What Women Want: Mental Health in the Context of Violence Against Women in Sri Lanka-A Qualitative Study of Priorities and Capacities for Care

Insufficient evidence guides mental health service development for survivors of violence against women in Sri Lanka. Provider and survivor perspectives on (1) what constitutes mental health, (2) quality of care, and (3) priority areas and stakeholders for intervention were identified through framework analysis of 53 in-depth interviews. Desired care is chiefly psychosocial-not psychological-prioritizing socioeconomic, parenting, and safe environment needs in non-clinical community settings. Our evidence points strongly to the need to strengthen non-mental health community-based providers as "first contacts" and reassessment of health system-centric interventions which neglect preferred community responses and more holistic approaches accounting for women's full circumstances.

Achievements and challenges in psychiatric education and training in Sri Lanka

When compared with other Asian countries, psychiatric education and training in Sri Lanka has made significant developments during the past two decades, such as introducing psychiatry as a separate final year subject in the undergraduate medical curricula. However, further developments in psychiatric training in medical education are needed.

The evolution of psychiatric care – a spiral model

The present trend towards community care with the continuing closure of the old Victorian institutions has given rise to much argument for and against community care. Incidents of violence by mentally ill patients against members of the public have resulted in some backlash against community care. There are fears of a return to the days of the institution. It is proposed that these changes can be predicted from a model that we have called the ‘spiral model’. An understanding of this model might help to prevent history from repeating itself.

Cognitive impairment and its relation to predominant polarity, number of episodes and illness duration in patients with euthymic bipolar affective disorder (BAD)

Introduction

Previous optimistic assumptions about the prognosis of BAD based on the control of mood symptoms is now challenged as majority of patients continue to have cognitive deficits during the euthymic phase.

Objectives

To describe cognitive impairment in euthymic BAD and study the association with clinical characteristics.

Aims

Identify the prevalence and severity of cognitive impairment (CI); to correlate CI with the first episode, illness duration, number of episodes and predominant polarity.

Methods

Patients attending the psychiatry clinic of the National Hospital of Sri Lanka diagnosed with BAD in the remission phase were recruited. An interviewer-administered questionnaire and Montreal Cognitive Assessment test was used to ascertain clinical characteristics and cognitive functions respectively. Scores of 18–26 described as mild, 10–17 moderate and < 10 as severe cognitive impairment.

Results

Total sample size was 58. Mean age = 48.84 (SD12.5). Fifty-five percent were females. Mean duration of illness was 179.7 months (SD128.5). A mean of 6 episodes were experienced during the course of illness (min = 1, max = 18); 58.6% had depression, 37.9% had manic and 3.4% had mixed as their first episode. The predominant polarity was depressive in 65.5%. No cognitive impairment – 8.6%, mild – 63.8%, moderate – 27.6% and none with severe. There was a significant association between the presence of cognitive impairment and the predominant polarity being depressive (r = 10.886, df = 4, P = 0.028). No significant association was found between illness duration, number of episodes or the type of first episode.

Conclusions

Patients with a predominant depressive polarity are more likely to experience cognitive impairment. Cognitive impairment had no association with illness duration, type of episode or number of episodes.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Antipsychotic-associated weight gain: management strategies and impact on treatment adherence

Antipsychotic-induced weight gain is a major management problem for clinicians. It has been shown that weight gain and obesity lead to increased cardiovascular and cerebrovascular morbidity and mortality, reduced quality of life and poor drug compliance. This narrative review discusses the propensity of various antipsychotics to cause weight gain, the pharmacologic and nonpharmacologic interventions available to counteract this effect and its impact on adherence. Most antipsychotics cause weight gain. The risk appears to be highest with olanzapine and clozapine. Weight increases rapidly in the initial period after starting antipsychotics. Patients continue to gain weight in the long term. Children appear to be particularly vulnerable to antipsychotic-induced weight gain. Tailoring antipsychotics according to the needs of the individual and close monitoring of weight and other metabolic parameters are the best preventive strategies at the outset. Switching to an agent with lesser tendency to cause weight gain is an option, but carries the risk of relapse of the illness. Nonpharmacologic interventions of dietary counseling, exercise programs and cognitive and behavioral strategies appear to be equally effective in individual and group therapy formats. Both nonpharmacologic prevention and intervention strategies have shown modest effects on weight. Multiple compounds have been investigated as add-on medications to cause weight loss. Metformin has the best evidence in this respect. Burden of side effects needs to be considered when prescribing weight loss medications. There is no strong evidence to recommend routine prescription of add-on medication for weight reduction. Heterogeneity of study methodologies and other confounders such as lifestyle, genetic and illness factors make interpretation of data difficult.

Metformin in prevention and treatment of antipsychotic induced weight gain: a systematic review and meta-analysis

BACKGROUND

Most antipsychotics are associated with weight gain and other metabolic complications. Several randomized trials have shown metformin to be effective, but this still hasn't been included in clinical guidelines on managing antipsychotic induced weight gain.

METHODS

All double blind placebo controlled trials assessing the efficacy of metformin in the treatment of antipsychotic induced weight gain were included. Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE were searched for the period January 2000-December 2015. Meta-analysis was carried out using the random effects model.

RESULTS

Meta analysis of 12 published studies with a total of 743 patients found that in patients treated with antipsychotics, metformin treatment resulted in significantly better anthropometric and metabolic parameters than placebo. The mean change in weight was -3.27 kg (95 % CI -4.66 to -1.89) (Z = 4.64, p < 0.001). Metformin compared to placebo resulted in significant reduction in BMI [-1.13 kg/m² (95 % CI -1.61 to -0.66)] and insulin resistance index [-1.49 (95 % CI -2.40 to -0.59)] but not fasting blood sugar [-2.48 mg/dl (95 % CI -5.54 to 0.57].

CONCLUSION

This meta-analysis confirms that metformin is effective in treating antipsychotic induced weight gain in patients with schizophrenia or schizoaffective disorder.

Diagnostic Validity and Factor Analysis of Montgomery-Asberg Depression Rating Scale in Parkinson Disease Population

BACKGROUND

The Montgomery-Asberg Depression Rating Scale (MADRS) is commonly used to assess major depression in Parkinson disease (PD), but studies on its utility are few. This study examines the validity and factor structure of MADRS in population with PD.

METHODS

In 104 patients with idiopathic PD, major depression was diagnosed by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR) criteria, and all patients were rated by MADRS.

RESULTS

The MADRS showed good concurrent validity with DSM-IV-TR criteria. The diagnostic cutoff was established as 16/17 (sensitivity 97.43, specificity 100%, positive predictive value 100%, and negative predictive value 98.48%). Factor analysis identified 3 factors, accounting for 76% of total variance: "sadness-anhedonia" comprising apparent sadness, reported sadness, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal ideas; "anxiety" with reduced sleep and inner tension; and "vegetative symptoms" with reduced appetite.

CONCLUSION

The MADRS has diagnostic utility in major depression in PD. The 3-factor structure of MADRS may help to understand the different dimensions of major depression and identify distinct symptom subgroups in this population.

Depressive disorder and grief following spontaneous abortion

BACKGROUND

Abortion is associated with moderate to high risk of psychological problems such as depression, use of alcohol or marijuana, anxiety, depression and suicidal behaviours. The increased risk of depression after spontaneous abortion in Asian populations has not been clearly established. Only a few studies have explored the relationship between grief and depression after abortion.

METHODS

A study was conducted to assess the prevalence and risk factors of depressive disorder and complicated grief among women 6-10 weeks after spontaneous abortion and compare the risk of depression with pregnant women attending an antenatal clinic. Spontaneous abortion group consisted of women diagnosed with spontaneous abortion by a Consultant Obstetrician. Women with confirmed or suspected induced abortion were excluded. The comparison group consisted of randomly selected pregnant, females attending the antenatal clinics of the two hospitals. Diagnosis of depressive disorder was made according to ICD-10 clinical criteria based on a structured clinical interview. This assessment was conducted in both groups. The severity of depressive symptoms were assessed using the Patients Health Questionnaire (PHQ-9). Grief was assessed using the Perinatal Grief Scale which was administered to the women who had experienced spontaneous abortion.

RESULTS

The sample consisted of 137 women in each group. The spontaneous abortion group (mean age 30.39 years (SD = 6.38) were significantly older than the comparison group (mean age 28.79 years (SD = 6.26)). There were more females with ≥10 years of education in the spontaneous abortion group (n = 54; SD = 39.4) compared to the comparison group (n = 37; SD = 27.0). The prevalence of depression in the spontaneous abortion group was 18.6 % (95 CI, 11.51-25.77). The prevalence of depression in the comparison group was 9.5 % (95 CI, 4.52-14.46). Of the 64 women fulfilling criteria for grief, 17 (26.6 %) also fulfilled criteria for a depressive episode. The relative risk of developing a depressive episode after spontaneous abortion was significantly higher than in females with a viable pregnancy (RR = 2.19, 95 % CI, 1.05 to 4.56). After adjustment for age and period of amenorrhoea, the difference was not significant. Prevalence of complicated grief was 54.74 % (95 % CI, 46.3-63.18).

CONCLUSION

The relative risk of developing a depressive episode after spontaneous abortion was not significantly higher compared to pregnant women after taking into account age and period of amenorrhoea (POA). Almost half the women developed complicated grief after spontaneous abortion. Of these, a significant proportion also had features of depressive disorder.

Simvastatin-induced cognitive dysfunction: two case reports

Background

Simvastatin is commonly prescribed for hypercholesterolemia to reduce vascular risk in patients. Some of these patients have dementia with cognitive defects of several domains. Although protective effects seem to be present, there is emerging evidence that statins cause cognitive impairment.

The role of cholesterol in cognitive function is complex. This is reflected in the effects that statins show on cognition functions. The reduction in cholesterol levels seen with statins is effective in improving learning and memory in some patients. However, there is emerging evidence that statins may worsen cognitive function. Similarly, there are major concerns over whether statins alleviate or worsen cognitive problems. The correlation between cholesterol levels and cognitive function is still controversial, mainly due to a lack of robust evidence.

Case presentation

We report the cases of two Asian patients who developed cognitive deficits after starting simvastatin. A 32-year-old man and a 54-year-old woman developed different but clear cognitive deficits that reversed after stopping simvastatin.

Conclusions

The possibility of new-onset cognitive dysfunction and the deterioration of existing cognitive deficits should be considered when prescribing simvastatin to patients.

Metformin for treatment of antipsychotic-induced weight gain in a South Asian population with schizophrenia or schizoaffective disorder: A double blind, randomized, placebo controlled study

BACKGROUND

Antipsychotic-induced weight gain causes serious health problems. We investigated the efficacy and safety of metformin in treating antipsychotic-induced weight gain in South Asian patients.

METHODS

Sixty six adult patients with schizophrenia or schizoaffective disorder treated, with atypical antipsychotics, and who had increased by more than 10% their pre treatment body weight, were randomly assigned to receive metformin or placebo in a double-blind study. Patients received usual treatment and metformin 500 mg or placebo twice daily for 24 weeks. The primary outcome measure was change in body weight from baseline to week 24. Linear mixed models were used in the analysis.

RESULTS

Mean change in body weight in the metformin group was -1.56 kg (95% CI=-3.06 to -0.05) and 1.0 kg (95% CI=0.03-1.97) in the placebo group. Between-group difference was 2.56 kg. At 24 weeks the between-group difference showed significant time-by-treatment interaction (F=3.23, p=0.004). Between-group difference in BMI showed significant time-by-treatment interaction (F=3.41 p=0.03). There was no significant difference in waist-hip ratio or fasting blood sugar.

CONCLUSIONS

Metformin is effective in reducing weight in South Asian patients with schizophrenia or schizoaffective disorder who had increased their body by more than 10% after treatment with atypical antipsychotics.

Major depressive disorder in Parkinson's disease: a cross-sectional study from Sri Lanka

BACKGROUND

Depression is common in Parkinson's disease (PD), and has a significant impact on the functional level of those affected. It is well studied in Western populations but data from Asia is limited. This study aims to estimate the prevalence of depression among PD patients attending a tertiary care outpatient clinic in Sri Lanka and identify potential risk factors.

METHODS

One hundred and four consecutive idiopathic PD patients as defined by the United Kingdom Parkinson's Disease Society Brain Bank Diagnostic Criteria were recruited to the study. An interviewer administered questionnaire, the Hoehn-Yahr staging scale and the Schwab-England Activities of Daily Living Scale (SEADL) were used for assessment. Depression was diagnosed through a semi-structured clinical interview based on DSM-IV-TR criteria and all subjects were rated with the Montgomery-Asberg Depression Rating Scale (MADRS).

RESULTS

The prevalence of depression in the study population was 37.5%. Among the depressed 12 (30.8%) had mild depression, 21 (53.8%) moderate depression and 6 (15.4%) had severe depression. Depression was significantly associated with the stage of PD, functional impairment, civil status, educational level, caregiver dependence and concomitant diabetes mellitus.

CONCLUSION

A significant proportion of PD patients suffers from depression. The prevalence rate of depression in the sample was similar to that reported in previous studies. Depression in PD is significantly associated with functional impairment.

Mental health status of Sri Lanka Navy personnel three years after end of combat operations: a follow up study

The main aim of this study was to assess the mental health status of the Navy Special Forces and regular forces three and a half years after the end of combat operations in mid 2009, and compare it with the findings in 2009. This cross sectional study was carried out in the Sri Lanka Navy (SLN), three and a half years after the end of combat operations. Representative samples of SLN Special Forces and regular forces deployed in combat areas were selected using simple random sampling. Only personnel who had served continuously in combat areas during the one year period prior to the end of combat operations were included in the study. The sample consisted of 220 Special Forces and 275 regular forces personnel. Compared to regular forces a significantly higher number of Special Forces personnel had experienced potentially traumatic events. Compared to the period immediately after end of combat operations, in the Special Forces, prevalence of psychological distress and fatigue showed a marginal increase while hazardous drinking and multiple physical symptoms showed a marginal decrease. In the regular forces, the prevalence of psychological distress, fatigue and multiple somatic symptoms declined and prevalence of hazardous drinking increased from 16.5% to 25.7%. During the same period prevalence of smoking doubled in both Special Forces and regular forces. Prevalence of PTSD reduced from 1.9% in Special Forces to 0.9% and in the regular forces from 2.07% to 1.1%. Three and a half years after the end of combat operations mental health problems have declined among SLN regular forces while there was no significant change among Special Forces. Hazardous drinking among regular forces and smoking among both Special Forces and regular forces have increased.

Use of lithium in clozapine-induced neutropenia: a case report

BACKGROUND

The literature describing the long-term use of lithium carbonate to reinstate reduced levels of white blood cell counts in patients treated with clozapine is scarce. We describe a case of successful recommencement of clozapine on a patient who developed risk level of neutropenia which was corrected by lithium carbonate. He was followed up for a period of one year.

CASE PRESENTATION

We report a 40-year-old Sri Lankan male who developed neutropenia and low white blood cell counts following commencement of clozapine. We were successful in restarting clozapine after the addition of lithium carbonate to increase the cell counts. Clozapine was increased to 700 mg a day with 500 mg of lithium carbonate. The patient remains stable after one year with no further episodes of neutropenia.

CONCLUSION

Lithium carbonate can successfully be used to treat clozapine-induced neutropenia.

Phagophobia: a case report

Background

Phagophobia is a rare disorder and the literature is sparse. There is no specific treatment described for this life threatening condition.

Case presentation

The patient is a 25-year-old Sri Lankan female with recurrent difficulty in swallowing. Following her initial episode which lasted one year, she presented to us with inability to swallow for one week. She was dependent on liquids and semisolids. The medical team confidently excluded an organic cause. She had difficulty swallowing solids with behaviours like swallowing with the aid of water and swallowing small boluses. She had difficulty eating in front of a crowd as well. She was preoccupied with misconceptions related to food and gastrointestinal disorders like gastritis. The symptom was soon becoming a maladaptive coping mechanism as it occurred when she was under stress and had difficulty solving a problem. The patient was managed with graded exposure and cognitive techniques.

Conclusion

The possibility of a psychological cause for dysphagia should be borne in mind although the occurrence is rare. Although no definitive treatment methods for phagophobia are described, cognitive behavioural techniques can successfully be used in the treatment.

Antipsychotic medication and tobacco use among outpatients with schizophrenia: a cross-sectional study

BACKGROUND

Many studies have shown that the prevalence of smoking in schizophrenia is higher than in the general population. Biological, psychological and social factors influence smoking in patients with schizophrenia.

METHODS

The study was carried out in psychiatry outpatient clinics in a tertiary care hospital in Sri Lanka. Every third patient was selected using systematic sampling from patients diagnosed with schizophrenia according to ICD-10 clinical criteria. Smoking behaviours were assessed using self-reports. Severity of illness was assessed using Brief Psychiatric Rating Scale (BPRS). Fagerstrom Test for Nicotine Dependence assessed level of dependence. Readiness to Change Questionnaire assessed motivation to change smoking behaviour.

RESULTS

The sample consisted of 306 patients with schizophrenia. Mean age was 38.93 years (SD 10.98). There were 148 males (48.4%). Mean duration of illness was 12.63 years (SD 8.38). Current medication was oral atypical antipsychotics 103, clozapine 136, oral typicals 29 and depot typicals 38. Prevalence of tobacco use among males was 30.41% (95% CI 22.91 to 37.90) and among females 1.90% (95% CI -0.25 to 4.05). Prevalence of current smoking among males was 20.27% (95% CI 13.72 to 26.82). None of the females smoked. Prevalence of smokeless tobacco use among males was 10.14 (95% CI 5.22 to 15.05) and among females 1.90 (95% CI -0.03 to 4.05). When patients treated with clozapine were excluded from the analysis, prevalence of tobacco use was 41.6% among males and 3.2% among females and prevalence of smoking was 29.9% among males. Prevalence of tobacco use was lowest in patients treated with clozapine 18.31 (95% CI 9.09 to 27.53) and highest in those treated with depot antipsychotics 47.83 (95% CI 25.74 to 69.91).

CONCLUSIONS

Prevalence of smoking was less than in many countries. This is influenced by prevalence in the general population and low affordability. Risk of tobacco use was significantly less among patients treated with clozapine.

Lower estimated glomerular filtration rates in patients on long term lithium: a comparative study and a meta-analysis of literature

BACKGROUND

Several studies have shown that long-term lithium use is associated with a subtle decline in estimated glomerular filtration rate. This study compared mean estimated glomerular filtration rates (eGFR) in patients on long term lithium, against matched controls.

METHODS

Patients with bipolar affective disorder, who are on lithium (for at least a year), were compared against controls that were matched (1:1) for age, gender and presence or absence of diabetes or hypertension. The eGFR was calculated from creatinine values according to the 'modification of diet in renal disease study' (MDRD) formula and was compared between cases and controls. A meta-analysis was performed to compare our findings with similar studies in literature.

RESULTS

Forty seven patients met the inclusion criteria. They were matched with 47 controls. The eGFR values of lithium users were significantly lower (p = 0.04) compared to controls. This difference persisted between the subgroup of lithium users without comorbidities (diabetes and hypertension) and their controls but disappeared for lithium users with comorbidities and their controls. Nonetheless, lithium users had lower eGFR values in both subgroups. A meta-analysis of 9 studies showed a significant lowering in the glomerular filtration rate in lithium users compared to controls [mean difference -10.3 ml/min (95% confidence interval: -15.13 to -5.55, p < 0.0001)].

CONCLUSIONS

Lithium causes a subtle decline in glomerular filtration rate; renal function needs to be monitored in patients on lithium treatment.

Chronic catatonia treated with electroconvulsive therapy: a case report

Introduction

In the International Statistical Classification of Diseases and Related Health Problems 10 and Diagnostic and Statistical Manual of Mental Disorders IV classification systems, catatonia is classified as a subtype of schizophrenia. However, catatonia is more frequently associated with mood disorders than schizophrenia. It is also associated with organic conditions. Catatonia responds to treatment with benzodiazepines and electroconvulsive therapy rather than antipsychotics. These features support the categorization of catatonia as an independent syndrome. There is a lack of consensus regarding the definition of chronic catatonia. There are two previous case reports of effective treatment of chronic catatonia with electroconvulsive therapy.

Case presentation

A 29-year-old South Asian woman was admitted to hospital because of poor food intake. Her condition had progressively worsened over the past seven months. She had features of catatonia. On admission, her Bush-Francis Catatonia Rating Scale score was 24. Her symptoms resolved after the administration of 17 electroconvulsive therapies but recurred later. She was given a further four electroconvulsive therapies. She remains well on aripiprazole at a dose of 60mg a day.

Conclusions

Bilateral electroconvulsive therapy is effective in the treatment of chronic catatonia and should be considered as a treatment option. A relapse of symptoms can occur after the discontinuation of treatment.

Multiple physical symptoms in a military population: a cross-sectional study

BACKGROUND

Medically unexplained symptoms have been reported among both civilians and military personnel exposed to combat. A large number of military personnel deployed to the Gulf War in 1991 reported non-specific symptoms. These symptoms did not constitute a clearly defined syndrome. Post-traumatic stress disorder (PTSD) and to a lesser degree exposure to combat are associated with physical symptoms.

METHODS

This is a cross-sectional study of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a 1-year period. Multiple physical symptoms were elicited using a checklist of 53 symptoms. Cases were defined as individuals with ten or more symptoms. Symptoms of common mental disorder were identified using the General Health Questionnaire 12 (GHQ-12). PTSD was diagnosed using the 17-item National Centre for PTSD checklist civilian version.

RESULTS

Prevalence of multiple physical symptoms was 10.4% (95% CI 8.11-12.75). Prevalence was significantly less in the Special Forces (5.79%) than in the regular forces (13.35%). The mean number of symptoms reported by those who met the criteria for PTSD was 12.19 (SD 10.58), GHQ caseness 7.87 (SD 7.57) and those without these conditions 2.84 (SD 3.63). After adjusting for socio-demographic and service variables, 'thought I might be killed' , 'coming under small arms fire' , and 'coming under mortar, missile and artillery fire' remained significant. Multiple physical symptoms were associated with functional impairment and poor perceived general health.

CONCLUSIONS

Prevalence of multiple physical symptoms was significantly lower in the Special Forces despite high exposure to potentially traumatic events. More multiple physical symptoms were reported by personnel with PTSD and common mental disorders. Multiple physical symptoms were associated with functional impairment.

Life threatening self starvation; a case report

Background

Obsessive compulsive disorders are a complex group that can have a variety of manifestations. Many authors now describe an obsessive compulsive spectrum disorder where many other specific diagnostic entities such as trichotillomania, tic disorders and body dysmorphic disorder are considered to be related and linked disorders.

Case presentation

We report a case of a twenty two year old Sri Lankan male who presented with life threatening self starvation due to severe obsessive compulsive disorder. The diagnosis was not considered till late due to the atypical presentation of the patient. While his symptoms bordered on a delusional psychosis, a decision was made to treat him as for obsessive compulsive disorder with behavioural therapy which was successful in the end.

Conclusions

In analysis of a patient with severe anorexia, the psychological causes should not be forgotten. In fact, if the feeding pattern of the patient was observed at the beginning, unnecessary investigating and life threatening worsening of the condition could have been avoided.

Caregiver strain and symptoms of depression among principal caregivers of patients with schizophrenia and bipolar affective disorder in Sri Lanka

Introduction

Data on caregiver strain and depression of principal caregivers of patients with mental illnesses are few in developing countries. Findings from developed countries cannot be applied directly to developing countries as culture specific factors may influence the outcome.

Methods

A prospective study was carried out in the University Psychiatry Unit of the National Hospital of Sri Lanka (NHSL) to identify symptoms of depression, caregiver strain and dissatisfaction with life in caregivers of patients with schizophrenia and bipolar affective disorder. Participants were assessed using the Center for Epidemiological Studies – Depression Scale, Satisfaction with Life Scale and the Modified Caregiver Strain Index.

Results and discussion

Eighty caregivers were interviewed (males; 36, 45%). Symptoms of depression were significant in 37.5%, while 48.8% had unsatisfactory scores on the Satisfaction with Life Scale. Depression and higher caregiver strain were associated with spending more time with the patient, interruption to work, disputes with relations, being assaulted by patient and self admission of needing professional help to overcome mental stress.

Conclusion

This study identified several associations for depression and increased caregiver strain among caregivers in a subset of patients with mental disorder in Sri Lanka. These can be used as markers to screen and increase pretest probability to identify caregivers needing help rather than applying the cumbersome questionnaires to all.

Mental health of Special Forces personnel deployed in battle

PURPOSE

To compare the mental health problems of Special Forces with regular forces engaged in combat in the Sri Lanka Navy (SLN).

METHODS

A population-based descriptive study was carried out to compare the mental health problems of Special Forces with regular forces in the Sri Lanka Navy (SLN) deployed in combat areas for at least 1 year. Participants were selected by simple random sampling. The outcome measures were common mental disorder measured using the General Health Questionnaire, PTSD, fatigue, multiple physical symptoms and hazardous alcohol use.

RESULTS

Overall exposure to potentially traumatic events was high in both groups, with Special Forces experiencing significantly more traumatic events. More than 80% of the Special Forces had experiences of discharging weapons in direct combat, engaging in combat with enemy vessels and seeing the dead or wounded. Special Forces had significantly less common mental disorders, fatigue and fair or poor general health than regular forces. Fair or poor general health (21.1%) and fatigue (18.4%) were the commonest problems in the regular forces. Hazardous drinking was the commonest mental health problem among the Special Forces (17%). Prevalence of PTSD was 1.9% in the Special Forces and 2.9% among the regular forces. Exposure to traumatic events and problems with family life were identified as risk factors.

CONCLUSIONS

Elite troops suffered less negative mental health consequences than regular forces despite higher combat exposure. Comradeship and unit cohesion protected Special Forces from negative mental health outcome of combat.

Smoking among troops deployed in combat areas and its association with combat exposure among navy personnel in Sri Lanka

Background

Among military personnel alcohol consumption and binge-drinking have increased but cigarette smoking has declined in the recent past. Although there is a strong association between smoking and PTSD the association between combat exposure and smoking is not clear.

Methods

This cross sectional study was carried out among representative samples of SLN Special Forces and regular forces deployed in combat areas. Both Special Forces and regular forces were selected using simple random sampling. Only personnel who had served continuously in combat areas during the one year period prior to end of combat operations were included in the study. Females were not included in the sample. The study assessed several mental health outcomes as well as alcohol use, smoking and cannabis use. Sample was classified according to smoking habits as never smokers, past smokers (those who had smoked in the past but not within the past year) and current smokers (those smoking at least one cigarette within the past 12 months).

Results

Sample consisted of 259 Special Forces and 412 regular navy personnel. Prevalence of current smoking was 17.9% (95% CI 14.9-20.8). Of the sample 58.4% had never smoked and 23.7% were past smokers. Prevalence of current smoking was significantly higher among Special Forces personnel compared to regular forces. (OR 1.90 (95% CI 1.20-3.02). Personnel aged ≥35 years had the lowest prevalence of smoking (14.0%). Commissioned officers had a lower prevalence (12.1%) than non commissioned officers or other ranks. After adjustment for demographic variables and service type there was significant association between smoking and combat experiences of seeing dead or wounded [OR 1.79 (95%CI 1.08-2.9)], handling dead bodies [OR 2.47(95%CI 1.6-3.81)], coming under small arms fire [OR 2.01(95%CI 1.28-3.15)] and coming under mortar, missile and artillery fire [OR 2.02(95%CI 1.29-3.17)]. There was significant association between the number of risk events and current smoking [OR 1.22 (95%CI1.11-1.35)].

Conclusions

There was significant association between current smoking and combat experiences. Current smoking was strongly associated with current alcohol use. Prevalence of current smoking was less among military personnel than in the general population. Prevalence of smoking was significantly higher among Special Forces personnel.

Alcohol use in a military population deployed in combat areas: a cross sectional study

Background

Alcohol misuse is more prevalent among military populations. Association between PTSD and heavy drinking have been reported in many studies. Most of the studies on alcohol use among military personnel are from US and UK. Aim of this study is to describe alcohol consumption patterns among military personnel in Sri Lanka, a country where the alcohol consumption among the general population are very different to that in US and UK.

Methods

Cross sectional study consisting of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a one year period was carried out. Data was collected using a self report questionnaire. Alcohol Use Disorder Identification Test (AUDIT) was used to assess alcohol consumption.

Results

Sample consisted of 259 Special Forces and 412 regular navy personnel. The median AUDIT score was 2.0 (interquartile range 6.0). Prevalence of current drinking was 71.2 %. Of the current users 54.81 % were infrequent users (frequency ≤ once a month) while 37.87 % of users consumed 2–4 times a month. Prevalence of hazardous drinking (AUDIT ≥ 8) was 16.69 % and binge drinking 14.01 %. Five (0.75 %) had AUDIT total ≥20. There was no significant difference between Special Forces and regular forces in hazardous drinking or binge drinking. Total AUDIT score ≥16 were associated with difficulty performing work.

Conclusions

High rates of hazardous drinking and binge drinking described among military personnel in US and UK were not seen among SLN personnel deployed in combat areas. This finding contrasts with previously reported association between combat exposure and hazardous alcohol use among military personnel. Alcohol use among military personnel may be significantly influenced by alcohol consumption patterns among the general population, access to alcohol and attitudes about alcohol use. Similar to findings from other countries, heavy alcohol use was associated with poorer psychological health and functional impairment.

From pesticides to medicinal drugs: time series analyses of methods of self-harm in Sri Lanka

OBJECTIVE

To explore if recent changes in methods of self-harm in Sri Lanka could explain the decline in the incidence of suicide.

METHODS

Time series analyses of suicide rates and hospitalization due to different types of poisoning were carried out.

FINDINGS

Between 1996 and 2008 the annual incidence of hospital admission resulting from poisoning by medicinal or biological substances increased exponentially, from 48.2 to 115.4 admissions per 100,000 population. Over the same period, annual admissions resulting from poisoning with pesticides decreased from 105.1 to 88.9 per 100,000. The annual incidence of suicide decreased exponentially, from a peak of 47.0 per 100,000 in 1995 to 19.6 per 100,000 in 2009. Poisoning accounted for 37.4 suicides per 100,000 population in 1995 but only 11.2 suicides per 100,000 in 2009. The case fatality rate for pesticide poisoning decreased linearly, from 11.0 deaths per 100 cases admitted to hospital in 1997 to 5.1 per 100 in 2008.

CONCLUSION

Since the mid 1990s, a trend away from the misuse of pesticides (despite no reduction in pesticide availability) and towards increased use of medicinal and other substances has been seen in Sri Lanka among those seeking self-harm. These trends and a reduction in mortality among those suffering pesticide poisoning have resulted in an overall reduction in the national incidence of accomplished suicide.

Signs and symptoms of acute mania: a factor analysis

BACKGROUND

The major diagnostic classifications consider mania as a uni-dimensional illness. Factor analytic studies of acute mania are fewer compared to schizophrenia and depression. Evidence from factor analysis suggests more categories or subtypes than what is included in the classification systems. Studies have found that these factors can predict differences in treatment response and prognosis.

METHODS

The sample included 131 patients consecutively admitted to an acute psychiatry unit over a period of one year. It included 76 (58%) males. The mean age was 44.05 years (SD = 15.6). Patients met International Classification of Diseases-10 (ICD-10) clinical diagnostic criteria for a manic episode. Patients with a diagnosis of mixed bipolar affective disorder were excluded. Participants were evaluated using the Young Mania Rating Scale (YMRS). Exploratory factor analysis (principal component analysis) was carried out and factors with an eigenvalue > 1 were retained. The significance level for interpretation of factor loadings was 0.40. The unrotated component matrix identified five factors. Oblique rotation was then carried out to identify three factors which were clinically meaningful.

RESULTS

Unrotated principal component analysis extracted five factors. These five factors explained 65.36% of the total variance. Oblique rotation extracted 3 factors. Factor 1 corresponding to 'irritable mania' had significant loadings of irritability, increased motor activity/energy and disruptive aggressive behaviour. Factor 2 corresponding to 'elated mania' had significant loadings of elevated mood, language abnormalities/thought disorder, increased sexual interest and poor insight. Factor 3 corresponding to 'psychotic mania' had significant loadings of abnormalities in thought content, appearance, poor sleep and speech abnormalities.

CONCLUSIONS

Our findings identified three clinically meaningful factors corresponding to 'elated mania', 'irritable mania' and 'psychotic mania'. These findings support the multidimensional nature of manic symptoms. Further evidence is needed to support the existence of corresponding clinical subtypes.

Prevalence of major depressive episode among patients with pre-dialysis chronic kidney disease

OBJECTIVE

To ascertain the prevalence of depression among pre-dialysis chronic kidney disease (CKD) patients.

METHODS

A cross-sectional study was carried out using the Structured Clinical Interview for DSM IV (SCID) to detect major depressive episode. Study was carried out in a nephrology outpatient clinic in Sri Lanka. Every fifth patient with CKD diagnosed according to the K/DQOI of the National Kidney Foundation of U.S.A. criteria stages 2-5 not undergoing dialysis was recruited. Primary outcome was major depressive episode diagnosed using the Structured Clinical Interview for DSM disorders (SCID).

RESULTS

Sample consisted of 140 patients. Eighty-nine (63.6%) were male. The mean age was 57.9 years (SD = 10.4). Only 41 (29.3%) were in paid employment. Percentage of patients in CKD stages 2, 3, 4, and 5 were 2.9%, 19.6%, 51.4%, and 25%, respectively. Only three patients had diabetes. One hundred and five were on treatment for hypertension. Prevalence of a major depressive episode was 27.9%. Among males, prevalence was 27% (95% CI 17.6-36.3) and among females, 29.4% (95% CI 16.5-42.4). Age, gender, income, employment status, and education were not associated with depression. The only significant variable associated with depression was patient's understanding of prognosis.

CONCLUSIONS

Prevalence of major depressive episode among pre-dialysis CKD patients was 27.9%. Rate of depression diagnosed using a structured clinical interview was lower than that reported when screening instruments were used. The only significant variable associated with depression was patient's understanding of prognosis. Future studies should aim to identify risk factors for depression among patients with kidney disease.

Association between concurrent alcohol and tobacco use and poverty

INTRODUCTION AND AIMS

The harm from alcohol and tobacco use in low- and middle-income countries includes substantial economic cost to the individual. Our aim was to describe the expenditure on concurrent alcohol and tobacco use in relation to family income in two districts in Sri Lanka.

DESIGN AND METHODS

A community-based cross-sectional study was carried out in two districts in Sri Lanka. We sampled 2684 men over 18 years of age using multistage cluster sampling. Cost of alcohol and cigarettes was calculated using the retail price for each brand and multiplying by the amount consumed.

RESULTS

Among current alcohol users 63.1% were also smokers. Among current smokers 61.9% were also using alcohol. Prevalence of concurrent alcohol and tobacco use in urban areas was 20.1% and in rural areas 14%. The two lowest income categories (<$US76 per month) spent more than 40% of their income on concurrent use while the next category ($US76-143 per month) spent 34.8% of their income on concurrent use.

DISCUSSION AND CONCLUSIONS

The poor spent less than those with higher income on alcohol and tobacco, but the expenditure constituted a much larger slice of their income thus compromising their ability to meet basic needs. In low-income countries, damaging economic consequences start at lower levels of alcohol and tobacco consumption and affect a significant proportion of the population. Defining risk levels and guidelines on safe limits based purely on individual health harm has, at best, little meaning in such settings.

Clozapine-associated weight loss

Clozapine is associated with weight gain. We report three patients with substantial weight loss following treatment with clozapine. The weight loss observed in the three patients was 33, 18 and 14.4 kg with percentage loss of body weight of 49, 18 and 21 respectively. Two patients had diabetes mellitus. History, physical examination and extensive investigations in the three patients did not reveal any cause that could account for the weight loss.

Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka

BACKGROUND

Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed.

METHODS

A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka. The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care.

RESULTS

Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively--complaints 6.1 and 3.8 (P = 0.001), GHQ 10.4 and 6.3 (P = 0.04), BSI score 15.6 and 132 (P < 0-01), visits 7.9 and 3.1 (P = 0.004).

CONCLUSIONS

Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction.