Improving psychosocial distress for young adolescents in rural schools of Pakistan: study protocol of a cluster randomised controlled trial

INTRODUCTION

Emotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents.

METHOD AND ANALYSIS

A two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver-adolescent relationship and caregivers' well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings.

ETHICS

Ethics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan.

DISSEMINATION

The findings of the study will be disseminated by WHO and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN17755448.

Feasibility and acceptability of a multicomponent, group psychological intervention for adolescents with psychosocial distress in public schools of Pakistan: a feasibility cluster randomized controlled trial (cRCT)

BACKGROUND

Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan.

METHODS

A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors.

RESULTS

The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions.

CONCLUSIONS

The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

A comparison of real-world effectiveness of vortioxetine along the treatment algorithm for major depressive disorder

OBJECTIVE

To evaluate the effectiveness of vortioxetine in major depressive disorder (MDD) when used as a first-line versus second-line treatment or later.

METHODS

This was a post-hoc analysis of three 3-month non-interventional, prospective studies of vortioxetine in MDD - REVIDA (Malaysia, Philippines, Singapore, Thailand), PREVIDA (Pakistan) and TREVIDA (Taiwan). Improvements in depressive symptoms (PHQ-9, CGI-S), cognitive function (PDQ-D) and work productivity (WPAI) were compared between studies, and in a pooled analysis of patients using vortioxetine as the first line versus second-line treatment or later. Safety was compared between studies.

RESULTS

Overall, 798 patients were analyzed (PREVIDA = 425, REVIDA = 130, TREVIDA = 243). Most patients in PREVIDA (60.5%)/REVIDA (57.4%) used vortioxetine as first-line treatment versus TREVIDA (21.8%). Generally, greater improvements from baseline were observed across outcome measures in PREVIDA/REVIDA versus TREVIDA (Month 3, p < .0001). Vortioxetine as first-line treatment was associated with greater improvements in depression severity, cognition, functioning outcomes compared to second-line or later users (PHQ-9: -16.1 [6.4] vs -10.8 [8.9]; CGI-S: -2.7 [1.1] vs -2.0 [1.4]; PDQ-D: -29.5 [17.7] vs -18.5 [21.4]; p < .0001 at Month 3) as well as greater response (PHQ-9: 88.6% vs 61.5%; p < .0001) and remission rates (PHQ-9: 75.4% vs 47.7%; p < .0001). No new adverse events were reported outside of the product label.

CONCLUSIONS

In the Asian real-world setting, vortioxetine showed greater improvements in depressive and cognitive symptoms, work functioning, and response and remission rates when used as first-line versus second-line treatment or later. Vortioxetine was well-tolerated irrespective of the study population across Asia.

Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial

Background

Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan.

Methods

In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters.

Results

At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes.

Conclusions

In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention.

Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894

Effect of adding a psychological intervention to routine care of common mental disorders in a specialized mental healthcare facility in Pakistan: a randomized controlled trial

BACKGROUND

In many low resource settings, the provision of government mental health care services is limited to specialized psychiatry units in urban hospital care facilities, where the most common treatment for common mental disorders (CMDs) is pharmacotherapy, occasionally with adjunct nonspecific psychological support. We aimed to evaluate the effectiveness of adding a low intensity, psychological intervention, Problem Management Plus (PM+) for CMDs into routine care in a specialized mental health care facility in Pakistan.

METHODS

A two arm, single-blind individual randomized controlled trial (RCT) was carried out with adults (N = 192), referred for psychological support by psychiatrists. The study participants were randomized (1:1) to PM + plus Treatment as Usual (TAU) (n = 96) or TAU only (n = 96). The primary outcomes were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) and functional impairment as measured by WHO Disability Assessment Schedule (WHODAS 2.0) at 20 weeks after baseline.

RESULTS

The analysis was done on intention-to-treat principle. The linear mixed model analysis showed that at 20 weeks after baseline, there was a significant reduction in symptoms of anxiety and depression (mean [SD], 16.23 [8.81] vs 19.79 [7.77]; AMD, - 3.10; 95% CI, - 0.26 to - 5.76); p = 0.03 and improvement in functioning (mean [SD], 22.94 [9.37] vs 27.37 [8.36]; AMD, - 4.35; 95% CI, - 1.45 to - 7.24); p = 0.004 in PM + plus TAU versus TAU arm. The follow-up rate was 67% at primary end-point.

CONCLUSIONS

Specialized care facilities in LMICs may consider adding brief, evidence-based psychological treatments for CMDs to their routine care. Trial Registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered March 23, 2016. Retrospectively registered, https://www.anzctr.org.au/Default.aspx/ ACTRN12616000381482.

Scaling-up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach

BACKGROUND

Ninety percent of children with mental health problems live in low or middle-income countries (LMICs). School-based programs offer opportunities for early identification and intervention, however implementation requires cross-sector collaboration to assure sustainable delivery of quality training, ongoing supervision, and outcomes monitoring at scale. In Pakistan, 35% of school-aged children are reported to have emotional and behavioral problems. As in many other LMICs, the government agencies who must work together to mount school-based programs have limited resources and a limited history of collaboration. The "Theory of Change" (ToC) process offers a way for new partners to efficiently develop mutual goals and long-term prospects for sustainable collaboration.

OBJECTIVE

Develop a model for scale-up of school based mental health services in public schools of Pakistan.

METHODS

We used ToC workshops to develop an empirically supported, 'hypothesized pathway' for the implementation of WHO's School Mental Health Program in the public schools of rural Pakistan. Three workshops included 90 stakeholders such as policy makers from education and health departments, mental health specialists, researchers, head teachers, teachers and other community stakeholders including non-governmental organizations.

RESULTS

The ToC process linked implementers, organizations, providers and consumers of school mental health services to develop common goals and relate them (improved child socioemotional wellbeing, grades and participation in activities) to interventions (training, monitoring and supervision of teachers; collaboration with parents, teachers and primary health care facilities and schools). Key testable assumptions developed in the process included buy-in from health care providers, education officials and professionals, community-based organizations and families. For example, teachers needed skills for managing children's problems, but their motivation might come from seeking improved school performance and working conditions. Poverty, stigma and lack of child mental health literacy among teachers, administration, and parents were identified as key hypothesized barriers. Children and their families were identified as key stakeholders to make such a program successful.

DISCUSSION

ToC workshops assisted in team building and served as a stakeholders' engagement tool. They helped to develop and support testable hypotheses about the structures, collaborations, and knowledge most important to scaling-up school based mental health services in Pakistan.

Technology-Assisted Teachers' Training to Promote Socioemotional Well-Being of Children in Public Schools in Rural Pakistan

BACKGROUND

The World Health Organization's (WHO) Eastern Mediterranean Regional Office (EMRO) developed a school mental health program (SMHP) to help reduce the burden of youth mental health problems. Designed in collaboration with international consultants, the SMHP draws on evidence-based interventions to train personnel to identify students in need, respond therapeutically, and engage families in seeking care.

METHODS

Teams from Pakistan, Egypt, Iran, and Jordan collaborated with the WHO EMRO and British and U.S. universities to form the School Health Implementation Network: Eastern Mediterranean Region (SHINE), a National Institute of Mental Health-funded global mental health hub. SHINE partners used a "theory of change" process to adapt the SMHP to be more readily adopted by school personnel and replicated with fidelity. The adapted SMHP more directly addresses teachers' priorities and uses technology to facilitate training.

RESULTS

A cluster-randomized implementation effectiveness trial enrolling 960 children ages 8-13 in 80 Pakistani schools will test the adapted SMHP against the original. Children who screen positive on first the teacher and subsequently the parent Strengths and Difficulties Questionnaires (SDQs) will be enrolled and tracked for 9 months. The primary trial outcome is reduction in parent-rated SDQ total difficulties scores. Secondary outcomes include children's well-being, academic performance, absenteeism, and perceived stigma; parent-teacher interaction; teachers' self-efficacy and subjective well-being; and school environment. Implementation outcomes include change in teachers' behavior and sense of program acceptability, cultural appropriateness, feasibility, penetration, and sustainability.

NEXT STEPS

The trial began in October 2019, and the expected completion date is March 2021. Outcomes will inform dissemination of the SMHP in Pakistan and elsewhere.

Pathways to care for people with dementia: An international multicentre study

OBJECTIVE

The aim of the present study was to characterize the clinical pathways that people with dementia (PwD) in different countries follow to reach specialized dementia care.

METHODS

We recruited 548 consecutive clinical attendees with a standardized diagnosis of dementia, in 19 specialized public centres for dementia care in 15 countries. The WHO "encounter form," a standardized schedule that enables data concerning basic socio-demographic, clinical, and pathways data to be gathered, was completed for each participant.

RESULTS

The median time from the appearance of the first symptoms to the first contact with specialist dementia care was 56 weeks. The primary point of access to care was the general practitioners (55.8%). Psychiatrists, geriatricians, and neurologists represented the most important second point of access. In about a third of cases, PwD were prescribed psychotropic drugs (mostly antidepressants and tranquillizers). Psychosocial interventions (such as psychological counselling, psychotherapy, and practical advice) were delivered in less than 3% of situations. The analyses of the "pathways diagram" revealed that the path of PwD to receiving care is complex and diverse across countries and that there are important barriers to clinical care.

CONCLUSIONS

The study of pathways followed by PwD to reach specialized care has implications for the subsequent course and the outcome of dementia. Insights into local differences in the clinical presentations and the implementation of currently available dementia care are essential to develop more tailored strategies for these patients, locally, nationally, and internationally.

Telomere Biology in Mood Disorders: An Updated, Comprehensive Review of the Literature

Major psychiatric disorders are linked to early mortality and patients afflicted with these ailments demonstrate an increased risk of developing physical diseases that are characteristically seen in the elderly. Psychiatric conditions like major depressive disorder, bipolar disorder and schizophrenia may be associated with accelerated cellular aging, indicated by shortened leukocyte telomere length (LTL), which could underlie this connection. Telomere shortening occurs with repeated cell division and is reflective of a cell’s mitotic history. It is also influenced by cumulative exposure to inflammation and oxidative stress as well as the availability of telomerase, the telomere-lengthening enzyme. Precariously short telomeres can cause cells to undergo senescence, apoptosis or genomic instability; shorter LTL correlates with compromised general health and foretells mortality. Important data specify that LTL may be reduced in principal psychiatric illnesses, possibly in proportion to exposure to the ailment. Telomerase, as measured in peripheral blood monocytes, has been less well characterized in psychiatric illnesses, but a role in mood disorder has been suggested by preclinical and clinical studies. In this manuscript, the most recent studies on LTL and telomerase activity in mood disorders are comprehensively reviewed, potential mediators are discussed, and future directions are suggested. An enhanced comprehension of cellular aging in psychiatric illnesses could lead to their re-conceptualizing as systemic ailments with manifestations both inside and outside the brain. At the same time this paradigm shift could identify new treatment targets, helpful in bringing about lasting cures to innumerable sufferers across the globe.

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

[This corrects the article DOI: 10.1186/s13033-017-0147-1.].

Terrorism in Pakistan: the psychosocial context and why it matters

Terrorism is often construed as a well-thought-out, extreme form of violence to perceived injustices. The after effects of terrorism are usually reported without understanding the underlying psychological and social determinants of the terrorist act. Since ‘9/11’ Pakistan has been at the epicentre of both terrorism and the war against it. This special paper helps to explain the psychosocial perspective of terrorism in Pakistan that leads to violent radicalisation. It identifies the terrorist acts in the background of Pakistan's history, current geopolitical and social scenario. The findings may also act as a guide on addressing this core issue.

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

Background

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

Methods

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

Discussion

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

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

Electronic supplementary material

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

Model for Service Delivery for Developmental Disorders in Low-Income Countries

As in many low-income countries, the treatment gap for developmental disorders in rural Pakistan is near 100%. We integrated social, technological, and business innovations to develop and pilot a potentially sustainable service for children with developmental disorders in 1 rural area. Families with developmental disorders were identified through a mobile phone-based interactive voice response system, and organized into "Family Networks." "Champion" family volunteers were trained in evidence-based interventions. An Avatar-assisted Cascade Training and information system was developed to assist with training, implementation, monitoring, and supervision. In a population of ∼30,000, we successfully established 1 self-sustaining Family Network consisting of 10 trained champion family volunteers working under supervision of specialists, providing intervention to 70 families of children with developmental disorders. Each champion was responsible for training and providing ongoing support to 5 to 7 families from his or her village, and the families supported each other in management of their children. A pre-post evaluation of the program indicated that there was significant improvement in disability and socioemotional difficulties in the child, reduction in stigmatizing experiences, and greater family empowerment to seek services and community resources for the child. There was no change in caregivers' well-being. To replicate this service more widely, a social franchise model has been developed whereby the integrated intervention will be "boxed" up and passed on to others to replicate with appropriate support. Such integrated social, technological, and business innovations have the potential to be applied to other areas of health in low-income countries.

Terrorism in Pakistan: a behavioral sciences perspective

This article reviews the behavioral science perspectives of terrorism in Pakistan. It can be argued that Pakistan has gained worldwide attention for "terrorism" and its role in the "war against terrorism". The region is well placed geopolitically for economic successes but has been plagued by terrorism in various shapes and forms. A behavioral sciences perspective of terrorism is an attempt to explain it in this part of the world as a complex interplay of historical, geopolitical, anthropological and psychosocial factors and forces. Drawing from theories by Western scholars to explain the behavioral and cognitive underpinnings of a terrorist mind, the authors highlight the peculiarities of similar operatives at individual and group levels. Thorny issues related to the ethical and human right dimensions of the topic are visited from the unique perspective of a society challenged by schisms and divergence of opinions at individual, family, and community levels. The authors have attempted to minimize the political descriptions, although this cannot be avoided entirely, because of the nature of terrorism.

Family networks to improve outcomes in children with intellectual and developmental disorders: a qualitative study

Background

There are at least 50 million children with an intellectual or developmental disorder in South Asia. The vast majority of these children have no access to any service and there are no resources to develop such services. We aimed to explore a model of care-delivery for such children, whereby volunteer family members of affected individuals could be organized and trained to form an active, empowered group within the community that, a) using a task-sharing approach, are trained by specialists to provide evidence-based interventions to their children; b) support each other, with the more experienced FaNs i.e. family networks, providing peer-supervision and training to new family members who join the group; and c) works to reduce the stigma associated with the condition.

Methods

We used qualitative methods to explore carers’ perspectives about such a care-delivery model.

Results

The key findings of this research are that there is a huge gap between the needs of the carers and available services. Carers would welcome a volunteer-led service, and some community members would have time to volunteer. Raising community awareness in a culturally sensitive manner prior to launching such a service and linking it to the community health workers programme would increase the likelihood of success. Gender-matching would be important. It would be possible to form family networks around the more motivated volunteers, with support from local non-governmental organizations. The carers were receptive to the use of technology to assist the work of the volunteers as well as for networking.

Conclusions

We conclude that family volunteers delivering evidence-based packages of care after appropriate training is a feasible system that can help reduce the treatment gap for childhood intellectual and developmental disorders in under-served populations.

Patients leaving against medical advice: an inpatient psychiatric hospital-based study

OBJECTIVE

To determine the frequency of patients leaving against medical advice (LAMA) in an inpatient psychiatric facility in Rawalpindi, Pakistan.

STUDY DESIGN

Descriptive cross-sectional study.

PLACE AND DURATION OF STUDY

Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, from August 2010 to February 2011.

METHODOLOGY

Patients who got admitted during study period irrespective of duration of illness and mode of admission were recruited through non-probability consecutive sampling and followed till discharge to determine their mode of leaving hospital. A thirteen-item proforma was developed and information was obtained on demographic, socioeconomic, patient related and disease related variables. Descriptive statistics were calculated on SPSS 14.

RESULTS

The total number (n) of participants was 246. Among the participants, 96 (39%) left against medical advice (LAMA) whereas 150 (61%) left on regular discharge on physician's advice. Frequency of patients who left against medical advice was found to be more in males (63.5%), younger age groups (21 - 30 years), lesser educated (more than half were under matric) and with the ICD-10 diagnosis of substance abuse (23.9%). About half of patients who LAMA had a prior history of psychiatric illness and a significant number (37.5%) had a history of previous psychiatric admission.

CONCLUSION

Leaving against medical advice is a frequent problem in psychiatric inpatients and is a matter of great concern for the treating doctors.

Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study

BACKGROUND

The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries.

OBJECTIVE

To explore the opinions of primary care professionals on proposed new diagnostic entities in draft ICD-11-PHC, namely anxious depression and bodily stress syndrome (BSS).

METHODS

Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants.

RESULTS

Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required.

CONCLUSION

Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.

Assessment of patient satisfaction with mental health services in a tertiary care setting

BACKGROUND

Patients' opinion regarding services has acquired great importance. Patient satisfaction is playing an increasingly important role in quality of care reforms and health-care delivery. The study aimed to measure patient satisfaction in a tertiary care hospital in order to know the patients' perspectives and expectations of the services and make appropriate improvements accordingly.

METHODS

This was a cross-sectional study conducted at the Out-patient and Inpatient Departments of the Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, for a period of 8 months from October 2008 till June 2009. Sample size was 246 patients; which included 123 participants from Out-patient and In-patient departments each. Patients aged 18 and above, of both genders, who gave informed written consent, were consecutively recruited for the study. Learning disabled patients, frankly psychotic and those with severe cognitive impairment and severe co-morbid physical illnesses were excluded. Performa was filled in by the participants for their demographic details. The Client Satisfaction Questionnaire-8 was then orally administered in the native language (Urdu/Punjabi) to assess the degree of patient satisfaction.

RESULTS

Among the participants, 72% were mostly satisfied, 18.7% mildly satisfied and 9.3% dissatisfied with the psychiatric care. Age was significantly associated with satisfaction however no such associations could be found for gender and economic status.

CONCLUSION

Majority of the patients were satisfied with the psychiatric services. The younger people were more satisfied. Gender and economic status had no influence on patient satisfaction.

Type of presentation of dissociative disorder and frequency of co-morbid depressive disorder

OBJECTIVE

To determine the frequency distribution of various types of dissociative disorders, along with existing co-morbid depression and its level of severity in patients with dissociative disorder.

STUDY DESIGN

Observational, cross-sectional study.

PLACE AND DURATION OF STUDY

The Institute of Psychiatry, Rawalpindi General Hospital from October 2004 to March 2005.

METHODOLOGY

Fifty consecutive patients were included in the study through non-probable purposive sampling technique. Encounter form included socio-demographic profile and brief psychiatric history. ICD 10 diagnostic criteria for research were administered for determining the presentation of dissociative disorder. Present state examination was applied to make diagnosis of depressive disorder in the studied patients. Descriptive statistics for frequency analysis of sociodemographic variables, type of presentation of dissociative disorder and the frequency of depressive disorder in patients of dissociative disorder.

RESULTS

The mean age was 23.6+/-8.67 years with female preponderance (n=40, 80% patients). Most of them were single, unemployed and belonged to urban population. Main stress was primary support group issue. Mixed category of dissociative disorder was highest (n=18, 38%) followed by unspecified and motor symptoms (n=13, 26%) in each group. Depression was present in 42 (84%) patients. Moderate depression was most frequent (n=19, 38%).

CONCLUSION

Mixed dissociative symptoms were found in 38%, while 26% had motor and unspecified category of dissociative symptoms respectively. Depressive disorder was present in 42 (84%) cases of dissociative disorder with 38% having moderate depression.

Stress and psychiatric disorder in urban Rawalpindi. Community survey

BACKGROUND

Recent studies in rural areas of Pakistan have yielded high prevalence rates of common mental disorders, especially among women.

AIMS

To investigate emotional distress and common mental disorders in a poor urban district using the same survey method.

METHOD

First-stage screening of a slum district of Rawalpindi used the Bradford Somatic Inventory. Psychiatric interviews were conducted with stratified samples using the ICD-10 research diagnostic criteria.

RESULTS

On a conservative estimate, 25% of women and 10% of men suffered from anxiety and depressive disorders. Levels of emotional distress increased with age in both men and women. Women living in joint households reported more distress than those living in unitary families. Higher levels of education were associated with lower risk of common mental disorders, especially in younger women. Emotional distress was negatively correlated with socio-economic variables among women.

CONCLUSIONS

This study found levels of emotional distress and psychiatric morbidity in a poor district of Rawalpindi to be less than half those in a nearby rural village in the Punjab, although rates in women were still double those in men. Possible explanations are that more healthy people migrate to the cities or that urban living is more conducive to good mental health in Pakistan.