Priorities for research promoting mental health in the south and east of Asia

Progress in promoting mental health, preventing mental illness, and improving care for people affected by mental illness is unlikely to occur if efforts remain separated from existing public health programs and the principles of public health action. Experts met recently to discuss integrating public health and mental health strategies in the south and east of Asia, especially in low- and middle-income countries. Areas of research identified as high priority were: 1) integrating mental health into perinatal care; 2) providing culturally-adjusted support for carers of people with mental and physical disorders; 3) using digital health technologies for mental health care in areas with limited resources and 4) building local research capacity. Selection of these areas was informed by their relative novelty in the region, ease of implementation, likely widespread benefit, and potential low costs. In this article, we summarise available evidence, highlight gaps and call for collaborations with research centres, leaders and persons with lived experience within and beyond the region.

Protocol for the systematic review and meta-analysis of factors associated with non-adherence to antidepressants in depressive disorders in those more than 18 years of age

OBJECTIVE

We have developed a protocol for the systematic review and meta-analysis of the factors associated with nonadherence to antidepressants in depressive patients more than 18 years of age.

METHODS

We will search articles with the databases PubMed- Medline, Scopus, Embase and PsychINFO. All the published literature reporting factors associated with nonadherence to antidepressants in depressive disorders in patients more than 18 years of age and fulfilling all the eligibility criteria till October 2022 will be included. The data will then be extracted and examined to be included in the systematic review. Finally, we will conduct meta-analysis for factors associated with non-adherence.

CONCLUSION

We will do extensive search on the proposed topic within the available literature and come up with a robust review of factors associated with nonadherence to antidepressants in patients age more than 18 years globally. The evidence generated would assist in designing interventions to address non-adherence in this group of patients leading to better productivity and quality of life.

Association of childhood trauma, and resilience, with quality of life in patients seeking treatment at a psychiatry outpatient: A cross-sectional study from Nepal

Quality of life is defined by the World Health Organization as "Individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns". It is a comprehensive measure of health outcome after trauma. Childhood maltreatment is a determinant of poor mental health and quality of life. Resilience, however, is supposed to be protective. Our aim is to examine childhood trauma and resilience in patients visiting psychiatry outpatient and investigate their relations with quality of life. A descriptive cross-sectional study was conducted with a hundred patients with trauma and visiting psychiatry outpatient. Standardized tools were applied to explore childhood trauma, resilience, quality of life and clinical diagnoses and trauma categorization. Sociodemographic and relevant clinical information were obtained with a structured proforma. Bivariate followed by multivariate logistic regressions were conducted to explore the relation between childhood trauma, resilience, and quality of life. Poor quality of life was reported in almost one third of the patients. Upper socioeconomic status, emotional neglect during childhood, current depression and low resilience were the determinants of poor quality of life in bivariate analysis. Final models revealed that emotional neglect during childhood and low resilience had independent associations with poor quality of life. Efforts should be made to minimize childhood maltreatment in general; and explore strategies to build resilience suited to the cultural context to improve quality of life.

Resilience and its association with post-traumatic stress disorder, anxiety, and depression symptomatology in the aftermath of trauma: a cross-sectional study from Nepal

Introduction

Resilience is a multidimensional construct. Despite being quoted as protective against mental disorders, it remains largely unexplored in our context.

Objectives

We attempted to explore the role of resilience in the development of various psychiatric symptoms as depression, anxiety and post-traumatic stress disorder following trauma in clinical population in a psychiatry outpatient of a university hospital.

Methods

We interviewed one hundred patients who sought treatment in psychiatry outpatient in a university hospital in Kathmandu, Nepal. We collected sociodemographic and trauma related information using semi-structured interview format. Other instruments used were the World Health Organization Composite International Diagnostic Interview version 2.1 for trauma categorization, the Post-Traumatic Stress Disorder Checklist-Civilian version to measure the post-traumatic stress disorder symptoms, and the 25-item Hopkins Symptom Checklist-25 to assess the level of depression and anxiety symptoms. We used Nepali adapted resilience scale derived from the original Wagnild and Young Resilience scale to measure resilience. We explored the associations between resilience scores and the scores on depression, anxiety and posttraumatic stress disorder using bivariate and multivariate analysis.

Results

Resilience had negative correlations with depression, anxiety, and post-traumatic stress disorder symptoms after adjusting for other variables such as gender, marital status, employment status, socioeconomic status and trauma types which were observed to have significant association in the bivariate analysis.

Conclusions

There was inverse correlation between resilience scores and depression, anxiety, and post-traumatic stress symptoms. Resilience should be considered in studies involving trauma population.

Disclosure

No significant relationships.

Internalized stigma in patients with schizophrenia: A hospital-based cross-sectional study from Nepal

Introduction

The aim of this study was to examine the internalized stigma of mental illness in patients with schizophrenia visiting psychiatry outpatient in a tertiary level hospital in Kathmandu, Nepal, and to explore the associated sociodemographic and clinical factors.

Methods

This was a cross-sectional study, where participants were selected by purposive sampling from the outpatient department of psychiatry in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. One hundred and fourteen patients were selected and given the Internalized Stigma of Mental Illness scale to complete to assess the level of stigma. A semi-structured sociodemographic form was used to get information on sociodemographic and clinical factors. Simple descriptive analysis was done followed by multivariate analysis to explore the sociodemographic and clinical correlates of stigma in these patients.

Results

A total of 114 patients were included in the study. Moderate to high levels of internalized stigma was reported in almost 90% of patients with schizophrenia. The subscale with the highest mean score was stereotype endorsement and that with the lowest mean score was stigma resistance. Duration of illness was the only clinical variable associated with stigma while occupation was the only sociodemographic variable related to stigma.

Conclusion

Moderate to high levels of internalized stigma were reported across all subscales of stigma in patients with schizophrenia and the prevalence was high. Further, duration of illness was associated with stigma. Stigma reduction should therefore be a component of the overall management of patients diagnosed with schizophrenia.

Complete agenesis of the corpus callosum in paranoid schizophrenia-a case report

Corpus callosum agenesis is a rare condition and is sometimes associated with schizophrenia. The co-existence of these two conditions adds value to the neurodevelopmental theory of schizophrenia.

Impact of Service User Video Presentations on Explicit and Implicit Stigma toward Mental Illness among Medical Students in Nepal: A Randomized Controlled Trial

This study evaluated the impact of didactic videos and service user testimonial videos on mental illness stigma among medical students. Two randomized controlled trials were conducted in Nepal. Study 1 examined stigma reduction for depression. Study 2 examined depression and psychosis. Participants were Nepali medical students (Study 1: n = 94, Study 2: n = 213) randomized to three conditions: a didactic video based on the mental health Gap Action Programme (mhGAP), a service user video about living with mental illness, or a control condition with no videos. In Study 1, videos only addressed depression. In Study 2, videos addressed depression and psychosis. In Study 1, both didactic and service user videos reduced stigma compared to the control. In Study 2 (depression and psychosis), there were no differences among the three arms. When comparing Study 1 and 2, there was greater stigma reduction in the service user video arm with only depression versus service user videos describing depression and psychosis. In summary, didactic and service user videos were associated with decreased stigma when content addressed only depression. However, no stigma reduction was seen when including depression and psychosis. This calls for considering different strategies to address stigma based on types of mental illnesses. ClinicalTrials.gov identifier: NCT03231761.

Quality of life and its association with psychiatric disorders in outpatients with trauma history in a tertiary hospital in Kathmandu, Nepal: a cross-sectional study

BACKGROUND

Quality of life is an important indicator of health and has multiple dimensions. It is adversely affected in patients with trauma history, and psychiatric disorders play an important role therein. Studies in trauma-affected populations focus mainly on the development of psychiatric disorders. Our study explored various aspects of quality of life in trauma patients in a clinical setting, mainly focusing on the association of psychiatric disorders on various domains of quality of life.

METHODS

One hundred patients seeking help at the psychiatry outpatient of a tertiary hospital in Kathmandu, Nepal, and with history of trauma were interviewed using the World Health Organization Composite International Diagnostic Interview version 2.1 for trauma categorization. Post-traumatic stress disorder symptoms were assessed using the Post-Traumatic Stress Disorder Checklist-Civilian Version; while the level of anxiety and depression symptoms was assessed using the 25-item Hopkins Symptom Checklist-25. Quality of life was assessed using the World Health Organization Quality Of Life-Brief Version measure. Information on sociodemographic and trauma-related variables was collected using a semi-structured interview schedule. The associations between psychiatric disorders and quality of life domains were explored using bivariate analyses followed by multiple regressions.

RESULTS

The mean scores (standard deviations) for overall quality of life and health status perception were 2.79 (.87) and 2.35 (1.11), respectively. The mean scores for the physical, psychological, social and environmental domains were 12.31 (2.96), 11.46 (2.84), 12.79 (2.89), and 13.36 (1.79), respectively. Natural disaster was the only trauma variable significantly associated with overall quality of life, but not with other domains. Anxiety, depression and post-traumatic stress disorder were all significantly associated with various quality of life domains, where anxiety had the greatest number of associations.

CONCLUSION

Quality of life, overall and across domains, was affected in various ways based on the presence of psychiatric disorders such as anxiety, depression and post-traumatic stress disorder in patients with trauma. Our findings therefore emphasize the need to address these disorders in a systematic way to improve the patients' quality of life.

Clinical and epidemiological features of COVID-19 deaths in Nepal

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has taken more than 1 million lives globally. This study, based on the official media releases of the Government of Nepal, analyses the clinical and epidemiological features of the individuals who died as a result of COVID-19 in Nepal from 23 January to 10 August 2020. We found that nearly half of the deaths were among people less than 50 years of age and being female increased the risk of death. The majority of deaths were associated with co-morbidities, the most common being cardiovascular diseases and diabetes followed by respiratory diseases. With the approaching festive season and relaxed lockdown, both government and citizens need to be more cautious about the severity of COVID-19 and take appropriate action.

COVID-19: the current situation in Nepal

The recent global pandemic of novel coronavirus disease 2019 (COVID-19) is increasingly alarming. As of 21 June 2020, there are more than 8.7 million cases worldwide, with 460 000 deaths. Nepal is not an exception to COVID-19 and is currently facing a challenge to prevent the spread of infection. The analysis of the detected cases, severity and outcomes of the cases within a country is important to have a clear picture of where the pandemic is heading and what measures should be taken to curb the infection before it becomes uncontrollable. We collected data regarding all the cases, recoveries and deaths attributed to COVID-19 in Nepal starting from the first case on 23 January to 21 June 2020. At present, COVID-19 has spread all over Nepal, with a rapid increase in the number of new cases and deaths, which is alarming in a low-income country with an inadequate healthcare system like Nepal. Although the government implemented early school closure and lockdown, the management to contain COVID-19 does not appear to be adequate. Understanding the current situation regarding COVID-19 in Nepal is important for providing a direction towards proper management of the disease.

Comparison of Disulfiram and Naltrexone in Cases of Alcohol Dependence Syndrome

BACKGROUND

Relapse prevention in alcoholism is recognised as an important component of management. Use of pharmacotherapies to prevent relapse in combination to psychological intervention is emerging. Disulfiram and Naltrexone are two of three FDA approved drugs for pharmacotherapy. The aim of the study is to compare the effectiveness of these two drugs in preventing relapse in alcohol dependence syndrome cases.

METHODS

A prospective crossectional study was conducted to compare disulfiram and naltrexone in alcohol dependent patients in tertiary institution. Cases of alcohol dependence syndrome were diagnosed based on ICD-10 DCR presenting to psychiatry department of Tribhuvan University Teaching Hospital, over the period of 6 months. After detoxification and fulfillment of inclusion criteria, semi structured proforma, Severity of alcohol dependence questionnaire, Stages of change readiness and treatment eagerness scale, Obsessive compulsive drinking scale were applied. Drug allocation was based on simple random method and on subsequent follow ups done at 2nd, 4th, 8th, 12th week semi structured proforma, Obsessive Compulsive Drinking Scale were completed and psychological intervention continued. After data collection, analysis and final results were computed.

RESULTS

Both drugs reduced craving and amount of alcohol intake(p less than 0.001). Relapse was more in naltrexone group but was not statistically significant (p>0.05). Side effects were more with disulfiram(p less than 0.001) whereas dropout was more in naltrexone group,(p less than 0.01).

CONCLUSIONS

Disulfiram and Naltrexone were equally effective in reducing craving, reducing amount of alcohol intake, and preventing relapse in 12 weeks follow up period. Naltrexone was found to be better in tolerability whereas disulfiram was better in terms of dropout from treatment.

Neuropsychiatric manifestations in General Paralysis of Insane (GPI)

General paralysis of insane is a form of neurosyphilis which brings parenchymatous changes in the central nervous system. Its manifestations include a variety of neuropsychiatric symptoms ranging from cognitive impairment to overt psychosis. Clinicians face difficulties in proper diagnosis as variety of symptoms changes from one form to other within a short period of time. Rarity of the disease at this modern era of penicillin is also another factor in timely diagnosis and management of such cases. Here we present a case of general paralysis of insane who presented with variety of neuropsychiatric symptoms and have had great difficulties to reach into the diagnosis.

Attitude of Treating Psychiatrist Towards Personality Disorder

BACKGROUND

Worldwide mental health professionals have negative attitude towards personality disorder. Aim of this study was to assess the attitudes toward personality disorder among Nepalese psychiatrists.

METHODS

A cross-sectional survey study was done. Survey questionnaire was developed which consisted of 10 questions to explore the feeling and views regarding personality disorder. It was distributed via e-mail to 80 registered psychiatrist who were randomly selected and responses were analyzed.

RESULTS

Results showed only 50% of psychiatrist assessed for personality disorders whereas only 55.6% diagnosed it. Cluster 'B'personality disorders were most commonly diagnosed personality disorder, 36.1% felt helpless for those patients, 75% felt overall treatment for personality disorder was very difficult and 50% reported they were not competent to care for personality disorder patients.

CONCLUSIONS

Nepalese psychiatrists were not optimistic towards personality disorder in terms of its recognition, diagnosis and its overall management. Thus, future researches are needed to explore such attitudes in depth in same population.

Socio-Demographic Correlates in Patients with First Episode Depression in a Tertiary Hospital

Introduction: Depression is the most chronic mental illness that afflicts mankind.It is widely believed to be the disease affecting mainly female gender, economically disadvantaged group with low level of education and those residing in the urban setup.There are only few studies looking into the socio-demographic correlates of depression in the context of Nepal. Methods: We looked at 70 patients with new-onset depression who met the criteria for diagnosis of depression as per ICD-10 DCR. A self- designed semi- structured proforma was developed to obtain the socio-demographic variables and was filled in the OPD and the data were analyzed.Results: Mean age of the patients was 30.30±9.75 years and 70% of the patients were females. There were almost equal number of patients residing in and out of Kathmandu valley. Most of the patients had attained secondary level of education and were married, housewives and belonged to nuclear family. Majority were Hindus, Brahmins, and from middle class family.Conclusions: We found that patients with first episode depression were relatively young with female predominance most attaining at least secondary level of education; and most belonging to middle class nuclear families.Keywords: depression; ICD- 10 DCR; socio-demographic correlates.

Socio-Demographic Correlates in Patients with First Episode Depression in a Tertiary Hospital

INTRODUCTION

Depression is the most chronic mental illness that afflicts mankind. It is widely believed to be the disease affecting mainly female gender, economically disadvantaged group with low level of education and those residing in the urban setup. There are only few studies looking into the socio-demographic correlates of depression in the context of Nepal.

METHODS

We looked at 70 patients with new-onset depression who met the criteria for diagnosis of depression as per ICD-10 DCR. A self- designed semi- structured proforma was developed to obtain the socio-demographic variables and was filled in the OPD and the data were analyzed.

RESULTS

Mean age of the patients was 30.30±9.75 years and 70% of the patients were females. There were almost equal number of patients residing in and out of Kathmandu valley. Most of the patients had attained secondary level of education and were married, housewives and belonged to nuclear family. Majority were Hindus, Brahmins, and from middle class family.

CONCLUSIONS

We found that patients with first episode depression were relatively young with female predominance most attaining at least secondary level of education; and most belonging to middle class nuclear families.

Association of thyroid dysfunction with depression in a teaching hospital

BACKGROUND

Thyroid dysfunction is common in patients with depression and depression is also common in patients with thyroid dysfunction. The purpose of this study was to estimate the prevalence of thyroid dysfunction in newly diagnosed depressed patients attending Psychiatry outpatient department of Tribhuvan University Teaching Hospital, Nepal and to find the correlation between the two.

METHODS

The study population comprised of 70 patients aged more than 15 years selected by simple random sampling technique who attended the Psychiatry OPD of Tribhuvan University Teaching Hospital, Kathmandu, Nepal and were diagnosed with first episode depression. A self- designed semi structured proforma was devised to obtain the socio- demographic characteristics of the study population. These patients were diagnosed as depression as per the ICD-10 DCR Criteria and HDRS scale was used at the same interview to verify it objectively.

RESULTS

Fifteen patients (21%) were found to have thyroid dysfunction, the most common being sub-clinical hypothyroidism, seen in 8 (11%). Thyroid dysfunction also showed positive correlation with depression severity. The diagnosis of depression by ICD- 10 DCR Criteria had positive correlation with HDRS grading of depression, though no significant association was found between different socio- demographic variables and depression.

CONCLUSIONS

This study concluded that thyroid dysfunction is common in depressed patients and larger studies are required in this field before TFTs are considered as an integral part of evaluation of these patients.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a condition which affects predominantly overweight women and is characterized by raised intracranial pressure without any identifiable pathology in the brain and with normal cerebrospinal fluid (CSF) composition. The cause of IIH is unclear and as such it remains a diagnosis of exclusion. Although the pathophysiology of IIH remains elusive, some observations have recently been added to our understanding of this, including the presence of transverse sinus stenosis on many patients and the possible role of leptin and inflammation in the disease pathogenesis. Headache is the most common symptom and papilloedema is the major clinical finding. Choices of medical treatment are limited to the use of diuretics particularly acetazolamide and encouragement of weight loss. Surgical therapies such as CSF diversion procedures and fenestration of the optic nerve may be necessary in some cases with persistent symptoms or progressive visual deterioration. While not life-threatening, IIH has a significant morbidity with up to 25% of patients developing visual impairment from optic atrophy. Visual surveillance is therefore vital. Long-term follow-up is recommended as the disease may worsen after an initial period of stability.

A review of violent and traumatic deaths in Kathmandu, Nepal

The objective was to study the external causes of death reported in the autopsy centre in Kathmandu, Nepal. A retrospective review of case report documentation of all violent and traumatic death autopsies was conducted in Kathmandu from mid-July 2000 to mid-July 2004. A total of 4383 autopsies were conducted by the Department of Forensic Medicine in Kathmandu. There were 1072 (25%) cases of suicide, 380 (9%) homicide, 1399 (32%) accidental, 598 (14%) deaths as a result of natural diseases and 923 (21%) undetermined causes of death. The number of males was almost twice that of females (sex ratio 2.2:1). Persons aged 15 to 44 years comprised about two-thirds of the total reported fatalities (65.4%). Suicides were mostly reported due to hanging, homicides mostly due to firearms and explosives, accidents mostly due to road traffic injuries. More than 60% of road traffic injuries resulted among pedestrians. Suicides, homicides and accidental deaths remain a poorly identified public health issue in Nepal. Medico-legal autopsy reports can serve as an important tool in understanding fatalities from violence and injuries for countries similar to Nepal. Strengthening a regular mechanism for compilation and utilization of the information, however, remains a major challenge.

Fe(III) coordination properties of two new saccharide-based enterobactin analogues: methyl 2,3,4-tris-O-[N-[2,3-di(hydroxy)benzoyl-glycyl]-aminopropyl]-alpha-D-glucopyranoside and methyl 2,3,4-tris-O-[N-[2,3-di-(hydroxy)-benzoyl]-aminopropyl]-alpha-D-glucopyranoside

The synthesis of two saccharide-based enterobactin analogues, methyl 2,3,4-tris-O[-N[2,3-di(hydroxy)benzoyl-glycyl]-aminopropyl]-alpha-D-glucopyranoside (H(6)L(A)) and methyl 2,3,4-tris-O-[N-[2,3-di(hydroxy)benzoyl]-aminopropyl]-alpha-D-glucopyranoside (H(6)L(B)), are reported along with their pK(a) values, Fe(III) binding constants, and aqueous solution speciation as determined by spectrophotometric and potentiometric titration techniques. Use of a saccharide platform to synthesize a hexadentate triscatechol chelator provides some advantages over other approaches to enterobactin models, including significant water solubility, resistance to hydrolysis, and backbone chirality which may provide favorable recognition and availability to cells. The protonation constants for the catechol ligand hydroxyl moieties were determined for both ligands and found to be significantly different, which is attributed to the differences in the spacer chain of the two triscatechols. Proton dependent Fe(III)-ligand equilibrium constants were determined using a model involving the sequential protonation of the Fe(III)-ligand complex. These results were used to calculate the formation constants, log beta(110) = 41.38 for Fe(III)-H(6)L(A) and log beta(110) = 46.38 for Fe(III)-H(6)L(B). The calculated pM values of 28.6 for H(6)L(A) and 28.3 for H(6)L(B) indicate that these ligands possess Fe(III) affinities comparable to or greater than other enterobactin models and are thermodynamically capable of removing Fe(III) from transferrin.

Crystal structure of ferrioxamine B: a comparative analysis and implications for molecular recognition

Ferrioxamine B was successfully co-crystallized with ethanolpentaaquomagnesium(II) and perchlorate ions as counter ions, C27H62Cl3FeMgN6O26, and the crystal structure has been determined by single-crystal X-ray diffraction. The crystals are monoclinic, space group P2(1)/n, four molecules per unit cell with dimensions a=21.1945(7) A, b=10.0034(3) A, c=106.560(1) A, and beta=106.560(1) degrees. The crystal structure contains a racemic mixture of Lambda-N-cis,cis and Delta-N-cis,cis coordination isomers. The structural parameters and the conformational features of ferrioxamine B compare very well with those of ferrioxamines D1 and E, with an exception of the orientation of the pendant protonated amine, which is pointing away from the connecting amide chains and towards the carbonyl face of the inner coordination shell distorted octahedron. This pendant protonated amine, in conjunction with the carbonyl face of the Fe(III) coordination shell, is proposed to play an important role in the recognition and membrane transport processes.