Survey 2015-16

AIM

To estimate the prevalence and distribution of psychiatric morbidity, and study pattern of help-seeking in a community representative sample from the state of Uttar Pradesh in northern India.

METHOD

A multi-stage, stratified, random cluster sampling was used. The survey was conducted on 3508 adults during 2015-16 using M.I.N.I 6.0.0, modified Fagerström Nicotine Dependence Scale for all forms of tobacco, questionnaires for epilepsy and intellectual disability. The WHO Pathway Interview Schedule was used to study pattern of help-seeking behaviour. Focused group discussions (FGDs) and key informant interviews (KIIs) were also carried out.

RESULT

Current and lifetime prevalence of 'any mental morbidity' (excluding tobacco use disorders) was 6.08% and 7.97%, respectively. The prevalence of substance use disorders, was 16.36%, of which tobacco use disorders alone contributed 16.06%. Neurotic and depressive disorders were the next most common morbidity. Schizophrenia and other psychotic disorders had a current prevalence of 0.09%. High-risk for suicide was reported to be 0.93%. Treatment gap varied between 75 and 100% for different disorders. FGDs and KIIs reflected a higher burden of substance use, including prescription drug abuse, substantial prevalence of cultural mental morbidity, deep rooted stigma, low help-seeking behaviour, and issues surrounding homeless mentally ill persons in the community.

CONCLUSION

The survey revealed high mental morbidity and alarming treatment gap. FGDs and KIIs also highlight the burden of morbidity that probably goes un-noticed, due to socio-cultural systems and stigma. Findings from this survey are intended to be the groundwork for the (re)planning of mental healthcare infrastructure in the state.

T, P. M, Vijayasagar KJ, Bhaskarapillai B, Thirthalli J, Loganathan S, Kumar N, Sudhir P, Sathyanarayana VA, Pathak K, Singh LK, Mehta RY, Ram D, T. M. S, Kokane A, R. K. LS, B. S. C, Sharma P, C. R, P. K. D, Saha PK, Deuri SP, Giri AK, Kavishvar AB, Sinha VK, Thavody J, Chatterji R, Akoijam BS, Das S, Kashyap A, R. V. S, M. S, S. K. S, Agarwal V, Misra R. National Mental Health Survey of India, 2016 - Rationale, design and methods

Understanding the burden and pattern of mental disorders as well as mapping the existing resources for delivery of mental health services in India, has been a felt need over decades. Recognizing this necessity, the Ministry of Health and Family Welfare, Government of India, commissioned the National Mental Health Survey (NMHS) in the year 2014–15. The NMHS aimed to estimate the prevalence and burden of mental health disorders in India and identify current treatment gaps, existing patterns of health-care seeking, service utilization patterns, along with an understanding of the impact and disability due to these disorders. This paper describes the design, steps and the methodology adopted for phase 1 of the NMHS conducted in India. The NMHS phase 1 covered a representative population of 39,532 from 12 states across 6 regions of India, namely, the states of Punjab and Uttar Pradesh (North); Tamil Nadu and Kerala (South); Jharkhand and West Bengal (East); Rajasthan and Gujarat (West); Madhya Pradesh and Chhattisgarh (Central) and Assam and Manipur (North East). The NMHS of India (2015–16) is a unique representative survey which adopted a uniform and standardized methodology which sought to overcome limitations of previous surveys. It employed a multi-stage, stratified, random cluster sampling technique, with random selection of clusters based on Probability Proportionate to Size. It was expected that the findings from the NMHS 2015–16 would reveal the burden of mental disorders, the magnitude of the treatment gap, existing challenges and prevailing barriers in the mental-health delivery systems in the country at a single point in time. It is hoped that the results of NMHS will provide the evidence to strengthen and implement mental health policies and programs in the near future and provide the rationale to enhance investment in mental health care in India. It is also hoped that the NMHS will provide a framework for conducting similar population based surveys on mental health and other public health problems in low and middle-income countries.

Factors associated with health service utilisation for common mental disorders: a systematic review

BACKGROUND

There is a large treatment gap for common mental disorders (CMD), with wide variation by world region. This review identifies factors associated with formal health service utilisation for CMD in the general adult population, and compares evidence from high-income countries (HIC) with that from low-and-middle-income countries (LMIC).

METHODS

We searched MEDLINE, PsycINFO, EMBASE and Scopus in May 2016. Eligibility criteria were: published in English, in peer-reviewed journals; using population-based samples; employing standardised CMD measures; measuring use of formal health services for mental health reasons by people with CMD; testing the association between this outcome and any other factor(s). Risk of bias was assessed using the adapted Mixed Methods Appraisal Tool. We synthesised the results using "best fit framework synthesis", with reference to the Andersen socio-behavioural model.

RESULTS

Fifty two studies met inclusion criteria. 46 (88%) were from HIC. Predisposing factors: There was evidence linking increased likelihood of service use with female gender; Caucasian ethnicity; higher education levels; and being unmarried; although this was not consistent across all studies. Need factors: There was consistent evidence of an association between service utilisation and self-evaluated health status; duration of symptoms; disability; comorbidity; and panic symptoms. Associations with symptom severity were frequently but less consistently reported. Enabling factors: The evidence did not support an association with income or rural residence. Inconsistent evidence was found for associations between unemployment or having health insurance and use of services. There was a lack of research from LMIC and on contextual level factors.

CONCLUSION

In HIC, failure to seek treatment for CMD is associated with less disabling symptoms and lack of perceived need for healthcare, consistent with suggestions that "treatment gap" statistics over-estimate unmet need for care as perceived by the target population. Economic factors and urban/rural residence appear to have little effect on treatment-seeking rates. Strategies to address potential healthcare inequities for men, ethnic minorities, the young and the elderly in HIC require further evaluation. The generalisability of these findings beyond HIC is limited. Future research should examine factors associated with health service utilisation for CMD in LMIC, and the effect of health systems and neighbourhood factors.

TRIAL REGISTRATION

PROSPERO registration number: 42016046551 .